WorksheetsFall 51-75
Total questions: 25
Worksheet time: 6hrs 15mins
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6o F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the charge nurse implement first?
Notify the healthcare provider of the assessment findings.
Determine if the client received anesthesia during delivery.
Assign a practical nurse (PN) to reassess the client's vital signs.
Obtain a STAT hemoglobin and hematocrit.
In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should recognize that which intervention is essential?
Keep the arm and shoulder of the affected side immobile at all times
Ensure that there is no fluctuation in the water-seal chamber.
Encourage the client to breathe deeply and cough at frequent intervals.
Maintain the Pleuravac® slightly above the chest level.
Immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include which interventions?
Assessing pedal pulses frequently and monitoring the nasogastric drainage.
Maintaining strict bedrest for 72 hours and assessing radial pulses.
Monitoring an infusion of IV heparin and checking the PTT level daily.
Assessing the right flank dressing and monitoring the suprapubic Foley catheter.
A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration?
Exhale forcefully into the tubing for 3 to 5 seconds.
Inspire deeply and slowly over 3 to 5 seconds.
Breathe into the spirometer using normal breath volumes
Perform IS breathing exercises every 6 hours.
65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse?
The nurse is guilty of negligence and will be sued.
The client would not be able to prove malpractice in court.
The nurse is protected by the Good Samaritan Act.
The healthcare provider should have given the morphine sulfate dose.
A client with which problem requires the most immediate intervention by the nurse?
Finger paresthesias related to carpal tunnel syndrome.
Increasing sharp pain related to compartment syndrome
Increasing burning pain related to a Morton's neuroma.
Increasing sharp pain related to plantar fascitis.
The charge nurse should intervene when what behavior is observed?
Two staff members are overheard talking about a cure for AIDS outside a client's
room.
A hospital transporter is reading a client's history and physical while waiting
for an elevator.
A UAP tells a client, "It's hard to quit drinking but Alcoholic Anonymous
helped me."
Two visitors are discussing a hospitalized client's history of drug abuse in the
visitor's lounge.
Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?
Client denies allergies to contrast media.
Skin prep to insertion site completed.
On-call sedation administered.
Oxygen at 2 L/minute per nasal cannula.
The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
Exercise in a swimming pool.
Splint affected joints during activity.
Perform passive range of motion exercises twice daily.
Begin a training program lifting weights and running.
An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?
Delirium
Presbyopia
Presbycusis
Cerebral dysfunction
A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?
Reports reduced nasal discharge.
Denies having coughing spells.
Able to sleep through the night.
Expectorating bronchial secretions.
The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?
The mother who took her children from school because aliens were after them
The young man who has a history of substance abuse and has no telephone.
The newly diagnosed client who needs to be evaluated for medication compliance.
The young woman who believes she is to blame for her recent miscarriage.
The nurse is caring for a client whose urine drug screen is positive for cocaine. What behavior is this client likely to exhibit during cocaine withdrawal?
Intense cravings.
Increased energy.
Talkativeness.
Euphoria
The nurse enters the room of a client with a history of seizure activity and observes that the unlicensed assistive personnel (UAP) is securing several pillows against the side rails to protect the client. What action should the nurse implement?
Ensure that the UAP has placed the pillows effectively to protect the client.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
Assume responsibility for placing the pillows while the UAP completes another task.
Ask the UAP to use some of the pillows to prop the client in a side-lying position.
A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?
Initiate normal saline IV at 50 ml/hr.
Administer a loading dose of penicillin IM.
Obtain a culture of any sputum or wound drainage
Administer the initial dose of folic acid PO.
A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Before being discharged, the nurse should provide the client with what instruction?
Keep the left leg in a dependent position.
Apply heat to the left leg cast.
Do not attempt to scratch the skin under the cast.
Apply a cold pack to any "hot spots" on the cast.
A client has 2nd degree electrical burns on both upper extremities. The nurse is preparing to administer the first application of the topical antimicrobial agent mafenide acetate (Sulfamylon) to the burned area. Which intervention should the nurse implement first?
Premedicate the client prior to applying the medication.
Use sterile gloves when applying this medication.
Cleanse the burned area with sterile normal saline.
Assess the client's most recent arterial blood gas test results.
The community health nurse must provide a primary prevention program in the community. Which type of program addresses this need?
Provide a nurse-practitioner to prescribe medications for clients with
heart disease.
Arrange cardiac-prudent diets to be delivered to individuals using Meals
on Wheels.
Incorporate an exercise program at a local Hispanic community center.
Conduct a weekly blood pressure screening at the Hispanic senior citizen center.
The nurse is conducting assessments at the beginning of the shift. Which client is most likely to have an increased blood pressure since the last set of vital signs was recorded four hours ago?
A young female with increased urinary output following administration of IV
furosemide (Lasix).
A middle-aged male receiving prazosin hydrochloride (Minipress).
An elderly male who received two units of packed red blood cells (RBCs).
An adolescent who is receiving azathioprine (Imuran) following a
cardiac transplant
A client is hemiplegic following a cerebrovascular accident. To prevent this client from experiencing a painful shoulder, what intervention should the nurse include in the plan of care?
Exercise the affected shoulder by using it when assisting the client out of bed.
Position the affected arm on pillows while the client is seated in a chair.
Keep the client's affected arm elevated above the level of the heart.
Avoid range of motion exercises on the affected shoulder until pain in the
shoulder has passed.
The pharmacist enters the wrong dose of a medication when transcribing prescriptions to a client's medication administration record (MAR). Which action should the nurse take to prevent a medication error from occurring?
Compare the medication label with the medication administration record (MAR).
Check the client's identification bracelet prior to administering the medication.
Compare the medication administration record (MAR) to the prescription.
Verify the room number on the medication administration record (MAR).
71. While on the delivery table, a primipara tells the nurse that she wishes to breastfeed
Verify the room number on the medication administration record (MAR).
71. While on the delivery table, a primipara tells the nurse that she wishes to breastfeed
Permit privacy for the mother and infant to bond.
Assist the mother to elicit a rooting reflex in the infant.
Place a small amount of glucose water on the breast.
Evaluate the infant's sucking reflex then give the infant to the mother.
A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond?
"Milk does contain tryptophan, which helps many people fall asleep."
"Drinking milk before bedtime can increase your symptoms at night."
"A warm drink, such as hot tea or cocoa should be substituted for the milk."
"Taking an antispasmodic medication with the milk will reduce the symptoms."
A client diagnosed with Type 1 diabetes is NPO for a diagnostic test. The nurse is preparing to administer 24 units of 70/30 insulin. Which intervention should the nurse implement first?
Administer the insulin subcutaneously in the client's abdomen
Administer the insulin when the client returns from the test.
Contact the healthcare provider to adjust the insulin dose.
Call the department and request that this client's test be done first.
The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid?
Toasted white bread with butter.
Whole grain cereal and milk.
Hard-boiled egg and juice.
Vanilla milkshake with protein supplement.
