FINAL EXAM STUDY
17. A client with a large pulmonary embolism is receiving thrombolytics. The nurse notes frank red blood in the foley catheter drainage bag. What is the nurse's 1st action? a. Notify the health care provider b. Perform a bladder scan c. Clamp the foley catheter d. Irrigate the foley
ANS: A This patient should not have bleeding in the foley catheter as this may indicate rupture or hemmorhage from the thrombolytics which are usually given to dissolve clots.
36. The client is admitted to the burn unit & prescribed protonix, a PPI. Which statement best supported the scientific rationale for administering the medications to a client with a severe burn? a. This medication will provide continuous vasoconstriction b. This medication will stimulate new skin growth c. This medication will help prevent a stress ulcer d. This medication will help prevent a stress ulcer
ANS: D This medication can treat stomach ulcers and high levels of stomach acids caused by tumors.
50. The nurse in a genetic counseling center determines that a disorder with a 50% occurrence rate in both males & females is classified as what? a. Chromosomal trisomy b. Autosomal dominant c. Autosomal recessive d. X-lined recessive
Ans: B Autosomal Dominant
5. A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution. How many units/hr is the client receiving?
500 units
2. The nurse is providing pre-op education regarding transplant rejection & GVHD to a client who is scheduled to have a kidney transplant. The nurse states "the most common problem with GVHD is"? a. Immune response/infection b. Hypokalemia c. Constipation d. Shingles
ANS A: GVHD occurs most frequently after allogeneic bone marrow transplant and initially leads to dermatitis (a skin rash), gastrointestinal problems and liver dysfunction.
25. The nurse is caring for a patient with lung cancer in a home hospice program. Which action by the nurse is appropriate? a. Encourage the patient to discuss past life events & their meanings b. Accomplish a thorough head to toe assessment several times a week c. Teach the patient about the purpose of chemotherapy & radiation d. Discuss cancer risk factors & appropriate lifestyle modifications
ANS A: The patient is in end of life care. It would be appropriate for the nurse to encourage the patient to discuss past life events & their meanings.
4. The nurse is educating the client who has been diagnosed with Hep C about the disease. Which statements made by the client indicated that the client understood the teaching? a. I should avoid sharing drinking cups & eating utensils with my family b. I should not drink any wine, beer, or other alcoholic beverages c. I will plan to do all my activities in the morning when I am most rested d. It is important for me to not use barrier protection when I have sex
ANS B: Hep C is spread through blood/needles/unprotected sex. All Hepatitis the client should be taught a alcohol cessation.
9. The nurse is caring for the client with problems of anxiety & confusion in the acute phase of burn management. Which intervention should the nurse implement? SATA a. Repeat orientation statements of person, place, & time b. Turn & reposition the client at least ever hour c. Place familiar objects from home near the client d. Implement a schedule for regular sleep-wake cycles e. Reduce distractions by keeping the television in the room off
ANS: A, C, D
13. Hepatitis is a viral infection that affects the entire body. What other signs & symptoms can a client with hepatitis present with? SATA a. Runny eyes & nose b. Distaste for cigarettes c. HOH- hard of hearing d. Pruritis e. Light colored stools
ANS: A,B, D, E Flu like symptoms like runny eyes and nose can be seen in these patients, as well as light colored stools, pruitis which would be seen if the patient has interic hepatitis. Also the patient can have a decreased sense of taste and smell thus a distaste for cigarettes.
11. The nurse is determining the IV fluid needs for the 110 lbs client with partial thickness burns to 40% TBSA. Using the parkland formula, how many mL of IV fluids are needed during the 1st 8 hrs after injury?
ANS: 4,000 Kg= 50 Formula : 4mL * kg * TBSA = 50*4*40=8000 DIVIDE BY 2 = 4000
33. The triage nurse in a hospital ED is determining the order of care for several clients. Which of the following clients would the nurse assign the highest priority? a. A 26 y/o client with respiratory distress & increasing anxiety b. A 38 y/o client with a broken leg & history of asthma c. A 46 y/o with multiple cuts & abrasions to the upper extremities d. A 68 y/o client suffering from dehydration & lethargy
ANS: A ABC- therefore the client with the breathing issue would make priority.
38. The nurse assess a client with a vit B12 deficiency (pernicious anemia). Which assessment finding would the nurse expect? a. Paresthesia of the extremities b. Gum bleeding & tenderness c. Cheilitis d. Yellow tinged sclarea
ANS: A Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
39. The nurse is caring for a client who fell off a ladder 5 hrs ago & has been diagnosed with a T4 SCI. the client presents with paresthesia to lower extremities, hyporeflexia, & bladder incontinence. The nurse recognizes the client's manifestations as? a. Spinal shock b. Paraplegia shock c. Neurogenic shock d. Neurogenic bladder
ANS: A Spinal shock
56. A serum K level of 3.2 is reported for a client with cirrhosis who has scheduled doses of Aldactone & Lasix due. The client's BP is 160/82. Which action should the nurse take? a. Withhold the Aldactone & administer the Lasix b. Withhold both drugs until discussed with the HCP c. Administer both drugs d. Administer the Aldactone
Ans: D We will give the aldosterone as it is potassium sparing and the clients potassium level is 3.2.
