,An older adult male reporting abdominal pain is admitted to the
hospital from a long term care facility. It has been seven days
since his last bowel movement, and his abdomen is distended,
and he just vomited 150 milliliters of dark brown emesis. In what
order should the nurse implement these interventions?
a. Elevate the head of bed
b. Complete focus assessment
c. Offer PRN pain medication
d. Send emesis sample to the lab - ans a. Elevate the head of bed
c. Offer PRN pain medication
b. Complete focus assessment
d. Send emesis sample to the lab
What is the primary purpose for initiating nursing interventions
that promote good nutrition, rest and exercise, and stress
reduction for clients diagnosed with and HIV infection?
a. Increase ability to carry out activities of daily living
b. Promote a feeling of general well-being
c. Prevent spread of infection to others
d. Improve function of the immune system - ans d. Improve
function of the immune system
A nurse who works in the nursery is attending the vaginal
delivery of a term infant. What action should the nurse complete
prior to leaving the delivery room?
a. Obtain the infants vital signs
b. Observe the instant latching on to the breast
c. Place the ID bands on the infant and mother
d. Administer vitamin K injection - ans c. Place the ID bands on
the infant and mother
,The nurse is preparing a client with an acoustic neuroma for a
magnetic resonance image (MRI). Which client complaint is life
threatening and should be reported to the health care provider
immediately?
a. Difficulty with balance
b. Intensifying headache
c. Right ear hearing loss
d. Facial numbness - ans b. Intensifying headache
A client with chronic kidney disease (CKD) is discharged with a
prescription for epoetin alpha subcutaneously. In teaching the
client about the medication, the nurse should emphasize the
benefit of increasing which food product in the diet?
a. Iron rich foods
b. High fiber foods
c. Citrus fruits and vegetables
d. Dairy products - ans a. Iron rich foods
An adult client is admitted to the psychiatric unit with a
diagnosis of major depression. After two weeks of antidepressant
medication therapy, the nurse notices the client has more energy,
is giving personal belongings away to visitors, and is in a better
mood. Which intervention is best for the nurse to implement?
a. Tell the client to keep one's belongings because they will be
needed at discharge
b. Support the client by validating the progress that has been
made
c. Reassure the client that the antidepressant drugs are apparently
effective
d. Ask the client if there are any recent thoughts of harming self -
ans d. Ask the client if there are any recent thoughts of harming
self
, While changing the clients postoperative dressing, the nurse
observes are red and swollen wound with a moderate amount of
yellow and green drainage and a foul odor. Before reporting this
finding to the health care provider, the nurse should evaluate
which of the client's laboratory values?
a. C reactive protein level
b. Serum albumin
c. Neutrophil count
d. Creatinine level - ans c. Neutrophil count
An adult woman who has a history of inferior myocardial
infarction, esophageal reflux, and type 1 diabetes mellitus is
admitted to the telemetry unit for sudden onset of dizziness with
palpitations and a burning sensation in her chest. Which
intervention should the nurse implement first?
a. Evaluate telemetry cardiac rhythm
b. Administer an oral antacid
c. Assess blood glucose level
d. Review clients last meal choices - ans a. Evaluate telemetry
cardiac rhythm
When conducting diet teaching for a client who was diagnosed
with a myocardial infarction, which snack foods should the nurse
encourage the client to eat? Select all that apply.
a. Chicken bouillon soup and toast
b. Fresh vegetables with mayonnaise dip
c. Fresh Turkey slices and berries
d. Raw unsalted almonds and apples
e. Soda crackers and peanut butter - ans c. Fresh Turkey slices and
berries
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