Sullivan's Comprehensive Exam Review

A sexually active young adult client has developed viral hepatitis. Which statement indicates the need for further teaching?

"I can go back to work right away."

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction?

17:00

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

Place a clock and calendar I the client's room.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which findings?

Waves of loud gurgles auscultated in all 4 quadrants

The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?

"I know I have to keep my insulin in the refrigerator at all times."

The primary health care provider prescribes 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops (gtts mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 gtt/minute

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the client's primary health care provider?

A decreased dosage of warfarin sodium

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

Cardiovascular disease

The nurse is providing care to a Puerto Rican-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client?

Make the necessary arrangements so that family members can visit.

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg. PaO2 of 80 mm Hg and HCO3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select All That Apply

The nurse encourages the client and family to identify and discuss feelings openly, The nurse assists the client and family in carrying out spiritually meaningful practices, The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?

Assessment of vital signs

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

Bloody

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?

Placing an eye patch over the client's affected eye.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chest

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select All that Apply

Sitting up and leaning on a table, Standing and leaning against a wall, Sitting up with the elbows resting on knees

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate?

"I will contact the medical examiner regarding your request."

The primary health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank

1.5 tablets

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend first?

A woman who is complaining. "My leg is bleeding so bad, I am afraid it is going to fall off?

A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is the expected outcome of the medication?

Achieve normal thyroid hormone levels

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider?

Dark red drainage

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

Deflate the cuff on the tube.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Document the findings.

The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply

Early menarche, Family history of breast cancer, High-dose radiation exposure to chest, Previous cancer of the breast, uterus, or ovaries

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?

Leukocytosis with a shift to the left.

A client has had radical neck dissection and begins to hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply

Monitor vital signs., Monitor the client's airway., Call the primary health care provider immediately.

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply.

Nocturia, Incontinence, Enlarged prostate

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions should be included in the list? Select all that apply

Obtain a Medic Alert bracelet., Prevent debris from entering the stoma., Avoid exposure to people with infections., Avoid swimming and use care when showering.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction?

"I will limit sun exposure to 1 hour daily."

A client newly diagnosed with diabetes mellitus is instructed by the primary health care provider to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication: What is the nurse's best response to the client's question?

"It is for the times when your blood glucose is too low from too much insulin."

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?

"Take a deep breath when I tell you, and hold it while I remove the tube."

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?

"The enema will be given while I am sitting on the toilet."

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my primary health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?

An expected coping mechanism

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan?

Check the weights to ensure that they are off of the floor.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

Checking for the presence of bowel sounds in all 4 quadrants

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position?

Elevated on a pillow

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

Encouraging active range-of-motion exercises

Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse should include in the client's teaching plan?

Gastrointestinal disturbances

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply

Head midline, Neck in neutral position, Head of bed elevated 30 to 45 degrees

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?

Inability to pass flatus

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply

Instruct the client about thyroid replacement therapy., Encourage the client to consume fluids and high-fiber foods in the diet., Instruct the client to contact the primary health care provider if episodes of chest pain occur

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?

Three sputum cultures are negative.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?

Use of confabulation