18. The client is admitted to the medical unit with a diagnosis of rule out DI. Which instructions should the nurse teach regarding fluid deprivation test? a. The client will be NPO & vitals & weight will be done hourly until the end of the test b. An IV will be started with NS & the client will be asked to try to hold the urine until a sonogram can be done c. The client will be administered an injection of ADH & urine output will be measured for 4 -6 hrs d. The client will be asked to drink 100mL of fluid as rapidly as possible & then will not be allowed fluid for 24 hrs
ANS: A Water deprivation test procedure will have the patient NPO, and obtain weight and send blood and urine back to lab hourly.
16. The nurse is caring for an elderly client who is confused & fell trying to get out of bed. There is no family at the client's bedside. Which priority action should the nurse implement 1st? a. Notify the health care provider to obtain an order for a sitter b. Place the client in a chair with a sheet tightly around him/her c. Administer a sedative medication to the client d. Contact an out of state family member to come & stay with the client
ANS: A We would always start with the least invasive intervention first which would be to have to doctor order a sitter.
22. A 52 y/o client has a new diagnosis of pernicious anemia. The nurse determines that the client understands the teaching about the disorder when the client makes which of the following statements? a. I could choose nasal spray rather than injections of vit B12 b. I will need to take a PPI such as Prilosec c. I will stop having a glass of wine with dinner d. I need to start eating more red meat & liver
ANS: A With pernicious Anemia the pt has a lack of intrinsic factor which prevents absorption of vitamin B12. Administer cyanocobalamin parenterally or intranasally (nasal spray). Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.
7. The nurse is caring for a client status post bone marrow transplant. The client's current vital signs are: temp 38.1, HR 84, BP 120/80, RR 18. The nurse recognizes the following as signs of GVHD. SATA a. Rash & itching b. Yellowing of sclera c. Rectal pain d. 40mL/hr output of clear amber urine e. WBC of 22,000
ANS: A, B GVHD occurs most frequently after allogeneic bone marrow transplant and initially leads to dermatitis (a skin rash), gastrointestinal problems and liver dysfunction.
26. The nurse receives a client from paramedic after a head on collision in which the client was the unrestrained driver. The client presents with hypothermia, hypotension, & lethargy. Which of the following interventions should the nurse plan to immediately implement for the client arrival to the ED? SATA a. Continue cervical immobilization b. Administer fluid boluses c. Obtain an advanced directive as the client does not have one d. Maintain a patent airway e. Ensure clothing is given to the family
ANS: A, B, D Emergent situations require cervical immobilization, fluid boluses, and maintain a patent airway.
12. Which of the following side effects might be expected for a client taking iron supplements? SATA a. Constipation b. Dysphagia c. Decreased appetite d. Black stool e. Insomnia
ANS: A, D, E
24. When providing teaching related to genetic counseling for client & families interested in learning about genetic testing, the genetic nurse should include which information? a. Client & families will only be referred to a genetic counselor after completion of genetic testing to receive genetic test results b. Genetic counseling can help clients & families understand the risk & benefits before making a decision to undergo a genetic test c. Genetic counselors make medical treatment decisions related to genetic testing for clients & families d. The only goal of genetic counseling is to interpret to client & families the genetic testing results
ANS: B Genetic counseling can help clients & families understand the risk & benefits before making a decision to undergo a genetic test
23. A nurse is caring for a client after a stroke. Which action may the nurse delegate to the UAP? SATA a. Assess neuro status with GCS b. Assist client with eating c. Document client's intake d. Assess client for aspiration during feeding e. Notify physician of worsening stroke symptoms
ANS: B, C UAP cannot assess, they can make observations and have the nurse come and assess if client is choking.
1. A client with a 10 yr. history of emphysema is admitted in acute respiratory distress. During the assessment, what does the nurse expect? a. S/S of respiratory alkalosis b. Decreased RR c. Prolonged expiration with use of accessory muscles d. Chest pain on inspiration
ANS: C Clients with COPD with respiratory distress may exhibit prolonged expiration and use of accessory muscles.
6. The client is diagnosed with an ischemic stroke & being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy? a. History of T1 DM b. Neurologic deficits started 2 hr ago c. History of serious head injury 4 weeks ago d. Brain CT scan results show no bleeding
ANS: C Contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage.
