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) A client is receiving NPH insulin 20 units subq at 7:00 AM daily, at 3 PM how would the nurse finds if the client were having a hypoglycemic reaction? A.) Feel the client and bed for dampness B.) Observe client kussmaul respirations C.) Smell client’s breathe for acetone odor D.) Check client’s pupils for dilation 2.) Postoperative thyroidectomy nursing care includes which measures? A.) Have the client speak every 5-10 mins if hoarseness is present B.) Provide a low calcium diet to prevent hypercalcemia C.) Check the dressing all the back of the neck for bleeding D.) Apply a soft cervical collar to restrict neck movement 3.) What would the nurse note as typical findings on the assessment of a client with acute pancreatitis? A.) Steatorrhea, abd. Pain, fever B.) Fever, hypoglycemia, DHN C.) Melena, persistent vomiting, hyperactive bowel sounds D.) Hypoactive bowel sounds, decreased amylase and lipase levels 4.) A client is found to be comatose and hypoglycemic with a blood suger level 50 mg/dl. What nursing action is implemented first? A.) Infuse 1000 ml of D5W over a 12-hour period B.) Administer 50% glucose IV C.) Check the client’s urine for the presence of sugar and acetone D.) Encourage the client to drink orange juice with added sugar 5.) Which medication will the nurse have available for the emergency treatment of tetany in the client who has had a thyroidectomy? A.) Calcium chloride B.) Potassium chloride C.) Magnesium sulfate D.) Sodium bicarbonate 6.) What is the primary action of insulin in the body? A.) Enhances the transport of glucose across cell walls B.) Aids in the process of gluconeogenesis C.) Stimulates the pancreatic beta cells D.) Decreases the intestinal absorption of glucose 7.) What will the nurse teach the diabetic client regarding exercise in his /her treatment program? A.) During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin B.) With an increase in activity the body will utilize more carbohydrates; therefore more insulin will be required. C.) The increase in activity results in an increase in the utilization of insulin; therefore the client should decrease his/her carbohydrate intake D.) Exercise will improve pancreatic circulation and stimulate the islet of Langerhans to increase the production of intrinsic insulin 8.) The nurse is caring for a client who has exophthalmos associated with her thyroid disease. What is the cause of exophthalmos? A.) Fluid edema in the retro-orbital tissues which force the eyes to protrude B.) Impaired vision, which causes the client to squint in order to see C.) Increased eye lubrication, which makes the client blink less D.) Decrease in extraocular eye movements, which results in the “thyroid stare.” 9.) What is characteristic symptom of hypoglycemia that should alert nurse to an early insulin reaction? A.) Diaphoresis B.) Drowsiness C.) Severe thirst D.) Coma 10.) A client is scheduled for routine glycosylated hemoglobin (HbA1c) test. What is important for the nurse to tell the client before this test? A.) Drink only water after midnight and come to the clinic early in the morning B.) Eat a normal breakfast and be at the clinic 2 hours because of the multiple blood draws

