PP 2 Final Review Questions

A young adult comes to the clinic complaining of dizziness, weakness, and palpitations. What will be important for the nurse to evaluate initially when obtaining the health history? 1. Activity and exercise patterns 2. Nutritional patterns 3. Family health status 4. Coping and stress tolerance

2

Clients with COPD usually receive low-dose oxygen via nasal cannula. The nurse understands that which problem may occur if the client receives too much oxygen? 1. Hyperventilation 2. Tachypnea 3. Hypoventilation or apnea 4. Increased snoring

3

For a client with COPD, what is the main risk factor for pulmonary infection? 1. Fluid imbalance with pitting edema 2. Pooling of respiratory secretions 3. Decreased fluid intake and loss of body weight 4. Decreased anterior-posterior diameter of the chest

2

An unknown chemical was splashed into a client's eyes. What is most important for the nurse to tell the client to do immediately? 1. Rinse the eye with a large amount of water or saline solution. 2. Put a pad soaked in sterile saline solution over the eye. 3. Go to the closest emergency department. 4. Have a coworker visually check the eye for a foreign body

1

A client's eye has been anesthetized for an ophthalmology examination. What instructions will be important for the nurse to give the client? 1. Do not watch television for at least 24 hours. 2. Do not rub the eye for 15 to 20 minutes. 3. Irrigate the eye every hour to prevent dryness. 4. Wear sunglasses when in direct sunlight for the next 6 hours.

2

A parent and an 8-month-old child come into a public health clinic for a well-child checkup. The parent tells the nurse the child has been crying more than usual. What information obtained during the nursing assessment would cause the nurse the most concern? 1. Crying when sucking on his bottle 2. Crying when placed in crib at night 3. On-and-off crying throughout the day 4. Crying when left at the child care center

1

A patient with a pituitary tumor is treated with a transsphenoidal hypophysectomy. What would be a priority postoperative action? 1. Ensure that any clear nasal drainage is tested for glucose. 2. Maintain the patient flat in bed to prevent cerebrospinal fluid (CSF) leak. 3. Assist the patient with tooth brushing to keep the surgical area clean. 4. Encourage deep breathing and coughing to prevent respiratory complications.

1

A client has been diagnosed with pernicious anemia. What will the nurse teach this client regarding the medication he will need to take after he goes home? 1. Monthly vitamin B12 injections will be necessary. 2. Daily ferrous sulfate (in oral form) will be prescribed. 3. Coagulation studies are important to monitor the effect of medications. 4. He should reduce his intake of leafy, green vegetables to decrease vitamin K.

1

A client is experiencing a sickle cell crisis during labor and de-livery. What is the best nursing action? 1. Maintain IV fluid infusion and assess adequacy of hydration. 2. Administer a high concentration of oxygen. 3. Insert a Foley catheter and monitor hourly urine output. 4. Provide continuous sedation for pain relief.

1

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 3 pm, the nurse finds the client apparently asleep. What priority action should the nurse perform to assess for a hypoglycemic reaction? 1. Feel the client and bed for dampness. 2. Observe the client for Kussmaul respirations. 3. Smell the client's breath for acetone odor. 4. Note if the client is incontinent of urine.

1

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client has a flat affect but is irritable when questioned, has a poor memory, reports a loss of appetite, wants to sleep all the time, and doesn't care if she gets well. What collaborative action should the nurse take in response to this information? 1. Discuss with the health care provider a concern for depression. 2. Request a neurology consult for a CT scan. 3. Discuss with the dietitian a need for a nutritional consult. 4. Request a social service consult for home evaluation.

1

The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What information confirms that the tube has migrated too far into the trachea? 1. Decreased breath sounds are heard over the left side of the chest. 2. Increased rhonchi are present at the lung bases bilaterally. 3. Client is able to speak and coughs excessively. 4. Ventilator pressure alarm continues to sound.

1

The nurse is caring for a client who has had a right-sided stroke. What would be appropriate nursing care for this client? 1. Performing passive ROM exercises to affected side, active ROM on unaffected side 2. Placing food on the affected side of the client's mouth 3. Applying hot packs to the right leg to decrease muscle spasms 4. Turning client every 2 hours and maintaining position on the right side for 2 hours

1

The nurse is caring for a postoperative client who had a thyroidectomy. The client develops difficulty breathing from laryngospasms, muscular spasms, and twitching, Which medication should the nurse have available for emergency treatment in the client who has had a thyroidectomy? 1. Calcium chloride. 2. Potassium chloride. 3. Magnesium sulfate. 4. Propylthiouracil.

