8.

After a cerebrovascular accident, a 75-year-old client is admitted to the health care facility. The client has leftsided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client? A. B. Checking stools for occult blood Performing range-of-motion (ROM) exercises to the left side Keeping skin clean and dry Elevating the head of the bed to 30 degrees

FUNDAMENTALS OF NURSING 1. What should the nurse do first for a client with a sucking -stab wound to the chest? A. B. C. D. 2. Draw blood for hematocrit and hemoglobin values. Apply a dressing and tape it on three sides. Prepare a chest-tube insertion tray. Prepare to start an I.V. line. 9.

C. D.

Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is: A. B. C. D. prolonged partial thromboplastin time (PTT). recent history of warfarin (Coumadin) usage. diminished breath sounds. orthostatic hypotension.

Emergency medical technicians transport a 28-year-old iron worker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag." Which intervention by the nurse has the highest priority? A. B. C. D. Assessing the left leg Assessing the pupils Placing the client in Trendelenburg's position Assessing level of consciousness

10. While caring for a patient, the nurse notices that a fire has started in the patient's room. Which of the following actions should the nurse take FIRST? A. B. C. D. Pull the fire alarm. Confine the fire to the patient's room. Rescue the patient. Put out the fire.

3.

Enteric precautions for a client with salmonellosis include: A. B. C. D. Isolation in a private room Wearing a gown if soiling is likely Limiting visiting hours during the acute phase Wearing a mask when emptying the client's bedpan

4.

The nurse is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first? A. B. C. D. Administer ipecac syrup. Call an ambulance immediately. Call the poison control center. Punish the child for being bad.

11. On the third postoperative day after a subtotal gastrectomy, a client complains of severe abdominal pain. The nurse palpates the client's abdomen and notes rigidity. The nurse should first: A. B. C. D. Assist the client to ambulate Assess the client's vital signs Administer the prescribed analgesic Encourage the use of the spirometer

5.

A client is scheduled for a subtotal thyroidectomy. When preparing for the client's return from surgery the nurse should give priority to having available: A. B. C. D. Sandbags Hemostats Tracheotomy tray Nasogastric suction

12. A bone mineral analysis reveals that a patient who is postmenopausal has severe osteoporosis. Which of the following instructions should the nurse give to the patient's family to ensure a safe environment for the patient? A. B. C. D. "Disinfect the bathroom weekly." "Carpet floor surfaces." "Install handrails on stairways." "Keep the lights dim."

6.

A 60-year-old patient is found pulseless and breathless by the nurse during evening rounds. The nurse calls for help and starts CPR. In order to prevent internal injuries when performing chest compressions, the nurse should depress the sternum A. B. C. D. 1/2 - 1 inch. 1 - 1 1/2 inches. 1 1/2 - 2 inches. 2 - 2 1/2 inches.

13. A client with scleroderma complains of having difficulty chewing and swallowing. When providing dietary counseling, the nurse should advise the client to: A. B. C. D. Liquefy the food in a blender Puree all foods before eating Take frequent sips of water with meals Use a local anesthetic mouthwash before eating

7.

A parent of a six-year-old child asks, "Is it safe for my child to ride in the front seat when I have an emergency air bag device in the car?" Which of the following replies should the nurse give? A. B. C. D. "Yes, air bags are designed to take the place of safety seats or seat belts." "Yes, however, you must keep the seat position as close to the front of the car as possible." "No, children are safest in the middle of the back seat in a manual seat belt." "No, children should ride in the rear seat behind the driver."

14. The physician orders 2 units of blood to be infused into a client who is bleeding. Before blood administration the nurse's highest priority should be: A. B. C. D. Obtaining the client's vital signs Allowing the blood to reach room temperature Monitoring the hemoglobin and hematocrit levels Determining proper typing and crossmatching of blood

15. The nurse enters the client's room as the client, who is sitting in a chair, begins to have a seizure. Which of the following actions should the nurse take first? A. B. Lift the client onto his bed. Ease the client to the floor. 1

C. D.

Restrain the client's body movements. Insert an airway into the client's mouth.

C. D.

Place the client in reverse Trendelenburg's position. Cover the wound with sterile saline-moistened dressings.

