Question

A nurse is collecting data from an adolescent client who has experienced sexual abuse. Which of the following statements by the client should the nurse recognized as the use of the use of defense mechanism of suppression?

1. I drink beer as often as I can so that I don’t have to think about all of the times it happened.
2. My mother is the real reason for it all because she doesn’t live in the real world.
3. Sometimes I get angry about it, but I know that just creates other problems.
4. I guess I have to take some of the blame because of the way my friends and I dress.
   
   A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend for a home care referral?

1. An adolescent client who has a tibia fracture and requires crutches.
2. A young adult client who has a substance use disorder
3. An older adult client who has heart failure and lives alone
4. A middle adult client who has a mastectomy and requires chemotherapy.

   A nurse is caring a female client who has as indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

1. Secure the tubing with adhesive tape to the lower abdomen
2. Instruct the client to hold the drainage bag at waist height when ambulating.
3. Coil the tubing on the bed above the collection bag.
4. Collect a sterile specimen from the urinary drainage bag.

   A nurse is collecting data from a client who is 12 hours postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

1. Apical pulse rate 88/min
2. Oxygen saturation 90%
3. Oral temperature 37.6 0C (99.7 0F)
4. Respiratory rate 20/min

A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take.

1. Place the bed in the lowest position.
2. Raise the head of the client’s bed.
3. Ask the client to flex her hips and knees.
4. Stand with the feet together.
   
   A nurse is reinforcing teaching with a female client who has a urinary tract infection and a prescription for an antibiotic. Which of the following instructions should the nurse include in the teaching?

1. Wear nylon undergarments as long as manifestations are present.
2. Empty the bladder every 4 hours.
3. Take the prescribed medication until the manifestations subside.
4. Limit alcoholic beverages to one per day.
5. A nurse is reinforcing teaching with a 36 year- old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse should include in the teaching that an amniocentesisis performed to identify which of the following findings?
6. Fetal breathing movements.
7. Chromosomal abnormalities
8. Placental circulation
9. Rh incompatibility
     
   A nurse in a long term care facility has just received change of shift report. Which of the following clients should the nurse attend to first?
10. A client who had a hip arthroplasty and is requesting pain medication.
11. A client who has a spinal cord injury and needs a dressing change.
12. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dl
13. A client who has a temperature of 38.4 0C (101.1 0F) and appears confused
    
    A nurse is collecting data from a parent of a school age child who is allergic to bee venom and has a bee sting injury. Which of the following actions should the nurse take first?

1. Clean the sting site with soapy water.
2. Administer epinephrine.
3. Apply a cool compress.
4. Administer diphenhydramine
   
   A nurse is caring for a client who has increased intracranial pressure following a closed head injury. Which of the following actions should the nurse take?

1. Wake the client every 6 to 8 hours.
2. Elevate the head of the bed to 30o
3. Monitor the client’s temperature every 4 hour.
4. Place the client in lateral Sims’ position

A nurse is caring for a preschool-age child who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

1. Understands that everyone dies eventually.
2. Recongnizes the parent will never wake up
3. Expresses curiosity about the funeral service.
4. Believes the death is punishment for bad behavior
   
   A nurse manager is seeking ways to increase cost effectiveness on the unit. In which of the following client care situations should the nurse manager intervene?
   

1. An assistive personnel is wearing gloves when feeding a client who has hepatitis B
2. An assistive personnel dons a mask when providing oral care for a client who has a staphylococcal infection.
3. A nurse discards a bottle of sterile saline after it has been open for 24 hours.
4. A nurse uses sterile gauze pads to replace a dressing on a surgical wound
   
   A nurse is contributing to the plan of care for a client who has delirium. Which of the following interventions should the nurse recommend to include in the plan?
   

1. Provide the client with four food choices at each meal.
2. Assist the client to the bathroom every 2 hour while awake.
3. Assign a different caregiver to the client each day.
4. Vary the client’s activities daily.
   
   A home health nurse is reinforcing teaching with a client about safe food handling to prevent food poisoning. Which of the following instructions should the nurse include in the teaching?
   a. Allow leftover food to cool before refrigerating.
5. Defrost frozen foods in the refrigerator.
6. Set refrigerator to 8 C (46.4 F)
7. Cook poultry to 60 C (140 F ).

   A Nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

8. You will need to urinate before the procedure.
9. You will feel pressure when inflate the catheter balloon
10. You will have a leg bag to collect the urine
11. You cannot drink fluids for 4 hours after the procedure

A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt with the charge nurse. Which of the following actions should the charge nurse take?

1. Perform a mental status examination to establish the client’s decision
2. Talk with the nurse about the need to support the client’s decision
3. Ask the client if he has any financial concerns
4. Meet with the client’s family to discuss treatment options

Answer 1

1. C

2.. C

3. A

4. B

5. C

6. B

7. G- Chromosomal abnormalities

8. J- The client with hip arthroplasty requesting for pain medication.

9. A- Clean the surface with soapy water

10. B- Elevate the head of the clent's bed to 30 degrees

11. B- Recognizes that the parent will never wake up

12. A- An assistive personal wearing gloves when feeding a client who has hepatitis B

13. B- Assist the client to wash room every 2 hours while awake.

14. E- Defrost frozen foods in the refrigerator.

15. H- You will need to urinate before the procedure.

16. D- Meet the client's family to discuss treatment options.