NP4

The nurse is caring for a child recovering from a tonsillectomy. Which fluid or food item would be offered to the child?

A. Clear Jell-O

B. Cold soda pop

 

C. Butterscotch pudding

D. Cool cherry-flavored Kool-Aid

A client receiving total parenteral nutrition (TPN) reports nausea, polydipsia, and polyuria. To determine the cause of the client’s report, the nurse would assess which client data?

A. Rectal temperature

B. Last serum potassium

C. Capillary blood glucose

D. Serum blood urea nitrogen and creatinine

The nurse caring for a client being treated for a bowel obstruction is preparing to administer an intermittent tube feeding through a nasogastric (NG) tube and assesses for residual volume. How do the resulting data assist in ensuring the client’s safety?

A. Confirm proper NG tube placement.

 

B. Determine client’s nutritional status.

C. Evaluate the adequacy of gastric emptying.

D. Assess client’s fluid and electrolyte status.

The nurse assists a postoperative appendectomy client from a lying to a sitting position to prepare for ambulation. Which nursing action is most appropriate initially to maintain the safety of the client?

A. Assess the client for signs of dizziness and hypotension.

B. Be sure that the client is wearing slippers with nonslip soles.

C. Secure the assistance of at least one additional staff member to help with the ambulation.

 

D. Encourage the client to support the abdomen with a small pillow while walking.

The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly?

A. The suction gauge reads low intermittent suction.

 

B. The client indicates that pain is a 3 on a scale of 0 to 10.

C. The distal end of the NG tube is pinned to the client’s gown.

D. The client denies nausea and has 250 mL of fluid in the suction collection container.

A client is admitted to the hospital with a suspected diagnosis of Graves’ disease. On assessment, which manifestation related to the client’s menstrual cycle would the nurse expect the client to report?

A. Amenorrhea

B. Menorrhagia

C. Metrorrhagia

 

D. Dysmenorrhea

The nurse is creating a plan of care for a client diagnosed with type 1 diabetes mellitus who is also experiencing acute gastroenteritis. To maintain food and fluid intake in order to prevent dehydration, which action would the nurse plan to include?

A. Offering only water until client is able to tolerate solid foods

B. Withholding all fluids until vomiting has ceased entirely for at least 4 hours

C. Encouraging client to take 8 to 12 ounces of fluid every hour while awake

D. Maintaining a clear liquid diet for at least 5 days before advancing to solid foods

The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action would the nurse plan to perform?

A. Obtain isopropyl alcohol to add to the bath water.

B. Allow 5 minutes for the child to soak in the bath water.

C. Have cool water available to add to the warm bath water.

D. Warm the water to the same body temperature as the child’s.

 

To monitor for a temporary but common postsurgical complication of a transsphenoidal resection of the pituitary gland, the nurse would regularly perform which assessment?

A. Pulse rate

B. Temperature

 

C. Urine output

D. Oxygen saturation

The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information would the nurse provide to the client to minimize the risk for surgery-related injury?

A. Cough and deep breathe hourly.

B. Nasal packing will be removed after 48 hours.

 

C. Report frequent swallowing or postnasal drip.

D. Acetaminophen is prescribed for severe postsurgical headache.

A client is receiving desmopressin intranasally. Which assessment parameters would the nurse monitor to determine the effectiveness of this medication?

A. Daily weight

B. Temperature

C. Apical heart rate

 

D. Pupillary response

The nurse creates a postoperative plan of care for a client scheduled for a hypophysectomy. Which interventions would be included in the plan of care? Select all that apply.

1. Obtain daily weights.

2. Monitor intake and output.

3. Elevate the head of the bed.

4. Use a soft toothbrush for mouth care.

5. Encourage coughing and deep breathing.

A. 1, 2

B. 1, 2, 3

C. 1, 2, 3, 4

D. 1, 2, 3, 4, 5

The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?

