ACM Take 2 Exams
What is a complication of using oxygen therapy long term?
"Oxygen toxicity and absorptive atelectasis"
How to prevent Fat emboli after patient falls off latter? A. Immobilize arm B. Give heparin SubQ
A
E3: MI puts patient at risk for what? A. Chronic renal failure B. Cerebrovascular accident C. Hypoexmia
C
What stage of shock does severe organ dysfunction occur? A. Initial B. Compensatory C. Progressive D. Irreversible (Refractory)
D
The nurse would assess the individual in the most serious stage of shock as a: A. 22-year old man with a pulse rate of 100 B. 50-year old woman with MAP of 90 C. 33-year old woman with a pulse pressure of 40 D. 60-year old woman with a falling BP
'D' (answer I put), but I've seen it as 'C' even though pulse pressure of 40 is normal?
E3: 3 Questions that ask about rhythm strips: normal sinus rhythm, sinus bradycardia, v tach
-
E3: Picture of EKG with parts. Asks where in the EKG where the P wave is.
- I believe the answer was 'A'
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1. Fever 2. Complaints of indigestion 3. Palpable mass in the left upper quadrant 4. Pain in the upper right quadrant after a fatty meal 5. Vague lower right quadrant abdominal discomfort
124
The nurse would assess for which of the following manifestations in a client with suspected arterial embolism to the left hand? Select all that apply. 1. Pain 2. Pale skin 3. Bounding radial pulse 4. Parasthesias 5. Pitting edema
124
The nurse determines that a client with a nasogastric tube on low suction for five days is at risk for developing which acid-base imbalance? 1. Respiratory acidosis 2. Metabolic alkalosis 3. Metabolic acidosis 4. Respiratory alkalosis
2
A client is admitted to the hospital with an acid-base imbalance. Arterial blood gas (ABG) results are pH 7.33; PaCO2 49; HCO3- 28. How would the nurse interpret these results? 1. Uncompensated respiratory acidosis 2. Metabolic alkalosis, uncompensated 3. Partially compensated respiratory acidosis 4. Partially compensated metabolic acidosis
3
The following arterial blood gas (ABG) results are on the client's chart: pH 7.50; PaCO2 36; HCO3- 30. How will the nurse interpret this report? 1. Partially compensated metabolic alkalosis 2. Compensated respiratory alkalosis 3. Uncompensated metabolic alkalosis 4. Uncompensated respiratory alkalosis
3
The physician is going to order a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered? 1. 0.9% normal saline 2. 5% dextrose in normal saline 3. Lactated Ringer's solution 4. 0.45% sodium chloride
4
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1. Diarrhea 2. Black, tarry stools 3. Hyperactive bowel sounds 4. Abdominal guarding and tenderness 5. Left upper quadrant pain with radiation to the back
45
The nurse is assessing a client with a gunshot wound to the chest, for which of the following findings should the nurse monitor to detect a pneumothorax? A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Endocardia pain
AB
When caring for a client with acute pancreatitis, which assessment finding requires immediate nursing intervention? A. HR of 105 BPM B. Glucose of 136 C. RR of 28 BPM D. BP of 102/76
C
A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse? A. Decreased LOC B. Tachycardia C. Increased temperature D. Decreased respiratory rate
B
A client with severe respiratory insufficiency becomes SOB during activities of daily living. Which nursing intervention is best? A. Call the rapid response team B. Decrease involvement in care till the episode has past C. Cluster morning activities to provide long rest periods D. Space out intervention to provide periods of rest
B
A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Are you taking corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"
B
A client admitted with a dx of liver cirrhosis would be questioned by the nurse abou the etiological factor of: A. Foodborne illness B. Alcohol ingestion C. Gallbladder removal D. Heart failure
B
E3: The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? SATA A. Platelet level B. Fluid status C. Cardiac Rhythm D. Action of medications E. Sputum volume
BCD
A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patient's health problem? A) Toxins have accumulated and inflamed your pancreas. B) Bacteria likely migrated from your intestines and became lodged in your pancreas. C) A virus that was likely already present in your body has begun to attack your pancreatic cells. D) The enzymes that your pancreas produces have damaged the pancreas itself.
D
A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.
D
A patient with Parkinson's disease is prescribed Semetol (?). What is an adverse effect of this medication?
DONT KNOW - PUT "INVOLUNTARY MOVEMENTS" AKA Dyskinesia
*Unsure of answer* A client is taking furosemide for hypertension and has low potassium - What is the priority for the nurse to monitor? A. Heart Dysrhythmias B. Seizures
Heart Dysrhythmias
Who is a candidate for a Non-invasive positive pressure mask/vent?
I put "spontaneous breather"
E3: Decreased cardiac output means what?
Increased BP
A client has been admitted for dehydration after fasting for five days. For which acid-base imbalance would the nurse assess this client? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
1
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort
1
A client is admitted with severe diarrhea. Arterial blood gas (ABG) results are pH 7.33; PaCO2 42; HCO3- 20. The nurse concludes this client has which acid-base imbalance? 1. Uncompensated metabolic acidosis 2. Compensated respiratory acidosis 3. Compensated metabolic acidosis 4. Uncompensated respiratory acidosis
1
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A) Slow the infusion rate and monitor the patient closely. B) Discontinue the transfusion and begin resuscitation. C) Pause the transfusion and administer a 250 mL bolus of normal saline. D) Discontinue the transfusion and administer a beta-blocker, as ordered.