16. The nurse observes that a patient has developed Parkinsonian side-effects of Thorazine. The nurse would expect which of the following drugs to be prescribed for the patient? A. B. C. D. Diazepam (Valium). Haloperidol (Haldol). Amitriptyline (Elavil). Benztropine (Cogentin).

24. The nurse is suctioning the tracheostomy of a 3-year-old client in a pediatric intensive care unit. The nurse should: A. B. C. D. Insert the catheter with the suction port of the catheter closed. Keep the catheter straight as it is removed from the tracheostomy tube. Use clean technique while suctioning. Insert the catheter slightly beyond the end of the tracheostomy tube.

17. A 5-year-old is being treated for asthma using adrenalin (epinephrine hydrochloride) SC stat. Which finding should be reported to the physician? A. B. C. D. Heart rate 120, BP 98/50 Tremors, BP 110/70 Heart rate 160, BP 140/96 Nausea, BP 20/70

25. After gathering all necessary equipment and setting up the supplies, which of the following would be the first step in performing endotracheal (ET) or tracheal suctioning in an infant? A. B. C. D. Provide extra oxygen by using a ventilator or through manual bagging. Insert a suction catheter to the appropriate measured length. Insert a few drops of sterile saline solution. Put on clean gloves.

18. A 5-year-old is admitted the emergency room for a possible appendicitis. Which of the following should the nurse perform first? A. B. C. D. Question parent and child about the illness Assess child's abdomen, beginning with least tender area Explain laboratory and diagnostic procedures Begin preoperative teaching to prevent complications

19. Which of the following instructions should be given to the family to ensure the safety of a patient who recently began experiencing periodic grand mal seizures? A. B. C. D. Place a tongue blade in the patient's mouth during a seizure Physically restrain the patient during the seizure Remove sharp objects in the patient's immediate environment Call the emergency medical squad when each seizure begins

26. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking one pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications? A. B. C. D. Weight reduction Decreasing salt intake Smoking cessation \Decreasing caffeine intake

27. A client is receiving 125 ml/hour of continuous I.V. fluid therapy. The nurse examines the venipuncture site and finds it red and swollen. Which of the following interventions would the nurse perform first? A. B. C. D. Slow the infusion to 10 ml/hour. Discontinue the infusion. Place cold towels on the site. Call the physician.

20. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by the triage nurse. The nurse would assign the highest priority to the client with the: A. B. C. D. lumbar spinal cord injury and lower extremity paralysis. maxillofacial injury and gurgling respirations. severe head injury and no blood pressure. second trimester pregnancy in premature labor.

28. In teaching a mother of an 18-month-old about prevention and safety in the home, the nurse should include which of the following measures in response to accidental ingestion? A. B. C. D. Induce vomiting with one dose of ipecac syrup Call the local Poison Control Center for advice prior to treatment Give the child several glasses of water to flush the substance Have the child eat the inner portion of a piece of bread

21. The physician has just inserted a central line for total parenteral nutrition (TPN) into a client who has a perforated bowel. The physician asks the nurse to begin infusing lactated Ringer's solution. Prior to starting the infusion, the nurse should verify which of the following? A. B. C. D. Clarity of the physician's order for I.V. solution The temperature of the solution The results of the chest X-ray taken after the insertion of the catheter The rate of the I.V. infusion

29. A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcer's location and severity. Immediately after the endoscopy, what would be a priority for the nurse to assess? A. B. C. D. Return of the gag reflex. Bowel sounds. Peripheral pulses. Intake and output.

22. What should the nurse do to ensure a safe hospital environment for a toddler? A. B. C. D. Place the child in a youth bed. Move stacking toys out of reach. Pad the crib rails. Move equipment out of reach.

23. The nurse determines that a client's abdominal wound has eviscerated. Which of the following would the nurse do first? A. B. Notify the client's physician immediately. Reinsert the protruding viscera into the abdominal cavity.

30. The nurse is providing care to a client with a catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should: A. B. C. D. ask the client which activity he would prefer to do first. negotiate a time when the client will perform activities. tell the client specifically and concisely what needs to be done. prepare the client ahead of time for the activity. 2

31. The parents of a six-month-old infant admitted with diarrhea are anxious and concerned. To involve the parents in the child's care, the nurse should first A. B. C. D. provide literature on diarrheal causes. allow the parents to record all diaper changes. teach the parents how to adhere to standard precautions. encourage the parents to continue the child's usual diet.

