1. The nurse is caring for a client
with emphysema. Which of the following nursing interventions are most appropriate?
Select all that apply.
A. Reduce fluid intake to less than
2,000 ml/day.
B. Teach client pursed lip breathing.
C. Administer low flow oxygen.
D. Keep the client in a supine
position as much as possible.
E. Encourage alternating activity with
rest periods.
2.
The nurse is planning care for a client with
hyperthyroidism. Which of the following nursing interventions are appropriate?
Select all that apply.
A. Provide small, well balanced meals
throughout the day.
B. Apply prescribed eye drops, as
necessary.
C. Encourage rest periods.
D. Provide a warm environment for
comfort.
E. Encourage family and friends to
visit the client
3.
A
nurse is teaching a class on Gastroesophageal Reflux Disease (GERD). A client complains his GERD causes a burning sensation halfway
between the navel and breastbone. Which of the following instructions should the
nurse recommend when teaching this client? Select all that apply.
A. Maintain a normal body weight.
B. Sleep in a low fowler’s position
and don’t eat at night.
C. Decrease frequency of meal.
D. Avoid caffeine.
E. Avoid spicy foods.
F. Wear loose fitting clothing.
4. A nurse is caring for a client with
diabetes insipidus, the client is diagnosed with a tumor and a decreased level
of the antidiuretic hormone. Which of the following interventions should be
included in the plan of care? Select all that apply.
A. Encourage fluids.
B. Restrict fluids.
C. Collect a 24 hour urine specimen.
D. Encourage intake of coffee or tea.
E. Monitor intake and output.
F. Take a daily weight.
5. A nurse is caring for a client with
delirium tremors. The client is violent and agitated. The physician orders a
vest restraint and bilateral soft wrist restraints. The client is disoriented
to time and place but is able to state name. Which of the following actions
should be performed by the nurse? Select all that apply.
A. Secure all loose ties to the side
rail.
B. Position the vest restraint so the
straps are crossed in the front.
C. Position the vest restraint so the
straps are crossed in the back.
D. Perform range of motion every 4
hours.
E. Offer toileting every 2 hours.
F. Tie the bilateral wrist restraints
in a double loop secure knot.
6. The home care nurse provides
medication instructions to an elderly hypertensive client who is taking
lisinopril (Prinivil), 40 mg orally daily. Which statements should be included
in the teaching plan? Select all that apply.
A. Instruct the client to avoid sudden
position changes.
B. Advise the client to report eye and
lip swelling immediately.
C. Teach the client to avoid salt
substitutions.
D. Teach the client to avoid dairy
products.
E. Teach the client a decrease in the white blood cell
count is normal at the beginning of therapy and no cause for concern.
7. A client with type 2 diabetes
mellitus is prescribed metoprolol I.V. for mild hypertension. Which nursing
interventions should be carried out?
Select all that apply.
A. Mix the medication with 100 ml
normal saline and infuse over 60 minutes.
B. Know this medication is compatible
with meperidine hydrochloride.
C. Monitor heart rate and blood
pressure carefully.
D. Monitor blood glucose levels closely.
E. Monitor for sinus bradycardia.
8.
A nurse is assessing a client who has a rash
on his left lower thigh and left foot. Which questions should the nurse ask in
order to gain further information about the client’s rash? Select all that
apply.
A. When did the rash start?
B. Do you drink alcohol?
C. How old are you?
D. Do you have allergies?
E. Have you traveled outside the
country?
9. A 55 year old male client arrives
to the emergency department. He is diagnosed with left ventricular dysfunction.
The nurse caring for this client is aware which of the following are signs of
left sided heart failure? Select all that apply.
A. Paroxysmal nocturnal dyspnea
B. Tachycardia
C. S4 heart sounds
D. Hepatomegaly
E. Right upper quadrant pain
10. A
28-year-old female is brought to the Emergency Department with complaints of
her “heart beating out of her chest." She is diaphoretic and her BP is 135/90.