34. After a ventriculostomy insertion procedure, the nurse would monitor the client's neuro status by using which test? a. NIHSS b. Monro-kelly doctrine c. GCS d. Electroencephalogram
ANS: C GLASCOW COMA SCALE 3-15
10. During change of shift report, the nurse is informed that the client has a high bilirubin level. Which assessment finding would the nurse expect with the client with an elevated bilirubin level? a. Erythema of the sclera b. Dark brown stool c. Dark brown urine d. Foamy light colored urine
ANS: C If sata The answers are B, C, and E. High bilirubin levels are because the hepatocytes are no longer able to properly conjugate the bilirubin because they are damaged. This causes bilirubin to leak into the blood and urine (rather than entering the bile and being excreted in the stool). Therefore, the bilirubin stays in the blood and will enter the urine. This will cause the patient to experience yellowing of the skin, sclera of the eyes, and mucous membranes ("jaundice") and have dark brown urine. The stools would be CLAY-COLORED not dark brown (remember bilirubin normally gives stool it brown color but it will be absent).
31. The ED nurse is caring for a client with hypovolemic shock. 2 units of PRCs are to be transfused STAT. The client's blood type of AB-. The blood bank does not have any units of AB- & provides a unit of O-. What should the nurse do next? a. Delay the transfusion until a unit of AB- is available b. Ask the client's family is any of them are AB- & would donate blood to the client c. Continue to prepare to transfuse the unit of O- d. Return the unit of O- to the blood bank
ANS: C O- is the universal donor and can be used for most any blood type for emergent situations.
20. A patient admitted with acute respiratory failure has ineffective airway clearance r/t thick secretions. Which nursing intervention would specifically address this patient problem? a. Teach the patient the importance of ambulation b. Titrate oxygen level to keep O2 saturation above 93% c. Offer the patient fluids at frequent intervals d. Encourage use of the incentive spirometer
ANS: C Offering fluids will help to loosen the secretions.
35. which topic is most important for the nurse to include when teaching a 41 y/o client diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Using Vit B supplements c. Avoiding alcohol ingestion d. Maintaining good nutrition
ANS: C Patients with cirrhosis will have to avoid any alcohol as well as acetominophen or NSAIDs.
29. The nurse is caring for a competent client who is actively bleeding from the upper GI tract & vomiting bright red blood. The HCP has ordered blood to be administered, but the client refused blood administration due to religious beliefs. Which statement best explains the basis for the nurse's expected actions? a. The client can be assure of his/her own right to privacy & confidentiality if circumstances allow b. The client's spiritual beliefs are not considered when healthcare providers make care treatment decisions c. The client has the right to refuse his/her own care & treatment regardless of the outcome d. The client should be involved in decisions about his/her own care if they are life saving measures
ANS: C The client has the right to refuse his/her own care & treatment regardless of the outcome
27. The nurse is caring for a client who came from a long term care facility. The admitting diagnosis is malnutrition & pneumonia. Current vitals include: BP 94/60, RR 24, Temp 101.5, HR 98 O2 sat 91%. A broad spectrum IV antibiotic was initiated as part of the admission. The nurse understands that the client is at risk for developing which type of shock? a. Cardiogenic b. Hypovolemic c. Septic d. Neurogenic
ANS: C this client is going into septic shock as evidenced by decline in vital signs and infection by pneumonia.
3. When caring for a preoperative patient on the day of surgery, which actions include in the plan of care can the nurse delegate to UAP? SATA a. Teach incentive spirometer use b. Explain routine pre-op care c. Obtain & document baseline vitals d. Remove nail polish & apply pulse Ox e. Transport the patient to the operating room by stretcher
ANS: C, D, E ANS include: UAP able to: Obtain & document baseline vital signs. Remove nail polish & apply pulse oximeter. Apply a warm blanket & transport the patient by stretcher to the operating room.
19. Which information is most important for the nurse to communicate rapidly to the HCP about a client admitted with possible SIADH? a. The client has a urine specific gravity of 1.025 b. The client complains of dyspnea with exertion c. The client has a recent weight gain of 5 lbs d. The client has a serum Na of 118
ANS: D A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action
21. When providing care to the dying client, the nurse understands that which pharmacological agents are usually not withdrawn at the end of life? a. Antibiotics b. Loop diuretics c. Vasopressors d. Opiates
ANS: D During end of life care we would not withhold pain medication the goal is to make the patient as comfortable as possible during this time.
32. The spouse of a client with terminal cancer visits daily & cheerfully talks with the client about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says "I'm busy at work, but otherwise things are fine." which nursing diagnosis is most appropriate? a. Caregiver role strain r/t feeling overwhelmed b. Hopelessness r/t knowledge deficit about cancer c. Anxiety r/t complicated grieving process d. Infective coping r/t lack of grieving
ANS: D Infective coping r/t lack of grieving
28. The client is diagnosed with sepsis secondary to an upper respiratory infection. Upon initial assessment of admission the nurse notes a blood pressure of 74/40 with a HR of 122, & a temp of 103.6. What should the nurse anticipate doing next? a. Infusing large amounts of hypertonic fluids b. Administering IV Benadryl for blood pressure support c. Administering osmotic &/or loop diuretics d. Infusing large amounts of isotonic IV fluids
ANS: D Infusing large amounts of isotonic fluids would be the appropriate intervention.
