Deck 1: American Association of Colleges of Nursing (AACN) Clinical Nurse Specialist

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Question
Nina the New Nurse has assessed a new client, admitted for sudden altered level of consciousness (ALOC). She also reviewed the current lab results, which are as follows: Na+ 156
CL- 100
K+ 4.0
HCO 21
BUN 86
Bld) Glucose 100
Nina the New Nurse is entering a nursing diagnosis on the care plan based on the information she has gathered. Which nursing diagnosis is most appropriate?

A)Fluid volume deficit.
B)Self-care deficit: feeding.
C)Alteration in urinary elimination.
D)Trick question! There isn't enough information provided in the above scenario to determine a nursing diagnosis!
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Question
After a complete bowel rest, a client is prescribed a clear liquid diet. The nurse making the dietary plan for the client keeps in mind that a clear liquid diet consists of the following except:

A)Bouillon
B)Gelatin
C)Milk
D)Coffee
Question
A nurse is assessing a newly-admitted client. Assessment reveals that the client has muscle weakness, muscle spasticity, and an unsteady gait. Based on the findings, which of the following is the most appropriate nursing diagnosis?

A)Activity intolerance
B)Impaired physical mobility
C)Risk for impaired skin integrity
D)Self-care deficit
Question
A high-fiber diet is thought to reduce the risk of colon cancer because it:

A)absorbs water from the intestinal wall.
B)promotes the excretion of bile.
C)stops diarrhea.
D)is low in kilocalories.
Question
Which of the following diets is suggested for the client with AIDS?

A)High calorie, high fat
B)High calorie, high carbohydrate
C)Low calorie, low protein
D)High calorie, high protein
Question
Nina the New Nurse loves her job! She is working on the medical/surgical. unit, and has received reports on the clients she will care for from the off-going shift. She is prioritizing her first rounds of the day. Which of the following clients should Nina the New Nurse see first?

A)55-year-old female, right mastectomy two days ago; Jackson-Pratt draining serosanguineous fluid, 23cc for last shift.
B)25-year-old male, gunshot wound to left thigh; 2.5cm area of dark drainage observed on dressing.
C)58-year-old male, abdominal-perineal resection 4 days ago; complaining of chills.
D)30-year-old female, hysterectomy 3 days ago; complaining of pain.
Question
Hank Smith, a 36-year-old bartender, was admitted for a total cystectomy with creation of an ileal conduit. Hank was diagnosed with a bladder tumor six months ago. While emptying and cleaning the stoma, the nurse is incorrect when she does which of the following?

A)Maintains an aseptic technique all throughout the procedure.
B)Changes the urine collection appliance on a timely schedule.
C)Instructs the client to sit upright on the bed.
D)Changes the appliance during early morning.
Question
Nina the New Nurse was floated to a unit she was unfamiliar with. Wanting to be helpful and thought of as a team player, she accepted a very heavy assignment. According to the ICN Code of Ethics for Nurses, which of the four principle elements did Nina the New Nurse violate?

A)Nurses and people
B)Nurses and practice
C)Nurses and co-workers
D)Nurses and the profession
Question
A nurse is caring for Mr. Kline, a 56-year-old client who was admitted because of esophageal cancer. A gastrostomy tube (PEG) was inserted six weeks ago. During assessment, the nurse notes reddish color and swelling around the insertion site. The most appropriate action of the nurse is to:

A)Clean the insertion site with normal saline solution and cover with sterile gauze.
B)Notify the physician immediately.
C)This is expected during the first few weeks after a creation of PEG, and she can continue feeding.
D)Flush the PEG with cold water to soothe the irritated insertion site.
Question
In an upper respiratory tract infection, secretion of copious amounts of mucus can affect a client's appetite. Which of the following interventions can best help increase the palatability of food for a client with an upper respiratory infection?

A)Increase oral fluid intake.
B)Offer oral care before eating.
C)Offer citrus juice before eating.
D)Remove sputum containers and trash from the eating area.
Question
A 20-year-old male client with a BMI of 33 has been admitted for recurrent chest pains and difficulty breathing. During the assessment, it is found that his father and mother both suffered from myocardial infarction before the age of 50. Which of the following nursing actions is the first step to prevent the client from having a myocardial infarction?

A)Encourage the client to initiate and maintain a regular exercise program.
B)Instruct the client to avoid fatty and high-calorie meals.
C)Assess the client's level of interest in weight reduction programs.
D)Educate the client about the risks of obesity and myocardial infarction.
Question
What is meant by the term values?

A)The belief that something is completely right or wrong, at all times.
B)Principles based on experience, culture, religion, and education that influence decisions and/or behavior.
C)Principles or standards influencing professional conduct.
Question
After receiving the client assignments for the day, which client should the nurse assess first?

A)A client newly diagnosed with Parkinson's disease preparing for discharge
B)A client scheduled for arthroscopy in two hours
C)A client requiring wound dressing changes
D)A client receiving oxygen who demonstrated labored breathing during the previous shift
Question
A nurse assesses the cranial nerves of a client with head trauma. The nurse assesses cranial nerve VIII by performing which of the following?

A)Checking the client's visual fields
B)Eliciting the gag reflex
C)Observing for swaying when walking
D)Asking the client to identify substances by their tastes
Question
A nurse is teaching a 75-year-old client how to use an aluminum walker appropriately. Which of the following techniques are accurate?

A)The client lifts and moves the walker forward, steps forward with the good leg, followed by the affected leg.
B)The client lifts and moves the walker forward 10 inches, and steps forward with the affected leg first, followed by the good leg.
C)The client pushes the walker forward as the walker bears the weight of the client.
D)The client glides the walker forward 18 inches and swings both legs forward.
Question
During a staffing crisis, the nurse manager decides that the most efficient nursing modality to implement is:

A)Primary nursing
B)Functional nursing
C)Team nursing
D)Case management
Question
A nurse is on the elevator when she overhears a group of medical interns discussing the case of a male client who was found to be positive for human immunodeficiency virus. The nurse knows that which client right might have been breached?

A)Right to continuity of care
B)Right to refuse treatment
C)Right to refuse third-party interference in their medical care
D)Right to be treated confidentially
Question
A client has an indwelling urinary catheter. Which of the following nursing interventions is best to prevent bladder infections?

