A client has experienced a narcotic overdose. What acid–base imbalance should the nurse expect to observe in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis ANSWER Correct Answer: 1 Rationale 1: Because narcotics generally act to decrease or suppress respirations, this client is probably hypoventilating. The expected acid–base […]
The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. […]
The unit manager is orienting a new staff nurse and evaluates which of the following as an ap-propriate technique for nasotracheal suctioning? 1. Placing the client in a supine position 2. Preparing for a clean or nonsterile technique 3. Suctioning the oropharyngeal area first, then the nasotracheal area 4. Applying intermittent suction for 10 seconds […]
The nurse is assessing an elderly client’s blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the client’s pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation […]
A client who has undergone a gastrointestinal surgery is permitted to have a clear liquid diet on the second postoperative day. Which fluid should the nurse order from the diet kitchen for this client? 1. Apricot nectar 2. Cranberry juice 3. Chicken broth 4. Cherry ice pop ANSWER Correct Answer: 3 Rationale 1: Apricot […]
A client’s nasogastric tube has been discontinued and needs to be removed. Place in order the steps the nurse will perform to remove this tube. 1. Place the tube in a plastic bag. 2. Ask the client to take a deep breath and to hold it. 3. Smoothly withdraw the tube. 4. Pinch the tube […]
The nurse recommends follow-up auditory testing for a child who was exposed in utero to: 1. Excessive oxygen 2. Diabetes 3. Respiratory tract infection 4. Rubella ANSWER ANS: 4 Children at risk for hearing impairment include those who were exposed to rubella in utero. Chil-dren at risk for visual impairment include those who received […]
An older client diagnosed with Alzheimer’s disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques. ANSWER […]
A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. The most appropriate diagnosis for this client is which of the following? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis ANSWER Correct Answer: 3 Rationale 1: A risk diagnosis is a clinical judgment […]
A 24-year-old male client has been scheduled to undergo surgery for an ACL repair of his right knee. The client states that he is confused about what the surgeon will be doing. The best re-sponse from the nurse is: 1. “The surgeon went over this procedure with you in his office” 2. “Let me get […]
