ttc PART C(1-60)

A nurse is caring for a client who has bipolar disorder and is experiencing

acute mania. The nurse obtained a verbal prescription for restraints. Which

of the following should the actions the nurse take?

A. Request a renewal of the prescription every 8 hr.

B. Check the client's peripheral pulse rate every 30 min

C. Obtain a prescription for restraint within 4 hr.

D. Document the client's condition every 15 minutes

D

A nursing planning care for a school-age child who is 4 hr

postoperative following perforated appendicitis. Which of the following

actions should the nurse include in the plan of care?

a. Offer small amounts of clear liquids 6 hr following surgery (assess for

gag reflex first)

b. Give cromolyn nebulizer solution every 6 hr (for asthma)

c. Apply a warm compress to the operative site every 4 hr

d. Administer analgesics on a scheduled basis for the first 24 hr

D

A nurse is receiving change-of-shift report for a group of clients.

Which of the following clients should the nurse plan to assess first?

a. A client who has sinus arrhythmia and is receiving cardiac monitoring

b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%

c. A client who has epidural analgesia and weakness in the lower

extremities

d. A client who has a hip fracture and a new onset of tachypnea

D

A nurse is preparing to apply a transdermal nicotine patch for a

client. Which of the following actions should the nurse take?

a. Shave hairy areas of skin prior to application (apply to hairless, clean &

dry areas to promote absorption; avoid oily or broken skin)

b. Wear gloves to apply the patch to the client's skin

c. Apply the patch within 1 hr of removing it from the protective pouch

d. Remove the previous patch and place it in a tissue (fold patch in

half with sticky sides pressed together)

B

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

a. A client who was just given a glass of orange juice for a low blood

glucose level

b. A client who is schedule for a procedure in 1 hr (can wait)

c. A client who has 100 mL fluid remaining in his IV bag (can wait)

d. A client who received a pain medication 30 min ago for postoperative pain.

A

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

a. A history of gastroesophageal reflux disease

b. Receiving a high osmolarity formula

c. Sitting in a high-Fowler's position during the feeding

d. A residual of 65 mL 1hr postprandial

A

A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

a.Serum glucose level increased

b. Serum calcium level-decreased

c. Lymphocyte count- decreased immune system.

d. Serum potassium level- decreased

A

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take?

a. Position the client supine

b. Prepare an IV bolus of dextrose 5% in water

c. Administer methylergonovine IM

d. Administer calcium gluconate IV

D

A charge nurse is teaching new staff members about factors that

increase a client's risk to become violent. Which of the following risk factors

should the nurse include as the best predictor of future violence?

a. Experiencing delusions

b. Male gender

c. previously violent behavior

d. A history of being in prison

C

A nurse is preparing to perform a sterile dressing change. Which of

the following actions should the nurse take when setting up the sterile

field?

a. Place the cap from the solution sterile side up on clean surface

b. Open the outermost flap of the sterile kit toward the body→ flap

AWAY from the body's first

c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the

sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap

that is considered contaminated.

d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW

waist level; should be ABOVE waist level

A

A nurse is providing teaching to an older adult client about methods

to promote nighttime sleep. Which of the following instructions should the

nurse include?

a. Eat a light snack before bedtime

b. Stay in bed at least 1 hr if unable to fall asleep

c. Take a 1 hr nap during the day

d. Perform exercises prior to bedtime

A

A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

a. Educate the client about current medical diagnosis

b. Refer the client to a meal delivery program

c. Identify environmental hazards in the home

d. The client is showing evidence of phenytoin toxicity

e. Arrange for client transportation to follow-up

C

A nurse is assessing the remote memory of an older adult client who

has mild dementia. Which of the following questions should the nurse

ask the client?

a. "Can you tell me who visited you today?"

b. "What high school did you graduate from

c. "Can you list your current medications?"

d. "What did you have for breakfast yesterday?"

