1. What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
...
1. What instruction should the nurse include in the discharge teaching plan
of a client who had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
2. A male adult comes to the urgent care clinic 5 days after being diagnose
with influenza. He is short of breath, febrile, and coughing green colored
sputum. Which intervention should the nurse implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
3. An elder male client tells the nurse that he is loosing sleep because he
has to get up several times at night to go to the bathroom that he has
trouble starting his urinary stream and that he does not feel like his
bladder is ever completely empty. Which intervention should the nurse
implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
4. An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary
tract infection (UTI) Prescriptions for intravenous antibiotics and insulin
infusion are initiated. Which serum laboratory value warrants the most
immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
5. A client with sickle cell anemia develops a fever during the last hour of
administration of a unit of packed red blood cell. When notifying the
healthcare provider what information should the nurse provide
first using the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting
diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
6. An adult male client is admitted for pneumocystis carinil pneumonia
(PCP) secondary to aids. While hospitalize he receives IV pentamidine
isethionate therapy. In preparing this client for discharge what important
aspect regarding his medication therapy should the nurse explain?
a. AZT therapy must be stopped when IV aerosol pentamine is being
used.
b. IV pentamine will be given until oral pentamine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or
aerosol pentamine every month
d. Iv pentamine may offer protection to others aids related conditions
such as kaposis sarcoma
7. A client subjective data includes dysuria, urgency, and urinary frequency.
What action should the nurse implement next?
a. collect a clean catch specimen
b. palpate the suprapubic region
c. instruct to wipe from front to back
d. inquire about recent sexual activity
8. A client tells the nurse that her biopsy results indicate that the
cancer cells are well differentiated How should the nurse respond?
a. offer the client reassurance that this information indicates that
the clients cancer cells are benign
b. explain that these tissue cells often respond more effectively
to radiation than to chemotherapy
c. ask the client in the healthcare provider has giving her any
information about the classification of her cancer
d. help the client make plans to begin inmediate treatment since her
cancer is likely to spread quickly
9. A client with a chronic kidney disease is treated on hemodialysis. During
the 1 treatment clients blood pressure drops from 150/90 to 80/30
Which action should the nurse take first?
a. monitor bp q45 minutes
b. lower the head of the chair and elevate feet
c. stop dialysis treatment
d. administer 5%albumin IV
10. A client with deep vain thrombosis (DVT) is receiving a continues
infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml.
The prescription indicates the dosage should be increase 900 units/hr.
The nurse should program the infusion pump to deliver how many
ml/hr?
=9
11. The nurse is obtaining the admission history for a client with
suspected peptic ulcer disease (PUD). Which subjective data reported
by the client supports this diagnosis?
a. upper mid abdominal gnawing and burning pain
b. severe abdominal cramps and diarrhea after eating spicy foods
c. marked loss of weight and appetite over the last few months
d. use of chewable and liquid antacids for indigestion
12. The nurse is providing preoperative education for a jewish client
schedule to receive a xenograft graft to promote burn healing. Which
information should the nurse provide this client?
a. the xenograft is taken from nonhuman sources
b. grafting increases the risk for bacterial infection
c. as the burn heals the graft permanently attaches
d. grafts are later removed by debriding procedure
13. A client who took a camping vacation two weeks ago in a country with a
tropical climate comes to the clinic describing vague symptoms and
diarrhea for the past week. Which finding is most important for the
nurse to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
14. During a home visit the nurse assesses the skin of a client with eczema
who reports than an exacerbation of symptoms has occurred during the
last week. Which information is most useful in determining the possible
cause of the symptoms?
a. an old friend with eczema came for visit
b. recently received an influenza immunization
c. corticosteroid cream was applied to eczema
d. a grandson and his new dog recently visited
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