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"The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh Peaches C. Cucumber salad
D. Yeast Rolls - CORRECT ANSWER=> C. Cucumber salad
why? the client with diverticulitis should avoid foods with seeds." "A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet
D. Facilitating perineal wound drainage - CORRECT ANSWER=> D. Facilitating perineal wound drainage
why? the client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illestomy. as in answer A he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this time." "The nurse is performing discharge teaching on a client with diverticulitis who has been placed on low- roughage diet. Which food would have to be eliminated from this client's diet?
A. Roasted Chicken B. Noodles C. Cooked Broccoli
D. Custard - CORRECT ANSWER=> C. Cooked Broccoli
why? the client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli." "The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium still, loss of extracelluar fluid, and initiation
of breast-feeding. - CORRECT ANSWER=> D. The baby can lose up to 10% of weight due to meconium
still, loss of extraceullar fluid, and initiation of breast-feeding. why? After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula" "The nurse if caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea
D. Chronic hiccups - CORRECT ANSWER=> C. Diarrhea
why? Diarrhea is not common in clients with mouth and throat cancer" "A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post- operative measure would usually be included? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube
why? Suctioning can cause a vagal response and bradycardia." "The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client's level of anxiety. B. Evaluation of the client's exercise tolerance C. Identification of peripheral pulses.
D. Assessment of bowel sounds and activity. - CORRECT ANSWER=> C. Identification of peripheral
pulses why? The assessment that is most crucial to the client is identification of peripheral pulses because aorta is clammed during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities." "A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. "You will be sitting for the examination procedure." B. "Portions of the procedure will cause pain or discomfort." C. "You will be given some medication to anesthetize the area."
D. "you will not be able to drink fluids for 24 hours before the study." - CORRECT ANSWER=> B.
"Portions of the procedure will cause pain or discomfort." why? Portions of the exam are painful especially when the sample is being withdrawn so this should be included in the session with the client." "The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue.
D. A hemoglobin level of 12.0 gm/dL - CORRECT ANSWER=> C. A red, beefy tongue
why? A red, beefy tongue is characteristic of a client with pernicious anemia."
"A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Bucks traction
D. An abduction pillow - CORRECT ANSWER=> C. Bucks traction
why? The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain." "A client with caner is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure. B. Ask the client to void immediately before the study. C. Hold medication that affects the central nervous system for 12 hours pre- and post-test.
D. Cover the client's reproductive organs with an x-ray shield. - CORRECT ANSWER=> B. Ask the client
to void immediately before the study. why? The client having an intravenous pyelogram will have orders for laxatives of enemas so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney, ureters, and urethra." "The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement
D. With distant mestastasis - CORRECT ANSWER=> B. That is in situ.
why? Cancer in situ means that the cancer is still localized in the primary site. Cancer is graded in terms of tumor, grade, node, involvement, and mestatasis." "A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
D. A history of the client's food intake - CORRECT ANSWER=> A. A history of radiation treatment in the
neck region why? Previous radiation to the neck might have damaged parathyroid glands, which are located on the thyroid gland and interfered with calcium and phosphorus regulation." "A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression
D. Pyschosis - CORRECT ANSWER=> B. Mania
why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior." "The nurse is obtaining a history of an 80 year old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. "My skin is always so dry." B. "I often use laxatives for constipation." C. "I have always liked to drink ice tea."
D. "I sometimes have a problem with dribbling urine." - CORRECT ANSWER=> B. "I often use laxatives
for constipation." why? Frequent use of laxatives can lead to diarrhea and electrolyte loss." "A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing."
D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened." - CORRECT
ANSWER=> D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened at
all." why?
Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief." "The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves
D. Shoe covers - CORRECT ANSWER=> A. Mask
why? If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate." "The nurse is caring for a client with a diagnosis of Hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers b.i.d. B. Add baby oil to the client's bath water C. Apply powder to the client's skin
D. Suggest a hot water rinse after bathing. - CORRECT ANSWER=> B. Add baby oil to the client's bath
water why? Oil can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin." "A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring
D. Dressing changes 2x per day - CORRECT ANSWER=> B. Insertion of a levine tube
why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated."
