214 mED sURG fINAL
MODULE 2
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MODULE 3
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Module 5
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Module 6
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Module 7
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Module 8
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Module 9:
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Modules 10-14
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20. The nurse is reviewing the orders of a patient who received packing for a posterior nosebleed. Which order does the nurse question? A. "Administer ibuprofen 800 mg every 8 hours PRN for pain" B. "Encourage bed rest, with the head of the bed elevated 45 to 60 degrees." C. "Provide humidified air." D. "Suction at the bedside."
A. "Administer ibuprofen 800 mg every 8 hours PRN for pain"
26. The nurse responds to a patient who states he is "feeling funny." The patient is slurring his words and has right-sided weakness. What does the nurse do next? A. Assesses airway, breathing, and circulation . B. Calls the provider. C. Performs a focused neurological assessment. D. Assists the patient to a sitting position.
A. Assesses airway, breathing, and circulation .
24. The nurse is performing a neurological assessment on an 81 year old patient. Which physiologic change does the nurse expect to find because of the patient's age? A. Decreased coordination B. Increased sleeping during the night C. Increased peripheral sensation D. Stability in pain perception
A. Decreased coordination
21. For patient safety and quality care, which technique is best for the nurse to use when suctioning the patient with a tracheostomy tube? A. Hyperoxygenate before and after suctioning. B. Apply suction until until tube is clear. C. Apply suction during insertion and removal of the tube. D. Suction for 30 seconds.
A. Hyperoxygenate before and after suctioning.
10. The nurse is assessing the legs of a patient with arterial insufficiency. Which of the following would the nurse most likely find? A. Mottling of the skin and absence of hair. B. Ankle discoloration and nonpitting edema. C. Pain with activity that subsides with rest. D. Distended peripheral veins.
A. Mottling of the skin and absence of hair.
8. The nurse is caring for a patient with peripheral artery disease (PAD). The nurse should assess for which symptoms? A. Reproducible leg pain with exercise. B. Edema in the affected leg. C. Decreased pain when legs are elevated. D. Pulse oximetry reading of 90%.
A. Reproducible leg pain with exercise.
25. The nurse has just received report on a group of patients on the neurosurgical unit. Which patient will be the nurse's first priority? A. Young adult patient whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10 B. Adult patient whose deep tendon reflexes have become hyperactive C. Middle-aged patient who displays plantar flexion when the bottom of the foot is stroked D. Older adult patient who consistently demonstrates decortication when stimulated
A. Young adult patient whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10
23. The patient has received contrast medium. Which teaching will the nurse provide to avoid any neurologic health problems after the procedure? A. "Practice memory drills this afternoon." B. "Drink at least 2000 to 2500 mL of water today." C. "Avoid sunlight." D. "Rest in bed for 24 hours."
B. "Drink at least 2000 to 2500 mL of water today."
15. After reviewing the laboratory test results, the nurse calls the health care provider about which patient? A. 44 year old receiving warfarin (Coumadin) with an INR of 3.0 B. 46 year old with a fever and a white blood cell (WBC) count of 500/µl C. 49 year old with hemophilia and a platelet count of 150,000/mm3 D. 52 year old who has diarrhea and a serum potassium level of 4.4 mEq/L
B. 46 year old with a fever and a white blood cell (WBC) count of 500/µl
17. Which patient needs immediate attention by the RN? A. 40 year old who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing B. 54 year old who is mechanically ventilated and has tracheal deviation C. 57 year old who was recently extubated and is reporting a sore throat D. 60 year old who is receiving O2 by facemask and whose respiratory rate is 22
B. 54 year old who is mechanically ventilated and has tracheal deviation
18. A 91 year old patient in ICU begins to pick at the bed covers. Which is the priority nursing intervention? A. Administer the PRN pain medication. B. Assess the patient's SpO2 C. Explain to the patient that he has a tube in his throat to help him breathe. D. Request that the family leave to decrease the patient's agitation.
B. Assess the patient's SpO2
27. The nurse is caring for a patient who is recovering from a stroke and complaining of double vision that is impairing his hand-eye coordination. How does the nurse help the patient compensate? A. Approaches him on the affected side. B. Covers the affected eye. C. Encourages turning the head from side to side. D. Places objects in the his field of vision.
B. Covers the affected eye.
12. A nurse is reviewing complete blood count (CBC) for a 76 year old female patient. Which of the following should cause the nurse concern? A. Hemoglobin (Hgb) level of 13.5 B. Platelet (thrombocyte) count of 80,000 C. Red blood cell (RBC) count of 4.9 D. White blood cell (WBC) level of 7,000
B. Platelet (thrombocyte) count of 80,000
28. The patient is receiving heparin 24 hours after receiving thrombolytic therapy for a stroke. Which drug does the nurse ensure is on the floor? A. Narcan. B. Protamine sulfate. C. Vitamin K. D. Physostigmine.
B. Protamine sulfate.
16. Which nursing intervention would be the priority for the patient with a respiratory rate of 24 and SpO2 of 90%? A. Raise the head of the bed. B. Offer the patient a sedative to slow their breathing. C. Administer oxygen. D. Ask the patient to cough, then reassess the SpO2.
C. Administer oxygen.
2. The nurse is preparing to administer 10 units of insulin to a diabetic patient. When administering the medication, the nurse should: a. Inject it IV push over two minutes. b. Insert the needle at a 90 degree angle, aspirate, then inject the medication. c. Insert the needle at a 45 degree angle, then inject the medication. d. Insert the needle at a 15 degree angle, and inject slowly to form a wheal.
C. Insert the needle at a 45 degree angle, then inject the medication.
29. The nurse is assessing the patient with a traumatic brain injury after a motor vehicle accident. Which symptom is the nurse most concerned about? A. Amnesia. B. A&Ox2. C. Pupil changes to one side. D. Restlessness.
C. Pupil changes to one side.
22. A patient who smokes is being discharged home on oxygen. The patient states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? A. "You can quit when you are ready." B. "It's never too late to quit." C. "If you're going to smoke, turn off your oxygen first." D. "You're right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
D. "You're right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
11. A patient with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? A. "How many hours are you sleeping at night?" B. "You are not getting enough iron." C. "You need to rest more when you are sick." D. "Your cells are delivering less oxygen than you need."
