Orange-Practice4

1)A 7week old infant boy is admitted with projectile vomiting, decreased bowel movement and weight loss, he has poor skin turgor and appears hungry. The nurse observes left to right peristaltic waves after vomiting. The nurse would expect to find which of the following during physical assessment?

2) The nurse is teaching the parent of a child with celiac disease. Which of the following diet is helpful for the patient?

3) A child was admitted to the hospital 3hrs ago with a closed head injury. The child responds appropriately but sluggish to stimuli and drift in and out of sleep. Which of the following best describes this patient`s LOC?

4) While caring for a patient prior to surgery to amputate the leg, what is the most effective measure to prevent phantom limp sensation after amputation?

5) A nurse is caring post left lobectomy patient. On assessment nurse observe that the patient become restless and nail beds are blue. Vital signs reveal tachycardia, tachypnea and BP are rising. Which of the following complication is most likely?

6) 3days ago patient underwent surgery, now patient is febrile with drop in blood pressure, lab result shows elevated WBC, this could be possible presentation of

7) A home care nurse reviews the lab results of a postpartum patient who had a cesarean section. Which of the following indicate possible wound infection?

8) A 32 yr old female come 14days after LSCS. The patient is very anxious and complaining of sharp stabbing pain in her chest. The patient has dyspnea, tachypnea and hypoxemia. Which of the following complication is most likely?

9) A nursing process in which involves the performance of nursing care is called

10) A diabetic client who is taking regular and NPH insulin asks why she must mix two insulin. The nurse explains that regular and NPH insulin are mixed to ensure?

11) A home care nurse observes that asthmatic patient has cough, wheezing. The nurse administers an albuterol nebulizer treatment as ordered. Which type of implementation is this?

12) A healthy 26yr old patient is at 39wks of gestation, the patient is not considered high risk at the time of admission. Which of the following pending lab work has priority?

13) A nurse has just started TPN as prescribed for a patient with severe dysphasia and low pre-albumin levels. One or two hrs after discontinuation of therapy the nurse should assess?

14) A home health nurse has completed the assessment of 72yr old patient with gait disturbance, who will begin home physical therapy. During the interview, the patient reported significant difficulty sleeping more than 4hrs at night. Which of the following response would be appropriate for the nurse to make?

15) The stages of dying as identified by Dr.Elizebath Kubbler Ross, occur in what order?

16) A patient with conjunctivitis, reports the presence of phobia and moderate eye drainage. The nurse should teach the patient to

17) An RTA patient is on mechanical ventilator, ET tube inserted. Most suitable drug that instilled via ET tube is:

18) 14yr old boy admitted with epigastric pain radiating to RLQ, surgery is performed. Postoperatively, the physician observe the wound, most probably the surgical scar is presenting in:

19) Patient is on blood transfusion develops fever, chills, red urine and dyspnea. Possible cause of this reaction is:

20) A 58yr old patient diagnosed with gout is on Allopurinol. RN educates the patient to increase fluid intake up to 2500ml/day. The reason behind the health education is:

21) A patient undergone left side mastectomy came for follow up after 2wks. A knowledgeable nurse should know which area should exclude for taking blood pressure?

22) A person was treated for UTI 1month ago. Now he is affected with the same disease condition, an appropriate treatment plan for this condition is

23) Client admitted in hospital with the complaints of muscle cramps, tingling sensation in extremities, fatigue. Lab values are as follows

Which dietary change is essential?

24) Staff inadequacy is exists in ward setting from last 6months. The census reveals that there is no falls, no infection, and no other complaints to staff. The ward in charge decided to give incentive to the staff. This type of action is known as:

25) An 80yr old lady has 3^rd stage bedsore, she complaints that” I can`t do anything”. This response reflects….

26) Advantages of post-operative position changing and breathing exercises?

27) An adolescent visit doctor in a clinic with the complaints of abdominal pain, chest pain, right scapular pain and dyspnea. Lab results are normal. After evaluating the results, the doctor advised Psychiatric counseling, this advice made the patient feel……

28) Home visit, a patient complaint to community health nurse that he has severe muscle weakness and fatigue, this affecting her daily activities. The nurse formulating a nursing care plan………….