38. Which of the following measures would be most helpful for the infant with gastroesophageal reflux? A. B. C. D. Thickening the formula Less frequent burping Using smaller nipple holes Positioning supine after feeding

39. While in the playroom, a 7-year-old child has a twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. The nurse's best initial action would be to: A. B. C. D. Take the other children to their rooms Put a plastic airway into the child's mouth Place a large pillow under the child's head Move the toys and furniture away from the child

32. Evaluation of an elderly patient first day postoperative reveals a temperature of 100.6F. Which of the following actions should the nurse take first? A. B. C. D. Examine the patient Set up the intravenous antibiotic dose two hours early Call the physician Obtain STAT blood cultures

40. After a child has a cardiopulmonary arrest, which of the following drugs would the nurse expect to administer during the initial phase of treatment? A. B. C. D. dopamine epinephrine sodium bicarbonate atropine

33. A client with myasthenia gravis has increased difficulty in swallowing. The nurse would be most effective in preventing the aspiration of food by: A. B. C. D. Placing an emergency tracheostomy set in the client's room Changing the client's diet order from soft foods to clear liquids Assessing the client's respiratory status before and after meals Coordinating the client's meal schedule with peak effect of pyridostigmine bromide

41. A client is sitting in a chair and begins having a tonicclonic seizure. The most appropriate nursing response is to: A. B. hold the client's arm still to keep him from hitting anything. carefully move him to a flat surface and turn him on his side. allow him to remain in the chair but move all objects out of his way. place an oral airway in his mouth to maintain an open airway.

34. Which of the following is the most common method used to prevent bronchopulmonary dysplasia (BPD) in very low birth weight infants? A. B. C. D. Using the lowest peak inspiratory pressure and O2 level necessary to maintain adequate oxygenation. Suctioning the neonate's hypopharynx vigorously before the delivery of the shoulders. Preventing premature delivery, especially in early delivery and cesarean sections. Administering exogenous surfactant shortly after a premature baby is born.

C. D.

42. The nurse reviews with the parents how to care for their child with sickle cell anemia at home. The nurse determines that the parents understand the basic principles of care when they state that they will do which of the following? A. B. C. D. Keep the child with them at all times. Restrict the child's fluids at night. Encourage their child to drink as much liquid as possible. Not allow their child to play with other children.

35. A 23-month-old pulled a pan of hot water off the stove and spilled it onto her chest and arms. Her mother was right there when it happened. Which of the following should the mother have done immediately? A. B. C. D. Apply ice directly to the burned areas. Place the child in the bathtub of cool water. Apply antibiotic ointment to the burned areas. Call the neighbor to come over and help her.

43. A 2-year-old child is brought to the emergency department (ED) after ingesting an unknown number of children's aspirin about 30 minutes ago. On entering the examination room, the child is crying and clinging to the mother. Which assessment data should the nurse obtain first? A. B. C. D. Heart rate, respiratory rate, and blood pressure Recent exposure to communicable diseases Number of immunizations received Height and body weight

36. A 59-year-old man is brought to the hospital emergency room after being found pulseless and breathless at his desk. Basic cardiopulmonary resuscitation (CPR) was initiated immediately by his co-workers. Before continuing chest compressions and rescue breathing on the patient in the emergency room, which of the following information would it be ESSENTIAL for the nurse to know? A. B. C. D. What caused the cardiac arrest. Whether his family wants him resuscitated. Whether he is breathing and has a pulse. How long he has been pulseless and breathless.

44. The nurse is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first? A. B. C. D. Administer ipecac syrup. Call an ambulance immediately. Call the poison control center. Punish the child for being bad.

37. During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with: A. B. C. D. alcohol. ammonia. acetone. bleach.

45. In teaching a client with tuberculosis about self-care at home, the nurse will include all of the following measures. Which of the measures would have the highest priority? A. B. C. D. Getting adequate rest. Eating a nourishing diet. Taking medications as prescribed. Quitting smoking.

