A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following

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A nurse is assisting with the plan of care for a client
who has aspiration pneumonia and hypoxia. Which of the following
actions should the nurse plan to take?
Apply petroleum jelly to the clients nares
Initiate fall precautions
Implement contact precautions
Maintain the client in supine position
A nurse is caring for an older adult client immediately
following a bronchoscopy with biopsy. Which of the following is the
priority action the nurse should take?
Document sputum color and consistency
Check for gag reflex
Offer ice chips
Instruct the client to gargle with warm
saline
A nurse is reinforcing health promotion education at a
community health fair. Which of the following statements by
attendees indicates understanding of the teaching?
“I will examine my breasts a week after each menstrual
period”
“I Should get a hepatitis B vaccine on a yearly
basis”
“I do my testicular self-exam every 6 months without
fail”
“The flu shot I received last year will last me for 2
years”
A nurse in a long term care facility is collecting data
from an older adult client. Which of the following findings
indicates that the client might be dehydrated?
Cool clammy skin
Decreased in pulse rate
Increase in blood pressure
Recent onset of confusion
A nurse is collecting data from a client who had a long
arm cast applied 2 hr ago. Which of the following findings of the
affected extremity should the nurse report to the provider
immediately?
The clients fingers are cool to the touch
The clients capillary refill is 3 seconds
The client reports increased pain at the area of the
fracture
The client reports severe itching under the
cast
A nurse in a long term care unit is assisting in the
care of a client who has Alzhiemers disease. Which of the following
actions should the nurse take?
Alternate the clients daily routine
Keep the lights dimmed
Raise the four side rails on the client's
bed
Participate in reminiscence therapy with the
client
A nurse is caring for a client who is postoperative
following a right radical mastectomy. Which of the following
actions should the nurse take to prevent the development of
lymphedema?
Limit range of motion exercises with the affected
arm
Use the clients left arm to obtain blood
samples
Keep both arms below the level of the client's
heart
Obtain blood pressure readings using the clients right
arm
MATH QUESTION
A nurse is assisting the provider with removing a
client's lower leg cast. Which of the following statements by the
nurse is appropriate?
“You can expect leg muscles to look a little
swollen”
“You should avoid elevating your leg while
sitting”
“You should hold still to prevent injury to your
skin”
“You can expect to feel pressure when we cut the
cast”
A nurse on a medical surgical unit is caring for an
older adult client who has developed sepsis due to a urinary tract
infection. A member of the client's family tells the nurse not to
perform any heroic measures to keep the client alive. Which of the
following responses by the nurse is appropriate?
“The client's condition is not critical enough to
discuss these issues”
“Let me check the client's medical record for advance
directives”
“You should contact the clients attorney to document
your wished legally”
“Why do you believe treatment would not benefit the
client”
A nurse is planning care for a client who is
receiving radiation therapy to treat throat cancer and reports a
change in the taste of food. Which of the following interventions
should the nurse include in the plan of care?
Offer artificial saliva frequently
Add honey to sweeten fruit smoothies
Heat before serving
Provide three large meals daily
A nurse working the night shift is caring for an older
adult client who has dementia anf is at risk for falls. Which of
the following actions should the nurse take?
Raise all four side rails while the client is in
bed
Apply a motion sensor mat to the clients
bed
Leave the television on in the clients room
Move the overbed table away from the bed
A nurse is reinforcing teaching with a client about
increasing her intake of fiber. Which of the following foods should
the nurse encourage the client to eat?
Cheese
Pears
Yogurt
Eggs
A nurse is reviewing the medical record of a client who
reports his urine is red-orange. The nurse should identify that
which of the following medications can cause this adverse
effect?
Isoniazid
Metoprolol
Furosemide
Rifampin
A nurse is caring for a client in hospice care who is
dying. The client's partner expresses concern that the client is
sleeping more than in the previous week. Which of the following is
an appropriate response by the nurse?
“Encourage your partner to wake up to interact with
family members”
“Sitting quietly near the bedside can provide comfort
and support”
“I will call the provider to discuss your
concerns”
“I can ask the provider to prescribe a medication that
will minimize drowsiness”
A nurse is reinforcing teaching with a client who is
postoperative following a tympanoplasty. Which of the following
information should the nurse include?
Drink fluids through a straw
Plan to shampoo hair in 1 week
Resume exercising in 10 days
Close mouth when sneezing
A nurse is reinforcing discharge teaching about dietary
changes with a client who has a new colostomy. Which of the
following foods should the nurse recommend?
Asparagus
Bananas
Grapes
Broccoli
A nurse is caring for a client who has diabetes
mellitus. Which of the following laboratory results should the
nurse report to the provider?
Glycosylated hemoglobin 5.2%
Urine positive for ketones
Urine negative for bilirubin
Fasting blood glucose 70 mg/dl
A nurse is caring for an older adult client who has
heart failure. Which of the following findings should the nurse
report to the provider?
Urinary output of 1000 mL in 12 hr
Potassium level 4.5 mEq/L
PaCO2 55 mm Hg
Chest x-ray showing cardiomegaly
A nurse is caring for a client who has diabetic
neuropathy of the lower extremities and has a new prescription for
a heating pad. The prescription reads, “Apply to the left foot for
20 min.” Which of the following actions should the nurse
take?
Complete Semmes-Weinstein monofilament testing following
treatment
Apply the heating pad as prescribed by the
provider
Clarify the prescription with the provider
Observer the skin 10 min after the start of
treatment
A nurse is reinforcing teaching with a client who has a
new colostomy. Which of the following statements by the client
indicates an understanding of the teaching?
“I should clean around the stoma with moisturizing
soap”
“I should avoid broccoli and chewing gum”
“I should decrease the amount of fresh fruit in my
diet”
“I should place an aspirin in the pouch to eliminate
odor”
A nurse is collecting data from a client who has a newly
placed colostomy. Which of the following findings should indicate
to the nurse the client has accepted their new altered body
image?
Denies feelings of sadness about the ostomy
Prefers not to look at the stoma site
Accepts that sexual activity will decrease
Participates in performing ostomy care
A nurse is reviewing the laboratory data of a client who
is scheduled for a liver biopsy. Which of the following values
should the nurse report to the provider?
Ammonia 55 mcg/dL
Bilirubin 1.0 mg/dL
Platelets 60,000/mm3
Aspartate aminotransferase 34 units/L
A nurse is assisting with the plan of care for a client
who requires contact precautions. Which of the following
interventions should the nurse include in the plan?
Keep a stethoscope at the client's bedside for the
duration of her hospital stay
Wear N95 mask when entering the room
Use an alcohol swab to clean the temperature probe
before removing it from the room
Remove personal protective equipment immediately after
leaving the clients room
A nurse is caring for a client who has a prescription
for propranolol for the treatment of atrial fibrillation. Which of
the following actions should the nurse take?
Request a dosage increase if the apical heart rate is
less than 60/min
Administer the medication with an antacid
Instruct the client to expect increased hair
growth
Withhold the medication if the systolic blood pressure
is than 90 mm Hg