30. The ED nurse is caring for a client who is experiencing acute blood loss secondary to a GSW. The HCP orders a STAT transfusion of FFP. Which action by the nurse is most appropriate? a. Infuse the FFP over 4 hrs b. Hang the FFP with the ancef 1 g IV infusion c. Hang the FFRP & titrate the drip rate according to the client's vitals d. Infuse the FFP as rapidly as the client can tolerate
ANS: D Rationale: The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.
15. When assessing an older client admitted to the ED with a broken arm & facial bruised, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate to ask the client? a. Would you like to see a social worker? b. I need to report my concerns to the police c. You should not return to your home d. Do you feel safe in your home?
ANS: D This client is exhibiting signs of abuse and the first question would be if the client feels safe at home.
8. What is an expected client nursing diagnosis when admitted to the hospital with symptoms of DI? a. Impaired gas exchange r/t fluid retention in lungs b. Risk for impaired skin intergrity r/t generalized edema c. Excess fluid vol. r/t intake greater than output d. Sleep pattern disturbance r/t frequent waking to void
ANS: D With Diabetes Insipidus patient can present with s/s of polyuria, polyphagia etxtreme thirst and frequent urination.
14. The nurse is caring for a client who is 20 days post stem cell transplant. Upon physical assessment, the nurse notes a red, raised rash to the client's lower extremities. The client reports diarrhea, constant nausea, & feels bloated. The nurse recognizes that the client is exhibiting manifestations related to? a. Chronic transplant rejection b. Acute transplant rejection c. GVHD d. Hyperacute transplant rejection
ANS:C This client is exhibiting signs of graft versus host disease as manifested in GI issues and integumentary skin rash.
81. The provider has ordered Fentanyl drip for sedation for a client on the ventilator. The drip comes as 1 mg/100mL of NS. The dose rate ordered is 100mcg/hr. How many mL/hr will this drip run at?
Ans: 10
84. The 79 y/o client with bacterial pneumonia becomes increasingly restless & confused. Temperature is 100F & pulse, BP, & RR are elevated since the last assessment 6 hrs ago. What action should the nurse preform initially? a. Give the ordered mild sedative b. Administer NSAIDs for discomfort c. Assess oxygen saturation d. Take the client off oral fluids
Ans: 1c
67. An IV nitroglycerin is infusing at 10mL/hr. the concentration of the IV is 50 mg in 250mL of D5W. How many mg/hr is the client receiving?
Ans: 2mg
74. The provider has ordered Nafcillin 500mg IVPB Q6H in 100mL D5W over 30 min. using a macrodrip tubing with a drip factor of 15 gttts/mL, how many gtt/min should the nurse set the IV flow rate at?
Ans: 50
43. The nurse is assigned to care for a patient in the ED admitted with an exacerbation of asthma. The patient has received a A-Adrenergic bronchodilator & supplemental oxygen. If the patient's condition doesn't improve, the nurse should anticipate what as the most likely next step in treatment? a. Systemic corticosteroids b. Pulmonary function test c. Biofeedback therapy d. IV fluids
Ans: A
83. The nurse is assessing a client who has a liver transplant a week previously. Assessment findings include a temperature of 103, dry lips & oral membranes, bilateral crackles at both lung bases, & pupils that are 4 mm. which finding is most important to communicate to the HCP? a. Temp of 103 b. Bilateral crackles at both lung bases c. Pupil sizes of 4 d. Dry lips & oral membranes
Ans: A
91. which assessment question is a priority for the nurse to ask the client diagnosed with end stage liver secondary to alcoholic cirrhosis? a. When did you have your last alcoholic drink b. What foods did you eat at your last meal c. Have you completed an advanced directive d. How many years have you been drinking alcohol
Ans: A
94. Which assessment finding of a client on a medical surgical floor requires the nurse's immediate action to activate the RRT? a. Change in RR & AMS b. Wheezing on auscultation c. Uneven breath sounds d. Being on supplemental O2 for 4 days
Ans: A
40. The nurse is providing care to the client with a T2 SCI & note the client to have a HR of 32 & upper chest, neck, & facial flushing diaphoresis. Which action by the nurse should be done 1st? a. Elevate the HOB b. Evaluate the client's pain level c. Plan to call the on call provider d. Check the BP
Ans: A Elevate the head of bed.
57. The nurse is caring for a client admitted to the critical care unit 48 hrs ago with a diagnosis of severe sepsis. In this stage of the client's care, what interventions is most important for the nurse to discuss with the multidisciplinary care team? a. Enteral feedings b. Pain management c. Monitoring I&Os d. Frequent turning
Ans: A Enteral feedings: The client was admitted 48 hours ago which inidcates the client is now in need of nutrition management- enteral feedings.
