Question part 5

31. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

❍ A. Feet
❍ B. Neck
❍ C. Hands
❍ D. Sacrum

32. The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

❍ A. Phlebostatic axis
❍ B. PMI
❍ C. Erb’s point
❍ D. Tail of Spence

33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

❍ A. Question the order.
❍ B. Administer the medications.
❍ C. Administer separately.
❍ D. Contact the pharmacy.

34. The best method of evaluating the amount of peripheral edema is:

❍ A. Weighing the client daily
❍ B. Measuring the extremity
❍ C. Measuring the intake and output
❍ D. Checking for pitting

35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

❍ A. Overnight stays by family members is against hospital policy.
❍ B. There is no need for him to stay because staffing is adequate.
❍ C. His wife will rest much better knowing that he is at home.
❍ D. Visitation is limited to 30 minutes when the implant is in place.

36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

❍ A. Roast beef sandwich, potato chips, pickle spear, iced tea
❍ B. Split pea soup, mashed potatoes, pudding, milk
❍ C. Tomato soup, cheese toast, Jello, coffee
❍ D. Hamburger, baked beans, fruit cup, iced tea

37. The physician has prescribed Novalog insulin for a client with dia- betes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

❍ A. “I will make sure I eat breakfast within 10 minutes of taking my insulin.”
❍ B. “I will need to carry candy or some form of sugar with me all the time.”
❍ C. “I will eat a snack around three o’clock each after- noon.”
❍ D. “I can save my dessert from supper for a bedtime snack.”

38. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recom- mended for the first two weeks of life because:

❍ A. New parents need time to learn how to hold the baby.
❍ B. The umbilical cord needs time to separate.
❍ C. Newborn skin is easily traumatized by washing.
❍ D. The chance of chilling the baby outweighs the benefits of bathing.

39. A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin cal- cium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

❍ A. Treat iron-deficiency anemia caused by chemothera- peutic agents
❍ B. Create a synergistic effect that shortens treatment time
❍ C. Increase the number of circulating neutrophils
❍ D. Reverse drug toxicity and prevent tissue damage

40. A four-month-old is brought to the well-baby clinic for immuniza- tion. In addition to the DPT and polio vaccines, the baby should receive:

❍ A. Hib titer
❍ B. Mumps vaccine
❍ C. Hepatitis B vaccine
❍ D. MMR