1) A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?
¾ cup of canned tomato juice
The nurse would recognize that the client didn't understand because tomato juice has a lot of sodium in it.
2)A nurse in a providers office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25mg every six hours as needed. Available is diphenhydramine 12.5/5mL. How many teaspoons of medicine does the nurse need to instruct the parents to administer per dose?
2 tsp
3) A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the clients diet?
Grape Juice, Ice Cream
4)A nurse is examining a client's lymphatic system. Identify the site nurse should palpate to assess the posterior cervical lymph nodes.
Toward the back of the neck
5) A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?
Sims
6) A nurse in a provider's office is caring for a client who has depression and is taking St. Johns Wort. The herbal supplement is thought to improve which of the following?
Mood
St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety.
7) A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?
partial thickness skin loss
Characteristics for a stage II ulcer include partial thickness skin loss. The nurse would know this because she is familiar with the stages of pressure ulcers.
8) A nurse on a pediatric unit is caring for an infant who is diagnosed with larynotrachebronchitis. While performing a respiratory examination the nurse hears which sound?
STRIDOR
Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchiti
9) A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should the client be elected over areas if consolidation during percussion?
Dullness
The nurse would know that a client with pneumonia likely would have a dullness sound in his lungs.
10) A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking blood pressure can result in an inaccurately low reading?
Using a cuff that is too wide.
Using a cuff that is too wide can result in a false low blood pressure reading.
11) A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take?
restrict fluid intake
Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.
12) A nurse in caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The clients states, I will quit smoking if the results don't come back positive for cancer.
Bargaining.
The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.
13) A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should indicate that the diseases could by transmitted in which of the following ways?
Vector
The nurse would know that the way Lyme disease is typically transmitted is through a tick, therefore it would fall in the vector category.
14) A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the vetrogluteal muscle?
1 ½
A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.
15) A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur?
lying on side
This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.
.
Explanation:
