AMS Final 2021

a nurse is preparing to administer ceftriaxone sodium (Rocephin) 1g via intermittent IV bolus over 30 min. available is 1 g ceftriaxone sodium in 100mL dextrose 5% in water. the nurse should set the pump to deliver how many mL/hr?

200 mL/hr

a nurse is preparing to administer cefazolin (Ancef) 1 g in dextrose 5% in water 100mL over 30 min. the IV tubing drop factor is 10 gtt/mL. the nurse should administer the medication at how many gtt/min?

33 gtt/min

a nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. which of the following HbA1c values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glycemic index?

6.3%

if dietary trays are usually brought to the nursing unit at 8:00 am, the nurse should plan to administer intermediate-acting insulin (Humulin N), 40 units, subcutaneously to a client between:

6:30 am and 7:00am

A nurse is caring for a client who came the emergency dept reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is

A heart muscle protein that appears in the bloodstream when there is damage to the heart

A nurse in the ICU is caring for a client who has acute respiratory distress syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The provider plans to exubate her within the next 24 hour. Which of the following is an important criterion for exubating the client?

Adequate tidal volume without manually assisted breaths

. A client with a diagnosis of disseminated intravascular coagulation (DIC) has the following assessment findings: blood pressure of 76/56, temperature 102.6 degrees, resp. 24 breath/min., with complaints of severe neck and back pain. Which nursing action should the nurse implement first?

Administer acetaminophen (Tylenol) PO.

A nurse is caring for a female client who came in to the ED reporting SOB and pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80 mmHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention?

Administer oxygen via face mask

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

Anti platelet aggregate

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?

Apical heart rate 44 beats/min

Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has:

Been receiving adequate IV fluid replacement

a patient admitted with a head injury has admission vital signs of temperature 98.6 F, blood pressure 128/86, pulse 110, and respirations 26. which of these vital signs if taken 1 hour after admission, will be of most concern to the nurse?

Blood pressure of 156/60 mm Hg, pulse of 60 beats/min, respirations of 14 breaths/min

. The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present?

CVP of 3 cm H20 and urine output of 20 mL/hr

A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn?

Cause of the burn

a nurse assesses a comatose, head injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. which of the following describes these findings?

Decorticate posturing

The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes after the infusion is started, the client's BP goes from 190/120 mm Hg to 120/90 mm Hg. What is the priority nursing action?

Decrease the infusion rate and recheck the blood pressure in 5 minutes

The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea?

Decreased breath sounds are heard over the left side of the chest

A nurse in an intensive care unit is caring for a client who hd an acute myocardial infarction (MI) and had cardiac enzymes drawn. The nurse should know that the results of the cardiac enzyme studies help determine the ?

Degree of damage to the myocardium

A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP)

ten minutes following administration of antibiotic, the nurse assessed a client to have edematous lips, hoarseness, and expiratory stridor. vital signs assessed by the nurse include blood pressure 70/40 mmHg, heart rate 130 beats/min, and respirations 36 breaths/min. what is the priority intervention?

Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously

the nurse is helping a client who was recently placed on a low sodium diet to reduce fluid retention to choose foods for lunch recommends which lunch menu that would be most beneficial for this client?

Grilled chicken sandwich on white bread, apple, salad, and iced tea

the client diagnosed with rule out myocardial infarction is experiencing chest pain while walking to the bathroom. which action should the nurse implement first?

Have the client sit down immediately.

a nurse is caring for a female client who has recurrent kidney stones. the client is scheduled for several diagnostic studies: 1) clean catch urine for urinalysis and for culture and sensitivity on admission 2) strain all urine 3) conduct an intravenous pyelogram (IVP) in the morning which of the following statements by the client should the nurse report to the provider?

I don't eat shellfish because it gives me hives

while talking with a client with a diagnosis of end-stage liver disease, the nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. the nurse recognizes these symptoms to be indicative of what condition?

Increased blood ammonia levels

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following should the nurse expect in the findings?

Increased clotting factors

What is the desired action of dopamine (Intropin) when administered in the treatment of shock?

It increases myocardial contractility

a nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escharotomy. the client's spouse asks the nurse what the procedure entails. which of the following nursing statements is appropriate?

Large incisions will be made in the eschar to improve circulation

a nurse is caring for a client who recently had surgery for insertion of permanent pacemaker. which of the following prescriptions should the nurse question?

MRI of the chest

A client arrives at the emergency dept following an explosion at the chemical plant. He has deep partial and full-thickness chemical burns over more than 25 % of his body surface area. What is the nurse's priority intervention?

Maintain a patent airway

a nurse is caring for a client who has a diagnosis of diabetes mellitus and hypertension and recently began taking propranolol. when the client reports dizziness upon standing, the nurse should perform which of the following actions?

