A nurse is caring for a client who has a tracheostomy. which of the following interventions

60, a nurse is caring for a client who has a tracheostomy tube. Upon data collection , the nurse observes the client is restless and hears crackles in the lungs, which of the following interventions should the nurse take?

A, instill saline into the tubing

B, check the cuff pressure 

C, perform suctioning 

D, increase the humidification 

61, a nurse is reviewing laboratory values for a client who is receiving long-term NSAID therapy for rheumatoid arthritis. Which of the following values should the nurse report to the provider?

A, BUN 40 mg/dl

B, total bilirubin 0.8 mg/dl

C, pao2 90 mm Hg 

D ,hematocrit 45%

62, a charge nurse is reinforcing teaching about infection control with a newly licensed nurse, which of the following actions by the newly licenced nurse indicates an understanding of the teaching?

A, instructs a female client to wipe the perineal area from back to front 

B, performs hand hygiene with hands at elbow level 

C, cleans a blood spill with chlorine bleach 

D, rolls solid line with the clean side in before placing it in the laundry bag 

63, a nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke, which of the following statements by the clients indicates an understanding of the teaching?

A, my provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke 

B, my risk for a stroke increases if my HbA1c level is 6 percent or less

C, i can decrease my risk for a stroke by losing excess weight 

D, having a total cholesterol level below 200 mg/dl increases my risk for a stroke 

64, a nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago , when collecting data from the test site, which of the following findings indicates a need for further testing?

A, nonpalpable area of redness less than 5 mm (0.2 in) in diameter 

B, palpable area of induration greater than 10 mm (0.4 in ) in diameter 

C, area of ecchymosis , greater than 12 mm (0.5 in )in diameter 

D, tenderness at the injection site 

66, a nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy. Which of the following information should the nurse include in the teaching?

A, you should warm the liquid bowel preparation before drinking it 

B, you may drink full liquids until 6 hours before the procedure 

C, you will lie on your right side for the procedure 

D, you will be moderately sedated during the procedure 

67, a nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

A, administer heparin to the client 

B, place the client in high-fowler's position 

C, obtain the client's vital signs 

D, encourage the lenient to cough and deep breathe 

68, a nurse on the oncology unit is evaluating a clients response after receiving a dose of aprepitant , which of the following therapeutic effects should the nurse expect/

A, decreased incisional pain 

B, absence of dizziness

C, absence of nausea

D, decreased dysrhythmias 

69, a nurse is reinforcing teaching with a client about heart disease prevention , which of the following client statements indicates an understanding of the teaching?

A, i will exercise by walking twice a week for 25 minutes

B, i will increased my dairy intake by drinking whole milk with every meal

C, i will improve my LDL cholesterol by raising it from 100 to 130

D, i will try to maintain my blood pressure around 116/72

70. A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?

A, reports periodic migraine headaches 

B, experiences nocturia 

C, recent exposure to tuberculosis 

D, history of generalized anxiety disorder 

71. A nurse is reinforcing teaching with a client who has anemia and has a prescription for ferrous sulfate. Which of the following foods should the nurse recommend that the client consume to increase the absorption of this medication?

a. Oatmeal

b. Baked potatoes

c. Cheese

d. Raw oranges

72. A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

a. The client consumed citrus juice 3 days before the test

b. The client has a history of breast cancer

c. The client has a hemorrhoidectomy 1 year ago

d. The client takes ibuprofen for headaches

73, anurse is reinforcing teaching with a client who has herpes simplex virus type 2 which of the following statements by the client indicates an understanding of the teaching 

A, i am only contagious while the lesions are present 

B, the lesions may recur in times of stress

C, the virus  cannot spread to areas other than the genital area 

D, i can have inprotected sex as long as i am taking acyclovir 

74. A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching?

a. Eat lighter, low-calorie foods first

b. Eliminate dairy products

c. Limit fluid intake during meals

d. Consume three regular meals daily

75. A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing. Which of the following actions should the nurse take next?

a. Maintain direct pressure over the site

b. Check whether the bleeding has stopped

c. Obtain a radial pulse

d. Reinforce the dressing over the site

76. A nurse is examining the abdominal wound of a client who is 3 days postoperative following a hemicolectomy. Which of the following findings indicates a wound infection?

a. Serous wound drainage

b. Bruising around the wound

c. Crusting along the incision

d. Redness around the incision line

77. A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?

a. Place white tape on the edges of stairs

b. Have the furnace inspected every 2 years

c. Run wires and cords under carpeting

d. Place area rugs on wooden floors

78. A nurse is reinforcing teaching with a client who is scheduled for a cardiac catheterization. Which of the following should the nurse tell the client to expect during injection of the contrast medium?

a. Numbness in the fingertips

b. Urge to urinate

c. Feeling of heat

d. Pain in the jawline

79, a nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

A, hypertension

B, bilateral tinnitus 

C, difficulty swallowing 

D, petechial rash on the abdomen 

80, a nurse is contributing to the plan of care for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. Which of the following interventions should the nurse include?

