1. A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours?

  • Maintain comfort
  • Prevent pressure ulcers
  • Prevent flexion contractures of the extremities
  • Improve venous circulation in the lower extremities

2. What should the nurse do to control edema of the residual limb 1 week after a client has an above-the-knee amputation?

  • Administer the prescribed diuretic.
  • Restrict the clients oral fluid intake.
  • Rewrap the elastic bandage as necessary.
  • Keep the residual limb elevated on a pillow.

3. A client who had a total hip replacement asks the nurse about the continuous regional analgesia being used. What information should the nurse include when explaining the benefits of this treatment over conventional methods to control pain?

  • Adjusting the dose is easily done.
  • Neuropathic pain can be relieved.
  • Systemic side effects are minimal.
  • The need for parenteral medication is avoided.

4. A health care provider orders the application of warm compresses for a client with arthritis. What is the appropriate temperature range for the compresses that the nurse applies?

  • 65° to 79° F (18.3° to 26.1° C)
  • 80° to 92° F (26.6° to 33.3° C)
  • 93° to 97° F (33.8° to 36.1° C)
  • 98° to 105° F (36.6° to 40.5° C)

5. Which position should a nurse avoid placing a client who had surgery for a total hip replacement?

  • Supine
  • Lateral
  • Orthopneic
  • Semi-Fowler

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1. What should the nurse do to obtain an accurate urine output for a client with a continuous bladder irrigation (CBI)?

  • Measure the contents of the bedside drainage bag.
  • Stop the irrigation and determine the urine output.
  • Subtract the volume of irrigant from the total drainage.
  • Ensure the urine and irrigant drain into two separate bags.

2. A pathology report states that a client’s urinary calculus is composed of uric acid. Which should the nurse instruct the client to avoid?

  • Milk
  • Liver
  • Cheese
  • Vegetables

3. A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. What does the nurse conclude is most likely the causative factor?

  • Edema
  • Dysuria
  • Retention
  • Suppression

4. A nurse is counseling a woman who had recurrent urinary tract infections. What factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection?

  • Altered urinary pH
  • Hormonal secretions
  • Juxtaposition of the bladder
  • Proximity of the urethra to the anus

5. A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the health care provider?

  • Prepare for urinary catheterization.
  • Teach how to perform perineal care.
  • Start a twenty-four-hour urine collection.
  • Obtain a urine specimen for culture and sensitivity.

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1. A nurse is caring for a client who had Clostridium welchii(Clostridium perfringens) cultured from a wound of the lower extremity. Which disease results when this organism enters a wound, causing crepitus?

  • Tetanus
  • Anthrax
  • Botulism
  • Gangrene

2. A client with a history of arthritis has an acute episode of right ventricular heart failure and is receiving furosemide (Lasix). The health care provider lowers the client’s usual dosage of aspirin. The client asks the nurse the reason for the lower dose. What is the nurse’s best response?

  • ‘Aspirin accelerates metabolism of furosemide and decreases the diuretic effect.”
  • “Aspirin in large doses after an acute stress episode increases the bleeding potential.”
  • “Competition for renal excretion sites by the drugs causes increased serum levels of aspirin.”
  • “Use of furosemide and aspirin concomitantly increases formation of uric acid crystals in the nephron.”

3. What should the nurse expect the health care provider to prescribe if a client exhibits clinical indicators of warfarin (Coumadin) overdose?

  • Heparin
  • Vitamin K
  • Iron dextran
  • Protamine sulfate

4. A nurse in a public health clinic is teaching clients how to prevent toxoplasmosis. What should the nurse instruct the clients to avoid?

  • Contact with cat feces
  • Working with heavy metals
  • Ingestion of freshwater fish
  • Excessive radiation exposure

5. In the postanesthesia care unit it is reported that the client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client’s initial 24-hour postoperative care?

  • Assessing the client for tachycardia
  • Monitoring of respiratory rate hourly
  • Administering naloxone every 3 to 4 hours
  • Observing the client for signs of CNS excitement

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1. What should the nurse monitor to evaluate the effectiveness of carbamazepine (Tegretol) in the management of a client’s trigeminal neuralgia?