46. A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission will be to: A. B. C. D. Monitor the client's vital signs Increase the client's fluid intake Improve the client's nutritional status Identify the client's reasons for drinking

scheduled. Which of the following nursing interventions would take priority during the first 24 postoperative hours? A. B. C. D. Monitoring vital signs hourly. Maintaining strict bed rest. Monitoring vaginal bleeding. Maintaining electrolyte balance.

47. When an individual lights a barbecue grill with lighter fluid, his shirt bursts into flames. To extinguish the flames most effectively, with as little further damage as possible, it is best to: A. B. C. D. Remove the burning clothes Slap the flames with the hands Log-roll the person in the grass Pour cold liquid over the flames

54. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, the nursing plan of care should include which intervention? A. B. C. D. Check on the client once per shift. Provide mouth and skin care only if the family requests it. Turn the client only if he's uncomfortable. Provide emotional support and pain relief.

48. The nurse discovers a 5-year-old child who is unresponsive, apneic, and pulseless. The correct sequence of events that should follow is to: A. B. C. D. call for help, open the airway, provide two rescue breaths, and begin compressions at a rate of 100 per minute. open the airway, provide two rescue breaths, and begin compressions at a rate of 100 per minute. call for help, open the airway, provide two rescue breaths, and begin compressions at a rate of 80 per minute. call for help, continue to attempt to arouse, and assess for breathlessness and lack of pulse until a second rescuer arrives.

55. A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. Once the flames are extinguished, it is most important to: A. B. C. D. Give the person sips of water Assess the person's breathing Cover the person with a warm blanket Calculate the extent of the person's burns

56. When assisting the physician in cardioversion of a client admitted with ventricular tachycardia, the nurse knows that cardioversion differs from defibrillation. Which of the following is associated with the delivery of the shock with cardioversion? A. B. C. D. Asynchronous shock with the R wave. Synchronous shock with the QRS complex. Use of a higher wattage. Use of a different machine.

49. A client's respiratory status necessitates endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for this client at this time would be to: A. B. C. D. Prepare the client for emergency surgery Facilitate the client's verbal communication Assess the client's response to the equipment Maintain sterility of the ventilation system the client is using

57. The client with cancer of the larynx is admitted to the unit with Acute Respiratory Distress Syndrome. Which nursing diagnosis should receive priority? A. B. C. D. Alteration in oxygen perfusion Alteration in comfort/pain Alteration in mobility Alteration in sensory perception 103. 1 Remember the ABCs: Airway is alwys first. (SR 5380) 58. Which of the following nursing diagnoses would receive the greatest priority in the care of an unconscious client with a head injury? A. B. Impaired Gas Exchange related to shallow irregular breathing. Risk for Injury related to disorientation and decreased level of consciousness. Disturbed Sensory Perception related to decreased level of consciousness. Ineffective Airway Clearance related to inability to remove respiratory secretions.

50. A home care nurse provides instructions regarding basic infection control to the mother of a child with human immunodeficiency virus (HIV) infection. Which statement if made by the mother indicates the need for further instructions? A. B. C. D. "I will carefully wash all fresh fruits and vegetables." "I will wash baby bottles, nipples, and pacifiers in the dishwasher." I will clean up any spills from the diaper with fullstrength alcohol." "I will rub the inside of the nipple with salt and rinse well if it becomes slimy."

51. In anticipation of the needs of a client who is being admitted with a gunshot wound to the chest, the nurse should first: A. B. C. D. Reserve an operating room Prepare equipment for a tracheotomy Prepare equipment for chest tube insertion Arrange for a portable chest x-ray examination

C. D.

52. A 16-year-old who is depressed cheers up and gives her teddy bear to her favorite nurse. Which of the following is the priority for the nurse at this time? A. B. C. D. Assess the adolescent for possible suicidal ideation Tell her mother to call for a psychiatric referral Give the bear back and discuss transitional objects Praise her mood change and her passage from childhood

59. A client with chronic obstructive lung disease tells the nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer a prescribed nebulizer treatment. The therapist says, "I have several more percussions to do on the unit where I am now. As soon as I'm done, I'll come assess the client." The nurse's most appropriate action is to: A. B. C. D. notify the primary physician immediately. stay with the client until the therapist arrives. administer the treatment by metered-dose inhaler. give the nebulizer treatment herself. 4

53. After examination and diagnostic testing, the client is diagnosed with cancer of the cervix in situ. A conization is

60. A home health nurse notes excessive swallowing in a 7year-old boy who had a tonsillectomy one week ago. Which of the following would be the nurse's priority intervention? A. B. C. D. Examine the child's throat, as this indicates bleeding. Administer extra fluids, as this indicates dehydration. Administer aspirin, as this indicates pain. Instruct the child to spit secretions instead of swallowing them.