D. "Your cells are delivering less oxygen than you need."
14. The nurse arrives on the floor and receives report from the night shift. Which patient does the nurse decide to assess first? A. 55 year old female with anemia who is reporting shortness of breath when ambulating down the hallway. B. 40 year old male complaining of nausea after receiving morphine. C. 52 year old who has just had a bone marrow aspiration and is requesting pain medication. D. 59 year old who has a nosebleed and is receiving heparin to treat a pulmonary embolism.
D. 59 year old who has a nosebleed and is receiving heparin to treat a pulmonary embolism.
30. The nurse is monitoring the patient in ICU who was admitted for a motor vehicle accident. Which sign does the nurse report immediately to the provider? A. Periorbital edema. B. Patient alert to pain. C. Serosanguineous drainage on the head dressing. D. Decorticate positioning.
D. Decorticate positioning.
19. The nurse answers the patient's call light and realizes that the patient has an upper airway obstruction. What is the nurse's priority action? A. Attempt to remove the obstruction. B. Call rapid response to intubate the patient immediately. C. Asks the patient to cough. D. Determines the cause of obstruction.
D. Determines the cause of obstruction.
131. The client exposed to human immunodeficiency virus (HIV) about 3 months ago has seroconverted to an HIV-positive status. The nurse anticipates that the client will experience which of the following at this time? A. Oral lesions B. Purplish skin lesions C. Chronic cough D. No signs and symptoms
D. No signs and symptoms
88. During a yearly physical, a 52 year old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 19 inches, his soft pallete and uvula are reddened and swollen, and that he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to this client? A. Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife B. Refer him to a dietician for a weight loss program C. Caution him not to drink or take sleeping pills since they may make his snoring worse D. Refer him to a sleep disorder center for evaluation and treatment for his symptoms
D. Refer him to a sleep disorder center for evaluation and treatment for his symptoms
9. The nurse is caring for a group of patients with hypertension. Which of these patients is at risk for secondary hypertension? A. Psychiatric disturbance. B. High sodium intake. C. Physical inactivity. D. Renal failure.
D. Renal failure.
52. Which test best determines hearing acuity? a. Audioscopy b. Electronystagmography c. Otoscope d. Snellen Test
a. Audioscopy
80. When taking a history of a client diagnosed with a duodenal ulcer, which assessment finding does the nurse expect? a. Severe weight loss b. Pain while eating c. Hematemesis after eating d. Waking at night with pain
d. Waking at night with pain
67. Which renal change associated with aging does the nurse expect the older adult patient to report? a. Nocturnal polyuria b. Micturition c. Hematuria d. Dysuria
a. Nocturnal polyuria
47. The nurse is caring for a client following enucleation. The nurses notes the presence of bright red drainage on the dressing. Which nursing action is appropriate? a. Notify the physician b. Document the finding c. Continue to monitor the drainage d. Mark the drainage on the dressing and monitor for any increase in bleeding
a. Notify the physician
79. An older adult is scheduled for a double contrast barium enema. What is the priority health teaching that the nurse will provide? a. "Be sure to take the laxative as prescribed after the test." b. "Drink a gallon of GoLYTELY the day before the test." c. "Do not take fluids or food for 24 hours before the test." d. "Tell the nurse if you have flatus after the test is completed."
a. "Be sure to take the laxative as prescribed after the test."
102. A nurse is instructing a group of teenagers about high-risk sexual behaviors. The nurse recognizes the student did not understand the concept when he stated: a. "I can French kiss my girlfriend and not contract HIV" b. "Having unprotected sex increases the risk of contracting HIV" c. "If I use a condom I have to make sure it's on correctly" d. "Exchange of body fluid is a high-risk behavior"
a. "I can French kiss my girlfriend and not contract HIV"
108. Which statement by an older adult regarding her diet indicates a need for further teaching by the nurse? (Iggy, Chapter 3) a. "I need to eat more calories to help me keep warm this winter." b. "I plan to eat more dairy foods like milk and yogurt every day." c. "I'm going to have dinner with my friends more often." d. "I plan to eat more raw fruits and whole grain foods every day."
a. "I need to eat more calories to help me keep warm this winter."
136. The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best understanding of the medication therapy? a. "The cimentidine (Tagamet) will cause me to produce less stomach acid." b. "Sucralfate (Carafate) will change the fluid in my stomach." c. "Antacids will coat my stomach." d. "Omeprazole (Prilosec) will coat the ulcer and help it heal."
a. "The cimentidine (Tagamet) will cause me to produce less stomach acid."
101. The type of immunity that is acquired from the administration of a vaccine is called: a. Active immunity b. Passive immunity c. Titer d. Vaccine
a. Active immunity
48. During the early postoperative period, the client who has had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: a. Call the physicians b. Reassure the client that this is normal c. Turn the client on his or her operative side d. Administer the prescribed pain medication and antiemetic
a. Call the physicians
57. A nurse is assessing a patient who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance? a. Diabetic ketoacidosis b. Heart failure c. Cushing's syndrome d. Thyroidectomy
a. Diabetic ketoacidosis
77. A nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to see documented in the record? a. Diarrhea b. Constipation c. Bloody stools d. Stool constantly oozing from the rectum
a. Diarrhea
54. A nurse is caring for a patient who has a laboratory finding of serum potassium of 5.4 mEq/ L. The nurse should assess for which of the following clinical manifestations? (ATI pg, 495) a. ECG b. Constipation c. Polyuria d. Hypotension
a. ECG
99. An older adult has several ecchymotic areas on the left arm. The nurse should further assess the patient for: a. Elder abuse. b. Self-inflicted injury. c. Increased skin turgor d. Pressure ulcer.
a. Elder abuse.
87. During a well-child visit, a mother tells the nurse that her 4 year old daughter typically goes to bed at 10:30pm and awakens each morning at 7am. She does not take a nap in the afternoon. Which is the best response by the nurse? a. Encourage the mother to consider putting her daughter to bed between 8 and 9pm. b. Reassure the mother that it is normal for 4 year olds to resist napping, but encourage her to insist that she rest quietly each afternoon c. Recommend that her daughter be allowed to sleep later in the morning d. Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap
a. Encourage the mother to consider putting her daughter to bed between 8 and 9pm.
7. The nurse is assessing a patient who was recently diagnosed with left sided heart failure. The nurse expects to assess which of the following symptoms related to right sided heart failure? a. Fine crackles in the bases of the lungs. b. Pitting edema in the lower extremities. c. Jugular vein distention. d. Pulsating abdomen.
a. Fine crackles in the bases of the lungs.