42. A client with a history of COPD is admitted with a diagnosis of acute respiratory acidosis. Oxygen is being administered at 6L/min nasal canula. 4 hrs after admission, the client has increased restlessness & confusion, followed by a decreased respiratory rate & lethargy. What should the nurse do? a. Decrease the O2 flow rate b. Place the client on a nonrebreather mask at 15L/min c. Percuss& vibrate the client's chest wall d. Question the client about the confusion
Ans: A May have oxygen toxicity need to turn down the oxygen flow rate.
87. The client develops SIADH secondary to pituitary tumor. The client's assessment findings include weight gain, fatigue, & serum sodium of 127. Which intervention, if prescribed, should the nurse implement to treat SIADH? a. Restrict fluids to 400-1000mL/day b. Give 0.3% NaCl IV infusion c. Administer vasopressin IV d. Elevate the HOB to 30 degrees
Ans: A Restrict fluids with clients with SIADH. position client to promote venous return to the heart. Vasopressin is an ADH and will aggravate the client's problem. If symptoms are mild and hyponatremia is not severe, treatment includes fluid restriction to 800-1000 ml/day. Hypertonic saline should be reserved for treatment of severe hyponatremia
76. While caring for a client preparing for a heart transplant, the nurse recognizes that the client understands the immunosuppression teaching when the client makes which statement? a. The medication that I take will help prevent my body from attacking my new heart b. My body will only have a problem with my new heart if the donor is not directly related to me c. I will have to make sure that I avoid being around people d. My body will treat the new hear like my original heart
Ans: A The client will be placed on immunosuppressants which would prevent the body from attacking the new organ and possibly rejecting it.
69. The nurse assesses that there is significant disagreement among family members about what course of treatment is best for their sick mom. What would be the best response by the nurse? a. Could we hold a family conference to develop the best plan for your loved one b. You need to decide on 1 family member to be the spokesperson & make the decisions c. Perhaps you should consult with your pastor or priest on the best decision d. You need to come to a decision quickly on what you want to be done
Ans: A The most therapeutic response would be to ask if the family could hold a conference to discuss the best plan for their loved one.
75. The sister of a client diagnosed with BRCA gene-related breast cancer asks the nurse, "Do you think I should be tested for the gene?" Which response by the nurse is most appropriate? a. There are many things to consider before deciding to have genetic testing b. You should decide 1st whether you are willing to have bilateral mastectomy c. It depends on how you will react if the test is positive for the BRCA gene d. No, the BRCA gene mutation is not he only factor to increase your risk for breast cancer
Ans: A There are many things to consider before having genetic counseling.
47. Which assessment finding of a client requires the nurse's immediate action? a. Change in respiratory rate with AMS b. Wheezing on auscultation c. Change in breath sounds d. Being on supplemental oxygen therapy for 4 days
Ans: A These are all bad the change in respirations would be worse.
96. the nurse recognizes that a coworker is demonstrating ageism when the coworker states: a. aging clients are not able to hear or follow direction b. aging clients are not victims of age related stereotypes & myths c. aging clients can experience negative attitudes & discrimination d. aging clients can experience new & different life occurrences despite normal loss of hearing & vision
Ans: A This would be considered biased.
85. A client with massive trauma & possible SCI is admitted to the ED. Which assessment findings by the nurse will help confirm a diagnosis of neurogenic shock? SATA a. BP 78/48 b. HR 45 c. Hyperreflexia d. Temp 97.8 e. Expiratory wheezes
Ans: A, B
82. To prevent complications for SIADH, which of the following nursing interventions should the nurse include in the nursing management of clients with SIADH? SATA a. Fluid resuscitation b. Client education c. Monitoring lab values d. Fluid boluses e. Bridging to oral corticosteroids
Ans: A, B, C
79. The nurse is caring for a client with hepatitis. In planning care for his client the nurse should be aware that symptoms manifested by persons with hepatitis may include: SATA a. Loss of appetite b. Fatigue c. Dark urine d. Jaundice e. Chronic dry eye
Ans: A, B, C, D
58. The nurse is caring for a client with cirrhosis & esophageal varices. As part of the discharge teaching, the nurse educated the client & his family on activities to avoid with esophageal varices. Which of the following activities should the nurse teach the client & family to avoid? SATA a. NSAIDs b. ETOH consumption c. Straining during bowel movement d. Acetaminophen e. Excessive exercise
Ans: A, B, C, D A client with Cirrhosis has an advanced degree of Hepatitis and the liver is unable to function normally. Therefore the client would need to avoid the use of NSAIDS and Acetaminophen. The client is to cease use of all alcohol products, and avoid straining during a bowel movement as they have active bleeding the esophageal varices and this could increase the risk of bleeding.
61. The nurse is caring for a client with DI. Which of the following sings & symptoms should the nurse expect this client to exhibit? SATA a. Polyuria b. Polydipsia c. Dry mucous membranes d. Low specific gravity e. Hyponatremia
Ans: A, B, C, D Low specific gravity can indicate the client's urine is very diluted as they may be drinking too many fluids- which would be seen in a client with Diabetes Insipidus. A high specific gravity would indicate the client is not drinking enough fluids as may be seen with SIADH, Clients with DI will have Hypernatremia.