68. A client is admitted to the hospital with weakness in the right extremities and a slight speech problem. Vital signs are normal. During the first 24 hours the nurse should give priority to: A. B. C. D. Checking the client's temperature Evaluating the client's motor status Monitoring the client's blood pressure Obtaining a urine specimen from the client

61. To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site? A. B. C. D. Radial Apical Carotid Brachial

69. A 65-year-old woman is scheduled for discharge after a cholecystectomy. She is found pulseless and breathless on the floor of her hospital room by the nurse. Two nurses initiate cardiopulminary resuscitation (CPR). Chest compressions and rescue breathing should be performed at a ratio of A. B. C. D. 30:1 30: 2 15: 1 15:2.

62. A nursing assistant reports that a blood pressure reading is elevated for a healthy child. Which of the following should the nurse do first? A. B. C. D. Check the size of the cuff Retake it in the same arm Take it in the other arm Question the child's past history

70. The nurse cares for a patient being maintained on a ventilator. The patient suddenly becomes distressed and agitated. Which of the following actions should the nurse take FIRST? A. B. C. D. Obtain an order for a tranquilizer. Restrain the patient. Check the last arterial blood gas result. Assess the patient and functioning of the ventilator.

63. Which of the following criteria are acceptable for a rescuer to discontinue CPR? A. B. C. D. When it is obvious that the victim will not survive. When the rescuer is exhausted. After 30 minutes of CPR without a pulse rate. When the family requests discontinuation.

71. The night nurse informs the primary nurse that a client receiving intermittent gavage feedings is not tolerating them. The primary nurse should first: A. B. C. D. Change the feeding schedule to omit nights Request that the type of solution be changed Observe the night nurse administering a feeding Suggest that the prescribed antiemetic be given first

64. A 10-month-old child with bronchitis is taken out of the 30% oxygen tent for breakfast because he refuses to eat unless in a high chair. During the feeding, the nurse notes that the child's respiratory rate has increased, he is becoming more irritable, and he is using accessory muscles to breathe. The first action of the nurse should be to: A. B. C. D. Discontinue the feeding and place the child back in the tent. Assess the pulse rate and respirations and notify the physician. Perform postural drainage then complete the feeding. Suction the child's nose with a bulb syringe.

72. A parish nurse conducts socialization groups for the elderly, health screening clinics, and home visits. If the nurse prioritizes her programs according to Maslow's hierarchy of basic human needs, on which effort would she work first? A. B. C. Organizing a group of volunteers to run a monthly food bank and assist at the blood bank Presenting a speakers' bureau on topics such as role adjustment and stress management Sponsoring potlucks, dances, and singles mixers for the seniors in the community Teaching a class on scheduling and organizing accurate medication usage to prevent underdosing or overdosing

65. What should the nurse do first for a client with a sucking stab wound to the chest? A. B. C. D. Draw blood for hematocrit and hemoglobin values. Apply a dressing and tape it on three sides. Prepare a chest-tube insertion tray. Prepare to start an I.V. line.

D.

66. A client with a history of hypertension and left ventricular failure arrives for a scheduled clinic appointment and tells the nurse, "My feet are killing me. These shoes got so tight." The nurse's best initial action would be to: A. B. C. D. Weigh the client Notify the physician Take the client's pulse rate Listen to the client's breath sounds

73. The nurse cares for a 72-year-old man with a diagnosis of cerebral vascular accident (CVA). The nurse is feeding the patient in a chair when he suddenly begins to choke. The patient is conscious, but unable to speak. Which of the following actions should the nurse take FIRST? A. B. C. D. Encourage the patient to cough to try to dislodge the food. Leave the patient in the chair and apply vigorous abdominal or chest thrusts from behind the patient. Return the patient to the bed and apply vigorous abdominal or chest thrusts while straddling the patient's thighs. Apply several vigorous back blows until the food dislodges.

