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NUR 202/NUR202 RN VATI from question 90

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90. A nurse is caring for a client who has a chest tube and notes continuous bubbling in the water-seal chamber. Which of the following actions should the nurse take? a. turn down the wall suction ... b. observe the system for an air leak c. obtain a prescription to discontinue the chest tube d. empty the drainage from the collection chamber 91. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care? a. assist the client to a supine position b. recommend prophylactic acyclovir c. initiate droplet precautions for the client d. perform a Glasgow coma scale every 24 hr 92. a nurse is caring for a child who has infectious mononucleosis. Which of the following findings are associated with this diagnosis? a. koplik spots b. splenomegaly c. malaise d. sore throat e. vertigo 93. a nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate nursing action? a. administer chlorpromazine with a loop diuretic b. check orthostatic blood pressure 1 hr after administration c. administer once daily 30 min before breakfast d. check weekly calcium levels 94. 95. a nurse is planning care for a child who is unresponsive and has increased intracranial pressure. Which of the following actions should the nurse take? a. schedule routine oral suctioning b. pad the side rails of the bed c. obtain isolation supplies d. place the child in Trendelenburg position 96. a nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? a. beef liver b. egg whites c. steamed clams d. broiled lobster 97. a nurse is caring for a client who has meningitis. Which of the following assessments should the nurse perform? a. homans’ sign b. trousseau’s sign c. brudzinski’s sign d. chvostek’s sign 98. a nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider? a. respiratory rate 14/min b. blood pressure 150/98 mm Hg c. magnesium 9 mEq/L d. 2+ deep tendon reflexes 99. a nurse is teaching a client who has a new prescription for digoxin. Which of the following statement should the nurse include in the teaching? a. “notify your provider if you experience muscle weakness” b. “report a weight gain of one- half pound per day” c. “expect this medication to increase your blood pressure” d. “you will need to take a diuretic while taking this medication” 100. an infection control nurse is reviewing the medical records of several clients. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention? a. candidiasis b. pelvic inflammatory disease c. MRSA d. syphilis 101. a nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of the following actions should the nurse take? a. maintain the child in a sitting position for 3 min following administration b. administer the drops directly to the center of the eyeball c. apply pressure to the lacrimal punctum for 1 min following administration d. wipe excess medication from the outer canthus toward the nose. 102. a nurse is caring for a client who has schizophrenia. The client states, “run cats spine the rain throwing procedure mechanical paper lake.” The nurse should document that the client is demonstrating which of the following speech alterations? a. echolalia b. word salad c. neolgisms d. clang association 103. a nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document? a. “it expressed my wishes about distribution of my belongings after death.” b. “it designates a family member to make my health care decisions.” c. “it is required for anyone undergoing surgery.” d. “it commuanicated my wishes for end-of-life care.” 104. a nurse is assessing a client who was brought to the ED by hid adult child. The client has visable contusions on all four extremities. Which of the following actions should the nurse take? a. report the incident to Adult Protective Services b. Interview the client with his adult child present c. tell the client he must answer every assessment question d. advise the client to consult a social worker 105. a nurse is planning care for a client who has new diagnosis of dysphagia. Which of the following foods should the nurse recommend? a. apple juice b. oatmeal c. beef broth d. toast 106. a nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognize as the priority finding? a. urinary output of 100 mL in 4 hr b. coughing frothy; pink secretions c. emesis of 110 mL of thick, yellow fluid d. red drainage on the dressing 107. a nurse is caring a client who has a diagnosis of antisocial personality disorder. The nurse should expect the client to demonstrate which of the following? a. magical thinking b. mood swings c. ritualistic behaviors d. poor impulse control 108. a nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? a. hallucinations b. agnosia c. bradycardia d. aphasia 109. 110. a home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first? a. confirm schedule for delivery of supplies b. coordinate interdisciplinary health care services c. demonstrate how to perform the procedure d. clarify the clients actual and perceived health needs 111. a nurse is using nagele’s rule to calculatethe expected delivery date for a newly pregnant primagravida. The first day of the clients last period was October 4. What is the expected delivery date? 0711 112. a nurse is caring for a client who has heart failure and a potassium of 3 mEq/L. the nurse should obtain verification of which of the following prescriptions from the provider? a. digoxin 0.125 mg PO daily b. strict intake and output c. cardiac monitoring d. spironolactone 25 mg PO daily 113. a nurse is teaching a client who is at 35 weeks of gestation about amniocentesis. Which of the following statements should the nurse include in the teaching? a. you should receive terbutaline subcutaneously at the start of the test b. you will need to have a fully bladder at the start of the test c. you will have to stay in the hospital overnight for fetal monitoring after the test d. you should monitor and report the onset of contractions after the test 114. a nurse is assessing a client for pitting edema. When pressing into the dorsal side of the clients foot, the nurse’s fingers leaves a depression in the skin that is 8 mm (0.3in) deep. With which of the following classifications should the nurse document this finding? a. 1+ edema b. 2+ edema c. 3+ edema d. 4+ edema 115. a nurse manager in a community health clinic is