B

A nurse is providing teaching to an adolescent who has type 1

diabetes mellitus. Which of the following goals should the nurse include in

the teaching

a. HbA1c level greater than 8%

b. Blood glucose level greater than 200 mg/dL at bedtime

c. Blood glucose level less than 60 mg/dL before breakfast

d. HbA1c level less than 7%

D

A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

a. The client is experiencing an adverse reaction to rifampin

b. The client's seizure disorder is no longer under control

c. The client is experiencing phenytoin toxicity

d. The client is having adverse effects due to combination antimicrobial

therapy

C

A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

a. Increase in frequency of swallowing→ may indicate bleeding

b. Moderate sanguineous drainage on the drip pad

c. Bruising to the face→ side effect

d. Absent gag reflex

A

A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

a. Give scheduled doses of acetaminophen every 6 hr

b. Monitor the child's cardiac status

c. Administer antibiotics via intermittent IV bolus for 24 hr

d. Provide stimulation with children of the same age in the playroom

B

A nurse is planning an educational program for high school students

about cigarette smoking. Which of the following potential consequences of

smoking is most likely to discourage adolescents from using tobacco?

a. Use of tobacco might lead to alcohol and drug abuse

b. Smoking in adolescence increases the risk of developing lung

cancer later in life

c. Use of tobacco decreases the level of athletic ability

d. Smoking in adolescence increases the risk of lifelong addiction

C

A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

a. Total bilirubin

b. Urine ketones

c. Serum potassium- diuretic that retains potassium

d. Platelet count

C

A nurse has agreed to serve as an interpreter for an older adult client

who is assigned to another nurse. Which of the following statements by the

nurse indicates an understanding of this role?

a. "I will let the client know that I am available as the interpreter."

b. "I will receive a small fee for interpreting for this client."

c. "I am glad I'm available today, but when I'm not, you can use a family

member."

d. "I will let the client know that an interpreter is unavailable during the

night shift."

A

A nurse on an acute unit has received change of shift report for

4 clients which of the following clients should the nurse assess first?

a. A client who is 1 hr postoperative and has hypoactive bowel sounds

b. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal

pulses

c. A client who has fractured left tibia and pallor in the affected extremity

d. A client who has a elevated AST level following administration of

azithromycin

B

A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider?
a. A 16-hour-old newborn who has yet to pass a meconium stool
b. A 2-day-old newborn who has a mall amount of blood-tinged vaginal
discharge
c. A 2-day-old newborn who has a respiratory rate of 70/min
d. A 16-hour-old newborn whose blood glucose is 45 mg/dl

c

A nurse is providing discharge instructions to a client who has a new

prescription for haloperidol which of the following adverse effects should

the nurse instruct the client to report to the provider?

a. Weight gain

b. Dry mouth→ anticholinergic effects

c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening

d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to

D

A nurse is planning discharge teaching about cord care for the parents

of a newborn which of the following instructions should the nurse plan to

include in the teaching? P . 177 ch 26

a. Clean the base of the cord with hydrogen peroxide daily- only with tub

and sponge baths

b. The cord stump will fall off in 5 days- about 10 - 14 days

c. Contact the provider if the cord stump turns black

d. Keep the cord stump dry until it falls off

D

A nurse is teaching dietary guidelines to a client who has celiac

disease which of the following food choices is appropriate for the

client?

a. White flour tortillas

b. potato flakes

c. Wheat crackers

d. Canned barley soup

B

A nurse is working in acute care mental health facility is

assessing a client who has schizophrenia. Which of the following

findings should the nurse expect?

a. All or nothing thinking

b. Euphoric mood

c.disorganized speech

d. Hypochondriasis ( anxiety disorder)

C

A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture?

a. Align a trochanter wedge between the clients legs

b. Place a towel roll under the clients neck

c. Apply an orthotic to the client's foot

d. Position a pillow under the client's knees

C

A public health nurse working in a rural area is developing a program

to improve health for the local population. Which of the following actions

should the nurse plan to take?

a. Provide anticipatory guidance classes to parents through

public schools

b. Have a nurse from the outside the community provide health

lectures at the county hospital

c. Encourage rural residents to focus health spending on tertiary

health interventions

d. Launch a media campaign to increase awareness about industrial pollution

a\A

A nurse in the emergency department is performing triage for

multiple clients following a disaster in the community. To which of the

following types of injuries should the nurse assign the highest priority?

