Med 3
Med 3
Med 3
All of these nursing interventions apply to the nursing diagnosis Risk for
Falls. Which intervention should you delegate to the nursing assistant?
a. Identify environmental factors that increase risk for falls
b. Monitor gait, balance, and fatigue level with ambulation
c. Collaborate with physical therapy to provide patient with walker
d. Assist the patient with ambulation to bathroom and in halls.
5. As charge nurse you are making assignments for the day shift. Which
patient would you assign to the nurse who has been pulled from the post-
anesthesia care unit (PACU) for the day.
a. A 35-year-old patient with osteomyelitis who needs teaching prior to
hyperbaric oxygen therapy
b. A 62-year-old patient with osteomalacia who is being discharged to a
long-term care facility
c. A 68-year-old patient with osteoporosis and a new orthotic device
whose knowledge of use of this device must be assessed
d. A 72-year-old patient with Paget’s disease who has just returned from
surgery for total knee replacement
8. You are providing nursing care for a patient with carpal tunnel
syndrome (CTS) who is preparing for surgery. Which intervention should
you delegate to the nursing assistant?
a. Initiate placement of a splint for immobilization during the day
b. Assess the patient’s wrist and hand for discoloration and brittle nails
c. Assist the patient with daily self-care measures such as bathing and
eating.
d. Test the patient for painful tingling in the four digits of the hand
11.As charge nurse you assign the nursing care of a patient who has just
returned form open carpal tunnel release surgery to an experienced
LPN/LVN, who will perform under the supervision of an RN. Which of
the following instructions will you provide for the LPN/LVN? (Choose
all that apply.)
a. Check the patient’s vital signs every 15 minutes in the first hour.
b. Check the dressing for drainage and tightness
c. Elevate the patient’s hand above the heart
d. The patient will no longer need pain medication
e. Check the neurovascular status of the fingers every hour
18.The charge nurse assigns the nursing care of a patient who is 1 day
post-operative after a left below-the-knee amputation to an experienced
LPN/LVN, what will you describe as the major focus for care today?
a. To attain pain control for phantom pain
b. To monitor for signs of sufficient tissue perfusion.
c. To assist the patient to ambulate as soon as possible
d. To elevate the residual limb when the patient is supine
3. Which of the following should the nurse teach the client about the
signs of digitalis toxicity.
a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing yellow spots
4. Nurse Trisha teaches a client with heart failure to take oral Furosemide
in the morning. The reason for this is to help.
a. Retard rapid drug absorption
b. Excrete excessive fluids accumulated at night
c. Prevention of electrolyte imbalance
d. Prevents sleep disturbances during night
5. What would be the primary goal of therapy for a client with pulmonary
edema and heart failure
a. Increase cardiac output
b. Enhance comfort
c. Improve respiratory status
d. Peripheral edema decreased
6. Nurse Linda is caring for a client with head injury and monitoring the
client with decerebrate posturing. Which of the following is a
characteristic of this type of posturing.
a. Upper extremity flexion with lower extremity flexion
b. Upper extremity flexion with lower extremity extension
c. Flexion of the extremities after stimulus
d. Extension of the extremities after a stimulus
7. A female client is taking Cascara Sagrada. Nurse Betty informs the
client that the following maybe experienced as side effects of this
medication:
a. GI bleeding
b. Peptic ulcer disease
c. Abdominal cramps.
d. Partial bowel obstruction
10. A 68 year old client is diagnosed with a right-sided brain attack and is
admitted to the hospital. In caring for this client, the nurse should plan to:
a. Application of elastic stockings to prevent flaccid by muscle
b. Use hand roll and extend the left upper extremity on a pillow to
prevent contractions.
c. Use a bed cradle to prevent dorsiflexion of feet
d. Do passive range of motion exercise
11. Nurse Liza is assigned to care for a client who has returned to the
nursing unit after left nephrectomy. Nurse Liza’s highest priority would
be
a. Hourly urine output
b. Temperature
c. Able to turn side to side
d. Able to sips clear liquid
12. A 64 year old male client with a long history of cardiovascular
problem including hypertension and angina is to be scheduled for cardiac
catheterization. During pre cardiac catheterization teaching, Nurse Cherry
should inform the client that the primary purpose of the procedure is…..
a. To determine the existence of CHD
b. To visualize the disease process in the coronary arteries.
c. To obtain the heart chambers pressure
d. To measure oxygen content of different heart chambers
13. During the first several hours after a cardiac catheterization, it would
be most essential for nurse Cherry to.
a. Elevate clients bed at 45°
b. Instruct the client to cough and deep breathe every 2 hours
c. Monitor clients temperature every hour
d. Frequently monitor client’s apical pulse and blood pressure
14. Kate who has undergone mitral valve replacement suddenly
experiences continuous bleeding from the surgical incision during
postoperative period. Which of the following pharmaceutical agents
should Nurse Aiza prepare to administer to Kate
a. Protamine Sulfate
b. Quinidine Sulfate
c. Vitamin C
d. Coumadin
15. In reducing the risk of endocarditis, good dental care is an important
measure. To promote good dental care in client with mitral stenosis in
teaching plan should include proper use of…
a. Dental floss
b. Electric toothbrush
c. Manual toothbrush.
d. Irrigation device
16. Among the following signs and symptoms, which would most likely
be present in a client with mitral gurgitation
a. Exceptional Dyspnea
b.Altered level of consciousness
c. Increase creatine phospholinase concentration
d. Chest pain
19. John suddenly experiences a seizure, and Nurse Gina notice that John
exhibits uncontrollable jerking movements. Nurse Gina documents that
John experienced which type of seizure.
a. Tonic seizure
b. Absence seizure
c. Clonic seizure
d. Myoclonic seizure.
