MedSurg Exam 3

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the front of the left arm. What extent of burns does the client most likely have, measured as a percentage?

18%

A 35-year-old male client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

A

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A) "That's something that you and your doctor will likely talk about after your scars mature." B) "That is something for you to talk to your doctor about because it's not a nursing responsibility." C) "I know this is really important to you, but you have to realize that no one can make you look like you used to." D) "Unfortunately, it's likely that these scars will look like this for the rest of your life."

A

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping

A

A patient is recovering from a thyroidectomy. The patient starts to complain of tingling and numbness in the face, toes, and fingers. Which of the following findings below warrants attention? A. Ca+ level: 6 mg/dL B. Na+ level: 145 mg/dL C. K+ level: 3.5 mg/dL D. Phosphate level: 4.3 mg/dL

A

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea

A

Which medication is contraindication for a patient scheduled for a craniotomy procedure the next day? A. Aspirin B. Non-opioid analgesics C. Corticosteroid D. Antiemetic

A

Which of the following is an appropriate recommendation for a client with a migraine? A. Rest in cool, dark room B, Medicate after the onset of symptoms C. Apply a warm moist cloth for head D. Rest in a warm, well lit room

A

A patient presents to the ER with a history of GERD. What symptoms would the nurse expect to find? SATA. A. Pyrosis B. Dull gnawing pain C. Pain relieving by sitting upright D. Reports pain like MI E. Black tarry stools

A, C, D pyrosis is the burning sensation

A patient presents to the ED with a possible diagnosis of gastritis. What symptoms would the nurse expect to observe upon the patient's arrival? SATA. A. Hiccuping B. Green sputum C. Lower abdominal pain D. Dyspepsia E. Bloating

A, D, E

A client has completed the acute treatment phase of care following a stroke and the client will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process? A. To provide 24-hour, collaborative care for the client B. To restore the client's ability to function independently C. To minimize the client's time spent in acute care settings D. To promote rapport between caregivers and the client

B

A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The client has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding? A) Inform the primary provider promptly B) Document this as an expected assessment finding C) Limit the client's fluid intake to 2 L for the next 24 hours D) Administer a loop diuretic as prescribed

B

A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? A) Taking an opioid analgesic as prescribed B) Applying a cold pack to the injured site C) Performing passive ROM exercises D) Applying a heating pad to the affected muscle

B

A client has sustained a long bone fracture and the nurse is preparing the client's care plan. Which of the following should the nurse include in the care plan? A) Administer vitamin D and calcium supplements as prescribed B) Monitor temperature & pulses of affected extremity C) Perform passive range of motion exercises as tolerated D) Administer corticosteroids as prescribed

B

A client is alarmed that she has tested positive for MRSA following culture testing during her admission to the hospital. What should the nurse teach the client about this diagnostic finding? A) "There are promising treatments for MRSA, so this is no cause for serious concern." B) "This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces." C) "The vast majority of clients in the hospital test positive for MRSA, but the infection doesn't normally cause serious symptoms." D) "This finding is only preliminary, and your doctor will likely order further testing."

B

A client is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The client is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A) "Actually, clients are only on bed rest for 2 to 3 days before they begin walking with assistance." B) "The physical therapist will likely help you get up using a walker the day after your surgery." C) "Our goal will actually be to have you walking normally within 5 days of your surgery." D) "For the first 2 weeks after the surgery, you can use a wheelchair to meet your mobility needs."

B

A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care? A) "Cover the cast with a blanket until the cast dries." B) "Keep your right leg elevated above heart level." C) "Use a clean object to scratch itches inside the cast." D) "A foul smell from the cast is normal after the first few days."

B

A patient hospitalized with hypoparathyroidism is about to order lunch. Which food selection is best for this patient based on their dietary needs at this time? A. Baked chicken, green beans, and boiled potatoes B. Spinach salad, cottage cheese, and peaches C. Roast beef, carrots, and pinto beans D. Hamburger, fries, and sorbet

B

The critical care nurse is caring for a patient who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the patient's left ventricular function? A) Central venous pressure (CVP) monitoring B) Pulmonary artery pressure monitoring (PAPM) C) Systemic arterial pressure monitoring (SAPM) D) Arterial blood gases (ABG)

B

A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemetics B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of PPI as prescribed

B. Insertion of an NG tube for decompression

A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the client to keep the wound site in a dependent position B) Administer PRN analgesia as prescribed C) Assess the client's peripheral pulses distal to the dressing D) Assist with passive range-of-motion exercises to "set" the new dressing

C

A patient admitted with a diagnosis of pneumonia develops left-sided weakness, slurred speech and dysphagia. What is the intervention of highest priority? A. Insert an indwelling urinary catheter B. Perform a bedside dysphagia screening C. Expedite a CT scan of the head without contrast Obtain a 12 lead ECG

C

The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a client receiving skeletal traction. What nursing intervention best addresses this risk? A) Encourage independence with ADLs whenever possible B) Monitor the client's nutritional status closely. C) Teach the client to perform ankle and foot exercises within the limitations of traction D) Administer clopidogrel as prescribed

C

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A. Complaint of headache off and on for past month B. No bowel movement since yesterday C. Nausea D. Frequent voiding E. Explanation

C Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for past month is significant and probably attributes to the evaluation at hand. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

A client was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The client's skin will eventually show what manifestation? A) Erythema B) Ecchymosis C) Desquamation D) Necrosis

D

The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse should expect to treat a large number of clients who have experienced what type of injury? A) Chemical burns B) Spinal cord injury C) Meningeal tears D) Tympanic membrane rupture

D

When assessing clients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A) Neuro toxin B) Blood agent C) Pulmonary agent D) Vesicant

D

Which of the following patients have the highest risk for developing neurogenic shock? A. Patient who had recent gunshot wound B. Patient who had recent parathyroid tumor removal C. Patient who had recent bariatric surgery D. Patient who had recent surgery and received spinal anesthesia

D

Your patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected? A. Expressive; Wernicke's area B. Receptive, Broca's area C. Expressive; hippocampus D. Receptive; Wernicke's area

D

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? A. Decreased heart rate B. Bradycardia C. Alteration in level of consciousness (LOC) D. Slurred speech

FIRST: LOC Others later w/o treatment

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal?

Hypocalcemia

https://www.youtube.com/watch?v=58Y0OfOVzMo

Sepsis

A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding? A. Vision problems B. Balance impairment C. Language difficulty D. Impaired short-term memory

The answer is B. The cerebellum is important for coordination and balance.

A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding? A. Brain stem B. Hippocampus C. Parietal lobe D. Occipital lobe

The answer is D. The occipital lobe is responsible for vision and color perception.

A client is brought by ambulance to the emergency room after suffering with the family thinks is a stroke. The nurse is caring for this client is aware that the absolute contraindication for thrombolytic therapy is what? a)Evidence of hemorrhagic stroke b)Blood pressure > 180/110 mm Hg c)Evidence of stroke evolution d)Previous thrombolytic therapy within the last 12 months

a

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse is primary assessment focus? a)Cardiac and respiratory status b)Seizure activity c)Pain d)Fluid and electrolyte balance

a

The nurse is assessing a client diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find?

bulging eyes

What foods contribute to GERD?

no alcoholic beverages

Family members are caring for a client with HIV in the client's home. What should the nurse encourage family members to do to reduce the risk of infection transmission? A) Use caution when shaving the client. B) Use separate dishes for the client and family members. C) Use separate bed linens for the client. D) Disinfect the client's bedclothes regularly.

A

Which of the following patients are most likely to experience secondary hyperparathyroidism? A. A 58 year-old male with chronic renal failure. B. A 69 year-old female with an adenoma on the parathyroid gland. C. A 56 year-old male with a magnesium level of 0.5 mg/dL. D. A 7 year-old with diabetes type 1.

