Final Exam Review

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? A. Check for an air leak B. Document the findings C. Notify the healthcare provider D. Change the chest tube drainage system

B. Document the findings

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? A. Infection B. Hemorrhage C. Chronic hypertension D. Disseminated intravascular coagulation (DIC)

B. Hemorrhage

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which times when performing care? A. Surgical mask and gloves B. Particulate respirator, gown, and gloves C. Particulate respirator and protective eye wear D. Surgical mask, gown, and protective eye wear

B. Particulate respirator, gown, and gloves

A gastrectomy is performed on a patient with gastric cancer. In the immediate postoperative period , the nurse notes blood drainage from the nasogastric tube. The nurse should take which most appropriate action? A. Measure abdominal girth B. Irrigate the nasogastric tube C. Continue to monitor the drainage D. Notify the health care provider

C. Continue to monitor the drainage

The nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret these findings? A. The client is measuring large for gestational age (LGA) B. The client is measuring small for gestational age (SGA) C. The client is measuring normal for gestational age D. More evidence is needed to determine size for gestational age

C. The client is measuring normal for gestational age

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? *Select all that apply* A. Padding the side rails of the bed B. Placing an airway at the bedside C. Placing the bed in the high position D. Putting a padded tongue blade at the head of the bed E. Placing oxygen and suction equipment at the bedside F. Flushing the intravenous catheter to ensure that the site is patent

A, B, E, F A. Padding the side rails of the bed B. Placing an airway at the bedside E. Placing oxygen and suction equipment at the bedside F. Flushing the intravenous catheter to ensure that the site is patent

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? A. "The enema will be given while I am sitting on the toilet." B. "I should try and hold the fluid as long as possible after it is instilled." C. "I know that there will be some cramping after the enema is administered." D. I should tell the nurse if cramping occurs during the instillation of the fluid."

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

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's chart should be reported before adminsistering dose of furosemide A. 3.2 mEq/L B. 3.8 mEq/L C. 4.3 mEq/L D. 4.8 mEq/L

A. 3.2 mEq/L

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? A. Client pain level B. Inadequate urinary output C. Client perception of body changes D. Potential for imbalanced fluid volume

A. Client pain level

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications of the client selects which items from the dietary menu? A. Cream of wheat, blueberries, coffee B. Sausage and eggs, banana, orange juice C. Bacon, cantaloupe melon, tomato juice D. Cured pork, grits, strawberries, orange juice

A. Cream of wheat, blueberries, coffee

A nurse assists a physician with the placement of a central venous catheter. The nurse notices the physician brush his sterile gloves against the client's bedspread. Which action by the nurse demonstrates professional conduct? A. Inform the physician of the break in sterile procedure and provide new sterile gloves B. Inform the physician of the break in sterile procedure is completed and observe for a central venous line infection C. Notify the supervisor of the break in sterile procedure D. Report the event to the infection control nurse to educate the physician on the proper use of sterile procedure

A. Inform the physician of the break in sterile procedure and provide new sterile gloves

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? A. Protecting the client from infection B. Providing emotional support to decrease fear C. Encouraging discussion about lifestyle changes D. Identifying factors that decrease immune function

A. Protecting the client from infection

A nurse calls a physician regarding a change in the client's condition. The physician gives orders over the telephone for arterial blood gases (ABGs) to be drawn stat. Which is the most important safety consideration when obtaining the order? A. Writing the order down and reading it back to the physician B. Calling the respiratory therapist stat to draw the ABGs C. Giving the order stat to the health unit coordinator to pace in the computer D. Writing down the orders for the ABG immediately

A. Writing the order down and reading it back to the physician

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? A. 5 seconds B. 10 seconds C. 30 seconds D. 60 seconds

B. 10 seconds

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating breath sounds? A. Stridor B. Crackles C. Scattered rhonchi D. Diminished breath sounds

B. Crackles

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? A. Peritonitis B. Hyperglycemia C. Hyperphospatemia D. Disequilibrium syndrome

