A client has just been admitted to the medical unit and the nurse is performing an initial physical assessment. The nurse finds that the client has difficulty hearing questions. The nurse also notices an empty glasses case that was sent up with the client from the emergency department. Based on this information, which action should first be taken by the nurse?

Determine out of which ear the client hears best and if there is a hearing deficit in both ears. Then ask the client about the empty glasses case.

Ask the client about use of any "assistive devices" and document the client's response.

Look through the client's belongings to determine if there is a pair of glasses and a hearing aid.

Notify the physician of the client's difficulty hearing and the empty glasses case.

A client has received platelet infusions. Which finding would indicate the most therapeutic effect from the transfusions?

Decrease in oozing of blood from IV site

Hgb level increase from 8.9 to 10.6

White blood cell count of 11,000

A pediatric client is admitted with Munchausen's syndrome by proxy. The nurse would expect the child to have:

Dermatitis of the lips and tongue

During routine hygiene care for a patient with AIDS, a nurse following standard precautions would take which action?

Wear gloves when giving mouth care.

Place the patient in a private room.

Put on a mask, gloves, and a gown.

A 72-year-old patient is being discharged from same-day surgery after having a cataract removed from his right eye. Which discharge instruction should the nurse give the patient?

Don't rub or place pressure on the eyes.

Resume all activities as before.

Wear an eye shield all day and remove it at night.

The nurse is discharging a client who is diagnosed with gout. The nurse recognizes further teaching is necessary when the client states:

I shouldn't drink too many fluids.

I'll have to tell my wife that I can't eat too much beef.

If I lose weight, I may have fewer gout attacks.

The doctor gave me medication to keep my uric acid levels down.

A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Have you noticed changes in his abdominal size?

The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

A 15-year-old with sternal bruises

A 10-year-old with lacerations of the face

A 34-year-old with a fractured femur

A 50-year-old with dislocation of the elbow

A client is brought to the emergency department by ambulance in an altered state of consciousness. The client does not answer questions appropriately, is alternately agitated and drowsy, and speaks loudly and incoherently at intervals. The client's significant other arrives in the emergency department and asks the nurse for the results of the client's urine drug screen. The client's significant other states that the client has used illegal drugs in the past. The significant other needs the information for personal safety and the safety of the couple's children. What is the best response by the nurse to the request for the results of the urine drug screen?

Thank you for the information about the client's history of illegal drug use. A complete health history helps us give better care. The health information of every client is confidential and protected by law and can not be released without the client's consent. Does the client have a Durable Power of Attorney for Health Care listing you as the surrogate decision-maker?

The results of the urine drug screen are positive for illegal substances.

You are wise to ask for the urine drug screen results for your safety and the children's safety. The drug screen results are positive for the drugs you gave me information about.

Thank you for the information about the client's history of illegal drug use. Because you live together and have children together, I can give you those results.

A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which of the following suggestions would be most helpful?

Practice relaxation techniques before bedtime.

Drink a cup of hot chocolate before bedtime.

Drink a small glass of wine with dinner.

Exercise for 30 minutes just before bedtime.

A client comes to the physician's office for a follow-up appointment. The nurse notes that the client is using correct cane walking technique. However, the nurse also notes that the client appears to lose balance each time the quad cane is lifted off of the floor and, upon examination, finds bruises on the client's arms and legs. The nurse asks the client about use of the cane at home. The client reports a history of recent falls. The client asks the nurse not to tell the physician because the client does not want to end up in "a home." What is the best action for the nurse to take?

Reassure the client that there are other assistive devices that are options for use at home, such as a walker, and that the nurse and physician will work to find one that will allow the client to remain at home. Inform the physician of the observations made regarding the quad cane.

Inform the client that there are only a few assistive devices available to help with ambulation.

Reassure the client that "homes" are not so bad.

Do not notify the physician of the observations due to patient confidentiality and hope the physician picks up on the client's unstable gait with the quad cane.

The nurse teaches an alcoholic client the signs and symptoms of alcohol withdrawal. Which statement by the client indicates that he understands the teaching?

My hands may begin to shake once I quit drinking.

My heart rate may slow down during withdrawal.

I will become very sleepy during withdrawal.

My blood pressure will drop once I quit drinking.

GCC 1201 - 1225

Authored by Global Nurse Force undefined

Health Sciences

Professional Development

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25 questions

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MULTIPLE CHOICE QUESTION

1 min • 1 pt

A transjugular intrahepatic portosystemic shunt (TIPS) is performed for which condition?

Portal hypertension.

Ruptured esophageal varices.

Jaundice.

Jugular venous distension.

MULTIPLE CHOICE QUESTION

1 min • 1 pt

A patient with pneumonia in the right lower lobe is prescribed percussion and postural drainage. When performing percussion and postural drainage, the nurse should position him:

in semi-Fowler's position with his knees bent.

in a right side-lying position with the foot of his bed elevated.

in a prone or supine position with the foot of his bed elevated higher than his head.

bent at the waist leaning slightly forward.

MULTIPLE CHOICE QUESTION

1 min • 1 pt

The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

The graduate places the client in a supine position to read the manometer.

The graduate turns the stop-cock to the off position from the IV fluid to the client.

The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.

The graduate notes the level at the top of the meniscus.

MULTIPLE CHOICE QUESTION

1 min • 1 pt

A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

Prevent the need for dressing changes

Reduce edema at the incision

Provide for wound drainage

Keep the common bile duct open

MULTIPLE CHOICE QUESTION

1 min • 1 pt

A client is having a CAT scan and is worried about being in an enclosed space for the test. The client also states that antianxiety medications cause confusion. The client asks if there are other ways of helping control the fear while the scan is being done. The client reports attending yoga classes and finds guided imagery very relaxing. What is the nurse's best action to take with this client?

Discuss the use of the breath work that the client does during yoga and inform the client that music headphones are available in the radiology department.

Discuss the use of Reiki therapy and therapeutic touch during the CAT scan. Provide instruction in the use of these two methods during the CAT scan.

Discuss use of the "Zone Diet" and meditation during the CAT scan as alternatives to yoga and guided imagery.

Discuss the use of hypnotherapy as an alternative to the guided imagery that the client does during yoga.

MULTIPLE CHOICE QUESTION

1 min • 1 pt

Which laboratory test result supports the diagnosis SLE?

Elevated serum complement level

Thrombocytosis and elevated sedimentation rate

Pancytopenia and elevated antinuclear antibody (ANA) titer

Leukocytosis and elevated blood urea nitrogen (BUN) and creatinine levels

MULTIPLE CHOICE QUESTION

1 min • 1 pt

A client who takes tranylcypromine (Parnate) is changed to fluoxetine (Prozac). Which manifestation indicates a serious interaction between these two medications?

Decreased salivary secretions.

Complete heart block.

Hyperthermia.

Hypoactive reflexes.

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GCC 1201 - 1225

A transjugular intrahepatic portosystemic shunt (TIPS) is performed for which condition?

A patient with pneumonia in the right lower lobe is prescribed percussion and postural drainage. When performing percussion and postural drainage, the nurse should position him:

The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

Which laboratory test result supports the diagnosis SLE?

A client who takes tranylcypromine (Parnate) is changed to fluoxetine (Prozac). Which manifestation indicates a serious interaction between these two medications?

A client has received platelet infusions. Which finding would indicate the most therapeutic effect from the transfusions?

A 36-year-old patient complains of fatigue, weight loss, and a low-grade fever. He also has pain in his fingers, elbows, and ankles. Which condition is suspected?

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