154. Parasympathetic (cholinergic) stimulation of the gastrointestinal tract: a. Increases peristalsis activity and relaxation of sphincters b. Maintains peristalsis and decreases digestion c. Slows peristalsis inhibits secretion and contracts sphincters d. Decreases blood supplied to the gastrointestinal tract
a. Increases peristalsis activity and relaxation of sphincters
100. The nurse is assessing the left lower extremity of a patient with type two diabetes and cellulitis. The nurse should do which of the following? a. Instruct the client to elevate the left leg while sitting in the chair. b. Encourage the patient to ambulate in the halls. c. Massage the left leg with alcohol to stimulate circulation. d. Cleanse the lower left leg with perfumed liquid soap.
a. Instruct the client to elevate the left leg while sitting in the chair.
73. A nurse is teaching the client about an upcoming colonoscopy procedure. The nurse would include in the instructions that the client will be placed in which of the following positions for the procedure? a. Left Sims' position b. Lichotomy position c. Knee chest position d. Right Sims' position
a. Left Sims' position
112. A primary care provider prescribes one tablet, but the nurse accidentally administers two. After notifying the primary care provider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for malpractice? (Kozier & Erb's, Chapter 4) a. No, the client was not harmed. b. No, the nurse notified the primary care provider. c. Yes, a breach of duty exists. d. Yes, foreseeability is present.
a. No, the client was not harmed.
34. Which statement is true about assessing pain in the older adult client? a. Older adults are at great risk for undertreated pain. b. The nurse should assess for present and past pain. c. Older adults actually believe that expressing pain is acceptable. d. Older adults usually believe that pain signifies a minor illness.
a. Older adults are at great risk for undertreated pain. Older adults are at great risk for undertreated pain because of outdated beliefs by some health care providers about older adults' pain sensitivity, tolerance, and ability to take opioids.
40. Error! Bookmark not defined. The nurse manager for an oncology unit is evaluating a newly hired staff nurse. Which action by the nurse is of greatest concern to the nurse manager? a. Preparing to administer a placebo to a client with chronic back pain b. Asking a client with chest pain if the pain is sharp and stabbing c. Instructing a confused postoperative client about how to use patient-controlled analgesia (PCA) d. Requesting that a client with chronic pain describe the specific location of the pain
a. Preparing to administer a placebo to a client with chronic back pain
1. The nurse is preparing to administer a medication using the Z-track method. The nurse knows that this is to: a. Prevent the drug from leaking through the subcutaneous tissue. b. Allow the needle to penetrate deeper into the muscle. c. Allow the drug to diffuse more quickly into the tissue. d. Reduce the pain associated with injections.
a. Prevent the drug from leaking through the subcutaneous tissue.
106. Which technique for obtaining a specimen for bacterial culture is most correct for the nurse to use with a client who has crusted skin lesions on the upper back? (Iggy, Chapter 26) a. Remove several crusts, and swab the underlying exudate. b. Dampen the culture swab with sterile water, and then roll the swab over the central crusts. c. Apply a gauze bandage to the area, remove it after 1 hour, and send the entire gauze to the laboratory. d. Clean an area with an antibacterial solution, remove a crust from the center of the cluster of lesion, and send it to the laboratory.
a. Remove several crusts, and swab the underlying exudate.
116. Following a motor vehicle crash, the parents refuse to permit withdrawal of life support from the child with no apparent brain function. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their decision. Which moral principle provides the basis for the nurse's actions? (Kozier & Erb's, Chapter 5) a. Respect for autonomy b. Nonmaleficence c. Beneficence d. Justice
a. Respect for autonomy
5. The nurse is preparing to administer medications to a patient. The nurse knows the 5 rights of drug administration are: a. Right patient, right dose, right drug, right route, right time. b. Right patient, right drug, right symptoms, right dose, right time. c. Right patient, right symptoms, right drug, right reason, right dose. d. Right patient, right reason, right drug, right dose, right time.
a. Right patient, right dose, right drug, right route, right time.
76. A nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following symptoms would indicate this occurrence? a. Sweating and pallor b. Dry skin and stomach pain c. Bradycardia and indigestion d. Double vision and chest pain
a. Sweating and pallor
120. The nurse hears a client calling out for help. The nurse hurries sown the hallway to the client's room and finds a client lying on the floor. The nurse performs a thorough assessment and assists the client back to bed. The nurse notifies the physician of the incident and completes an incident report. Which of the following would the nurse document on the incident report? a. The client was found lying on the floor. b. The client climbed over the side rails c. The client fell out of bed d. The client became restless and tried to get out of bed.
a. The client was found lying on the floor.
134. In the treatment of H. Pylori, the nurse must recognize that the use of two or more antibiotic is essential for what reason? a. To lower the potential for bacterial resistance b. To decrease the chances of bacterial resistance c. To increase the likelihood of eliminating redevelopment of gastric ulcers d. To decrease the cost of future drug therapies
a. To lower the potential for bacterial resistance
50. The nurse prepares the client for an ear irrigation as prescribed by the physician. In performing the procedure, the nurse. a. Warm the irrigating solution to 98*F b. Positions the client with the affected side up following the irrigation c. Directs a slow steady stream of irrigation solution toward the eardrum d. Assists the client to turn his or her head so that the ear to be irrigate is facing upward
a. Warm the irrigating solution to 98*F
89. A new nursing graduate's first job requires 12 hour night shifts. Which strategy will make it easier for the graduate to sleep during the day and remain awake at night? a. Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom b. Exercise on the way home to avoid having to stand around waiting for equipment at the gym c. Drink several cups of strong coffee or 16 ounces of caffeinated soda when beginning the shift d. Try to stay in a brightly lit area when working at night
a. Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom
62. The patient who has fluid overload has been taking a diuretic for the past 2 days and now experiences these changes. Which change indicates to the nurse that the diuretic is effective? (Med- Surg pg. 180) a. Weight loss of 7 lbs. b. Heart rate increased from 72 to 80. c. Respiratory rate increased from 18 to 20. d. Morning glucose decreases from 142 mg/dL to 110 mg/dL
a. Weight loss of 7 lbs.