A)Irrigate the catheter with sterile saline solution twice daily.
B)Encourage the client to take showers and prevent tub baths.
C)Restrict fluid intake.
D)Open the drainage system once daily.
Question
An elderly client with a swallowing disorder is at increased risk for aspiration. Which of the following is an inappropriate nursing action?

A)Encourage the client to increase consumption of full-fat milk products
B)Dentures are securely worn while eating
C)Syringes are avoided when feeding the client
D)The client is placed in semi-Fowler's during feeding and for 30 minutes thereafter
Question
Nina the New Nurse is preparing to receive a client who will be transferred from the recovery room to her unit. The recovery room nurse reports the client is awake and alert after colon surgery and vital signs are stable. The patient has no complaints of pain or nausea and has an NG tube to low suction draining serosanguineous fluid. Nina the New Nurse's team is very busy now; she is trying to determine which task can safely be delegated to the nursing assistant on her team. Which of the following tasks can safely be delegated to the nursing assistant?

A)Observe the color and record the amount of drainage collected by the NG tube.
B)Measure and record vital signs every two hours.
C)Irrigate NG tube as needed.
D)Perform mouth care, and skin care to nares, as needed.
Question
A 39-year-old male client, brought to the Emergency Department after sustaining a traumatic brain-stem injury during a football game, has died. You have met with the family about the possibility of organ and tissue donation, and they are considering the option. You are showing an awareness of his role in providing care for this family by (select all that apply):

A)Using the client's name rather than the word "donor" when speaking with the family.
B)Providing care to the deceased in a respectful and caring manner.
C)Explaining the time limitations associated with the most effective "harvest" to the family.
D)Encouraging family members to seek advice from other family members. Provide privacy for family to confer if necessary.
Question
By returning to a client's room at the time promised, the nurse is demonstrating:

A)Confidentiality
B)Beneficence
C)Veracity
D)Fidelity
Question
You are caring for a 55-year-old client experiencing mid-sternal chest pain. What is the priority nursing action for this client?

A)Auscultation of the chest and lungs
B)Getting a complete history, along with questioning the events preceding the start of the pain
C)Taking a complete set of vitals
D)Starting an IV and administering analgesics
Question
A nurse is caring for a female client who complains of easy fatigability and weakness. Laboratory tests reveal that the client has an iron-deficiency anemia. History reveals that the client is a practicing vegetarian. Which of the following food items is correctly included in the client's daily diet to correct iron-deficiency anemia?

A)Brewer's yeast
B)Raisins
C)Soybean milk
D)Banana
Question
A nurse gathered the assessment findings from a group of clients assigned to her during the shift. Among the details of information she noted, which of the following is most likely attributed to poor hygiene care?

A)Dry and flaky skin over the ear and scalp
B)Reddish skin that doesn't blanch when touched.
C)Dry, itchy and highly demarcated scaling plaques.
D)A reddish rash on the wrist underlying a watch strap
Question
What is the most fundamental principle of professional behavior?

A)Respect for persons
B)Justice
C)Respect for autonomy
D)Beneficence
Question
A 35-year old client says that both of her parents were diagnosed with hypertension and that she is afraid that she might get it as well. Although the client is not demonstrating any sign of the disease, what should the nurse include in her home care teaching to help the client prevent hypertension?

A)Maintain a regular exercise program, consisting of moderate aerobic exercises.
B)Increase her intake of foods rich in sodium
C)Get rid of all forms of stress right away
D)Teach the client how to obtain her blood pressure measurement
Question
A nurse is caring for a client with genital herpes. The nurse uses which of the following measures to promote comfort?

A)Instructing the client to wear loose cotton underwear
B)Application of hydrogen peroxide solution over the lesions
C)Application of lubricants to lesions
D)Application of warm compresses
Question
Which of the following is the number 1 modifiable risk factor for stroke?

A)Diabetes
B)Hypertension
C)Hypotension
D)Congestive heart failure
Question
What kind of ulcers are usually formed as a result of the chronic usage of nonsteroidal anti-inflammatory drugs?

A)Esophageal
B)Jejunal
C)Duodenal
D)Gastric
Question
A client was rushed in due to severe abdominal pain unrelieved by repositioning. Assessment shows a high fever and yellowish hue of the skin. The client's friends reported that they had been drinking hard liquor the whole night. The client was diagnosed with pancreatitis. The nurse understands that pancreatitis is caused by:

A)Significant alcohol ingestion
B)Pancreatic infection
C)Pancreatic inflammation from fatty foods
D)Pancreatic breakdown from its own enzymes
Question
Each of the following is a cause of vitamin B-12 deficiency EXCEPT

A)pernicious anemia.
B)duodenal resection.
C)gastric resection.
D)specific dietary deficiency.
Question
According to the International Council of Nurses, Code of Ethics for Nurses, which one or more of the following statements reflect(s) the fundamental responsibility of a nurse?

A)The promotion of health.
B)To alleviate suffering.
C)The prevention of illness.
D)To restore health.
Question
A nurse is giving instructions to a client who just had an arthroscopy of the right knee. Which of the following instructions is the least appropriate?

A)The elastic wrap should be worn for at least 2 to 4 days
B)Complete non-weight bearing on the affected leg for the rest of the day
C)Avoid strenuous activities for a few days
D)Notify the doctor if fever or increased knee pain occurs
Question
A nurse prepares a nursing care plan for a newly-admitted client with myasthenia gravis. Understanding the risks of myasthenia gravis, it is a must that the nurse prepares which of the following near the client's bedside?

A)Defibrillator
B)Telemetry equipment
C)Incentive spirometer
D)Suction equipment
Question
A nurse is caring for a client admitted due to bowel obstruction and a nasogastric tube is about to be inserted, as ordered. The nurse knows that nasogastric tube is inserted to:

A)Remove stomach fluid contents and gas
B)Remove contents and gas in the small and large bowel
C)Control bleeding
D)Remove bile
Question
A nurse is providing discharge instructions to a 75-year-old client who had surgery to remove a cataract from her left eye. The nurse should include which of the following instructions?

A)Use an eye shield continuously
B)Increase fiber intake
C)Wipe excess drainage from the outer to inner canthus
D)Resume all activities immediately
Question
A nurse is assessing a client with peripheral arterial disease. The client's pulses are not palpable in the left foot or leg. The nurse's most immediate action is which of the following?