B. Hyperglycemia

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure was rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

A client informs a nurse that a physician is recommending a kidney biopsy. The client fears the result will be cancer and would not want treatment. The client feels it would be better just "not to know." Which action should be taken by the nurse to determine if the client understands his/her rights? A. Explain to the client that the physician is doing what is best for the client B. Inform the client of his/her right to make decisions based on personal values and beliefs C. Encourage the client to talk with family and let the family decide D. Talk with the physician about the client's fear of having the biopsy

B. Inform the client of his/her right to make decisions based on personal values and beliefs

A nurse is caring for a client immediately following insertion of a permanent pacemaker via the right subclavian vein approach. The nurse best prevents pacemaker lead dislodgement by A. Inspecting the incision site dressing for bleeding and incision for approximation B. Limiting the client's right are activity and preventing the client reaching above shoulder level C. Assisting the client with getting out of bed and ambulating with a walker D. Ordering a stat chest x-ray following return from the implant procedure

B. Limiting the client's right are activity and preventing the client reaching above shoulder level

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? A. Placing a safety knot in the safety device straps B. Safely securing the safety device straps to the side rails C. Applying safety device straps that do not tighten when force is applied against them D. Securing so that 2 fingers can slide easily between the safety device and the client's skin

B. Safely securing the safety device straps to the side rails

The nurse is performing an initial postoperative assessment on a client following upper gastrointestinal surgery. The client has a nasogastric type to low intermittent suction. To best assess the client for the presence of bowel sounds, the nurse should A. Place the stethoscope to the left of the umbilicus B. Turn off the nasogastric suction C. Use the bell of the stethoscope D. Turn the section on the nasogastric tube to continuous

B. Turn off the nasogastric suction

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? A. Chess B. Writing C. Ping Pong D. Basketball

B. Writing

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? A. Strict bed rest is required after the procedure B. Hospitalization is necessary for 24 hours after the procedure C. An informed consent needs to be signed before the procedure D. A fever is expected after the procedure because of the trauma to the abdomen

C. An informed consent needs to be signed before the procedure

The client has developed atrial fibrillation, with a ventricular rate of 150 beast/min. The nurse should assess the client for which associated signs and symptoms? A. Flat neck veins B. Nausea and vomiting C. Hypotension and dizziness D. Hypertension

C. Hypotension and dizziness

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? A. Document the findings B. Arrange for a hearing test C. Notify the healthcare provider D. Cover the ears with gauze pads

C. Notify the healthcare provider

A surgical patient tells the nurse that he/she has been in significant pain since surgery earlier that day. The nurse reviews the medication administration record (MAR) and notes that hydrocodone plus acetaminophen (Vicodin) has been administered at the highest possible dose and at regular intervals since surgery. The nurse brings the patient two Vicodin tablets. The patient states, "This isn't what I had before. I only had one pink pill." Which action should be taken by the nurse? A. Call the pharmacy and ask the pharmacist to send the pink hydrocodone plus acetaminophen B. Complete a variance report because the MAR is incorrect C. Report the event to the supervisor D. Confront the nurse on the previous shift with the suspicion that the nurse took the Vicodin

C. Report the event to the supervisor

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? A. Remove the intravenous line B. Rena solution of 5% dextrose in water C. Run normal saline at the keep-vein-open (KVO) rate D. Obtain a culture of the tip of the catheter device removed from the client

C. Run normal saline at the keep-vein-open (KVO) rate

A nurse assesses that a laboring client receiving an oxyocin (Pitocin) infusion has a contraction occurring 1 minute after the previous contraction and remains strong after 70 seconds. Which should be the nurse's first action? A. Notify the physician B. Reassess the fetal heart tones C. Stop the oxytocin (Pitocin) infusion D. Prepare to administer terbutaline sulfate (Brethine)

C. Stop the oxytocin (Pitocin) infusion

The low pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? A. Administer oxygen B. Check the client's vital signs C. Ventilate the client manually D. Start cardiopulmonary resuscitation

C. Ventilate the client manually

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no p-waves, the QRS complexes are wide, and the ventricular rate is regular, but more than 140 beats/min. The nurse determines that the client is experiencing which dysrhythmia? A. Sinus tachycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions

C. Ventricular tachycardia

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication. A. "You have everything to live for." B. "Why do you see yourself as a failure." C. "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?"