A
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema
A
A patient who is being treated for pneumonia starts complaining of SOB. An ABG is drawn with the followings: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. What does this reflect? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A
A patient with a head injury has admission vital signs of BP 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hours after admission, will be of most concern to the nurse? A. BP 156/60, pulse 55, respirations 12 B. BP 130/72, pulse 90, respirations 32 C. BP 148/78, pulse 112, respirations 28 D. BP 110/70, pulse 120, respirations 30
A
A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient? A. Packed Red Blood Cells (PRBCs) B. Vitamin K C. Oral anticoag D. Heparin
A
A patient with a hx of cirrhosis is admitted to the ICU with a dx of bleeding esophageal varcies; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient? A. Packed red blood cells (PRBCs) B. Vitamin K C. Oral anticoag. D. Heparin infusion
A
A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both arms above heart level with pillows. d. Encourage the patient to flex and extend the fingers.
A
All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory distress and faintness. Which one will the nurse administer first? a. Epinephrine (Adrenalin) b. Normal saline infusion c. Dexamethasone (Decadron) d. Diphenhydramine (Benadryl)
A
E3: A client reporting heart palpitations is diagnosed with atrial fibrillation caused by mitral valve prolapse. To relieve the symptoms, the nurse should teach the client which dietary intervention? A. Eliminate caffeine and alcohol B. Decrease the amount of acidic beverages and fruits C. Eliminate dairy products and carbonated drinks D. Decrease the amount of sodium and saturated fat
A
E3: A nurse is teaching a partner of a client who had an acute MI about the reason blood was drawn from a client. Which of the following statements should the nurse make about cardiac enzyme studies? A. There studies help determine the extent of the damage to the heart tissues B. Cardiac enzymes will identify the location of the MI C. These tests will enable the provider to determine the heart structure and mobility of the heart valves D. Cardiac enzymes assist in diagnosing the presences of pulmonary congestion
A
E3: A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? A. In a high fowler's position B. On the left side lying position C. In a flat, supine position D. In the Trendelenburg position
A
E3: A patient whose cardiac monitor shows sinus tachycardia, rate 102, is apneic and no pulses are palpable by the nurse. Which is the first action that the nurse should take? A. Start CPR B. Defibrillate C. Administer atropine per hospital protocol D. Give 100% O2 per nonrebreather mask
A
E3: How do you know teaching has been effective for a patient with a cardiac pacemaker? A. "I will not lift my affected arm up high above" B. "I will notify the airport about my cardiac pacemaker" C. "I will wait 6 weeks until I can take a bath"
A
E3: What patient statement would be correct? (Cardiac) - Don't remember exact question A. "I will report a weight gain of 6 lbs in a week" B. "I will add another pillow each time I have trouble sleeping"
A
Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.
A
The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way? A) Through a central venous line B) By a gravity infusion IV set C) By IV push for rapid onset of action D) Mixed with parenteral feedings to balance osmosis
A
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B) The patient is in the progressive stage of shock. C) The patient will stabilize and be released by tomorrow. D) The patient is in the irreversible stage of shock.
A
The nurse is admitting a patient to the ICU with a dx of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital? A. Severe abdominal pain B. Fever C. Jaundice D. Mental agitation
A
The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? A) Lactated Ringers B) Albumin C) Dextran D) 3% NaCl
A
The nurse is caring for a patient who sustained an open fracture of the right femur in an automobile crash. Which is the most serious complication this patient will need to be monitored for? A. Infection B. Muscle atrophy caused by loss of supporting bone structure C. Necrosis of adjacent soft tissue caused by blood loss D. Nerve damage
A
The nurse performs an assessment on a client with cancer and notes that the client is recieving pain meds, via this type of catheter (pictured). What should the nurse document? A. Epidural catheter B. Hickman catheter C. Central venous catheter D. PCA pump
A
The nurse suspects that the client who has entered the emergency department with severe uterine bleeding is in the early stages of shock. The nurse's first priority is to: A. Administer oxygen per nasal cannula B. Apply super-absorbent perineal pads C. Place the client in Trendelenburg position D. Start an IV line
A
What advice should a nurse give to a patient with sickle cell to prevent sickle cell crisis? A. Avoid cold weather and ensure adequate hydration B. Eat a high fiber diet and hand wash C. Eat a low fat diet D. Avoid people
A
What are risk factors for cardiogenic shock? A. Older adults with MI and cardiopathy B. Raynaud's Disease and Cardiac Stenosis
A
What is expected with diminished CO2? A. Hyperventilation B. Hypoventilation
A
Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.
