A 56-year-old male is newly admitted to the medical unit. Which factor alerts the nurse that this client has a risk for acid-base imbalances? A. The client takes antacids for occasional indigestion. B. The client gets short of breath with extreme exertion. C. The client has a history of myocardial infarction 1… Read More »
Sally is a nurse working in an emergency department and receives a client after a radiological accident. Which task is the utmost priority for the nurse to do first? A. Decontaminate the client’s clothing. B. Decontaminate the open wound on the client’s thigh. C. Decontaminate the examination room the client is placed in. … Read More »
You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up? A. Frequent swallowing B. Hypotonic bowel sounds C. Complaints of a sore throat D. Heart rate of 112 beats/min … Read More »
The nurse is assigned to a client with meningococcal meningitis. Which information about the client is the best indicator that the nurse can discontinue droplet precautions? A. Appropriate antibiotics have been given 24 hours B. Cough is productive of clear, nonpurulent mucus C. Pupils are equal and reactive to light D. Temperature is… Read More »
The monitor watcher from the telemetry units informs the assigned nurse that the client developed prominent U waves. Which laboratory value should the nurse monitor? A. Sodium level B. Potassium level C. Calcium level D. Magnesium level Correct Answer: B. Potassium level The nurse should immediately check… Read More »
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action? A. Perform endotracheal intubation and initiate mechanical ventilation. B. Immediately begin continuous… Read More »
Paige is a nurse preceptor who is working with a new nurse, Joyce. She notes that Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is most likely due to: A. Role modeling behaviors of the preceptor B. The philosophy of the new nurse’s school of nursing… Read More »
A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are sounding, “We were running around outside the school and he got hit in the abdomen with a stick!” Which statement should be a priority? A. “The stick was absolutely filthy and… Read More »
A newly admitted client is suspected to have avian influenza (“bird flu”) due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first? A. Give first dose of oseltamivir (Tamiflu) B. Instill 5% dextrose in water at 100 mL/hr C. Collect blood and sputum specimens for testing … Read More »
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant? A. Assisting the patient to sit up on the side of the bed. B. Instructing the patient to cough effectively. C. Teaching the patient to use incentive spirometry. D. Auscultation of… Read More »