1

The nurse is monitoring a client who is experiencing an acute asthma attack. What observations would indicate an improvement in the client's condition? 1. Respiratory rate of 18 breaths/min 2. Pulse oximetry of 88% 3. Pulse rate of 110 beats/min 4. Productive cough with rapid breathing

1

The nurse is providing preoperative care for client who is scheduled for cardiac surgery. During the preoperative preparation, what is an important nursing action? 1. Perform a thorough nursing assessment to provide an accurate baseline for evaluation after surgery. 2. Discuss with the client the steps of myocardial cellular me-tabolism and the anticipated surgical response. 3. Provide preoperative education regarding the mechanics of the cardiopulmonary bypass machine. 4. Discuss with the client and family the anticipated amount of postoperative chest tube drainage.

1

The nurse is taking the history of a client with heart failure caused by chronic hypertension. Which statement by the client is most concerning? 1. "I get short of breath after walking about half a block." 2. "My weight has dropped 15 pounds over the past 3 months." 3. "My legs get swollen in the evenings." 4. "Sometimes I get dizziness when I get up too quickly.

1

The nurse would question which medication order for a client with PACG (primary angle-closure glaucoma)? 1. Atropine 1 to 2 drops in each eye now 2. Hydrochlorothiazide 25 mg PO daily 3. Propranolol 20 mg PO two times a day 4. Carbamylcholine eye drops, 1 drop two times a day

1

The vital signs of a client with cardiac disease are as follows: blood pressure of 102/76 mmHg, pulse of 52 beats/min, and respiratory rate of 16 breaths/min. Atropine sulfate is administered IV push. What nursing assessment indicates a therapeutic response to the medication? 1. Pulse rate has increased to 70 beats/min. 2. Systolic blood pressure has increased by 20 mmHg. 3. Pupils are dilated. 4. Oral secretions have decreased.

1

What finding on the nursing assessment would be associated with a diagnosis of pneumonia in the older adult? 1. Acute confusion 2. Hypertension 3. Hematemesis in the morning 4. Dry hacking cough at night

1

What symptoms would the nurse expect to observe in a 19-month-old client with a diagnosis of laryngotracheobronchitis (LTB)? 1. Stridor on inspiration 2. Expiratory wheezing 3. Paroxysmal coughing 4. Hemoptysis

1

The nurse is monitoring a client after thrombolytic therapy has been initiated. Shortly after the infusion is started, the client becomes confused, disoriented, cool, and clammy. The heart rate progressively increases to 120 and blood pressure drops to 60/40. What actions should the nurse take? Select all that apply. 1. Stop the thrombolytic 2. Apply oxygen 3. Raise the head of the bed 4. Call for assistance 5. Reorient the client

1, 2, 4

The nurse received handoff for a client returning from a cardiac angiogram and begins the initial assessment. The right femoral groin dressing has a dime-sized area of blood. What additional actions should the nurse perform? Select all that apply. 1. Assess peripheral pulses in both legs and feet. 2. Mark the dressing with a pen, circling the bloody drainage. 3. Hold pressure on the dressing site for 20 minutes. 4. Assess blood pressure. 5. Place the client in a high-Fowler position.

1, 2, 4

The nurse is caring for a client with a history of heart failure. Which statements by the client require additional inquiry? Select all that apply. 1. "I've noticed that I've gained 3 lbs. This week." 2. "I sleep best in my recliner chair." 3. "I've noticed that the swelling in my feet seems less." 4. "I cannot make it through the grocery store without resting." 5. "I often have to use the restroom at night.

1, 2, 4, 5

The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to assess during the initial visit? Select all that apply. 1. Presence of cardiac discomfort 2. Medications taken before hospitalization 3. Presence of jugular vein distention 4. Heart sounds and apical rate 5. Presence of diaphoresis 6. History of difficulty breathing

1, 3, 4, 5

Which of the following would be appropriate discharge instructions for the client that has just been diagnosed with polycythemia vera? Select all that apply. 1. "You can expect to have repeated phlebotomies." 2. "Take an iron supplement daily." 3. "Low-dose aspirin may be prescribed by your health care provider." 4. "A warm bath may be used to decrease generalized pruritus." 5. "Avoid crowds due to increased risk of infection secondary to your low white blood cell (WBC) count." 6. "Try to keep well hydrated by drinking at least 2 liters of fluid per day."

