1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the
client tells the nurse she is considering not going forward with the treatment. Which of the following
statements by the nurse is appropriate?
a. “You don’t have to go through with the tr...
1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the
client tells the nurse she is considering not going forward with the treatment. Which of the following
statements by the nurse is appropriate?
a. “You don’t have to go through with the treatment.”
b. “Most people who have this procedure feel better following the treatment.”
c. “It’s okay to be nervous before this treatment.”
d. “Your doctor wouldn’t have ordered this treatment unless it was necessary.”
2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s
CPM device. Which of the following actions should the nurse take first?
a. Report the defect to the equipment maintenance staff.
b. Ensure the device inspection sticker is current
c. Remove the device from the room
d. Initiate a requisition for a replacement CPM device
3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone.
Which of the following actions should the nurse take?
a. Document administration of the medication upon removal from the medication dispensing
system
b. Withhold the medication if the client does not appear to be in pain.
c. Count the current number of unit doses available in the medication dispensing system
d. Withhold the medication if the client has a fever
4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority
finding?
a. Type 2 DM and a blood glucose of 250 mg/dL
b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F)
c. 2 hr. post cast placement and has 2+ pitting edema and pallor
d. First-degree heart block and a heart rate of 62/min
5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which
of the following statements by a client indicates an understanding of the teaching?
a. “I will limit my alcohol use to one drink daily while taking disulfiram.”
b. “I will avoid foods containing tyramine while taking fluoexetine.”
c. “I will take the sustained-release methylphenidate every morning.”
d. “I will take my lithium on an empty stomach.” (pharm pg. 64: taking lithium with food will
help decrease GI distress)
6. A nurse in the emergency department is assessing client who has major depressive disorder. Which
of the following actions should the nurse take first? [View Exhibit]
a. Administer Zofran to the client for nausea
b. Implement seizure precautions for the client
c. Encourage the client to verbalize feelings
d. Obtain the client’s weight
7. A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder.
Which of the following should the nurse expect?
a. Suspicious of others
b. Exhibits separation anxiety
c. Ritualistic behavior
d. Preoccupied with aging
8. Drug Calc: Client weighs 99 lb. Prescribed diet of 1.5 g protein/kg/day. How many grams of protein
per day should the nurse include in the client’s dietary plan?
9. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the
following actions should the nurse take first to manage her time effectively?
a. Develop an hourly time frame for tasks
b. Schedule daily activities
c. Determine goals of the day
d. Delegate tasks to the AP
,10. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium
sulfate via continuous IV infusion. Which of the following actions should the nurse include in the
plan?
a. Restrict the client’s total fluid intake to 250 mL/hr.
b. Measure the client’s urine output every hour
c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium
gluconate)
d. Monitor the FHR via Doppler every 30 min
11. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to
heal by primary intention?
a. Infected laceration
b. Stage II pressure ulcer
c. Approximated surgical incision
d. Partial-thickness burn
12. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the
following clients should the nurse see first?
a. Client taking clozapine to treat schizophrenia and reports sore throat (pharm pg. 72:
monitor for infection [fever, sore throat, etc.])
b. Client has OCD and is upset about a change in daily routine
c. Client has narcissistic personality disorder and is mocking others during group therapy
d. Client who has depressive disorder and requires assistance with ADLs
13. A nurse is caring for a client who has an implanted venous access port. Which of the following should
the nurse use to assess the port?
a. An angiocatheter
b. A butterfly needle
c. A noncoring needle
d. A 25 gauge needle
14. A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting
on my chest.” The client is weak and unable to walk. After the nurse indicates chest pain protocol,
which of the following is the priority diagnostic test?
a. PT and INR
b. 12 lead ECG
c. Chest X-ray
d. Serum potassium
15. A nurse is assessing the growth and development of a 3 y/o child. Which of the following questions
should the nurse ask the parent to determine if the child is exhibiting typical developmental
expectations?
a. “Can your child draw a stick figure?”
b. “Can your child catch and throw a small ball?”
c. “Can your child ride a tricycle?”
d. “Can your child name five colors?”
16. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of
the following actions should the nurse take?
a. Measure the fundal height to determine the placement of the ultrasound stethoscope
b. Perform Leopold maneuvers prior to auscultating the FHR
c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR
d. Place the client in a side-lying position prior to assessing the FHR
17. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon
assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for
the tidaling?
a. There is a loop of tubing below the drainage system
b. The system is working properly (medsurg pg. 104: tidaling in the water seal chamber and
continuous bubbling only in the suction chamber)
c. The lung has re-expanded
d. The tubing is partially obstructed by clots
, 18. A charge nurse on a medical surgical unit is assisting with the emergency response plan following an
external disaster in the community. In anticipation of multiple client admissions, which of the
following current clients should the nurse recommend for early discharge?
a. A client who is receiving heparin for DVT
b. A client who is 1 day postoperative following a vertebroplasty
c. A client who has COPD and a respiratory rate of 44/min
d. A client who has cancer with a sealed implant for radiation therapy
19. A nurse is caring for a client who has ESRD. The client’s adult child asks the nurse about becoming a
living kidney donor for her father. Which of the following conditions in the child’s medical history
should the nurse identify as a contraindication to the procedure?
a. Osteoarthritis
b. HTN
c. Amputation
d. Primary glaucoma
20. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings
should the nurse expect? (SATA)
a. Foul perineal odor
b. Fundus displaced to the right
c. Lochia serosa
d. Fundus 4 cm (1.6 in) below the umbilicus
e. Postpartum chill
21. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the
following actions should the nurse take?
a. Perform the procedure twice a day
b. Hold hand to perform percussions on the child
c. Administer a bronchodilator after the procedure
d. Perform the procedure prior to meals
22. A home care nurse is making a follow up visit with a client who has COPD and is using a compressed
oxygen system in his home. Which of the following action should the nurse take?
a. Ensure that the client checks the gauge weekly
b. Store the oxygen tank wrench in a locked cabinet
c. Have the client store smaller tanks under his bed
d. Place the oxygen tank away from curtains or drapes
23. Location of crackles [IMAGE]
24. A nurse is caring for a newly client who has bacterial meningitis. Which of the following actions
should the nurse take? (medsurg pg. 31)
a. Implement seizure precautions
b. Place the client in high-Fowler’s position
c. Perform ROM exercises once per shift
d. Monitor the client for hypoglycemia
25. A nurse is reviewing the preadmission lab tests results of a client who is to undergo hip arthroplasty
in 2 days. Which of the following results should the nurse report to the provider?
a. Na 142 mEq/L
b. Blood glucose 80 mg/dL
c. K 3.3 mEq/L
d. PT 11.5 seconds
26. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a
closed-suction drain. Which of the following actions should the nurse take?
a. Reset the vacuum by compressing the container
b. Secure the drain to the bedding
c. Position the affected extremity below the level of the client’s heart
d. Maintain the client in a supine position for the first 24 hr.
27. A nurse is receiving change of shift report for four clients. Which of the following clients should the
nurse assess first?
a. DM and HbA1c of 5.2%
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ViaWave. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.29. You're not tied to anything after your purchase.
