CP20_TEST_QUESTIONS_AND_ANSWERS.docx | Exams Advanced Education

CP20 TEST QUESTIONS AND ANSWERS/100%

CORRECT

A nurse is caring for a client who had a partial laryngectomy and is receiving

continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which

of the following findings requires immediate intervention by the nurse?

Correct ans - The infusion pump for administering contimuous feeding is

turned off.

A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which

of the following findings should the nurse expect? Correct ans -

Hypotension

A nurse is providing dietary teaching to a client who has an increased

cholesterol level. Which of the following foods should the nurse recommend?

Correct ans - Egg whites

A nurse is caring for a toddler who has respiratory syncytial virus. Which of

the following actions should the nurse plan to take? Correct ans - Use

a designated stethoscope when caring for the toddler.

A nurse is assessing a client who has a chest tube following a thoracotomy.

Which of the following findings requires intervention by the nurse?

Correct ans - 1 cm of water present in the water seal

A nurse is reviewing the medical history of a client who is taking garlic

supplement. The nurse should identify that which of the following findings is

a contraindication for taking this supplement? Correct ans - The client

takes aspirin daily.

A nurse is planning to provide community education about viral hepatitis.

Which of the following should the nurse plan to include in the teaching?

Correct ans - series of four hepatitis vaccines is recommended to prevent

viral hepatitis.

A nurse is reviewing the history and physical of a client who has right

ventricular heart failure. Which of the following is an expected finding?

Correct ans - Elevated pulmonary artery pressure

A home health nurse is conducting an initial home visit for a client who has

terminal breast cancer. The client has two school-age children and a limited

support system. Which of the following is the priority nursing action?

Correct ans - Inform the client of available community resources.

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A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? Correct ans - The infusion pump for administering contimuous feeding is turned off. A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? Correct ans - Hypotension A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? Correct ans - Egg whites A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? Correct ans - Use a designated stethoscope when caring for the toddler. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? Correct ans - 1 cm of water present in the water seal A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? Correct ans - The client takes aspirin daily. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? Correct ans - series of four hepatitis vaccines is recommended to prevent viral hepatitis. A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding? Correct ans - Elevated pulmonary artery pressure A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? Correct ans - Inform the client of available community resources.

A nurse is providing postoperative teaching to a client who has a newly- inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? Correct ans - "I will use my cell phone on the ear opposite of my pacemaker." A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? Correct ans - Decreased reflexes A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? Correct ans - Wear an N95 respirator. A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.) Correct ans - The nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The provider's prescription should include the A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? Correct ans - Educating the client how to cover nose and mouth with tissues when coughing A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? Correct ans - Schedule routine care tasks during hours when the client is awake. A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? Correct ans - Review deep breathing and coughing exercises. A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take? Correct ans - Report to the nurse manager. A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following? Correct ans

The tubing may be kinked. A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is

A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? Correct ans - Shellfish allergy A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? Correct ans - A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? Correct ans - Rephrase sentences the client does not understand. A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? Correct ans - Lean in slightly when speaking to the client. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? Correct ans - A client who had a stroke 2 days ago and needs help toileting A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? Correct ans - A brainstorming session with nurses A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? Correct ans - "Try to have your baby empty your breasts with each feeding." A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Correct ans - Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins. A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include? Correct ans - Eat a dry carbohydrate before getting out of bed.

A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? Correct ans - Check the FHR. A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? Correct ans - Report the incident to Adult Protective Services. A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine? Correct ans - Hypertension A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states, Correct ans - "My stoma will drain liquid fluid continuously." At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? Correct ans - Indigestion A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? Correct ans - Opioid intoxication A nurse is reviewing the medical record of a client who has new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity? Correct ans - Furosemide A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? Correct ans - Urine output of 250 mL/hr A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis? Correct ans

Sputum culture

Correct ans - Hospice care encourages the family to coordinate health care services. A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? Correct ans - Monitoring the insertion site for infection A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? Correct ans - Require the cient wear a dosimeter badge. A community health nurse is teaching a group of restaurant workers about hepatitis A. Which of the following statements should the nurse make? Correct ans - "Hepatitis A can be spread by fecal-oral contact." A nurse in a mental health clinic is observing clients the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic? Correct ans - "You're curious why I am interested in you and not the others?" A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? Correct ans - HBA1C the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of Correct ans - Abdominal rigidity A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? Correct ans - Fever A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? Correct ans

"This technique decreases the risk of subcutaneous infiltration." A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of following findings should the nurse expect? Correct ans - Hyperreflexia

A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include? Correct ans - relieved by position change A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? Correct ans - Pulse 54/min A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation? Correct ans

Sucralfate 1 g PO 1 hr ac A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan? Correct ans - lodine A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first? Correct ans - Open the client's windows. A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply.) Correct ans - witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave client who signs an informed consent form should understand the treatment plan." "A client who signs an informed consent form should be competent." "The nurse should disclose the purpose of the treatment before the client signs the consent form." A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching? Correct ans - Administer the medication with a glass of orange juice. A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make? Correct ans - "Bring the child to the funeral service before visitors arrive." A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings Indicates fluid overload? Correct ans - Bounding pulses

A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make? Correct ans - "Please stop this discussion." A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first? Correct ans - Determine the client's pain level. A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? Correct ans - Avoid foods that have high levels of oxalates. A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first? Correct ans - A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? Correct ans

Maintain the head at a midline position. A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage? Correct ans - Troponin I 1.8 ng/mL A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? Correct ans - 0900 A client who has a diagnosis of com acenta is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? Correct ans - Prepare the client for a cesarean section. A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating? Correct ans - Justice A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? Correct ans - Hyperemesis

A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe? Correct ans - Sertraline A nurse is performing change-of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first? Correct ans - A client who has gastroenteritis and is lethargic and confused A nurse is planning care for a client who has a gambling disorder. Which of following instructions should the nurse provide to the client? Correct ans

Participate in a 12-step program. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? Correct ans - Notify the facility A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Correct ans - Infuse 0.9% sodium chloride V. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? Correct ans - Pulse oximeter A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? Correct ans - "Notify your provider if you experience muscle weakness." A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding? Correct ans - Swollen lips A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include? Correct ans - Gently massage the skin under the straps once per day. A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first? Correct ans - Identify the reason for the client's refusal. A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is Correct ans - asymmetric, with variegated coloring. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? Correct ans - Consistent contractions last 80 seconds. A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective? Correct ans - Pedal pulses 2+ A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration? Correct ans - The client pockets food on one side of his mouth. A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? Correct ans - Burning A nurse is creating a plan care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? Correct ans - Monitor the client for 1 hr after meals. A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? Correct ans - A dient who has a traumatic arm amputation A nurse performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take prevent a pressure injury? Correct ans - Encourage client fluid intake of 2,500 ml daily. A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching? Correct ans - Change clothes after working in the field. A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene? Correct ans - Viewing the newborn's actions to be uncooperative

A nurse is caring for a client following insertion of a subclavian prescription to initiate an IV infusion of Ringer's lactate at 150 ml per hr. Prior to starting the infusion, which of the following actions should the nontunneled percutaneous central venous catheter (CVC). The provider writes a nurse take? Correct ans - Review the chest x-ray report. A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? Correct ans - Uses others for personal gain

CP20_TEST_QUESTIONS_AND_ANSWERS.docx, Exams of Advanced Education

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CP20 TEST QUESTIONS AND ANSWERS/100%

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