• A client who had an intraosseous (IO) cannula placed by the healthcare
providerfor an emergent fluid resuscitation is complaining of severe pain and
numbness below the IO site. The skin around the site is pale and edematous. What
action should the nurse takes first?
• Discontinue the IO infusion
• Administer an analgesic via the IO site
• Elevate the extremity with the IO site
• Notify the healthcare provider Correct A
• The nurse-manager of a perinatal unit is notified that one client from the
medical-surgical unit needs to be transferred to male room for new admissions.
Which client should the nurse recommend for transfer to theantepartal unit?
• A 45-year-old who has a chronic hepatitis B.
• A 35-year-old with lupus erythematous
• A 19-year-old who is diagnosed with rubella
• A 25-year-old with herpes lesions of the vulva Correct B
• A nurse is teaching a client postoperative breathing techniques using an
incentive spirometer (IS). What should the nurse encourage this client to doto
maintain sustained maximal inspiration?
• Breathe into the spirometer using normal breath volumes
• Exhale forcefully into the tubing for 3 to 5 seconds
• Inspire deeply and slowly over 3 to 5 seconds
• Perform IS breathing exercises every 6 hours
Correct C
• The nurse plans to educate a client about the purpose for taking the
prescribed antipsychotic medication clozapine (Clozaril). Which statementshould
the nurse provide?
,• You will be able to cope with your symptoms
• It will help you function better in the community
• The medication will help you think more clearly”
• It will improve your grooming and hygiene Correct C
• A 59-year-old male client is brought to the emergency room where he is
assessed to havea Glasgow Coma Scale of 3. Based on this assessment, how should
the nurse characterizes the client’s condition?
• The client has increased intracranial pressure
• He has a good prognosis for recovery
• This client is conscious, but is not oriented to time and place
• He is in a coma, and has a very poor prognosis Correct D
• At a community health fair, a 50-year-old woman tells the nurse that she has
an annual physical exam that includes a clinical breast exam and an annual
mammogram. How should the nurse respond?
• Encourage the woman to explore her fears about breast cancer.b. Ask the
woman if she also performs monthly breast self- exams.
• Commend the woman for adhering to the recommended cancer detection
guidelines.
• Advise the woman that mammograms are only needed every two years ather
age.
Correct B
• Which assessment finding should indicate to the nurse that a client with
arterialhypertension is experiencing a cardiac complication?
• Complaints of an occipital headache
,• A palpable dorsal is pedis pulse bilaterally
• Complaints of shortness of breath on exertion
• A blood pressure of 160/90Correct C
• A college student who is diagnosed with a vaginal infection and vulva
irritation
describes the vaginal discharge as having a “cottage cheese” appearance.
Which prescription should the nurse implement first?
• Cleanse perineum with warm soapy water 3 times per day
• Instill the first dose of nystatin (Mycostatin) vaginally per applicator
• Perform glucose measurement using a capillary blood sample
• Obtain a blood specimen for sexually transmitted disease (STDs)Correct B
• A client in acute renal failure has serum potassium of 7.5 mEq/L. Based on
thisfinding,
the nurse should anticipate implementing which action?
• Administer an IV of normal saline rapidly and NPH insulsubcutaneously.
• Administer a retention enema of Kayexalate
• Add 40 mEq of KCL (potassium chloride) to present IV solution.
• Administer a lidocaine bolus IV push.
Correct B
10 – A male client with diabetes mellitus takes Novolin 70/30 insulin before meals
and azithromycin (Zithromax) PO daily, using medication he brought from home.
When the nurse delivers his breakfast tray, the client tells the nurse that he took his
, insulin but forgot to take his daily dose of the Zithromax an hour before breakfast
asinstructed. What action should the nurse implement?
• Offer to obtain a new breakfast tray in an hour so the client can take the
Zithromax
• Instruct the client to eat his breakfast and take the Zithromax two hours after
eating
• Tell the client to skip that day’s dose and resume taking the Zithromax
thenext day
• Provide a PRN dose of an antacid to take with the Zithromax right after
breakfast
Correct B
• What instruction is most important for the nurse to provide a female client
whohas just been diagnosed with trichomoniasis?
• Avoid douching
• Treat sexual partner (s) concurrently
• Avoid using moist washcloths when bathing
• Postpone becoming pregnant until the infection is treatedCorrect B
• A primigravida at term comes to the prenatal clinic and tells the nurse that
she ishaving contractions every 5 min. The nurse monitors the client for one hour,
using an external fetal monitor, and determines that the client’s contractions every 5
minutes. The nurse monitors the client for one hour, using an external fetal monitor,
and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20
to30 seconds, with mild intensity by palpation. What action should the nurse take?
• Tell the client to go directly to the hospital for admission to labor and
deliveryfor active labor
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