Review

Question 1

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?

A. Fluid overload
B. Intracardiac shunt
C. Hypovolemia
D. Left ventricular failure

Answer 1

C. Hypovolemia

Question 2

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

A. Obtain a cardiology consult.
B. Perform pre-oxygenation prior to suctioning.
C. Suction the client less frequently.
D. Administer an antidysrhythmic medication.

Answer 2

B. Perform pre-oxygenation prior to suctioning.

Question 3

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

A. Bradypnea
B. Somnolence
C. Pallor
D. Tachycardia

Answer 3

D. Tachycardia

Question 4

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

A. Decrease respiratory secretions.
B. Induce sedation
C. Suppress respiratory effort
D. Decrease chest wall compliance

Answer 4

C. Suppress respiratory effort

Question 5

A nurse is reviewing a client’s laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3* 18 mEq/L, and PaCO2 36 mm Hg. Which of the following conditions should the nurse anticipate when interpreting these findings?

a. metabolic acidosis
b. respiratory acidosis
c. metabolic alkalosis
d. respiratory alkalosis

Answer 5

a. metabolic acidosis

Question 6

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A. “DIC is controllable with lifelong heparin usage.”
B. “DIC is caused by abnormal coagulation involving fibrinogen.”
C. “DIC is a genetic disorder involving a vitamin K deficiency.”
D. “DIC is characterized by an elevated platelet count.”

Answer 6

B. “DIC is caused by abnormal coagulation involving fibrinogen.”

Question 7

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
a. Bradypnea
b. Hypertension
c. Oliguria
d. Flushing of the skin

Answer 7

c. Oliguria

Question 8

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

A. Decrease in the respiratory rate from 20 to 16/min.
B. Decrease in the urinary output from 50 mL to 30 mL per hour.
C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F)
D. Increase in the heart rate from 88 to 110/min.

Answer 8

D. Increase in the heart rate from 88 to 110/min.

Question 9

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing the pain, which of the following desired effects of medications should the nurse identify as most important for the client’s recovery?

a. It decreases the client’s level of anxiety.
b. It facilitates the client’s deep breathing.
c. It enhances the client’s ability to sleep.
d. It reduces the client’s blood pressure.

Answer 9

b. It facilitates the client’s deep breathing.

Question 10

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PacO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L.

A. Metabolic alkalosis.
B. Respiratory acidosis.
C. Metabolic acidosis.
D. Respiratory alkalosis.

Answer 10

B. Respiratory acidosis.

Question 11

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

A. Sinus bradycardia
B. Sinus tachycardia
C. Atrial fibrillation
D. First-degree AV block

Answer 11

C. Atrial fibrillation

Question 12

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

A. Hypotension
B. Muscle pain
C. Ototoxicity
D. Hyperthermia

Answer 12

A. Hypotension

Question 13

A nurse in a provider’s office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

A. Narrowed pulse pressure
B. Night sweats
C. Bradycardia
D. Confusion

Answer 13

D. Confusion

Question 14

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia.

Which of the following actions should the nurse take?

A. Obtain a sputum culture.
B. Position head of bed at 10 degrees.
C. Cough and deep breathe every 8 hr.
D. Encourage fluid intake of 1500 mL/day.

Answer 14

A. Obtain a sputum culture.

Question 15

A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply)

A. Severe dyspnea
B. Nausea
C. Decreased level of consciousness
D. Headache
E. Hypotension

Answer 15

A. Severe dyspnea
C. Decreased level of consciousness
D. Headache
E. Hypotension

Question 16

A nurse is caring for a client who has chemotherapy-induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms?

A. Jerking movements of the extremities
B. Extremities that turned blue when exposed to cold
C. Spasms of the extremities
D. Tingling feeling in the extremities

Answer 16

D. Tingling feeling in the extremities

Question 17

A nurse is caring for a client who has HIV.

Which of the following laboratory values is the nurse’s priority?

