KAPLAN EXIT EXAM V2

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1. The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective? 1. “I should use t... his medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” 2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test? 1. “I take medication to control my blood pressure” 2. “I have had diabetes for about 10 years now” 3. “I had a knee replacement 5 years ago” 4. “I am allergic to penicillin and sulfa medications” 3. The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action? 1. Feed the newborn 30mL of infant formula 2. Administer low flow oxygen to the newborn 3. Wrap the newborn in a warmed blanket 4. Perform a guaiac test on the newborns stool 4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions? 1. Turn the patient from side to side at 2 PM 2. Offer pain medication to the patient at 3:30PM 3. Encourage the patient to use the incentive spirometer at 3PM 4. Cough and deep-breathe the patient at 2:30PM 5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure? KAPLAN EXIT EXAM V2 1. A 50 year old female who is having difficulty with sleeping, eating, and social interaction. 2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20 pounds overweight. 3. A 42 year old female who has problems with decision making who paces continuously, wringing her hands. 4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or sunglasses. (photosensitivity;causes sensitivity to sun) 6. A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following? 1. “Patient complains of rash and itching over most of his body. Patient is concerned about how it looks” 2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch” 3. “Allergic skin reaction to medication experienced by patient. Started several hours ago” 4. “Vital signs stable. Patient scratching arms and chest area frequently” 7. An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions? 1. Schedule an in-service with the staff about emphysema 2. Place a sign above the patient’s bed stating that the oxygen level is not to be changed 3. Tell the patient she will be well cared for in the hospital 4. Convey the patient’s concern to the nursing staff 8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST? 1. “You are 24 weeks pregnant. It is good that you came in for prenatal care” 2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby” 3. “You are 16 weeks pregnant. Let’s talk about what that means” 4. “You are 8 weeks pregnant. Are your periods usually irregular?” 9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions? 1. Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside. 2. Ask the client if she has swallowed the medication completely. 3. Watch the client’s behavior to see if the medication is having its desired effect. 4. Observe the clients throat while she swallows several times after putting the medication in her mouth. 10. The nurse assesses a patient 72 hours after a total joint replacement of the right hip. Which finding requires an intervention by the nurse? 1. There is a pillow between the patients legs 2. The patient’s legs are internally rotated 3. The patients hip joint is flexed at a 70 degree angle when the patient sits in the chair 4. The patient has not requested pain medication for 12 hours. 11. A client newly diagnosed with Meniere’s disease plans a trip to an amusement park with the family. The client asks the clinic nurse which of the following rides is best. The nurse should suggest which of the following rides? 1. Roller coaster 2. Merry go round 3. Ferris wheel 4. Train 12. A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days ago. During discharge teaching, the client asks the nurse “When can I resume sexual intercourse with my wife?” it is best for the nurse to make which of the following statements? 1. “You can resume sexual activity when you feel strong enough” 2. “You can resume sexual activity when you are able to walk one block without chest pain or discomfort” 3. “You may have difficulty maintaining an erection because of your recent surgery” 4. “You should abstain from sexual activity because it may be detrimental to your recovery” (one block or two flights of stairs without chest pain) 13. A woman complains to the nurse about the care provided to her husband by the nursing staff the previous night. Initially, the nurse should take which of the following actions? 1. Ask the wife to voice her expectations about a solution to the problem 2. Gain consensus with the woman on the specific steps that will be taken care for her husband 3. Explain to the wife that the problems she identified will be fixed 4. Notify the wife that everything possible is being done for her husband 14. A patient is restrained bodily by the nursing team. The hands of the nurse assigned to hold down the patients leg should be placed in which of the following positions? 1. One hand on the patients knee and the other hand on the patients ankle 2. One hand directly above the patient’s knee and the other hand directly above the patient’s ankle 3. Both hands side by side on the patients thighs 4. One hand at the patients groin and the other hand at the patients mid-calf area 15. The nurse in the community mental health center works with a client who is diagnosed with depression. Cognitive therapy is initiated. The nurse should take which of the following actions? 1. Assist the client to review past intellectual achievements 2. Help the client develop more positive thoughts 3. Help the client to identify the source of his depression 4. Change the client’s values and beliefs. Cognitive Therapy; determined that how individuals feel and behave is determined by how they think about the world and their place in it. 16. The nurse plans to perform a physical assessment of a young adult who has been deaf since birth. Although the client indicates using sign language, no interpreter is available. The nurse should take which action? 1. Face the client and speak slowly using low-pitched voice 2. Write out each question, and ask the client to write out each answer 3. Sit on the clients right side and use gestures and nonverbal clues 4. Show the client pictures of the parts of the body that will be examined 17. A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The patient has bathroom privileges. The nurse should take which of the following actions? 1. Obtain a bedside commode for the patient to use 2. Provide a warmed fracture bedpan for the patient to use 3. Tell the patient to breathe deeply as he walks to the bathroom 4. Ask the patient sit on the side of the bed before proceeding to the bathroom Answer#4 18. The nurse cares for a patient on the psychiatric unit with a history of drug use and poor impulse control. After the patient’s mother visits, the patient begins pacing rapidly, with arms swinging, and kicking at chair legs. The nurse should approach the patient and take which of the following actions? 1. Sit in a chair several feet away from the patient and lean forward with hands clasped together 2. Stand facing the patient with legs apart, knees locked, and weight on back leg 3. Sit in a chair next to the patient and lean back with arms folded 4. Stand facing the patient, legs together, knees locked, with weight on both legs Answer#2 19. The nurse observes the nursing assistant giving morning care to an elderly client who has an area of warm, reddened skin on the sacrum that does not blanch with pressure. Which action by the nursing assistant requires an intervention by the nurse? 1. The aide cleanses and then applies A and D ointment to the reddened area 2. The aide firmly massages the reddened area in a circular motion 3. The aide placed a piece of sheepskin under the patients sacrum 4. The aide positions the patient on the left side with head of the bed flat Answer#2 (Stage I pressure ulcer, do not massage can damage capillary beds and cause tissue necrosis) 20. The school nurse identifies several children who have food allergies. Which sequence should the nurse teach the staff to follow if an allergic reaction is observed in a child? 1. Call 911, call the physician, administer EpiPen, call the parents 2. Administer the EpiPen, call 911, call the physician, call the parents 3. Call the physician, administer the EpiPen, call 911, call the parents 4. Call the parents, administer the EpiPen, call the physician Answer#2 21. A client comes to the ER complaining of shortness of breath, fatigue, insomnia, and weight loss. The client states that the client’s company forced the client into early retirement. The client says that the client has been sick ever since the client stopped working. The nurse should take which of the following actions first? 1. Encourage the patient to find outlets for his job skills in a consultative or volunteer basis in the community 2. Help the client see a connection between his symptoms and emotions, while i [Show More]

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