reviewing the medical records of clients who have diagnoses of communicable diseases. Which of the following infectious diseases should the nurse report to the Centers for Disease Control and Prevention? a. impetigo b. pneumocystis pneumonia c. HPV d. Hep a 116. a nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take? a. administer antitoxin b. quarantine the client c. monitor the client for a productive cough d. begin prophylactic treatment with ciprofloxacin 117. a nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. encourage the client to gain 2.3 kg per week b. weigh the client once per week throughout hospitalization c. monitor the client for 1 hr after meals d. allow the client to choose meal times 118. a nurse is caring for a client who is receiving gentamicin. Which of the following indicates the client is developing toxicity? a. lethargy b. weight gain c. tinnitus d. blurred vision 119. a nurse is preparing to discharge a newborn who has an atrial septal defect. The nurse should expect the provider to refer the client to which of the following inter professional team members? a. case manager b. physical therapist c. occupational therapist d. nurse manager 120. a nurse is assessing an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect? a. hypertension b. menorrhagia c. hypokalemia d. diarrhea 121. a nurse is reviewing the medical records of four clients. Which of the following prescriptions represent correct documentation? a. atropine 4 mg IV stat b. lorazepam 1.0 IV PRN every 6 hr c. sucralfate 1g PO 1 hr ac d. enoxaparin 30 mg SC every 12 hr 122. a nurse is admitting a client to the medical surgical unit. Which of the following actions should the nurse take first? a. place the clients valuables in the facility’s safe. b. observe the cleints level of mobility c. administer prescribed medications d. electronically enter the prescriptions from the provider. 123. a nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching? a. change clothes after working in the field b. apply petroluem jelly to the nostrils prior to working in the field c. wipe fruits and vegetables from the field with a dry cloth before consuming d. take a hot shower 1 hr after finishing work 124. a nurse is caring for a client who is manic. Which of the following activates is appropriate for the nurse to suggest? a. participating in a basketball game with other clients b. playing a computer game with another client c. taking a daily walk on the hospital grounds d. reading quietly in the room 125. a nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? a. a client who has agonal respirations b. a client who has an open skull fracture and is unresponsive c. a client who has a traumatic arm amputation d. a client who has a fracture of the femur 126. a nurse manage is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching? a. include the complete name of the medication morphine sulfate b. do not use a leading zero to a decimal point c. write the letter U when noting the dosage of insulin d. use the abbreviation QOD when indicating every other day. 127. 128. a community health nurse is caring for a client who requests a referral for family therapy. The nurse should initate a referral to which of the following members of the interdisciplinary team? a. occupational therapist b. social worker c. recreational therapist d. paramedical technologist 129. a nurse on an orthopedic floor is completing the morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)? a. a 24 yr old male who has a casted femur fracture b. a 10 yr old female who has an ulnar fracture in an external fixator c. a 49 yr old male who has multiple rib fractures d. a 62 yr old female who has vertebral fractures due to osteoporosis 130. a nurse is assessing a full-term new born who is 24 hr old. Which of the following findings should the nurse report to the provider? a. the newborns neck is short and surrounded by skin folds b. the newborns glucose level is 50 mg/dl c. the newborns sclera have a yellowish tiny d. the newborn has experienced a weight loss of 3% since birth 131. a nurse on a mental health unit receives report on four clients. Which of the following clients should the nurse attend to first? a. a client who had compulsive behavior and is frequently drinking from the water fountain b. a client who has begun to demonstrate catatonic behavior c. a client who is making sexual comments to clients of the opposite sex d. a client who is having auditory hallucinations and is becoming agitated 132. a nurse is setting up a sterile field for a dressing change on a postoperative client. Which of the following actions should the nurse plan to take to maintain the sterile field? a. select a work surface at the nurses hip level b. drop the items onto the sterile field from a height of 20.3 cm c. open the first flap of the sterile package away from the nurse body d. apply sterile gloves to the non dominant hand first 133. a nurse is teaching the parent of a n infant about manifestations of food allergies. The nurs should identify which of the following findings as a common manifestation of a food allergy? a. vomiting b. dry mouth c. decreased respiratory rate d. hypertension 134. a nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding? a. dry, raised facial rash b. subcutaneous nodules c. hyperuricemia d. polycythemia 135. a nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take? a. inject the medication in the lateral abdominal wall b. expel the air bubbles at the top of the prefilled syringe c. massage the injection site to evenly distribute the medication d. administer an NSAID for injection site discomfort 136. at the beginning of the day shift, a team leader delegates the following tasks to the assistive personnel: bathe four clients, distribute fresh water, and obtain the morning vital signs. At noon the nurse asks the AP to transport one client to physical therapy. The AP reports two clients still need bed baths. Which of the following is an appropriate strategy for the nurse to delegate more effectively in the future? a. plan a reasonable job assignment b. co-assign a more qualified individual to assist the AP c. set a clear time frame for the completion of each task d. volunteer to give the baths for the AP 137. a nurse is caring for a client who is postoperative following a hip arthroplasty and notes the dressing is saturated with sanguineous