A. WBC 5,000/mm³.
B. Platelets 150,000/mm³.
C. O Positive Western blot test.
D. CD4-T-cell count 180 cells/mm.

Answer 17

D. CD4-T-cell count 180 cells/mm.

Question 18

A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained:
Glucose 648 mg/dL
pH 6.88
PaCO2 20 mm Hg
PaO2 95 mm Hg
HCO3- undetectable
Anion gap >31
Na +127 mEq/L
K+ 3.5 mEq/L
Creatinine 1.8 mg/dL

After the patient’s airway and ventilation have been established, the next priority for this
patient is:

a. administration of a 1-L normal saline fluid bolus.
b. administration of 0.1 unit of regular
insulin IV push followed by an insulin
infusion.
c. administration of 20 mEq KCl in 100 mL.
d. IV push administration of 1 amp of
sodium bicarbonate.

Answer 18

a. administration of a 1-L normal saline fluid

Question 19

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?

a. An 18-year-old college student with type 1 diabetes who exercises excessively
b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections
d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza

Answer 19

d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza

Question 20

A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers?

a. 12-lead electrocardiogram
b. Cardiac catheterization
c. Echocardiogram
d. Electrophysiology study

Answer 20

c. Echocardiogram

Question 21

An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first?

a. Obtain the blood pressure.
b. Obtain blood for laboratory testing.
c. Assess for the presence of an abdominal bruit.
d. Determine any family history of kidney disease.

Answer 21

a. Obtain the blood pressure.

Question 22

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

A. Monitor the quality and presence of the pedal pulses
B. Teach the patient the sign of possible wound infection
C. Check the lower extremities for strength and movement
D. Help the patient to use a pillow to splint while coughing

Answer 22

D. Help the patient to use a pillow to splint while coughing

Question 23

A nurse is assessing a client’s cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

A. Eliciting the gag reflex
B. Testing visual acuity
C. Observing for facial symmetry
D. Checking the pupillary response to light

Answer 23

D. Checking the pupillary response to light

Question 24

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.

Answer 24

Open the airway using a jaw-thrust maneuver.
Determine effectiveness of ventilator efforts.
Establish IV access.
Perform a Glasgow Coma Scale assessment.
Remove clothing for a thorough assessment.

Question 25

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority? A. Perform passive range of motion on each extremity. B. Record the client's intake and output. C. Suction saliva from the client's mouth. D. Monitor the client's electrolyte levels.

Answer 25

C. Suction saliva from the client's mouth.

Question 26

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? A. Limit the client's ambulation to once a day. B. Place the client in protective isolation. C. Minimize environmental stimuli. D. Elevate the head of the client's bed 45 degrees.

Answer 26

C. Minimize environmental stimuli.

Question 27

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? A. Reduce edema of the brain. B. Provide fluid hydration. C. Increase cell size in the brain. D. Expand extracellular fluid volume.

Answer 27

A. Reduce edema of the brain.

Question 28

A nurse is caring for a client who had an evacuation of a subdural hematoma. Immediately after the evacuation, which of the following nursing actions is a priority? A. observe for CSF leaks from the evacuation site B. assess for an increase in temperature C. check the pulse oximeter D. monitor for signs of increasing ICP

Answer 28

C. check the pulse oximeter

Question 29

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. Which of the following ethical principles was demonstrated? A. Veracity. B. Autonomy. C. Nonmaleficence. D. Fidelity.

Answer 29

C. Nonmaleficence.

Question 30

A nurse is caring for a client who is admitted to the emergency department for fatigue. Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply). A. Assessment of lower extremities B. Sodium level C. Lung sounds D. Creatinine level E. Assessment of Incision site F. Bowel sounds G. Blood pressure.

Answer 30

A. Assessment of lower extremities D. Creatinine level E. Assessment of Incision site G. Blood pressure.

Question 31

A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent? A. Bring the child to the office for a rapid infusion of deferoxamine. B. Give the child syrup of ipecac. C. Contact the poison control center. D. Provide a high-carbohydrate meal.

Answer 31

C. Contact the poison control center.

Question 32

A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse suspect which of the following? A. Carbon monoxide poisoning B. Meniere’s disease C. Migraine D. Benign paroxysmal positional vertigo.

Answer 32

A. Carbon monoxide poisoning

Question 33

A nurse is planning care for a client who ingested a large amount of acetylsalicylic acid. Which of the following actions should the nurse take? A. Administer N-acetylcysteine. B. Initiate chelation therapy with deferoxamine. C. Perform gastric lavage with activated charcoal. D. Induce vomiting with syrup of ipecac.