The cardiac monitor shows an inferior wall myocardial infarction (MI). Which of
the following ECG changes is associated with a MI? Select all that apply.
A. Prolonged
PR-interval
B. U
wave
C. Repolarization
of Purkinje fibers
D. T
wave inversion
E. ST
segment elevation
F. Pathologic
Q wave
11. A client is prescribed lisinopril
and asks the nurse about the potential adverse reactions. Which of the following
are related to the adverse effect of an angiotensin-converting-enzyme (ACE)
inhibitor? Select all that apply.
A. Hyperthyroidism
B. Constipation
C. Dizziness
D. Headache
E. Hypotension
12. A nurse is teaching a class about
cardiac disease. The daughter of a client diagnosed with hypertension asks
about the risk factors. Which of the following should be included as the risk
factors for primary hypertension? Select all that apply.
A. Closed head injury
B. Diabetes mellitus
C. Stress
D. Oral contraceptives
E. High intake of sodium
13. A nurse is caring for a client who
recently had a cystoscopy to remove the bladder. The client now
has an ileal conduit. What assessment by the nurse would indicate the client is
developing complications? Select all that apply.
A. Sharp abdominal pain with rigidity
B. Dusky appearance of the stoma
C. Urine output greater than 30 ml/hr
D. Mucus shreds in the urine
collection bag
E. Stoma edema during the first 24
hours after surgery
14. The nurse is caring for a client
who is immunosuppressed
and at risk for infections. Which of the following activities should be
included in the discharge teaching plan?
A. Avoid shaving with a straight razor
B. Increase intake of fresh vegetables
C. Avoid contact sports
D. Treat a fever with over the counter
medicines
E. Wash hands frequently
F. Avoid crowded places
15. A client with testicular cancer is prescribed cisplatin (Platinol). Which of the following should the nurse monitor? Select all that apply.
A.
Hearing
B.
Urine output
C.
Hematocrit (HCT)
D.
Blood urea nitrogen (BUN)
E.
Magnesium level
F.
Creatinine level
16. Which of the following are findings
common in neonates born with esophageal atresia? Select all that apply.
A. Decreased production of saliva
B. Cyanosis
C. Coughing
D. Inadequate swallow
E. Choking
F. Inability to cough
17. The client with Crohn's disease has a nursing diagnosis of acute
pain. Which of the following should the nurse expect to be part of the care
plan? Select all that apply
A. Lactulose therapy
B. High fiber diet
C. High protein milkshakes
D. Corticosteroid therapy
E. Anti-diarrheal medications
18. A nurse is caring
for a client with a stage 3 pressure ulcer on the back of the right thigh.
Which of the following are characteristics of a stage 3 pressure? Select all
that apply.
A.
The ulcer looks like a blister
B.
There is partial thickness skin loss of the epidermis
C.
Sinus tracts have developed
D.
There is full thickness skin loss
E.
The skin is intact
19. The medical surgical nurse is
working with an unlicensed
assistive personnel (UAP). The nurse has delegated
the UAP to care for a client with human immunodeficiency virus (HIV). Which
statement by the UAP indicates a correct understanding of the HIV transmission
process? Select all that apply.
A.
“I will implement contact precautions for all care.”
B.
“I do not need to wear any personal protective equipment
because I am not at low risk for occupational exposure.”
C.
“I will wash my hands after toileting the client.”
D.
“I will wear a mask if the client has a cough from a
viral infection”
E.
“I will wear a mask, gown, and gloves if I will come
in contact with splattering blood or body fluids.”
20. A nurse is caring
for a client with rheumatoid arthritis. The client asks the nurse about nonpharmacologic
interventions that could be implemented. Which measures should the nurse
educate the client on? Select all that apply.
A.
Using assistive devices at all times
B.
Massaging inflamed joints
C.
Applying splints in times of increased inflammation
D.
Removing splints in times of increased inflammation
E.
Utilizing range of motion exercises
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