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3-A client who is one day postpartum tells nurse that her baby cannot catch onto the breast. The nurse determines that the client nipples are inverted. Which action should the nurse implement? a) Rec... ommending using breast shield b) Offer supplemental formula feeding c) Teach about the use of a breast pump d) Encourage the use of ice on the areola Ans; A 6- The mother of a school age child calls the school to ask when her daughter can return to school after treatment for pediculosis capitis. What is the nurse best respond?(nits liendra) a) Until all lice are dead b) Until the epidemic in school subside c) Stay in home. ANS; A 10- The mother of the 7 month old bring the infant to the clinic because the skin in the diaper area is and red, but there are no blister or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a) Instruct the mother to change the child’s diaper more often. b) Tell the mother to cleanse with soap and water at each diaper change c) Encourage the mother to apply lotion with each diaper change. d) Ask the mother to decrease the infant’s intake of fruits for 24 hours ANS; A 12- When conducting discharge teaching of an older client. Which instruction regarding medication administration should the nurse include? a) The direction of the prescription container can be enlarge for including b) Medication should be moved for a similar condition that made... in the future c) Don’t share meds with family and friend (older people like to share medicine) ANS; C 15- A client was admitted to the cardiac observation unit 2 hour ago complaining of chest pain, On admission the client’s EKG showed bradycardia, ST depression, but no ventricular ectopic. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What interventions should the nurse perform? a) Notify the healthcare provider of the client’s increased chest pain and call for the defibrillator crash cart. b) Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels c) Administer prescribed morphine sulfate IV and provide oxygen at 2L/minute per nasal cannula d) Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock ANS; C 16-Which intervention should the nurse include in the plan of care for tetanus.... a) Open the window shades toprovide natural light b) Encourage coughing and deep breathing. c) Minimize the amount of stimuli in the room d) Reposition from side to site every hour. ANS; B or C ojo, I put C 23- The nurse who is working on surgical unit receives change –of –shift report on a group of clients for the upcoming shift .The client with which description requires the most immediate attention by the nurse? a) Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain b) Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. c) Abdominal –resection 2 days ago with no drainage on dressing who has fever and chills. d) Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container. ANS; D , I put C 29- A client experiencing withdrawal from the Benzodiazepine alprasolan (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? a) Administer Narcan PRN protocol b) Obtain serum drug screen c) Instruct the family about withdrawal symptom d) Initiate seizure precautions ANS; D 34- The nurse is feeding a client who was admitted this morning with syncope and generalized weakness .The client has a history of aspiration and begins coughing while attempting to drink trough a straw. Which action should the nurse implement? a) Elevate the head of bed for 30 minutes after meal b) Perform oral care before meals c) Allow small amount of liquid with meals d) Provide nectar thickened liquids ANS; D, I put A 39- A HOME HEALTH NURSE IS VISITING A CLIENT WITH A HISTOY OF HEART FAILURE (HF) WHEN INTERVIEWING THE CLIENT, WHICH QUESTION PROVIDES THE MOST USEFUL INFORMATION FOR THE NURSE. A) – HAVE YOU HAD ANY HEADACHES LATELY? B) HOW MUCH CAFFEINE ARE YOU DRINKING C) HAVEYOU BEEN WEIGHING YOURSELF ONCE A MONTH D) HOW MANY PILLOWS DO YOU SLEEP ON AL NIGHT ANS; D 43- The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction following administration of ampicillin (omnipen-N). What instruction is essential for the nurse to provide this client prior discharge? A-Teach the client how to self-administer epinephrine in cases a reaction occur again B- Instruct the client to wear a medic-alert bracelet so penicillin will not be given again C- Tell the client to make medication with food to decrease will not be given again D- Inform the client that it is essential to take all of the prescribed ampicillin AnS: B 50- A CLIENT WITH A PRESCRIPTION FOR “DO NOT RESUSCITATE (DNR) BEGING TO MANISFEST SINGS OF IMPENDING DEATH. AFTER NOTIFYING OF THE CLIENT STATUS , WHAT PRIORITY ACTION SHOULD THE NURSE IMPLEMENT ? A) THE CLIENT NEED FOR PAIN MEDICATION SHOULD BE DETERMINED B) THE NURSE MANAGER SHOULD BE UPDATED ON THE CLIENT STATUS C) THE IMPENDING SINGOF DEATH SHOULD BE DOCUMENTED D) THE CLIENT STATUS SHOULD BE CONVEYED TO THE CHAPLAIN ANS; A One of them was which medication will you question to administer through a PEG tube Only one that made sense to question was enteric coated aspirin because that one you cant crush 55-WHAT INSTRUCTION SHOULD THE NURSE PROVIDE TO A CLIENT WHO IS PREPARING TO HAVE A CYSTOSCOPY a) LAY PRONE FOR 24 HOURS AFTER THE PROCEDURE b) REPORT ANY PAINFUL URINATION, BLOOD URINE ,OR FEVER c) AVOID STRENUOUS ACTIVITY AND SPORTS FOR AT LEAST 2 WEEK d) REPORT ANY ALLERGIES TO SHELLFISH OR IODINE ANS; B 60- An adult male report that the last time he received penicillin he developed a severe maculapapular rash all over his chest. What information should the nurse provide to this client? A) Watch daily urine output and weight gain while taking antibiotic B) Be alert for possible cross-sensitivity to cephalosporin agents. C) Wear sun block and protective clothing to avoid exposure to sun ANS; B 61- A client who had a right hip replacement 3 days ago is pale has diminished breath sounds over the left lower field ,a temperature of 100.2 F, and oxygen saturation rate of 90% . The client is scheduled to be transferred to a skilled nursing facility tomorrow for rehabilitative critical pathway .Based on the client symptoms .What recommendation should the nurse give the healthcare provider? a) Reassess readiness for skilled nursing facility (SNF) transfer. b) Confer with family about home care planes. c) Arrange physical therapy for strengthening. d) Obtain specimens for culture analysis ANS; A 64- The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, mouth drooping, and aspiration pneumonia .What is the priority nursing assessment that she will be done before administering the med? a) Determine what side of the body is weak b) Auscultate breath sounds c) Obtain and record client vital sign d) Ask the client about soft food preferences ANS; A 65- A client with diagnostic of schizophrenia sits in the day room and fails to interact which others .which intervention is best for the nurse to implement with this client? a) Complete and assessment of social support b) Encourage the client to have lunch off the unit C) Give the client a schedule of planned daily activities d) Engage the client in a game of cards ANS; D [Show More]

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