A)Notify the physician
B)Re-assess in 30 minutes
C)Administer vasodilators, as prescribed
D)Verify the assessment with Doppler ultrasonography
Question
A client is diagnosed with trichomoniasis. On assessment, the nurse notes which of the following signs and symptoms?

A)Dysuria and mucoid purulent vaginal discharge
B)Frothy, green or gray vaginal discharge
C)Thin, grayish-white vaginal discharge that smells fishy
D)Thick, white, cottage cheese-like vaginal discharge
Question
A nurse is delegating nursing activities to the nursing assistant. The female client being cared for has been diagnosed with fluid volume deficit due to massive bleeding. The client was accidentally shot. Which of the following activities can be safely delegated to the nursing assistant?

A)Regulate the IV rate.
B)Monitor fluid intake and output.
C)Teach the client to accurately measure the fluid intake.
D)Report decreased urine output.
Question
Mrs) Oates is scheduled for a bowel diversion surgery next week. She is diagnosed with bowel obstruction due to malignancy of the rectum. The physician informed her that they will create a permanent descending colostomy. When the nurse starts preparing the client for tests prior to the procedure, she asks the client if she has any questions about the procedure. Which of the following statements indicates a good understanding of the procedure?

A)"I can pick the location of the stoma."
B)"I can still eat all the foods I want, just like before."
C)"After my surgery, I will be expecting watery stool without odor."
D)"The colostomy will be closed when my cancer disappears."
Question
A woman prescribed digoxin is complaining of weakness, nausea, and anorexia. A serum potassium test revealed a level of 3.2 mEq/L. The physician orders a digoxin level for to rule out digoxin toxicity. The nurse checking the results knows that the therapeutic levels for digoxin range from:

A)3)5 to 5.0 ng/mL
B)0)5 to 2.0 ng/mL
C)2)0 to 3.5 ng/mL
D)0)3 to 1.2 ng/mL
Question
A client with hypertension is prescribed furosemide (Lasix). When the client asks why this medication is given for hypertension, the nurse tells the client that furosemide:

A)Dilates the blood vessels
B)Inhibits sodium and water reabsorption in the Loop of Henle
C)Inhibits sodium and water reabsorption in the proximal tubule
D)Inhibits the angiotensin-converting enzyme
Question
A nurse prepares to administer potassium chloride to a client with hypokalemia. Which of the following actions is included in the nurse's plan of care?

A)Potassium chloride is given in bolus
B)Potassium chloride is diluted in dextrose solution
C)Monitor for signs of phlebitis
D)Monitor for urinary retention
Question
A physician orders 1000 ml of normal saline solution to be infused over 12 hours. The drop factor is 15 drops per 1 ml. A nurse sets the flow rate at how many drops per minute?

A)21 drops
B)24 drops
C)30 drops
D)31 drops
Question
A nurse finds that the site of a client's intravenous catheter is reddened, warm, and slightly edematous. The client complains of pain. The immediate action of the nurse is to:

A)Notify the physician
B)Apply warm and moist compresses
C)Irrigate the catheter
D)Remove the IV immediately and restart in the opposite extremity
Question
What class of drugs is recommended as the first line therapy for hypercholesterolemia, after lifestyle modifications?

A)HMG-CoA reductase inhibitors (statins)
B)Calcium channel blockers
C)Beta channel antagonists
D)Antithrombolytics
Question
What medication has long been the drug of choice for strep pharyngitis?

A)Penicillin
B)Tetracycline
C)Metronidazole
D)Acyclovir
Question
Which of the following drugs is NOT a calcium channel blocker?

A)Nifedipine
B)Verapamil
C)Amlodipine
D)Metoprolol
Question
The nurse is assessing a 27-year-old patient who came in to the clinic for severe dysmenorrhea. After being assessed by the physician, the patient was started on hormonal therapy. The most suitable type of HT for this patient is:

A)Premarin (conjugated estrogen)
B)Depo-Provera (medroxyprogesterone acetate)
C)Estrace (estradiol)
D)Ogen (estropipate)
Question
A nurse is caring for a female client who was admitted less than a week ago, due to moderate depression. The client tells the nurse that she feels much better now and is more than excited to interact with other clients. The nurse's immediate action is to:

A)Notify the physician to reduce the dosage of the client's medications
B)Allow the client to have some in-room activities
C)Increase suicide precautions
D)Recommend discharge
Question
A client was ordered to have urinalysis. The laboratory report reveals that the specific gravity of the client's urine is 1.50. What is the most probable cause of the client's urine specific gravity result?

A)Dehydration
B)Diabetes insipidus
C)Use of diuretic drugs
D)Renal failure
Question
An older client with Alzheimer's disease is agitated and angry. The most appropriate nursing action to calm the client is to:

A)Encourage the client to join a group activity in the day room.
B)Restrain the client using soft restraints until the client calms down.
C)Isolate the client in a room until the client is less agitated.
D)Turn down the volume of the radio.
Question
A client with obsessive-compulsive disorder is admitted for treatment of skin breakdown. The nurse asked the client to refrain from washing his hands too much. Upon hearing this, the client became agitated. The client's nursing care should be based upon the understanding that:

A)OCD behavioral patterns decrease anxiety.
B)Behavioral patterns increase during stressful times.
C)OCD behavioral patterns result in undoing and repression.
D)Behavioral patterns can be interrupted consciously if the client tries.
Question
Which of the following shows therapeutic use of a defense mechanism?

A)A 25-year-old client with paranoid delusions
B)A 38-year-old client who had a traumatic experience and developed amnesia
C)A 15-year-old client dressing and talking like his attending physician
D)A 27-year old client who suddenly experienced blindness after seeing her husband with another woman
Question
A nurse is conducting preoperative teaching for a client scheduled for coronary artery bypass graft surgery in 1 week. The client has been taking aspirin. Which of the following statements, if made by the client, suggests that the client understands the teachings?

A)"I need to continue my intake of aspirin until the day of the surgery to prevent bleeding."
B)"I must discontinue my intake of aspirin at least 48 hours before surgery to prevent blood clots."
C)"Aspirin can cause blood clot formation."
D)"I must discontinue my intake of aspirin at least 48 hours before surgery to prevent bleeding after surgery."
Question
A client was diagnosed with panic disorder a few months ago after going through a traumatic accident. The client has been taking medications and attending therapy for two months now. What is a desirable outcome observed by the nurse?

