#121.
A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with ___________________.
A
Normal Saline
B
Heparinized normal saline
C
Lactated Ringer’s solution
D
5% dextrose in water
Answer: Normal Saline
#122.
The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?
A
Supine with the head turned to the left
B
Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
C
Low Fowler’s with knees gatched at 30 degrees
D
Bed sloped at a 45 degree angle with the head lowest and the legs highest
Answer: Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
#123.
The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?
A
Check respiration, stabilize spine, check circulation
B
Assess the level of consciousness and circulation
C
Check respirations, circulation, neurological response
D
Align the spine, check pupils, check for hemorrhage
Answer: Check respiration, stabilize spine, check circulation
#124.
A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?
A
Eat solid food
B
Sit in an upright position to eat
C
Feed the client
D
Give liquids with meals
Answer: Sit in an upright position to eat
#125.
During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?
A
Remove the inner cannula
B
Limit suction pressure to 150-180 mmHg
C
suction for 15-20 seconds
D
Wear eye goggles
Answer: Wear eye goggles
#126.
The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?
A
Hunger and thirst
B
Palpitation and weakness
C
Increase urinary output
D
Warm, flushed skin
Answer: Palpitation and weakness
#127.
A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?
A
Providing a low-sodium diet
B
Administering insulin-replacement therapy
C
reducing physical and emotional stress
D
Restricting fluids to 1500 ml/day
Answer: reducing physical and emotional stress
#128.
The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?
A
Aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
B
Encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions
C
Administering 100% oxygen to reduce the effects of airway obstruction during suctioning
D
Removing oral and nasal secretions
Answer: Administering 100% oxygen to reduce the effects of airway obstruction during suctioning
#129.
An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding?
A
Facial edema with ecchymosis and handprint mark: crackles and wheezes
B
Red bruise mark and ecchymosis on face
C
Facial edema, with red marks; crackles in the lung
D
Facial edema with ecchymosis that looks like a handprint
Answer: Facial edema, with red marks; crackles in the lung
#130.
On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?
A
A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon
B
A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
C
A football player limping and complaining of pain and swelling in the right ankle
D
an elderly woman complaining of a loss of appetite and fatigue for the past week
Answer: A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
#131.
A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?
A
check the laboratory data for serum albumin, hematocrit, and hemoglobin
B
Complete a gastrointestinal and neurological assessment
C
Complete a police report on elder abuse
D
talk to the client about the caregiver and support system
Answer: Complete a gastrointestinal and neurological assessment
#132.
The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?
A
Chart that the patient fell
B
fill out an incident report
C
Chart that the client was found on the floor next to the bed
D
Call the physician
Answer: Call the physician
#133.
The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask ______________________.
A
The adult visiting, "The child’s name is ____________________?"
B
The child, "Is your name____________?"
C
Another staff nurse to identify this child
D
The other children in the room what the child’s name is
Answer: Another staff nurse to identify this child
#134.
The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?
A
abnormally felt area in the right breast, drainage noted
B
hard nodular mass in right breast nipple
C
firm mass at five ‘ clock, outer quadrant, 1cm from right nipple
D
mass in the right breast 4cmx1cm
Answer: firm mass at five ‘ clock, outer quadrant, 1cm from right nipple
#135.
The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to ______________.
A
Determine the size, shape, and placement of the kidneys
B
Outline the kidney vasculature
C
Measure renal blood flow
D
Test renal tubular function and the patency of the urinary tract
Answer: Test renal tubular function and the patency of the urinary tract
#136.
A client visits the clinic for screening of scoliosis. The nurse should ask the client to ___________.
A
Bend all the way over and touch the toes
B
Bend over at a 45-degree angle from the waist
C
Stand up as straight and tall as possible
D
Bend over at a 90-degree angle from the waist
Answer: Bend over at a 90-degree angle from the waist
#137.
A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they ____________________.
A
Avoid contact with the client’s roommate
B
wash their hands when leaving
C
Keep the client’s room door open
D
Put on gowns, gloves and masks
Answer: wash their hands when leaving
#138.
An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?
A
Your baby can’t empty the formula that is in the stomach into the bowe
B
Your baby eats too rapidly and overfills the stomach, which causes vomiting
C
The vomiting is due to the nausea that accompanies pyloric stenosis
D
Your baby needs to be burped more thoroughly after feeding
Answer: Your baby can’t empty the formula that is in the stomach into the bowe
#139.
A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this?
A
reactivation of an old tuberculosis infection
B
Respiratory problems are characteristic in this population
C
Greater exposure to diverse health care workers
D
increased incidence of new cases of tuberculosis in persons over 65 years old
Answer: increased incidence of new cases of tuberculosis in persons over 65 years old
#140.
The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure ______________________.
A
The entire area that feels itchy to the child
B
Both the areas that look red and feel raised
C
Only the area that feels raised
D
Only the area that looks reddened
Answer: Only the area that feels raised
Share this resultHelp your batchmates find the official result
