C471

During the evening after a thoracentesis, the pt reports anxiety. Which action would the nurse take FIRST? A) administer the prescribed analgesic B) listen to the pts breath sounds C) give the pt the prescribed as needed lorazepam D) ask the pt about specific concerns or worries

B

The nurse is providing post-op care to a pt after an abdominal surgery. Which assessment finding would be reported to the surgeon immediately? A) RR drops to 12 during sleep compared with 16 during admission history-taking B) oxygen sats drops to 90% compared with 99% during admission history- taking C) reports pain during deep breathing and coughing exercises D) breath sounds diminished in lung bases before deep- breathing exercises.

B

When a pt with COPD has a new prescription for daily low-dose prednisone, which info will the nurse include when teaching the pt? A) take the med an hour before eating B) report any dark stools to the HCP C) weight loss is a common side effect of the med. D) take the med as soon as you experience any dyspnea

B

Which action would the nurse anticipate when admitting a clean having a sickle cell crisis to the nursing unit? Select all that apply A) place on strict isolation B) administer hydroxyurea C) administer aspirin 325 mg daily D) apply oxygen via nasal cannula E) administer IV hydration F) avoid opiate- type analgesics

B) administer hydroxyurea D) apply oxygen via nasal cannula E) administer iv hydration

Which symptoms requires the MOST rapid action by the nurse when caring for a client with known peripheral arterial disease who calls the clinic and tells the nurse about experiencing several symptoms? A) anxiety B) chest pain C) weak pulse quality D) cool and pale lower legs

B) chest pain

Which finding will cause the nurse to suspect cardiac tamponade in a client who has had cardiac surgery? A) hypertension B) pulsus paradoxus C) muffle heart sounds D) jugular vein distention E) increased urine output

B, C, D

Which action by the nurse is the PRIORITY when a client who had abdominal surgery 24 hours ago develops pain, redness, and swelling in the left calf? A) elevate legs B) document the findings C) notify the health care provider D) give the prescribed pain meds

C) notify the health care provider

Which medical intervention would the nurse anticipate will be included in the management of a pt with acute respiratory distress syndrome( ARDS)? A) chest tube insertion B) aggressive diuretic therapy C) administration of beta- blockers D) positive end- expiratory pressure (PEEP)

D

What medication is given to treat rapid atrial fibrillation?

Diltiazem

In which order would the nurse complete these steps when administering a blood transfusion? 1. Change main line solution to normal saline 2. Obtain VS and history of transfusions 3. Check client identification before hanging unit of blood 4. Check PHP prescription 5. Ascertain that IV catheter size is 18-20 gauge.

1. Check PHCP prescription 2. Obtain VS and history of transfusions 3. Ascertain that IV catheter size is 18-20 gauge. 4. Change main like solution to normal saline. 5. Check client identification before hanging unit of blood.

In which order will the nurse take these actions when caring for a client who is having a hemolytic reaction to a transfusion of packer RBC? 1. Notify the HCP and blood bank 2. Change the IV administration set 3. Run 0.9% normal saline at a rapid rate 4. Stop the transfusion

1. Stop the transfusion 2. Change the IV administration set 3. Run 0.9% normal saline at a rapid rate 4. Notify the HCP and blood bank

Which action would the nurse take FIRST when a client who is receiving a potassium infusion via a peripheral IV site reports a burning sensation above the IV site? A) check the IV access for a blood return B) apply warm compresses to the affected extremity C) slow the IV infusion until the burning sensation is gone D) request an oral supplement from the primary health care provider

A) check the IV access for a blood return

Which topic will the nurse include when teaching a client who has a new diagnosis of polycythemia Vera? A) need for high fluid intake B) purpose for iron supplements C) avoidance of any aspirin use D) self- administration of erythropoietin

A) need for high fluid intake

Which action would the nurse take when a client with CAD and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of SOB? A) suggest that the client call 911 B) have the client take slow, deep breaths C) schedule the client to be seen in the clinic in 1 hour D) have the client take a low does aspirin tablet immediately

A) suggest that the client call 911

Which actions will the nurse take when caring for a pt with a chest tube in place after thoracotomy? Select all that apply A) administer prescribed analgesic meds. B) check around chest tube insertion site for crepitus C) clamp the chest tube before the pt ambulates D) add fluid to the suction control chamber as needed E) milk the tubing toward the collection chamber F) check for air bubbling in the water-seal chamber

A, B, D, F

Which action by the nurse is a priority in the immediate post- op period after splenectomy? A) monitor HR B) take BP C) listen to vowel sounds D) Check urine output E) auscultate lung sounds F) look for abdominal distention

A,B,D,E,F

Which info will the nurse consider when planning care for a client with HIV who has been diagnosed with class 3 TB? Select all that apply A) class 3 TB is a clinically active disease, which is contagious B) TB is the leading cause of mortality in pts infected with HIV C) HIV- positive pts are more likely to have multi drug resistant TB D) individuals with HIV usually have high fevers with active TB infection. E) persons with active TB are usually treated on an outpatient basis.

A,B,E

A pt has a leaking thoracic duct after a radical neck surgery. The nurse expected that the post-op place of care will include which prescriptions? A) a gastrostomy tube, a high- fat diet, and bed rest B) a chest tube, TPN, and bed rest C) a rectal tube, a low- fat diet, and increased activity D) a NG tube, moderate-fat diet, and increased activity

B

Which collaborative action will the nurse anticipate a need to implement when a client with acute myelocytic leukemia who is receiving chemotherapy develops tumor lysis syndrome? A) offer analgesics frequently B) infuse large amounts of fluids C) administer antibiotic therapy D) give anticoagulant medication

B) infuse large amounts of fluids

A pt with AIDS and cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this pt a bath, which protective equipment would the nurse use? Select all that apply A) goggles B) surgical mask C) shoe covers D) gown E) gloves F) N95 HEPA mask

B, D, E

The nurse determined a pt's ABG's reflected a compensated respiratory acidosis. The pH was 7.34; which addition lab value did the nurse consider? A) the partial pressure of oxygen (PO2) value is 80mm Hg. B) the partial pressure of carbon dioxide (PCO2h value is 60mm Hg. C) the bicarbonate (HCO3) value is 50mEq/l D) serum potassium value is 4mEq/L

C

Which client is at an increased risk for hospital- acquired pneumonia? A) pt who was admitted yesterday with hypoxia and fever B) pt who has been on mechanical ventilation for 5 days C) pt who reports being on an airplane with other sick individuals D) pt who was admitted to the hospital 5 days ago for abdominal pain

D)

which abnormal lab value will the nurse expect when caring for a client with iron-deficiency anemia? A) macrocytic RBC's B) thrombocytopenia C) decreased folate levels D) increased total iron- binding capacity (TIBC)

D) increased total iron- binding capacity (TIBC)

Which action by the nurse is a PRIORITY when review of lab results for a client with heart failure who has been receiving furosemide daily reveals a blood urea nitrogen (BUN) of 42mg/dL and a creatinine of 1.1mg/dL? A) administering the furosemide as scheduled B) starting strict I&O's measurements C) sending a urine specimen for specific gravity testing D) notifying the HCP about the results

D) notifying the HCP about the results

Which finding in a client with right calf venous thrombosis is MOST important to communicate to the HCP? A) severe right calf pain B) right calf redness & swelling C) oxygen saturation 89% D) heart rate of 136 bpm

Oxygen saturation of 89%