A)Resumed work at the office.
B)Panic attacks lasting for 10 minutes.
C)Gaining more appetite.
D)Titrating medications when feeling better.
Question
A client is admitted, presenting with hypertension, tachycardia, and hyperthermia. The client is combative and paranoid. The client's bowel sounds are diminished and the urine output is lower than normal. These are the characteristic symptoms of:

A)Alcohol intoxication
B)Heroine toxicity
C)Cocaine toxicity
D)Marijuana use
Question
A nurse finds a client lying unconscious on the floor. An empty bottle of tricyclic antidepressant pills is found near the client. The immediate nursing action is to:

A)Determine the number of pills taken
B)Induce vomiting
C)Alert the medical resuscitation team
D)Determine the last dose of TCA taken
Question
A nurse is assigned to a 25-year-old woman scheduled for therapeutic termination of pregnancy due to a recently discovered heart condition of the mother. The nurse refuses to care for this client because of a conflict in religious beliefs. How should the charge nurse handle this situation?

A)Insist that the nurse accept the delegated task.
B)Ask the nurse to set aside her beliefs for the sake of nursing care.
C)Assign the nurse to another client.
D)Ask the nurse to document her refusal in the client's chart.
Question
A nurse is assessing the living arrangement of a client with Alzheimer's disease. The client is currently living with his daughter's family. Which of the following indicates a good adjustment to the living arrangement?

A)"Dealing with his condition is difficult. We have to hire home health aides to help with the work."
B)"He seems to have more lucid moments now; we're working on establishing a daily routine."
C)"Sometimes I just want to give up on this job, but we're all that he has."
D)"I think we bit off more than we can chew; the last few weeks have been really hard."
Question
A 27-year-old woman has died after falling from a ladder and hitting her head on the floor. The nurse is providing grief support to the client's husband and four-year-old daughter. When observing the child, the nurse should be aware that this child may react by:

A)Expressing strong emotional reaction
B)Feeling responsible for her mother's death
C)Being concerned about who will take care of her
D)Screaming and withdrawing from others
Question
A group of physicians attending a patient with hepatic cirrhosis are discussing possible treatments for variceal bleeding. The physicians were planning to give a sclerosant. The nurse, a part of the health care team, knows that the immediate complication involved with this drug is:

A)Substernal chest pain
B)Pneumothorax
C)Esophageal strictures
D)Mucosal ulceration
Question
Johnny, a 39-year-old bartender, is admitted because of a growing tumor in the larynx. A nurse is preparing him for a hemilaryngectomy. When planning care, the nurse recognizes which of the following as the procedure's most common post-op complication?

A)Bleeding
B)Aspiration
C)Changes in voice quality
D)Wound care
Question
A client admitted for treatment of pressure ulcers on the left heel is being assessed by the nurse. The nurse documents that the wound is red, soft and bleeds easily, indicating second intention of wound healing. This wound type is managed by:

A)Application of dry dressing
B)Packing with wet sterile dressing and then covering with dry sterile dressing
C)Tight packing with sterile saline dressing
D)Lightly covering the wound with thin, dry gauze
Question
A nurse reviews the laboratory results of a client admitted due to crushing left-sided substernal chest pain. The nurse determines that which of the following findings supports a diagnosis of acute myocardial infarction?

A)Level of LDH rises within the first 8 hours of MI
B)Myoglobulin level rises after the first 24 hours
C)Normal CK-MB within the first 24 hours
D)Total creatine kinase rises within 24 hours after cardiac damage
Question
A nurse is caring for an elderly female with a right-sided weakness. The client is immobile and bed-bound for most of the day. The nurse implements which intervention for the prevention of skin breakdown and development of pressure ulcers in the elderly?

A)Increase the client's intake of carbohydrates.
B)Application of alcohol to the skin.
C)Use antibacterial soaps during bathing.
D)Use layer of cornstarch on sheet.
Question
A staff nurse recognizes that the dose prescribed for a client is higher than the safe dosage for the client. The medication is scheduled to be administered, but the nurse is unable to reach the physician. The most appropriate nursing action is to:

A)Administer the medication as prescribed
B)Administer the safe dose
C)Hold the medication until the physician is contacted
D)Call the nursing supervisor
Question
A client diagnosed with acquired immune deficiency syndrome is admitted for pneumocystis carinii pneumonia. In which of the following situations should the nurse intervene?

A)A medical technician wears a pair of gloves to obtain a blood sample from the client.
B)The LPN takes the client's blood pressure wearing gloves and a mask.
C)A maintenance staff cleans spilled blood with a household bleach diluted in water.
D)The nurse student washes her hands before and after contact with the client.
Question
A client is evaluated for seizures for the first time. The nurse expects which of the following diagnostic procedures to be ordered first?

A)Computed tomography scan
B)Magnetic resonance imaging
C)Electroencephalography
D)Skull radiography
Question
A nurse is reviewing the clients' records. The nurse determines that which of the following clients would require airborne precautions?

A)A client with HIV who is admitted due to pneumocystis carinii
B)A client with chicken pox
C)A client diagnosed with impetigo
D)A client suspected with meningitis
Question
A client had a purified protein derivative test 48 hours ago after his roommate tested positive for tuberculosis. On assessment, a 3 millimeter reddened and raised area is noted by the nurse. The nurse determines that the finding is which of the following?

A)Negative
B)Positive
C)Indeterminate
D)Further testing is necessary
Question
A registered nurse is admitting a male client suspected of active tuberculosis. As the health care team waits for the results of the tests, the nurse assigns the client to which room?

A)Single room maintained under negative pressure.
B)Semi-private room; if the test verifies the presence of Mycobacterium tuberculosis, the client is placed in a single room.
C)Semi-private room; airborne precautions are implemented.
D)Single room maintained under positive pressure.
Question
A nurse is planning a health teaching program for accident prevention in the community. The main targets of the program are mothers with young children. What is considered as an undesirable outcome after the health teaching?

