3. The nurse is implementing a plan of care for a client with deep pain thrombosis of the right leg. Which of the following interventions does the nurse avoid when delivering care to this client?
A. elevation of the right leg
B. ambulation in the hall twice per shift
C. application of moist ...
JohnJ.Teodor
TRP, RN I
II 2023
1. The home health nurse is visiting the client who has had a prosthetic valve replacement
for severe mitral valve stenosis. Which statement by the client reflects an understanding
of specific postoperative care for this surgery?
A. “I threw away my straight razor and brought an electric razor.”
B. “I have to go to the bathroom several times at night”
C. “I count my pulse everyday”
D. “I still do my deep breathing exercise”
2. A client has been diagnosed with thromboangitis obliterans. The nurse is considering
measures to help the client cope up with lifestyle changes needed to control the disease
process. The nurse plans to refer the client to a:
A. medical social worker
B. dietician
C. smoking cessation program
D. pain management clinic
3. The nurse is implementing a plan of care for a client with deep pain thrombosis of the
right leg. Which of the following interventions does the nurse avoid when delivering care
to this client?
A. elevation of the right leg
B. ambulation in the hall twice per shift
C. application of moist heat to the right leg
D. administration of acetaminophen (Tylenol)
4. The client was hospitalized 5 days ago have developed left calf tenderness and have a
positive Homan’s sign. The nurse assigned to this client, assesses the client for:
,A. coolness and pallor of the affected limb
B. diminished distal peripheral pulses
C. increased calf circumference
D. bilateral edema
5. The nurse is monitoring a client with leukemia who is receiving Doxorubicin
(Adriamycin) by IV infusion. Which of the following assessment findings indicate
toxicity of the medication? A. Elevated BUN
B. elevated creatinine
C. ECG changes
D. a red coloration of the urine * one of the adverse rxn, but transient
6. A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is
requesting for some water. The nurse must:
A. keep the client NPO until n order is written
B. check the vital signs first
C. check the gag and swallowing reflex
D. encourage coughing and deep breathing
7. A 45-year-old client is receiving heparin sodium for a pulmonary embolus. The nurse
evaluates which of the following laboratory reports of partial thromboplastin time as
indicative of effective heparin therapy. A. within normal range
B. one to 1.5 times the control value
C. two to 2.5 times the control value
D. three times the control value
8. A client is taking Wafarin (coumadin) following the placement of an artificial mitral
valve. The nurse instructs this client to avoid taking the following commonly used drug:
A. Maalox plus
By Abel Saboke(abelcomms1@gmail.com)
,B. sudafed
C. Tylenol cold and flu medication
D. aspirin
9. A client with insulin dependent diabetes mellitus (IDDM) is being discharged. The
nurse knows that the client has understood essential teaching when the following
statement is heard:
A. “I need to cut my nails straight across”
B. “I can’t make any substitutions in my diet”
C. “my insulin should be given into my arms”
D. “I should eat less before exercising”
10. A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the
following laboratory test daily:
A. complete blood count
B. electrolyte studies
C. prothrombin time – for bleeding time
D. BUN and creatinine
11. A client has developed depression of the bone marrow from anti-neoplastic drugs.
The nurse states the nursing diagnosis of highest priority as:
A. fluid volume deficit C. ineffective thermoregulation
B. High risk for aspiration D. high risk for infection
12. Radioactive iodine is being used to treat a client with cancer of the thyroid gland. The
nurse knows that the client has understood teaching about the treatment when the
following statement is heard:
A. “only my thyroid gland will be radioactive”
B. “I need not be concerned about radioactivity”
C. “my whole body will be radioactive”
, D. “my body fluids will be radioactive for a short time”
13. A client’s TPN is 6 hours behind schedule. The nurse would:
A. run the fluid at rate to make up the lost time.
B. report the situation to the physician
C. run the IV at the prescribed site
D. check the blood glucose level
14. A 45-year-old client is in acute congestive heart failure. The nurse and client establish
a goal of highest priority as:
A. rest mentally as well as physically
B. learn stress management
C. train for a less demanding job
D. prevent complications of immobility
15. A client diagnosed with IDDM becomes irritable and confused; the skin is cool and
clammy and the pulse rate is 110. The first action of the nurse would be to:
A. give a half-cup of orange juice
B. check the serum glucose
C. administer regular insulin
D. call the physician
16. A client with IDDM is recovering from DKA. Information of the serum level of the
following substance will be very important to the nurse:
A. sodium C. potassium
B. calcium D. magnesium
17. A 17-year-old client’s mother has been recently diagnosed with pulmonary
tuberculosis. The nurse would expect the doctor to order which of the following tests
initially?
By Abel Saboke(abelcomms1@gmail.com)
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