89. Which of the following are factors that increase the risk of sustaining a SCI? SATA a. Age 16-30 b. Male c. Obesity d. Female e. Family history
Ans: A, B, E
68. Which stroke risk factor for a 48 y/o male client is important for the nurse to address? SATA a. The client is 55 lbs above ideal weight b. The client drinks an occasional glass of red wine c. The client's usual BP is 170/94 d. The client works at a desk & relaxes in the afternoon by walking 2 miles with his spouse e. The client smokes one pack of cigarettes per day
Ans: A, C, E Risk factors would include, HTN, smoking, obesity, chronic alcohol use, sedentary lifestyle, DM.
78. Which severity & resource factors are used to determine the client's classification with ESI triage systems? SATA a. Whether the client requires immediate life saving b. Medical insurance c. Vitals d. Expected resource intensity e. How soon client should be seen by provider
Ans: A, C, E The emergency severity index gives us limits on how to move forward with triage in emergency care disaster situations.
90. The nurse is caring for a client admitted with the early stages of septic shock. The nurse assess the client to be tachypneic, with a RR of 32. ABG assessed on admission are: pH 7.50, CO2 28, HCO3 26. Which diagnostic study result reviewed by the nurse indicated progression of the shock state? a. pH 7.35, CO2 40, HOC3 22 b. pH 7.30, CO2 45, HCO3 18 c. pH 7.45, CO2 45, HCO3 26 d. pH 7.40, CO2 40, HCO3 24
Ans: B - this condition is worsening.
51. The ED nurse has received a status report on the following clients who have been admitted with head injuries. Which client should the nurse assess 1st? a. 40 y/o who lost consciousness for a few seconds after a fall b. 50 y/o whose right pupil is 10 mm & unresponsive to light c. 30 y/o who has an initial GCS of 13 d. 20 y/o whose cranial x-ray shows a linear skull fracture
Ans: B 50 y/o whose right pupil is 10 mm & unresponsive to light This clients condition is worsening to a late stage of ICP as indicated by the pupil enlargement and beign unresponsive to light.
65. The nurse is providing teaching to client with SIADH. Which statement indicated the client understands the management of their SIADH? a. Once being on medication for a few months, I can stop taking it because my SIADH will resolve. b. Since I'm on fluid restriction, I will need to monitor my weight daily c. If I experience any side effects from the medications, I shouldn't report them as they will resolve on their own d. I need to start increasing my daily fluid intake
Ans: B Clients with SIADH will have fluid overload and will most likely be placed on fluid restrictions. For any clients on fluid restrictions and especially those with sodium issues- SIADH or DI, we will need to monitor daily weights.
46. Which statement made by the nurse educator explains the role of the nurse when planning care for a culturally diverse population? a. The nurse should blend the values of the nurse that are for the good of the client & minimize the client's individual values & beliefs during care b. The nurse should provide care while aware of one's own cultural beliefs, while focusing on the client's individual needs rather than the staff's practices c. Client care should focus only on the needs of the client, ignoring the nurse's beliefs & practices d. The nurse should include care that is culturally congruent with the staff from predetermined criteria
Ans: B Culturally competant care is composed of being aware of your own beliefs while yet including the clients needs.
66. The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? a. 42 y/o female patient who takes oral contraceptives & has migraine headaches b. 72 y/o male patient who has HTN & DM & smokes tobacco c. 28 y/o male who uses marijuana to control nausea d. 92 y/o female patient who takes warfarin for A-Fib
Ans: B Patients with Hypertension and DM have classic hallmark high risk profiles for a stroke. This client is also a smoker which increases the risk.
55. Which intervention is most appropriate when communicating with a patient with aphasia after a stoke? a. Finish the patient's sentences to minimize frustration associated with slow speech b. Use simple, short sentences accompanied by visual cues to enhance comprehension c. Ask open ended questions to provide the patient the opportunity to speak d. Present several thoughts at once so that the patient can connect the ideas
Ans: B Patients with aphasia will have trouble with speech.
63. After receiving a change of shift report on medical unit, which client should the nurse assess 1st? a. A client with emphysema who has an oxygen saturation of 90-92% b. A client with septicemia who has intercostal & suprasternal retractions c. A client with pneumonia who has crackles bilaterally in the lung bases d. A client with cystic fibrosis who has thick, green-colored sputum
Ans: B The client with septicemia has now gone into respiratory distress evidenced by intercostal and suprasternal retractions. All of the other clients are exhibitng s/s related to their conditions.