A
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems? A. Diminished deep tendon reflexes B. Tachycardia C. Cool, clammy skin D. Acute flank pain
A
You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A) Extravasation of the medication B) Discomfort to the patient C) Blanching at the site D) Hypersensitivity reaction to the medication
A
E3: The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A) Dyspnea B) Unusual fatigue C) Hypotension D) Syncope E) Peripheral cyanosis
ABD
E3: A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? SATA A. I am limiting my intake of fast foods B. I will need to monitor my weight C. I need to stop consuming alcohol D. I should limit my exercise E. I must stop smoking
ABE
A client assessment and dx testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment question addressed likely etiologic factors? SATA A. "How many alcoholic drinks do you typically consume in a week?" B. "Have you ever been tested for diabetes?" C. "Have you ever been dx with gallstones?" D. "What do you say that you eat a particularly high fat diet?" E. "Does anyone in your family have cystic fibrosis?"
AC
A nurse determines that a client receiving a unit of packed red blood cells (RBCs) is experiencing a transfusion reaction. After stopping the blood transfusion, what action should the nurse promptly take next? SATA A. The health care provider should be notified. b. Obtain a white blood cell count c. Run normal saline at keep vein open (KVO) rate d. Infuse a normal saline bolus e. obtain vitals every 4 hours
AC
Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? Select all that apply. A. Place client in isolation. B. Encourage multiple visitors to support client. C. Ensure that no plants or flowers are in the client's room. D. Teach family members not to bring fresh fruit and vegetables to the client. E. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.
ACD
A nurse is caring for a post-op 70kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? SATA A. Urine output of 100 mL in 4 hours B. Urine output of 500 mL in 12 hours C. Large amount of sediment in the urine D. Amber, odorless urine E. BP of 90/60 mm Hg
ACE
The student learning about neurological disorders remembers that key features of ICP include which of the following? SATA A. Projectile vomiting B. Hyperactivity C. Narrowed pulse pressure D. Decerebrate posturing E. Aphasia
AD
What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the patient's prognosis? (Select all that apply) A. Assess the patient who is at risk for shock B. Administer vasoconstrictive medications to patients at risk for shock C. Administer prophylactic packed red blood cells to patients at risk for shock D. Administer Intravenous fluids E. Monitor for changes in vital signs
ADE
A client with anemia is unable to tolerate increased periods of activity without onset of fatigue. Which intervention should the nurse implement? SATA A. Space intervention during the day B. Teach the client the basics of good nutrition C. Promote AROM or PROM activities D. Teach the client to change positions slowly to prevent dizziness E. Encourage rest periods during the day
AE
What usually develops in CKD?
ANEMIA
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
ANYTHING THAT INDICATES METABOLIC ACIDOSIS
A patient newly dx with the thrombocytopenia is admitted to the medical unit. After the admission assessment, the patient asked the nurse to explain the disease. What should the nurse explain to this patient? A. There could be an attack on the platelets by antibodies B. There could be decreased production of platelets C. There could be impaired communication between platelets D. There could be an autoimmune process causing platelet malfunction
B
A patient with a TBI has nonreaction and dilated pupils. What would the nurse anticipate? A. Loss of vision B. Brain stem herniation C. Intense headache D. Projectile vomiting
B
A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a BP of 190/100 mm Hg and heart rate of 52 bpm. What is the priority nursing intervention? A. Notify the health care provider B. Place the patient in a sitting position C. Check the patient for fecal impaction D. Check the urinary catheter for kinks or obstruction
B
A patient with poorly controlled diabetes has developed ESRF and anemia. When reviewing this patient treatment plan the nurse should anticipate the use of what drug? A. Magnesium sulfate B. Epoetin alpha C. Low- molecular weight heparin D. Vitamin K
B
A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response? A) Perform mechanical dbridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.
B
An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize? A. Establishing central venous access and beginning fluid resuscitation B. Establishing a patent airway and beginning pulmonary resuscitation C. Establishing a peripheral IV access and administering IV Epinephrine D. Performing a comprehensive assessment and initiating rapid fluid replacement
B
E3: A 5cm thoracic aortic aneurysm was discovered during a regular chest x-ray. When obtaining a nursing history from the patient, it will be most important to ask about: A. Flank pain B. Difficulty swallowing C. Abdominal pain D. Changes in bowel habits
B
E3: A fib strip or is mentioned in question. What should the nurse do immediately? A. Observe for 1 min before notifying pcp B. Initiate CPR C. Get a BP
B
E3: A nurse and physician are preparing to visit a hospitalized client with perepheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? A. The client experiences shortness of breath after walking about 50 feet. B. The client can walk about 50 feet before getting pain in the right lower leg. C. The client's legs awaken him during the night with itching. D. The client's fingers tingle when left in one position for too long.
