65. While the nurse was checking the BP of the client, the wife was intently observing the nurse. The wife asks the nurse how to ensure accurate measurement of BP reading. Identify all the nurse mentioned that will ensure accurate BP reading. 1. Taking the BP 15 minutes after intake of antihypertensive drug 2. Measuring the BP after the client has been seated for 5 minutes 3. Seating the client with arm bared supported and at the heart level 4. Using the cuff with rubber bladder that encircles at least 80% of the arm 5. Gauges of BP apparatus should be calibrated every 8 hours 6. The client should rest quietly for 5 minutes before reading and can talk while BP is being checked

65. While the nurse was checking the BP of the client, the wife
was intently observing the nurse. The wife asks the nurse
how to ensure accurate measurement of BP reading. Identify
all the nurse mentioned that will ensure accurate BP reading.
1. Taking the BP 15 minutes after intake of
antihypertensive drug
2. Measuring the BP after the client has been
seated for 5 minutes
3. Seating the client with arm bared supported and
at the heart level
4. Using the cuff with rubber bladder that encircles
at least 80% of the arm
5. Gauges of BP apparatus should be calibrated
every 8 hours
6. The client should rest quietly for 5 minutes
before reading and can talk while BP is being
checked
by

1 Answer

Answer :

A. 1, 2, 3, and 4
by

Related questions

69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Description : 69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Last Answer : C. Check the physician’s order in case CBG is below 70 mg/dl

If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. b) every hour. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. c) every 24 hours. Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. d) when a tube feeding is continuous, it is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Description : 64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Last Answer : C. Fruits and vegetables

40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time the medication was ordered 4. Dosage, route, frequency and strength 5. Physician’s signature and specialty 6. Physician’s signature and PRC license number

Description : 40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time ... and strength 5. Physician's signature and specialty 6. Physician's signature and PRC license number

Last Answer : C. All except 5 and 6

An elderly hypertensive was treated with hydrochlorothiazide 50 mg daily. Even after a month, his BP was not reduced to the desired level and another antihypertensive was added. After 2 hours of taking the other drug his BP fell precipitously. The most likely other drug given to him is: A. Atenolol B. Captopril C. Methyldopa D. Amlodipine

Description : An elderly hypertensive was treated with hydrochlorothiazide 50 mg daily. Even after a month, his BP was not reduced to the desired level and another antihypertensive was added. After 2 hours of taking the ... likely other drug given to him is: A. Atenolol B. Captopril C. Methyldopa D. Amlodipine

Last Answer : B. Captopril

The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. b) Minimize intake of caffeine, ****, milk, and foods containing peppermint and spearmint. The patient should be instructed to avoid the listed foods and food components. c) Elevate the foot of the bed on 6- to 8-inch blocks The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

Trousseau’s sign is positive when a) carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff. A positive Trousseau’s sign is suggestive of latent tetany.

Description : Trousseau's sign is positive when a) carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff. A positive Trousseau's sign is ... Homans' sign is demonstrated when the patient complains of pain in the calf when his foot is dorsiflexed.

Last Answer : a) carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff. A positive Trousseau’s sign is suggestive of latent tetany.

79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, “How old is the client?” Holding the fallopian tube, the surgeon asks for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said, “Doctor there is no signed consent for tubal ligation.” The nurse just demonstrated which of the following?

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a vial that is almost empty. She was able to aspirate 60 mg only. Nurse Kristine decided to inject it instead of making the client wait until the next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Description : 77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a ... next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Last Answer : A. Justice

99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Description : 99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Last Answer : A. “These supplements enhance the production of RBC.”

61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Description : 61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Last Answer : D. Liver

63. A hypertensive client is taking herbal supplement for his hypertension. He was prescribed antihypertensive medication. The client wants to continue taking his herbal medication to lower his blood pressure. The nurse’s most appropriate action is to

Description : 63. A hypertensive client is taking herbal supplement for his hypertension. He was prescribed antihypertensive medication. The client wants to continue taking his herbal medication to lower his blood pressure. The nurse’s most appropriate action is to

Last Answer : B. Tell the client that herbal supplements have no proven therapeutic effects

To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 – 2 cm and inflammation. The nurse would prepare the client for which specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds is the description given to auscultation of one to two bowel sounds in 2 minutes. c) sluggish. Sluggish is not a term a nurse would use to accurately describe bowel sounds. d) absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Description : When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds ... absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Last Answer : a) normal. Normal bowel sounds are heard every 5-20 seconds.

54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Description : 54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Last Answer : C. Round the clock on a consistent basis

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes. b) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. c) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger. d) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Description : Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to ... the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Last Answer : a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes.

Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. b) Peroneal The peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes. c) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. d) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Description : Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation ... The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Last Answer : a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve.