A

A critical care nurse is caring for a patient with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. A) Pneumothorax B) Infection C) Atelectasis D) Bronchospasm E) Air embolism

A, B, E

A nurse is educating a patine who is schedules for R-Y gastric bypass. Which statement made by the pt indicates further education is needed? SATA. A. I won't need to change my diet if I maintain adequate daily exercise B. I will likely need to take a multivitamin daily C. I should increase the protein in my diet D. I should report experience feelings of fullness and dizziness E. I can resume drinking soda, beer and other carbonated drinks after my PO visit

A, E

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? A. Flat B. Supine, with the head of the bed elevated 30 degrees C. Flat, except for logrolling as needed D. A head elevation of 90 degrees to prevent cerebral swelling

A, using cervical collar and logrolling

The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to see ordered to reduce edema and inflammation around the tumor? A. Solumedrol B. Aspirin C. Vasopressin D. Furosemide

A. Solumedrol

A nurse is triaging clients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis

B

A patient presents with hypovolemic shock. Which CM would be expected? SATA. A. Bradycardia B. Hypotension C. Tachypnea D. Anxiety E. Tachycardia

B, C, D, E

A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? SATA. A. Administering diuretics to prevent fluid overload B. Administering beta-blockers to reduce heart rate C. Administering insulin to reduce blood glucose levels D. Applying interventions to reduce the client's temperature E. Administering corticosteroid

B, D

A client is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russell traction B) Dunlop traction C) Buck's extension traction D) Cervical halter

C

A client is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the client's need for exercise? A) Performing gentle leg lifts with both legs B) Performing massage to stimulate circulation C) Encouraging frequent use of the over-bed trapeze D) Encouraging the client to logroll side to side once per hour

C

A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? A) Determining whether the incident was managed effectively B) Educating survivors on potential coping strategies for future disasters C) Providing individuals with education about recognizing stress reactions D) Determining if individuals responded appropriately during the incident

C

A nurse has had contact with a client who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment? A) Watchful waiting B) Treatment with colony-stimulating factors (CSFs) C) Vaccination D) Treatment with ceftriaxone

C

A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A) Unclassified seizure B) Absence seizure C) Generalized seizure D) Focal seizure

C

An elderly pt has been in the ICU for a week and continues to require mechanical ventilation. Which of the following medications would the nurse expect to administer for peptic ulcer prophylaxis? A. Fluoxetine B. Calcium carbonate C. Omeprazole D. Furosemide

C

A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? A) Place slight additional tension on the traction cords B) Release the weights and replace them immediately after positioning C) Reposition the bed instead of repositioning the client D) Maintain consistent traction tension while repositioning

D

A patient is receiving IV antibiotics to treat Ann infection. The nurse notes the patient begins to experience wheezing, stridor, flushing, and pruritus. What is the priority nursing intervention? A. Document the patient's symptoms B. Administer norepinephrine and reassess vital signs C. Call the HCP D. Assure a patent airway and administer oxygen

D first time don't stopp med

The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? A. It slows the proliferation of bacterial and viruses during shock B. It decreases the energy expended through the functioning of the GI system C. It assists in expanding the intravascular volume of the body D. It promotes GI function through direct exposure to nutrients

D. It promotes GI function through direct exposure to nutrients.

A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care? A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours.

The answer is A. It is important to watch for neglect syndrome. This tends to happen in right side brain damage. The patient ignores the left side of the body in this condition. The nurse needs to remind the patient to use and touch both sides of the body daily and that the patient must make a conscious effort to do so.

A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected? A. Frontal lobe B. Occipital lobe C. Parietal lobe D. Temporal

The answer is D. The temporal lobe is responsible for hearing, learning, and feelings/emotions.

Your patient has expressive aphasia. Select all the ways to effectively communicate with this patient? A. Fill in the words for the patient they can't say. B. Don't repeat questions. C. Ask questions that require a simple response. D. Use a communication board. E. Discourage the patient from using words.

The answers are C and D. Patients with expressive aphasia can understand spoken words but can't respond back effectively or at all. Therefore be patient, let them speak, be direct and ask simple questions that require a simple response, and communicate with a dry erase board etc.

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury? A)Hematoma B)Skull fracture C)Embolus D)Stroke

a

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? a)Generalized pain b)Alteration in the level of consciousness c)Tonic clonic seizures d)Shortness of breath

b

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A)Prepare to transfuse packed red blood cells. B)Prepare for interventions to increase the patient's BP. C)Place the patient in the Trendelenberg position. D)Prepare an ice bath to lower core body temperature.

b

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hyper-motility C) Respiratory arrest D) Hypokalemia

A

A nurse who provides care in a busy ED is in contact with hundreds of clients each year. The nurse has a responsibility to receive what vaccine? A) SARS-CoV-2 vaccine B) Human Papillomavirus (HPV) vaccine C) Clostridium difficile vaccine D) Staphylococcus aureus vaccine

A

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? A. Fluid volume circulating in the blood vessels decreases. B. There is an uncontrolled increase in cardiac output. C. Blood pressure regulation becomes irregular. D. The client experiences tachycardia and a bounding pulse.

A

The ED staff has been notified of the imminent arrival of a client who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis/problem? A) Impaired gas exchange B) Decreased cardiac output C) Chronic pain D) Excess fluid volume

A

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? A) Knots in the rope should not be resting against pulleys. B) Weights should rest against the bed rails. C) The end of the limb in traction should be braced by the footboard of the bed. D) Skeletal traction may be removed for brief periods to facilitate the client's independence.

A

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

A

The HCP suspects a pt is experiencing a dissecting abdominal aortic aneurysm. Which of the following CM are indicative of this condition? SATA. A. Tachycardia B. Bradycardia C. Hypotension D. Pale, clammy skin E. HTN

A, C, D

What are clinical manifestations specifically for HH? SATA. A. heartburn, reflux and chest pain B. N/V C, dysphagia and belching D. worse when reclining E. pain may radiate to the neck, back and jaw

A, C, D

Which of the following symptoms are indicative of Cushing's Triad? SATA. A. Increase in systolic BP B. Tachycardia Temperature of 101.5 F D. Bradycardia E. Bradypnea

A, D, E

A client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, the client reports a new onset of pain at the surgical site. What is the nurse's best action? A) Administer pain medication as prescribed B) Assess the surgical site and the affected extremity C) Reassure the client that pain is a direct result of increased activity D) Assess the client for signs and symptoms of systemic infection

B

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? A)Inflammation of the lining of the stomach B)Erosion of the lining of the stomach or intestine C)Bleeding from the mucosa in the stomach D)Viral invasion of the stomach wall

B

A patient with a cervical spinal cord injury would require what non-surgical nursing intervention to prevent further injury ? A. Closely monitor VS B. Maintain skeletal traction C. Lay patient on affected side D. Elevate HOB

B

What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis? A) To decrease nurses' susceptibility to healthcare-associated infections B) To decrease risk of transmission to vulnerable clients C) To eventually eradicate the influenza virus in the United States D) To prevent the emergence of drug-resistant strains of the influenza virus

B

The nurse is teaching a class on the prevention of cerebrovascular accidents. Which of the following risk factors should the nurse identify as the most important factor contributing to a stroke? A. Obesity B. Hypertension C. Sedentary lifestyle D. Smoking

B About the correct answer: A sedentary lifestyle predisposes a client to obesity and cardiovascular disease, which increases the risk of a cerebrovascular accident. Smoking and obesity are modifiable risk factors that do increase the risk of a stroke, but hypertension is supported by research to put the client at the greatest risk for a stroke. Successful treatment of hypertension is the best prevention of a CVA

The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan? A. A reduced calorie diet, high in nutrients B. Small, frequent meals, high in protein and calories C. Three large, bland meals a day D. A diet high in fiber and plant-sourced fat

B. Small, frequent meals, high in protein and calories

The nurse is caring for a client whose worsening infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock? A. Elevated systolic blood pressure B. Elevated mean arterial pressure (MAP) C. Shallow, rapid respirations D. Bradycardia

C

The organization of a client's care while receiving palliative care is based on interdisciplinary/interprofessional collaboration. How does interdisciplinary/ interprofessional collaboration differ from multidisciplinary practice? A) It is based on the participation of clinicians without a team leader. B) It is based on clinicians of various backgrounds integrating separate plans of care. C) It is based on communication, cooperation and collaboration between disciplines. D) It is based on medical expertise and client preference with the support of nursing.

C

There has been a radiation-based terrorist attack and a client is experiencing vomiting, diarrhea, and shock after the attack. How will the client's likelihood of survival be characterized? A) Probable B) Possible C) Improbable D) Extended

C

Which of the following circumstances would most clearly warrant autologous blood donation? A) The patient has type-O blood. B) The patient has sickle cell disease or a thalassemia. C) The patient has elective surgery pending. D) The patient has hepatitis C.

C

While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity should take place? A) Deciding when the facility will go from disaster response to daily activities B) Conducting practice drills for the community and facility C) Conducting a critique and debriefing for all involved in the incident D) Replacing the resources in the facility

C

You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition? A. The patient is unable to read. B. The patient has limited vision in half of the visual field. C. The patient is unable to wink or move his arm to scratch his skin. D. The patient doesn't recognize a pencil or television.

C

The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? A. The nurse should make the patient sit in a chair and then assess his or her head for bleeding or swelling. B. The nurse should only move the patient's head with the help of an assistant. C. The nurse should explain the procedure of head assessment to the patient before doing the assessment. D. The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.