A)The mother of a two-year-old child removes the doors and covers of unused appliances.
B)A new mother choosing a crib that is lead-free with slats measuring three inches apart.
C)The mother of a nine-month-old child covers the electrical outlets.
D)The mothers in the community set aside "play areas" away from the streets and railroad tracks.
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Deck 1: American Association of Colleges of Nursing (AACN) Clinical Nurse Specialist
1
Nina the New Nurse has assessed a new client, admitted for sudden altered level of consciousness (ALOC). She also reviewed the current lab results, which are as follows: Na+ 156
CL- 100
K+ 4.0
HCO 21
BUN 86
Bld) Glucose 100
Nina the New Nurse is entering a nursing diagnosis on the care plan based on the information she has gathered. Which nursing diagnosis is most appropriate?

A)Fluid volume deficit.
B)Self-care deficit: feeding.
C)Alteration in urinary elimination.
D)Trick question! There isn't enough information provided in the above scenario to determine a nursing diagnosis!
Fluid volume deficit.
2
After a complete bowel rest, a client is prescribed a clear liquid diet. The nurse making the dietary plan for the client keeps in mind that a clear liquid diet consists of the following except:

A)Bouillon
B)Gelatin
C)Milk
D)Coffee
Milk
3
A nurse is assessing a newly-admitted client. Assessment reveals that the client has muscle weakness, muscle spasticity, and an unsteady gait. Based on the findings, which of the following is the most appropriate nursing diagnosis?

A)Activity intolerance
B)Impaired physical mobility
C)Risk for impaired skin integrity
D)Self-care deficit
Impaired physical mobility
4
A high-fiber diet is thought to reduce the risk of colon cancer because it:

A)absorbs water from the intestinal wall.
B)promotes the excretion of bile.
C)stops diarrhea.
D)is low in kilocalories.
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5
Which of the following diets is suggested for the client with AIDS?

A)High calorie, high fat
B)High calorie, high carbohydrate
C)Low calorie, low protein
D)High calorie, high protein
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6
Nina the New Nurse loves her job! She is working on the medical/surgical. unit, and has received reports on the clients she will care for from the off-going shift. She is prioritizing her first rounds of the day. Which of the following clients should Nina the New Nurse see first?

A)55-year-old female, right mastectomy two days ago; Jackson-Pratt draining serosanguineous fluid, 23cc for last shift.
B)25-year-old male, gunshot wound to left thigh; 2.5cm area of dark drainage observed on dressing.
C)58-year-old male, abdominal-perineal resection 4 days ago; complaining of chills.
D)30-year-old female, hysterectomy 3 days ago; complaining of pain.
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7
Hank Smith, a 36-year-old bartender, was admitted for a total cystectomy with creation of an ileal conduit. Hank was diagnosed with a bladder tumor six months ago. While emptying and cleaning the stoma, the nurse is incorrect when she does which of the following?

A)Maintains an aseptic technique all throughout the procedure.
B)Changes the urine collection appliance on a timely schedule.
C)Instructs the client to sit upright on the bed.
D)Changes the appliance during early morning.
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8
Nina the New Nurse was floated to a unit she was unfamiliar with. Wanting to be helpful and thought of as a team player, she accepted a very heavy assignment. According to the ICN Code of Ethics for Nurses, which of the four principle elements did Nina the New Nurse violate?

A)Nurses and people
B)Nurses and practice
C)Nurses and co-workers
D)Nurses and the profession
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9
A nurse is caring for Mr. Kline, a 56-year-old client who was admitted because of esophageal cancer. A gastrostomy tube (PEG) was inserted six weeks ago. During assessment, the nurse notes reddish color and swelling around the insertion site. The most appropriate action of the nurse is to:

A)Clean the insertion site with normal saline solution and cover with sterile gauze.
B)Notify the physician immediately.
C)This is expected during the first few weeks after a creation of PEG, and she can continue feeding.
D)Flush the PEG with cold water to soothe the irritated insertion site.
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10
In an upper respiratory tract infection, secretion of copious amounts of mucus can affect a client's appetite. Which of the following interventions can best help increase the palatability of food for a client with an upper respiratory infection?

A)Increase oral fluid intake.
B)Offer oral care before eating.
C)Offer citrus juice before eating.
D)Remove sputum containers and trash from the eating area.
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11
A 20-year-old male client with a BMI of 33 has been admitted for recurrent chest pains and difficulty breathing. During the assessment, it is found that his father and mother both suffered from myocardial infarction before the age of 50. Which of the following nursing actions is the first step to prevent the client from having a myocardial infarction?

A)Encourage the client to initiate and maintain a regular exercise program.
B)Instruct the client to avoid fatty and high-calorie meals.
C)Assess the client's level of interest in weight reduction programs.
D)Educate the client about the risks of obesity and myocardial infarction.
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12
What is meant by the term values?

A)The belief that something is completely right or wrong, at all times.
B)Principles based on experience, culture, religion, and education that influence decisions and/or behavior.
C)Principles or standards influencing professional conduct.
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13
After receiving the client assignments for the day, which client should the nurse assess first?

A)A client newly diagnosed with Parkinson's disease preparing for discharge
B)A client scheduled for arthroscopy in two hours
C)A client requiring wound dressing changes
D)A client receiving oxygen who demonstrated labored breathing during the previous shift
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14
A nurse assesses the cranial nerves of a client with head trauma. The nurse assesses cranial nerve VIII by performing which of the following?

A)Checking the client's visual fields
B)Eliciting the gag reflex
C)Observing for swaying when walking
D)Asking the client to identify substances by their tastes
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15
A nurse is teaching a 75-year-old client how to use an aluminum walker appropriately. Which of the following techniques are accurate?

A)The client lifts and moves the walker forward, steps forward with the good leg, followed by the affected leg.
B)The client lifts and moves the walker forward 10 inches, and steps forward with the affected leg first, followed by the good leg.
C)The client pushes the walker forward as the walker bears the weight of the client.
D)The client glides the walker forward 18 inches and swings both legs forward.
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16
During a staffing crisis, the nurse manager decides that the most efficient nursing modality to implement is:

A)Primary nursing
B)Functional nursing
C)Team nursing
D)Case management
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17
A nurse is on the elevator when she overhears a group of medical interns discussing the case of a male client who was found to be positive for human immunodeficiency virus. The nurse knows that which client right might have been breached?

A)Right to continuity of care
B)Right to refuse treatment
C)Right to refuse third-party interference in their medical care
D)Right to be treated confidentially
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18
A client has an indwelling urinary catheter. Which of the following nursing interventions is best to prevent bladder infections?

