Med Surg Exam 4 Ques
A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe
b. Client who reports shortness of breath
A student nurse learns that the spleen has several functions. What functions do they include? (Select all that apply.) a. Breaks down hemoglobin b. Destroys old or defective red blood cells (RBCs) c. Forms vitamin K for clotting d. Stores extra iron in ferritin e. Stores platelets not circulating
a. Breaks down hemoglobin b. Destroys old or defective red blood cells (RBCs) e. Stores platelets not circulating
A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a. Calling the Rapid Response Team b. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest
a. Calling the Rapid Response Team
A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful? a. Assist the client to make sick day plans for household responsibilities. b. Determine if there are family members or friends who can help the client. c. Help the client inform friends and family that they will have to help out. d. Refer the client to a social worker in order to investigate respite child care.
a. Assist the client to make sick day plans for household responsibilities.
A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition? a. Bence-Jones protein in urine b. Epstein-Barr virus: positive c. Hemoglobin: 18 mg/dL d. Red blood cell count: 8.2/mm3
a. Bence-Jones protein in urine
A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.) a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections
a. Chemical exposure c. Ionizing radiation exposure e. Viral infections
An older client asks the nurse why people my age have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.) a. Bone marrow produces fewer blood cells. b. You may have decreased levels of circulating platelets. c. You have lower levels of plasma proteins in the blood. d. Lymphocytes become more reactive to antigens. e. Spleen function declines after age 60.
a. Bone marrow produces fewer blood cells. c. You have lower levels of plasma proteins in the blood.
A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringers solution
a. 0.45% normal saline
A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV line.
a. Administer oxygen.
A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.) a. Argatroban (Argatroban) b. Bivalirudin (Angiomax) c. Clopidogrel (Plavix) d. Lepirudin (Refludan) e. Methylprednisolone (Solu-Medrol)
a. Argatroban (Argatroban) b. Bivalirudin (Angiomax) d. Lepirudin (Refludan)
A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best? a. Assess client fears and coping mechanisms. b. Reassure the client this is a common test. c. Sedate the client prior to the procedure. d. Tell the client he or she will be asleep.
a. Assess client fears and coping mechanisms.
A nurse is assessing a dark-skinned client for pallor. What action is best? a. Assess the conjunctiva of the eye. b. Have the client open the hand widely. c. Look at the roof of the clients mouth. d. Palpate for areas of mild swelling.
a. Assess the conjunctiva of the eye.
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running. c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.
a. Assess vital signs more often. b. Hold other IV fluids running.
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. Clean the skin and clip hairs if needed. b. Add gel to the electrodes prior to applying them. c. Place the electrodes on the posterior chest. d. Turn off oxygen prior to monitoring the client.
a. Clean the skin and clip hairs if needed.
A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? a. Client who had two bloody diarrhea stools this morning b. Client who has been premedicated for nausea prior to chemotherapy c. Client with a respiratory rate change from 18 to 22 breaths/min d. Client with an unchanged lesion to the lower right lateral malleolus
a. Client who had two bloody diarrhea stools this morning
The health care provider tells the nurse that a client is to be started on a platelet inhibitor. About what drug does the nurse plan to teach the client? a. Clopidogrel (Plavix) b. Enoxaparin (Lovenox) c. Reteplase (Retavase) d. Warfarin (Coumadin)
a. Clopidogrel (Plavix)
A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3
a. Creatinine: 2.9 mg/dL
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output
a. Decrease in cardiac output d. Increase in blood pressure e. Decrease in urine output
A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy
a. Dehydration c. Extreme stress d. High altitudes e. Pregnancy
The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued
a. Doing activities of daily living (ADLs) using rest periods
A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) a. Donor blood type A can donate to recipient blood type AB. b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone. d. Donor blood type O can donate to anyone. e. Donor blood type A can donate to recipient blood type B.
a. Donor blood type A can donate to recipient blood type AB. d. Donor blood type O can donate to anyone.
A client has Crohns disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconis anemia c. Hemolytic anemia d. Vitamin B12 anemia
a. Folic acid deficiency
A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication.
a. Give the client pain medication if it is time for another dose.