  • Pain intensity
  • Liver function
  • Cardiac output
  • Seizure activity

2. A nurse is planning care for a client with cancer who is receiving the plant alkaloid vinCRIStine. In contrast to the side effects of most chemotherapeutic agents, what is a common side effect of vinCRIStine that the nurse must address in the client’s care plan?

  • Nausea
  • Alopecia
  • Constipation
  • Hyperuricemia

3. A client receiving chemotherapy asks the nurse why an antibiotic was also prescribed. Which tissue affected by chemotherapy should the nurse consider when formulating a response?

  • Liver
  • Blood
  • Bone marrow
  • Lymph nodes

4. A nurse administers the drug desmopressin acetate (DDAVP) to a client with diabetes insipidus. What should the nurse monitor to evaluate the effectiveness of the drug?

  • Arterial blood pH
  • Intake and output
  • Fasting serum glucose
  • Pulse and respiratory rates

5. A nurse administers leucovorin calcium to a client before the prescribed methotrexate (Trexall). The client asks the reason for this. What effect of leucovorin calcium should the nurse consider when formulating a response?

  • Potentiates metabolite required for destruction of cancer cells
  • Supplies levels of folic acid required by blood-forming organs
  • Acts synergistically with antineoplastic drugs to destroy cancer cells
  • Increases production of phagocytes to help remove debris from destroyed cancer cells

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1. Which is the most important assessment data for a nurse to gather from the client in crisis?

  • The client’s work habits
  • Any significant physical health data
  • A history of emotional problems in the family
  • The client’s perception of the circumstances surrounding the crisis

2. A staff member tells a nurse that an older client gets irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response?

  • Decreased ability to cope
  • Loss of ability to cooperate
  • Ambivalence toward authority
  • Difficulty performing step procedures

3. A nurse reminds a client that it is time for group therapy. The client responds by yelling at the nurse, “You are always telling me what to do, just like my father!” What defense mechanism is the client using?

  • Regression
  • Transference
  • Reaction formation
  • Cognitive distortion

4. What is the most difficult initial task when developing a nurse-client relationship?

  • Remaining therapeutic and professional
  • Being able to understand and accept a client’s behavior
  • Developing an awareness of self and the professional role in the relationship
  • Accepting responsibility for identifying and evaluating the real needs of a client

5. A person mowing the lawn is badly disfigured by the lawn mower blade. According to Erikson’s theory, which age will demonstrate the greatest risk of longer-term psychological effects?

  • 11-year-old
  • 35-year-old
  • 55-year-old
  • 70-year-old

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1. A nurse is teaching clients in a medication education group about side effects of medications. Which drug will cause a heightened skin reaction to sunlight?

  • Lithium
  • Sertraline
  • Methylphenidate
  • Chlorpromazine

2. A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, a nurse expresses disgust that the woman returns to the same situation. What is the nurse manager’s best response?

  • “She must not have the financial resources to leave her husband.”
  • “Most woman attempt to leave about six times before they are able to do so.”
  • “There is nothing the staff can do because people are free to choose their own life.”
  • “These women should be told how foolish they are to remain in their current situation.”

3. A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, “Sometimes I forget to take the Cogentin.” What should the nurse teach the client to do if this happens again?

  • Use 2 pills at the next regularly scheduled dose.
  • Notify the health care provider about the missed dose immediately.
  • Take a dose as soon as possible, up to 2 hours before the next dose.
  • Skip the dose, and then take the next regularly scheduled dose 2 hours early.

4. A nurse is caring for a client who abruptly withdrew from barbiturate use. What should the nurse anticipate that the client may experience?

  • Ataxia
  • Seizures
  • Diarrhea
  • Urticaria

5. A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the 6-week course of treatment?

  • Provision of tyramine-free meals
  • Avoidance of exposure to the sun
  • Maintenance of a steady sodium intake
  • Elimination of benzodiazepines for nighttime sedation

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