A)Irrigate the catheter with sterile saline solution twice daily.
B)Encourage the client to take showers and prevent tub baths.
C)Restrict fluid intake.
D)Open the drainage system once daily.
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19
An elderly client with a swallowing disorder is at increased risk for aspiration. Which of the following is an inappropriate nursing action?

A)Encourage the client to increase consumption of full-fat milk products
B)Dentures are securely worn while eating
C)Syringes are avoided when feeding the client
D)The client is placed in semi-Fowler's during feeding and for 30 minutes thereafter
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20
Nina the New Nurse is preparing to receive a client who will be transferred from the recovery room to her unit. The recovery room nurse reports the client is awake and alert after colon surgery and vital signs are stable. The patient has no complaints of pain or nausea and has an NG tube to low suction draining serosanguineous fluid. Nina the New Nurse's team is very busy now; she is trying to determine which task can safely be delegated to the nursing assistant on her team. Which of the following tasks can safely be delegated to the nursing assistant?

A)Observe the color and record the amount of drainage collected by the NG tube.
B)Measure and record vital signs every two hours.
C)Irrigate NG tube as needed.
D)Perform mouth care, and skin care to nares, as needed.
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21
A 39-year-old male client, brought to the Emergency Department after sustaining a traumatic brain-stem injury during a football game, has died. You have met with the family about the possibility of organ and tissue donation, and they are considering the option. You are showing an awareness of his role in providing care for this family by (select all that apply):

A)Using the client's name rather than the word "donor" when speaking with the family.
B)Providing care to the deceased in a respectful and caring manner.
C)Explaining the time limitations associated with the most effective "harvest" to the family.
D)Encouraging family members to seek advice from other family members. Provide privacy for family to confer if necessary.
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22
By returning to a client's room at the time promised, the nurse is demonstrating:

A)Confidentiality
B)Beneficence
C)Veracity
D)Fidelity
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23
You are caring for a 55-year-old client experiencing mid-sternal chest pain. What is the priority nursing action for this client?

A)Auscultation of the chest and lungs
B)Getting a complete history, along with questioning the events preceding the start of the pain
C)Taking a complete set of vitals
D)Starting an IV and administering analgesics
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24
A nurse is caring for a female client who complains of easy fatigability and weakness. Laboratory tests reveal that the client has an iron-deficiency anemia. History reveals that the client is a practicing vegetarian. Which of the following food items is correctly included in the client's daily diet to correct iron-deficiency anemia?

A)Brewer's yeast
B)Raisins
C)Soybean milk
D)Banana
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25
A nurse gathered the assessment findings from a group of clients assigned to her during the shift. Among the details of information she noted, which of the following is most likely attributed to poor hygiene care?

A)Dry and flaky skin over the ear and scalp
B)Reddish skin that doesn't blanch when touched.
C)Dry, itchy and highly demarcated scaling plaques.
D)A reddish rash on the wrist underlying a watch strap
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26
What is the most fundamental principle of professional behavior?

A)Respect for persons
B)Justice
C)Respect for autonomy
D)Beneficence
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27
A 35-year old client says that both of her parents were diagnosed with hypertension and that she is afraid that she might get it as well. Although the client is not demonstrating any sign of the disease, what should the nurse include in her home care teaching to help the client prevent hypertension?

A)Maintain a regular exercise program, consisting of moderate aerobic exercises.
B)Increase her intake of foods rich in sodium
C)Get rid of all forms of stress right away
D)Teach the client how to obtain her blood pressure measurement
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28
A nurse is caring for a client with genital herpes. The nurse uses which of the following measures to promote comfort?

A)Instructing the client to wear loose cotton underwear
B)Application of hydrogen peroxide solution over the lesions
C)Application of lubricants to lesions
D)Application of warm compresses
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29
Which of the following is the number 1 modifiable risk factor for stroke?

A)Diabetes
B)Hypertension
C)Hypotension
D)Congestive heart failure
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30
What kind of ulcers are usually formed as a result of the chronic usage of nonsteroidal anti-inflammatory drugs?

A)Esophageal
B)Jejunal
C)Duodenal
D)Gastric
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31
A client was rushed in due to severe abdominal pain unrelieved by repositioning. Assessment shows a high fever and yellowish hue of the skin. The client's friends reported that they had been drinking hard liquor the whole night. The client was diagnosed with pancreatitis. The nurse understands that pancreatitis is caused by:

A)Significant alcohol ingestion
B)Pancreatic infection
C)Pancreatic inflammation from fatty foods
D)Pancreatic breakdown from its own enzymes
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32
Each of the following is a cause of vitamin B-12 deficiency EXCEPT

A)pernicious anemia.
B)duodenal resection.
C)gastric resection.
D)specific dietary deficiency.
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33
According to the International Council of Nurses, Code of Ethics for Nurses, which one or more of the following statements reflect(s) the fundamental responsibility of a nurse?

A)The promotion of health.
B)To alleviate suffering.
C)The prevention of illness.
D)To restore health.
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34
A nurse is giving instructions to a client who just had an arthroscopy of the right knee. Which of the following instructions is the least appropriate?

A)The elastic wrap should be worn for at least 2 to 4 days
B)Complete non-weight bearing on the affected leg for the rest of the day
C)Avoid strenuous activities for a few days
D)Notify the doctor if fever or increased knee pain occurs
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35
A nurse prepares a nursing care plan for a newly-admitted client with myasthenia gravis. Understanding the risks of myasthenia gravis, it is a must that the nurse prepares which of the following near the client's bedside?

A)Defibrillator
B)Telemetry equipment
C)Incentive spirometer
D)Suction equipment
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36
A nurse is caring for a client admitted due to bowel obstruction and a nasogastric tube is about to be inserted, as ordered. The nurse knows that nasogastric tube is inserted to:

A)Remove stomach fluid contents and gas
B)Remove contents and gas in the small and large bowel
C)Control bleeding
D)Remove bile
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37
A nurse is providing discharge instructions to a 75-year-old client who had surgery to remove a cataract from her left eye. The nurse should include which of the following instructions?

A)Use an eye shield continuously
B)Increase fiber intake
C)Wipe excess drainage from the outer to inner canthus
D)Resume all activities immediately
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38
A nurse is assessing a client with peripheral arterial disease. The client's pulses are not palpable in the left foot or leg. The nurse's most immediate action is which of the following?