D The nurse evaluates the patient's body posture and any abnormal position of the head, neck, trunk, or extremities. The nurse carefully examines the head for bleeding, swelling, or wounds. The nurse does not move or manipulate the patient's head during physical assessment, especially if there is a recent history of trauma. The nurse should not make the patient sit on a chair or seek the help of an assistant while doing the head assessment. The nurse need not explain in detail about the procedure of head assessment to the patient.

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? a)Facial droop b)Dysrhythmias c)Periorbital edema d)Projectile vomiting

a

You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is: A. Little stroke symptoms B. Severe stroke symptoms

b

A client is being treated in the ED following a terrorist attack. The client is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this client has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent

A

A client is in a hospice receiving palliative care for lung cancer which has metastasized to the client's liver and bones. For the past several hours, the client has been experiencing dyspnea. What nursing action is most appropriate? A) Deliver a bolus of normal saline, as prescribed. B) Initiate high-flow oxygen therapy. C) Administer high doses of opioids. D) Administer bronchodilators and corticosteroids, as prescribed.

A

A client is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client? A) Post-traumatic arthritis B) Fat embolism syndrome (FES) C) Osteomyelitis D) Compartment syndrome

A

A client on airborne precautions asks the nurse to leave his door open. What is the nurse's best reply? A) "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in." B) "I'll keep the door open for you, but please try to avoid moving around the room too much." C) "I can open your door if you wear this mask." D) "I can open your door, but I'll have to come back and close it in a few minutes."

A

A client presents to the clinic reporting vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B.. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance

A

A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man's current mental health problem? A) The man is experiencing a common response following a disaster. B) The man fails to appreciate the fact that he survived the disaster. C) The man most likely feels guilty about his actions during the disaster. D) The man's depression most likely predated the disaster.

A

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit (hyponatremia) B) Decreased prothrombin time (PT) C) Potassium deficit (hypokalemia) D) Decreased hematocrit

A

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A) Risk for Infection B) Risk for Ineffective Role Performance C) Risk for Perioperative Positioning Injury D) Risk for Powerlessness

A

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A) Client is likely experiencing a delayed onset of respiratory complications B) The client has likely developed a systemic infection C) The client's respiratory complications are likely related to psychosocial stress D) The client is likely experiencing an anaphylactic reaction to a medication

A

A patient is admitted to the ICU after experiencing MI with the following initial vital signs: HR 130 BPM, BP 90/50, respiratory rate 26. The patient also has decreased capillary refill and a decreased urinary output. What condition is the client most likely experiencing? A. Cardiogenic shock B.. Hypovolemic shock C. Distributive shock D. Obstructive shock

A

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A)Check the patient's indwelling urinary catheter for kinks to ensure patency. B)Lower the HOB to improve perfusion. C)Administer analgesia. D)Reassure the patient that headaches are expected after spinal cord injuries.

A

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? A) The client will be monitored closely to detect malignant changes. B) Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C) Small amounts of blood are likely to be present in the stools and are not cause for concern. D) Antacids may be discontinued when symptoms of heartburn subside

A

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A) Education about home safety B) Education about safe storage of chemicals C) Education about workplace health threats D) Education about safe driving

A

An adult oncology client has a diagnosis of bladder cancer with metastasis and the client has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? A) The client and family should be viewed as a single unit of care. B) Persistent symptoms of terminal illness should not be treated. C) Each interdisciplinary team member should develop an individual plan of care. D) Terminally ill clients should die in the hospital whenever possible.

A

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells

A

During a health education session, a participant asks the nurse how a vaccine can protect from future exposures to diseases against which she is vaccinated. What would be the nurse's best response? A) The vaccine causes an antibody response in the body. B) The vaccine responds to an infection in the body after it occurs. C) The vaccine is similar to an antibiotic that is used to treat an infection. D) The vaccine actively attacks the microorganism.

A

Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the client's clothing and then perform what action? A) Rinse the client with water. B) Wash the client with a dilute bleach solution. C) Wash the client Chlorhexidine. D) Rinse the client with hydrogen peroxide.

A

The nurse places a client in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection? A) Mode of transmission B) Agent C) Susceptible host D) Portal of entry

A

The nurse, a member of the health care team in the ED, is caring for a client who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A. Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock. B. Protect the client's airway, optimize intravascular volume, and initiate the early rehabilitation process. C. Closely monitor fluid replacement therapy, and inform the family that the client will probably survive and return to normal life. D. Inform the client's family immediately that the client will likely not survive to allow the family time to make plans and move forward.

A

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? A. When symptoms cease, the client will return to presymptomatic state. B. A TIA is an insidious, often chronic episode of neurologic impairment. C. Symptoms of a TIA may linger for up to a week. D. Two thirds of people that experience a TIA will go on to develop a stroke.

A Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. A. Administer stool softeners daily. B. Maintain the head of the bed at 60 degrees of elevation. C. Administer mild sedatives. D. Ensure that pulse oximeter reading is higher than 93%.

A, C, D Perform deep nasal suction every two (2) hours. About the correct answer: Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness. The head of the bed should be elevated no more than 30 degrees to help decrease cerebral edema by gravity. Noxious stimuli, such as suctioning, increase intracranial pressure and should be avoided

A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A) Preventing skin breakdown B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure

B

The nurse is preparing the client for mechanical debridement and informs the client that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from viable tissue B) Removal of eschar until the point of bleeding occurs C) Shaving of burned skin layers until bleeding occurs D) Early closure of the wound

B

The nurse assess a patient with a temperature of 102.2 F, flushed skin, RR of 26 and Sp02 of 91%. What is the nurse's priority action? A. Call a code B. Draw blood for a lactate level of CBC C. Make the patient NPO and start IV fluids D. Perform an ECG and chest x-ray

B to determine if they are going into septic shock

The nurse is caring for a patient and suspects neurogenic shock. What early clinical signs should the nurse monitor the patient for? SATA. A. Poikilothermia B. Hypotension C. Bradycardia D. Hypothermia E. Warm skin

B, C, E

Which findings should indicate to a nurse that a traumatic brain injury has resulted in brain death? Select all that apply. A. Glasgow Coma Scale (GCS) score of 6. B. Electroencephalogram (EEG) tracing is flat. C. No response to the cold caloric test. D. Positive gag reflex. E. No spontaneous respirations.

B, C, E About the correct answer: No response to the cold caloric test is correct because the cold caloric test is a test of the oculovestibular reflex, and absence of this reflex indicates severe brainstem injury. Electroencephalogram (EEG) tracing is flat is correct because a flat EEG indicates the absence of electrical activity in the brain. No spontaneous respirations is correct because the absence of spontaneous respirations indicates the absence of brain function. TIP: Remember that brain death is an irreversible loss of all brain functions.Glasgow Coma Scale (GCS) score of 6 is incorrect because a GCS of less than 7 indicates coma, not brain death. Positive gag reflex is incorrect because a gag reflex would indicate brain function.

How should a nurse caring for an elderly client with receptive and expressive aphasia communicate with the client? Select all that apply. A. Encourage the client to initiate meaningful communication. B. Use a picture board or flash cards. C. Use hands to communicate. D. Provide support and encouragement. E. Speak loudly. F. Speak slowly.

B, C, F About the correct answer: Use a picture board or flash cards is correct because a visual mode is helpful when the client has difficulty hearing (auditory aphasia, receptive) or writing (expressive aphasia, visual). Use hands to communicate is correct because using gestures such as pointing is one way to establish and encourage communication. Speak slowly is correct because facing the client and speaking slowly allows time to respond. Speak loudly is incorrect because the nurse needs to speak distinctly, not loudly. Encourage the client to initiate meaningful communication is incorrect because, with expressive aphasia, the client will have difficulty in initiating speech, but may be able to articulate words that have no meaning. Provide support and encouragement is incorrect because, although support and encouragement need to be offered, these are general nursing approaches and not specific to this client.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? A. Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. B. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. C. Reassure the client that a headache is expected and will go away without treatment. D. Notify the physician; a headache is an early sign of worsening neurologic status.

B. Headache is common after head injury administer acetaminophen reassess 30 min. Do not administer opioids that may cause sedation. They may mask signs of neuro changes

A nurse caring for a patient with a parathyroid disturbance and notes a positive Chovstek's sign, bronchospasm, and tingling in the extremities. What electrolyte imbalance are these manifestations due to? A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hypernatremia

B. hypocalcemia

A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? A) Inadequate vitamin D intake B) Bleeding at the injury site C) Inadequate immobilization D) Venous thromboembolism . .. (VTE)

C

A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome

C

A client who was in a motor vehicle accident presents to the ER with loss of respiratory muscle function and tetraplegia. These clinical manifestations indicate what level of injury to the spinal cord? A. Below level of C4 B. Lumbar spine C. Above level of C4 D. Thoracic spine

C

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? a. Acute pain b. Septicemia c. Bleeding d. Seizures

C

A nurse is caring for a client who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the client does what action to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable B) Use supplementary oxygen when transferring or mobilizing C) Increase fluid intake and perform prescribed foot exercises D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon

C

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Takes over-the-counter antacids frequently throughout the day. B. Reports a history of social drinking on a weekly basis. C. Smokes one pack of cigarettes daily. D. Consumes one or more protein drinks daily.