B
A 19-year old man who was involved in a motor vehicle accident is brought to the ED. The patient was stopped at a red light when he was hit from behind by another vehicle traveling at 15 mph. The patient was placed in a cervical immobilizer by the paramedics. He is alert and oriented, states that his neck hurts, and is in no apparent distress. He currently rates his neck pain as a "5" on a 0-to-10 scale. Which assessment will the nurse perform first? A. Airway B. Circulation C. Sensory-motor D. LOC
A
A client in the ICU is scheduled for a lumbar puncture today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? A. Notify the provider immediately B. Give prescribed preprocedural medication C. Document the findings in patients record D. Ensure informed consent is on chart
A
A client tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increasing while working. This may indicate that the client could possibly have what health problem? A. Carpal tunnel syndrome B. Tendonitis C. Impingement syndrome D. Dupuytren Syndrome
A
E3: A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease
B
E3: A nurse is caring for a client who had left femoral cardiac angioplasty. Identify where the nurse will palpate to assess the most distal pulse on the affected side. A. Brachial B. Dorsalis Pedis C. Tibialis Posterior D. Popliteal
B
E3: A nurse is caring for a client who has SVT. In addition to an ECG, which of the following assessment parameters should the nurse monitor closely during IV administration of verapamil (Calan)? A. Respiratory rate B. BP C. Urine output D. LOC
B
A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications
A
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? A. Fatty stools B. Straw-colored urine C. Tenderness in the left upper abdomen D. Ecchymosis of the extremeties
A
A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the clinical manifestations would the nurse expect to note? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseaus sounds D. Hypoactive deep tendon reflexes
A
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line. D. Apply a cold pack to the client's upper arm.
A
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action? A. Perform a neurovascular assessment B. Explain the discharge instructions C. Provide reassurance to the client D. Apply an ice pack to the casted leg
A
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? A. Gallstones B. Hypolipidemia C. COPD D. Asthma
A
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation
A
E3: A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking
B
E3: The nurse has received the lab results for a client that developed chest pain 4 hours ago, and may be having an MI. The most important lab result to review will be: A. LDL cholesterol B. Troponin T & I C. C-reactive protein D. Creatinine kinase MB (CK-MB)
B
E3: The nurse is taking a health history of a new client who reports pain in his left lower leg and foot when walking. The pain is relieved with rest and the nurse observes the left lower leg is slightly edematous and is hairless. When planning this client's care the nurse should most likely address what health problem? A. Coronary artery disease (CAD) B. Intermittent claudication C. Arterial embolus D. Raynaud's disease
B
E3: The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI C) The patient admitted with malignant hypertension D) The patient admitted following a stroke
B
A 40-year old patient has a tight cast on her lower left leg. Which assessment finding would prompt the nurse to assess further for early signs of compartment syndrome? A. Numbness of the toes B. Paralysis of the left leg C. Diminished pulse on the left lower extremity D. Pain more intense than expected based on initial injury
D
A client had a 20- gauge peripheral IV access device inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? A. Relocate the IV site B. Change the occlusive dressing covering the IV site C. Discontinue the IV D. Assess the IV site for swelling, redness, and pain
D
A client who had an elective below-the-knee amputation reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling increases/decreases" B. "That's phantom limb pain, and every amputee has that" C. "Your foot has been amputated, so its in your head" D. "On a scale of 0 to 10, how would you rate your pain?"
D
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
D
Following a head injury, an unconscious 32-year old patient is admitted to the ED. The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given? What is the appropriate response by the nurse? A. Ask the family to stay in the waiting room until the initial assessment is done. B. Allow the family to briefly stay with the patient and briefly explain all procedures to them. C. Call the family's spiritual advisor or pastor to stay with them while care is being given. D. Refer the family to the hospital counseling service to deal with their anxiety.
B
The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? A. Position the patient supine B. Maintain the head of bed elevated at 30 to 45 degrees C. Position patient in prone position D. Maintain bed in Trendelenburg position
B
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.
B
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? A) A patient with a history of polycystic kidney disease B) A patient with diabetes mellitus and poorly controlled hypertension C) A patient who is morbidly obese with a history of vascular disorders D) A patient with severe chronic obstructive pulmonary disease
B
The nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus B. Bradykinesia C. Hypertension D. Xerostomia
B
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.
B
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for? a. Abdominal distention owing to reflex cessation of intestinal peristalsis b. Hypovolemic shock caused by hemorrhage c. Paralytic ileus caused by manipulation of the colon during surgery d. Pneumonia caused by shallow breathing because of severe incisional pain
B
The nurse is caring for a patient who has a midline in place for fluid replacement when caring for the client's mid-line site, the nurse should: A. Ensure that anticoagulants are placed on hold for the duration of IV therapy B. Replace the IV dressing with a new, clean dressing if it is soiled C. Ensure that the tubing is firmly anchored to the client skin D. Periodically remove hair from 2 cm around the IV site
B
The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI C) The patient admitted with malignant hypertension D) The patient admitted following a stroke
B
The nurse plans to care for a patient with acute pancreatitis. Which intervention would the nurse include in the patient's plan of care to reduce discomfort? A. Administer morphine sulfate IV every four hours as needed B. Maintain nothing by mouth (NPO) and administer IV fluids C. Provide small, frequent feedings with no concentrated sweets D. Place the patient in semi fowler's position with the HOB elevated
B
What is the best indicator for fluid status/hydration? A. Daily weight B. Urine specific gravity C. BUN D. Hct and Hgb
B
When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? A. Crackles at both lung bases B. Temperature of 100.8F C. Dry lips and oral mucosa D. No bowel movement for four days
B
Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimer's disease (AD)? A. Encourage the patient to discuss events from the past B. Maintain a consistent daily routine for the patient's care C. Reorient the patient to the date and time every 2 to 3 hours D. Provide the patient with current newspapers and magazines
B
Which priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? A. Insert indwelling catheters for incontinent patients B. Use strict hand hygiene techniques C. Administer prophylactic antibodies for all patients at risk D. Have patients wear masks in the health care facility
B
Which statement by a patient who is being discharged from the ED after a concussion indicates a need for intervention by the nurse? A. "I will return if I feel dizzy or nauseated" B. "I am going to drive home and go right to bed" C. "I do not even remember being in an accident today" D. "I can take acetaminophen (Tylenol) for my headache"
B
The nurse assesses a blood pressure reading of 80/50 mm Hg from a patient in shock. What is the MAP for this patient? A. 130 B. 60 C. 70 D. 30
B (Diastolic x 2) + Systolic = Ans./3. (50x2) + 80. 180/3 = 60
A nurse is caring for a client who is 1 day postop following a left lower lung lobectomy. When checking the client's closed chest drainage system, the nurse notes that there is no bubbling in the suction control chamber. The nurse should: A. Continue to monitor the client as this is an expected finding B. Add more water to the suction control chamber of the drainage system C. Verify that the suction regulator is on and check the tubing for leaks D. Milk the chest tube to dislodge any clots in the tubing that may be occluding it
C
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position. B) Administer PRN analgesia as ordered. C) Assess the patients peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to set the new dressing.