D. "You've been feeling like a failure for a while?"

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A. A client who is ambulatory demonstrating a steady gait B. A postoperative client who has just received an opioid pain medication C. A client scheduled for physical therapy for the first crutch-walking session D. A client with a white blood cell count of 14,000 mm3 and temperature of 38.4°C (101.1°F)

D. A client with a white blood cell count of 14,000 mm3 and temperature of 38.4°C (101.1°F)

The nurse is assigned to care for four clients. In planning rounds, which client should the nurse assess first? A. A postoperative client preparing for discharge with a new medication B. A client requiring daily dressing changes of a recent surgical incision C. A client scheduled for a chest x-ray after insertion of a nasogastric tube D. A client with asthma who requested a breathing treatment during the previous shift

D. A client with asthma who requested a breathing treatment during the previous shift

A charge nurse receives a phone call from the emergency department where a client is being admitted. The admission diagnosis of the client is rental failure. The client is also confused and restless. Which is the safest room assignment for this client? A. A semi-private room 50 feet from the nurse's station B. A small private room at the end of the hallway C. A seclusion room that is monitored by a camera for the client safety D. A large private room within view of the nurse's station

D. A large private room within view of the nurse's station

A 30-year-old client is brought to an emergency trauma center with a hand injury from a nail gun sustained while remodeling an old barn. There is a storng odor of alcohol and the client admits to having three beers during a 3-hour period. Which assessment finding is most important for the nurse to evaluate first? A. Blood type B. Time of last void C. Current blood alcohol level D. Date of last tetanus immunization

D. Date of last tetanus immunization

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? A. Notify the health care provider of the findings B. Reposition the mother and check the monitor for changes in the fetal tracing C. Take the mothers's vital signs and tell the other that bed rest is required to conserve oxygen D. Document the findings and tell the mother that the pattern on the monitor indicates the fetal well-being

D. Document the findings and tell the mother that the pattern on the monitor indicates the fetal well-being

The nurse is performing an assessment on a regnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis. A. Enlargement of breasts B. Complaints of feeling hot when the room is cool C. Periods of fetal movement followed by quiet periods D. Evidence of bleeding, such as gums, petechiae, and purpura

D. Evidence of bleeding, such as gums, petechiae, and purpura

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take what action? A. Stay very still B. Exhale very quickly C. Inhale and exhale quickly D. Perform the valsalva maneuver

D. Perform the valsalva maneuver

A client is in sinus bradycardia with a heart rate of 45 beats/min, complains of dizziness, and has a blood pressure of 82/60 mmHg. Which of the following should the nurse anticipate will be prescribed? A. Administer digoxin B. Defibrillate the client C. Continue to monitor the client D. Prepare for transcutaneous pacing

D. Prepare for transcutaneous pacing

A client who has received 50 mL of a unit of whole blood complains of low back pain. In response to this client's symptom, a nurse should first A. Reposition the client B. Assess the pain further C. Administer an analgesic D. Stop the blood transfusion

D. Stop the blood transfusion

A client has an advanced health care directive on file at a hospital that identifies a friend as the legal health care agent. A nurse is to obtain informed consent for the client to have an exploratory laparotomy. Because of the sedation, the client is unable to sign the form or give verbal consent. Who should provide consent for this client? A. The client's spouse B. The client's oldest adult child C. Since the client is unable to give consent, the surgery cannot be performed D. The client's durable power of attorney (DPOA) for healthcare

D. The client's durable power of attorney (DPOA) for healthcare