) A client has been inhalation vasopressin therapy. What will the nurse evaluate to determine the therapeutic response to this medication? A.) Blood glucose C.) Vital signs D.) A client admitted with a pheochrocytoma returns from the operating room after adrenalectomy.) A priority nursing diagnostic for a client admitted to the hospital with a diagnosis of diabetes insipidus is: A.) A nurse assessing a client with SIADH would expect to find laboratory values of: A.) Bulging eyes D.) Fluid volume excess r/t intake greater that output D.) Increased platelet aggregation C.) Oxygen saturation levels 12.) Increased ketone level in urine 13.) Marked fluctuations in BP 19. the nurse would question an order for: A.) When caring for client in thyroid crisis.) The nurse performing an assessment on a client who has been receiving long-term steroid therapy would expect to find: A.) Should be taken with meals D.) Hypokalemia B. The most important instruction to give the client for administration of this drug is: A.) May increase the effects of aspirin 16.) Prophylthiouracil D.) Serum Na=120 mEq/L and low serum osmolality D.C.) 1100 and 1700 hours C.) A client is prescribed levothyroxine (Synthroid) daily.) Increased blood glucose level B.) A diabetic client receives a combination of regular and NPH insulin at 0700 hours. An expected change that requires close monitoring by the nurse is.) Expect to be at the clinic for several hours because of the multiple blood draws D.) Come to the clinic at the earliest convenience to have blood drawn 11.) Activity intolerance r/t muscle weakness C.) Risk for impaired skin integrity r/t generalized edema 18. The nurse should carefully assess this client for: A.) Increased ceatinine clearance D.) 1000 and 2200 hours D.) 0800 and 1100 hours 15. The nurse teaches the client to be alert for signs of hypoglycemia at A.) Jaundice B.) A hyperthermia blanket 20.) 1200 and 1300 hours B.) Hyperglycemia C.) Marked Na and water intake D.) Taper dose and discontinue if mental and emotional statuses stabilize B. A.) Serum K= 5 mEq/L and low serum osmolality C.) May cause nocturia B.) A client with diagnosis of type 2 diabetes has been ordered a course of prednisone for her severe arthritic pain.) Take it at bedtime to avoid the side effects of nausea and flatus .) Serum K= 3 mEq/L and high serum osmolality 17.) Sleep pattern deprivation related nocturia B.) IV fluid B.) Serum Na= 150 mEq/L and low urine osmolality B.) It is important for the nurse to teach the client that metformin (Glcucophage): A.) Propanolol (Inderal) C.) Urine specific gravity B.) Should be taken at night C.) Central obesity 14.) Flank pain C.

) Do not watch TV for at least one day B.) Provides mechanical transmission for damaged part of the ear B.) “There may be a genetic factor with glaucoma and your children over 30 y/o should be screened yearly.) “Are your grandchildren complaining of any eye problems? Glaucoma generally skips a generation.) Carbanyl choline (Isopto carbachol) eye drops.) “I’ll just do some laundry this afternoon instead of going to work.) Stimulates the neural network of the inner ear to amplify sound C.) Correct a malformation in the inner ear D.) “It’s okay for me to let my friends use my sunglasses while we are playing together.) “It’s okay for me to softly rub my eye.) Irrigate the eye every hour to prevent dryness D.) “I’ll take my acetazolamide (Diamox) drops with my other morning medications 30.” B.) Do not rub the eye for 15-20 minutes C.D.) “Screening for glaucoma should be included in an annual eye exam for everyones over 50. what instructions will be important for the nurse to give the client? A.) Atropine (Atrposil) 1-2 drops in each eye now B.” C.C.) Amplifies sound but does not improve the ability to hear D.) A client is walking down the hall and begins to experience vertigo. What is the most important nursing action when this occurs? .) Call the M.) Nifedipine B. D.” D.” B.) Wear sunglasses when in direct sunlight for the next 6 hours 26.) “I can pick the crustly stuff out of my eyelashes with my fingers when I wake up in the morning.” 27.) “I’ll continue to take my Metamucil for another week.) Hydrochloride (Hydro DIURIL) 28. glaucoma is not hereditary order.” B.) What will be important to include in the nursing care for the client with angle-closure glaucoma? A.” C.) A child is scheduled for a myringotomy.) Amoxicillin C.) Tunes out extraneous noise in the lower-frequency sound spectrum 29.) After a client’s eye has been anesthetized.) What statement by the client recovering from cataract surgery would indicate to the nurse need for additional teaching? A.” D.” 23. it can be reversed if promptly identified. What is the best response? A. 1 drop 2 times a day 22.) What medication would the nurse anticipate giving a client with Meniere’s dse? A.) Equalize pressure on the tympanic membrane 25.) Assessment for a level of discomfort.) Evaluation of medications to determine if any of them cause an increase in IOP is a side effect.) The nurse would question which medication order for a client with acute-angled glaucoma? A. the nurse will base the teaching on what information regarding the hearing aid? A. B. C.) A child diagnosed with conjunctivitis.) When teaching a family and a client about the use of a hearing aid. immediately at the onset of palpitations or nervousness D. Which statement reflects that the child understood the nurse’s teaching? A.) “I’ll call if I have a significant amount of pain.) Observation for an increase in loss of vision.) “There is no need for concern.) Control BP to decrease the client’s potential loss of peripheral vision.) Propanolol (Inderal) 20 mg PO 2 times a day D. the client may experience considerable pain until the optic nerve atrophies 24.) Irrigate the Eustachian tube C. What goal of this procedure will the nurse discuss with the parents? A.” D.) Hydrochloride (Diuril) 25 mg PO daily C. as long as I use the back of my hand.) A client tells you she has heard that glaucoma may be a hereditary problem and she is concerned about her adult children.) Propanolol D.) Promote drainage from the ear B.) “I will use my own washrag and towel while my eyes are sick.” C.) Decrease intake of juices and fruits with high potassium and calcium contents 21.

