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1. A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hr ago. Which of the following actions should the nurse take first? ANS: Obtain a set of the client's vital signs RAT: The first $17.99
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1. A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hr ago. Which of the following actions should the nurse take first? ANS: Obtain a set of the client's vital signs RAT: The first
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Course
Nursing
Institution
Nursing
1. A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hr ago. Which of the following actions should the nurse take first?
ANS: Obtain a set of the client's vital signs
RAT: The first action the nurse should take when using the nur...
1. A nurse is reviewing a client's medication record and notices that a double
dose of oral digoxin was administered 1 hr ago. Which of the following
actions should the nurse take first?
ANS: Obtain a set of the client's vital signs
RAT: The first action the nurse should take when using the nursing process is to collect
data from the client. Digoxin can cause bradycardia. By obtaining the client's vital
signs, the nurse can identify the need for intervention
2. A nurse is instructing assistive personnel (AP) about caring for a client who
has hepatitis A and is incontinent of stool. Which of the following infection
control precautions should the nurse instruct the AP to use?
, COMPREHENSIVE EXAM Q & A WITH
RATIONALES.Approved
ANS: Contact
RAT: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually
sufficient to prevent the spread of infection. However, if the client who has hepatitis A
is also incontinent of stool, then contact precautions are indicated
3. A nurse is assisting with the transfer of a client to a long-term care facility.
The nurse should review which of the following sections of the electronic
health record to locate information about the client's personal health
insurance?
ANS: Admission sheet
RAT: The nurse will find client data, such as date of birth, occupation, and the client's
source of health insurance, on the client's admission sheet
4. A nurse is inspecting the skin of a newborn. Which of the following findings
should the nurse report to the provider?
ANS: Generalized petechiae
RAT: Petechiae are an expected finding over the presenting part of the newborn, such
as on the forehead in a brow presentation, and also anywhere on the head of the
newborns who has a nuchal cord, which is an umbilical cord around the neck.
However, petechiae all over the newborn's body can indicate infection or a decreased
platelet count and should be reported to the provider
5. A nurse in a provider's office is obtaining the health history from a client who is
scheduled to undergo a cardiac catheterization in 2 days. Which of the following
questions is the priority for the nurse to ask?
ANS: "Do you know if you're allergic to iodine?"
, COMPREHENSIVE EXAM Q & A WITH
RATIONALES.Approved
RAT: The greatest risk to the client is an allergic reaction to the contrast agent, which
contains iodine. Therefore, the priority question is to identify the client's allergies
6. A nurse is reviewing the medical record of a client who is receiving warfarin and
has atrial fibrillation. Which of the following laboratory values should the nurse
report to the provider?
, COMPREHENSIVE EXAM Q & A WITH
RATIONALES.Approved
ANS: INR 5.0
RAT: The international normalized ratio (INR) is a measurement of the body's blood
clotting ability. A client receiving warfarin to prevent clot formation related to atrial
fibrillation should have an INR of 2.0 to 3.0. An INR of 5.0 or greater indicates that the
client is at risk for bleeding. Therefore, the nurse should notify the provider about this
laboratory value
7. A nurse is evaluating the safe use of electrical equipment by a newly hired
assistive personnel (AP). Which of the following actions by the AP
demonstrates an understanding of the proper use of electrical equipment?
ANS: Grasps the plug of a device in the client's room to pull it straight out from the
wall
RAT: The nurse should recognize that by grasping the plug, rather than the cord, the
AP is demonstrating an understanding of proper equipment use and preventing risk
of injury from electronic equipment.
8. A nurse is reinforcing discharge teaching with the parents of a school-age
child who has severe hemophilia A. Which of the following statements by the
parents indicates an understanding of the teaching?
ANS: "I will soak my child's toothbrush in warm water to soften it before my child uses
it."
RAT: The nurse should instruct the parents to soften their child's toothbrush in warm
water before they use it or allow them to use a sponge-tipped disposable toothbrush.
These actions will minimize trauma to the gums and prevent bleeding of the oral
cavity
9. A nurse is assisting with the development of an in-service for newly licensed
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