Exam 4 (Quiz 10, 12, 13)

Question 1

A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following information should the nurse include?

Answer 1

“Monitor for any changes in the color of your stool such as dark or black-colored stool”.

Question 2

A nurse is preparing discharge instructions for a client who has been treated for acute pancreatitis. Which of the following statements is important to include in the information?

Answer 2

Cease from smoking and consuming alcohol

Question 3

A nurse is caring for a client in the primary care office who states, “I think I have been experiencing symptoms of reflux”. Which of the following manifestations should the nurse anticipate for a client who has GERD?

Answer 3

Dyspepsia

Question 4

A nurse is caring for a client in a primacy care office who presents with a diagnosis of oral herpes simplex virus type 1. Which of the following statements best describes a recommendation the nurse should teach the client?

Answer 4

“Replace your current toothbrush with a new one after the illness”.

Question 5

A nurse is caring for an older adult client who has significant issues with ascites related to end-stage liver disease. Which of the following precaution is important for the nurse to include in the teaching?

Answer 5

“Due to the increased abdominal weight, take your time with walking as your balance might be affected and cause a fall”.

Question 6

A nurse is educating a client about the risk factors for GERD. Which of the following statements should the nurse include?

Answer 6

“You should avoid or cut down on alcohol and caffeine which can aggravate GERD.”

Question 7

A nurse is caring for an older adult client who has just been admitted to the intensive care unit with a diagnosis of confusion/delirium. The client has an end-stage liver failure diagnosis with increasing ascites. Their spouse questions the nurse about the client’s mental status because they state that the client is usually lucid. Which of the following indication is likely the contributing factor for the admitting diagnosis?

Answer 7

“This is likely related to new-onset hepatic encephalopathy”.

Question 8

A nurse is preparing discharge instructions for a client who has cirrhosis of the liver. Which of the following statements should be included in the education material?

Answer 8

“Avoid high-sodium foods such as canned soups/vegetables, processed meats and prepackaged frozen dinners”.

Question 9

A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following responses from the nurse best explains how a person can become infected with the virus?

Answer 9

“Coming into contact with infected blood, such as from that of a dirty needle, can cause you to become infected with hepatitis C.”

Question 10

A nurse is caring for a client who sustained extensive third-degree burns over a month ago and is currently still in the intensive care unit (ICU). The client now has a diagnosis of cholecystitis and their spouse is confused about this diagnosis. Which of the following is the best response from the nurse?

Answer 10

“A calculous cholecystitis can happen more often in client who are critically ill and is not related to gallstones”.

Question 11

A nurse is providing teaching to a client who has a new diagnosis of Crohn’s disease. Which of the following statements by the nurse provides the most simplistic and non-medical description of the disorder?

Answer 11

Crohn’s diseases has the appearance of a patchwork quilt with some areas that are clear and some with sores.

Question 12

A nurse is providing teaching to a client who has long-term symptoms of GERD. Which of the following statements should the nurse include in the educational materials?

Answer 12

“It is important to follow up with GI specialist for recommended surveillance for Barrett’s esophagus”.

Question 13

A nurse is providing education to a client who needs a cholecystectomy due to a build-up of calculi gallstones. Which of the following is the best response from the nurse to explain what caused this problem?

Answer 13

The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct.

Question 14

A preoperative nurse is caring for a client who is being prepared fro emergency surgery related to a small bowel obstruction. The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage . Which of the following statements is the best response from the nurse?

Answer 14

“This means that scar tissue formed from the healing for a past abdominal surgery is now constricting the opening in your intestines”.

Question 15

A nurse is caring for a client who has a new diagnosis of liver disease. Which of the following manifestations should the nurse expect?

Answer 15

Pruritus

Question 16

A nurse is caring for a client with a chronic wound and is discussing smoking cessation. The client does not underhand how smoking may impact would healing. Which of the following would be the best nurse response?

Answer 16

Nicotine causes vasoconstriction so your wound might not get enough blood flow to heal.

Question 17

A nurse is caring for a client with peripheral artery disease who has an arterial ulcer. Which of the following best describes the mechanism for developing the clinical problem?

Answer 17

Decreased blood flow to the area can cause the would and decrease the healing.

Question 18

A nurse is caring doe a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

Answer 18

Keeping the would clean and noninflected.

Question 19

A nurse is assessing a clean who reports trauma to the arm from falling of a bicycle. The skin has a large abrasion that is warm, darker than the surrounding skin, and edematous. Which of the following stages of healing is the would in?

Answer 19

Hemostasis and inflammation.

Question 20

A nurse is caring for a client who is scheduled for abdominal surgery. Which of the following nursing interventions should the nurse include in the preoperative education?

Answer 20

Provide instructions about how to cough and deep breathe effectively.

Question 21

A nurse is reviewing the clients medical record in the pre surgical holding area. Which of the following places the client at risk for a surgical site infection?

Answer 21

Type 2 diabetes mellitus

Question 22

The nurse is caring for a client with a chronic wound. Which of the following are would treatments that may assist with the healing process?

Answer 22

Remove any non-viable tissue.

Question 23

A nurse is preparing to witness informed consent for a client having surgery. Which of the following priority information should the nurse share with the client while witnessing consent?

Answer 23

The type of anesthesia that will be used.

Question 24

A client was admitted to the surgical unit following a repair of a right femur fracture. Which of the following assessment is a priority in the postoperative period?

Answer 24

Operative leg skin color.

Question 25

A nurse is discussing moisture-related skin condition with a nursing student. Which of the following clients is most likely to have a moisture-related skin condition?

Answer 25

A client in the intensive care unit in a coma.

Question 26

A nurse removes a client's Foley catheter and documents that the client urinates 4hr later. Which of the following elements of postoperative care is the nurse performing?