Monitor blood pressure lying, sitting, and standing.

The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented?

Monitor the pulse oximetry reading

which nursing intervention is most important for a client with diabetes insipidus?

Monitoring fluid intake and output

a nurse is caring for a client who was found to have a spinal cord transection at the level of the T2-T3 vertebrae. when planning care, the nurse should anticipate which of the following types of disability?

Paraplegia

the client with acute renal failure has a serum potassium level of 6.0 mEq/L. the nurse would plan which of the following as a priority action?

Place the client on a cardiac monitor.

A nurse is reviewing the client's laboratory values who is receiving total parenteral nutrition (TPN) has the following lab values: glucose = 72, Chloride 98, sodium 138, and potassium 3. Which of the following may the nurse expect to implement?

Plan to infuse a potassium replacement

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. The nurse should know that the client requires?

Pre-oxygenation prior to suctioning

A nurse is caring for a client who was admitted with bleeding esophageal varices and has a segstaken-blakemore tube to control the bleeding. Which of the following nursing interventions is appropriate?

Provide oral and nares care every 2 hr

Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful?

Pulmonary artery wedge pressure (PAWP) is normal.

The vital signs of a client with cardiac disease are as follows: blood pressure of 102/76 mmHg pulse of 52 beats/min and respiratory rate of 16 breaths/min. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication?

Pulse rate has increased to 70 beats/min.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Reduce the clients intake of protein

a client arrives at the emergency department with deep partial thickness and burns over 15% of his body. at admission, his vital signs are: blood pressure 100/50 mmHg heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. which nursing interventions are appropriate for this client? SATA

Starting an I.V. infusion of lactated Ringer's solution Administering 6 mg of morphine I.V.F. Administering tetanus prophylaxis as ordered

in planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?

The rehabilitation plan will be guided by it.

The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client who has a history of coronary artery disease is now in congestive heart failure. What side effects will be particularly important to observe for when the client takes the medication?

Tremors and central nervous system stimulation

a nurse is caring for a client who is scheduled for a colonoscopy. the client asks the nurse if there will a lot go pain during the procedure. which of the following is an appropriate nursing response?

You'll be sedated for the procedure

a nurse is caring for four hospitalized clients. which of the following clients is at greatest risk for fluid volume deficit?

a client who has just been admitted, has severe diarrhea and is fatigue

after receiving change of shift report which of these patients should the nurse assess first?

a patient with smoke inhalation who has wheezes and altered mental status

a nurse is reviewing the EKG strip of a client who has prolonged vomiting. which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

abnormally prominent U wave

the client Is admitted to the ED with chest trauma. which signs and symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax?

absent breath sounds and tachypnea

a triage nurse in an emergency department is caring for a client who has a gunshot wound to the right side of her chest. the nurse notes a thick dressing on the chest and sucking noise coming from the wound. the client has a blood pressure of 100/60 mmHg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. which of the following actions should the nurse take initially?

administer oxygen via nasal cannula

a client admitted to the hospital reports recurrent flank pain, nausea, and vomiting for 24 hr. which of the following would be a priority nursing action?

administer pain medication

the nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client in CCU who has a PT/PTT of 22/39 and an INR of 2.8. what action should the nurse implement?

administer the medication as ordered

a client comes into the er with complaints of midsternal chest pain radiation to the neck and left arm which is unrelieved by sublingual nitroglycerin. an electrocardiogram is obtained. what observationon the ECG or on the cardiac monitor would indicate to the nurse the need to immediately notify the physician?

an ST segment elevation from the isoelectric baseline

a nurse is creating a plan of care for a client who is receiving enteral feedings via a gastrostomy tube. which of the following is the first action the nurse should take when administering enteral feedings

aspirate and measure stomach contents

the client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. which intervention should the nurse implement first?

assess the respiratory status and pulse oximeter reading

a nurse is caring for a client who is having difficulty breathing. the client is lying in bed and is already receiving oxygen therapy via nasal cannula. which of the following interventions is the nurse's priority?

assist the client to fowler's position

while reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities?

atrial depolarization

a nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. which of the following techniques should the nurse use to assess the potency of this graft?

auscultate the antecubital area using a Doppler stethoscope

apical pulse?

bottom left

a nurse is shipping and finds a woman who has collapsed with right sided weakness and slurred speech. which of the following are appropriate actions by the nurse?

call emergency management services

a nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. the nurse should document that the client has

cheyne-stokes respirations

a nurse on a medical-surgical unit is Caring for a group of clients. the nurse should notify the rapid response team for which of the following clients?