67. A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased work of breathing, and a decreased oxygen saturation level. Which of the following should be the nurse's first action? A. B. C. D. Suction the tracheostomy. Turn the child to a side-lying position. Administer pain medication. Perform chest physiotherapy.

74. A 48-year-old man is brought to the emergency room. Cardiopulmonary resuscitation (CPR) is initiated by the nursing staff and the patient is prepared for defibrillation. After the physician discharges the defibrillator paddles once, which of the following actions would be MOST important for the nurse to take next? A. B. Start an IV. Continue CPR. 5

C. D.

Assess the patient's respirations. Check the cardiac monitor.

A. B.

75. What would be the most important nursing intervention in caring for the client's residual limb during the first 24 hours after amputation of the left leg? A. B. C. D. Keeping the residual limb flat on the bed. Abducting the residual limb on a scheduled basis. Applying traction to the residual limb. Elevating the residual limb on a pillow.

C. D.

Covering the child's nose and mouth with their own mouth when giving breaths. Locating the brachial artery to check for the presence or absence of a pulse. Placing the fingers for compression on an imaginary line between the child's nipples. Giving one rescue breath for every five chest compressions.

76. A nurse is presented with a group of patients in the emergency room. The nurse knows that which of the following patients needs immediate attention? A. B. C. D. A child who is bleeding from a facial injury. A middle-aged patient with mid-sternal chest pain. A middle-aged patient in respiratory distress. An infant who has been vomiting for 2 days.

83. Following a laryngectomy, a client, who is being discharged, exhibits concern that the laryngectomy tube may become dislodged. The nurse should teach the client to first: A. B. C. D. Notify the physician at once Reinsert another tube immediately Keep calm because there is no immediate emergency Recognize that prompt closure of the tracheal opening may occur

77. A client's chest tube accidentally disconnects from the drainage tube when she turns onto her side. Which of the following actions should the nurse take first? A. B. C. D. Notify the physician. Clamp the chest tube. Raise the level of the drainage system. Reconnect the tube.

84. Which technique is most effective in preventing nosocomial infection transmission when caring for a preschooler? A. B. C. D. Client isolation Standard precautions Hand washing Needleless syringe system

78. While preparing to start a STAT I.V. infusion, the nurse notices that the ground on the infusion pump's plug is missing. What should the nurse do first? A. B. C. D. Use the pump as is because the medication is ordered STAT. Obtain another pump from central supply for the infusion. Tape the broken ground to the plug and use the pump. Report the broken prong to the supervisor.

85. A client with heart failure has been receiving an I.V. infusion at 125 ml per hour. Now the client is short of breath, and the nurse notes bilateral crackles, neck vein distention, and tachycardia. What should the nurse do first? A. B. C. D. Notify the physician. Discontinue the I.V. access device. Administer the prescribed diuretic. Slow the infusion and notify the physician.

79. A 68-year-old man is being discharged after having a transurethral prostatectomy (TURP) for benign prostatic hypertrophy (BPH). The nurse's discharge teaching plan should reinforce adherence to which of the following measures? A. B. C. D. Avoiding vigorous exercise for three weeks. Avoiding cold foods for one week. Avoiding hot baths for one month. Avoiding high-residue foods for two weeks.

86. At midnight, two days following his hemicolectomy, a 60year-old male patient awakens frightened and agitated. He climbs out of bed, removes his indwelling urinary drainage catheter and runs down the hall screaming. Which of the following actions would be most appropriate for the nurse to take INITIALLY? A. B. C. D. Call the physician and request a sedative for the patient. Return the patient to his bed and restrain him immediately. Replace the patient's indwelling urinary drainage catheter. Return the patient to his bed and assess his condition.