) A 15-year old client in sickle cell crisis 39. What is the most important for the nurse to tell the client to do immediately? A.) Have the client sit in a chair and lower his head B.) Avoid fresh vegetables that are not cooked or peeled C.) Monitor V/S every 2 hours during the transfusion .) Coping and stress tolerance 37.) Go to the closest emergency room D.) Provide a diet low in protein and high in carbohydrates B. What instructions will the nurse include in the teaching plan for the parents of this child? A.) 72 y/o with nystagmus and Bell’s palsy 32. if the child’s temperature exceeds 101F (39 C) D.) Prevent aspirations C.) Begin oxygen 2-4L/min via nasal cannula D.) Monitor the client’s vital signs for the first 5 minutes D.) Assist the client to sit or lie down D.) A client with cancer receiving radiation therapy twice a week B.) Screening hearing test C.) Which client is most likely to have iron deficiency anemia? A.) A client with peptic ulcer who had surgery 6 weeks ago D. weakness and palpitations. What would be included in the nursing care plan? A.) Nutritional patterns C.) Change inner ear dressing when saturated 33.) Epinephrine HCL (Epirate) 34.) Betaxolol (Betoptic) C.) Effect on client’s activities of daily living (ADLs) D. What is most important to the nurse to assess? A.) Notify the M.) A client calls the nurse regarding an accident that just occurred during which an unknown chemical was splashed in his eyes.) Diet history B.year old woman comes to the clinic complaining of dizziness.) Implement fall precautions B.) A toddler whose primary nutritional intake is milk C.) Administer meclizine (Antivert) PO C. What is a correct nursing action? A.) To promote and maintain safety for a client after a stapedectomy.A.) A child with leukemia is being discharged after beginning chemotherapy.) A 25.) The nurse would question the administration of which eye drop in a patient with increased ICP? A.) Frequency and severity 35.) Have a co-worker visually checks the eye for a foreign body 36.) 4-year old with amblyopia B. What will be important for the nurse to initially evaluate when obtaining the health history? A.) Put a pad soaked in the sterile saline solution over the eye C.) Family health status D.) Increase the use of humidifiers throughout the house 38.) Artificial tears B.) Which client is at highest risk for retinal detachment? A.) 17 y/o who plays physical contact C.D.) A client is being admitted for problems with Meniere’s disease.) Rinse the eye with large amount of water or saline solution B.) Activity and exercise patterns B.) Initiate an IV with 5% dextrose in water (D5W) to maintain a patent access site B.) A client has an order for one unit of whole blood.) Assess if the occurrence is vertigo or dizziness 31.) Initiate the transfusion within 30 minutes of receiving the blood C.) 33 y/o with severe ptosis and diplopia D.) Acetazolamide (Diamox) D.