55. A nurse is caring for a patient who has a Nasogastric tube on low intermittent suctioning. The nurse should monitor for which electrolyte imbalances? (ATI pg. 495) a. Hypercalcemia b. Hyponatremia c. Hyperphosphatremia d. Hypomagnesemia
b. Hyponatremia
91. Which of the following changes are associated with normal aging? a. Collagen becomes elastic and strong. b. Subcutaneous fat and extracellular water decrease. c. Gain more muscle mass. d. Appearance of less wrinkles.
b. Subcutaneous fat and extracellular water decrease.
66. What is the average urine output of a healthy adult for a 24-hour period? a. 500 mL to 1000 mL per day b. 1500 mL to 2000 mL per day c. 3000 mL to 5000 mL per day d. 5000 mL to 7000 mL per day
b. 1500 mL to 2000 mL per day
146. Which of the following patients is most susceptible to skin breakdown? a. 35 year old patient with AIDS b. 83 year old patient bedbound status post stroke c. 50 year old patient status post knee replacement patient d. 90 year old patient with early dementia
b. 83 year old patient bedbound status post stroke
39. Which client does the RN arriving for duty assess first? a. A 27-year-old who has chronic severe back pain with movement b. A 56-year-old with acute pancreatitis who complains of increasing abdominal pain c. A 63-year-old who complains of ongoing pain associated with rheumatoid arthritis d. A 51-year-old with lung cancer who complains of pain "whenever I cough"
b. A 56-year-old with acute pancreatitis who complains of increasing abdominal pain
123. The registered nurse (RN) has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first? a. A client who is ambulatory. b. A client with a fever who is diaphoretic and restless. c. A client scheduled for physical therapy at 1 PM. d. A postoperative client who has just received pain medication.
b. A client with a fever who is diaphoretic and restless.
133. The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that an immunization will provide. a. Natural immunity from disease. b. Acquired immunity from disease. c. Innate immunity from disease. d. Protection from all disease.
b. Acquired immunity from disease.
127. The nurse employed in a long-term care facility is caring 127. The nurse employed in a long-term care facility is caring for an older male client. Which of the following nursing actions would contribute to encouraging autonomy in the client? a. Scheduling his barber appointments b. Allowing him to choose social activities c. Decorating his room d. Planning his meals
b. Allowing him to choose social activities
129. The nurse manager is planning the clinical assignments for the day. The nurse manager avoids assigning which of the following staff members to the client with herpes zoster? a. The nurse who never had mumps. b. An experienced registered nurse who never had chickenpox. c. The nurse who never had roseola. d. The nurse who never had German measles.
b. An experienced registered nurse who never had chickenpox.
35. A nursing assistant reports that a client receives PCA morphine is very drowsy and has a respiratory rate of 10 breaths/min. What is the nurse's best action at this time? a. Continue to monitor the client for further changes b. Assess the client with a focus on sedation and respirations c. Stop the PCA morphine infusion immediately d. Call the physician to report the client's changes
b. Assess the client with a focus on sedation and respirations
44. A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? a. Increase sodium in the diet b. Avoid sudden head movements c. Lie still and watch the television d. Increase fluid intake of 3000 mL a day
b. Avoid sudden head movements
64. The nurse is teaching a patient on potassium sparing diuretics, and already showing signs of hyperkalemia. The nurse would teach the patient to avoid all of these foods except? (Med- surg pg. 188) a. Dairy, soybeans, and potatoes b. Bread, butter, and eggs c. Steak, kiwi, and broccoli d. Spinach, avocado, oranges
b. Bread, butter, and eggs
141. A patient with a fractured femur is post-op open reduction internal fixation (ORIF) of a hip fracture is receiving a continuous infusion of morphine sulfate IV for pain relief. He is unable to move his bowels. Which of the following is a priority nursing diagnosis for the patient? a. Risk for impaired skin integrity related to immobility b. Constipation related to inadequate physical mobility c. Constipation related to inadequate pain medication d. Perceived constipation related to inadequate peristalsis
b. Constipation related to inadequate physical mobility
124. The nurse is giving a bed bath to an assigned cent. A nursing assistant enters the client's room and tell the nurse that another assigned client is in pain and needs pain medication. The most appropriate nursing action is which of the following? a. Finish the bed bath and then administer the pain medication to the other client. b. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. c. Ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete. d. Ask the nursing assistant to find out when the last pain medication was given to the client.
b. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
126. The nurse is providing medication instructions to an older client who is taking digoxin (Lanoxin) daily. The nurse bears in mind that which age-related body changes could place the client at risk of digoxin toxicity. a. Decreased cough efficiency and decreased vital capacity. b. Decreased lean body mass and decreased glomerular filtration rate. c. Decreased salivation and decreased gastrointestinal motility. d. Decreased muscle strength and loss of bone density.
b. Decreased lean body mass and decreased glomerular filtration rate.
82. The nurse is caring for a patient with an exacerbation of ulcerative cholitis. Which laboratory finding for the client will the nurse expect? a. Decreased erythrocyte sedimentation rate b. Decreased serum potassium c. Decreased C-reactive protein d. Decreased platelet count
b. Decreased serum potassium
36. A client reports increasing pain during dressing changes. Which interventions does the nurse recommend for the client? Select all that apply. a. Transcutaneous electrical nerve stimulation (TENS) b. Distraction c. Epidural analgesic d. Music therapy e. Premedication
b. Distraction d. Music therapy e. Premedication
33. A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical manifestations of pain. What does the nurse do next? a. Decreases the client's standard pain medication dose b. Gives the pain medication as requested c. Withholds the pain medication d. Gives the client a placebo and monitors the outcome
b. Gives the pain medication as requested Both types of chronic pain (chronic cancer pain and chronic non-cancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's responses when it is chronic cancer pain.
122. The nurse gives an inaccurate dose of medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the a. Error will result in suspension. b. Incident report is a method of promoting quality care and risk management. c. Incident will be reported to the board of nursing. d. Incident will be documented in the personnel file.
b. Incident report is a method of promoting quality care and risk management.
74. A nurse is preparing to perform an abdominal examination. The initial step would be which of the following? a. Palpation b. Inspection c. Percussion d. Auscultation
b. Inspection
157. When evaluating the laboratory data for a client with Crohn's disease, the nurse should expect which of the following? 1280 a. Elevated hemoglobin b. Low serum albumin c. Positive stool culture d. Decreased sedimentation rate
b. Low serum albumin
111. A nurse discovers that a primary care provider has prescribed an unusually large dose of medication. Which is the most appropriate action? (Kozier & Erb's, Chapter 4) a. Administer the medication. b. Notify the prescriber. c. Call the pharmacist. d. Refuse to administer the medication.
b. Notify the prescriber.