C
A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics? A) Management of fluid balance in the home setting B) The need for blood glucose monitoring for the next week C) Signs and symptoms of intra-abdominal complications D) Appropriate use of prescribed pancreatic enzymes
C
A patient with cirrhosis has been vomiting blood is admitted to the ED. Which action should the nurse take first? A. Insert a large gauge IV catheter B. Draw blood for coag. studies C. Check BP, HR, RR D. Place the patient in the supine position
C
After receiving 1000 mL of normal saline, the MAP for the patient who has septic shock is 54 and the BP is still 82/40 mm Hg. The nurse will anticipate the administration of: A. Nitroglycerin B. Sodium Nitropusside C. Norepinephine D. Drotrecogin alpha
C
E3: A client admitted for an acute myocardial infarction is getting ready for discharge. The client states, "I have so much work to do around the house". The nurse instructs the client on the need for rest periods especially if beginning to feel chest discomfort. What is the rationale for rest in the treatment of acute MI? A. Decrease the peripheral vascular resistance B. Decrease the HR C. Reduce the workload of the heart D. Negative tourniquet test
C
E3: A nurse is caring for a client who has thrombophlebitis and is receiving heparin for continuous IV infusion. The client asks the nurse how long it will take for the herparin to dissolve the clot. Which of the following responses should the nurse give? A. It usually takes heparin two to three days to reach a therapeutic blood level. B. A pharmacist is the person to answer that question. C. Heparin does not dissolve clots. It stops new ones from forming. D. The oral medication you take after this IV will dissolve the clots.
C
E3: A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? A. Sudden increase in BP B. Cessation of pulsating in an aneurysm that has been previously pulsating C. Sudden onset of severe back or abdominal pain D. New onset of hemoptysis
C
E3: The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition? A. Blood glucose testing reveals a glucose level of 158 mg/dL. B. The patient's blood pressure (BP) is 144/99. C. Crackles are audible on chest auscultation. D. The patient has put out 600 mL of dilute urine over the past 8 hours.
C
You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient? A) Hyperthermia B) Tachycardia C) Lung sounds D) Pain
C *unsure
A patient has yellowing of the sclera. What would you do next pertaining to your assessment? A. Check pulses B. Obtain O2 sat. C. Check oral mucosa
C - UNSURE
E3: The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.) A. Need for increased fluid intake B. Need for early resumption of prediagnosis activity C. Need for careful monitoring for cardiac symptoms D. Need for dietary modifications E. Need for carefully regulated exercise
CDE
A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The clients left lower extremity is cool to the touch.
D
A nurse assesses a client's IV site and notices edema and tenderness above the site. Which should the nurse do? A. Apply cold compress to site B. Elevate extremity C. Flush catheter with normal slaine D. Stop infusion
D
A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position d. Gather appropriate equipment and prepare for an emergency airway
D
A nurse is assessing clients who have IV therapy prescribed. Which assessment finding requires immediate attention? A. Initial site dressing is 3 days old. B. PICC was inserted 4 days ago. C. A securement device is absent. D. Upper extremity swelling is noted.
D
A nurse is caring for a client who has a hx of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client is manifesting which of the following conditions? A. Malnutrition B. Hepatitis A C. Diabetes D. Cirrhosis
D
A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? A. Pale yellow B. Greenish-brown C. Red D. Dark and foamy
D
A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond? a. The pain you are feeling does not actually exist. b. This type of pain is common and will eventually go away. c. Would you like to learn how to use imagery to minimize your pain d. How would you describe the pain that you are feeling?
D
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client
D
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Assess for indications of pulmonary embolism. B. Prepare for mechanical ventilation. C. Prepare to administer a sedative. D. Administer oxygen via face mask.
