Nuchal rigidity (neck stiffness), photophobia (intolerance of bright light) and headache.
180. A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial
meningitis. Which of t
...
Nuchal rigidity (neck stiffness), photophobia (intolerance of bright light) and headache.
180. A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial
meningitis. Which of the following findings should the nurse expect?
179. A nurse is planning client care for a shift. Which of the following should the nurse plan to delegate to an assistive personnel?
d. Ambulating a client receiving patient-controlled analgesia.
178. A nurse is reinforcing teaching to an adult client who is prescribe Lipitor. The nurse should advise the client that which of the following is an adverse effect of this medication and should be reported to the provider?
b. Unexplained muscle pain
177. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
a. Dependent edema
A pregnant client presents with bright red painless vaginal bleeding at 30 weeks. What should the nurse plan to assess for?
a. Placenta previa
b. Placental abruption
c. Cervical dilation
d. Cervical tears
a. Placenta previa
The new graduate nurse on a surgical oncology floor is reviewing osteosarcoma signs and symptoms. Which of the following findings does the nurse review that can be seen in a client with osteosarcoma? Select all that apply
a. Localized acute pain
b. increased range of motion
c. gait disturbance
d. increased appetite
e. palpable mass
a. Localized acute pain-e. palpable mass-. c. gait disturbance
A client with COPD is receiving care at the primary provider's clinic with worsening of symptoms of emphysema. The provider orders an outpatient chest xray to determine if there have been any changes in lung structure. Which best describes what would show on a chest x-ray in the later stages of emphysema?
a. increase size of heart
b. flattened diaphragm
c. plaque formation scattered throughout the lung
d. mediastinal shift to the right
b. flattened diaphragm
A client presents for the care of a primary care facility. The client is coughing and has a fever of 102. Which statement from the nurse regarding protective equipment is most appropriate in preventing the potential spread of this client's infection?
a. please wait while I put on a mask before taking your vital signs
b. I'm sorry, but you cannot come in here with your symptoms
c. you will need to wear a mask, gown, and gloves while you wait to see the doctor
d. you will need to wear a mask while you wait to see the provider
you will need to wear a mask while you wait to see the provider
The nurse speaking to parents about treating head lice advises that any children with allergies to which of the following should avoid using permethrin 1%?
a. ragweed
b. strawberries
c. grass and hay
d. peanut butter
a. ragweed
A client has developed a reaction after receiving a blood transfusion. The nurse suspects that it is a bacterial reaction due to a contaminated blood product. Which of the following signs or symptoms would the nurse see with this type of reaction? Select all that apply
a. hypertension
b. distended neck veins
c. vomiting
d. nausea
e. fever and chills
c. vomiting
d. nausea
e. fever and chills
A nurse assessing a four-year-old's language development knows to be concerned by which one of the following assessment findings?
a. speech that is unintelligible
b. repeating the same question many times until the child gets an answer
c. frequent imitation of words that the child is unfamiliar with
d. the ability to form sentences of about three to four words
a. speech that is unintelligible
Which best describes the difference between a do-no-resuscitate (DNR) order and an advanced directive?
a. an advance directive is a medical order, while a DNR is not
b. A DNR is a medical order, while an advance directive is not
c. An advance directive needs to be removed, but a DNR does not
d. An advance directive cannot be revoked, while a DNR can be revoked
b. A DNR is a medical order, while an advance directive is not
A 58 year old client has been admitted to the hospital for treatment of septic arthritis. Which of the following is NOT a risk factor for this condition?
a. poorly controlled diabetes
b. an artificial joint implant
c. taking medications for rheumatoid arthritis
d. a history of femur fracture
d. a history of femur fracture
A nurse is admitting a 70-year-old client for the treatment of pneumonia. The nurse notes the client is in distress about being in the hospital. Which of the following areas are common psychosocial concerns for older adults? Select all that apply
a. adjustment to deteriorating physical health
b. fear of loss of independence
c. dependence on government programs
d. adjusting to retirement
e. coping with the loss of loved ones
a. adjustment to deteriorating physical health
b. fear of loss of independence
c. dependence on government programs
d. adjusting to retirement
e. coping with the loss of loved ones
A nurse is giving education on completing a breast self-exam to a client who appears uneasy. Which of the following is the most appropriate action for the nurse to do next?
a. discuss the purpose of self-exam
b. acknowledge the uneasiness and address it
c. tell the client there is nothing to worry about
d. continue giving the education
b. acknowledge the uneasiness and address it
which best describes the order in which the nurse should assess a client's abdomen?
a. inspection, auscultation, percussion, palpation
b. inspection, palpation, percussion, auscultation
c. percussion, inspection, palpation, auscultation
d. auscultation, palpation, percussion, inspection
a. inspection, auscultation, percussion, palpation
A nurse must move the medication cart on the unit from one end of the hallway to the other. Which principles would the nurse utilize in order to best stay protected from being injured while pushing this cart? Select all that apply
a. keep the elbows close to the body
b. keep an eye out for obstacles in the way of the cart
c. push with the shoulders and upper back instead of the arms and legs
d. assess the weight of the cart before pushing it
e. if possible, pull the cart instead of pushing it
d. assess the weight of the cart before pushing it
Which of the following medications lower blood pressure by decreasing the volume of blood in the body?
a. beta-adrenoreceptors
b. ACE inhibitors
c. Calcium channel blockers
d. diuretics
d. diuretics
A nurse is caring for a postpartum client with a suspected DVT in one leg, what symptoms would be indicative of this? Select all that apply
a. left calf 3 cm larger than right
b. bilateral leg edema
c. discoloration of the leg
d. cold foot on affected leg
e. pedal pulses 1+ bilaterally
b. bilateral leg edema
A client has been diagnosed with stress incontinence and has frequent episodes of leaking urine. Which of the following nursing interventions are most appropriate in this situation? Select all that apply
a. examine the client for signs of pelvic muscle weakness
b. teach the client how to perform intermittent catheterization
c. help the client to use an anti-incontinence device
d. collect a urine sample to test for infection
e. teach the client to perform Kegal exercises
a. examine the client for signs of pelvic muscle weakness
c. help the client to use an anti-incontinence device
d. collect a urine sample to test for infection
e. teach the client to perform Kegal exercises
A nurse is caring for a client who recently had an NG tube placed. Before starting the first enteral feeding, the nurse wants to check for proper placement. Which of the following techniques is most appropriate to confirm placement?
a. ask the client to open his mouth and check the back of the throat
b. drawback a small amount of gastric fluid and test the pH
c. inject 10 ml of air into the tube while auscultating over the abdomen
d. inject 10 ml of normal saline into the tube and listen over the chest
b. drawback a small amount of gastric fluid and test the pH
A nurse is preparing to give blood products to a client who is experiencing excess bleeding after surgery. Prior to administration, which action should the nurse perform first?
a. ensure that there is an order for the transfusion
b. gather appropriate equipment for blood product administration
c. document the client's vital signs
d. prime the IV tubing with NS
ensure that there is an order for the transfusion
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