1, 3, 6

A client with a diagnosis of type 2 diabetes has been prescribed a course of prednisone for severe arthritis pain. How should the nurse adjust the plan of care? Select all that apply. 1. Monitor blood glucose levels more frequently. 2. Monitor for signs of bleeding. 3. Monitor urine output every 4 hours. 4. Monitor for increased signs of infection. 5. Monitor for increased confusion.

1, 4

The nurse is caring for a client with thyroid disease who is experiencing a "racing heart," weight loss, exophthalmos, and heat intolerance. What additional actions should the nurse take? Select all that apply. 1. Evaluate if the client is receiving a beta-blocker. 2. Assess for hypotension. 3. Request increased calories with three balanced meals a day. 4. Apply lubricating eye drops throughout the day. 5. Place a circulating fan in the room.

1, 4, 5

The nurse is preparing a client for a cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure? Select all that apply. 1. Verify consent form has been signed. 2. Explain procedure to client. 3. Provide clear liquid, no caffeine diet. 4. Evaluate peripheral pulses. 5. Obtain a 12-lead ECG. 6. Obtain history for shellfish allergy.

1, 4, 6

The nurse is caring for a client who began showing signs of diabetes insipidus 4 hours ago and was treated with IV fluids and one dose of nasal desmopressin (DDAVP). How will the nurse know the treatment is effective? Select all that apply. 1. Urine output will decrease. 2. Blood pressure will lower. 3. Glucose level will normalize. 4. Sodium level change from 128 mEq/L to 134 mEq/L. 5. Urine specific gravity of 1.029.

1, 5

The nurse is evaluating a client recently diagnosed with primary open-angle glaucoma (POAG). What will be an important nursing action(s)? Select all that apply. 1. Review all medications the client is currently taking to deter-mine whether any of them cause an increase in intraocular pressure as a side effect. 2. Determine whether the client has experienced any sudden loss of vision accompanied by pain. 3. Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision. 4. Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes.

1, 5, 6

A nurse is caring for a client with Addison's disease who has been in a car accident and presents to the emergency department with severe hypotension, fever, weakness, and confusion. Place the nurse's action in a priority order. 1. Vital sign assessment. 2. Delivery of 0.9% saline and 5% dextrose solution. 3. Placement of an IV. 4. Delivery of high-dose hydrocortisone replacement. 5. Health history information.

1,3,2,4,5

A nurse is caring for a client who is receiving a blood transfusion. The transfusion was started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action? 1. Slow the infusion and evaluate the vital signs and the client's history of transfusion reactions. 2. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution. 3. Stop the infusion of blood and begin infusion of normal saline solution from the Y connector. 4. Recheck the unit of blood for correct identification numbers and cross-match information.

2

A child with leukemia is being discharged after beginning chemotherapy. What instructions will the nurse include in the teaching plan for the parents of this child? 1. Provide a diet low in protein and high in carbohydrates. 2. Avoid unwashed fruits and vegetables. 3. Notify the doctor if the child's temperature exceeds 102°F (39°C). 4. Increase the use of humidifiers throughout the house.

2

A client comes to the clinic with decreased hearing. Examination of the ear canal reveals a large amount of cerumen. What is the recommended method for removal of the cerumen? 1. Curettage with suction and irrigation 2. Warm sterile solution irrigation 3. Cool tap water irrigation 4. Cotton swab applicator

2

A client has a diagnosis of right-sided empyema. Thoracentesis is to be performed in the client's room. The nurse will place the client in what position for this procedure? 1. Prone position with feet elevated 2. Sitting with upper torso over bedside table 3. Lying on left side with right knee bent 4. Semi-Fowler's position with lower torso flat

2

A client has an order for one unit of packed cells. What is a correct nursing action? 1. Initiate the IV with 5% dextrose in water (D5W) to maintain a patent access site. 2. Initiate the transfusion within 30 minutes of receiving the blood. 3. Monitor the client's vital signs for the first 5 minutes. 4. Monitor the client's vital signs every 2 hours during the transfusion

2

A client has been diagnosed with disseminated intravascular coagulopathy (DIC). The nurse will anticipate administering which of the following fluids? 1. Packed red blood cells (PRBCs) 2. Fresh frozen plasma (FFP) 3. Volume expanders, such as D10W 4. Whole blood

2

A client is found to be comatose with a blood glucose level of 50 mg/dL (2.8 mmol/L). What action should the nurse implement first? 1. Infuse 1000 mL of D5W over a 12-hour period. 2. Administer 50% glucose intravenously. 3. Check the client's urine for the presence of sugar and acetone. 4. Encourage the client to drink orange juice with added sugar.