Answer 33

C. Perform gastric lavage with activated charcoal.

Question 34

A nurse on a medical surgical unit is admitting a client from a provider's office. Click to highlight the information in the Nurse's Notes and Vital Signs that should be reported to the provider. Changes in the client's condition such as increased temperature and heart rate, and decreased blood pressure should be reported to the provider. These changes might be an indication the client is experiencing fluid volume deficit. The client's report of headache, dizziness, and dry mucous membranes should be provided to the provider. These reports indicate changes in the client's condition that may be an indication the client is experiencing fluid volume deficit.” The nurse's assessment of the client's abdominal cramping, lethargy, projectile vomiting, and voiding dark and concentrated urine should be reported to the provider. These are changes in the client's condition that might be an indication the client is experiencing fluid volume deficit. The client's oxygen saturation, cardiac sounds, and hyperactive bowel sounds do not need to be reported to the provider. The oxygen saturation and cardiac sounds are within the expected reference ranges. The client does have hyperactive bowl sounds, which is outside of the expected reference range; however, this is an expected finding for a client who has food poisoning and is not a change in the client's condition; therefore, it does not need to be reported to the provider.

Answer 34

- increased temperature and heart rate, and decreased blood pressure - headache, dizziness, and dry mucous - abdominal cramping, lethargy, projectile vomiting, and voiding dark

Question 35

A nurse is performing for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first? A. A client experiencing a tension pneumothorax B. A client who has closed upper extremity fracture C. A client who has fill thickness burns over 80% of his body D. A client who has agonal respirations

Answer 35

A. A client experiencing a tension pneumothorax

Question 36

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F) and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration. B. Shivering. C. Seizures. D. Burns.

Answer 36

B. Shivering.

Question 36

A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? Select all. A. Hypotension B. Bradycardia C. Clubbing of the nail beds D. Weak pulses E. Murmur

Answer 36

A. Hypotension D. Weak pulses E. Murmur

Question 37

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications. A. Insert a nasogastric (NG) tube. B. Measure lactate level. C. Obtain a wound culture. D. Administer broad-spectrum antibiotics. E. Obtain blood cultures. F. Type and cross-match for 2 units of packed RBCs. G. Rapidly administer 30 mL/kg of normal saline. H. Obtain a urine specimen.

Answer 37

B. Measure lactate level. D. Administer broad-spectrum antibiotics. E. Obtain blood cultures. G. Rapidly administer 30 mL/kg of normal saline.

Question 38

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply) A. Do not have a microwave oven in the home. B. Request to be scanned with a handheld metal detector when in the airport. C. Count your pulse for 1 min each morning. D. Do not wear tight clothing over the insertion area. E. Resume activities that can cause jolting, such as horseback riding, after 4 weeks.

Answer 38

C. Count your pulse for 1 min each morning. D. Do not wear tight clothing over the insertion area.

Question 39

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Use log rolling to reposition the client. B. Place a warming blanket on the client. C. Instruct the client to cough and deep breathe. D. Place the client in a supine position.

Answer 39

A. Use log rolling to reposition the client.

Question 40

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) A. Headache B. Neck pain and stiffness C. Slurred speech D. Pupillary changes E. Disorientation

Answer 40

A. Headache C. Slurred speech D. Pupillary changes E. Disorientation

Question 41

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting? a. "My wife tries to get me to go to the grocery store, but I don't like to go out much." b. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." c. "My greatest pleasure each day is having a few beers every day." d. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

Answer 41

b. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better."

Question 42

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count trajectory b. HIV genotype and phenotype c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen

Answer 42

d. Patient's ability to follow a complex medication regimen

Question 43

The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient reports feeling "constantly tired." b. The patient reports having no side effects from the medications. c. The patient is unable to explain the effects of atorvastatin (Lipitor). d. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

Answer 43

d. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

Question 44

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation c. Finish the airway, breathing, circulation, disability survey d. Start normal saline fluid infusion with a large-bore IV line.

Answer 44

d. Start normal saline fluid infusion with a large-bore IV line.

Question 45

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor

Answer 45

b. obtain a Glasgow Coma Scale score.

Question 46

A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Check pupil reaction to light.

Answer 46

c. Auscultate breath sounds.

Question 47

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

Answer 47

b. Assist with intubation of the patient.