A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing
D. Ignore the situation until items are reported missing - CORRECT ANSWER=> B. Report the behavior
to the charge nurse why? The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse." "The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant's assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client's family
D. Initiate a group session with the nursing assistant. - CORRECT ANSWER=> B. Explore the interaction
with the nursing assistant why? The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation." "A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with a laryngeal cancer with a laryngetomy
D. A client with diabetic ulcers to the left foot - CORRECT ANSWER=> C. A client with a laryngeal cancer
with a laryngetomy why? The client with laryngeal cancer has a potential airway alteration and should be seen first." "The nurse is assigned to care from infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increase the infant's fluid intake B. Maintain the infant's body temp at 98.6 F C. Minimize tactile stimulation
D. Decrease caloric intake - CORRECT ANSWER=> A. Increase the infant's fluid intake
why? Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temp is important but will not assist in eliminating bilirubin." "The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A.Maintain the client's systolic blood pressure at 70 mm/Hg or greater B. Maintain the client's urinary output greater than 300 cc/hr C. Maintain the client's body temp of greater than 33 F rectal
D. Maintain the client's hematocrit less than 30% - CORRECT ANSWER=> A. Maintain the client's
systolic blood pressure at 70 mm/Hg or greater why? When the cadaver client is being prepared to donate and organ, the systolic blood pressure should be maintained at 70 mm/Hg or greater to ensure a blood supply to the donor organ." "Which action by the novice nurse indicates need for further teaching? A. A nurse fails to wear gloves to remove a dressing B. The nurse applies the oxygen saturation monitor to the earlobe C. The nurse elevates the head of the bed to check blood pressure D. The nurse places the extremity to a dependent position to acquire a peripheral blood sample -
CORRECT ANSWER=> A. A nurse fails to wear gloves to remove a dressing
why? The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction" "The nurse is preparing the client for a mammogram. To prepare the client for a mammogram, the nurse should tell the client: A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams
D. That mammography requires higher does of radiation than an x-ray. - CORRECT ANSWER=> B. To
omit creams, powders, or deodorants before the exam. why?
A. A client with hypothyroidism B. A client with Chron's disease C. A client with pylonephritis
D. A client with bronchitis - CORRECT ANSWER=> A. A client with hypothyroidism
why? The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet." "The nurse employed in the ER is responsible for triage for 4 clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10 year old with lacerations to the face B. A 15 year old with sternal bruising C. A 34 year old with fractured femur
D. A 50 year old with dislocation of the elbow - CORRECT ANSWER=> B. A 15 year old with sternal
bruising why? The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first." "The client is receiving peritoneal dialysis. If the dialysis returns cloudy the nurse should" A. Document the finding B. Send a specimen to the lab C. Strain the urine
D. Obtain a complete blood count - CORRECT ANSWER=> B. Send a specimen to the lab
why? If the dialysate returns cloudy, infection might be present and must be evaluated" "The client with cirrhosis of the liver is receiving lactulose. The nurse is aware that the ratio for the order of lactulose is : A. To lower the blood glucose level B. To lower the uric acid level C. To lower ammonia level
D. To lower the creatinine level - CORRECT ANSWER=> C. To lower ammonia level
why? Lactulose is administered to the client with cirrhosis to lower ammonia levels." "The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement by the client indicates a need for follow-up after discharge? A."I live by myself." B." I have trouble seeing." C. "I have a cat in the house with me."
D. " I usually drive myself to the doctor." - CORRECT ANSWER=> B. "I have trouble seeing"
why? A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help." "The client is receiving total parenteral nutrition (TPN). Which lab should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose
D. White blood cell count - CORRECT ANSWER=> C. Blood glucose
why? When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose." "The client with a myocardial farction comes to the nurse's station stating that he is ready to go come because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection
D. Conversion reaction - CORRECT ANSWER=> B. Denial
why? The client who says he has nothing wrong is in denial about his myocardial infarction." "Which lab test would be the least effective in making the diagnosis of myocardial infarction?
Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises" "The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. "You will need to lay flat during the exam." B. "You need to empty your bladder before the procedure." C. "You will be alseep during the procedure."