2

A client who has glaucoma is concerned about her adult children "inheriting" the condition. What is the best nursing response? 1. "There is no need for concern; glaucoma is not a hereditary disorder." 2. "Your children should have an ophthalmologic examination with screening for glaucoma around age 40. After that, examinations should be done every 2 to 3 years." 3. "There may be a genetic factor with glaucoma, and your children over 30 years of age should be screened yearly." 4. "Are your grandchildren complaining of any eye problems? Glaucoma generally skips a generation."

2

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. At what point in the day should the client be educated about peak incidence of hypoglycemia? 1. 12 p.m. to 1 p.m. (1200-1300 hours). 2. 9 a.m. and 5 p.m. (0900 and 1700 hours). 3. 10 a.m. and 10 p.m. (1000 and 2200 hours). 4. 8 a.m. and 11 a.m. (0800 and 1100 hours).

2

The nurse applies a nitroglycerin patch on a client who has undergone cardiac surgery. What nursing observation indicates that a nitroglycerin patch is achieving the desired effect? 1. Chest pain is completely relieved. 2. Client performs activities of daily living without chest pain. 3. Pain is controlled with frequent changes of patch. 4. Client tolerates increased activity without pain.

2

The nurse is assigned to care for a newly admitted client with acute pancreatitis. Admitting assessment includes mid-epigastric pain of an 8 out of 10, low-grade fever, and elevated amylase and lipase levels with hypocalcemia and hyperglycemia. What should be the nurse's priority action? 1. Deliver proton pump inhibitor. 2. Place nasogastric (NG) tube. 3. Administer IV calcium gluconate. 4. Administer oral analgesic.

2

The nurse is caring for a client with leukemia who is experiencing bleeding into the knee joints. What is the best nursing care for this client regarding joint mobility and activity? 1. Encourage short walks around the room every 2 hours. 2. Keep the joint immobilized and maintain bed rest for the client. 3. Gently put the legs through passive range of motion every 4 hours. 4. Keep the legs wrapped with elastic bandages and immobilized in splints.

2

The nurse is caring for an infant who is experiencing respiratory distress and being treated with continuous positive airway pressure (CPAP). The nurse knows that for this treatment to be most effective, the infant must be: 1. Intubated with respiration maintained by controlled ventilation 2. Able to breathe spontaneously 3. Frequently stimulated to maintain respiratory rate 4. Suctioned frequently to maintain alveolar ventilation

2

The nurse is preparing a teaching plan for a family with a child who has been diagnosed with sickle cell anemia and crisis. What will the nurse include in the teaching regarding the pathophysiology of sickle cell crisis? 1. It results from altered metabolism and dehydration. 2. Tissue hypoxia and vascular occlusion cause the primary problems. 3. Increased bilirubin levels will cause hypertension. 4. There are decreased clotting factors with an increase in white blood cells

2

The nurse is providing discharge instructions to a client who has had a splenectomy. The teaching is based on the knowledge that splenectomy clients have: 1. Decreased leukocytes 2. Increased platelets 3. Decreased hemoglobin 4. Increased eosinophils

2

The nurse understands clamping a chest tube may cause what problem? 1. Atelectasis 2. Tension pneumothorax 3. Bacterial infections in the pleural cavity 4. Decrease in the rate and depth of respirations

2

The parents of a client with hemophilia are taking their child home. Which statement indicates a need for further education regarding hemophilia? 1. "We should ensure that our child has regular dental appointments." 2. "We need to wrap our child's limbs daily to prevent bleeding." 3. "We should help our child select activities that minimize the risk of injury." 4. "We should not give our child aspirin."

2

What nursing observation indicates that an unplanned extubation of an endotracheal tube has occurred? 1. The high-pressure ventilator alarm activates 2. Client is able to speak 3. Increased swallowing efforts by client 4. Increased crackles (rales) over left lung field

2

Which client is at highest risk for retinal detachment? 1. A 4-year-old with amblyopia 2. A 17-year-old who plays physical contact sports 3. A 33-year-old with severe ptosis and diplopia 4. A 72-year-old with nystagmus and Bell palsy

2

Which client is most likely to have iron deficiency anemia? 1. A client with cancer receiving radiation therapy twice a week 2. A toddler whose primary nutritional intake is milk 3. A client with a peptic ulcer who had surgery 6 weeks ago 4. A 15-year-old client in sickle cell crisis

2

A client is walking down the hall, and he begins to experience vertigo. What is the most important nursing action when this occurs? 1. Have the client sit in a chair in a brightly lit room. 2. Administer meclizine PO. 3. Help the client sit or lie down. 4. Assess whether the problem is vertigo or dizziness.

