Samenvatting

67. Client experiencing acute mania. Which of the foods should the nurse provide for this client?
a. Peanut butter sandwich
b. Chicken noodle soup
c. Celery sticks
d. Oatmeal with butter
68.
69. A home health nurse is completing screenings for elder abuse during client visits. Which of the following
findings should the nurse identify as an indication of potential elder abuse?
a. Client who reports being given sedative medications by family members
b. Client who istaking warfarin and has several small bruises on her shins and hands
c. Client who schedules multiple visits with his provider every month
d. Client who lives with family members and begins to take more responsibility for self-care
70. A nurse is caring for a school age child who is postoperative and received morphine IV bolus for pain 10
min ago. Which of the following findings is the nurse’s priority?
a. Bradypnea
b. Sedation
c. Euphoria
d. Constipation
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71. A nurse is planning to administer 2 units of packed RBCs to an older adult who has anemia. Which of the
following actions should the nurse plan to take? [SATA] (medsurg pg. 249)
a. Prime the infusion tubing with 0.45 NaCl
b. Infuse blood over 4 hr.
c. Don sterile gloves to prepare blood administration setup
d. Assess the client’slung sounds prior to the infusion
e. Verify with another nurse that the unit of blood is compatible with the client’s blood type
72. A nurse is planning care for a client who is scheduled to receive a PICC in the arm. Which of the following
interventions is appropriate for the nurse to include in the plan of care? (medsurg pg. 166)
a. Administer sedation for the procedure
b. Measure the arm circumference above the insertion site daily
c. Use gauze to secure an arm board to the involved extremity
d. Schedule and MRI postprocedure to verify placement
73. Which of the following clients should the nurse place near the nurses’ station?
a. A client who isin Buck’s traction
b. A client who has orthostatic hypotension
c. A client who has an open wound
d. A client who is on fluid restriction
74. Older client transferred from another facility. Nurse notes ulcers on the coccyx and abrasions around both
wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?
a. Notify risk management
b. Inform the transferring agency of the client’s condition
c. Privately interview the client about her condition
d. Contact the family regarding the client’s condition
75. Client receiving intermittent enteral tube feedings. Which of the following places the client at risk for
aspiration?
a. History of GERD
b. Sitting in a high-Fowler’s position during the feeding
c. A residual of 65 mL 1 hr. postprandial
d. Receiving a high osmolarity formula
76. Adverse effects of sertraline
a. Dry cough
b. Increased urinary frequency
c. Metallic taste in mouth
d. Excessive sweating (pharm pg. 53: serotonin syndrome)
77. Teaching for a client undergoing radiation therapy and has stomatitis. Which of the responses by the client
indicates an understanding of the teaching?
a. “I should limit my intake of dairy products to prevent nausea.”
b. “Ishould use a soft-bristle toothbrush to clean my teeth after meals.”
c. “I should moisten my lips with lemon-glycerin swabs.”
d. “I should gargle with an alcohol-based mouthwash to kill germs.”
78. Client placed in seclusion and restraints. Which of the following actionsshould the nurse plan to take?
a. Ensure that the prescription for restraints be renewed every 6 hr.
b. Have a provider evaluate the client in person within 1 hr.
c. Plan to monitor the client every 30 min while restrained
d. Complete a written record regarding the seclusion and restraint every 2 hr.
79. Client with acute glomerulonephritis. Which of the following food choices should the nurse recommend?
(lowin potassium, sodium, and protein)
a. Bagel
b. Banana
c. Eggs
d. Smoked salmon
80. Client asks about acupuncture to manage his osteoarthritis pain. The nurse should identify which of the
following conditions as a contraindication for receiving this treatment?
a. HTN
b. Herpes zoster
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c. Obesity
d. Hypothyroidism
81. Reviewing client’s lab results. Which of the following should the nurse review to evaluate the client’s
nutritional status?
a. Serum albumin
b. Serum sodium
c. Troponin
d. ESR
82. Nurse manger observes two staff nursesreviewing the computer records of a client who is not under their
care. Which of the following should the nurse manager take first

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