D. "The doctor will injuect a medication to treat your illness during the procedure." - CORRECT
ANSWER=> B. "You need to empty your bladder before the procedure."
why? The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity." "To ensure safety while administering a Nitroglycerin patch, the nurse should: A. Wear gloves B. Shave the area where the patch should be applied C. Wash the area thoroughly with soap and rinse with hot water
D. Apply the patch to the buttocks - CORRECT ANSWER=> A. Wear gloves
why? To protect herself, the nurse should wear gloves when applying a nitroglycerin patch or cream." "A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object B. Rinse the eye thoroughly with saline C. Cover both eyes with paper cups
D. Patch the affected eye only - CORRECT ANSWER=> C. Cover both eyes with paper cups
why? Covering both eyes prevents consensual movement of the affected eye." "The physician has order sodium warfrin ( Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900
B. 1200
C. 1700
D. 2100 - CORRECT ANSWER=> C. 1700
why? Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. this allows for accurate bleeding times to be drawn in the morning." "The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. Secrurity guard B. RN C. LPN
D. The nursing assistant - CORRECT ANSWER=> B. RN
why? The RN is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor." "The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal a pH of 7.36, CO at 45, O2 at 84, HCO3 at 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis C. Compensated respiratory acidosis
D. Uncompensated metabolic acidosis - CORRECT ANSWER=> C. Compensated respiratory acidosis
why? The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be in inverse of the CO2 and bicarb level. This means that if the pH is low, the CO2 and bicarb levels will be elevated." "The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: A. Take blood pressure, pulse, and temp B. Ask the client to rate his pain from 1- C. Watch the client's facial expression
D. Ask the client if he is in pain - CORRECT ANSWER=> B. Ask the client to rate his pain from 1-
"The nurse is caring for a client with cerebral plasy. The nurse should provide frequent rest periods because: A: Grimacing and withering movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest C. Stretch reflexes become more increases with rest
D. Fine motor movements are improved - CORRECT ANSWER=> A. Grimacing and withering
movements decrease with relaxation and rest. why? Frequent rest periods help to relx tense muscles and preserve energy" "The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer's B. A client with pnuemonia C. A client with appendicitis
D. A client with thrombophebitis - CORRECT ANSWER=> A. A client with Alzheimer's
why? The client with Alzheimer's disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living." "A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering a hard candy B. Administering an analgesic medication C. Splinting swollen joints
D. Providing saliva substitue - CORRECT ANSWER=> D. Providing saliva substitute
why? Xerostomia is dry mouth, and offering the client a saliva substitute will help the most." "A home health nurse is making preparations for morning visits. Which of the following clients should the nurse visit first? A. A client with brain- attack (stroke) with tube feeding B. A client with congestive heart failure complaining of nighttime dyspnea C. A client with a thoracotomy 6 months ago
D. A client with Parkinson disease - CORRECT ANSWER=> B. The client with congestive heart failure
complaining of nighttime dyspnea why? The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway si number one in nursing care" "A client with glomerulonephritis is placed on a low sodium diet. Which of the following snacks is suitable for the client with low sodium restritctions? A. Peanut butter cookies B. Grilled cheese sandwich C. Cottage cheese and fruit
D. Fresh peach - CORRECT ANSWER=> D. Fresh peach
why? The fresh peach is the lowest in sodium of these choices" "Due to a high census, it had been necessary for a number of clients to be transferred to another unit within the hospital. Which client should be transferred to the post-partum unit? A. A 66 year old female with gastroenteritis B. A 40 year old female with a hysterectomy C. A 27 year old male with sever depression
D. A 28 year old male with ulcerative colitis - CORRECT ANSWER=> B. A 40 year old female with a
hysterectomy why? The best client to transport to the postpartum units it the 40 year old female with a hysterectomy. The nurses on the postpartum unit will be aware of moral amounts of bleeding and will be equipped to care for this client." "During the change of the shift, the ongoing nurse notes a discrepancy in the number of Perocept (oxycodone) listed in the number present in the narcotics drawer. The nurse's first action should be to: A. Notify the hospital pharmacist B. Notify the nursing supervisor C. Notify the board of nursing
D. Notify the director of nursing - CORRECT ANSWER=> B. Notify the nursing supervisor
why?