A)Notify the physician
B)Re-assess in 30 minutes
C)Administer vasodilators, as prescribed
D)Verify the assessment with Doppler ultrasonography
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39
A client is diagnosed with trichomoniasis. On assessment, the nurse notes which of the following signs and symptoms?

A)Dysuria and mucoid purulent vaginal discharge
B)Frothy, green or gray vaginal discharge
C)Thin, grayish-white vaginal discharge that smells fishy
D)Thick, white, cottage cheese-like vaginal discharge
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40
A nurse is delegating nursing activities to the nursing assistant. The female client being cared for has been diagnosed with fluid volume deficit due to massive bleeding. The client was accidentally shot. Which of the following activities can be safely delegated to the nursing assistant?

A)Regulate the IV rate.
B)Monitor fluid intake and output.
C)Teach the client to accurately measure the fluid intake.
D)Report decreased urine output.
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41
Mrs) Oates is scheduled for a bowel diversion surgery next week. She is diagnosed with bowel obstruction due to malignancy of the rectum. The physician informed her that they will create a permanent descending colostomy. When the nurse starts preparing the client for tests prior to the procedure, she asks the client if she has any questions about the procedure. Which of the following statements indicates a good understanding of the procedure?

A)"I can pick the location of the stoma."
B)"I can still eat all the foods I want, just like before."
C)"After my surgery, I will be expecting watery stool without odor."
D)"The colostomy will be closed when my cancer disappears."
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42
A woman prescribed digoxin is complaining of weakness, nausea, and anorexia. A serum potassium test revealed a level of 3.2 mEq/L. The physician orders a digoxin level for to rule out digoxin toxicity. The nurse checking the results knows that the therapeutic levels for digoxin range from:

A)3)5 to 5.0 ng/mL
B)0)5 to 2.0 ng/mL
C)2)0 to 3.5 ng/mL
D)0)3 to 1.2 ng/mL
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43
A client with hypertension is prescribed furosemide (Lasix). When the client asks why this medication is given for hypertension, the nurse tells the client that furosemide:

A)Dilates the blood vessels
B)Inhibits sodium and water reabsorption in the Loop of Henle
C)Inhibits sodium and water reabsorption in the proximal tubule
D)Inhibits the angiotensin-converting enzyme
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44
A nurse prepares to administer potassium chloride to a client with hypokalemia. Which of the following actions is included in the nurse's plan of care?

A)Potassium chloride is given in bolus
B)Potassium chloride is diluted in dextrose solution
C)Monitor for signs of phlebitis
D)Monitor for urinary retention
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45
A physician orders 1000 ml of normal saline solution to be infused over 12 hours. The drop factor is 15 drops per 1 ml. A nurse sets the flow rate at how many drops per minute?

A)21 drops
B)24 drops
C)30 drops
D)31 drops
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46
A nurse finds that the site of a client's intravenous catheter is reddened, warm, and slightly edematous. The client complains of pain. The immediate action of the nurse is to:

A)Notify the physician
B)Apply warm and moist compresses
C)Irrigate the catheter
D)Remove the IV immediately and restart in the opposite extremity
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47
What class of drugs is recommended as the first line therapy for hypercholesterolemia, after lifestyle modifications?

A)HMG-CoA reductase inhibitors (statins)
B)Calcium channel blockers
C)Beta channel antagonists
D)Antithrombolytics
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48
What medication has long been the drug of choice for strep pharyngitis?

A)Penicillin
B)Tetracycline
C)Metronidazole
D)Acyclovir
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49
Which of the following drugs is NOT a calcium channel blocker?

A)Nifedipine
B)Verapamil
C)Amlodipine
D)Metoprolol
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50
The nurse is assessing a 27-year-old patient who came in to the clinic for severe dysmenorrhea. After being assessed by the physician, the patient was started on hormonal therapy. The most suitable type of HT for this patient is:

A)Premarin (conjugated estrogen)
B)Depo-Provera (medroxyprogesterone acetate)
C)Estrace (estradiol)
D)Ogen (estropipate)
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51
A nurse is caring for a female client who was admitted less than a week ago, due to moderate depression. The client tells the nurse that she feels much better now and is more than excited to interact with other clients. The nurse's immediate action is to:

A)Notify the physician to reduce the dosage of the client's medications
B)Allow the client to have some in-room activities
C)Increase suicide precautions
D)Recommend discharge
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52
A client was ordered to have urinalysis. The laboratory report reveals that the specific gravity of the client's urine is 1.50. What is the most probable cause of the client's urine specific gravity result?

A)Dehydration
B)Diabetes insipidus
C)Use of diuretic drugs
D)Renal failure
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53
An older client with Alzheimer's disease is agitated and angry. The most appropriate nursing action to calm the client is to:

A)Encourage the client to join a group activity in the day room.
B)Restrain the client using soft restraints until the client calms down.
C)Isolate the client in a room until the client is less agitated.
D)Turn down the volume of the radio.
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54
A client with obsessive-compulsive disorder is admitted for treatment of skin breakdown. The nurse asked the client to refrain from washing his hands too much. Upon hearing this, the client became agitated. The client's nursing care should be based upon the understanding that:

A)OCD behavioral patterns decrease anxiety.
B)Behavioral patterns increase during stressful times.
C)OCD behavioral patterns result in undoing and repression.
D)Behavioral patterns can be interrupted consciously if the client tries.
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55
Which of the following shows therapeutic use of a defense mechanism?

A)A 25-year-old client with paranoid delusions
B)A 38-year-old client who had a traumatic experience and developed amnesia
C)A 15-year-old client dressing and talking like his attending physician
D)A 27-year old client who suddenly experienced blindness after seeing her husband with another woman
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56
A nurse is conducting preoperative teaching for a client scheduled for coronary artery bypass graft surgery in 1 week. The client has been taking aspirin. Which of the following statements, if made by the client, suggests that the client understands the teachings?

A)"I need to continue my intake of aspirin until the day of the surgery to prevent bleeding."
B)"I must discontinue my intake of aspirin at least 48 hours before surgery to prevent blood clots."
C)"Aspirin can cause blood clot formation."
D)"I must discontinue my intake of aspirin at least 48 hours before surgery to prevent bleeding after surgery."
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57
A client was diagnosed with panic disorder a few months ago after going through a traumatic accident. The client has been taking medications and attending therapy for two months now. What is a desirable outcome observed by the nurse?

