Reduction of Risk Practice Exam
A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make?
"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?
"I will take my medications at the first sign of an attack."
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?
125
A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?
Chvostek's sign
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
Cold and numb numbness distal to the fistula site
A nurse is caring for a client who is at 36 weeks of gestation.
FHR declined, HA improved, Epigastric discomfort improved, urine no change, patella reflex declined, edema improved, liver function declined
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action?
Initiate IV access.
A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching?
Instruct the client about the use of a sequential compression device.
A nurse is caring for a client on the medical-surgical unit.
NPO, NG tube, at risk of a paralytic illeus, monitor for potassium and sodium and pain
A nurse is caring for a client who has been admitted to a medical-surgical unit.
Phlebitis as evidence by the right forearm.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
Position the client with one hip elevated.
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?
Provide a quiet, low-stimulus environment.
A nurse is caring for a newborn 1 hr following birth.
Respiratory, glucose, hematocrit, WBC, Hemoglobin, HR
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
Test the drainage for glucose.
A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
adjust the suction, don sterile gloves, check function, hyperoxygenation, insert catheter, apply suction while rotating, assess clearance.
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor?
bicarb excess, circumoral paresthesia.
A nurse is caring for a 50-year-old client in the emergency department
blood cultures and ABX, endocarditis, monitor temp and neuro status.
A nurse is preparing to perform a capillary blood glucose test. Identify the sequence of steps the nurse should follow. (
check expiration, perform a quality control test, perform hand hygiene, clean puncture site, apply blood onto test strip, document.
A nurse is caring for a newborn who was born at 37 weeks of gestation and is 12 hr old.
give surfactant and oxygen. at risk of respiratory distress. monitor oxygen and ABGs
A nurse is caring for a client who has an impulse control disorder.
how anger is expressed, statement regarding rules, and attitude toward school
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications?
hypotension, absence of bowel sounds, weakened gag reflex.
A nurse is caring for a client who was recently admitted and has symptomatic bradycardia.
incisional site bleeding, and bradycardia
A nurse is caring for a client. risk of falling
macular degeneration, osteoarthritis, throw rugs, blood pressure,
A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client?
on the unoperated side
A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?
painless red vaginal bleeding
Select the 5 findings that can cause delayed wound healing. A nurse is caring for a client.
prealbumin, DM, wound infection, decreased pedal perfusion, and fasting BGL.
A nurse is preparing to insert an NG tube for a client who requires gastric suctioning. Place the following steps in the appropriate order.
prepare at bedside, measure NG tube, extend the neck backward, then flex forward, obtain an xray then apply suction
A nurse is caring for a 20-year-old client who has a fever and reports severe headache.
provide education, obtain coagulation studies, ensure informed consent is signed, place in a lateral position with knees to abdomen.
A nurse is reviewing the medical record of a client.
renal failure and hypothyroidism.
A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.
stop the infusion, remove IV, apply sterile dressing, elevate, then apply warm or cold compress
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?
sudden decrease in abdominal pain.
A nurse is caring for a client who has an indwelling urinary catheter.
temp, urine clarity, HR, WBC
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?
yellow/green drainage.
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
Bleeding from the gums
A nurse is reviewing the laboratory results of a client who was admitted with a history of multiple myeloma. The nurse should expect to find an increase in which of the following laboratory values?
Calcium
A nurse is caring for a 6-month-old who had a cardiac catheterization.
Call provider if right leg is cool to touch, and administer ibu or acetaminophen for pain.
A nurse is caring for a client.- drag 1 condition and 1 client finding.
DVT due to recent car ride
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
Deep tendon reflexes.
A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?
Dehydration
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client?
dyspnea, barrel chest, clubbing of fingers'
A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan?
elevate the leg on 2 pillows.
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)
feeling pressure, tenderness, distended bladder, voiding 30 mL
A nurse is caring for an infant. Which of the following nursing actions should the nurse plan to take postoperatively?
keep HOB above 60-90 contraindicated, apply pressure dressing is contraindicated, assess for unilateral pupil is essential, measure head circumference daily is essential, monitor for abdominal distension is essential, test for glucose is essential, and intermittent cath is non essential.
A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side.
left foot
A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include?
lubricate lips, brush teeth with a soft toothbrush, blow nose gently.
A nurse is caring for a client who has AIDS.
risk of infection because of their CD4 count.
A nurse is caring for a client who is scheduled for surgery. A nurse is providing preoperative teaching to a client about pain management using a patient-controlled analgesia (PCA) system. Which of the following 3 statements should the nurse include?
there is minimal risk of over dose, use the PCA regularly will provide consistent levels of pain relief. and push prior to pain is severe.
A nurse in an antepartum clinic is caring for a client who is pregnant.
vaginal exam- preterm pain- preterm and UTI discharge- preterm temp- UTI
A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding.
verify placement, check residual, administer feeding, then evaluate tolerance.
A nurse is admitting a client who reports chest pain. The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take?
witness signature, obtain vitals, confirm allergies.