77. The daughter of a client recently diagnosed with lung cancer, informs the nurse that she does not want her mother told of the cancer diagnosis. Which response by the nurse is best? a. We must be honest with your mother. Unfortunately, I will need to inform her b. Lets discuss your concerns with the oncologist & then decide the best approach c. Your mother has a right to know. How would you feel if you weren't told? d. Are you afraid that your mother's condition will worsen more rapidly if she is told?
Ans: B This would be the most therapeutic in this situation to allow the daughter to express her concerns but also still being aware there should be an approach on how to still respect the mothers autonomy.
88. The nurse is caring for a client with partial thickness burns to the chest & back area. Which assessment data would warrant notifying the HCP immediately? a. The client has a temp of 99.2 b. The client's urinary output is 50mL in the past 2 hrs c. The client's pulse Ox is 95% d. The client is complaining of 9/10 pain
Ans: B urinary output less than 30mL/hr is dangerous and needs to be reported to the HCP immediately.
62. The nurse is caring for a client admitted with new onset of slurred speech, facial drooping, & left sided weakness 3 hrs ago. Diagnostic CT scan rules out the presence of an intracranial bleed. Which actions are most important to include in the client's plan of care? SATA a. Restrain affected limb to prevent injury b. Prepare for thrombolytic administration c. Maintain SBP less than 180 d. Maintain CO2 level at 65 e. Perform neuro assessment per policy
Ans: B, C, E If the doctor has ruled out an intracranial bleed that indicates that they have ruled out a hemmorhagic stroke which represents a bleed or burst, and that means we have an Ischemic stroke which means there is a clot. Treatment for TPA therapy requires the presence of Ischemic stroke, and the symptoms have to have been within 4.5 hours. For TPA therapy there would be fine line in hypertension because we need the blood pressure high enough to help release the clots but also not too high that it puts the patient in a hypertensive crisis. Therefore around 180, and perform neuro assessments after administration of TPA.
92. The nurse is caring for a client who reports flu like symptom: N/V/D for 3 days & recent travel outside of the U.S. The nurse suspects Hepatitis related to recent abroad traveling. Which precautions should the nurse implement to decreased risk for hepatitis exposure? a. Droplet precautions b. Exposure precautions c. Standard precautions d. Airborne precautions
Ans: C
70. The client informs the nurse that the HCP is recommending a kidney biopsy. The client fears the results will be cancer & would not want treatment. The client feels it would be better just not to know. Which action should be taken by the nurse to empower the client to take control of his/her health care needs? a. Talk with the HCP about the client's fears of having the biopsy b. Encourage the client to talk with family, & let the family decide c. Inform the client of his/her right to make decisions based on personal values & beliefs d. Explain to the client that the HCP is doing what is best for the client
Ans: C Autonomy is critical in nursing care and would be important for the nurse to follow the wishes of the client, while still making sure they understand the risk and benefits of their decision.
45. The nurse understands that which factor can contribute to FTR situation? a. Quality improvement measures b. Ongoing education training for staff c. Short staffing d. Healthy work environment
Ans: C Failure to rescue can come from short staffed.
60. A couple in their late 30s who wish to have a child are referred for genetic counseling. They tell they nurse that they have a family history of an inheritable problem; however they have reservations about genetic counseling because they believe that genetic clinics favor abortions when the studies reveal a defective fetus. How should the nurse reason regarding genetic counseling? a. Recommendations are made to consider adoption when deficits are predicted b. After the probability of a deficit is determined, the couple's own primary HCP helps the couple decide on the appropriate action c. Families are helped to understand the diagnosis, the probable cause of the disorder, & how the condition can be managed d. Abortion is suggested only when the fetus is found to have a sever defect that is not compatible with life
Ans: C It should not be recommended for a family to get an abortion, unless there would be fatalities to the mother or there is certainly that the baby will not survive. Any psyche issue- families should be helped to understand the Dx, and cause, treatment and management.
64. The nurse is implementing generalized falls precaution for clients who are at risk for falls. Which interventions indicates a lack of understandings of these precautions? a. The client's cell phone is within reach on the bedside b. The client's call light is within reach c. The client is wearing regular socks d. The bed is places in the low position
Ans: C The client should have on non-slip footwear when deemed a fall risk.
59. The nurse & UAP are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP? a. Assisting a client who has a lacerated arm & broken leg to the BSC b. Help a client to cough & deep breathe c. Performing a dressing change on the client who has septectomy d. Obtaining the I&O on a client diagnosed with food poisoning
Ans: C UAP cannot perform a dressing change on any client that is in the professional scope of the nurse.
48. A client is admitted with a diagnosis of blunt trauma to the abdomen after a MVA. What should the nurse assess 1st when the client arrives in the ED? a. Cervical spine for tenderness b. Signs of neurological deficits c. Abdomen for any abnormalities d. Airway for patency
Ans: D Airway is first ABC.
49. The nurse is admitting a client with significant burns to the ED notes the presence of symptoms consistent with an inhalation burn. Which should the nurse be preparing to do next? a. Administer tetanus shot b. Administer a fluid bolus c. Provide oropharyngeal suctioning d. Assist in endotracheal intubation
Ans: D Assist in endotracheal intubation.
