A nurse is assisting with the development of a plan of care to manage pain for a client who has
herpes zoster with lesions on the lower extremities. Which of the following interventions should
the nurse include in the plan of care?
Keep bed linens o of the affected areas.
Position a heat lamp over the lower extremities.
Apply warm, moist compresses to the affected areas.
Initiate droplet isolation precautions. - ANS Keep bed linens o of the affected areas.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which
of the following instructions should the nurse include to promote comfort?
Sleep on a firm mattress.
Try jogging in place when joints feel stiff.
Use a soft chair or recliner for sitting.
Apply ice packs to painful joints - ANS Sleep on a firm mattress.
A nurse is caring for a client who has an intestinal obstruction and reports a new onset of
nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV
infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?
Check for kinks in the NG tube.
Increase the IV uid rate.
Provide ice chips.
Administer an antiemetic - ANS Check for kinks in the NG tube.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is
receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following
findings should indicate to the nurse that the client's therapeutic regimen is effective?
Adventitious lung sounds
Decrease in exertional dyspnea
Respiratory rate of 26/min while sitting in a chair
Elevation of the head of the bed is required to sleep - ANS Decrease in exertional dyspnea
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports
increased pain at the site of the fracture. Which of the following actions should the nurse take?
Massage the area.
Remove the weights.
Loosen the ropes.
Reposition the client - ANS Reposition the client
,A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify
the sequence of actions the nurse should follow. (Move the steps into the box on the right,
placing them in the order of performance. Use all the steps.)
Lower the client to the floor.
Loosen the clothing around the client's neck.
Place a pad beneath the client's head.
Time the length of the client's seizure.
Reorient and reassure the client. - ANS Lower the client to the floor.
Place a pad beneath the client's head.
Loosen the clothing around the client's neck.
Time the length of the client's seizure.
Reorient and reassure the client.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for
regular and NPH insulin. Which of the following instructions on preparing the insulins should the
nurse include?
Withdraw both types of insulin and then add 0.2 mL of air to the syringe
Gently shake the NPH insulin prior to withdrawing the dose.
Withdraw the regular insulin before withdrawing the NPH insulin.
Inject air into the NPH vial after withdrawing regular insulin. - ANS Withdraw the regular insulin
before withdrawing the NPH insulin.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated
hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the
teaching?
The expected therapeutic reference range for HbA1c for a client who has diabetes mellitus is
9.5% to 10%.
An HbA1c level below the expected reference range indicates ineffective glucose control
HbA1c results measure glucose control for the prior 3 months.
HbA1c testing is used to provide a diagnosis of diabetes mellitus - ANS HbA1c results measure
glucose control for the prior 3 months.
A nurse is collecting data from a client who has 30% body surface area deep partial-thickness
and full-thickness burns. Which of the following findings indicates that fluid resuscitation is
adequate?
Granulation tissue is present.
Urine output is 50 mL/hr.
Lung sounds are clear.
Oxygen saturation level is 95%. - ANS Urine output is 50 mL/hr.
, A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the
following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube attached to low suction
A client who is dehydrated, has mental confusion, and has tried to get out of bed several times
during the night
A client who had a right lower lobectomy 4 days ago and has 50 mL/hr of serous drainage from
a chest tube
A client who has pneumonia, has an elevated oral temperature, and is requesting medication for
a cough - ANS A client who is dehydrated, has mental confusion, and has tried to get out of bed
several times during the night
A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of
the following information should the nurse include?
"Use barrier methods for sexual contact when lesions are present."
"Look for lesions that have a wart-like appearance."
"The virus can be transmitted without lesions being present."
"The lesions resolve in 2 weeks and usually do not recur." - ANS "The virus can be transmitted
without lesions being present."
A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse
should document the sound as which of the following? (Click on the audio button to listen to the
clip.)
Pleural friction rub
Wheezes
Vesicular
Crackles - ANS Wheezes
A nurse is reviewing the medication record of a client who is taking digoxin. Which of the
following medications should the nurse identify as increasing the risk for the client to develop
digoxin toxicity?
Potassium chloride
Famotidine
Levothyroxine
Furosemide - ANS Furosemide
A nurse is changing the dressing for a client who has an abdominal incision and a
closed-suction drain. Which of the following actions should the nurse take?
Secure the drainage tube to the client's bedding.
Wear sterile gloves to empty the drainage system.
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