70. The nurse is auscultating the renal artery and hears a bruit. What does this finding indicate? a. Acute renal failure b. Renal artery stenosis c. Renal artery aneurysm d. Renal tumor
b. Renal artery stenosis
86. Because of significant concerns about financial problems a middle aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? By day 5, the client will: a. Sleep 8-10 hours per day b. Report falling asleep within 20-30 minutes c. Have a plan to pay all the bills d. Decrease worrying about financial problems and will keep busy until bedtime
b. Report falling asleep within 20-30 minutes
147. A client is complaining of pain from her canker sores. Which of the following would the nurse expect to administer? a. Encourage the use of an antibacterial mouthwash b. Rinsing of the mouth with viscous lidocaine c. Rinse the mouth with hydrogen peroxide d. The use of lemon glycerin swabs
b. Rinsing of the mouth with viscous lidocaine
41. The client arrives in the emergency department following an automobile accident. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse places the client in which position? a. Flat on bed rest b. Semi-Fowler's on bed rest c. Lateral on the affected side d. Lateral on the unaffected side
b. Semi-Fowler's on bed rest
128. The clinic nurse assesses the skin of a white client with a diagnoses of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? a. Clear, thin nail beds b. Silvery white, scaly patches on the scalp, elbows, knees, and sacral regions c. Oily skin and no episodes of pruritus d. e. Red-purplish scaly lesions
b. Silvery white, scaly patches on the scalp, elbows, knees, and sacral regions
148. The nurse is caring for a client with Candida Albicans. Which intervention is a priority? a. Tell the client to use chewable antacid tablets to decrease the pain b. Teach the client to swish and swallow the antifungal medication c. Teach the client to use mint flavored mouthwash after eating d. Rinse the mouth with viscous lidocaine
b. Teach the client to swish and swallow the antifungal medication
104. Which snack choice does the nurse recommend to the client with AIDS to help improve nutrition status? (Iggy, Chapter 21) a. An ice cream sandwich b. Two soft-cooked eggs c. A wand of cotton candy d. A serving of French fried potatoes
b. Two soft-cooked eggs
98. An alert and oriented elderly patient is admitted to the hospital for treatment of cellulitis. Which fall prevention strategy is most appropriate for this patient? a. Keep all the lights on in the room at all times. b. Use a night light in the bathroom. c. Keep all four side rails up at all times. d. Place the patient in a room with a camera monitor.
b. Use a night light in the bathroom.
117. Which of the following situations is most clearly in violation of the underlying principles associated with profession nursing ethics? (Kozier & Erb's, Chapter 5) a. The hospital policy permits the use of internal fetal monitoring during labor. However, there is literature to both support and refute the value of this practice. b. When asked about the purpose of a medication, a nurse colleague responds, "Oh, I never look them up. I just give what is prescribed." c. The nurses on the unit agree to sponsor a fundraising event to support a labor strike proposed by fellow nurses at another facility. d. A client reports that he didn't quite tell the doctor the truth when asked if he was following his therapeutic diet at home.
b. When asked about the purpose of a medication, a nurse colleague responds, "Oh, I never look them up. I just give what is prescribed."
85. A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? a. Do you have a history of cardiac irregularities? b. Do you have a history of any kind of nasal obstruction? c. Have you had chest pain with or without activity? d. Do you have difficulty with daytime sleepiness?
d. Do you have difficulty with daytime sleepiness?
69. Which over-the-counter product used by the patient does the nurse explore further for potential impact on renal function? a. Peroxide containing mouthwash b. Milk of magnesia laxative c. Vitamin C d. NSAIDs
d. NSAIDs
145. The patient post hip fracture surgery is noted to have redness on her left buttocks, a small amount of blood on the surgery dressing, concentrated urine, and reports feeling dizzy when she gets up for physical therapy. Which of the following would the nurse report to the doctor? a. "I am calling you about the patient's concentrated urine output" b. "I am calling you about a consult with the wound care nurse" c. "I am calling you about the low blood pressure" d. "I am calling you about the bleeding on the surgery dressing"
c. "I am calling you about the low blood pressure"
103. Which statement by the nursing assistant indicates a need for further teaching by the nurse regarding infection control? (Iggy, Chapter 25;) a. "I will wash my hands after direct client care." b. "I will wear gloves when emptying the Foley bag." c. "I don't need to wash my hands if I wear gloves." d. "I will use a hand sanitizer when I can't wash my hands."
c. "I don't need to wash my hands if I wear gloves."
125. The nurse is teaching an older client about measures to prevent constipation. Which statement, if made by the client, indicates that further teaching about bowel elimination is necessary? a. "I drink six to eight glasses of water per day." b. "I walk 1 to 2 miles per day." c. "I need to decrease fiber in my diet." d. "I have a bowel movement every other day".
c. "I need to decrease fiber in my diet."
105. The client who is prescribe highly active antiretroviral therapy (HAART) is flying to a wedding and will be gone 1 days. He asks if he can skip his drugs that day so that he doesn't have to show them all at the airport. What is the nurse's best response? (Iffy, Chapter 21) a. "Yes, just 1 day off your drugs will not make any difference." b. "Yes, as long as you avoid direct contact with anyone who is ill." c. "No, even one day off the drugs can help the virus become drug resistant." d. "No, even one day off the drugs increases the chances that you can spread the disease."
c. "No, even one day off the drugs can help the virus become drug resistant."
63. The family of a patient with chronic hyponatremia asks if the water restriction is a punishment for uncooperative behavior. What is the nurse's best response? (Med- Surg pg. 182) a. "No, limiting the fluid intake decreases the risk for kidney failure." b. "No, limiting the fluid intake prevents him from losing to much fluid by vomiting." c. "No, limiting the fluid intake keeps his blood from becoming too diluted and causing other problems." d. "No, limiting the fluid intake decreases his sense of thirst and prevents him from drinking an excess of sodium."
c. "No, limiting the fluid intake keeps his blood from becoming too diluted and causing other problems."
119. A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The most appropriate response by the nurse educator is. a. The hospital's liability insurance will cover your actions. b. "It is very expensive and not necessary." c. "Nurses are encouraged to have their own malpractice insurance." d. "The majority of suits are filed against physicians and the hospital."
c. "Nurses are encouraged to have their own malpractice insurance."