a. Below the knee amputation

b. 10cm (4 in) laceration

c. Fractured tibia

d. 95% full thickness body burn

A

A nurse is preparing a change of shift report for an adult female

client who is postoperative. Which of the following client information

should the nurse include in the report

a. Hgb 12.8 g/dl (12- 16g/dl)

b. Potassium 4.2 meq ( 3.5 - 5.0 meq)

c. RBC 4.4 million/mm3

d. Platelets 100,000/mm3 - (150,000 - 300,000/mm3) risk for bleeding

D

A nurse is admitting a client who has anorexia nervosa. Which of the

following is an expected finding?

a. Iron 90 mcg/dl

b. prealbumin 10 mcg/dl

c. Serum creatinine 0.8 mg/dl

d. Calcium 9.5 mg/dl

B

A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN?

a. A client who is postoperative following a bowel resection with an NGT set to

continuous suctionb.

b. A client who has fractured a femur yesterday and is expecting SOB

c. A client who sustained a concussion and has unequal pupils

d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs

A

A nurse is caring for a client who is at 41 week of gestation and is

receiving oxytocin for labor induction. The nurse notes early deceleration

on the fetal heart rate monitor . Which of the following nursing actions

should the nurse take ? p . 88 ch 13 maternity

a. Continue the monitor the fetal heart rate

b. Stop the oxytocin infusion

c. Perform a vaginal examination

d. Initiate an amnioinfusion

A

A nurse is conducting an initial assessment of a client and noticed a

discrepancy between the clients current IV infusion and the information

received during the shift report. Which of the following actions should the

nurse take?

a. Complete an incident report and place it in the client's medical record.

b.Compare the current infusion with the prescription in the client's medication

record.

c. Contact the charge nurse to see if the prescription was changed.

d. Submit a written warning for the nurse involved in the incident.

B

A nurse is reviewing the medical record of a client who has

schizophrenia and is taking clozapine. Which of the following findings

should the nurse identify as a contraindication to the administration of

clozapine ?

a. WBC count 2,900 /mm3

b. FAsting blood glucose 100 mg/dl

c. Hgb 14 g/Dl

d. Heart rate 58/min

A

A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?

a.You may breastfeed unless your nipples are cracked or bleeding.

b. You must use a breast pump to provide breast milk.

c. You must use nipple shield when breastfeeding.

d. You may breastfeed after your baby develops his antibiotics.

A

A nurse is caring for a client who has returned to the medical surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information?

a. Level of consciousness.

b. Skin turgor

c. Deep-tendon reflexes

d. Bowel sounds

A

A nurse is caring for a client who has hyperthermia. Which of the following actions for the nurse to take ?

a. Submerge the adolescent feet in ice water

b. Cover the adolescent with a thermal blanket

c. Administer oral acetaminophen

d. Initiate seizure precautions

D

A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?

a. Document the client's conditions every 15 minutes

b. Attach the restraints to the beds side rails

c. Request a PRN restraints prescription for clients who are aggressive

d. Remove the client restraints every 4 hours

A

A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

a. Providing pain management

b. Offering emotional support

c. Preventing infection

d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing

D

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA)

A. Hospice will take good care of your mom, so I wouldn't worry about that.

B. Let's talk about your moms cancer and how things will progress from here.

C. Tell me about how you are feeling

D. Tell her not to worry. She still has plenty of time left.

E. You sound like you have questions about your mom dying. Let's talk about it.

B, C, E

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care?

a. A client who is taking bumetanide and has potassium level of 3.6mEq/L (normal)

b. A client who is scheduled for colonoscopy and taking sodium

phosphate

c. A client who received a Mantoux test 48 hours ago and has induration

d. A client who is taking warfarin and has INR of 1.8 (normal if taking

warfarin)

C

A community health nurse receives a referral for a family home visit.

Which of the following tasks should the nurse perform first?

a. Clarify the source of the referral

b. Implement the nursing process

c. Schedule a time for the home visit

d. Contact the family by phone

A

A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner.