Answer 26

Monitoring urinary function.

Question 27

A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following 'is a priory safety concern when caring for this client?

Answer 27

Decontamination of the client.

Question 28

A postoperative client begins to experience cardiac arrhythmia and muscular rigidity. The nurse notes that the client is breathing rapidly and their blood oxygen is low on the monitor. Which of the following complications should the nurse suspect?

Answer 28

Malignant Hyperthermia.

Question 29

A nurse is assisting a client with ambulation several hours after a hip replacement. Which of the following postoperative complications is the nurse trying to prevent?

Answer 29

Venous Thromboembolism.

Question 30

The nurse is preparing the client wit5h a pressure injury to return home and self-manage the wound. Which of the following are important for the nurse to determine the client's understanding of the wound care instructions?

Answer 30

Have the client teach back what the nurse has taught.

Question 31

A nurse is caring for serval clients. Which of the following clients is most prone to skin infection?

Answer 31

A 35 year-old client receiving chemotherapy.

Question 32

The nurse reviews data from a new client's kidney function test. Which of the following standards of transplant nursing practice is the nurse primarily performing?

Answer 32

Assessment.

Question 33

A nurse is caring for a client who complains of a painful, blistery rash that has occurred on the left side of the chest. The nurse identifies that this is most likely which of the following?

Answer 33

Shingles.

Question 34

A nurse is completing a surgical checklist for a client scheduled for surgery. According to the WHO checklist, which of the following terms is used 'for the phase that takes place after the induction of anesthesia and before the first surgical incision?

Answer 34

Time-Out.

Question 35

During a preoperative assessment, a nurse documents that the client has a history of vertigo and orthostatic hypotension. The assessment findings of vertigo and orthostatic hypotension put the client as high risk for which of the following postoperative complications?

Answer 35

Frequent Falls.

Question 36

A nurse is caring for a client who has DVT. Which of the following findings should cause the nurse to suspect the client has a pulmonary embolism?

Answer 36

Hemoptysis SOB Lightheadness Tachycardia

Question 37

A critical care nurse finds a postoperative client unresponsive and calls for a code blue. Which of the following next actions should the nurse take?

Answer 37

Begin chest compressions

Question 38

A charge nurse is teaching a newly licensed nurse about DVT. Which of the following should the charge nurse include as risk factors for developing DVT's?

Answer 38

Immobility Fractures A-FIB Estrogen Therapy

Question 39

A nurse is caring for a client who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?

Answer 39

Been of bedrest for 3 days

Question 40

A nurse manager is providing an in-service for a group of nurses about thromboembolism. Which of the following conditions should the nurse manager indulge as life-threatening?

Answer 40

DVT MI Ischemic Stroke PE

Question 41

A nurse is providing teaching yo a client about the prevention of DVT. Which of the following recommendations should the nurse include in the teaching?

Answer 41

Avoid crossing legs when sitting Move frequently while on an airplane Discontinue estrogen therapy if your medical provider recommends Stop smoking and avoid secondhand smoke

Question 42

A nurse is assessing a client during a disaster triage. The client is not breathing has no carotid or radial pulse, and does not response to commands. Which of the following color tags should be attached to this client?

Answer 42

Black

Question 43

A charge nurse is teaching a group of newly licensed nurses about hemorrhage. Which of the following types of hemorrhage should the nurse include as having a headache manifestation?

Answer 43

Intracranial bleed

Question 44

A nurse is triaging disaster clients. Client who have the highest priority for being treated first should have which of the following color triage tags?

Answer 44

Red

Question 45

A emergency department nurse is assessing a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurses priority?

Answer 45

Assess the client reporting chest pain

Question 46

A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

Answer 46

fatigue

Question 47

An emergency department nurse is caring for a client who is becoming increasingly agitated. Which of the following actions can the nurse take to decrease the risk of violence from this client?

Answer 47

Assess their pain level and intervene as necessary

Question 48

A nurse is caring for a client who has sickle cell anemia. The client asks "why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?

Answer 48

"You have fewer red blood cells"

Question 49

A nurse is caring for a client who has DVT of their right lower leg. Which of the following manifestations should the nurse expect?

Answer 49

Warmth Erythema Swelling

Question 50

A nurse is caring for a postoperative client following a total knee replacement. Which of the following medication should the nurse anticipate the provider to prescribe to prevent the formulation of a DVT?

Answer 50

Enoxaparin

Question 51

A nurse is caring for several clients who were admitted to the ED. Which of the following client scenarios represents the secondary survey process?

Answer 51

A client was admitted to the ED following a MVA resulting in a liver laceration. The stabilized client was transferred to the ICU and a follow-up X-ray notes a broken clavicle.

Question 52

An ED nurse who is leaving the shift is reporting off to the oncoming ED nurse. The off-going nurse reports that the client was admitted to the ED at 0800 today with head trauma from a fall in the clients bathroom where the clients head hit the edge of the bathtub. Which of the following parts of SBAR report does this represent?

Answer 52

Background

Question 53

A nurse is preforming a primary surgery on a newly admitted client to the ED. Using ABCDE assessment which of the following areas are assessed under there "C" category?

Answer 53

Heart and blood vessels

Question 54

An ED nurse is providing handoff communication using SBAR to the nurse accepting a client in the ICU. The ED nurse reports that the client will require a suction set up for gastric tube drainage and will need an endoscopy performed. Which of the following parts of SBAR is being communicated?

Answer 54

Recommendation

Question 55

A nurse is caring for a client in the ED during a regional disaster. A reporter for the local TV station reaches out to the nurse via social media and asks for an update. Which of the following is the nurse best course of action?

Answer 55

Follow their agency's policy regarding media relations