D
A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain
D
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A) Alterations in glucose metabolism B) Retention of bile salts C) Inadequate production of albumin by hepatocytes D) Inability of the liver to use vitamin K
D
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.
D
A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness
D
A nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. The client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "You will receive magnesium in a series of IM injections B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "You will have your deep-tendon reflexes monitored while you are receiving magnesium."
D
A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present. b. The client is in a blast crisis and has too many WBCs. c. There must be a mistake; the WBCs should be very low. d. Those WBCs are abnormal and don't provide protection.
D
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management
D
A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness
D
A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? a. Spontaneous pneumothorax b. Cardiac tamponade c. Pneumonia d. Fat emboli
D
A patient with acute SOB is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? A. Complete a full physical examination to determine the systemic effects of the respiratory distress B. Obtain a comprehensive health history to determine the extent of any prior respiratory problems C. Delay the physical assessment and ask family members about any history of respiratory problems D. Preform a respiratory system assessment and ask specific questions about this episode of respiratory distress
D
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? A) Ensure that the patient moves the extremity with the vascular access site as little as possible. B) Change the dressing over the vascular access site at least every 12 hours. C) Utilize the vascular access site for infusion of IV fluids. D) Assess for a thrill or bruit over the vascular access site each shift
D
A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicates that it is most important for the nurse to monitor the patients A. Hemoglobin B. Temperature C. Activity level D. Albumin level
D
A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? A. Riboflavin deficiency B. Folic avid deficiency C. Vitamin A deficiency D. Vitamin K deficiency
D
A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A) 0.45% NaCl with 20 mEq/L KCl B) 0.45% NaCl with 40 mEq/L KCl C) Normal saline D) Lactated Ringers
D
After an employee spills industrial acids on the arms and legs at work, what is the priority action that the occupational health nurse at the facility should take? a. Apply an alkaline solution to the affected area. b. Place cool compresses on the area of exposure. c. Cover the affected area with dry, sterile dressings. d. Flush the burned area with large amounts of water.
D
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patients infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patients risk of septic shock? A) Apply an antibiotic ointment to the patients mucous membranes, as ordered. B) Perform passive range-of-motion exercises unless contraindicated C) Initiate total parenteral nutrition (TPN) D) Remove invasive devices as soon as they are no longer needed
D
During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.
D
E3: A patient with chronic A-fib develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the healthcare provider and what is her next priority action? A. Elevate the left leg on a pillow B. Apply an elastic wrap to the leg C. Assist the patient in gently exercising the leg D. Keep the patient in bed in supine position
D
E3: The nurse administers a beta blockers after a MI. What assessment finding should the nurse expect? A. BP increase of 10% B. Increasing Respiratory rate C. Increased cardiac output D. Pulse decreases from 100 to 80 BPM
D
E3: The nurse is caring for a client who had a permanent pacemaker inserted because of a complete heart block. The nurse determines that which client outcome determines a successful procedure? A. Client ambulating in the hall within 4 hours of the procedure without dyspnea or chest pain B. Client ECG monitor determines normal sinus rhythm C. Pulse of 80 bpm, BP 112/74 D. Clients ECG showed paced beats at the rate of 72 bpm
D
E3: The nurse is discharging a client with a new diagnosis of atrial fibrillation. The nurse should explain the onset of which symptom is most important to report to the health care provider? A. Irregular pulse B. Fever C. Fatigue D. Hemoptysis
D
E3: The nurse is teaching the client with a new permanent pacemaker. Which statement by the client indicates the need for further discharge education? a. "I will be able to shower again soon." b. "I need to take my pulse every day." c. "I might trigger airport security metal detectors." d. "I no longer need my heart pills."'
D
E3: When teaching a client with an aneurysm about signs and symptoms that indicate impending rupture the nurse first considers which client data? A. Medication therapy the client is receiving B. Client's usual BP C. Age and Gender D. Size and location of the aneurysm
D
The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situation can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crisis, what measures should the nurse recommend? A. Using prophylactic antibiotics and performing meticulous hygiene B. Maximizing PT and taking OTC iron supplements C. Limiting psychosocial stress and eating a high protein diet D. Avoiding cold temperatures and ensuring sufficient hydration
D
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding? A. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes B. Inform the physician promptly that there is in imminent leak in the drainage system C. Encourage the patient to do deep breathing and coughing exercises D. Document that the chest drainage system is operating as it is intended
D
The nurse learns that the pathophysiology of Guillain-Barre syndrome include segmental demyelination. The nurse should understand that this causes what? A. Delayed afferent nerve impulses B. Paralysis of affected muscles C. Paresthesia in upper extremities D. Slowed nerve impulse transmission
D
Three days following intracranial surgery a client develops fever, nuchal rigidity, and headache. The nurse would suspect: A. Cerebral emboli B. Extradural hematoma C. Increased ICP D. Meningitis
D
Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level
D
4 Questions for one scenario: 1. Mr. M has several symptoms listed. What test is initially ordered? A. CT B. MRI C. X-ray D. ECG 2. The doctor realizes the patient has ICP after completing a CT scan. Based on the CT scan results, what is most likely the cause? A. Epidural Hematoma B. Stroke C. Hypertensive Bleed 3. What should you NOT do for ICP? A. Stimulate client B. Keep room quiet 4. What will INCREASE ICP? A. Keeping head of bed flat B. Keeping head of bed 30 to 40 degrees up
1. A 2.C 3. A 4. A
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Maintain the client in a supine and flat position. 4. Give hydromorphone intravenously as prescribed for pain. 5. Maintain intravenous fluids at 10 mL/hr to keep the vein open.