Question 48

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4" F (40.8" C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take? A. Give acetaminophen (Tylenol) rectal suppository. B. Provide O2 at 2 L/min with a nasal cannula. C. Apply wet sheets and a fan to the patient D. Start lactated Ringer's solution at 1000 mL/hr

Answer 48

C. Apply wet sheets and a fan to the patient

Question 49

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? a. Suction the patient's oropharynx. b. Increase the prescribed O2 flow rate. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

Answer 49

b.Increase the prescribed O2 flow rate.

Question 50

A nurse is caring for a client on the medical- surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. BOWTIE

Answer 50

Dx: ventricular tachycardia action: 12-lead ECG and prepare the client for cardioversion monitor: client's cardiac rhythm and serum potassium

Question 51

A nurse is caring for a client in the emergency department (ED). Nurses' Notes 1500: Client presents to the ED and reports dyspnea, chest pain, and tachycardia. Client returned home from a vacation out of the country 24 hr ago. 1515: The client has become diaphoretic, increasingly dyspneic, and states that their chest pain is sharp and increasing. The client states, "I feel like I'm going to die." Crackles auscultated in bilateral lower lobes, S3 and 54 heart sounds noted. Petechiae noted on the client's chest. Pulmonary embolism protocol initiated. Vital Signs 1500: Temperature: 38.1° C (100.6° F) Heart rate: 110/min Respiratory rate: 24/min BP: 138/52 mm Hg Oxygen saturation: 92% oxygen at 2 L/min via nasal cannula 1515: Temperature: 38.1° C (100.6° F) Heart rate: 135/min Respiratory rate: 32/min BP: 120/50 mm Hg Oxygen saturation: 90% on 4 L/min via nasal cannula The nurse should first __________ followed by ______________

Answer 51

place the client in high-Fowler's position obtaining IV access

Question 51

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. c. ventricular fibrillation. b. sinus tachycardia. d. ventricular tachycardia.

Answer 51

d. ventricular tachycardia.

Question 51

A patient who was admitted with a myocardial infarction has a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare for synchronized cardioversion per agency protocol. d. Prepare to give IV amiodarone per agency dysrhythmia protocol.

Answer 51

d. Prepare to give IV amiodarone per agency dysrhythmia protocol.

Question 52

The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side until I see the health care provider."

Answer 52

d. "I won't lift the arm on the pacemaker side until I see the health care provider."

Question 53

The nurse is caring for a patient suspected of having ketoacidosis. What early manifestation(s) may be noted with this condition? (Select all that apply.) a. Fruity breath b.Polyuria c.Nausea d.Thirst e.Sunken eyes

Answer 53

a. Fruity breath b.Polyuria c.Nausea

Question 54

A nurse is admitting a client who has type 1 diabetes mellitus. Select the 7 findings that require immediate attention.

Answer 54

ECG findings Sodium level Client's self-monitoring of blood glucose Bicarbonate level Blood pressure results Glasgow Coma Scale score IV access

Question 55

A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH? A.Lung cancer B.Osteoarthritis C.Dyspepsia D.Liver cirrhosis

Answer 55

A.Lung cancer

Question 56

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care? A. Measure blood glucose levels every 4 hr. B.Check urine specific gravity. C.Administer a diuretic D.Initiate fluid restrictions

Answer 56

B.Check urine specific gravity.

Question 57

Which finding indicates to the nurse that demeclocycline is effective for a patient with a syndrome of inappropriate antidiuretic hormone (SIADH)? A.Urine-specific gravity is increased. B.Patient's weight is increased. C.Peripheral edema is decreased. D.Patient’s urinary output is increased.

Answer 57

A.Urine-specific gravity is increased.

Question 58

Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)? a. "I should weigh myself daily and report sudden weight loss or gain." b. "I need to stop for foods low in sodium and avoid adding salt to food." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I should eat foods high in potassium because diuretics cause potassium loss."

Answer 58

b. "I need to stop for foods low in sodium and avoid adding salt to food."

Question 59

Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus? a. Generalized edema b. Fluid volume overload c. Disturbed sleep pattern d. Decreased gas exchange

Answer 59

c. Disturbed sleep pattern

Question 60

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? A. Pulmonary embolism B. Bradycardia C. Peripheral vascular disease D. Hypertension.

