NC3 Exam 2 Practice Questions (3)

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes the clients indwelling urinary catheter has not drained in the last so many hours? What will you do?

Check for kinks

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% NaCl. Which of the following interventions should the nurse include in the plan of care?

Check the clients IV infusion every 8 hours

The nurse is caring for a client who has a Jackson Pratt drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which reason?

To keep fluid from accumulating in the wound

The nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. which parameter should nurse assess first?

Airway patency

The nurse is preparing to admit a client to the PACU who receives a competitive neuromuscular blocking agent. What should the nurse place at the clients bedside?

Bag Mask

the nurse is providing instructions for a 52 year old client scheduled for a colonoscopy. the client reports he has not had the procedure before and he is very anxious about feeling pain during the procedure. What will the nurse say?

Before the examination your provider will give you a sedative that will make you sleepy

The nurse is caring for a client who is one day postoperative following a subtotal thyroidectomy. The nurse notes a tingling sensation in the hands, soles of the feet, and around the lips. Which sign is this?

Chvostek Sign - Hypocalcemia

While assessing a client who is receiving continuous IV therapy via his left forearm a nurse notes that the site is red, swollen, and painful and the surrounding tissues are hard. What should you do?

Discontinue existing IV line

The nurse is caring for a client following an abdominal surgery. the client has a prescription for dressing changes every 4 hours and as needed. Which of the following should the nurse use to reduce stress on the abdominal wall?

Montgomery Straps

The nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which activity should the nurse anticipate as being the most difficult at this time?

Hair brushing

The nurse reviewing a clients lab values, and discovers the client has a potassium serum of 6.2 Which of the following interventions should the nurse anticipate?

Administer polystyrene sulfonate (Kyexalate)

The nurse is reviewing and EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the EKG should the nurse interpret as a sign of Hypokalemia?

Abnormally prominent U wave

A nurse is caring for a client who is postoperative following knee arthroplasty and is on a continuous passive motion machine. Which action should the nurse take?

Apply ice to the operative knee

The nurse is assessing a client who has diabetes insipidous. Which finding should the nurse expect?

Dehydration from Polyuria

The nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation the next day. Which instruction should you give?

Do not apply heat to the area of radiation

The nurse is caring for a client who is being with a radioactive implant. The client tells the nurse I feel so isolated and alone in this room. After acknowledging the clients feeling of loneliness, what should the nurse suggest?

Do you have a cellphone? You can talk to friends and family on it.

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client does what?

Makes up stories and is unable to remember actual events

The nurse is providing teaching to a client who is postoperative following CABG and is receivng opioid medication to manage discomfort. Aside from managing pain why else would you give an opioid?

Facilitate deep breathing

The nurse is monitoring a client who was admitted with a sever burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following finding?

Heart Rate

A nurse is providing information about pain control for a client who has acute pain from a subtotal gastric resection. Which client statement indicates the understanding of pain?

I will call for pain medication before the previous dose wears off

A nurse is teaching a client who has acute kidney dz about fluid restrictions. Which statement by the client should the nurse identify as an understanding of the teaching?

I will make a list of my favorite beverages

The nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk of ventilator associated pneumonia?

Oral Care

The nurse is admitting a client to the PACU following a cholecystectomy. Which of the following assessment is the nurses priority?

Oxygen Saturation

The nurse is assessing a client who has been admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nursing priority?

Oxygen saturation

A nurse is reviewing the lab values for a client who has respiratory acidosis. Which of the following findings should the nurse expect?

PaCO2 50 (35-45) Normal HCO3 22-26 Normal Potassium 3.5-5.0 Normal pH 7.35-7.45

A client is admitted to the ER with a RR of 7 per minute. ABGs reveals what?

Respiratory Acidosis

The nurse is caring for a client who has Syndrome of Inappropriate Antidiuretic Hormone and a Sodium level of 123. Which of the following prescriptions should the nurse anticipate?

Restrict fluid intake to 1,000 mL/day

The nurse is caring for a client who has had a total thyroidectomy and a serum calcium level of 7.6. Which of the following findings should the nurse expect?

Tingling of the extremities

A nurse is reviewing the ABGs of a client who has Chronic Kidney Dz. Which of the following sets of values should the nurse expect?

pH 7.25, PaCO2 30, HCO3 19 Metabolic Acidosis