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Quiz
1. The client has an intravenous (IV) cannula inserted, and the nurse prepares the IV solution and tubing. Arrange the actions in the order that they should be performed.
a.Uncap the distal end of the tubing
b.Close the roller clamp on the IV tubing
c.Open the roller clamp and fill the tubing
d. Attach the distal end of the tubing to the client
e. Spike the IV bag and half-fill the drip chamber
2. The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.
a.Proteinuria
b.Hypertension
c.Low-grade fever
d. Generalized edema
e. Increased pulse rate
f. Increased respiratory rate
3. A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a –2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.
a. Less pressure on her cervix
b. Decreased number of contractions
c. Increased efficiency of contractions
d. The need for increased maternal blood pressure monitoring
e. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
4. A10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?
a. Warm, dry skin
b. Decreased wheezing
c. Pulse rate of 90 beats/minute
d. Respirations of 18 breaths/minute
5. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?
a. “I will encourage my child to perform prescribed exercises.”
b. “I will have my child wear soft fabric clothing under the brace.”
c. “I should apply lotion under the brace to prevent skin breakdown.”
d. “I should avoid the use of powder because it will cake under the brace.”
6. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.
a. A low arterial PCo2 level
b. A hyper-inflated chest noted on the chest x-ray
c. Decreased oxygen saturation with mild exercise
d. A widened diaphragm noted on the chest x-ray
e. Pulmonary function tests that demonstrate increased vital capacity
7. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client’s breath sounds?
a. Stridor
b. Crackles
c. Scattered rhonchi
d. Diminished breath sounds
8. The nurse is caring for a client with clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate. Select all that apply:
a. Applies sterile gloves before performing client care
b. Ensures surgical masks are worn by staff in the client’s room
c. Requests that the client be assigned to a single client room
d. Uses alcohol based sanitizers for hand hygiene
e. Wears a single use, disposable gown during client care.
9. The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply.
a. Administers 100% oxygen prior to suctioning the client
b. Applies suction while withdrawing the catheter from the airway
c. Instills sterile normal saline into the tracheostomy prior to suctioning
d. Limits suctioning to 20 seconds during each suction pass.
e. Uses sterile gloves and technique throughout the procedure.
10. The registered nurse (RN) is discussing care of shared clients with the licensed practical nurse. Which of the following clients require intervention by the RN? Select all that apply.
a. A client receiving a blood transfusion who reports severe anxiety and has blood pressure 90/60 mmHg and pulse 110/min
b. A client receiving oral metoprolol whose heart rate has decreased to 60/min after administration.
c. A client whose blood pressure decreased from 130/80 mmHg to 110/70 mm Hg following administration of 1mg hydromorphone IV
d. A client whose blood pressure was 90/65 mmHg before prescribed oral nifedipine was administered
e. A client whose pulse increased from 70/min to 100/min after albuterol administration.
11. A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?
a. Notify the HCP before performing the catheterization.
b. Use a small-sized catheter and an anesthetic gel as a lubricant.
c. Administer parenteral pain medication before inserting the catheter.
d. Clean the meatus with soap and water before opening the catheterization kit
12. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?
a. Monitor the client.
b. Elevate the head of the bed.
c. Assess the fistula site and dressing.
d. Notify the health care provider (HCP)
13. Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
a. Hemoglobin level of 14.0 g/dL (140 mmol/L)
b. Creatinine level of 0.6 mg/dL (53 mcmol/L)
c. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)
d. Fasting blood glucose level of 99 mg/dL (5.5 mmol/L
14. The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first?
a. Administer 0.25 mg hydromorphone IV push for pain
b. Draw blood for complete count and electrolyte level
c. Initiate IV access and infuse normal saline 100ml/hr
d. Obtain urine specimen for urinanalysis.
15. A health care provider prescribes cefuroxime 30mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection and the available dose is 250mg/5ml. The child weighs 34lb based on the available concentration of cefuroxime, how many ml would the nurse administer per dose? Record your answer using one decimal place.
a. 16.2 ml
b. 14.6 ml
c. 15.5 ml
d. 14.2 ml
16. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?
a. Avoid overuse of the eyes.
b. Decrease the amount of salt in the diet.
c. Eye medications will need to be administered for life.
d. Decrease fluid intake to control the intraocular pressure
17. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client’s hand?
a. A pink, edematous hand
b. Fiery red skin with edema in the nail beds
c. Black fingertips surrounded by an erythematous rash
d. A white color to the skin, which is insensitive to touch
18. A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results?
a. Prothrombin time of 12.5 seconds
b. Activated partial thromboplastin time of 60 seconds
c. Activated partial thromboplastin time of 28 seconds
d. Activated partial thromboplastin time longer than 120 seconds
19. The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up?
a. Edema of the scalp crossing the suture lines
b. Flat, blush, discoloured area on the buttocks
c. Small tuft of hair at the base of the spine
d. White, waxy substance in the axillae and labial folds.
20. The nurse is caring for a client with acute pericarditis. Whichclinical finding would require immediate intervention by the nurse?
a. Client reports chest pain that is worse with deep inspiration
b. Distant heart tones and jugular venous distension
c. ECG showing ST-segment elevations in all leads
d. Pericardial friction rub auscultated at the left sternal border
Quiz
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