A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutes d. Using gloves to start the clients IV if needed and to handle the blood product e. Verifying the clients identity, and checking blood compatibility and expiration time
a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion d. Using gloves to start the clients IV if needed and to handle the blood product
A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best? a. It inhibits thrombin. b. It inhibits fibrinogen. c. It thins your blood. d. It works against vitamin K.
a. It inhibits thrombin.
A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences
a. Medication reconciliation
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
a. Mid-sternal chest pain
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching? a. Minimize or abstain from caffeine. b. Lie on your side until the attack subsides. c. Use your oxygen when you experience PACs. d. Take amiodarone (Cordarone) daily to prevent PACs.
a. Minimize or abstain from caffeine.
A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium
a. Smoking cessation b. Stress reduction and management d. Adverse effects of medications
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.) a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder for 8 weeks.
a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. e. Do not lift your left arm above the level of your shoulder for 8 weeks.
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching? a.Avoid carrying your grandchild with the arm that has the central catheter. b.Be sure to place the arm with the central catheter in a sling during the day. c.Flush the peripherally inserted central catheter line with normal saline daily. d.You can use the arm with the central catheter for most activities of daily
a.Avoid carrying your grandchild with the arm that has the central catheter.
A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? a.Check for kinking of the catheter. b.Flush the catheter with a thrombolytic enzyme. c.Get a new infusion pump. d.Remove the IV catheter
a.Check for kinking of the catheter.
While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? a.Grade 3 phlebitis at IV site b.Infection at IV site c.Thrombosed area at IV site d.Infiltration at IV site
a.Grade 3 phlebitis at IV site
A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a.Include a review for the need of the device each day in the clients plan of care. b.Remind the provider to perform hand hygiene prior to starting the procedure. c.Cleanse the preferred site with alcohol and let it dry completely before insertion. d.Ask everyone in the room to wear a surgical mask during the procedure. e.Plan to complete a sterile dressing change on the device every day.
a.Include a review for the need of the device each day in the clients plan of care. b.Remind the provider to perform hand hygiene prior to starting the procedure. d.Ask everyone in the room to wear a surgical mask during the procedure.
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications? a.Initiate a dedicated team to insert access devices. b.Require additional education for all nurses. c.Limit the use of peripheral venous access devices. d.Perform quality control testing on skin preparation products.
a.Initiate a dedicated team to insert access devices.
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.) a.Phlebitis b.Pneumothorax c.Thrombophlebitis d.Excessive bleeding e.Extravasation
a.Phlebitis c.Thrombophlebitis
A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.) a.State Nurse Practice Act b.The facilitys Policies and Procedures manual c.The LPNs level of education and experience d.The Joint Commissions goals and criterion e.Client needs and prescribed orders
a.State Nurse Practice Act b.The facilitys Policies and Procedures manual
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a.Unique facility identifier b.Lot number related to the donor c.Name of the client receiving blood d.ABO group and Rh type of the donor e.Blood type of the client receiving blood
a.Unique facility identifier b.Lot number related to the donor d.ABO group and Rh type of the donor
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease
b. A 50-year-old who is post coronary artery bypass graft surgery
A nursing student learns that many drugs can impair the immune system. Which drugs does this include? (Select all that apply.) a. Acetaminophen (Tylenol) b. Amphotericin B (Fungizone) c. Ibuprofen (Motrin) d. Metformin (Glucophage) e. Nitrofurantoin (Macrobid)
b. Amphotericin B (Fungizone) c. Ibuprofen (Motrin) e. Nitrofurantoin (Macrobid)
The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Delegate taking a set of vital signs. d. Look at todays laboratory results.
b. Assess the client for infection.
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature
b. Assess vital signs and level of consciousness.
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.
b. Avoid straining while having a bowel movement.
A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.) a. Azacitidine (Vidaza) b. Darbepoetin alfa (Aranesp) c. Decitabine (Dacogen) d. Epoetin alfa (Epogen) e. Methylprednisolone (Solu-Medrol)
b. Darbepoetin alfa (Aranesp) d. Epoetin alfa (Epogen)
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Documenting the events in the clients medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies
b. Double-checking the client and blood product identification
A client is having a bone marrow biopsy today. What action by the nurse takes priority? a. Administer pain medication first. b. Ensure valid consent is on the chart. c. Have the client shower in the morning. d. Premedicate the client with sedatives.
b. Ensure valid consent is on the chart.
