Nle Np 605s62

NLE NP-1

D. Using bladder that is 15cm long

1. A client is itted to the emergency room with a gunshot wound to the right arm. After dressing the wound and istering the prescribed antibiotic, the nurse should: A.Ask the client if he has any medication allergies B.Check the client’s immunization record C.Apply a splint to immobilize the arm D.ister medication for pain

8. A nurse manager may appropriately delegate which task? A. Scheduling staff assignment for next month B. Terminating a nursing assistant C. Deciding on salary increase D. Telling a staff nurse to initiate a disciplinary action.

2.A physician orders an intestinal tube to decompress a client’s GI Tract, When gathering equipment for this procedure, a nurse should obtain a: A. Sengstaken – Blakemore Tube B. Miller Abbott Tube C. Levin Tube D. Salem pump tube 3.A nurse identifies a client’s responses to actual or potential health problems during which step of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation 4. A nurse can auscultate heart sounds more easily if the client is: A. Supine B. On his right side C. Holding his breath D. Leaniing Forward 5. When a nurse enters a client’s room, the client complains that she’s spitting blood when she coughs. The nurse takes a quick health history that includes: A. hx of present problem, medication, allergies, review of system B. hx of present problem allergies, medication and recent major operation C. hx of present problem, mecation, family hx, review of system D. hx of present problem, allergies, medication, review of system, recent major operation 6. A nurse implements a health care facility’s disaster plan, Which action should she perform first? A. Turn of cellular and pagers B. Instruct essential off duty personnel to report to the facility w/in 24 hrs. C. Identify a command center D. Provide treatment for incoming patients according to time of ission. 7. A nurse prepares to measure a client’s blood pressure. What is the correct procedure for measuring BP? A. Wrapping the cuff around the limb, with uninflated bladder covering about ¼ of the limb circumference. B. Measuring the arm about 2” above the antecubital space C. Wrapping the cuff around the limb, with uninflated bladder covering about ¾ of the limb circumference.

9. A client complains of abdominal pain. Which question should the nurse ask first? A. B. C. D.

Are you having pain? Is the pain constant? Is the pain sharp? What does the pain feel like?

10. When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction? A. B. C. D.

Apply heat to the fracture site Apply ice to the fracture site Perform ankle dorsiflexion Use crutches for 1 week

11. The correct pressure of the wall suction unit when suctioning an adult patient is: A.) 95-110 mm Hg B.) 100-120 mm Hg C.) 50-95 mm Hg D.) 10-15 mm Hg 12. During insertion of NGT, which position is best assumed by the client? A. Low Fowlers B. Semi Fowlers C. High Fowlers D. Lateral 13. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should: a. Be injected into the deltoid muscle b. Be injected into the abdomen c. Aspirate after the injection d. Clear the air from the syringe before injections

14. The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client's bedside table. There is no label to indicate the date or time of initial use. The nurse should: a. Lip the bottle and use a pack of sterile 4x4 for the dressing b. Obtain a new bottle and label it with the date and time of first use c. Ask the ward secretary when the solution was requested d. Label the existing bottle with the current date and time 15. The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should ister the medication: a. 30 minutes before meals b. With each meal c. In a single dose at bedtime d. 60 minutes after meals 16. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug? a. Changes in vision b. Nausea c. Urinary frequency d. Changes in skin color 17. The nurse caring for a client in the neonatal intensive care unit isters adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: a. Negligence b. Tort c. Assault d. Malpractice 18. The nurse is suspected of charting medication istration that he did not give. After talking to the nurse, the charge nurse should: a. Call the Board of Nursing b. File a formal reprimand c. Terminate the nurse d. Charge the nurse with a tort 19.The client is having an arteriogram. During the procedure, the client tells the nurse, "I'm feeling really hot." Which response would be best? a. "You are having an allergic reaction. I will get an order for Benadryl." b. "That feeling of warmth is normal when the dye is injected." c. "That feeling of warmth indicates that the clots in the coronary vessels are dissolving." d. "I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing."

20. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan? a. Assess for signs of abnormal bleeding b. Anticipate an increase in the Coumadin dosage c. Instruct the client regarding the drug therapy d. Increase the frequency of neurological assessments 21. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? a. Roast beef sandwich, potato chips, pickle spear, iced tea b. Split pea soup, mashed potatoes, pudding, milk c. Tomato soup, cheese toast, Jello, coffee d. Hamburger, baked beans, fruit cup, iced tea 22 The best method of evaluating the amount of peripheral edema is: a. Weighing the client daily b. Measuring the extremity c. Measuring the intake and output d. Checking for pitting 23. The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing? a. Occipital b. Frontal c. Temporal d. Parietal 24. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching? A “I will have blood drawn every month.” B “I will assess my skin for a rash.” C “I take aspirin for a headache.” D “I will use an electric razor to shave.” 25. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort the client is experiencing associated with xerostomia by: A. Offering hard candy B. istering analgesic medications C. Splinting swollen ts D. Providing saliva substitute 26. The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for?