62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Description : 62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Last Answer : A. 140 mg/dl

72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Description : 72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Last Answer : A. It decreases the risk of bleeding

The Code of Ethics states that the nurse’s primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical principle called justice? A. The nurse providing care on a “first come – first served” basis B. Referring the client for evaluation to the social worker on duty regarding her socio-economic status C. The client’s preference is least considered D. The nurse’s providing care to maximize health according to available resources

Description : The Code of Ethics states that the nurse's primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical ... is least considered D. The nurse's providing care to maximize health according to available resources

Last Answer : A. The nurse providing care on a “first come – first served” basis

Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration. b) 10-15 mm Hg water pressure. A measure of 10–15 mm Hg water pressure would indicate that the cuff is underinflated. c) 30-35 mm Hg water pressure. A measure of 30–35 mm Hg water pressure would indicate that the cuff is overinflated. d) 0-5 mm Hg water pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Description : Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the ... pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Last Answer : a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Description : When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person ... 20/20 line, the person of normal vision will be standing at a distance of 20 feet from the chart.

Last Answer : a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

53. Albert’s mother asks why the client’s breathing is shallow. The correct response of the nurse would be

Description : 53. Albert’s mother asks why the client’s breathing is shallow. The correct response of the nurse would be

Last Answer : D. “Respiratory movement intensifies pericardial pain.

43. Mr. Gomez, 71 years old, has a history of chronic back pain. He thinks that his family perceives him as a “weakling” because he often asks for pain medication. Which of the following is the most therapeutic response of the nurse?

Description : 43. Mr. Gomez, 71 years old, has a history of chronic back pain. He thinks that his family perceives him as a “weakling” because he often asks for pain medication. Which of the following is the most therapeutic response of the nurse?

Last Answer : A. “It seems that you are worried. Which matter to you more? What people will say or getting relief from your pain?”

41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Description : 76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Last Answer : D. Preserving privacy

42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Description : 42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Last Answer : C. Anticipatory response

When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and immediate action? A. Stop the intern and do the catheterization yourself B. Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Description : When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and ... . Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Last Answer : B. Offer to change the catheter

The nurse auscultates the apex beat at which of the following anatomical locations? a) Fifth intercostal space, midclavicular line The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. b) Mid-sternum The right ventricle lies anteriorly, just beneath the sternum. c) 2” to the left of the lower end of the sternum Use of inches to identify the location of the apex beat is inappropriate based upon variations in human anatomy. d) 1” to the left of the xiphoid process Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.

Description : The nurse auscultates the apex beat at which of the following anatomical locations? a) Fifth intercostal space, midclavicular line The left ventricle is responsible for the apex beat or the point of ... of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.

Last Answer : a) Fifth intercostal space, midclavicular line The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space.

The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

Description : The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin ... A broken cast should be reported to the physician; the patient should not attempt to fix it.

Last Answer : a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Description : Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Last Answer : A. 1, 2, and 3

When fluid intake is normal, the specific gravity of urine should be a) 1.010-1.025. Urine specific gravity is a measurement of the kidney’s ability to concentrate urine.

Description : When fluid intake is normal, the specific gravity of urine should be a) 1.010-1.025. Urine specific gravity is a measurement of the kidney's ability to concentrate urine. b) 1.000. The ... intake. d) greater than 1.025. A urine specific gravity greater than 1.025 may indicate overhydration.

Last Answer : a) 1.010-1.025. Urine specific gravity is a measurement of the kidney’s ability to concentrate urine.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Description : What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the ... oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

Last Answer : a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen ... literally be pulled away with such great force that they can fly like projectiles towards the magnet.

88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Description : 88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Last Answer : A. Discharge plan

51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Description : 51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Last Answer : C. Sit the client upright and lean forward

The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

The principles of antihypertensive drug usage enunciated in JNC VI and WHO-ISH guidelines include the following except: A. Therapy for grade I and II hypertension should be initiated with a single drug B. Dose of thiazide diuretic should be 12.5-25 mg hydrochlorothiazide or equivalent per day C. All subjects with BP higher than 140/90 mmHg should be put on antihypertensive medication immediately D. If the drug chosen initially fails to lower BP, it should be replaced by a drug/combination from another class

Description : The principles of antihypertensive drug usage enunciated in JNC VI and WHO-ISH guidelines include the following except: A. Therapy for grade I and II hypertension should be initiated with a single drug ... initially fails to lower BP, it should be replaced by a drug/combination from another class

Last Answer : C. All subjects with BP higher than 140/90 mmHg should be put on antihypertensive medication immediately

Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling catheter, the patient is placed on a timed voiding schedule, usually two to three hours. At the given time interval, the patient is instructed to void. a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

Description : Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling ... in the bladder after voiding, straight catheterization may be performed for complete bladder emptying.

Last Answer : a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

Description : When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a ... the external vulva and vaginal walls. d) chlamydia. Chlamydia causes a profuse purulent discharge.

Last Answer : a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Description : 57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Last Answer : A. Abdominal pain

55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Description : 55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Last Answer : B. “Have you ever vomited blood or noticed very black stools?”

38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Description : 38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Last Answer : C. Explore the possible reason why the client refuses the prescribed medication