A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiers b. Ensuring informed consent is obtained if required c. Hanging the blood product with Ringers lactate d. Staying with the client for the entire transfusion
b. Ensuring informed consent is obtained if required
A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? a. Both you and the father are equally responsible for passing it on. b. I can see you are upset. I can stay here with you a while if you like. c. Its not your fault; there is no way to know who will have this disease. d. There are many good treatments for sickle cell disease these days.
b. I can see you are upset. I can stay here with you a while if you like.
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. I should wear a snug-fitting shirt over the ICD. b. I will avoid sources of strong electromagnetic fields. c. I should participate in a strenuous exercise program. d. Now I can discontinue my antidysrhythmic medication
b. I will avoid sources of strong electromagnetic fields.
A nurse works in a gerontology clinic. What age-related changes cause the nurse to alter standard assessment techniques from those used for younger adults? (Select all that apply.) a. Dentition deteriorates with more cavities. b. Nail beds may be thickened or discolored. c. Progressive loss of hair occurs with age. d. Sclerae begin to turn yellow or pale. e. Skin becomes dry as the client ages.
b. Nail beds may be thickened or discolored. c. Progressive loss of hair occurs with age. e. Skin becomes dry as the client ages.
A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.) a. Headaches b. Night sweats c. Persistent fever d. Urinary frequency e. Weight loss
b. Night sweats c. Persistent fever e. Weight loss
A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? a. Encourage high-protein foods. b. Perform a Hemoccult test on the clients stools. c. Offer frequent oral care. d. Prepare to administer cobalamin (vitamin B12).
b. Perform a Hemoccult test on the clients stools.
After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98 F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2 F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.
b. Slow the amiodarone infusion rate.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity
b. Speech alterations
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side
b. Turn off oxygen therapy.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)
b. Warfarin (Coumadin)
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? a.Notify the health care provider. b.Administer the prescribed medication. c.Discontinue the PICC. d.Switch the medication to the oral route.
b.Administer the prescribed medication.
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a.Begin the prescribed infusion via the new access. b.Ensure an x-ray is completed to confirm placement. c.Check medication calculations with a second RN. d.Make sure the solution is appropriate for a central
b.Ensure an x-ray is completed to confirm placement.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a.Administer topical lidocaine to the site. b.Place warm compresses on the site. c.Administer prescribed oral pain medication. d.Massage the site with scented oils.
b.Place warm compresses on the site.
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a.Administer a sublingual nitroglycerin tablet. b.Prepare to assist with chest tube insertion. c.Place a sterile dressing over the IV site. d.Re-position the client into the Trendelenburg position.
b.Prepare to assist with chest tube insertion.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a.Redness at the catheter insertion site b.Report of headache and stiff neck c.Temperature of 100.1 F (37.8 C) d.Pain rating of 8 on a scale of 0 to 10
b.Report of headache and stiff neck
A nurse is caring for four clients. After reviewing todays laboratory results, which client should the nurse see first? a. Client with an international normalized ratio of 2.8 b. Client with a platelet count of 128,000/mm3 c. Client with a prothrombin time (PT) of 28 seconds d. Client with a red blood cell count of 5.1 million/L
c. Client with a prothrombin time (PT) of 28 seconds
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond? a. Substance abuse puts clients at risk for many health issues. b. The hospital requires that I ask you about cocaine use. c. Clients who use cocaine are at risk for fatal dysrhythmias. d. We can provide services for cessation of substance abuse.
c. Clients who use cocaine are at risk for fatal dysrhythmias.
A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist with oral hygiene using a firm toothbrush. b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.
c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.
A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? a. Arrange a visitation schedule among friends and family. b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.
c. Help the client find things to hope for each day of recovery.
A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition? a. I brush and use dental floss every day. b. I chew hard candy for my dry mouth. c. I usually put ice on bumps or bruises. d. Nonslip socks are best when I walk.
c. I usually put ice on bumps or bruises.
A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the clients legs. b. Elevate the clients legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the clients legs.
c. Keep the lower extremities warm.
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability
c. Level of consciousness
A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.) a. Not allowing any visitors until engraftment b. Limiting the protein in the clients diet c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants
c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.
c. Schedule periods of exercise and rest during the day.