29) Elderly women Linda has stooped posture, resting tremors and bradykinesia, she is on some regular medicines. One day, during evening rounds, doctor changed the brand name of medicine. On the next day patient develops drowsiness, agitation, and restlessness. This shows…..

30) An 18yr old lady approach CHN to know more about safe `sex practice`. From the following which statement indicates correct understanding?

31) An 18yr old lean, emaciated looking lady is hospitalized. After a meal, she is purging. A nurse observe this incident and ask questions regarding….

32) A client diagnosed with DVT of the left lower extremity and is on bed rest. Which of the routine morning care should a nurse must follow most likely?

33) Which of the following nursing interventions is of highest priority in helping a patient expectorate thick secretions related to pneumonia?

34) A patient diagnosed with DM is being discharged home and you are teaching them about preventing DKA. Which of the following statement by the patient demonstrate they understood the teaching?

35) During a routine physical examination, the health care provider auscultates patient`s lungs. What type of lung sounds will be heard in a healthy patient?

36) A nurse educates a patient about the use of breathing exercise after surgery. The nurse performs which step of nursing process?

37) A client present with microcytic hyprochromic anemia. Which of the following would the nurse expect to find in the initial physical assessment?

38) A nurse is caring for a patient with second and third degree burns over 30% of the body. The most critical nursing diagnosis for this patient is

39) A nurse teaching a client with right side weakness how to ambulate with a cane. Nurse determines that the client knows how to use the cane properly when she observes that….

40) A client experiences tachycardia, palpitations, hypertension, diaphoresis, cramping, nausea, vomiting and diarrhea with meals after gastrectomy. Based on these findings the nurse should suspect which complication of gastrectomy?

41) A nurse is caring for a client had an above knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. The nurse immediately:

42) A client who has suffered a CVA is too weak to move on his own. To help the patient avoid pressure ulcer, the nurse:

43) Which of the following component is truly associated with hypertonic dehydration?

44) A client is admitted with complaints of sudden decrease in urine output, hypertension, vomiting, pruritis, elevated BUN and creatine and the client is diagnosed with acute renal failure. Which of the following electrolyte will be most affected with this condition?

45) A nurse administered a dose of morphine sulphate, as prescribed to patient in the PACU. The patient appears to be resting comfortably. The respiratory rate is 8 and oxygen saturation is on 2L oxygen via nasal canula is 86%. The nurse should immediately administer.

46) A patient is admitted with wheezing and coughing and saturation is 80% on room air. Which of the following nursing diagnosis would take as priority?

47) A nurse is providing dietary instructions for a client with iron deficiency anemia. Which food is poor source of iron?

48) A client is admitted with suspected abnormal aortic aneurism.  Common complaint of the client with an abdominal aortic aneurism?

49) Mother of a 3 month old baby with GERD ask the nurse what she can do lessen the baby`s reflux. The nurse should tell the mother to:

50) A nurse is evaluating the developmental level of a 2yr old boy. Which of the following does the nurse expect to observe in this child?

51) A client diagnosed with HIV infection. The nurse prepares a care plan for the client, knowing that HIV is primarily a condition in which

52) A home nurse visits a pregnant client who has a diagnosis of mild pre-eclampsia and is being monitored for PIH. Which assessment finding indicates a worsening of pre-eclampsia and the need to notify the physician?

53) A physician on the medical unit orders Mellaril (thioridazine hydrochloride) 75mg PO once daily. Pharmacy sent up liquid mellaril with concentration of 30mg/ml. How much drug in ml, will the nurse give for one dose?

54) Client is ordered to receive Omeprazole 40mg PO daily. The pharmacy dispenses Omeprazole 20mg capsules. How many capsules should the nurse administer to this patient for a single dose?

55) Physician orders IVF 5%Dextrose at 125ml/hr. Total volume 1000ml. Calculate infusion rate?

56) A patient who receiving Digoxin and furosimide. The nurse knows that which of the following , if reported by the patient, must be assessed immediately?

57) A patient in the medical unit rings the bell and explains, “my urine has been orange today! What medication is doing this to me“? Which of the following medications would explain this side effect? Select all that apply?

58) A nurse receives a client in emergency room, suspected with Botulism. Which action is priority for the nurse to initiate?