A. “Do you have tremors in your hands?”

B. “Are you experiencing pain in your joints?”

C. “Have you had problems with diarrhea lately?”

D. “Do you notice any swelling in your legs at night?”

A client is diagnosed with diabetes insipidus. The nurse would plan interventions to address which manifestations of this disorder? Select all that apply.

1. Bradycardia

2. Hypertension

3. Poor skin turgor

4. Increased urinary output 

5. Dry mucous membranes 

6. Decreased pulse pressure

A. 1, 2

B. 3, 4, 5, 6

C. 1, 3, 4, 5, 6

 

D. 1, 2, 3, 4, 5, 6

A client diagnosed with pneumonia reports a decreased sense of taste that has greatly affected the motivation to eat and drink. Which action would the nurse take to help increase the client’s appetite?

A. Offer snacks in between meals.

B. Provide three large meals daily.

C. Provide mouth care before meals.

D. Offer to sit with client during meals.

The clinic nurse wants to develop a teaching program for clients with a diagnosis of diabetes mellitus. Which strategy would the nurse initiate first in order to best meet the clients’ needs?

A. Assess the clients’ functional abilities.

B. Ensure that insurance will pay for participation in the program.

C. Discuss the focus of the program with the multidisciplinary team.

 

D. Include everyone who comes into the clinic in the teaching sessions.

The nurse is preparing the client’s morning prescribed NPH insulin dose and notices a clumpy precipitate inside the insulin vial. Which action would the nurse take?

A. Draw the dose from a new vial.

B. Draw up and administer the dose.

C. Shake the vial in an attempt to disperse the clumps.

D. Warm the bottle under running water to dissolve the clump.

The nurse is instructing a client with diabetes mellitus regarding hypoglycemia. Which statement by the client indicates the need for further teaching?

A. “Hypoglycemia can occur at any time of the day or night.”

B. “I need to drink 6 to 8 ounces of milk if hypoglycemia occurs.”

 

C. “If I feel sweaty or shaky, I might be experiencing hypoglycemia.”

D. “If hypoglycemia occurs, I need to take my regular insulin as prescribed.”

The nurse is teaching a client who had been newly diagnosed with diabetes mellitus about blood glucose monitoring. With knowledge that the reference range for the blood glucose is 70 to 99 mg/dL (3.9 to 5.5 mmol/L), the nurse would teach the client to report glucose results that consistently exceed which level?

A. 150 mg/dL (8.35 mmol/L)

 

B. 200 mg/dL (11.14 mmol/L)

C. 250 mg/dL (13.92 mmol/L)

D. 350 mg/dL (19.5 mmol/L)

A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse would provide the client with information concerning which condition?

A. Diabetes insipidus

B. End-stage renal disease (ESRD)

C. Chronic urinary tract infection (UTI)

D. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion

 

Which nursing assessment finding indicates the presence of an inguinal hernia on a child?

A. Reports of difficulty defecating

 

B. Reports of a dribbling urinary stream

C. Absence of the testes within the scrotum

D. Painless groin swelling noticed when the child cries

The nurse is caring for a child diagnosed with Reye’s syndrome. The nurse monitors for manifestations of which condition associated with this syndrome?

A. Protein in the urine

B. Symptoms of hyperglycemia

C. Increased intracranial pressure

D. A history of a Staphylococcus infection

The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse would include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?

A. Assist client to develop a daily bowel routine to prevent constipation.

B. Teach client to manage emotional stressors by using mental imaging.

C. Assess vital signs and observe for hypotension, tachycardia, and tachypnea.

 

D. Administer dexamethasone orally per the physician’s prescription.

A client diagnosed with epilepsy has a prescription for valproic acid 250 mg once daily. To maximize the client’s safety, which time is best for the nurse to schedule administration of the medication?

A. With lunch

B. With breakfast

C. Before breakfast

 

D. At bedtime with a snack

A client with a diagnosis of subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To promote safety, the nurse would ensure that which intervention is provided to the client?