Which of the following is an appropriate response for the nurse to make?

a. You have the right to decide who receives information

b. Your partner can be a great source of support for you at this time

c. Is there a reason you don't want your partner to know about your procedure?

d. The provider will be tactful when talking to your partner

A

A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage?

a. 7.5%

b. 15%

c. 8.1%

d. 13.3%

A

A nurse is caring for a client who is 4 hr postpartum and reports

that she cannot urinate. Which of the following interventions should the

nurse implement?

a. Perform fundal massage ( massage if fundus is boggy)

b. Pour water from a squeeze bottle over the client's perineal area

c. Insert an indwelling urinary catheter.

d. Apply cold therapy to the client's perineal area.

B

A nurse is providing discharge teaching to a client who has cancer

and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of

the following instructions should the nurse include in the teaching?

a. Avoid hot tub while wearing the patch

b. Apply patch to your forearm

c. Avoid high-fiber foods while taking this medication

d. Remove the patch for 8 hours every day to reduce the risk for

tolerance.

A

A nurse working on a surgical unit is developing a care plan for a

client who has paraplegia. The client has an area of non-blanchable

erythema over his ischium. Which of the following interventions should the

nurse include in the care plan?

a. Teach the client to shift his weight every 15 min while sitting

b. Place the client upright on a donut-shaped cushion

c. Assess pressure points every 24 hr.- must assess

d. Turn and reposition the client every 3 hrs. while in bed.

B

A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?

a. We should discuss resources to implement in your daily life

b. Let me show you simple relaxation exercises to manage stress.

c. Let's talk about how you can change your response to stress

d. We should establish our roles in the initial session

D

A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?

a. Avocados

b. Whole grain bread

c. Pepperoni pizza

d. Smoked salmon ?????

B

A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps)

a. Transport the client to another area of the nursing unit (1)

b. Activate the facility's fire alarm system (2)

c. Close all nearby windows and doors (3)

d. Use the unit's fire extinguisher to attempt to put out the fire (4)

A, B, C, D

A nurse is caring for a client who is experiencing mild anxiety.

Which of the following findings should the nurse expect?

a. Heightened perceptual field

b. Rapid speech -severe

c. Feelings of dread

d. Purposeless activity

A

A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

a. Tremors

b. Polydipsia

c. Acetone Breath odor.

d. Diaphoresis

e. Inability to concentrate

A, D, E

A nurse is caring for an infant who has coarctation of the aorta.

Which of the following should the nurse identify as an expected

finding?

a. Upper extremity hypotension

b. Increased intracranial pressure

c. Frequent nosebleeds

d. Weak femoral pulses

D

A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the

plan?

a. Instruct healthcare professionals to identify abusive situations

b. Locate financial support to open a shelter for abuse survivors

c. Teach parenting skills to families at risk for abuse

d. Connect abuse survivors with legal counsel

C

A nurse and an assistive personnel (AP) are caring for a group of

clients. Which of the following tasks is appropriate for the nurse to delegate to the AP?

a. Documenting the report of pain for a client who is postoperative

b. Administering oral fluids to a client who has dysphagia

c. Applying a condom catheter for a client who has a spinal cord injury.

d. Reviewing active range-of-motion exercise with a client who had a stroke

C

A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?

a. "I will take sucralfate with meals three times per day"

b. "I will avoid food and beverages that contain caffeine"

c. "I will decrease my daily protein intake to 15 grams per day"

d. "I will use ibuprofen as needed to control abdominal pain"

B

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

a. Offer the client saltine crackers between meals

b. Suggest rinsing his mouth with an alcohol-based mouthwash

c. Provide humidification of the room air

d. Instruct the client on the use of esophageal speech

C

A nurse is caring for four clients. Which of the following tasks can

the nurse delegate to an assistive personnel?

a. Assess effectiveness of antiemetic medication

b. Perform chest compressions during cardiac resuscitation

c. Perform a dressing change for a new amputee

d. Apply a transdermal nicotine patch-

B

A nurse is caring for a client who states he recently purchased

lavender oil to use when he gets the flu. The nurse should recognize which

of the following findings as a potential contraindication for using

lavender?

a. The client takes vitamin C daily

b. The client has a history of alcohol use disorder

c. The client has a history of asthma

d. The client takes furosemide twice daily

C