The nurse is caring for a 75- year-old male client who is beginning to form a decubitus
ulcer at the coccyx. Which intervention will be most helpfull in preventing further
development of the
decubitus?
A. Encourage the client to eat foods high in protein
B. Assess the client with daily range of motion exercises
C. Teach the family how to perform sterile wound care
D. Ensure the IV fluids are administered as prescribed - A. Encourage the client to eat
foods high in protein
What is the homeostatic cellular transport mechanism that moves water from a
hypotonic to a hypertonic fluid
space?
A. Filtration
B.
Diffusion
C. Osmosis
D. Active transport - C. Osmosis
The nurse is taking blood presure of a client admitted with a possible myocardial
infarction. When taking the client's BP at the brachial artery, the nurse should place the
client's arm in which position?
A. Slightly above the level of the
heart
B. At the level of the
heart
C. At the level of comfort for the client
D. Below the level of the heart - B. At the level of the heart
What are the final parameters that produce blood pressure? (select all that apply)
A. Heart rate
,B. Stroke volume
C. Peripheral resistance
D. Neuroendocring hormones
E. Muscle tone - A. Heart rate
B. Stroke volume
C. Peripheral resistance
The nurse is planning care for the a client who has fourth degree midline laceration that
occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has
the highest priority?
A. Administer Prescribed stool softner
B. Administer prescribed PRN sleep medications.
C. Encourage breastfeeding to promote uterine involution
D. Encourage use of prescribed analgesic perineal sprays. - A. Administer Prescribed
stool softner
The nurse is palpating the right upper hypochondriac region of the abdomen of a client.
What organ lies underneath this area.
A. Duodenum
B. Gastric Pylorus
C. Liver
D. Spleen - C. Liver
A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant.
Which sign is she most likely to report?
A. Decreased sexual libido
B. Amenorrhea
C. Quickening
D. Nocturia - B Amenorrhea
A client's daughter phones the charge nurse to report that the night nurse did not
provide good care for her mother. What response should the nurse
make?
A. Ask for a description of what happened during the night
B. Tell the daughter to talk to the unit's nurse manager
C. Reassure the daughter that the mother will get better care.
D. Explain that all the staff are doing the best they can. - A. Ask for a description of what
happened during the night
, A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's
"mine". According to Erikson's theory of psychosocial development, this child's behavior
is a demonstration of which developmental stage?
A. Autonomy vs. Shame and
doubt.
B. Industry vs.
Inferiority
C. intiative vs.
Guilt
D. Trust vs. Mistrust - A. Autonomy vs. Shame and
doubt.
Which action should the nurse implement in caring for a client following an
electroencephalogram
(EEG)?
A. Monitor the client's vital signs q4h
B. Assess for sensation in the client's lower extremities
C. Instruct the client to maintain bed rest for eight hours
D. Wash any paste from the client's hair and scalp - D. Wash any paste from the client's
hair and scalp
A client begins an antidepressant drug during the second day of hospitalization. Which
assessment is most important for the nurse to include in this client's plan of care while
the client is taking the antidepressant?
A. Appetite
B. Mood
C. Withdrawl
D. Energy level - B. Mood
Based on the documentation in the medical record, which action should the nurse
implement
next?
A. Give the rubella vaccine
subcutaneously
B. Observe the mother breastfeeding her
infant
C. Call the nursery for the infant's blodd type
result
D. Administer Vicodin one tablet for pain - A. Give the rubella vaccine subcutaneously
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