3

A client with chest pain is on a cardiac monitor. The monitor is showing ventricular tachycardia at a rate of 150 beats/min with multiple PVCs. The client is awake and coherent, and oxygen is being administered at a rate of 6 L/min via a nasal cannula. What is the nurse's next action? 1. Immediately defibrillate. 2. Administer adenosine IV push. 3. Assess the blood pressure. 4. Auscultation lung sounds.

3

A nurse is urgently called to a homebound neighbor's house. The neighbor is found unconscious and has a history of insulin-dependent diabetes. After determining there is no functioning glucometer available, what should the nurse's next action be? 1. Administer 10 units of regular insulin subcutaneously. 2. Arouse the client to drink 4 to 6 ounces of orange juice. 3. Administer glucagon 1 mg subcutaneously. 4. Find a phone to call EMS.

3

The nurse is caring for a client postoperative thyroidectomy. What action should the nurse prioritize? Select all that apply. 1. Have the client speak every 5 to 10 minutes if hoarseness is present. 2. Support the head with pillows and avoid flexion of the neck. 3. Check the breath sounds for stridor. 4. Assess for tingling in the toes, fingers, and around the mouth or muscular twitching. 5. Assess every 4 hours for the first 24 hours for signs of hemorrhage. 6. Place with head of bed flat, in a side-lying position in case of vomiting.

2, 3, 4

The nurse is creating a plan of care about exercise for a client newly diagnosed with diabetes. What should be included in the plan? Select all that apply. 1. Exercise needs to be vigorous and daily. 2. Properly fitting footwear is important. 3. Exercise is best done after meals when glucose levels are rising. 4. It is important to monitor glucose levels before, during, and after exercise. 5. Exercise-induced hypoglycemia may occur several hours after exercise.

2, 3, 4, 5

The nurse is preparing discharge teaching for a client with aplastic anemia. What will be important to include in the teaching plan? Select all that apply. 1. Take your iron with meals every day and decrease the amount of green, leafy vegetables in your diet. 2. Establish a balance between rest and activity; avoid excessive fatigue. 3. Rest and supplemental oxygen may be required during periods of dyspnea. 4. Drink a glass of wine in the evening to help increase your appetite. 5. Notify your health care provider if you begin to experience frequent bruising. 6. Increase your intake of dairy products (milk and cheese) and protein.

2, 3, 5

Which of the following are appropriate nursing actions when measuring visual acuity using a Snellen chart? Select all that apply. 1. Position the client 30 feet (9 meters) away from the chart. 2. Have the client first read the chart with both eyes open. 3. Record visual acuity as the largest line that the client can read correctly. 4. Test each eye individually with the opposite eye covered. 5. Repeat the test with the client wearing corrective lenses. 6. Use a picture chart if the client is unable to read

2, 4, 5, 6

The nurse is caring for a client who is experiencing an acute asthma attack. He is dyspneic and experiencing orthopnea; his pulse rate is 120 beats/min. In what order will the nurse provide care to this client? Number the following options in the order in which they will be performed, with 1 being the first action and 4 being the last action. 1. ________ Administer humidified oxygen. 2. ________ Place in semi-Fowler's position. 3. ________ Provide nebulizer treatment with bronchodilator. 4. ________ Discuss factors that precipitate attack.

2,1,3,4

A 3-year-old child had a myringotomy about a week ago. The mother calls the nurse to report that one of the tubes fell out. She found the tube on the child's pillow. After the nurse makes an appointment for the child to be seen in the clinic, what would be important to tell the mother? 1. Observe for any purulent or bloody drainage from the ear. 2. Rinse the tube in soapy water and keep it. 3. Do not allow any water to get into the child's ears. 4. Do not allow the child to play outside.