80. A child survives a near-drowning episode in a cold pond but still has many problems to overcome. The nurse is aware that the ultimate prognosis will depend mainly on the extent of damage resulting from the: A. B. C. D. Hypoxia Hyperthermia Emotional trauma Aspiration pneumonia

87. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation? A. B. C. D. Stop the flow of solution temporarily. Reposition the client on to her right side. Remove the irrigation tube. Massage the abdomen gently.

81. A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a three-way urinary drainage catheter with a 30 ml balloon tip. Tension has been applied to the catheter. The patient complains that he feels pressure in his bladder and rectum and feels as though he has to urinate. Which of the following actions should the nurse take FIRST? A. B. C. D. Assess the patency of the catheter. Give the patient a bedpan. Empty the urinary drainage bag. Decrease the tension on his catheter.

88. For a client with a sucking stab wound in the chest wall, the nurse should first: A. B. C. D. Start administering oxygen. Cover the wound with a petroleum-impregnated dressing. Prepare to do a tracheostomy. Prepare for endotracheal intubation.

82. Which of the following would the nurse include when teaching the parents how to perform cardiopulmonary resuscitation for their 2-year-old child?

89. A 2-year-old boy is admitted for evaluation of a convulsive disorder. While playing on the floor in his hospital room, he has a grand mal seizure. Which of the following actions, if taken by the nurse, would be MOST appropriate? A. B. Insert a tongue depressor in his mouth. Place a pillow under his head. 6

C. D.

Restrain him. Cover him with a blanket.

90. Which of the following should the school nurse do first when a child with diabetes mellitus becomes unresponsive during recess? A. B. C. D. Administer glucagon as prescribed. Administer 3 to 6 ounces of orange juice. Give the child milk and peanut butter crackers. Immediately transport the child by car to the hospital.

98. The community health nurse develops a health education program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the community residents identify which of the following activities to be high risk for acquiring hepatitis B? A. B. C. D. Frequent use of marijuana. Ingestion of large amounts of acetaminophen (Tylenol). Sharing needles for drug use. Ingestion of contaminated seafood.

91. A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure the client is placed: A. B. C. D. on protective isolation. on neutropenic precautions. in a negative-pressure room. on contact isolation.

99. The nurse is caring for a client who is about to have a lumbar puncture. Planned care following the procedure should include: A. B. C. D. Having the client lie in the supine position for 6 to 12 hours Encouraging the client to ambulate every hour for 6 to 8 hours Maintaining the client in the Trendelenburg's position for 4 hours Placing the client in high-Fowler's position immediately after the procedure

92. A man who had a cerebral vascular accident (CVA) develops dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take FIRST? A. B. C. D. Place him in high-Fowler's position. Order a soft diet. Check his gag reflex. Offer to cut his food.

100.The nurse knows a client has understood the teaching about limiting the discomfort associated with a hiatal hernia when the client states, "After meals I will: A. B. C. D. Take a short walk." Drink 8 oz of water." Rest in a sitting position for l/2 hour." Lie down in bed for at least 20 minutes."

93. Home safety for an elderly patient whose mobility is impaired should include which of the following measures? A. B. C. D. Carpeting stairways Waxing kitchen floors Installing handrails next to the tub and toilet Placing throw rugs in hallways and doorways

94. In caring for the client with hepatitis B, which of the following situations would most likely expose the nurse to the virus? A. B. C. D. Contact with fecal material. A blood splash into the nurse's eyes. Touching the client's arm with ungloved hands while taking a blood pressure. Disposing of syringes and needles without recapping.

95. A client has been in a coma for 2 months and is maintained on bed rest. The nurse understands that to prevent the effects of shearing force, the head of the bed should be at an angle of: A. B. C. D. 30 degrees 45 degrees 60 degrees 90 degrees

96. A client is admitted to the hospital with blunt chest trauma following a motor vehicle accident. The first nursing priority for this client would be to: A. B. C. D. assess the client's airway. provide pain relief. encourage deep breathing and coughing. splint the chest wall with a pillow.

97. The nurse performs cardiopulmonary resuscitation (CPR) for a patient found pulseless and breathless on the floor of the bathroom. After CPR, the patient's pulse returns and only rescue breathing is required. The nurse performing rescue breathing should breathe at a rate of A. B. C. D. 8 times per minute. 12 times per minute. 15 times per minute. 20 times per minute.