1. What instruction should the nurse in the discharge teaching plan of a client who had a cataract extraction today? a. Sexual activities may be resumed upon return home. b. Light housekeeping is permitted but avoid heavy lifting. c. Use a mental eye shield on operative eye during the day. d. Administer eye ointment before applying eye drops. ANS:B 2. A male adult comes to the urgent care clinic 5 days after being diagonose with influenza.He is short of breathe, ferbile and coughing green coloured sputum.Which intervention should the nurse implement first? a. Obtain a sputum sample for culture. b. Check the oxygen saturation level. c. Administer on oral antipyretic. d. Aauscultate bilateral lung sound. ANS:A 3. An elder male client tells the nurse that he is loosing sleep because he has to get up several times to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty.Which intervention should the nurse implement? a. collect urine specimen for culture analysis. b. Obtain a fingerstick blood glucose level. c. Palpate the bladder above the symphysis pubis. d. Review the client fluid intake. ANS:C 4. An adult client is admitted with diabetic ketoacidosis(DKA) and a urinary tract infection (UTI) Prescripions for intravenous antibiotics and insulin infusion are intiated.Which serum laboratory value warrants the most immediate intervention by the nurse? a. Blood ph of 7.30 b. Glucose of 350mg/dl c. White blood cell count of 15000mm d. Potassium of 2.5 meq/l ANS:D @Hanningtonstuvia 5. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? a. "I strap the infant car seat on the front seat to face backwards." b. "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." c. "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." d. "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." ANS:D 6. Upon completing the admission documents, the nurse learns that the 87 year-old Client does not have an advance directive. What action should the nurse take? a. Record the information on the chart b. Give information about advance directive c. Assume that this client wishes a full code d. Refer this issue to the unit secretary ANS:B 7. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes After the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to? a. Maintain the airway b. Administer epinephrine 1:1000 as ordered c. Monitor for hypotension with shock d. Administer diphenhydramine as ordered ANS:B @Hanningtonstuvia 5. Which of these children at the site of a disaster at a child day care center would The triage nurse put in the "treat last" category? a. An infant with intermittent bulging anterior fontanel between crying episodes b. A toddler with severe deep abrasions over 98% of the body c. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture d. A school-age child with singed eyebrows and hair on the arms The ANS:B 6. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’sbest action is to? a. Change whichever item is incorrect to the correct information d. Use the bracelet and admission form until a replacement is supplied c. Notify the admissions office and wait to apply the bracelet d. Make a corrected identification bracelet for the client ANS:D 7. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? a. Leave the order for the oncoming staff to follow-up b. Contact the charge nurse for an interpretation c. Ask the pharmacy for assistance in the interpretation d. Call the provider for clarification The correct answer is D: Call the provider for clarification ANS:D @Hanningtonstuvia 8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse Discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? a. Ask the client if there are any breathing problems b. Have the client void as much as possible c. Check the vital signs d. Auscultate the lungs ANS:D