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis
c. Short period of asystole
A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? a. Genetic testing b. Infection prevention c. Sperm banking d. Treatment options
c. Sperm banking
A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug? a. Enoxaparin (Lovenox) b. Salicylates (aspirin) c. Unfractionated heparin d. Warfarin (Coumadin)
c. Unfractionated heparin
A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? a.You will need to wear a sling on your arm while the device is in place. b.There is no risk of infection because sterile technique will be used during insertion. c.Ask all providers to vigorously clean the connections prior to accessing the device. d.You will not be able to take a bath with this vascular access device.
c.Ask all providers to vigorously clean the connections prior to accessing the device.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.
d. Ensure that everyone is clear of contact with the client and the bed.
A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best? a. It is due to side effects of medications for bronchodilation. b. It is from overactive bone marrow in response to chronic disease. c. It combats the anemia caused by an increased metabolic rate. d. It compensates for tissue hypoxia caused by lung disease.
d. It compensates for tissue hypoxia caused by lung disease.
A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best? a. Encourage high-protein foods. b. Institute neutropenic precautions. c. Limit visitors to healthy adults. d. Place the client on safety precautions.
d. Place the client on safety precautions.
A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusion b. Placing the client on NPO status c. Placing the client in isolation d. Putting on a pair of gloves
d. Putting on a pair of gloves
A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? a. Preparing to administer a blood transfusion b. Reinforcing the dressing and documenting findings c. Removing the dressing and assessing the surgical site d. Taking a set of vital signs and notifying the surgeon
d. Taking a set of vital signs and notifying the surgeon
A client is having a radioisotopic imaging scan. What action by the nurse is most important? a. Assess the client for shellfish allergies. b. Place the client on radiation precautions. c. Sedate the client before the scan. d. Teach the client about the procedure
d. Teach the client about the procedure
A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best? a. Because of immunosuppression, the donor cells take over. b. Its like a transfusion reaction because no perfect matches exist. c. The clients cells are fighting donor cells for dominance. d. The donors cells are actually attacking the clients cells.
d. The donors cells are actually attacking the clients cells.
A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present. b. The client is in a blast crisis and has too many WBCs. c. There must be a mistake; the WBCs should be very low. d. Those WBCs are abnormal and dont provide protection.
d. Those WBCs are abnormal and dont provide protection.
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
d. Ventricular and atrial depolarizations are initiated from different sites.
A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately? a. Hematocrit: 25% b. Hemoglobin: 9.2 mg/dL c. Potassium: 3.2 mEq/L d. White blood cell count: 38,000/mm3
d. White blood cell count: 38,000/mm3
A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client? a. Bortezomib (Velcade) b. Dexamethasone (Decadron) c. Thalidomide (Thalomid) d. Zoledronic acid (Zometa)
d. Zoledronic acid (Zometa)
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? a.Allergic reaction b.Bowel obstruction c.Catheter lumen occlusion d.Infection
d.Infection
A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure? a.Lower the extremity below the level of the heart. b.Apply warm compresses to the extremity. c.Tap the skin lightly and avoid slapping. d.Place a washcloth between the skin and tourniquet.
d.Place a washcloth between the skin and tourniquet.
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a.Amount of pressure in fluid container b.Date of catheter tubing change c.Percent of heparin in infusion container d.Presence of an ulnar pulse
d.Presence of an ulnar pulse
A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a.Apply cold compresses to the IV site. b.Elevate the extremity on a pillow. c.Flush the catheter with normal saline. d.Stop the infusion of intravenous fluids.
d.Stop the infusion of intravenous fluids.
A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a.The catheter has been in place for 20 hours. b.The client has poor vascular access in the upper extremities. c.The catheter is placed in the proximal tibia. d.The clients left lower extremity is cool to the touch.
d.The clients left lower extremity is cool to the touch.
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a.The initial site dressing is 3 days old. b.The PICC was inserted 4 weeks ago. c.A securement device is absent. d.Upper extremity swelling is noted
d.Upper extremity swelling is noted
A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a.Provide a bed bath instead of letting the client take a shower. b.Use sterile technique when changing the dressing. c.Disconnect the intravenous fluid tubing prior to the clients bath. d.Use a plastic bag to cover the extremity with the device.
d.Use a plastic bag to cover the extremity with the device.