drainage. Which of the following actions should the nurse take? a. remove the dressing to allow the site to air dry b. cleanse the site with hydrogen peroxide c. reinforce the dressing with sterile gauze d. cover the incision with a transparent dressing 138. a nurse manage at a public health clinic is concerned about the rising number of STI’s in the community. The purpose of which of the following is to generate new ideas to address the public health concern? a. a brainstorming session with nurses b. a community-wide program c. role playing with nurses d. personal discussion with clients 139. a home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory test to determine effective long term management of blood glucose levels? a. 3-hr glucose tolerance test b. HbA1c c. fasting blood glucose test d. urinalysis for ketones 140. a nurse is teaching a client who is to start taking phenelzine for major depressive disorder. Which of the following foods should the nurse teach the client to avoid while taking this medication? a. cheddar cheese b. bananas c. chicken d. peanut butter 141. a nurse is about to administer an injection toa client when the client states. “I don’t want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection the clients wishes. The nurse committed which of the following? a. battery b. assault c. coercion d. a break of duty 142. a nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? a. hyperflexia b. meiosis c. euphoria d. hypothermia 143. a community health nurse is performing a vision screening on a 4 month old infant. When shining a light source into the infants visual field, which of the following Is an expected finding? a. the infants eyes turn toward the light b. the infants head turns away from the light c. the infants eyes remain focused toward the floor d. the infant closes their eyes 144. 145. a nurse is teaching the parent of a school age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of this medication? a. burning b. discoloration c. photosensitivity d. alopecia 146. a nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should take? AEBCD a. assess the appearance of the wound b. place the swab in the culture tube c. cleanse the wound with 0.9% sodium chloride irrigation d. cover the wound with a sterile dressing e. obtain the specimen from granulation tissue of the wound 147. a nurse is caring for a group of clients in an inpatient health facility. Which of the following tasks should the nurse delegate to an assistive personnel? a. obtain the vital signs of a client who has experienced a seizure b. witness a clients signature on an informed consent document c. sit with a client who has anorexia nervosa during meals d. complete an incident report following a client fall 148. a nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? a. generalized edema b. elevated urine specific gravity c. thready pulse d. increase hematocrit 149. at the start of an evening shift on a cardiac unit a license practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? a. constipation b. indigestion c. swollen ankles d. urinary frequency 150. a nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk of metabolic alkalosis? a. a client who has kidney failure b. a client who has severe hyperemesis c. a client who has type 2 diabetes mellitus d. a client who has chronic constipation 151. a nurse is assessing a client who has COPD and experienced recent weight loss. Which of the following findings should the nurse report to the provider immediately? a. a barrel chest b. coughing and wheezing after eating c. abdominal bloating d. a drop in oxygen saturation to 91% while eating 152. a nurse is proving teaching about nutrition to the parents of a preschooler who has chronic renal failure. Which of the following statements by the parent indicated an understanding of the teaching? a. I should encourage my child to eat foods that are high in phosphorous b. I should limit my childs intake of unsaturated fats c. I should encourage my child to eat more foods that contain sodium d. I should limit my childs intake of proteins 153. a nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I should place a rolled blanket along each side of my babys head in the car seat b. I should place my babys car seat rear facing until 6 months of age c. I should put the care seat retainer clip at the level of the babys belly button d. I should position my babys car seat at a 90 degree angle in the care 154. a nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis? a. massage the lower extremities while resting in bed b. place a pillow under the clients knees c. apply venous plexus foot pumps d. encourage client to dangle legs when sitting on the edge of the bed 155. a community health nurse is preparing to collect data to study the health of a local community. The nurse should plan to obtain information about which of the following factors during a windshield survey? a. the availability of religious facilities b. influenza incidence rates the current year c. the leading cause of death for the prior year d. individual perceptions about how residents interact 156. a nurse is assessing the vital signs of a newborn who was born 8 hr ago. Which of the following findings requires intervention by the nurse? a. blood pressure 72/45 mm Hg b. respiratory rate 44/min c. heart rate 156/min d. temperature 36.2 C 157. a nurse on a medical- surgical unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter? a. a female client who is prone to development of blood clots in the urine b. a female client who has a history of chronic urinary tract infections c. a male client who has spontaneous bladder emptying d. a male client who has a postoperative acute urinary retention 158. a nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contractions of the head and neck muscles. Which of the following medications should the nurse administer? a. hydromorphone b. diphenhydramine c. albuterol sulfate d. amitriptyline 159. 160. 161. a nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. Which of the following information should the nurse include in the teaching? a. estrogen therapy decreases the risk for breast cancer b. estrogen therapy increase the risk for thrombus formation c. estrogen therapy can cause weight loss d. estrogen therapy increases the risk for seizures. [Show More]

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