Answer 60

A. Pulmonary embolism

Question 61

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? A. Red-brown drainage from nasogastric tube B. Blood urea nitrogen (BUN) level 32 mg/dL C. Scattered coarse crackles heard throughout lungs D. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

Answer 61

A. Red-brown drainage from nasogastric tube

Question 62

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

Answer 62

d. Lower the positive end-expiratory pressure (PEEP).

Question 63

A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O2 saturation above 93%.

Answer 63

b. Offer the patient fluids at frequent intervals.

Question 64

A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b.Endotracheal suctioning results in clear mucous return. c.Sputum and blood cultures show no growth after 48 hours. d.The skin on the patient's back is intact and without redness

Answer 64

a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.

Question 65

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

Answer 65

c. Extremity movement

Question 66

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

Answer 66

a. Notify the health care provider.

Question 67

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

Answer 67

c. Increase the rate of the ordered IV solution.

Question 68

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Pulse b. Heart rhythm c. Breath sounds d. Body temperature

Answer 68

a. Pulse

Question 69

A nurse is assisting in performing triage on several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients? Sata A. A client who has a sprained left ankle. B. A client who has an open traumatic brain injury and agonal breaths. C. A client who has sustained a partial amputation of the right leg. D. A client who is deceased. E. A client who has sustained a major burn to the upper torso and extremities.

Answer 69

C. A client who has sustained a partial amputation of the right leg. E. A client who has sustained a major burn to the upper torso and extremities.

Question 70

A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first? A. A client who has heart failure and peripheral edema. B. A client who has cirrhosis of the liver and bruising on their arms. C. A client who reports urinary burning and a temperature of 39.2° C (102.5° F). D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min.

Answer 70

D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min.

Question 71

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? A. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds B. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of <2 seconds C. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds D. An unconscious adult client who has no respirations, capillary refill is 2 seconds and paramedics have already tried to reposition airway without results

Answer 71

C. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds

Question 72

A nurse assisting with field triage following a motor vehicle crash involving a bus with multiple victims. The nurse assess a child who has an open fracture of the femur. Which of the following actions should the nurse take? A. Locate the child's parents to obtain consent for treatment B. Place a yellow triage tag on the child C. Notify the emergency department of the child's imminent arrival D. Perform a complete head-to-toe-assessment

Answer 72

B. Place a yellow triage tag on the child

Question 73

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? A. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around D. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

Answer 73

D. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

Question 74

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.

Answer 74

c. Clean the perianal area carefully after every bowel movement.

Question 75

The nurse should suggest which food choice for a patient scheduled to receive external-beam radiation for abdominal cancer? a. Fruit salad b. Baked chicken c. Creamed broccoli d. Toasted wheat bread

Answer 75

b. Baked chicken

Question 76

A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient.

Answer 76

c. Remind the patient about the need to return for retesting to verify the results.

Question 77

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

Answer 77

Sensitivity to light

Question 78

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? A. Measure the circumference of the thigh. B. Instruct the client to wiggle his toes. C. Palpate the femoral pulse. D. Monitor the client's calf for edema.

Answer 78

B. Instruct the client to wiggle his toes.

Question 79

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of Your injury What percentage of body surface area should the nurse estimate the client has burned?

Answer 79

54%

Question 80

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)? A. Tachycardia B. Restlessness C. Hypotension D. Amnesia

Answer 80

B. Restlessness

Question 81

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A. Dehydration. B. Bradycardia. C. Polyphagia. D. Hyperglycemia.

Answer 81

A. Dehydration.

Question 82

The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. Heart rate B. Blood pressure C. Weight D. Urine output

Answer 82

A. Heart rate

Question 83

A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply) a. Provide skin care with a moisture barrier cream. b. Administer artificial tear PRN. c. Obtain vital signs every 2 hr. d. Perform mouth care every hour. e. Administer oxygen 2L/min via nasal cannula.

Answer 83

a. Provide skin care with a moisture barrier cream. b. Administer artificial tear PRN. d. Perform mouth care every hour. e. Administer oxygen 2L/min via nasal cannula.

Question 84

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? A.Eliciting the gag reflex B.Testing visual acuity C.Observing for facial symmetry D.Checking the pupillary response to light

Answer 84

D.Checking the pupillary response to light

Question 85

A nurse suspects that a family caregiver is neglecting an older adult client. Which of the following statements by the caregiver should the nurse identify as the highest priority to address? a. "We don't have air conditioning" b. "We usually have just two meals a day." c. "We only buy the prescription we can afford." d. "We cannot afford new batteries for his hearing aid."