A, apply 4.5 kg (10lb) traction weight to the distal end of the fixator 

B, monitor the neurovascular status of the clients affected limb every 8 hr 

C, administer pain medication 30 min prior to pin care 

C, adjust the clamps on the devices frame daily 

81, a nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take?(select all that apply?

A, run cool water over the affected area 

B, allow the affected area to remain open to air

C, maintain skin integrity over the blisters 

D, apply ice to the large blisters

E, administer ibuprofen for pain

82, a nurse is caring for a client who has been receiving epoetin alfa in preparation for a hip arthroplasty , which of the following findings indicates the medication has been effective 

A, total calcium 10 mg/dl

B, hemoglobin 11 g/dl

C, pt 12 seconds 

D, WBC count 9,000/mm3 

83, a nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?

A, provide the client privacy with a set time to defecate 

B, auscultate the client's abdomen for bowel sounds

C, administer a fiber-based laxative to the client 

D, encourage the client to increase oral intake of fluids 

84, a nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

A, limit range-of-motion exercise with the affected arm 

B, use the clients left arm to obtain blood samples 

C, obtain blood pressure readings using the clients right arm

D, keep both arms below the level of the client's heart 

85, a nurse is reinforcing teaching about liquid iron supplements with a client who has anemia. Which of the following information should the nurse include in the teaching ?

A, check for orange - colored stools after 4 days of treatment 

B.mix iron supplements with milk to prevent staining of the teeth 

C, reduce gastric distress by taking iron supplements with an antacid 

D, take iron supplements between meals for maximum absorption 

86, a nurse is caring for a client  who is visually impaired. When delivering the client's meal tray , which of the following actions should the nurse take?

A, describe the food placement as through the plate were a clock

B, arrange for an assistive personnel to feed the client 

C, discourage conversations during the clients mealtime 

D, provide the client with small-handled adaptive utensils 

87, a nurse is reinforcing teaching with a client who is 24 hr postoperative following a total hip arthroplasty , which of the following instructions should the nurse include in the teaching?

A, apply moist heat to the incision while in bed 

B, cleanse the surgical incision with hydrogen peroxide 

C, sit in a straight - backed chair 

D, perform range of motion by adducting the hip 

88, a nurse is reinforcing teaching with a client who has heart failure and new prescription for furosemide, the nurse should instruct the client to monitor for which of the following adverse effects?

A, ringing in ears 

B, rhinitis 

C, agitation 

D, metallic taste 

89, a nurse is preparing a client for a sigmoidoscopy, in which of the following positions should the nurse place the client ?

A, orthopneic 

B, knee-chest

C, prone

D, Trendelenburg 

90, a nurse reviewing vital signs obtained by an assistive personnel on a group of clients , the previous vital signs for each of the client were obtained 4 hr earlier , which of the following changes should the nurse identify as the priority finding?

A, blood pressure charge from 118.78 mm hg to 86/50 mm hg 

B, respiratory rate change from 12/mm to 20/min 

C, heart rate change from 110/mm to 68/min

D, temperature change from 36.6 C (97.8 F) TO 38.8 C (101.9 F)

91, a nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

a. inability to follow directions

b. Right-sided weakness 

C. difficulty speaking 

D. a change in pupil size

92, a nurse is collecting data for an older adult client who has cystitis , which of the following findings should the nurse expect? ( select all that apply )

A, bradycardia 

B, confusion 

C, dysuria 

D, pruritus 

E, hematuria 

94, a nurse is caring for a client who is 8 hr postoperative following a left hip arthroplasty , which of the following laboratory values indicates the nurse should notify the provider A, blood glucose 98 mg/dl

B, potassium 3.6 mEq/l

C, BUN 18 mg/dl

D, hemoglobin 8.6 g/dl

95, A nurse is transporting a client who has pneumonia and is on droplet precations to radiology , which of the following safety measures should the nurse take while transporting the client?

A, the nurse should wear a gown during transport

B, the client should wear a gown during transport 

C, the client should wear a mask during transport 

D, the nurse should wear a mask during transport

96, a nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis ?

A, walk 30 min per day 

B, uses a beclomethasone inhaler 

C, applies an estrogen vaginal cream daily 

D, includes canned sardines in her diet 

97, a nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority ?

A, report of a sore throat 

B, serum calcium level 9.2 mg/dl

C, oral temperature 39 C ( 102.2 F)

D, moderate amount of serosanguineous drainage on dressings 

98, a nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

A, monitor for muscle paralysis 

B, check for increased salivation 

C, administer clindamycin hydrochloride 

D, place in contact isolation 

99, a nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take ?

A, leave the television on in the clients room 

B, raise all four side rails while the client is in bed 

C, apply a motion sensor mat to the clients bed 

D, move the overbed table away from the bed 

100, a nurse is caring for a client who is 4 hr postoperative following an abdominal surgery and notes that the client's abdominal incision is open and the internal organs are protruding , after contacting the rapid response team , which of the following actions should the nurse take next?

A, obtain a set of vital signs 

B, flex the client's knees and hips 

C, elevate the head of the clients bed 20 

D, apply a moist saline dressing to the area 

Answer & Explanation

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Step-by-step explanation

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