C

The nurse suspects septic shock on a patient with all of the following except what? A. Altered mental status B. High RR C. severe HTN D. hypotension

C

The nurse is assessing a patient admitted for abdominal pain, distention and anorexia. Which of the following is most indicative of an intestinal obstruction? SATA. A. Hyperactive bowel sounds below the abdominal distention B. Persistent headache and decreased LOC C. Feeling an urge to defecate but only pass ribbon-like stool D. Fever and urinary retention E. Projectile vomiting and abdominal cramping

C, E

A workplace explosion has injured 21 workers. A 40-year-old man has full thickness burns over 80% of his body. The man is unconscious but breathing. How would this person be triaged? A) Green B) Yellow C) Red D) Black

D

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.

D

A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis

The answer is B. If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for herself when she is obviously struggling. What would be the nurse's best answer? :a. "We are trying to help her be as useful as she possibly can." b. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible" c. "We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home." d. "Rehabilitation means helping clients do exactly what they did before their stroke."

b

A client has returned to the post-surgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial post-surgical assessment were unremarkable but the client has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action? A) Apply a tourniquet B) Elevate the residual limb C) Apply sterile gauze D) Call the surgeon

A

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit B) Hypokalemia, hypernatremia, decreased hematocrit C) Hyperkalemia, hypernatremia, decreased hematocrit D) Hypokalemia, hyponatremia, elevated hematocrit

A

A client is admitted to the burn unit after being transported from a facility a large distance away. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism

A

A client who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the client's condition is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Sudden thirst, unrelieved by oral fluid administration C. Diaphoresis and sudden onset of abdominal pain D. Tarry, foul-smelling stools

A

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? A) A patient-controlled analgesia (PCA) system B) Oral opioids supplemented by NSAIDs C) Distraction and relaxation techniques supplemented by NSAIDs D) A combination of benzodiazepines and topical anesthetics

A

A client who is recovering from bariatric surgery reports a rapid onset of nausea, bloating, and cramping after eating a meal. The nurse's assessment reveals diaphoresis and a heart rate of 98 beats per minute. What assessment should the nurse prioritize once the client's immediate symptoms resolve? A. Capillary blood glucose B. Bowel auscultation C. Electrolytes A. Respiratory rate and oxygen saturation

A

A client with a diagnosis of peptic ulcer disease has just been prescribed omeprazole. How should the nurse best describe this medication's therapeutic action? A. This medication will reduce the amount of acid secreted in your stomach B. This medication will make the lining of your stomach more resistant to damage C. This medication will specifically address the pain that accompanies peptic ulcer disease D. This medication will help your stomach lining to repair itself

A

A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety? A) Place the patient in a side-lying position. B) Pad the patient's bed rails. C) Administer antianxiety medications as ordered. D) Reassure the patient and family members.

A

A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A) Perform life-saving measures. B) Classify clients according to acuity. C) Provide health promotion education. D) Modify the emergency operations plan.

A

A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance? A) Office of Emergency Management B) Local police and fire departments C) Centers for Disease Control and Prevention (CDC) D) American Red Cross

A

A medical nurse is careful to adhere to infection control protocols, including hand washing. Which statement about hand washing supports the nurse's practice? A) Frequent hand washing reduces transmission of pathogens from one client to another. B) Wearing gloves is known to be an adequate substitute for hand washing. C) Bar soap is preferable to liquid soap. D) Waterless products should be avoided in situations where running water is unavailable.

A

A medical nurse is providing palliative care to a client with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care? A) To improve the client's and family's quality of life B) To support aggressive & innovative treatments for cure C) To provide financial support for the client and their family D) To help the client develop a separate plan with each health care team discipline

A

A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A) Practice outside of her normal area of clinical expertise. B) Perform interventions that are not based on assessment data. C) Prioritize psychosocial needs over physiologic needs. D) Prioritize the interests of older adults over younger clients.

A

A nurse has reported for a shift at the burn unit in a large university hospital. Which client is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female client burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

A

A nurse is caring for a client who is postoperative day 1 right hip replacement. How should the nurse position the client? A) Keep the client's hips in abduction at all times B) Keep hips flexed at no less than 90 degrees C) Elevate the head of the bed to high Fowler's D) Seat the client in a low chair as soon as possible

A

A nurse is caring for a patient who is admitted to a rehabilitation facility after having a stroke. What intervention is most appropriate and a priority for this setting? A. Implement range of motion exercises to improve physical mobility B. Obtain CT scan of the head to determine type of stroke C. Teach about dietary modifications to prevent a future stroke D. Initiate thrombolytic therapy as prescribed by the HCP

A

A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A) Having an ethical framework in place prior to an emergency B) Allowing staff to provide care anonymously during an emergency C) Assuring staff that they are not legally accountable for care provided during an emergency D) Teaching staff that principles of ethics do not apply in an emergency situation

A

A nurse is planning the care of a client who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions? A) Improving the client's level of function B) Helping the client come to terms with limitations C) Administering medications safely D) Improving the client's adherence to treatment

A

A nurse is planning the care of a client who will require a prolonged course of skeletal traction. When planning this client's care, the nurse should prioritize interventions related to what risk nursing diagnosis? A) Risk for Impaired Skin Integrity B) Risk for Falls C) Risk for Imbalanced Fluid Volume D) Risk for Aspiration

A

A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A) Slow the infusion rate and monitor the patient closely. B) Discontinue the transfusion and begin resuscitation. C) Pause the transfusion and administer a 250 mL bolus of normal saline. D) Discontinue the transfusion and administer a beta-blocker, as ordered.

A

A patient present s to the ER with hypotension and tachycardia. Earlier in the day the pt had a laparoscopic cholecystectomy and was discharged home. Upon further evaluation by the inter professional team, the pt is diagnosed with hypovolemic shock due to PO hemorrhage. Which of the following interventions would the nurse prioritize? A. Isotonic fluids administration B. Dopamine infusion C. Epinephrine IV push D. Cardioversion

A

An adult client in the ICU has a central venous catheter in place. Over the past 24 hours, the client has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the client's care may have increased susceptibility to CLABSI? A) The client's central line was placed in the femoral vein. B) The client had blood cultures drawn from the central line. C) The client was treated for vancomycin-resistant enterococcus (VRE) during a previous admission. D) The client has received antibiotics and IV fluids through the same line.

A

The nurse is caring for a client in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What assessments and interventions should the nurse prioritize? A. Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B. Reviewing medications, performing a focused cardiovascular assessment, and providing client educationCorrect! C. Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions D. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema

A

The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort has increased. What is the nurse's most appropriate response? A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patient's LOC. C) Increase the patient's bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered.

A

The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized? A) Achieve as high a level of function as possible. B) Enhance the quantity of the patient's life. C) Teach the family proper care of the patient. D) Provide community assistance.

A

The nurse is caring for an older adult client who is receiving rehabilitation following an ischemic stroke. A review of the client's electronic health record reveals that the client usually defers her self-care to family members or members of the care team. What should the nurse include as an initial goal when planning this client's subsequent care? A. The client will demonstrate independent self-care. B. The client's family will collaboratively manage the client's care. C. The nurse will delegate the client's care to a nursing assistant. D. The client will participate in a life skills program

A

The nurse is creating the care plan for a client newly admitted to the rehabilitation unit. The client is an older adult who has had a stroke but who lived independently until this event. What is a goal that the nurse should include in this client's nursing care plan? A. Maintain joint mobility B. Refer to social services C. Help the client ambulate three times every day D. Perform passive range of motion with the client twice daily

A

The nurse is helping to set up Buck's traction on an orthopedic client. How often should the nurse assess circulation to the affected leg? A) Within 30 minutes, then every 1 to 2 hours B) Within 30 minutes, then every 4 hours C) Within 30 minutes, then every 8 hours D) Within 30 minutes, then every shift

A

The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform? A) Administer the platelets as rapidly as the patient can tolerate. B) Establish IV access as soon as the platelets arrive from the blood bank. C) Ensure that the patient has a patent central venous catheter. D) Aspirate 10 to 15 mL of blood from the patient's IV immediately following the transfusion.