59) The physician has decided to perform a thoracentesis based on Mr. David’s assessment. Which of the following instruction is most appropriate to follow?

60) Normal range of blood ph?

61) Plan for rescue, evacuation, and caring for disaster victims include which phase of disaster management?

62) From the following which leadership has strict hierarchy and leader relies on organizational policies and procedures for decision making?

63) Sand paper like rash is a typical manifestation of…….

64) Whole blood administration causes which acid base imbalance?

65) A student is nervous and breathing rapidly before exam, what do you expect out the following?

66) From the following which one is NOT a source of potassium?

67) BMI 23 indicates……

68) Solumetrol 1.5mg/kg ordered for a child weighing 74.8 pounds. Solumetrol is available as 125mg/2ml. How many ml the nurses need to administer?

69) In Bio -medical waste management, infectious wastes are discarded in which container?

70) A patient is admitted with chest pain and diagnosed as IWMI. Then the patient has block in which coronary artery?

71) Which score is used to assess phlebitis?

72) Common step in CPR and ACLS………..

73) A baby is admitted with meningitis, physician plan to perform Lumbar Puncture. Which position is suitable for lumbar puncture?

74) A known Type1 Diabetic patient admitted with c/o dehydration, polyurea, and fruity ordered breath. Physician diagnosed this as DKA. Which insulin is used to manage DKA?

75) Treatment given for pulse less electrical activity?

76) A child who is lying on a crib suddenly have seizure. What is the priority action of a nurse?

77) A patient admitted with chest pain, dyspnea, and cyanosis, diagnosed as having CCF. Doctor advised Digoxin and loop diuretics. Which lab value should monitor?

78) Who is more prone for infection?

79) A baby admitted in hospital with the diagnosis of meningomyelocele. A knowledgeable nurse understood that:-

80) A patient has facial puffiness, decreased activity, cold intolerance, confusion, fatigue and also decline in T3 and T4 level. This condition is

81) Patient has allergy to sea foods, muscle cramps and muscle weakness. Diagnosis which relate to this condition is…..

82) Purified protein derivative 0.1ml administered to an HIV patient. A positive test result stand in a range of……

83) A 38yr old women admitted in the clinic, she is very weak, bruises seen all over body, mild bleeding from vagina, perineal pain and swelling. History collection reveals that, her husband sexually abuse her. Which health education is helpful to the client?

84) Nurse can`t administer medicine to a patient and left her duty. Further the nurse may face which consequence…………..

85) In an NICU, a newborn suddenly stop breathing, and become unconscious. RN plan to start CPR, hand should placed over?

86) A 60yr old lady arrived in the emergency department with chest tightness, wheezing, use of accessory muscles for breathing. X-ray shows narrowing of airway. The condition diagnosed as?

87) Community health services are very necessary in which group of people?

88) Which type of solution is D5NS?

89) Which solution is used to clean colostomy bag to prevent odour from colostomy bag?

90) A 40yr old male client has been hospitalized with peptic ulcer disease. He is being treated with a Histamine receptor antagonist (cimetidine), antacids and diet. The nurse doing discharge planning will teach him that the action of cimetidine is to…..

91) A female client complaints of epigastric pain for a few hours after meals, at times when the pain is severe, vomiting occurs. Specific test are indicated to rule out:

92) The client with duodenal ulcer can be distinguished from that of gastric ulcer by which of the following characteristics?

93) A multi gravid client is receiving Oxytocin augmentation. When the client`s cervix is dilated to 6cm, her membrane ruptures spontaneously with meconium stained amniotic fluid. Which of the following action should the nurse take first?

94)  The nurse is teaching the mother of a newborn to develop her baby`s sensory system. To further improve the infants most developed sense, the nurse should instruct the mother to:

95) The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which of the following activities should the nurse and family decide the child should avoid?

96) The client with cirrhosis receives 100ml of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect?

97) Which of the following foods should the nurse from the diet of a client in alcohol withdrawal?

98) Furosemide is administered IV to client with heart failure. How soon after administration should the nurse begin to see evidence of the drug`s desired effect?

99) A client receiving radiation to head and neck is experiencing stomatitis. The nurse should recommend?