3

A client admitted with a pheochromocytoma returns from the operating room after adrenalectomy. Which assessment is most concerning? 1. Glucose of 70 mg/dL. 2. Potassium of 3.4 mEq/L. 3. Blood pressure of 169/98 mm Hg. 4. Sodium of 146 mEq/

3

A client and her husband are positive for the sickle cell trait. The client asks the nurse about the chances of her children having sickle cell disease. The nurse understands that this genetic problem will reflect what pattern in the client's children? 1. One of her children will have sickle cell disease. 2. Only the male children will be affected. 3. Each pregnancy carries a 25% chance of the child being affected. 4. If she has four children, one of them will have the disease.

3

A client has a history of atherosclerotic heart disease with a sustained increase in his blood pressure. What is important to discuss with this client before he uses an over-the-counter decongestant? 1. Urinary frequency and diuresis 2. Bradycardia and diarrhea 3. Vasoconstriction and increased arterial pressure 4. Headache and dysrhythmias

3

A client in sickle cell crisis is admitted to the emergency department. What are the priorities of care in order of importance? 1. Nutrition, hydration, electrolyte balance 2. Hydration, pain management, electrolyte balance 3. Hydration, oxygenation, pain management 4. Hydration, oxygenation, electrolyte balance

3

During the night, a client with a diagnosis of acute coronary syndrome is found to be restless and diaphoretic. What is the best nursing action? 1. Check his temperature and determine his serum blood glucose level. 2. Turn the alarms low and promote sleep by decreasing the number of interruptions. 3. Check the monitor to determine his cardiac rhythm and evaluate vital signs. 4. Call the physician to obtain an order for sedation.

3

During the shift handoff report, the nurse learns that one of the assigned clients is in first-degree heart block. What action should the nurse take? 1. Count the radial pulse for 1 full minute. 2. Determine the cardiac rate at the point of maximum impulse. 3. Evaluate an ECG or monitor strip. 4. Take hourly pulse checks and correlate with blood pressure.

3

On auscultation, the nurse hears wheezing in a client with asthma. Considering the pathophysiology of asthma, what would the nurse identify as the primary cause of this type of lung sound? 1. Increased inspiratory pressure in the upper airways 2. Dilation of the respiratory bronchioles and increased mucus 3. Movement of air through narrowed airways 4. Increased pulmonary compliance

3

On the first postoperative day after a right lower lobe (RLL) lobectomy, the client deep breathes and coughs but has difficulty raising mucus. What nursing observation would indicate the client is not adequately clearing secretions? 1. Chest x-ray film showing right-sided pleural fluid 2. A few scattered crackles on RLL on auscultation 3. Increase in Paco2 from 35 to 45 mmHg 4. Decrease in forced vital capacity

3

The nurse is administering nitroglycerin intravenously to a client experiencing chest pain of an 8 on a 1 to 10 scale. What assessment changes would cause the nurse to decrease the infusion rate? 1. Pain drops from an 8 to a 4. 2. Heart rate increases from 110 to 115 beats per minute. 3. Blood pressure drops from 110/65 (80) to 89/44 (59) mmHg. 4. Client verbalizes his head is pounding.

3

The nurse is admitting a postoperative client after removal of an acoustic neuroma. What would be most important to include in the postoperative nursing care for this client? 1. Determining when the client will begin chemotherapy 2. Evaluating hearing status 3. Assessing for clear, colorless nasal discharge 4. Encouraging the client to discuss problems with hearing loss

3

The nurse is assessing a client whose condition is being stabilized after experiencing a ST-segment-elevation myocardial infarction. Which assessment is most indicative of inadequate renal perfusion? 1. Increasing serum blood urea nitrogen (BUN) level 2. Urine specific gravity of less than 1.010 3. Urine output of less than 30 mL/hr 4. Low urine creatinine clearance

3

The nurse is assessing a client with a tentative diagnosis of a brain tumor. What primary client complaint would the nurse anticipate? 1. Decreased appetite 2. Frequent insomnia 3. Recurrent headaches 4. Peripheral edema

3

The nurse is caring for a client being discharged after experiencing infective endocarditis. What is most important to include with the discharge teaching? 1. Begin an exercise regimen as soon as possible, progressively increasing intensity each day. 2. Monitor urinary output daily and report a change in color or quantity. 3. Continue antibiotic therapy until the prescription is completed. 4. Track and monitor heart rate and blood pressure daily upon arising.

3

The nurse is discharging a client with bilateral cataracts following cataract surgery on one eye. What statement by the client would indicate to the nurse the need for additional teaching? 1. "I'll call if I have a significant amount of pain." 2. "I'll remember to wash my hands before changing the eye dressing." 3. "I'll be okay by myself at home today." 4. "I will have someone help me with my eye medications.