A)Resumed work at the office.
B)Panic attacks lasting for 10 minutes.
C)Gaining more appetite.
D)Titrating medications when feeling better.
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58
A client is admitted, presenting with hypertension, tachycardia, and hyperthermia. The client is combative and paranoid. The client's bowel sounds are diminished and the urine output is lower than normal. These are the characteristic symptoms of:

A)Alcohol intoxication
B)Heroine toxicity
C)Cocaine toxicity
D)Marijuana use
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59
A nurse finds a client lying unconscious on the floor. An empty bottle of tricyclic antidepressant pills is found near the client. The immediate nursing action is to:

A)Determine the number of pills taken
B)Induce vomiting
C)Alert the medical resuscitation team
D)Determine the last dose of TCA taken
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60
A nurse is assigned to a 25-year-old woman scheduled for therapeutic termination of pregnancy due to a recently discovered heart condition of the mother. The nurse refuses to care for this client because of a conflict in religious beliefs. How should the charge nurse handle this situation?

A)Insist that the nurse accept the delegated task.
B)Ask the nurse to set aside her beliefs for the sake of nursing care.
C)Assign the nurse to another client.
D)Ask the nurse to document her refusal in the client's chart.
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61
A nurse is assessing the living arrangement of a client with Alzheimer's disease. The client is currently living with his daughter's family. Which of the following indicates a good adjustment to the living arrangement?

A)"Dealing with his condition is difficult. We have to hire home health aides to help with the work."
B)"He seems to have more lucid moments now; we're working on establishing a daily routine."
C)"Sometimes I just want to give up on this job, but we're all that he has."
D)"I think we bit off more than we can chew; the last few weeks have been really hard."
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62
A 27-year-old woman has died after falling from a ladder and hitting her head on the floor. The nurse is providing grief support to the client's husband and four-year-old daughter. When observing the child, the nurse should be aware that this child may react by:

A)Expressing strong emotional reaction
B)Feeling responsible for her mother's death
C)Being concerned about who will take care of her
D)Screaming and withdrawing from others
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63
A group of physicians attending a patient with hepatic cirrhosis are discussing possible treatments for variceal bleeding. The physicians were planning to give a sclerosant. The nurse, a part of the health care team, knows that the immediate complication involved with this drug is:

A)Substernal chest pain
B)Pneumothorax
C)Esophageal strictures
D)Mucosal ulceration
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64
Johnny, a 39-year-old bartender, is admitted because of a growing tumor in the larynx. A nurse is preparing him for a hemilaryngectomy. When planning care, the nurse recognizes which of the following as the procedure's most common post-op complication?

A)Bleeding
B)Aspiration
C)Changes in voice quality
D)Wound care
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65
A client admitted for treatment of pressure ulcers on the left heel is being assessed by the nurse. The nurse documents that the wound is red, soft and bleeds easily, indicating second intention of wound healing. This wound type is managed by:

A)Application of dry dressing
B)Packing with wet sterile dressing and then covering with dry sterile dressing
C)Tight packing with sterile saline dressing
D)Lightly covering the wound with thin, dry gauze
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66
A nurse reviews the laboratory results of a client admitted due to crushing left-sided substernal chest pain. The nurse determines that which of the following findings supports a diagnosis of acute myocardial infarction?

A)Level of LDH rises within the first 8 hours of MI
B)Myoglobulin level rises after the first 24 hours
C)Normal CK-MB within the first 24 hours
D)Total creatine kinase rises within 24 hours after cardiac damage
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67
A nurse is caring for an elderly female with a right-sided weakness. The client is immobile and bed-bound for most of the day. The nurse implements which intervention for the prevention of skin breakdown and development of pressure ulcers in the elderly?

A)Increase the client's intake of carbohydrates.
B)Application of alcohol to the skin.
C)Use antibacterial soaps during bathing.
D)Use layer of cornstarch on sheet.
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68
A staff nurse recognizes that the dose prescribed for a client is higher than the safe dosage for the client. The medication is scheduled to be administered, but the nurse is unable to reach the physician. The most appropriate nursing action is to:

A)Administer the medication as prescribed
B)Administer the safe dose
C)Hold the medication until the physician is contacted
D)Call the nursing supervisor
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69
A client diagnosed with acquired immune deficiency syndrome is admitted for pneumocystis carinii pneumonia. In which of the following situations should the nurse intervene?

A)A medical technician wears a pair of gloves to obtain a blood sample from the client.
B)The LPN takes the client's blood pressure wearing gloves and a mask.
C)A maintenance staff cleans spilled blood with a household bleach diluted in water.
D)The nurse student washes her hands before and after contact with the client.
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70
A client is evaluated for seizures for the first time. The nurse expects which of the following diagnostic procedures to be ordered first?

A)Computed tomography scan
B)Magnetic resonance imaging
C)Electroencephalography
D)Skull radiography
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71
A nurse is reviewing the clients' records. The nurse determines that which of the following clients would require airborne precautions?

A)A client with HIV who is admitted due to pneumocystis carinii
B)A client with chicken pox
C)A client diagnosed with impetigo
D)A client suspected with meningitis
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72
A client had a purified protein derivative test 48 hours ago after his roommate tested positive for tuberculosis. On assessment, a 3 millimeter reddened and raised area is noted by the nurse. The nurse determines that the finding is which of the following?

A)Negative
B)Positive
C)Indeterminate
D)Further testing is necessary
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73
A registered nurse is admitting a male client suspected of active tuberculosis. As the health care team waits for the results of the tests, the nurse assigns the client to which room?

A)Single room maintained under negative pressure.
B)Semi-private room; if the test verifies the presence of Mycobacterium tuberculosis, the client is placed in a single room.
C)Semi-private room; airborne precautions are implemented.
D)Single room maintained under positive pressure.
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74
A nurse is planning a health teaching program for accident prevention in the community. The main targets of the program are mothers with young children. What is considered as an undesirable outcome after the health teaching?

A)The mother of a two-year-old child removes the doors and covers of unused appliances.
B)A new mother choosing a crib that is lead-free with slats measuring three inches apart.
C)The mother of a nine-month-old child covers the electrical outlets.
D)The mothers in the community set aside "play areas" away from the streets and railroad tracks.
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