90. A nurse is answering questions after a presentation on sleep at a local senior citizen center. A woman in her late 70's asks for an opinion about the advisability of allowing her husband to nap for 15-20 minutes each afternoon. Which is the nurse's best response? a. "Taking an afternoon nap will interfere with his being able to sleep at night. If he's tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake" b. "He shouldn't need to take an afternoon nap if he's getting enough sleep at night" c. "Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine" d. "Encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon"
c. "Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine"
109. A primary care provider's orders indicate that a surgical consent form needs to be signed. Since the nurse was not present when the primary care provider discussed the surgical procedure, which statement best illustrates the nurse fulfilling the client advocate role? (Kozier & Erb's, Chapter 4) a. "The doctor has asked that you sign this consent form." b. "Do you have any questions about the procedure?" c. "What were you told about the procedure you are going to have?" d. "Remember that you can change your mind and cancel the procedure."
c. "What were you told about the procedure you are going to have?"
37. A nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone (Percocet) orally for pain every 4 hours and is due to receive them at 4 PM. When does the nurse change the dressing? a. 3:30 PM b. 4:00 PM c. 4:30 PM d. 7:00 PM
c. 4:30 PM
61. The nurse at a family picnic on a hot day in July is aware that which person is at the greatest risk for dehydration while playing softball? (Med-surg pg. 171) a. 32 year old male cousin who is a professional hockey player. b. 28 year old female cousin who has type 1 diabetes mellitus. c. 72 year old grandmother who is 15 lbs. overweight. d. 72 year old grandfather taking 81 mg of aspirin daily.
c. 72 year old grandmother who is 15 lbs. overweight.
93. Which of the following clients should receive the shingles vaccine? a. A patient who has never had chickenpox b. A patient at risk for genital herpes c. A patient over 60 years of age d. A patient with a compromised immune system
c. A patient over 60 years of age
115. The nurse's partner/spouse undergoes exploratory surgery at the hospital where the nurse is employed. Which practice is most appropriate? (Kozier & Erb's, Chapter 4) a. Because the nurse is an employee, access to the chart is allowed. b. The relationship with the client provides the nurse special access to the chart. c. Access to the chart requires a signed release form. d. The nurse can ask the surgeon to discuss the outcome of the surgery.
c. Access to the chart requires a signed release form.
78. A client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse understands that this medication is used for which condition? a. Constipation b. Abdominal pain c. An episode of diarrhea d. Hematest positive nasogastric tube drainage
c. An episode of diarrhea
144. The elderly patient is admitted with the diagnosis of pneumonia. The nurse notes that the patient has severe kyphosis (hump back) of the spine and has limited mobility. The patient is suddenly acting combative and confused. Which of the following assessments should the nurse do first? a. Assess PERRLA b. Assess the cranial nerves c. Assess oxygen saturation d. Assess blood pressure
c. Assess oxygen saturation
83. An older adult with a history of diverticulitis is admitted to the emergency department stating that she has severe abdominal pain and has not had a bowel movement in 6 days. What priority assessment will the nurse perform? a. Listen to the client's breath sounds b. Take the client's height and weight c. Auscultate the client's bowel sounds d. Perform a rectal examination
c. Auscultate the client's bowel sounds
31. In the role of client advocate, what does the nurse do first for a client who reports pain? a. Administers pain medication b. Assesses the level of pain c. Believes the client's report of pain d. Calls the provider for a medication order
c. Believes the client's report of pain
58. A nurse is admitting a patient who reports nausea, vomiting and weakness upon assessment. The patient has dry oral mucous membranes, a temperature of 101.3 F, Pulse 92, respiration rate 24, skin cool, tenting present and a blood pressure of 102/64. Urine concentrated with high specific gravity. Which of the following are NOT clinical manifestations of fluid volume deficit? (ATI pg. 483) a. Decreased skin turgor b. Concentrated urine c. Bradycardia d. Low grade fever
c. Bradycardia
92. The nurse will anticipate which of the following problems that can result from the older adult undergoing abdominal surgery? a. Decrease scaring b. Decreased melanin and melanocytes c. Decreased healing d. Increased kidney function
c. Decreased healing
140. Which is the best way for the nurse to assess the complications of sleep deprivation in the elderly patient? a. Determine if the patient has received a hypnotic b. Determine if the patient has a regular bedtime routine c. Determine any changes in the patient's neurological status d. Determine any history of insomnia
c. Determine any changes in the patient's neurological status
118. The nurse has made an error in documenting an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by a. Trying to erase the error for space to write in the correct data. b. Using whiteout to delete the error and writing in the correct data c. Drawing one line through the error, initialing and dating the line, and then documenting the correct information. d. Documenting a late entry into the client's record.
c. Drawing one line through the error, initialing and dating the line, and then documenting the correct information.
53. The nurse is assessing the client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? Select all that apply a. Acetaminophen b. Beta blockers c. Erythromycin d. Ibprofen e. Lasix
c. Erythromycin d. Ibprofen e. Lasix
4. The nurse is preparing to give an IM injection in the vastus lateralus. The nurse knows that this is a. In the shoulder, just below the acromium process. b. In the abdomen, at least two inches away from the umbilicus. c. In the outer thigh, between the hip and the knee. d. In the outer side of the buttocks, three inches below the iliac crest.
c. In the outer thigh, between the hip and the knee.
153. What is the result of stimulation of erythropoietin production in the kidney tissue?1471 a. Increased blood flow to the kidney b. Inhibition of vitamin D and loss of bone density c. Increased bone marrow production of red blood cells d. Inhibition of the active transport of sodium, leading to hyponatremia
c. Increased bone marrow production of red blood cells
96. A stage II pressure ulcer is characterized by: a. Redness in the area. b. Muscle spasms in the area. c. Pain in the area. d. Tissue necrosis in the area
c. Pain in the area.
32. A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? a. Addiction b. Equianalgesia c. Physical dependence d. Pseudoaddiction
c. Physical dependence Physical dependence occurs in everyone who takes opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms.