) Precautions are necessary because oxygen can spontaneously ignite and explode D.) An increase in peak pressure on the ventilator B.) Chest x-ray film shows right sided pleural fluid B.) Decrease intake of leafy green vegetables because of increased Vit.) Whole blood 44.) Client is able to speak C.) Packed RBC B.) The nurse is caring for a client who is receiving a blood transfusion.45NaCl C.) The nurse is preparing to start an IV infusion before the administration of a unit of packed red blood cells. dyspnea.) The use of oxygen will eliminate the client’s shortness of breath C.) Stop the transfusion.) Increased crackles (rales) over left lung field 48. ecchymosis.) Back pain. the client will have to limit activity at home B. oxygenation. such as D10W D.) Monthly Vit. what fluid will the nurse select to maintain the infusion before hanging the unit of blood? A.) Nutrition.) A few scattered crackles on RLL on auscultation C.40. apin management D. and joint tenderness 45.) D5W/.) Decrease in forced vital capacity 47.) Use oxygen during activity to relieve the strain on the client’s heart 49.) A client has been diagnosed with pernicious anemia what will the nurse teach this client regarding medication he will need to take after he goes home? A.) Stop the infusion of blood and begin infusion of NSS from the Y connector D. B12 injections will be necessary B.) Volume expanders.) .) Hemoglobin below 13 mg/dl C.) The wife of a client with COPD is worried about caring for her husband at home.) Increased fatigue and bleeding tendencies B.9% Na Cl 42.) Hydration.) Coagulation studies are important to evaluate medications D.) Because of his need for oxygen.) Headaches. electrolyte balance C.) A client in the ICU has been diagnosed with DIC. K 46.) D5W B. pain management.) First postop day after a right lower lobe (RLL) lobectomy.) Fresh Frozen plasma (FFP) C. What indicates that the client is not adequately clearing secretions? A.) What nursing observations indicate that the cuff on an endotracheal tube is leaking? A. disconnect the blood tubing and begin a primary infusion of normal saline solution C. the client breathes and coughs but has difficulty raising mucus.) Hydration.) Hydration.) Increased swallowing efforts by client D. What information does the nurse provide to the client and his wife regarding the use of oxygen at home? A.) PCO2 increases from 35-45 mm Hg D. The nurse will anticipate administering which of the following fluids? A.) LR solution D. The transfusion was started 30 mins ago at a rate of 100 ml/hr. electrolyte balance B.) A client in sickle cell crisis is admitted to the emergency department what are the priorities of care? A.) Ferrous sulfate PO daily will be prescribed C.) Recheck the unit of blood for correct identification numbers and cross-match information 41.) The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. electrolyte balance 43. What characteristics will the nurse anticipate finding when assessing this client? A. Which statement by the nurse provides the most valid information? . The client begins to complain of low back pain and headache and is increasing restless.) Slow the infusion and evaluate the V/S and client’s history of transfusion reaction B. oxygenation. hydration. claudication D.) The nurse is assessing a client who has been given a diagnosis of polycythemia vera. what is the first nursing action? A.

and the upper airway is suctioned. B 15. the catheter is inserted into the endotracheal tube. A C A B A A A A A 10. C 29. and intermittent suction is applied during withdrawal. C . A 24.” C. B 26. C 21. A 13. A 25. B 18. 5. D 11. D 20.) “Arrange a schedule so your husband does all necessary activities before noon. 8.” 50. the catheter is then withdrawn. intermittent suction is applied until no further secretions are retrieved. D 14. 7.A.) The catheter is inserted through the nose.” B.” D. Answers 1.) “You should avoid emotional situations that increase his shortness of breathe. B. when resistance is met. 4.) With suction applied.) “Your husband will be no more short of breath when he walks but that will not hurt him. C 23.) Which statement correctly describes suctioning through an endotracheal tube A.) The catheter is inserted into the endotracheal tube to a point of resistance. A 12. the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway C. C 16. C 17. D 27. 9. D 28. then he can rest during the afternoon and evening. D 19. the catheter is slowly withdrawn D. A 22. 2. 3.) The catheter is inserted into the endotracheal tube. 6.) “Help your husband arrange activities so that he does as little walking as possible.

D 35. B 32. operating room concept nclex question . B 48. B 37. B 38. D 34. A 46. 3 nursing diagnosis for hypercalcemia. A 36. C 45. C 43. D 42. C 31. nursing diagnosis for hypercalemia. C 47. questions operating room with rationale.30. B 39. D operating room questions with rationale. C 50. B 41. A 49. B 44. nursing care plan for leukemia(activity intolerance). A 33. nclex questions on copd. B 40.

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