3

The nurse is evaluating a teenager for hearing loss. In reviewing the client's history, the nurse knows that which finding is not associated with a hearing loss? 1. Listening to loud music on an iPod 2. Repeated chronic ear infections 3. Taking penicillin and cephalosporin medication 4. History of increased ear cerumen

3

The nurse is obtaining a health history from a client who reports having pain in the left arm. Which question by the nurse will elicit the most useful response from the client? 1. "Does the pain feel like pins and needles in your arm?" 2. "Does the pain radiate from your neck to your arms?" 3. "Can you describe the pain you are experiencing in your arm?" 4. "Is the numbness in your arm intermittent or constant?"

3

The nurse is providing teaching to a family whose child has been recently diagnosed with hemophilia. Which of the following would the nurse include in this discussion? 1. Hemophilia is a genetic disease that is more common in females. 2. Hemophilia is correctable through transfusions and bone marrow transplantation. 3. Hemophilia is most often a sex-linked congenital disorder. 4. Hemophilia is preventable through genetic counseling.

3

The nurse prepares to irrigate the external auditory canal for a client with impacted cerumen. What would be included in the correct technique for irrigation? 1. Use cool tap water. 2. Pour solution into ear canal. 3. Assess for signs of pain and tenderness in the ear. 4. Use a cotton-tipped applicator to clean near the tympanic membrane.

3

When teaching a family and a client about the use of a hearing aid, the nurse will base the teaching on what information regarding the hearing aid? 1. It provides mechanical transmission for the damaged part of the ear. 2. It stimulates the neural network of the inner ear to amplify sound. 3. It amplifies sound and directs it into the ear canal. 4. It will assist the client to interpret the incoming sounds more effectively.

3

While a client's wife is visiting, she observes the client's chest drainage system and begins to nervously question the nurse regarding the amount of bloody drainage in the system. What is the best response from the nurse? 1. "Your husband has been really sick; this must be a very difficult time. Let's sit down and talk about it." 2. "I have checked all of the equipment, and it is working fine; you do not need to worry about it." 3. "The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding." 4. "The chest tube is draining the secretions from his chest; it is important for him to deep breathe frequently."

3

An older adult client is taking digoxin 0.25 mg once a day and furosemide 40 mg daily. She states having increasing lethargy and nausea over the past 2 days, but she is still able to take her medication. Her blood pressure is 150/98 mmHg; pulse is 110 beats/min and irregular; respiratory rate is 18 breaths/min. What laboratory information is most important for the nurse to evaluate? 1. Hemoglobin, hematocrit, and white blood cell count 2. Arterial blood gases and acid-base balance 3. Blood urea nitrogen (BUN) and serum creatinine levels 4. Serum Electrolyte level

4

In discharge planning for the client with heart failure, the nurse discusses the importance of adequate rest. What information is most important? 1. A warm, quiet room is necessary. 2. Bed rest promotes venous return. 3. A hospital bed is necessary. 4. Adequate rest decreases cardiac workload.

4

A client is prescribed levothyroxine daily. What should the nurse include in the discharge teaching? Select all that apply. 1. Taper the dose, never stop abruptly. 2. Take it at bedtime to avoid the side effects. 3. Call the health care provider if you experience palpitations or nervousness. 4. Decrease the intake of juices and fruits with high potassium and calcium contents. 5. Regular follow-up care will be required.

3, 5

A 6-year-old client is admitted to the postoperative recovery area after a tonsillectomy. In what position will the nurse place the client? 1. Semi-Fowler's position, with the head turned to the side 2. Prone position, with the head of the bed slightly elevated 3. On the back, with the head turned to the right side 4. On the abdomen, with the head turned to the side

4

A child is scheduled for a myringotomy with placement of tympanostomy tubes. What is the long-term goal of this procedure that the nurse will discuss with the parents? 1. To decrease pressure on the tympanic membrane 2. To irrigate the eustachian tube 3. To correct a malformation in the inner ear 4. To prevent recurrent ear infections

4

A client is admitted for evaluation of his permanent pace-maker. Which assessment is most concerning? 1. Pulse rate of 96 beats/min with regular rate and rhythm 2. Irregular pulse rate with premature ventricular beats 3. Atrial premature beats shown on the monitor 4. Pulse rate of 48 beats/min with premature ventricular beats

4

A client is being admitted for problems with Ménière disease. What is most important for the nurse to assess to promote the client's safety? 1. Diet history 2. Screening hearing tests 3. Effect on client's activities of daily living (ADLs) 4. Frequency and severity of attacks

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A client is scheduled for a routine glycosylated hemoglobin A1c. What needs to be included in the teaching about the test? 1. Drink only water after midnight and come to the clinic early in the morning. 2. Eat a normal breakfast and be at the clinic 2 hours later. 3. Expect to be at the clinic for several hours because of the multiple blood draws. 4. Come to the clinic at the earliest convenience to have blood drawn.