A. A client with Alzheimer’s disease B. A client with pneumonia C. A client with appendicitis D. A client with thrombophlebitis 27. A new nursing graduate indicates in charting entries that he is a licensed ed nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in a charge of: A. Fraud B. Tort C. Malpractice D. Negligence 28. The nurse is asg staff for the day. Which client should be assigned to the nursing assistant? A. A 5-month-old with bronchiolitis B. A 10-year-old 2-day post-appendectomy C. A 2-year-old with periorbital cellulitis D. A 1-year-old with a fractured tibia 29 During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse’s first action should be to: A. Notify the hospital pharmacist B. Notify the nursing supervisor C. Notify the Board of Nursing D. Notify the director of nursing 30. The child with a history of respiratory infections has an order for a sweat test to be done. Which finding would be positive for cystic fibrosis? A. A serum sodium of 135meq/L B. A sweat analysis of 69 meq/L C. A potassium of 4.5meq/L D. A calcium of 8mg/dL 31. A new diabetic is learning to ister his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching? a.

“When drawing up my insulin, I should draw up the regular insulin first.” b. “When drawing up my insulin, I should draw up the NPH insulin first.” c. “It doesn’t matter which insulin I draw up first.” d. “I cannot mix the insulin, so I will need two shots.” 32. The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant’s assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client’s family D. Initiate a group session with the nursing assistant

33 The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the ed nurse? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing 34. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count 35. The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is: a. Inspection, auscultation, palpation b. Auscultation, palpation, inspection c. Palpation, inspection, auscultation d. Inspection, palpation, auscultation 36 The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority? A Anxiety B Pain C Knowledge deficit D Altered thought process 37. The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be: A “Yes, you should be able to swim again, even with the colostomy.” B “You should avoid immersing the colostomy in water.” C “No, you should avoid getting the colostomy wet.” D “Don’t worry about that. You will be able to live just like you did before.” 38 The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorroidectomy. The nurse would be correct in instructing the patient to: A Avoid a high-fiber diet B Continue to use ice packs C Take a laxative daily to prevent constipation D Use a sitz bath after each bowel movement 39. Which of the following lab studies should be done periodically if the client is taking warfarin sodium (Coumadin)? A Stool specimen for occult blood B White blood cell count C Blood glucose

D Erthyrocyte count 40. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the: A Hip B Ankle C Earlobe D Chin 41. Heparin has been ordered for a client with pulmonary emboli. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication? A “I will ister the medication 1-2 inches away from the umbilicus.” B “I will ister the medication in the abdomen.” C “I will check the PTT before istering the medication.” D “I will need to aspirate when I give Heparin.” 42. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: a. In 5–10 minutes b. In 10–20 minutes c. In 30–60 minutes 43. The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take? a. Change the nurse’s assignment to another client b. Explain to the nurse that there is no risk to the client c. Ask the nurse if the chickenpox have scabbed d. Ask the nurse if she has ever had the chickenpox

44. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? a. Using Karaya powder to seal the bag. b. Irrigating the ileostomy daily. c. Using stomahesive as the best skin protector. d. Using Neosporin ointment to protect the skin. 45. The client has an order for FeSO 4 liquid. Which method of istration would be best? b. ister the medication with milk c. ister the medication with a meal d. ister the medication with orange juice e. ister the medication undiluted

46. The client presents to the emergency room with a hyphema. Which action by the nurse would be best? a. Elevate the head of the bed and apply ice to the eye b. Place the client in a supine position and apply heat to the knee c. Insert a Foley catheter and measure the intake and output d. Perform a vaginal exam and check for a discharge 47 The client with cancer refuses to care for herself. Which action by the nurse would be best? a. Alternate nurses caring for the client so that the staff will not get tired of caring for this client b. B. Talk to the client and explain the need for self-care c. C. Explore the reason for the lack of motivation seen in the client d. D. Talk to the doctor about the client’s lack of motivation 48. The nurse is assisting in the assessment of the patient itted with “extreme abdominal pain.” The nurse asks the client about the medication that he has been taking because: a. Interactions between medications will cause abdominal pain. b. Various medications taken by mouth can affect the alimentary tract. c. This will provide an opportunity to educate the patient regarding the medications used. d. The types of medications might be attributable to an abdominal pathology not already identified. 49. Which action by the healthcare worker indicates a need for further teaching? A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client’s vital signs.

50. A client is itted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what? A. Hypovolemia B. Laryngeal edema C. Hypernatremia D. Hyperkalemia