A

The nurse is preparing to insert an NG tube into an elderly pt who is feeling nauseated and has been having abdominal pain with vomiting. Upon assessment his abdomen is distended and hard on palpation. He is suspected of having an intestinal obstruction. The pt asks the nurse why an NG tube is necessary? What response from the nurse is most appropriate? A. The tube will help to drain the stomach contents and prevent further vomiting B. The tube will push pas the area that is blocked and help to stop the vomiting C. The tube is just a standard procedure before many types of surgery to the abdomen D. The tube will measure your stomach contents so that we can plan for IV fluid replacement

A

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A) Increased warmth of the calf B) Decreased circumference of the calf C) Loss of sensation to the calf D) Pale-appearing calf

A

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A)Ensure that the player is not moved. B)Obtain the player's vital signs, if possible. C)Perform a rapid assessment of the player's range of motion. D)Assess the player's reflexes.

A

What are appropriate interventions for blood administration? A. Directed observe patient for initial 15-30 mins per facility policy B. VS every 5 mins for first 15 mins C. Begin administration within 60 minutes of picking up blood from the blood bank D. Prime the blood administration UV tubing with 5% dextrose in water before the transmission

A

While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as: A. Dysarthria B. Apraxia C. Alexia D. Dysphagia

A

You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can't write. This is known as what: A. Agraphia B. Alexia C. Hemianopia D. Apraxia

A

You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as: A. Hemianopia B. Opticopsia C. Alexia D. Dysoptic

A

When the nurse is developing a rehab plain for a patient with a C6 spinal cord injury, what would be an appropriate goal for that patient? A. Maintain an SpO2 of at least 95 B. Transfer independent to a wheelchair C. Turn and resosition self when in bed D. Propel a manual wheelchair on flat, smooth surface

A Cervival think breathing first

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: A. decrease the potential for brain damage. B. assess for infection. C. follow hospital protocol. D. prevent embolism.

A It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications? A. Do you feel any muscle twitches or spasms B. Do you feel flushed or sweaty C. Are you experiencing any dizziness or lightheadedness D. Are you having any pain that seems to be radiating from your bones

A "Do you feel any muscle twitches or spasms?" ..... This is characteristic of hypoparathyroidism

A client's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this client's care, the nurse should identify what primary aim? A) To prioritize emotional needs B) To prevent and relieve suffering C) To bridge between curative care and hospice care D) To provide care while there is still hope

A or B unsure

A patient is on the medsurg floor with a suspected infection. The nurse uses qSOFA. What criteria should the nurse select that is needed to suspect sepsis? SATA. A. Systolic BP is 80 B. RR 26 C. Temp 100.1 F D. Tremors E. Positive blood cultures

A, B and plus looks at their LOC

An older adult client experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness

A, B, C, E

A 67-year old patient is admitted to the neuro ICU with manifestations of right-hemisphere stroke. Which symptoms can the nurse expect? SATA. A. Impulsiveness B. Left sided weakness C. Right sided neglect D. Short attention span E. Impaired speech/language

A, B, D

A patient is diagnosed with hyperparathyroidism. Which of the following signs and symptoms would you NOT find in this patient? Select all that apply: A. Calcium level 6 mg/dL B. Bone fracture C. Positive Trousseau's Sign D. Tingling and numbness of lips and fingers E. Calcium level of 15 mg/dL F. Phosphate level 1.2 G. Renal calculi

A, C, D

A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. A. Balloon angioplasty of the carotid artery followed by stent placement B. Removal of the carotid artery C. Percutaneous transluminal coronary artery angioplasty D. Carotid endarterectomy E. Administration of tissue plasminogen activator

A, D If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain.

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply. a.Anaphylactic b.Hypovolemic c.Cardiogenic d.Septic e.Neurogenic

A, D, E

The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. a.Drop in systolic blood pressure of ≥40 mm Hg from baselines b.Hypotension that responds to bolus fluid resuscitation c.Exaggerated response to vasoactive medications d.Serum lactate >4 mmol/L e.Mean arterial pressure (MAP) of ˂65 mm Hg

A, D, E

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. A. Report changes in neurologic status as soon as a worsening trend is identified. B. Use a well-lighted room for assessments every 2 hours. C. Follow the healthcare provider's orders to increase fluid volume. D. Maintain the head of the bed at 30 degrees. E. Avoid any activities that cause a Valsalva maneuver.

A, D, E Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A) Perform mechanical debridement to remove the exudate and prevent further infection. B) Inform the primary provider promptly because the graft may need to be removed. C) Perform ROM exercises to increase perfusion to the graft site & facilitate healing. D) Document this finding as an expected phase of graft healing.

B

A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? A) Alcohol causes hormone fluctuations. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain.

B

A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A) Viral agents B) Nerve agents C) Pulmonary agents D) Blood agents

B

A home care nurse is performing a visit to a client's home to perform wound care following the client's 5-week hospitalization for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A) Psychosis B) Post-traumatic stress disorder C) Delirium D) Vascular dementia

B

A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture? A) Compression B) Compound C) Impacted D) Transverse

B

A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem? A. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion. B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D. Blood is shunted from vital organs to peripheral areas of the body.

B

A nurse in the ICU receives report from the nurse in the ED about a new client being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that client is probably experiencing? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

B

A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A) Perform chest physiotherapy once per shift and as needed B) Teach the client to perform deep breathing and coughing exercises C) Administer prophylactic antibiotics as prescribed D) Administer nebulized bronchodilators and corticosteroids as prescribed

B

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A) Client is able to perform ADLs independently. B) Client is able to perform transfers safely. C) Client is able to weight-bear equally on both legs. D) Client is able to demonstrate full ROM of the affected hip.

B

A nurse is reviewing a client's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? A) Straining during a bowel movement B) Bending down to put on socks C) Lifting items above shoulder level D) Transferring from a sitting to standing position

B

A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status? A)Reflex activity B)Level of consciousness C)Cognitive ability D)Sensory involvement

B

A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following? A) Evaluate the care that he or she provided during the disaster. B) Discuss own emotional responses to the disaster. C) Explore the ethics of the care provided during the disaster. D) Provide suggestions for improving the emergency operations plan.

B

A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A) Victims' pre-existing medical conditions are exacerbated. B) Victims are thrown by the pressure wave. C) Victims experience burns from the blast. D) Victims suffer injuries caused by debris or shrapnel from the blast.

B

A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A) "He's on a calorie-restricted diet in order to divert energy to wound healing." B) "His body has consumed his fat deposits for fuel because his calorie intake is lower than normal." C) "He actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat." D) "He lost many fluids while he was being treated in the emergency phase of burn care."

B

A patient arrives in the ER with petechiae, complaints of join pain, and tachypnea. Lab test results include an elevated PTT and D-dimer. What is the patient likely experiencing and the appropriate initial care? A. Vasculitis; provide oxygen and respiratory support B. DIC; fluid volume replacement C. Idiopathic thrombocytopenia purport; administer ordered blood products D. DIC; insert foley catheter for an accurate output

B

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status examination

B

A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action? A. Patient heart rate is 115 bpm B. Patient experiences dyspnea and crackles in lung fields C. Patient is anxious D. Patient's urinary output is 35 mL/hr

B

A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction? A) Antibodies to donor leukocytes remained in the blood. B) The donor blood was incompatible with that of the patient. C) The patient had a sensitivity reaction to a plasma protein in the blood. D) The blood was infused too quickly and overwhelmed the patient's circulatory system.

B

A patient is receiving the first two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? A) Position the patient in high Fowler's. B) Discontinue the transfusion. C) Auscultate the patient's lungs. D) Obtain a blood specimen from the patient.

B

A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? A) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. C) Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D) Administer the remaining PRBCs by the IV direct (IV push) route.

B

A physician writes a prescription to discontinue skeletal traction on an orthopedic client. The nurse should anticipate what subsequent intervention? A) Application of a walking boot B) Application of a cast C) Education on how to use crutches D) Passive range of motion exercises

B

A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions? A) Wearing a mask and gown when starting an IV line B) Washing hands immediately after removing gloves C) Recapping all needles promptly after use to prevent needle-stick injuries D) Double-gloving when working with a client who has a blood-borne illness

B

After undergoing a pyloroplastry to treat a gastric ulcer, the nurse educates the pt about lifestyle changes. Which current lifestyle habit would warrant the most change? A. The pt typically eats 4-5 snack necks a day avoiding foods that cause gastric stress B. The patients limits his drinking to 1-2 glasses of wine per night with dinner C. The patient is sure to eat a small breakfast before taking Ibuprofen for back pain D. After eating dinner, the patient typically takes an antacid to relieve dyspepsia

B

An adult is postoperative day 2 following bariatric surgery. The nurse's most recent assessment reveals abdominal pain that the client rates at 8 out of 10, HR 102 BPM, temp 100.6 F. What is the nurse's best action? A. Slow the client's oral intake in consultation with the dietitian to prevent further dumping syndrome B. Communicate the findings to the HCP because the client may have an anastomotic leak C. Insert a NG tube as prescribed to facilitate STAT gastric decompression D. Report the signs and symptoms of a possible surgical site infection the the HCP

B

An elite high school football player has been diagnosed with a shoulder dislocation. The client has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? A) The need to take analgesia regardless of the short-term absence of pain B) The importance of adhering to the prescribed treatment and rehabilitation regimen C) The fact that he has a permanently increased risk of future shoulder dislocations D) The importance of monitoring for intracapsular bleeding once he resumes playing

B

An industrial site has experienced a radiation leak and workers who have been potentially affected are In route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A) Place all potential victims on reverse isolation. B) Establish a triage outside the hospital. C) Have hospital staff put on PPE. D) Place hospital staff on abbreviated shifts of no more than 4 hours.