A. Liquid diet

 

B. Enemas as needed

C. Help with ambulation

D. Daily stool softeners

The nurse prepares for the admission of the child with a diagnosis of tonic-clonic seizures and plans to place which items at the bedside?

A. A tracheotomy set and oxygen

B. Suction apparatus and oxygen

C. An endotracheal tube and an airway

 

D. An emergency cart and laryngoscope

The nurse prepares to transfer a client who has residual right-sided weakness as a result of a stroke from the bed to the wheelchair. With the client dangling on the side of the bed, which location would the nurse best position the wheelchair in for safety?

A. Directly in front of the client

B. At a right angle to the client’s left leg

C. Ninety degrees to the client’s right leg

D. At a right angle to the client’s right leg

The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data would indicate to the nurse that the standard of care as an organ donor has been maintained?

A. Urine output: 100 mL/hr

B. Capillary refill: 5 seconds

C. Blood pressure: 90/48 mm Hg

D. Heart rate: 60 beats per minute

A client diagnosed with brain death as a result of a severe head injury had received vigorous treatment to control cerebral edema. Which intervention would the nurse plan to implement as a priority to maintain viability of the kidneys before organ donation?

A. Screen the donor for infection.

B. Administer intravenous (IV) fluids.

C. Maintain ventilation and oxygenation.

 

D. Administer vasopressors intravenously.

The home care nurse visits a client who had a stroke with resultant unilateral neglect who was recently discharged from the hospital. Which instruction would the nurse provide to the family regarding care?

A. Assist the client from the affected side.

B. Place personal items directly in front of the client.

C. Discourage the client from scanning the environment.

D. Assist the client with grooming the unaffected side first.

The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to ensure client safety?

A. Monitoring for heel breakdown

B. Monitoring for bladder distention

 

C. Monitoring for extremity shortening

D. Monitoring for blanching ability of toenail beds

The nurse is performing pin-site care on a client in skeletal traction. Which normal finding would the nurse expect to note when assessing the pin sites?

A. Numbness at the pin sites

 

B. Warm skin around the pin sites

C. Clear drainage from the pin sites

D. Redness and swelling around the pin sites

The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how would the nurse respond?

A. A bone fragment has injured the nerve supply in the area.

B. An injured artery causes impaired arterial perfusion through the compartment.

 

C. Bleeding and swelling cause increased pressure in an area that cannot expand.

D. The fascia expands with injury, causing pressure on underlying nerves and muscles.

The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

A. Weak pedal pulses

B. Drainage at the pin sites

C. Complaints of leg discomfort

D. Toes are warm and demonstrate a brisk capillary refill

The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method?

A. Placing ice on top of the cast

B. Supporting the cast with the fingertips only

C. Asking client to support the cast during transfer

 

D. Using the palms of the hands

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care?

A. Avoid overuse of the eyes.

 

B. Decrease the amount of salt in the diet.

C. Eye medications will need to be administered for life.

D. Decrease fluid intake to control the intraocular pressure.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clini- cal manifestation would the nurse expect to note in the early stages of cataract formation? 

A. Diplopia

B. Eye pain

C. Floating spots

 

D. Blurred vision

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identies the accurate procedure for this visual acuity test?

A. The right eye is tested, followed by the left eye, and then both eyes are tested.

B. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye.

C. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart.

D. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?

A. Assessing for edema

B. Monitoring temperature

C. Monitoring blood pressure

D. Assessing blood glucose level

A client is prescribed an eye drop and an eye oint- ment for the right eye. How would the nurse best ad- minister the medications?

A. Administer the eye drop first, followed by the eye ointment.

B. Administer the eye ointment first, followed by the eye drop.

C. Administer the eye drop, wait 20 minutes, and ad- minister the eye ointment.

 

D. Administer the eye ointment, wait 20 minutes, and administer the eye drop.