Exam Review

Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.(SATA)
A)Screen for orthostatic hypotension
B)Provide oral care at least twice a day
C)Monitor calcium levels
D)Assess mental status regularly
E)Assist the client to the bathroom
F)Have an opioid agonist at the bedside
Patient Data What other treatments might be helpful for this client? Select all that apply.(SATA)
A)Phototherapy
B)Administration of lithium
C)Consciousness-raising
D)Cognitive behavioral therapy
E)Animal therapy
F)Electroconvulsive therapy
A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dL (18 mmol/L). The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which intervention(s) should the nurse implement? (Select all that apply.) Reference Range Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)](SATA)
A)Have the client demonstrate technique used to monitor blood glucose levels.
B)Evaluate the client's asthma medications that can elevate the blood glucose.
C)Ask the client if they want a different manufacturer's glucose monitoring device.
D)Have the client describe a typical day at work, home, and social activities.
E)Determine if the client is using a new insulin needle each administration.
A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg intravenously to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

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Exam Review

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]
A)Assess urine and stool for occult blood.
B)Obtain client's temperature every 4 hours.
C)Monitor for signs of activity intolerance
D)Require visitors to wear respiratory masks.
An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each dose? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)
An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)(SATA)
A)Obtain the client's tympanic temperature measurement.
B)Review the client's current food and medication allergies.
C)Ask if the client is experiencing any pain with urination.
D)Encourage increasing the intake of high protein foods.
E)Determine if the client has recently experienced a fall.
The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?
A)A 12-year-old reporting neck, arm, and lower back discomfort.
B)An 8-year-old with a full leg air splint for a possible broken tibia.
C)A 6-year-old with multiple superficial lacerations of all extremities.
D)An 11-year-old with a headache, nausea, and projectile vomiting.

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Exam Review

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?
A)Refer the parents to the chaplain to provide grief counseling.
B)Tell the parents that blaming each other will not change the situation
C)Assure the parents that a terminal diagnosis is inevitable.
D)Explain to the parents that anger is a common response to grief.
When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?
A)Observe for swelling at the fracture site.
B)Analyze the cardiac rhythm in another lead.
C)Obtain a 12-lead electrocardiogram.
D)Begin chest compressions at 100/minute.
A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?
A)Remove electrodes and observe for skin redness.
B)Decrease the strength of the electrical signals.
C)Check the amount of gel coating on the electrodes.
D)Determine if the sensation feels uncomfortable.
The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?
A)New screening protocols were developed, validated, and implemented.
B)Clients who incurred disease complications promptly received rehabilitation.
C)Average client scores improved on specific risk factor knowledge tests.
D)More than half of at-risk clients were diagnosed early in their disease process.

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Exam Review

An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. Vital Signs Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60 Arterial blood gases (ABGs) Ph- 7.34 PaCO2- 34 mmHg HCO3- 20 mmol/L pO2- 90 mmHg Electrolytes Results Sodium 130 mEq/L(mmol/L) Potassium 2.5 mEq/L (mmol/L) Chloride 95 mEq/L (mmol/L) Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)] Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] Chloride [98 to 106 mEq/L (98 to 106 mmol/L)] PaCO2 [35 to 45 mm Hg] HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg) The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)
A)Initiate continuous dopamine infusion at 2 mcg/kg/minute.
B)Administer promethazine 25 mg slow intravenous (IV) push every 4 hours.
C)Begin potassium chloride 10 mEq over 1 hour per secondary infusion.
D)Give a bolus of 0.9% sodium chloride 1,000 ml over 30 minutes.
The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?
A)New screening protocols were developed, validated, and implemented.
B)Clients who incurred disease complications promptly received rehabilitation.
C)Average client scores improved on specific risk factor knowledge tests.
D)More than half at risk clients were diagnosed early in the disease process
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?
A)A salad with three kinds of lettuce and fruit.
B)Vegetable soup, crackers, and milk.
C)A peanut butter sandwich with soda and cookies.
D)A tuna fish sandwich with chips and ice cream.
A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?
A)Encourage the use of ice on the areola.
B)Teach about the use of a breast pump.
C)Offer supplemental formula feedings.
D)Recommend using a breast shield.
E)None
F)None

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Exam Review

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
A)Diapering will be provided since hospitalization is stressful to preschoolers.
B)A retraining program will need to be initiated when the child returns home.
C)A potty chair should be brought from home so he can maintain his toileting skills.
D)Children usually resume their toileting behaviors when they leave the hospital.
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
A)A salad with three kinds of lettuce and fruit.
B)Vegetable soup, crackers, and milk.
C)A peanut butter sandwich with soda and cookies.
D)A tuna fish sandwich with chips and ice cream.
In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? Reference Range: Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]
A)Hematocrit of 28% (0.28 volume fraction).
B)Heart rate of 92 beats per minute.
C)Systolic murmur.
D)Elevated thyroid hormone level.
After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)(SATA)
A)Red blood cell count (RBC).
B)Core body temperature.
C)Swollen lymph nodes in the groin.
D)Location of the initial intravenous (IV) site.
E)White blood cell count (WBC).

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Exam Review

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?
A)Discuss that partners without similar symptoms may not be infected.
B)Answer questions directly and correct any misinformation.
C)Provide counseling that most contraceptives protect against infection.
D)Notify that persons with STIs are reported to local health departments.
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?
A)Have the client vocalize the instructions provided.
B)Provide written instructions for eye drop administration.
C)Speak clearly and face the client for lip reading.
D)Ensure that someone will stay with the client for 24 hours.
An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)(SATA)
A)Place a bedside commode next to bed.
B)Measure neurological vital signs every 4 hours.
C)Suction oral cavity every 4 hours.
D)Encourage family to participate in the client's care.
E)Play classical music in room while client is
A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?
A)Dizziness reported after initial dose.
B)A change in the sleep-wake cycle.
C)Mild sedation.
D)Somnambulism.

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