B

The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? A) Position the patient supine. B) Maintain head of bed (HOB) elevated at 30 to 45 degrees. C) Position patient in prone position. D) Maintain bed in Trendelenberg position.

B

The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.

B

The nurse is caring for a client recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? a. Providing frequent small meals rather than three larger meals b. Teaching the client to perform deep breathing and coughing exercises c. Keeping a urinary catheter in situ for the full duration of recovery d. Limiting intake of insoluble fiber

B

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. what dysrhythmia does the client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supra ventricular tachycardia D. Bundle branch block

B

The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What would be an appropriate intervention for this diagnosis? A) Change the patient's position as indicated. B) Monitor serum electrolytes. C) Maintain NPO status. D) Monitor arterial blood gas (ABG) values.

B

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? A. The client has periorbital edema and ecchymosis. B. The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. C. The client's level of consciousness has improved. D. The client prefers to rest in the semi-Fowler's position.

B

The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A) Administer prophylactic antibiotics. B) Survey the victims using a radiation survey meter. C) Irrigate victims' open wounds. D) Perform soap and water decontamination.

B

The nurse is part of the health care team at an oncology center. A client has been diagnosed with advance metastatic cancer the prognosis is poor, but the client is not yet aware of the prognosis. How can the bad news best be conveyed to the client? A) Family should be given the prognosis first. B) The prognosis should be delivered with the client at eye level. C) The physician should deliver the news to the client alone. D) The appointment should be scheduled at the end of the day.

B

The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patient's treatment? A) Computed tomography (CT) scan B) Lumbar puncture C) Magnetic resonance imaging (MRI) D) Venous Doppler studies

B

The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? A) Maintaining accurate records of intake and output B) Maintaining a patent airway C) Inserting a nasogastric (NG) tube as ordered D) Providing appropriate pain control

B

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? A) Administer analgesics as required B) Place a pillow between the client's legs when turning C) Maintain prone positioning at all times D) Encourage internal and external rotation of the affected leg

B

Which of the following patients are MOST at risk for hypoparathyroidism? A. A 75 year-old female who is diabetic and takes Os-Cal daily. B. A 59 year-old male with a Mg+ level of 0.9 mg/dL. C. A 85 year-old female complaining of flank pain and constipation. D. A 19 year-old male with a Ca+ level of 8.9 mg/dL.

B

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? A) Risk for Infection B) Risk for Ineffective Peripheral Tissue Perfusion C) Unilateral Neglect Related to Hematoma D) Disturbed Kinesthetic Sensory Perception

B

While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity

B

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided stroke? A. expressive aphasia, defects in the right visual fields, problems with abstract thinking B. impulsive behavior, poor judgment, deficits in left visual fields C. problems with abstract thinking, impairment of short-term memory, poor judgment D. cautious behavior, deficits in left visual fields, misjudgment of distances

B Impulsive behavior, poor judgment, deficits in left visual fields are symptoms of right hemispheric stroke. Expressive aphasia, defects in the right visual fields, problems with abstract thinking are symptoms of left hemispheric stroke. Problems with abstract thinking, impairment of short-term memory, poor judgment are symptoms inconsistent with each other as some indicate left and others indicate right hemispheric stroke. Cautious behavior, deficits in left visual fields, misjudgment of distances are symptoms inconsistent with each other as some indicate left and others indicate right hemispheric stroke.

An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize? A. Establishing central venous access and beginning fluid resuscitation B Establishing a patent airway and beginning cardiopulmonary resuscitation C. Establishing peripheral IV access and administering IV epinephrine D. Performing a comprehensive assessment and initiating rapid fluid replacement

B Establishing a patent airway and beginning cardiopulmonary resuscitation

What is the immediate nursing care for a patient that is post-op for bariatric surgery? SATA. A. Lay patient supine to decrease pressure on the surgical area B. Apply abdominal binder when ambulating C. Nutrition counseling with a dietician prior to discharge D. Start patient on a soft diet as tolerated E. Restrict oral intake to 30-120 mL/hr for first several days

B, C, D won't start soft diet for a couple weeks only liquids very slowly to normal diet

The nurse is caring for a client following a motor vehicle accident. During the neurological assessment when eliciting the client's response to pain, the client pulls his arms inward and upward. This position represents: (Select all that apply.) A. Decerebrate posturing. B. Decorticate posturing. C. Injury to the brainstem. D. Injury to the pons. E. Injury to the midbrain.

B, C, E About the correct answer: Decorticate posturing is a late sign of significant deterioration in neurologic status and is manifested by clients' rigidly flexing their elbows and wrists. It can also signal injury to the midbrain.Clients with significant intracranial injury and edema will frequently exhibit decorticate posturing first and then decerebrate posturing. Decerebration frequently precedes brainstem herniation, while Injury to the pons is not directly related to the question.

A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. Most affected clients acquired the infection during international travel B. Infection typically occurs due to ingestion of contaminated food and water C. Many people possess genetic factors causing a predisposition to H. pylori infection D. The H. pylori microorganism is endemic in warm, moist climates

B. Infection typically occurs due to ingestion of contaminated food and water.

A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boy's mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock? A. Rapid onset of acute hypertension B. Rapid onset of respiratory distress C. Rapid onset of neurologic compensation D. Rapid onset of cardiac arrest

B. Rapid onset of respiratory distress

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A. The client has abdominal bloating that developed rapidly B. The patient has a rigid, "boardlike" abdomen that is tender C. The client is experiencing intense lower right quadrant pain D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes

B. The patient has a rigid, "boardlike" abdomen that is tender.

A client with obesity is early in the process of preparing for a Roux-en-Y gastric bypass (RYGB). The client states, "After the surgery, the amount of food that I consume will be limited and I'll absorb fewer calories from what I do eat." When responding to the client, the nurse should: A. Explain that the surgery will not affect the absorption of nutrients B. Validate what the client understands about the surgical procedure C. Teach the client that RYGB does not restrict food intake D. Encourage the client to discuss the procedure with the surgeon

B. Validate what the client understands about the surgical procedure.

A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to?A. Collect a urine sample B. Obtain an EKG C. Establish 2 large-bore IV access sites D. Place a warming blanket on the patient

C

A 91-year-old client is slated for orthopedic surgery and the nurse has integrated gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A) Administration of prophylactic antibiotics B) Total parenteral nutrition (TPN) C) Use of a pressure-relieving mattress D) Use of a Foley catheter until discharge

C

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? a)To decrease cerebral edema b)To prevent seizure activity that is common following a TIA c)To remove atherosclerotic plaques blocking cerebral flow d) determine the cause of the TIA

C

A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the client's IV fluid infusion B) Report the client's early signs of acute kidney injury (AKI) C) Recognize that the client is experiencing an expected onset of diuresis D) Administer sodium chloride as prescribed to compensate for this fluid loss

C

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Hypotension D) Sudden agitation

C

A nurse is caring for a client in skin traction. In order to prevent bony fragments from moving against one another, the nurse should caution the client against performing what action? A) Shifting one's weight in bed B) Bearing down while having a bowel movement C) Turning from side to side D) Coughing without splinting

C

A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the client to continue to scratch inside the cast with a pencil but encourage him to be cautious B) Give the client a sterile tongue depressor to use for scratching instead of the pencil C) Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe itching persists D) Obtain a prescription for a sedative, such as lorazepam , to prevent the client from scratching

C

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent joint ossification

C

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome

C

A nurse is preparing to administer a client's scheduled dose of subcutaneous heparin. To reduce the risk of needle-stick injury, the nurse should perform what action? A) Recap the needle before leaving the bedside. B) Recap the needle immediately before leaving the room. C) Avoid recapping the needle before disposing of it. D) Wear gloves when administering the injection.