client who reports right calf pain and shortness of breath

a nurse is observing the closed chest drainage system of a client who is 1 day post thoracotomy. the nurse notes continuous bubbling in the suction control chamber. the nurse should

continue to monitor client's respiratory status

the best way to count the respiration rate is to

count the rate while holding the patient's wrist

A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury?

d. lactated ringers

the nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg and urinary output of 20mL for the past hour. the nurse would interpret these findings as suggestive of which pathophysiology?

decrease in the cardiac output and inadequate tissue perfusion

The client is having difficulty climbing stairs and says it is difficult to catch his breath. The nurse notes that he is breathing heavy and his face Is red. What word will the nurse use to document this observation?

dyspnea

a nurse in a cardiac care unit is caring for a client with acute heart failure. which of the following findings should the nurse expect?

elevated CVP

the nurse is caring for a patient receiving a continuous dopamine IV infusion. which patient assessment information indicates that the infusion rate may be too high?

elevated systemic vascular resistance (SVR)

a nurse is teaching a client who has end-stage renal disease about a renal diet. which of the following information should the nurse include?

eliminate infection of foods high in protein

A nurse is evaluating the cardiac rhythm of a client on telemetry. The nurse identifies the location of the P wave by pointing to which of the following areas?

first

a nurse is teaching a client who has cute renal failure (ARF) about the oliguric phase. which of the following is appropriate to include in the teaching?

fluid output is less than 400mL per 24 hours

a nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. the nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

heart rate

a nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. which of the following findings should the nurse expect?

hyperpigmentation

a nurse is planning care for a client who has end stage renal disease. on assessment, the client has a 20lb weight gain, crackle lung sounds, elevated blood pressure, and jugular neck vein distention. which of the following findings explains the client's symptoms?

hypervolemia

a patient's cardiac rhythm is sinus tachycardia with a heart rate of 124 beats/min. the nurse would expect the patient to exhibit which of the following clinical associations?

hypervolemia

a nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. which of the following clinical manifestations indicates a complication that requires notifying the provider immediately?

increased HR

a client comes to the emergency department reporting nausea and vomiting that worsens when he lies down. antacids do not help. the provider suspects acute pancreatitis. which of the following laboratory test results should the nurse expect to see if the client has acute pancreatitis?

increased serum amylase

a nurse is assessing a client who has an 8 score using the Glasgow coma scale to evaluate levels of consciousness. which of the following nursing statements most accurately describes the score?

indicates the need for total nursing care

a client comes to the emergency department via ambulance to report severe radiating chest pain and shortness of breath. the client appears restless, frightened and slightly cyanotic. the provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. which of the following actions should the nurse take first?

initiate oxygen therapy

a nurse is preparing to administer insulin lispro (Humalog) to a client who has type 1 diabetes mellitus. which of the following nursing actions is appropriate?

inject the insulin 15 minutes before a meal

A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is priority nursing action when the client is brought to the ED?

inspect mouth for signs of inhalation

a nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. when the client asks what this medication will do, which of the following is an appropriate nursing response?

it prevents strokes in clients who have atrial fibrillation

a nurse is caring for an older adult female who was admitted with hemiplegia following a cerebrovascular accident. the client's adult son is distressed to see the client's distress and deteriorating condition and asks the nurse to help calm his mother. which of the following is an appropriate response to this request?

its hard to see your mother so ill

the nurse determines that a client with diabetes mellitus is experiencing fat breakdown for conversion to glucose if the client has elevated levels of which substance in the urine?

ketones

a nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. the nurse is aware that hyperkalemia is associated with changed to the T wave. on the graph, point to the spot on the ECG...

last one

in planning care for a client with hypervolemia, which intervention should the nurse expect to initiate?

limit sodium and water intake

the nurse is caring for a client who underwent cardiac catheterization 1 hour ago. what is an important nursing measure at this time?

maintain pressure over catheter insertion site and determine distal circulation status

A nurse is preforming teaching with a client who has newly diagnosed type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following manifestations of hypoglycemia? SATA

moist clammy skin , tachycardia , dizziness

a nurse is caring for ac client who has type 1 diabetes mellitus. the nurse misread the client's morning blood glucose level as 210 mg/dl instead of 120 mg/dl. based on this error, she administered the insulin dose appropriate for a reading over 200 mg/dl before the client's breakfast. which of the following is the nurse's priority action upon realizing the error?

monitor the client for hypoglycemia

the nurse is assessing the motor function of an unconscious client. the nurse would plan to use which of the following to test the client's peripheral response to pain?

nail bed pressure

A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system

obtain a central venous pressure

an older adult client comes into the ER stating that he has no appetite, is nauseated, his heart feels funny and has noticed a haziness in his vision. the client states that he has been taking an antihypertensive drug and digitalis for more than a year. based on the presenting symptoms, what would be the priority nursing action?