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A client is scheduled for an electroencephalogram. What will the nurse explain to the client regarding the purpose of this test? 1. Evaluates electrical currents of skeletal muscles 2. Measures ultrasonic waves in the brain 3. Determines size and location of brain activity 4. Records brain electrical activity

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A client with hemophilia comes to the emergency department after bumping his knee. The knee is rapidly swelling. What is the first nursing action? 1. Initiate an IV site to begin administration of cryoprecipitate. 2. Perform a type and cross-match for possible transfusion. 3. Draw blood for determination of hemoglobin and hematocrit values. 4. Apply an ice pack and compression dressings to the knee.

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A nurse is planning care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). What is a priority problem that the nurse should consider for the patient, based on an understanding of this condition? 1. Disturbed sleep pattern related to nocturia. 2. Risk for fall related to hypovolemia. 3. Electrolyte imbalance related to metabolic acidosis. 4. Risk for seizures related to hyponatremia.

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A teenager is diagnosed with conjunctivitis. Which statement indicates that the teenager understood the nurse's teaching? 1. "I can let my friends use my sunglasses while we are together." 2. "It's okay for me to softly rub my eye, as long as I use the back of my hand." 3. "I can pick the crusty stuff out of my eyelashes with my fingers when I wake up in the morning." 4. "I will use my own wash cloth and towel for my face while my eyes are sick."

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The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home? 1. Because of his need for oxygen, the client will have to limit activity at home. 2. The use of oxygen will eliminate the client's shortness of breath. 3. Precautions are necessary because oxygen can spontaneously ignite and explode. 4. Use oxygen during activity to relieve the strain on the client's heart.

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The nurse is caring for a client who has hypersplenism. What laboratory test finding would indicate that the client has splenomegaly? 1. Presence of Reed-Sternberg cells 2. Elevated red blood cell count 3. Increased Bence-Jones protein in urine 4. Presence of Howell-Jolly bodies in a blood smear

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The nurse receives the new orders below for a client admitted in thyroid crisis. Which order should the nurse question? Jane Johnson MR: 96837 DOB: 6/5/1962 Allergies: NKDA Admission Orders - 5/20/19 · Admit to hospital for thyroid crisis · Cardiac monitor continuous · Hyperthermia blanket PRN · IV fluids 0.9% 50 mL/hr 3 1 liter · Propranolol · Propylthiouracil · Stat T3, T4, and TSH serum level 1. IV fluids. 2. Serum blood tests. 3. Propylthiouracil. 4. A hyperthermia blanket.

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The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information? 1. "You should avoid emotional situations that increase his shortness of breath." 2. "Help your husband arrange activities so that he does as little walking as possible." 3. "Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening." 4. "Your husband will be more short of breath when he walks, but that will not hurt him."

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Which statement correctly describes suctioning through an endotracheal tube? 1. The catheter is inserted into the endotracheal tube; intermit-tent suction is applied until no further secretions are retrieved; the catheter is then withdrawn. 2. The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway. 3. With suction applied, the catheter is inserted into the endo-tracheal tube; when resistance is met, the catheter is slowly withdrawn. 4. The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.

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When caring for a client with diabetes insipidus, which assessment changes require a priority action? Select all that apply. 1. Urine output change from 270 mL/hr to 100 mL/hr. 2. Finger stick glucose of 182 mg/dL. 3. Weight decrease of 1 kg overnight. 4. Urine becoming paler in color. 5. Serum osmolality of 300 mOsm/kg

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The nurse identifies which problems as risk factors for the development of a sickle cell crisis? Select all that apply. 1. Recurrence of acute otitis media 2. A fall with swelling at the kneecap and joint 3. Fractured radius requiring internal fixation 4. Recurrence of respiratory tract infection 5. Traveling to a location of higher altitude 6. Dehydration

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