68. The nurse and nutritionist are evaluating the diet and nutritional therapies for a patient with kidney problems. Blood Urea Nitrogen (BUN) levels for this patient are tracked because of the direct relationship to the intake and metabolism of which substance? a. Lipids b. Carbohydrates c. Protein d. Fluids
c. Protein
95. The nurse is assessing a client who is immobile and notes an area of sacral skin is reddened but not broken. The reddened area is blanchable with fingertip pressure. The most appropriate nursing action at this time is to: a. Apply a moist dressing to pack the wound. b. Consult with the wound nurse specialist. c. Reposition the client off the reddened skin and reassess in a few hours. d. Document a stage III pressure ulcer or in clients chart
c. Reposition the client off the reddened skin and reassess in a few hours.
151. When a client has a duodenal ulcer, the nurse needs to be concerned about which of the following signs and symptoms?1227 a. Pyrosis b. Odynophagia : Pain on swallowing c. Rigid abdomen d. Pain radiating to the shoulder
c. Rigid abdomen
132. The client with acquired immunodeficiency syndrome has raised, dark purplish-colored lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are due to Kaposi's sarcoma? a. Enzyme-linked immunosorbent assay b. Western blot c. Skin biopsy d. Lung biopsy
c. Skin biopsy
43. The nurse is caring for a hearing impaired client. Which of the following approaches will facilitate communication? a. Speak loudly b. Speak frequently c. Speak at a normal volume d. Speak directly into the impaired ear
c. Speak at a normal volume
56. A nurse is assessing a patient for Chvostek's sign. Which of the following techniques will the nurse use to perform this test? (ATI pg. 495) a. Apply a blood pressure cuff to the patient's arm. b. Place the stethoscope over the patient's carotid artery. c. Tap lightly on the patient's cheek. d. Ask the patient to lower his chin to his chest
c. Tap lightly on the patient's cheek.
150. The nurse is caring for a client with a gastric ulcer on Famotidine (Pepcid). Which of the following would indicate to the nurse that the medication is effective?1229-30 a. The client denies nausea b. The client gains 2 pounds in one week c. The client states epigastric pain is decreased d. Gastric cultures are negative for Helicobacter Pylori
c. The client states epigastric pain is decreased
156. The nurse is caring for a client with ulcerative colitis. The nurse includes the nursing diagnosis of "Risk for ineffective individual coping." Why is this diagnosis appropriate?1273-79 a. A total colectomy will be the only way to treat the disease. b. The client will eventually require Total Parenteral Nutrition (TPN) c. The disease is unpredictable and can be exhausting and incapacitating d. Significant weight gain is common with this disease
c. The disease is unpredictable and can be exhausting and incapacitating
114. The primary care provider wrote a do-not-resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? (Kozier & Erb's, Chapter 4) a. The client may no longer make decisions regarding his or her own health care. b. The client and family know that the client will most likely die within the next 48 hours. c. The nurses will continue to implement all treatments focused on comfort and symptom management. d. A DNR order from a previous admission is valid for the current admission.
c. The nurses will continue to implement all treatments focused on comfort and symptom management.
75. A nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that this client is at risk for which vitamin deficiency? a. Vitamin A b. Vitamin C c. Vitamin E d. Vitamin B12
d. Vitamin B12
155. What client instructions would be appropriate after a barium swallow?1191-1187 a. "Sit in bed with your head elevated to allow the barium to pass through." b. "You may have stools that are darker in appearance for a few days." c. "You may not eat or drink anything for 6 hours after the test." d. "Drink plenty of fluids."
d. "Drink plenty of fluids."
113. A nursing student is employed and working as an unlicensed assistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be graduating soon. A nurse asks the UAP if he has performed a urinary catheterization on clients while in the nursing program. When the UAP says, "Yes," the nurse asks him to help her out by doing a urinary catheterization on a postsurgical client. What is the best response by the UAP? (Kozier & Erb's, Chapter 4) a. "Let me get permission from the client first." b. "Sure. Which client is it?" c. "I can't do it unless you supervise me." d. "I can't do it. Is there something else I can help you with?"
d. "I can't do it. Is there something else I can help you with?"
142. A patient is post op right knee replacement. The nurse notes an elevation in the patient's baseline heart rate. Upon assessment, the patient is easily aroused from sleep and appears to be without distress. Which of the following statements is most appropriate for the nurse to make? a. "I will be right back to give you more morphine sulfate" b. "I will call the doctor about your elevated heart rate" c. "I need to reposition you every 2 hours" d. "I need to assess your right foot pulse"
d. "I need to assess your right foot pulse"
51. The nurse is talking to the client about ear hygiene safety. Which statement by the client indicates a need for further teaching? a. "After I shower, I dry my ears using my fingertip and a towel." b. "I irrigate my ears with tap water." c. "I never clean my ears with a cotton swab." d. "I use a bobby pin to remove ear wax
d. "I use a bobby pin to remove ear wax
6. The nurse is treating a patient who has atherosclerosis and a history of smoking. The patient complains that the patch isn't working and asks if he can smoke in addition to using the patch. The nurse explains: a. "If you smoke while using the nicotine patch, you could get a decrease in blood pressure." b. "If you smoke while using the nicotine patch, you could experience nausea/vomiting or diarrhea." c. "If you smoke while using the nicotine patch, you increase your chances of respiratory infection." d. "If you smoke while using the nicotine patch, you increase your chances of getting a heart attack."
d. "If you smoke while using the nicotine patch, you increase your chances of getting a heart attack."
3. The nurse has an order administer Morphine Sulfate via IV push. The nurse knows to administer this drug over: a. 5-10 seconds. b. 15-30 seconds. c. 45 seconds-1 minute. d. 1-2 minutes.
d. 1-2 minutes.
130. Which of the following clients would least likely be at risk of developing skin breakdown? a. A client who is unable to move about and is confined to bed. b. A client incontinent of urine and feces. c. A client with chronic nutritional deficiencies. d. A client with a lowered mental awareness status.
d. A client with a lowered mental awareness status.
42. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which of the following would the nurse expect to observe? a. A pink-colored tympanic membrane b. A pearly colored tympanic membrane c. A transparent and clear tympanic membrane d. A red, dull, thick, and immobile tympanic membrane
d. A red, dull, thick, and immobile tympanic membrane
135. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcers? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, board like abdomen
d. A rigid, board like abdomen
49. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder a. Total loss of vision b. Pain in the affected eye c. A yellow discoloration of the sclera d. A sense of a curtain falling across the field of vision
d. A sense of a curtain falling across the field of vision
138. Since being in the hospital, a client has taken her baths in the morning according to hospital routine; however at home she always took a warm bath just before going to bed. Now she has developed difficulty sleeping. What should the nurse do to help the client sleep better? a. Rub her back for 15 minutes before she retires b. Offer her warm milk and crackers at 9:00 pm c. Ask her physician for a p.m. pain medication d. Allow her to take her bath in the evening
d. Allow her to take her bath in the evening
137. A client whit a peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves. a. Cutting the vagus nerve. b. Removing the distal portion of the stomach. c. Removal of the ulcer and a large portion of the cells that produce hydrochloric acid. d. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.
d. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.
110. Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? (Kozier & Erb's, Chapter 4) a. An unintentional tort b. Assault c. Invasion of privacy d. Battery
d. Battery
143. The patient (48) hours post lumbar spinal surgery has bilateral crackles at the bases of the lungs. Oxygen saturation is 94% on room air. Which of the following actions should the nurse do first? a. Check the chart for the baseline oxygen saturation b. Check the chart for the estimated blood loss during surgery c. Check the chart for the preop chemistry lab values d. Check the chart for the preop chest xray report findings
d. Check the chart for the preop chest xray report findings
121. The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which of the following actions would the nurse take? a. Hold the medication until the physician ca be contacted. b. Administer the dose prescribed. c. Administer the recommended dose until the physician can be located. d. Contact the nursing supervisor.
d. Contact the nursing supervisor.
46. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which of the following cranial nerves would identify a complication specifically associated with this surgery. a. Cranial nerve I, olfactory b. Cranial nerve IV, trochlear c. Cranial nerve III, oculomotor d. Cranial nerve VII, facial nerve
d. Cranial nerve VII, facial nerve
97. An older adult reports being cold in a room even though the thermostat is set at 75°F. The client may feel cold because older adults have: a. Increased moisture content of the sacrum area. b. Increase blood supply to the skin. c. More wrinkles. d. Decreased ability to Thermoregulate
d. Decreased ability to Thermoregulate
71. The patient has undergone a renal biopsy. In the immediate post procedural period, the nurse notifies the health care provider about which finding? a. Hematuria b. Localized pain at the site c. "Tamponade effect" d. Decreasing urine output
d. Decreasing urine output
152. The client is admitted to the hospital for possible cholelithiasis. While taking the history, the nurse notes that the client has which of the following risk factors for development of gallstones? 1317 a. History of hypertension b. Has just gained 20 pounds c. Is a vegetarian d. Has just lost 30 pounds
d. Has just lost 30 pounds
139. The nurse plans to provide active and passive range of motion for the patient post cerebral vascular accident (CVA) since it provides which of the following benefits? 1134-1138 a. Minimizes cardiac output b. Improves gastric motility c. Minimizes heart rate d. Improves circulation
d. Improves circulation
60. A nurse is caring for an elderly patient in a long term facility. The patient has become weak and confused. Upon assessment the patient's temperature is 100.9, a pulse of 92, blood pressure 108/60. He has lost ¾ lbs. and reports dizziness when assisted to the bathroom. He has an unproductive cough, and diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take? (ATI pg 483) a. Initiate fluid restrictions to limit intake. b. Observe signs of hypertension. c. Encourage patient to ambulate to promote oxygenation. d. Monitor respirations for shortness of breath.
d. Monitor respirations for shortness of breath.
84. A client is admitted to the same-day surgery unit after recovery from a laproscopic cholecystectomy. Which action is the nurse's priority in caring for the patient? a. Turn the client on the right side to help the flow of bile into the drainage bag b. Check that the NG tube is connected to low intermittent suction c. Document the client's use of the patient controlled analgesia (PCA) pump d. Monitor the client's oxygen saturation level via pulse oximetry
d. Monitor the client's oxygen saturation level via pulse oximetry
149. What intervention is most appropriate for a client with complaints of bloating and fullness first day post op from a subtotal gastrectomy?1288 a. Give the client a cold water b. Lie the client supine for 30 minutes c. Place the client in a semi Fowler's position d. Prepare to connect low intermittent suction to the nasogastric tube
d. Prepare to connect low intermittent suction to the nasogastric tube
81. A nurse is caring for a client one day after an open hernia repair surgery. Which assessment finding will the nurse report to the surgeon immediately? a. Pain in the incisional area b. Blood pressure of 130/82 mm Hg c. Bronchovesicular breath sounds d. Rigid, board like abdomen
d. Rigid, board like abdomen
107. The newly admitted client has all of the following laboratory test values. Which value suggests to the nurse that the client may be at an increased risk for pressure ulcer formation? (Iggy, Chapter 27) a. INR of 1.5 b. WBC of 5200/mm3 c. Serum sodium of 134 mEq/L d. Serum prealbumin of 15.2 mg/dL
d. Serum prealbumin of 15.2 mg/dL
59. A nurse is caring for a patient who is dehydrated. Which of the following should the nurse assess that would indicate fluid volume deficit? (ATI pg. 483) a. Moist skin b. Distended neck veins c. Increased urinary output d. Tachycardia
d. Tachycardia
72. The client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis , the nurse would look at the results of the prostate examination, which would reveal that the prostate gland is: a. Soft and swollen b. Reddened, swollen, and boggy c. Tender, and edematous with ecchymosis d. Tender, indurated, and warm to the touch
d. Tender, indurated, and warm to the touch
45. The client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. The nurse interprets this as: a. The client is legally blind b. The client's vision is normal c. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet d. The client can read only a distance of 20 feet what a client with normal vision can read at 60 feet.
d. The client can read only a distance of 20 feet what a client with normal vision can read at 60 feet.
38. A newly admitted client who was in an automobile accident has a concussion and is complaining of pain from a fractured femur and broken fingers. Which staff member does the charge nurse on the orthopedic unit assign to care for this client? a. An experienced RN travel nurse who arrived on the unit this morning b. An LPN/LVN who has worked on the orthopedic unit for 6 years c. The RN orthopedic case manager who is responsible for discharge planning d. The neurology unit RN who has floated to the orthopedic unit
d. The neurology unit RN who has floated to the orthopedic unit
94. Palpation of the skin provides the nurse useful information regarding: a. Bruising of the skin. b. Color of the skin. c. Hair distribution. d. Turgor of the skin.
d. Turgor of the skin.
65. Which of the following is a common cause of hypercalcemia? (Med- surg pg.189) a. Lactose intolerance b. Crohn's disease c. Diarrhea or steatorrhea d. Use of thiazide diuretics
d. Use of thiazide diuretics