124
A client is admitted to the hospital after vomiting for three days. Which arterial blood gas (ABG) result would the nurse expect? 1. pH 7.30; PaCO2 50; HCO3- 27 2. pH 7.47; PaCO2 43; HCO3- 28 3. pH 7.34; PaCO2 50; HCO3- 28 4. pH 7.48; PaCO2 30; HCO3- 23
2
An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness
ABCE
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running. c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.
AB
The nurse is teaching family members about precautions to take in visiting a client who has neutropenia. Which instructions should the nurse include in the discussion? SATA A. People who have cold or infectious diseases should not visit B. Visitors must wash their hands before and after a visit C. Fresh fruits and vegetables will help fortify the client's immune system D. It is helpful to keep the clients water pitcher full to prevent dehydration E. Fresh flowers will help to provide a cheerful environment
AB
E3: A nurse suspects the presence of an abdominal aortic aneurysm in a patient, What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? SATA A. A pulsatile abdominal mass B. Low back pain C. Lower abdominal pain D. Decreased bowel sounds E. Diarrhea
ABC
E3: The nurse should assess for which manifestation in a client of suspected arterial embolism in the left hand? SATA A. Pain B. Pale skin C. Paresthesia D. Pitting edema E. Bounding radial pulse
ABC
When a patient is in shock receiving fluid replacement, which will the nurse monitor frequently? SATA A. Urinary output B. Mental status C. Vital Signs D. Ability to perform ROM exercises E. Visual acuity
ABC
E3: A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? SATA A. Smoking B. Obesity C. Hypertension D. Hypercholesterolemia E. Genetic Predisposition
ABCD
A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply). A. Slurred speech B. Bone pain C. Bradypnea. D. Pruritus E. Hypotension
ABD
A client had a stroke. A nurse had arranged a consult with an occupational therapist in order to enhance the clients ability to: A. Acquire job skills B. Feed himself C. Swallow D. Use a walker
B
A nurse admits a client to the ED who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The nurse suspects the patient has acute pancreatitis. Which lab result would confirm this suspicion? A. Decreased WBC B. Increased Amylase C. Decrease Lipase D. Increased Calcium
B
A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? a. Blood pressure increases to 130/86 mm Hg b. Traction weights are resting on the floor c. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds
B
A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? A) Anaphylactic shock B) Neurogenic shock C) Septic shock D) Hypovolemic shock
B
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? A. Begin the infusion B. Ensure an x-ray is completed to ensure placement C. Check medication calculation D. Check medication solution
B
A nurse is presenting discharge instruction to a client who has MS. The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. Plan to relax in a hot tub spa each day B. Implement a schedule to include periods of rest C. Engage in a vigorous exercise program D. Wear an eye patch on the right eye at all times
B
A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action? A. Place the client in a supine position postoperatively. B. Encourage ambulation once fully awake. C. Offer the client ice cream postoperatively. D. Instruct the client not to lift over 4.5 kg (10 lb)
B
A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. "I should consume most of the fluid during the evening." B. "I will make a list of my favorite beverages." C. "I will put beverages in large containers to give the appearance of drinking a lot." D. "I will not add ice cream to the amount of fluid intake."
B
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of bed elevated.
B
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? A. Do not get dehydrated in warm weather B. Drink fluids on a regular schedule. C. Seek attention for any lacerations. D. Take medications as prescribed
B
A patient is admitted to the burn unit with burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patients respiratory rate. d. Reposition the patient in high-Fowlers position and reassess breath sounds.
B
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data is the most important to monitor? A. Urinary output B. Lung sounds C. Peripheral pulses D. Peripheral edema
B
A patient is receiving the first of the ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurses priority action? A) Position the patient in high Fowlers. B) Discontinue the transfusion. C) Auscultate the patients lungs. D) Obtain a blood specimen from the patient
B
A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the Healthcare provider? A. There is bruising at the shoulder area. B. The right arm is shorter than the left. C. Present arm and shoulder pain D. Decreased range of motion (ROM) is present.
B
You are caring for a 65-year old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. What imbalance are they at risk for? A. Hypercalcemia B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis
C
The critical care nurse is caring for a client who is in cardiogenic shock. What assessments should the nurse perform on this client? SATA A. Platelet level B. Fluid status C. Cardiac Rhythm D. Action of medications E. Sputum volume
BCD
What do you expect with alkalosis? {The nurse is teaching a group of students about the manifestation of alkalosis in the central nervous system. Which statements by a student nurse are accurate? Select all that apply. A. "The client's Chvostek sign would be negative." B. "The client's Trousseau sign would be positive." C. "The client would be suffering from paresthesias." D. "The client would show signs of anxiety and irritability." E. "The client's central nervous system should have a decrease activity in case alkalosis."
