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1. While auscultating a client's abdomen, the nurse her a low pitched blowing
sound in the upper midline area. What is the likely indication of this
finding?
a) normal borborygmus sounds
b) a minor variation
c) hyperactive bowel sounds
d) possible renal artery stenosis:
Answer:
d) possible renal artery stenosis
This sound is a vascular bruit, which is a blowing sound that is auscultated over a
stenosed artery. The location of the sound at the upper midline area is suggestive
of a renal artery stenosis.
2. A post-menopausal female client with osteoporosis tells the nurse that
she has increased her physical activity and hopes to participate in a charity
walk-a-thon. How should the nurse respond?
a) Affirm the benefits of increasing her weight-bearing activity
b) Review the need for her to avoid large crowds of people
c) Teach her how to take her pulse during prolonged activity
d) Explain the need to limit phyiscal activity to reduce fracture risk:
Answer:
a) Affirm the benefits of increasing her weight-bearing activity increasing weight-
bearing activity may help restore the early bone loss in those with osteopenia and
help prevent osteoporosis so the nurse should affirm the client's increase in
activity.
3. Which substance produced by the liver assists in maintaining the colloid
osmotic pressure within the vasculature?
a) Ammonia
b) Bilirubin
c) Glycogen
d) Albumin:
Answer:
d) Albumin
proteins, such as albumin maintain the colloid osmotic pressure within the
vasculature by holding on to fluid.
,4. The nurse is monitoring a client who has liver failure and is taking
lactulose. Which findings indicate that the medication has the desired effect?
SATA
a) Increased urine output
b) Increased serum ammonia
c) Improved level of consciousness
d) Increased bowel movements
e) Decreased serum potassium:
Answer:
c) Improved level of consciousness
d) Increased bowel movements
Lactulose draws ammonia and water into the gut which increases bowel
movements
which in turn improves LOC.
Lactulose does not increase urine output or lower serum potassium levels.
5. What action should the nurse take first after obtaining a urine specimen
for culture and sensitivity from an indwelling urinary catheter?
a) Label the container with the client's identifies
b) Securely fasten the clamp on the drainage bag
c) Ensure continued sterility of the specimen container
d) Ensure that the drainage bag is attached to the bed frame:
Answer:
c) Ensure continued sterility of the specimen container
6. An adult male who fell from a roof and fractured his left femur is admitted
for surgical stabilization after having a soft cast applied in the emergency
department. Which assessment finding warrants immediate intervention by
the nurse?
a) Onset of mild confusion
b) Pale, diaphoretic skin
c) Pain scale 8 out of 10
d) Weak palpable distal pulses:
Answer:
d) Weak palpable distal pulses
7. The mother of a one-month-old calls the clinic to report that the back of
her infant's head is flat. How should the nurse respond?
a) Place a small pillow under the infant's head while lying on the back
b) Turn the infant on the left side braced against the crib when sleeping
c) Prop the infant in a sitting position with a cushion when not sleeping
d) Position the infant on the stomach occasionally when awake and active:
,Answer:
d) Position the infant on the stomach occasionally when awake and active
8. An adult female with eroded tooth enamel presents to the clinic with
complaints fo abdominal distention and esophagitis?. The client tells the
nurse that her diet consists mostly of high-sugar, high-far foods that she
usually consumes while drinking. She also describes taking laxatives and
eating prunes whenever she overeats. What actions should the nurse take
when developing a plan of care for this client? SATA
a) Ask the client how she prefers to eat
b) Encourage the client to record everything she eats
c) Ask the client what she would like to do about her eating habits
d) Monitor lab values, particularly for electrolytes
e) Have the client self-report vomiting incidents:
Answer:
a) Ask the client how she prefers to eat
c) Ask the client what she would like to do about her eating habits
d) Monitor lab values, particularly for electrolytes
9. the nurse is preparing a client for discharge to home who had a below-
the-knee amputation. which recommendations does the nurse provide
the client? SATA
a) inspect skin for redness
b) use a residual limb shrinker
c) apply alcohol after bathing
d) wash with soap and water
e) avoid range of motion exercises:
Answer:
a) inspect skin for redness
b) use a residual limb shrinker
d) wash with soap and water
10. when triaging emergency room clients, which client should the
nurseassess first?
a) a male adolescent who has been vomiting for the past 12 hours and
describes himself as very weak.
b) an elderly client with peripheral vascular disease who is complaining of
severe leg pain when ambulating
c) a female client with severe lower right abdominal pain who is febrile and
vomiting
d) a child who has a cold for two days and now is coughing up green
sputum:
, Answer:
c) a female client with severe lower right abdominal pain who is febrile
and vomiting
11. after assessing a client, the nurse identifies three nursing problems.
Whendeveloping the client's plan of care, which action should the nurse
take?
a) collaborate with client to establish goals
b) cluster supportive client data
c) identify client care interventions
d) prioritize the identified nursing diagnoses:
Answer:
d) prioritize the identified nursing diagnoses the nursing problems must be
identified, then prioritized (D) before (A and C) can be implemented. (b) should be
completed before identifying the nursing problem
12. A 55-year-old female client with symptoms of osteoarthritis asks what
form of exercise would be most beneficial for her. What is the best response
by the nurse?
a) "limit your exercise to just your daily activities"
b) "Jogging or running are excellent aerobic exercises"
c) "swimming is an excellent exercise for you"
d) "Tennis or racquetball will increase your muscle strength":
Answer:
c) "swimming is an excellent exercise for you"
13. a client receives a new prescription for guaifensesin (Robutissin) 2
tablespoonsPO every 6 hours. The client takes the perscribed dose for 3 days
every 6 hours. What is the total number of ounces of Robitussin the client
has taken?:
Answer:
12
14. At 20-weeks gestation, a client who has gained 20 pounds during
this pregnancy tells the nurse that she is feeling fetal movement. Fundal
heightmeasurement is 20 cm, and the client's only complaint is that her
breath sounds are leaking clear fluid. Which assessment finding warrants
furtherevaluation?
a) Presence of fetal movement
b) leakage from breasts
c) gestational weight gain
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