80. The nurse responds to a scene of a bus crash involving multiple victims. The nurse recognizes the client with triage category green, minor injuries as: a. Conscious with garbled speech & abnormal behavior b. Pregnant with multiple fractures to bilateral lower extremities & experiencing paresthesia c. Unconscious with a weak pulse & deep scalp lacerations d. Ambulatory with multiple contusions &minor lacerations
Ans: D Clients who are ambulatory with lacerations would be considered "walking wounded" and would be placed in the green category.
73. The nurse is caring for a client who has been diagnosed with septic shock & is now developing signs of MODS. What is the priority nursing diagnosis for this client? a. Ineffective tissue perfusion b. Dysfunctional GI motility c. Risk for impaired skin integrity d. Risk for infection
Ans: D Clients with sepsis are at a very high risk for infection, MODS could indicate a worsening of the infection.
44. Which is the primary reason nurses activate the RRT for a client? a. Overwhelmed by the client's condition b. Inability to implement the HCP's orders c. Too many interventions needed for the client d. Concern over the client's worsening condition
Ans: D Concern over the clients worsening condition.
41. The male client presents to the ED complaining of fatigue, abdominal pain, N/V, & informed the nurse that he has been eating lunch every day for the past 2 weeks from the food trucks outside of his office building. He has a fever or 102 & yellowing of his sclera. The nurse suspects that the client has which type of hepatitis? a. C b. D c. B d. A
Ans: D Hepatitis A comes from contaminated food or water.
71. A client hospitalized with an OD of benzodiazepines & presents with a RR of less than 10. Which nursing intervention should be provided as the 1st priority? a. Obtain a sputum sample b. Place the client in Trendelenburg c. Administer a bronchodilator d. Administer supplemental oxygen
Ans: D Oxygen should be given as the first priority intervention for clients with a respiratory rate below 10 breaths per minute due to an overdose of benzodiazepines.
72. Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. Patient with right leg cellulitis b. Patient with multiple abdominal drains c. Patient who has viral pneumonia d. Patient with chronic Heart failure
Ans: D Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
86. The nurse is caring for a client with DI. The client has a constant thirst, drinks fluids continuously, & voids 3-4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this client's urinary output? a. Anuria b. Enuresis c. Oliguria d. Polyuria
Ans: D Polyuria
54. The nurse anticipates which lab values will be elevated in the septic client with an ABG of: pH 7.33, PaCO2 30, HCO3 20, PaO2 90. a. Na b. Eosinophil c. RBC d. Lactate
Ans: D The client with a metabolic acidosis would have an elevated lactate level. The lactate level is elevated due to an increase of anaerobic metabolism.
95. The nurse is caring for a client with acute respiratory failure. Which ABG result indicated ARF & requires invasive O2 therapy? a. pH 7.45, CO2 38, PaO2 80, HCO3 28 b. pH 7.46, CO2 46, PaO2 75, HCO3 30 c. pH 7.38, CO2 40, PaO2 70, HOC3 24 d. pH 7.35, CO2 54, PaO2 52, HCO3 30
Ans: D The client with the PaO2 of 52 is not getting adequate oxygenation.
93. When caring for a client after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings? a. Systolic hypotension & bradycardia b. Systolic hypotension & tachycardia c. Systolic HTN & tachycardia d. Systolic HTN & bradycardia
Ans: D This could indicate Cushing's Triad.
52.The nurse is caring for a client who was admitted with thermal burns to each lower extremity. The nurse notes the client's bilateral lower extremities appear white & leather-like without blisters or bleeding. The client reports a small amount of pain. How does the nurse categories this type of burn? a. Superficial b. Full partial thickness c. Partial thickness d. Full thickness
Ans: D Full thickness burns These burns reach down into the nerves therefore the client may not even feel pain, needs repair via skin graft cannot heal on its own.
53. The nurse is caring for a 25 y/o female client with full thickness & partial thickness burns to 70% of her body, including the chest area. After establishing a patent airway, which collaborative intervention is a priority for this client? a. Monitor hourly urine output b. Prepare to assist with escharotomy c. Prevent contractures of extremities d. Replace F&E
Ans: D Replace fluid and electrolytes Clients with burns are in dire need of electrolyte replacement due to vascular changes such as third spacing and fluids shifting and an increase of permeable blood capillaries allowing large molecules like proteins to pass through the capillary pores easily.
37. A client is scheduled for a mastectomy. As she is about to receive the pre-op medication, she informs the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicated that the nurse is acting as a client advocate? a. Holding the client's hand & offering to pray with her for a good outcome b. Arranging for a post-op visit from a cancer survivor c. Calling the surgeon to come & explain all treatment options to the client d. Telling the client her surgeon is excellent & knows what is best for her condition
ans: c. Calling the surgeon to come & explain all treatment options to the client