C

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptying C. It protects the stomach's lining D. It increases lower esophageal sphincter pressure

C

A patient is 24 hours post op for a bariatric surgery procedure and reports back and shoulder pain. Upon further assessment, the nurse finds the patient is restless and has a pulse of 112. Which PO complication would the nurse suspect? A. Dumping syndrome B. Dehydration C. Anastomotic leak D. Malabsorption

C

A patient is admitted to the ICU post-cardiac arrest and is now presenting with symptoms of DIC. After further assessment, which would be the intervention of the highest priority for the nurse? A. Apply a new dressing to control bleeding from the IV site and assess for other sites of hemorrhage B. Notify the HCP of ECG changes from previous ECG strips C. Apply oxygen and expedite administration of prescribed blood products D. Administer pain medications for their joint and abdominal pain

C

A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A)Risk for impaired skin integrity related to immobility and sensory loss B)Impaired physical mobility related to loss of motor function C)Ineffective breathing patterns related to weakness of the intercostal muscles D)Urinary retention related to inability to void spontaneously

C

A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to administer what priority medication? A) Hydrochlorothiazide (HydroDIURIL) B) Furosemide (Lasix) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

C

A patient is recovery from a parathyroidectomy. Which of the following findings causes concern and requires nursing intervention? A. The patient is in Semi-Fowler's position. B. The patient's calcium level is 8.9 mg/dL. C. The patient's voice is hoarse. D. The patient is drowsy but arouses to name.

C

A patient presents to the ER with back pain and describes it as very painful and "tearing". The pt BP begins to drop and there is a noticeable change in LOC. The pt may be experiencing what condition? A. HH B. Intestinal obstruction C. Aortic dissection D. Abdominal hernia

C

A patient with a history of hyperthyroidism presents to the ED with agitation and SOB. VS are BP 190/90, HR 125 bpm, and temp 102.1 F. What priority of care should the nurse implement first? A. Start IV access B. Place a cooling blanket on the patient C. Administer oxygen to patient as prescribed D. Give the patient a glass of water

C

A patient with hypoparathyroidism is seen in the ED. What would the nurse expect upon assessment? A. Muscle wasting and loss of bone matrix B. Slow wound healing and profound hypotension C. Paresthesia and twitching facial muscles D. Abdominal swelling and black tarry stools

C

A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patient's vital signs to establish baselines. D) Facilitate insertion of a central venous catheter.

C

A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups? A) Preschool-aged children B) Adults with diabetes and/or kidney disease C) Older adults with compromised health status D) Infants under the age of 12 months

C

A young client is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the client is uncharacteristically confused. What diagnostic test should be performed on this client? A) Electrolyte assessment B) Electrocardiogram C) Arterial blood gases D) Abdominal ultrasound

C

An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? A) The presence of leg shortening B) The client's complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation

C

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A. Epistaxis B. Periorbital edema C. Bruising over the mastoid D. Unilateral facial numbness

C

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

C

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? D. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months C. Promoting communication with the client and family along with addressing end-of-life issues A. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

C

The nurse is caring for a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting? A) Using antibacterial soap when bathing clients with MRSA B) Conducting culture surveys on a regularly scheduled basis C) Performing hand hygiene before and after contact with every client D) Using aseptic housekeeping practices for environmental cleaning

C

The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction B) Have the client reposition himself independently C) Protect the affected leg from internal rotation D) Keep the hip flexed by placing pillows under the client's knee

C

The nurse is caring for a patient who experienced a generalized tonic-clonic seizure/ Which of the following is the priority action for the nurse to take? A. Take a set of vital signs B. Reorient the patient to their surroudings C. Maintain side lying position and keep the airway open D. Assess for musculoskeletal injury

C

The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state? A. Third spacing of fluid B. Gastric hypermotility C. Tachycardia D. Dysrhythmias

C

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A. Naproxen 250 PO b.i.d. B. Calcium carbonate 1,000 mg PO b.i.d. C. Aspirin 81 mg PO o.d. D. Lorazepam 1 mg SL b.i.d. PRN

C

You are providing discharge teaching to a patient who is prescribed calcium supplements with vitamin D for treatment of hypoparathyroidism. Which of the following statements by the patient warrants you to re-educate the patient on how they should take this medication? A. "I will also make sure I eat foods rich in calcium, such as dairy and green leafy vegetables while I'm taking this medication." B. "A side effect of this medication is constipation. Therefore, I should drink plenty of fluids." C. "I will take my calcium supplements in the morning when I take my Synthroid." D. All the statements above are correctly stated by the patient.

C

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? A. Anticipate the client will exhibit some degree of expressive or receptive aphasia. B. Place the wheelchair on the client's left side when transferring him into a wheelchair. C. Provide close supervision because of the client's impulsiveness and poor judgment. D. Support the right arm with a sling or pillow to prevent subluxation.

C The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.

Which of the following is not a manifestation of hypovolemic shock? A. Tachypnea B. Decreased urinary output C. Increased BP D. Anxiety

C , hypotension

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism

C, D, E

A patient presents to the ER with a severe unilateral headache accompanied by nausea and visual disturbances that has been worsening since the previous day. What type of headache aligns with these manifestations? A. Cluster headache B. Sinus headache C. Migraine D. Tension headache

C. Migraine

A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client? A. Side-lying with one pillow under the head B. HOB elevated 30 degrees and no pillows placed under the head C. Semi-Fowler with the head supported on two pillows D. Supine, with a small roll supporting the neck

C. Semi-Fowler with the head supported on two pillows

A patient is started on a new IV antibiotic and calls for the nurse. Upon entering the patient's room, the nurse notes facial swelling, wheezing, stridor and a RR of 32. The nurse suspects anaphylactic shock. What should the nurse do first. A. Administer IM epinephrin B. Call a rapid response C. Stop the IV infusion D. Notify the HCP

C. Stop infusion

After initiating a blood transfusion, the patient starts displaying chills, fever, lower back pain, and flushing. What would be the first action that the nurse should take in this situation? A. Notify the provider and continue the transfusion B. Administer an antipyretic and continue to monitor the patient C. Stop the infusion and discontinue the blood tubing D. Continue the infusion and monitor patient vital signs

C. Stop infusion

A nurse is closely monitoring a client who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the client's aneurysm? A. Sudden increase in blood pressure and a decrease in heart rate B. Cessation of pulsating in an aneurysm that has previously been pulsating visibly C. Sudden onset of severe back or abdominal pain D. New Oset of hemoptysis

C. Sudden onset of severe back or abdominal pain

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

D

A client is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine

D

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

D

A client is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A) Use of a cardiopulmonary bypass machine B) Postoperative blood salvage C) Prophylactic blood transfusion D) Autologous blood donation

D

A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? A) Standard precautions only B) Droplet precautions C) Standard and contact precautions D) Standard and airborne precautions

D

A client who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A) Integumentary assessment B) Assessment for signs of hemorrhage C) Neurologic assessment D) Assessment of respiratory status

D

A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the client's health care is holistic C) Facilitate the client's adjustment to a new body image D) Promote the client's highest possible level of function

D

A client's large bowel obstruction has failed to resolve spontaneously and the client's worsening condition has warranted admission to the medical unit. Which of the following aspect of nursing care is most appropriate for this client? A. Administering bowel stimulants as prescribed B. Administering bulk-forming laxatives as prescribed C. Performing deep palpation as prescribed to promote peristalsis D. Preparing the client for surgical bowel resection

D

A nurse in the ICU is providing care for a patient who has been admitted witha hemorrhagic stroke. The nurse is performing frequent neurologicassessments and observes that the patient is becoming progressively moredrowsy over the course of the day. What is the nurse's best response to thisassessment finding? A)Report this finding to the physician as an indication of decreasedmetabolism. B)Provide more stimulation to the patient and monitor the patient closely. C)Recognize this as the expected clinical course of a hemorrhagic stroke. D)Report this to the physician as a possible sign of clinical deterioration.

D

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? A) Warm the client's foot and determine whether circulation improves B) Reposition the client with the affected foot dependent C) Reassess the client's neurovascular status in 15 minutes D) Promptly inform the primary provider

D

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Techniques for positioning correctly to promote gastric healing B. Safe technique for self-suctioning C. Strategies for maintaining an alkaline gastric environment D. Strategies for avoiding irritating foods and beverages

D

A nurse is caring for a client who has had a plaster arm cast applied. Immediately post-application, the nurse should provide what teaching to the client? A) The cast will feel cool to touch for the first 30 minutes. B) The cast should be wrapped snuggly with a towel until the client gets home. C) The cast should be supported on a board while drying. D) The cast will only have full strength when dry.

D

A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching? A) "I'll need to keep several pillows between my legs at night." B) "I need to remember not to cross my legs. It's such a habit." C) "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D) "I will need my husband to assist me in getting off the low toilet seat at home."