BCD
Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema
BCE
A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which action by the patient indicates that the problem is resolving? a. Stating that the scarring will only be temporary. b. Avoiding using a pillow to prevent neck contractures. c. Asking about how to use make-up to cover up the scars. d. Expressing sadness and anger about the scar appearance.
C
A child with sickle cell disease comes to the emergency department with a parent. The patient complains of severe pain in the back, right hip and right arm. What intervention is important for the nurse to provide? A. Administer aspirin B. Administer ibuprofen C. Start an intravenous line with dextrose 5% in 0.24 normal saline D. Begin oxygen at 2L/M
C
A community health nurse is caring for a patient whose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A) Administer a PRN dose of pancreatic enzymes as ordered. B) Teach the patient about the importance of abstaining from alcohol. C) Arrange for the patient to be transported to the hospital. D) Insert an NG tube, if available, and stay with the patient.
C
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his/her appearance? A. I will allow my spouse to change my dressings. B. I want to have surgical reconstruction C. I will bathe and dress before breakfast.
C
E3: The nurse is caring for a client who has just undergone cardiac angiography. The catheter insertion site is free from bleeding or signs of hematoma. The vital signs and distal pulses remain in the client's normal range. The IV fluids were discontinued. The client is not hungry or thirsty and refuses any food or fluids, asking to be left alone to rest. Which of the following is the nurse's best response? A. "You are recovering well from the procedure and resting is a good idea". B. "It is important for you to walk, so I will be back in 1 hour to walk with you". C. "It is important to drink fluids after this procedure, to protect your kidney function. I will bring you a pitcher of water, and I encourage you to drink". D. "You will need to do the leg exercises that you practiced before the procedure to keep good circulation to your legs. After you exercises, you can rest"
C
E3: The nurse performing an assessment on a patient who has chronic PAD of the left and an ulcer of the left great toe should expect to find: A. Positive homan's sign B. swollen dry, scaly ankles C. Prolonged cap refill in all toes D. A large amount of drainage from the ulcer
C
E3: Triage a process used to determine the severity of illness/injury generally use in ED prioritizes to ensure the patient receives the right level of care using the proper allocation of resources in order to meet needs prior to the insertion of an arterial line in the radial artery, which assessment would the nurse perform? a. Homan's test b. Kernig's test c. Allen's test d. Leopold's maneuver
C
Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to: A) increase the respiratory rate. B) increase the FIO2. C) decrease the respiratory rate. D) increase the tidal volume.
C
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? 1. Recommend lying in the prone position with legs extended. 2. Maintain a tripod position over the bedside table. 3. Place in side-lying position with knees flexed. (fetal positioning) 4. Encourage a supine position with a pillow under the knees.
C
The critical care nurse is caring for a 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient? A. Maintaining the patient's functional independence B. Promoting mobility C. Monitoring neurologic status closely D. Providing health education
C
The nurse is caring for a patient who sustained severe burns to 50% of the body 3 days previously. What should the nurse report immediately when reviewing laboratory studies indicating massive cell destruction? A. hypernatremia B. hypokalemia C. hyperkalemia D. hypercalcemia
C
The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)? A) The patient is complains of an inability to initiate voiding. B) The patients urine is cloudy with a foul odor. C) The patients average urine output has been 10 mL/hr for several hours. D) The patient complains of acute flank pain.
C
The nurse is performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe would expect to find: A. A positive Homan's sign B. Swollen, dry, scaly, ankles C. Prolonged cap refill in all toes D. A large amount of drainage from the ulcer
C
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient? A) Safe technique for self-suctioning of secretions B) Technique for performing postural drainage C) Correct and safe use of oxygen therapy equipment D) How to provide safe and effective tracheostomy care
C
The nurse notes a bright red skin color for a patient who was found unconscious from smoke inhalation in a burning house. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patients orientation. c. Place the patient on 100% oxygen using a non-rebreather mask. d. Assess for singed nasal hair and dark oral mucous membranes.
C
The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero
C
What will prevent tracheal tissue damage in a patient who has a ET tube? A. Suctioning B. Oral care C. Positioning
C
When caring for a patient with Parkinson disease, the nurse understands that progressive difficulty with which factor is a primary expected outcome? A. Nutrition B. Elimination C. Motor ability D. Effective communication
C
You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the IV site. How should you document this? A. Air emboli B. Phlebitis C. Infiltration D. Fluid Overload
C
What is a risk for shock? Select all A. 20 year old football player B. Obesity C. Spinal cord injury D. Heart Diseases
CD
A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
CDE
A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? SATA A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D
DE
E3: An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness
DE
Patient is agitated and intubated. Becomes hypotensive, reports pain in right side of chest. Tries to yank out ET tube. What is the first action the nurse should do? A. Suction for mucus plug B. Access for tension pneumothorax
DONT KNOW - PUT B
What is not a risk factor for HAP? (I think it was HAP - HOSPITAL ACQUIRED PNEUMONIA or VAP - VENTILATOR ASSOCIATED PNEUMONIA) A. Hypertension B. Hyperglycemia C. Hypoalbuminemia D. Intubated and Sedated
DONT KNOW - PUT C
