Final Exam Test Bank

Decrease the IV flow rate

A 70 year old client is admitted to the PACU with an intravenous (IV) solution of 0.9% NaCl which is running at 125cc/hour. The nurse detects new onset of crackles in the lung bases and distended neck veins. What is nurses the priority action?

pH less than 7.35.

A client was given a prescribed narcotic pain med at 0800. At 0900 the nurse finds the patient slumped in the chair, hard to arouse, with respirations of 6 /minute. Arterial blood gases are ordered what would you expect to see in the ABG results?

It helps eliminate the barium

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

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

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.)

Are signs of impending death

A nurse assesses a hospice client. The assessment reveals BP 74/40, urine output 30 cc over 3 hours, poor skin turgor and skin cool to touch, resp 8 and irregular, and dysphagia. The nurse recognizes these combined assessment findings.

Dispose of the dressing in a biohazardous waste container

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

i am hoping this will limit my discomfort

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment?

42 units

A nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?

The date of the incident. The time the client was to receive the medication. The client's vital signs

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)

Mask/Respirator

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last?

denial

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving?

Movement of the ET tube into the right main bronchus

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Determine if the client uses hearing aids.

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Airborne

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Cover the area with saline-soaked dressings

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

Necrotic subcutaneous tissue and full thickness skin loss

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Atelectasis

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

Paralytic ileus

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

Yellow-green drainage on the surgical incision

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Viral infection

A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect?

Cover the wound with a sterile saline-soaked dressing.

A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take?

fatigue

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Serosanguineous

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Breathing ranging from very deep to very shallow with periods of apnea

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

1370 mL

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?

I just can't believe that this dialysis is going to ruin my whole life.

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving?

Explore the client's feelings about dietary modifications

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?

Call the prescribing physician and inform her of the client's serum potassium level results.

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?

transparent dressing

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

"The doctor says I only have a few moments to live, but I know he is exaggerating to get me to take my medication."

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

Denial

A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following defense mechanisms should the nurse manager expect the staff nurse to use?

Discuss imitating hospice care with the client in a nursing home

A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first?

passage of flatus

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

The client's self-report of pain severity

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

Explaining the operative procedure, risks, and benefits.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Respiratory acidosis

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

"I don't eat shellfish because it gives me hives."

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?

Discontinue suction when assessing for peristalsis- Irrigate the NG tube with 0.9% sodium chloride irrigation solution.- Place sequential compression devices on the bilateral lower extremities.- Reposition the client form side to side every 2 hr.

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)

Provide the client with a diet high in protein

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

-Decreased gastric motility -Decreased skin elasticity -Increased pain threshold

A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply.)

The surgical dressing.

A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

serosanguineous drainage at this time is a manifestation of possible dehiscence.beyond the 5th post day --> possible dehiscence

A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

Pain

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Encourage the use of an incentive spirometer.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Oral contraceptive use. Immobility

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)

Administer analgesics on a scheduled basis for the first 24 hr

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

increase ambulation

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?

Each clients expression of pain may be different and individual. Patient-controlled analgesic (PCA) offers a constant level of opioids within therapeutic. Pain level and pain tolerance can be assess using a scale from 0 to 10

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.)

- Apply skin barrier around the stoma site- Educate the client that hematuria is expected- Monitor hourly urine output

A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).

Determine what the client knows about the surgery

A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

125 mL/hr

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Check the client's medical record for the provider's prescription

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

0.2 mL

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Have short teaching sessions

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?

Before the examination your provider will give you a sedative that will make you sleepy

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

1) Make sure the provider has pronounced the client dead2) Verify the client's organ and tissue donation status3) Remove medical equipment from the client4) Cleanse the body while adhering to the body-fluid precautions5) Attach identification tags to the body

A nurse is providing postmortem care for a client. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

- Bathe the patient - Place patient in anatomical position - Remove endotracheal tube

A nurse is providing postmortem care to a hospitalized patient. Nursing interventions include? ( Check all that apply)

I will tie a restraint to the portion of the bed that moves when the head of the bed is moved

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?

pH below 7.35

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

Urine specific gravity 1.035

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?

The client is 71 years old

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

oncology nurse

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified?

Yogurt

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

Take the medication with food

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?

Decompress the stomach.

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

Ten years

A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test (FOBT) and a colonoscopy at which of the following intervals?

Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

Removing the abdominal dressing

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?

low self esteem

A nurse manager is discussing the differences between normal and maladaptive grief with nursing staff. Which of the following findings should the nurse manager identify as being a unique component of the maladaptive grieving process?

Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion)

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?

shoulders drop, facial muscles relax, pulse is within expected range

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.)

Dysphagia

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Laceration

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

Demonstrate how fill insulin syringe and give insulin injection

The nurse is caring for a new diabetic client who is being taught how to administer insulin. The nurse knows that the patient care objectives have been met when the patient is able to?