D

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain

D

A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care? A) Apply occlusive dressings to the pin sites B) Encourage the client to push up with the elbows when repositioning C) Encourage the client to perform isometric exercises once a shift D) Assess the pin insertion site every 8 hours

D

A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication? A) Cellulitis B) Septic arthritis C) Sepsis D) Osteomyelitis

D

A nurse is emptying an orthopedic surgery client's closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse's best action? A) Aspirate a small amount of drainage for culturing B) Advance the drain 1 to 1.5 cm C) Irrigate the drain with normal saline D) Inform the surgeon of this finding

D

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, which of the following would be most important as part of the recovery phase? A) Assess for signs of electrolyte imbalances B) Administer IV fluids as prescribed C) Develop a teaching plan for home safety D) Assess the client's psychosocial state

D

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session? A) Using crutches efficiently B) Exercising joints above and below the cast, as prescribed C) Removing the cast correctly at the end of the treatment period D) Reporting signs of impaired circulation

D

A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care? A) Increased cultural diversity B) Staffing shortages in health care and questions concerning quality of care C) Increased costs of health care coupled with inequalities in access D) Ability of technology to prolong life beyond meaningful quality of life

D

A patient has a history of seizures. What medication would the nurse expect to be prescribed? A. Pantoprazole B. Lithium C. Prednisone D. Valproate

D

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A) "Drinking beverages after your meal, rather than with your meal, may bring some relief." B) "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." C) "Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating." D) "Instead of eating three meals a day, try eating smaller amounts more often."

D

A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.

D

A pt arrive in the ER with has left-sided weakness and left facial droop. The patient states they woke up with symptoms at 0700. Initial VS are HR 85, Sp)2 96%, RR 18, BP 160/95. After returning from a STAT CT scan of the head, what is the next priority action for the nurse to take? A. Manage the pt's BP B. Begin tPA treatment to destroy the clot causing stroke C. Start anticoagulation therapy to prevent further clotting D. Complete the NIH Stroke Scale

D

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn

D

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock? a.Apply an antibiotic ointment to the client's mucous membranes, as prescribed. b.Perform passive range-of-motion exercises unless contraindicated c.Initiate total parenteral nutrition (TPN) d.Remove invasive devices as soon as they are no longer needed

D

An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU clients most likely faces the highest risk of DIC? A. A client with extensive burns B. A client who has a diagnosis of acute respiratory distress syndrome C. A client who suffered multiple trauma in a workplace accident D. A client who is being treated for septic shock

D

An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A) Ensure that blood components are never infused at a rate greater than 125 ml/hr. B) Administer prophylactic antihistamines prior to all blood transfusions. C) Establish baseline vital signs for all patients receiving transfusions. D) Be vigilant in identifying the patient and the blood component.

D

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A) Apply ice burn site for 5 to 10 minutes. B) Wrap the client's affected extremity in ice until help arrives. C) Apply an oil-based substance to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

D

Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower extremity. The right pedal pulse is difficult to palpate, and the right foot is cool and pale. Which complication should the nurse most suspect? a. Hypothermia b. Wound infection c. Bleeding from the graft site d. Graft occlusion

D

Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A) Impacted B) Compound C) Compression D) Greenstick

D

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? A. Absence of infarcts or emboli B. Reduced stroke volume and cardiac output C. Absence of pulmonary and peripheral edema D. Maintenance of adequate mean arterial pressure

D

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A) Apply skin emollients as prescribed after granulation has occurred B) Keep injured areas immobilized whenever possible to promote healing C) Administer oral or IV corticosteroids as prescribed D) Encourage physical activity and range-of-motion exercises

D

The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent? A) Mottling of the lower limbs B) Slow, steady pulse C) Bowel incontinence D) Increased swallowing

D

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? A. Assess frequent vital signs. B. Reposition frequently. C. Assess for pupillary response frequently. D. Record intake and output.

D A record of intake and output is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. Excessive output will alert the nurse to possible fluid imbalance early in the process.

A patient is post op for a subtotal thyroidectomy and presents with the following symptoms: tachycardia, HTN, A-fib, feeling of nervousness/anxiety, and a temp of 101.1 F. What post op complication is the patient most likely experiencing? A. Hypovolemic shock B. DKA C. Hypothyroidism D. Thyrotoxicosis

D took part of thyroid, pushing around gland, pushes out T3 and T4 into bloodstream. thyroid storm. post op expected thyroid storm but later on may develop hypothyroidism

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? A. Assess neurological status. B. Initiate an intravenous access. C. Monitor pulse, respiration, and blood pressure. D. Maintain an adequate airway.

D About the correct answer: The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.Assessing the neurological status is important, but ensuring an airway is priority over assessment.Monitoring vital signs is important, but maintaining an adequate airway is higher priority.Initiating an IV access is an intervention the nurse can implement, but it is not the priority intervention.

A patient is 6 hours post-opt from thyroid surgery. The patient's calcium level is 5 and phosphate level is 4.2. What physical signs and symptoms would NOT present with these findings? (Select-all-that-apply) A. Bronchospasm B. Constipation C. Numbness and tingling in the face D. Positive Chvostek's Sign E. Absent Trousseau's Sign F. Hypertension

D, E, F

You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to: A. Keep the head of bed less than 30′. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.

The answer is B. Because the patient has weakness on the right side and dysphagia the nurse should regularly check for pouching of food in the right cheek. Pouching of food in the cheek can lead to aspiration or choking. The HOB should be >30′, liquids thickened per MD order, and the patient should tuck in the chin to the chest while swallowing.

Which patient below is at most risk for a hemorrhagic stroke? A. A 65 year old male patient with carotid stenosis. B. A 89 year old female with atherosclerosis. C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55 year old female with atrial flutter.

The answer is C. A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.

A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury? A. Wearing anti-embolism stockings daily B. Consume soft foods and tuck in chin while swallowing C. Scanning the room from side to side frequently D. Muscle training

The answer is C. Hemianopia is limited vision in half of the visual field. The patient needs to scan the room from side to side to prevent injury.

In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms

The answer is C. tPa dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!

You're educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke: A. Aphasia B. Denial about limitations C. Impaired math skills D. Issues with seeing on the right side E. Disoriented F. Depression and anger G. Impulsive H. Agraphia

The answers are A, C, D, F, and H. Patients who have left side brain damage will have aphasia, be AWARE of their limitations, impaired math skills, issues with seeing on the right side, no deficit in memory, depression/anger, cautious, and agraphia. All the other options are found in right side brain injury.

During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable? A. Smoking B. Family history C. Advanced age D. Obesity E. Sedentary lifestyle

The answers are A, D, and E. These risk factors are modifiable in that the patient can attempt to change them to prevent another stroke in the future. The other risk factors are NOT modifiable.

You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: A. TIAs are caused by a temporary decrease in blood flow to the brain. B. TIAs produce signs and symptoms that can last for several weeks to months. C. A TIAs is a warning sign that an impending stroke may occur. D. TIAs don't require medical treatment.

The answers are B and D. Options A and C are CORRECT statements about TIAs. However, option B is wrong because TIAs produce signs and symptoms that can last a few minutes to hours and resolve (NOT several weeks to months). Option D is wrong be TIAs do require medical treatment.

Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.

The answers are B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.

A patient has right side brain damage from a stroke. Select all the signs and symptoms that occurs with this type of stroke: A. Right side hemiplegia B. Confusion on date, time, and place C. Aphasia D. Unilateral neglect E. Aware of limitations F. Impulsive G. Short attention span H. Agraphia

The answers are B, D, F, and G. Patients who have right side brain damage will have LEFT side hemiplegia (opposite side), confused on date, time, and place, unilateral neglect (left side neglect), DENIAL about limitations, be impulsive, and have a short attention span. Agraphia, right side hemiplegia, aware of limitations, and aphasia occur in a LEFT SIDE brain injury.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family? a)The client should mobilize as soon as she is physically able b)to prevent contractures and muscle atrophy the bed rest should not exceed 4 weeks c)the client should remain on bed rest until she experiences expresses a desire to mobilize d)lack of mobility will greatly increase the client's risk of stroke recurrence

a

A client who suffered an ischemic stroke now has disturbed sensory perception. What principles should guide the nurses care of this client? a)The client should be approached on the side where the visual perception is intact b)Attention to the affected side should be minimized in order to decrease anxiety c)The client should avoid turning on the direction of the defective visual field to minimize shoulder subluxation d)The client should be approached on the opposite side of where the visual perception is intact to promote recovery

a

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the clients atmosphere more conducive to communication? a)Provide a board of commonly used needs and phrases b)Have the client speak to loved ones on the phone daily c)Help the client complete their sentence is as needed d)Speak in a loud and deliberate voice to the client

a

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite? A) Female gender B) Asian American race C) Advanced age D) Smoking

c