CM2- Exam 1 Practice Questions

The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data?

"I usually drink two vodkas to help me get to sleep each night."

A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PC button for the sleeping client. What will the nurse say to the visitor?

"Please allow the client to push the button when needed."

A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate?

"That sounds like a great plan; can you tell me more about it?"

The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client?

"When does the pain occur?"

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Elevating the head of the bed

For which client does the nurse remain alert for the possibility of respiratory acidosis?

Client with multiple rib fractures

An adult client in the clinic reports a cough, fever, feeling weak and dizzy, and having nausea and vomiting for three days. Examination reveals dry tongue and oral mucosa, and concentrated urine. To best assess the client's fluid status, the nurse checks which assessment parameters?

Blood pressure and pulse in lying, sitting, and standing positions

The nurse is assessing a client's peripheral IV infusion site. The nurse is aware that all the following are signs of infiltration except:

Warmth of skin at the insertion site with the appearance of a red and inflamed vein

Arterial blood gases on a client with pneumonia indicate that client is in respiratory acidosis. In order to best improve this acid-base imbalance, the nurse implements which of the following nursing interventions? Select all that apply

-Ambulate the client in hallwavs twice each shift -Encourage frequent coughing and deep breathing exercises -Administer bronchodilators as ordered

The nurse is admitting an older adult client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and changes in cognition. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? Select all that apply

-Decreased skin turgor/ tenting -Concentrated urine -Low-grade fever -Orthostatic hypotension

A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.)

-Distraction -Music therapy -Premedication

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 b) in 48 hr. Which of the following manifestations of fluid volume overload? Select all that apply

-Dyspnea -Dependent, pitting edema -Hypertension -Bounding pulses

The nurse is documenting a pain assessment. Which pain descriptions document location of pain? (Select all that apply.)

-Referred pain -Localized pain -Radiating pain

A client is being transferred from the post-anesthesia care unit (PACU) to the medical-surgical unit. The nurse from PACU should report which information to the nurse in the medical-surgical unit? Select all that apply

-Type of surgery -Current vital sians -Amount of blood loss -IV fluids infusing including rate and what type of fluid

The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action?

Administer a dose of naloxone 0.4 mg slow IV push.

A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next?

Administer the pain medication as requested.

Before surgery a client states that she is afraid of surgery because her cousin died in surgery when having her tonsils removed. What is the nurse's best response?

Ask the client if anyone else in her family has had complications when they had surgery

A dehydrated client is to receive a continuous infusion of IV fluids. What best practice standard must the nurse consider when placing a short peripheral venous catheter?

Avoid choosing a site in an area of joint flexion

The nurse assesses a client diagnosed with human immunodeficiency virus (HIV) infection. Which scenario suggests to the nurse that the client has acquired immunodeficiency syndrome (AIDS) wasting syndrome?

A 46-year-old female who has lost an extreme amount of body weight due to anorexia has had diarrhea for the past 5 days, has oral and esophageal lesions, and appears emaciated

The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client?

Accept the client's report of pain.

The medical-surgical floor receives a patient from the post-anesthesia care unit (PACU). Ten minutes ago, the final assessment in PACU indicated that the client had a patent airway and stable vital signs. The client's pain level was "2." What should the nurse do next?

Check the dressings for signs of bleeding

The nurse evaluates the patency of a peripheral intravenous (IV) site. Which action would the nurse take to determine if phlebitis is present?

Check the regional tissue for redness and warmth

The health care provider has written these orders for a patient with fluid volume overload that has developed pulmonary edema. The patient's morning assessment reveals bounding peripheral pulses, a weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?

Give Diuretics/ meds (furosemide)

After receiving detailed information about a bowel resection surgery from the primary health care provider (PHCP), the nurse asks the client to sign the informed consent form and discovers the client cannot write. Which is the best intervention for the nurse to implement?

Have 2 nurses witness the client sign with an X

An older adult client admitted to the hospital for heart failure has a history of a fractured hip due to a previous fall. The client is taking hydrocodone-acetaminophen as needed for pain secondary to an extensive dental procedure. Which risk factor puts this client at greatest risk for a fall?

History of a fall

At a follow-up homecare visit after repair of a fractured radial bone, an older adult client states, "I am not sleeping at all during the night." The client's partner reports that the client is sleeping all day. Which intervention does the nurse suggest?

Increasing the client's daytime activities

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)?W

Initiating continuous cardiac monitoring

Overuse and intoxication of the following substances all have the potential to cause respiratory acidosis except:

Methylprednisolone, a corticosteroid

An older adult client with end-stage lung cancer and metastasis to the brain has been admitted to the hospital. After trying all options to provide a safe environment, the nursing staff has to apply restraints. Which nursing intervention is required for this client?

Releasing the restraints at least every 2 hours

A nurse is instructing a client who had an abdominal surgery to do deep-breathing exercises. The nurse should teach the client that which of the following should be done first when performing deep breathing and coughing?

Splint the incision site

An older adult client whose spouse died the previous year says to the nurse, "Life is not fun anymore." How does the nurse respond?

Tell me about your support network, such as friends or family."