obtain an order for an EKG and determine cardiac enzyme levels

a nurse is assessing a client who has asthma and signs of central cyanosis. which of the following is a reliable indicator of cyanosis?

oral mucosa

Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective?

oxygen saturation

the nurse is assessing a client experiencing motor loss as a result of a left sided cerebrovascular accident (CVA). which clinical manifestations would the nurse document?

paralysis of the right side of the body and ataxia

after striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. he's unconscious and his pupils are nonreactive. which intervention would be the most dangerous for the client?

perform a lumbar puncture

the client diagnosed with acute pancreatitis is in pain. which position should the nurse assist the client to assume to help decrease the pain?

place in side-lying position with knees flexed

a family member is instructed by a nurse on the interventions for safe swallowing for a client who has residual effects from a stroke. which of the following concepts is most important for the family members to understand?

place the client in the upright position to facilitate swallowing

the nurse is administering alteplase (tPA, Activase) to a client who has been diagnosed with acute coronary syndrome (ACS). what is an important nursing implication for this medication?

place the client on bleeding precautions

a nurse is developing an educational poster regarding risk factors for cerebrovascular accidents (CVA) for a group of clients. in a listing of non modifiable risk facets, the nurse should include

race

a nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. diabetic ketoacidosis is suspected. the nurse should anticipate using which of the following types of insulin to treat this client?

regular insulin

a nurse gives a client morphine sulfate 2 mg IV push after the client reports pain. the nurse evaluates the client 15 after the injection. which of the following findings represent an adverse effect?

respiratory rate of 8 breaths per minute

the nurse Is developing a care plan for a client with hypocalcemia. which nursing diagnosis is appropriate for this client?

risk for injury related to tetany and seizures

a client begins to complain of chills and discomfort after about 50mL of blood has transfused from a unit of packed red blood cells. the best nursing action at this time is to:

slow down the infusing blood and dilute it with the normal saline solution

the nurse is obtaining a health history from a client who is visiting the clinic with complaints of a severe headache. the client provides the following data to the nurse based on a review systems. the nurse identifies the following as modifiable risk factors for stroke. SATA

smoking obesity decreased physical activity alcohol consumption

A nurse is caring for a client following a CT scan with dye who suffered from an anaphylactic reaction. Which of the following conditions requires a priority nursing response?

stridor

A nurse is collecting information on a group of clients who are experiencing renal disorders. Considering the general client selection criteria for hemodialysis. Which of the following clients should qualify for hemodialysis?

the client who has thrombosis of a renal artery following transplant surgery

a nurse is planning a low-protein diet for a client who has chronic renal failure. the client states, "Why do I have to be concerned with protein?" Which of the following nursing responses is appropriate?

the kidneys are unable to rid the body of urea, a waste product of protein

a nurse is caring for a client with burns to face, ears, and eyelids. which of the following is the priority finding to report to the provider?

urinary output 25mL/hr

a nurse administers desmopressin (DDAVP) to a client who has a diagnosis of diabetes insipidus. which of the following indicates the desired therapeutic effect?

urine specific gravity 1.015

a nurse is assessing a client's cranial nerves. which of the following assessment methods determine a potential problem with cranial nerve II?

use a snellen chart

a nurse is caring for a client who is postoperative. which of the following should the nurse include in the postoperative teaching to prevent pulmonary complications?

use of an incentive spirometer

the low pressure alarm sounds on a ventilator. a nurse assess the client and then attempts to determine the cause of the alarm. the nurse is unsuccessful in determining the cause of the alarm and takes what initial action?

ventilates the client manually

a nurse is observing a newly hired nurse on the unit who is preparing to administer a blood transfusion. which of the following actions by the newly hired nurse requires intervention by the nurse?

verifies blood compatibility and expiration date with an assistive personnel (AP)

a nurse is preparing to complete a daily weight on a client in renal failure. which of the following actions should the nurse implement?

weigh the client at the same time each day

a client who has had a significant myocardial infarction receives a referral to the cardiac rehabilitation unit. during his first visit to the unit, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do as the damage is done. which of the following is an appropriate nursing response?

"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."

which nursing actions should be completed before a physician performs a thoracentesis? SATA

-assessing the client for any allergy to local anesthetics -placing the client in an upright position leaning forward, if able -making sure that the consent form is signed and in the chart

the client is admitted to the ICU diagnosed with DKA. which interventions should the nurse implement? SATA

1. Maintain adequate ventilation.2. Assess fluid volume status.3. Administer intravenous potassium.4. Check for urinary ketones.5. Monitor intake and output.