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Question 1 of 30
1. Question
Category: Management of CareWhich action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply.
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Question 2 of 30
2. Question
Category: Management of CareThe patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?
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Question 3 of 30
3. Question
Category: Physiological AdaptationYou have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?
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Question 4 of 30
4. Question
Category: Management of CareYou are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?
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Question 5 of 30
5. Question
Category: Management of CareA 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Select all that apply.
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Question 6 of 30
6. Question
Category: Physiological AdaptationWhile working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?
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Question 7 of 30
7. Question
Category: Pharmacological and Parenteral TherapiesA patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?
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Question 8 of 30
8. Question
Category: Management of CareAfter receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?
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Question 9 of 30
9. Question
Category: Management of CareAll of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply.
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Question 10 of 30
10. Question
Category: Management of CareAs the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer’s disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?
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Question 11 of 30
11. Question
Category: Basic Care and ComfortAn 89-year-old female patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer’s disease. The patient’s husband reports to you that he rarely gets a good night’s sleep because he needs to make sure his wife does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?
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Question 12 of 30
12. Question
Category: Pharmacological and Parenteral TherapiesYou are caring for a patient with recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?
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Question 13 of 30
13. Question
Category: Management of CareA 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
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Question 14 of 30
14. Question
Category: Management of CareWhich of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
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Question 15 of 30
15. Question
Category: Physiological AdaptationWhat is the priority nursing diagnosis for a patient experiencing a migraine headache?
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Question 16 of 30
16. Question
Category: Reduction of Risk PotentialNurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is:
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Question 17 of 30
17. Question
Category: Physiological AdaptationWhere would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?
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Question 18 of 30
18. Question
Category: Physiological AdaptationA male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?
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Question 19 of 30
19. Question
Category: Pharmacological and Parenteral TherapiesIn evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:
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Question 20 of 30
20. Question
Category: Physiological AdaptationNurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse’s next action?
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Question 21 of 30
21. Question
Category: Physiological AdaptationNurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should:
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Question 22 of 30
22. Question
Category: Pharmacological and Parenteral TherapiesA male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
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Question 23 of 30
23. Question
Category: Physiological AdaptationA client underwent ileostomy, when should the drainage appliance be applied to the stoma?
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Question 24 of 30
24. Question
Category: Reduction of Risk PotentialA client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
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Question 25 of 30
25. Question
Category: Physiological AdaptationWhile monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
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Question 26 of 30
26. Question
Category: Physiological AdaptationMrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?
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Question 27 of 30
27. Question
Category: Physiological AdaptationA male client has active tuberculosis (TB). Which of the following symptoms will be exhibited?
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Question 28 of 30
28. Question
Category: Physiological AdaptationMark, a 7-year-old client, is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?
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Question 29 of 30
29. Question
Category: Pharmacological and Parenteral TherapiesMarichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?
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Question 30 of 30
30. Question
Category: Health Promotion and MaintenanceA 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?
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