Answer 85

c. "We only buy the prescription we can afford."

Question 86

A client who has metastatic bone cancer tells the nurse, “I want to go home to die.” The client’s family is concerned about meeting the client’s care needs at home. Which of the following actions should the nurse take? A. Discuss a referral to home health and hospice care with the client and family. B. Contact the social worker to assist with nursing home placement. C. Talk with the provider about extending the client’s hospital stay. D. Instruct the family about meeting the client’s palliative care needs at home.

Answer 86

A. Discuss a referral to home health and hospice care with the client and family.

Question 87

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis? A. I am thinking of getting a second opinion. B. This is not working, and I plan to stop treatment. C. I am hoping this will help relieve my discomfort. D. This is making me stronger every day.

Answer 87

C. I am hoping this will help relieve my discomfort.

Question 88

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make? A. He has an electrical burn, which caused coagulation of some tissues B. He is doing well, although he might be in the hospital for some time. C. He does not appear to have much damage and should be fine soon D. He has an electrical burn. He is stable, and we will update you with any changes.

Answer 88

D. He has an electrical burn. He is stable, and we will update you with any changes.

Question 89

A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses.Which of the following information should the nurse include? a. The nurse caring for the client at the time of death requests organ donation. b. Donation costs are the responsibility of the donor's family and estate. c. The nurse may serve as a witness to informed consent for organ donation. d. Clients are placed on artificial life support before organ and tissue donation can occur.

Answer 89

c. The nurse may serve as a witness to informed consent for organ donation.

Question 90

A nurse is caring for a client who experienced severe head trauma. The client's partner asks the nurse why they are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of the following? a. regulation of blood pressure b. resorption of cerebrospinal fluid c. cerebral blood flow d. the client's intake and output needs

Answer 90

c. cerebral blood flow

Question 91

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock? A. The client who has chronic kidney disease B. The client experiencing an asthma attack C. The client who has Guillain-Barré syndrome D. The client who has a severe burn injury

Answer 91

C. The client who has Guillain-Barré syndrome

Question 92

A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit? A. Hypoxia and acidosis B. Hearing deficits and increased risk of glaucoma C. Bipolar behaviors and schizotypal behaviors D. Disorientation and depression

Answer 92

D. Disorientation and depression

Question 93

A nurse is providing care for a client who was involved in a motor-vehicle crash. Complete the following sentence.by using the list of options. The nurse should first address the client's ______ followed by the client's ______.

Answer 93

dropdown: Level of Consciousness Dropdown: Oxygen saturation

Question 94

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? A. Hemodynamic status B. Spinal cord perfusion C. Renal function D. Intracranial pressure

Answer 94

A. Hemodynamic status

Question 95

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock? A. Widening pulse pressure B. Increased heart rate C. Increased deep tendon reflexes D. Pulse oximetry 96%

Answer 95

B. Increased heart rate

Question 96

A nurse is assisting with the care of a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective? A. Respiratory rate 28/min B. Pink mucous membranes C. Heart rate 110/min D. Restlessness

Answer 96

B. Pink mucous membranes

Question 97

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula. B. Offer high-protein and high-carbohydrate foods frequently. C. Place in a prone position. D. Encourage oral intake of at least 3,000 mL of fluids per day.

Answer 97

C. Place in a prone position.

Question 98

A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? A. Assist the client to the orthopneic position. B. Instruct the client to remain as still as possible during the recording. C. Attach a blood pressure cuff to the client's upper arm. D. Tell the client to expect a mild stinging sensation during the test.

Answer 98

B. Instruct the client to remain as still as possible during the recording.

Question 99

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood

Answer 99

d. Stools for occult blood

Question 100

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply)' a. The shoulders droop b. The facial muscles relax c. The respiratory rate increases d. The pulse is within the expected range e. The client draws his legs into a fetal position

Answer 100

a. The shoulders droop b. The facial muscles relax d. The pulse is within the expected range

Question 101

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Decreased level of consciousness B. Increased respiratory rate C. Hypotension D. Anuria

Answer 101

B. Increased respiratory rate