A clonic seizure may sometimes be hard to distinguish from a myoclonic
seizure. The jerking is more regular and sustained during a clonic seizure.
Most often, clonic movements are seen as part of a tonic-clonic seizure.
20. Smoking cessation is critical strategy for the client with Burgher’s
disease, Nurse Jasmin anticipates that the male client will go home with a
prescription for which medication.
a. Paracetamol
b. Ibuprofen
c. Nitroglycerin
d. Nicotine (Nicotrol)
The exact cause of Buerger disease is unknown. The condition is strongly
linked to tobacco use. It's thought that chemicals in tobacco may hurt the
lining of the blood vessels
Buerger disease also called TAO.
21. Nurse Lilly has been assigned to a client with Raynaud’s disease.
Nurse Lilly realizes that the etiology of the disease is unknown but it is
characterized by.
a. Episodic vasospastic disorder of capillaries
b. Episodic vasospastic disorder of small veins
c. Episodic vasospastic disorder of the aorta
d. Episodic vasospastic disorder of the small arteries.
Experts don't fully understand the cause of Raynaud's attacks. But blood vessels in the
hands and feet appear to react too strongly to cold temperatures or stress.
22. Nurse Jamie should explain to male client with diabetes that self-
monitoring of blood glucose is preferred to urine glucose testing because
a. More accurate.
b. Can be done by the client
c. It is easy to perform
d. It is not influenced by drugs
23. Jessie weighed 210 pounds on admission to the hospital. After 2 days
of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate
the amount of fluid Jessie has lost
a. 2.0 L
b. 1.5 L
c. 0.3 L
d. 3.5 L
24. Nurse Donna is aware that the shift of body fluids associated with
Intravenous administration of albumin occurs in the process of
a. Osmosis
b. Diffusion
c. Active transport
d. Filtration
26. Which of the following statements should the nurse teach the
neutropenic client and his family to avoid?
a. Performing oral hygiene after every meal
b. Using suppositories or enemas.
c. Performing perineal hygiene after each bowel movement
d. Using a filter mask
33. A client has 15% blood loss. Which of the following nursing
assessment findings indicates hypovolemic shock
a. Systolic blood pressure less than 90mm Hg
b. Pupils unequally dilated
c. Respiratory rate of 4 breath/min
d. Pulse rate less than 60bpm
34. Nurse Lucy is planning to give pre operative teaching to a client who
will be undergoing rhinoplasty. Which of the following should be
included.
a. Results of the surgery will be immediately noticeable postoperatively
b. Normal saline nose drops will need to be administered preoperatively
c. After surgery, nasal packing will be in place 8 to 10 days
d. Aspirin containing medications should not be taken 14 days before
surgery.
36. Dr. Marquez tells a client that an increase intake of foods that are rich
in Vitamin E and beta-carotene are important for healthier skin. The nurse
teaches the client that excellent food sources of both of these substances
are:
a. Fish and fruit jam
b. Oranges and grapefruit
c. Carrots and potatoes
d. Spinach and mangoes.
40. Nurse Rachel teaches a client who has been recently diagnosed with
hepatitis A about untoward signs and symptoms related to Hepatitis that
may develop. The one that should be reported immediately to the
physician is.
a. Restlessness
b. Yellow urine
c. Nausea
d. Clay- colored stools
41. Which of the following antituberculosis drugs can damage the 8th
cranial nerve.
a. Isoniazid (INH)
b. Paraoaminosalicylic acid (PAS)
c. Ethambutol hydrochloride (myambutol)
d. Streptomycin.
42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie
responds that recent research indicates that peptic ulcers are the result of
which of the following.
a. Genetic defect in gastric mucosa
b. Stress
c. Diet high in fat
d. Helicobacter pylori infection.
43. Ryan has undergone subtotal gastrectomy. The nurse should expect
that nasogastric tube drainage will be what color for about 12 to 24 hours
after surgery.
a. Bile green
b. Bright red
c. Cloudy white
d. Dark brown
44. Nurse Joan is assigned to come for client who has just undergone eye
surgery. Nurse Joan plans to teach the client activities that are permitted
during the post operative period. Which of the following is best
recommended for the client?
a. Watching circus
b. Bending over
c. Watching TV.
d. Lifting objects
most patients are able to watch some television or look at a computer
screen for a short period of time.
45. A client suffered from a lower leg injury and seeks treatment in the
emergency room. There is a prominent deformity to the lower aspect of
the leg, and the injured leg appears shorter that the other leg. The affected
leg is painful, swollen and beginning to become ecchymotic. The nurse
interprets that the client is experiencing:
a. Fracture.
b. Strain
c. Sprain
d. Contusion
46. Nurse Jenny is instilling an otic solution into an adult male client left
ear. Nurse Jenny avoids doing which of the following as part of the
procedure
a. Pulling the auricle backward and upward
b. Warming the solution to room temperature
c. Pacing the tip of the dropper on the edge of ear canal.
d. Placing client in side lying position
47. Nurse Bea should instruct the male client with an ileostomy to report
immediately which of the following symptom
a. Absence of drainage from the ileostomy for 6 or more hours
b. Passage of liquid stool in the stoma
c. Occasional presence of undigested food
d. A temperature of 37.6 °C