NRS 3015: Exam #1 Practice Questions
A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? a. Urine output of 20 mL/hr b. Temperature of 36.5 C (97.7 F) c. A 2 cm x 2cm area of bloody drainage on the dressing d. WBC count 9,000 mm^3
a
A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? a. Assess oxygen saturation b. Measure blood pressure c. Palpate pulse rate d. Check temperature
a
A nurse is caring for a client who has a pheochromocytoma. Which of the following actions should the nurse take? a. Elevate the head of the client's bed. b. Palpate the client's abdomen c. Monitor the client for hypotension d. Check the client's urine specific gravity
a
A nurse is reviewing the medical records of several clients in the PACU to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (Select all that apply.) a. A client who has a WBC of 22,500/uL b. A client who uses an insulin pump c. A client who takes warfarin daily d. A client who has heart failure e. A client who has a BMI of 26
a, b, c, d
To ensure safe patient care transition from the perioperative nurse to the intraoperative nurse, optimal hand-off communication about the patient includes which elements? (Select all that apply.) A. Providing a recent patient history B. Communicating vital signs, allergy, and medication updates C. Verbally verifying that the operating room nurse understands the report D. Using a standardized hand-off communication tool to provide report (for example, SBAR, Five-Ps, PACE) E. Encouraging the operating room nurse to interrupt to ask questions as the perioperative nurse provides report
a, b, c, d
Which of the following are side effects of opioid agonists? (Select all that apply.) a. Diminished cough reflex b. Pruritus c. Constipation d. Increased fall risk
a, b, c, d
A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? (Select all that apply.) a. Infuse iced IV fluids b. Provide 100% oxygen c. Place a cooling blanket on the client d. Treat the complication while the surgeon continues surgery e. Administer IV dantrolene
a, b, c, e
A nurse is caring for a client who has chronic cancer pain + has a permanent epidural catheter for administration of a fentanyl/bupivacaine solution. The nurse should monitor the client for which of the following findings? (Select all that apply.) a. Respiratory depression b. Hypotension c. Sedation d. Muscle spasticity e. Sensory blockage
a, b, c, e
A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) a. Encourage the use of the incentive spirometer every 2 hr. b. Instruct the client to splint the incision when coughing and breathing. c. Reposition the client every 2 hr. d. Administer antibiotic therapy. e. Assist with early ambulation
a, b, c, e
Which of the following is the nurse responsible before in the pre-operative setting? (Select all that apply.) a. Confirm health insurance and obtain consent b. Complete a physical assessment c. Explain risk/benefits of procedure d. Review labs including coagulation studies, CBC
b, d
A nurse administered midazolam IV bolus to a client before a procedure. The client's blood pressure is 86/40 mmHg, and the heart rate is 134/min. Which of the following IV medications should the nurse administer? a. Naloxone b. Morphine c. Flumazenil d. Atropine
c
A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? a. Phantom limb pain b. Mixed pain c. Breakthrough pain d. Neuropathic pain
c
A nurse in a PACU is assessing a client who is postoperative. Which of the following findings should the nurse report to the provider? a. Blood pressure 10% lower than baseline. b. Pain level of 4 on a 0 to 10 scale.. c. Presence of inspiratory stridor. d. Small amount of sanguineous drainage on dressing.
c
A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings? a. Cold intolerance b. Lethargy c. Tremors d. Sunken eyes
c
A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect? a. Decreased blood pressure b. Weight loss c. Hirsutism d. Increased skin thickness
c
A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect? a. Moon-shaped face b. Weight gain c. Calcium 12.8 mg/dL d. Sodium 150 mEq/L
c
A nurse is assessing a client who is recovering from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first? a. Pain b. Cool c. Touch d. Warmth
c
A nurse is assessing a client who is taking propylthiouracil. The nurse should identify which of the following findings as an indication that the medication has been effective? a. Increased ability to sweat b. Increased bowel movements c. Increased body weight d. Increased libido
c
A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia? a. Strong, bounding pulse b. Decreased bowel sounds c. Tingling and numbness of the hands and feet d. Diminished deep-tendon reflexes
c
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse perform to treat respiratory complications? a. Instruct the client to exhale into the incentive spirometer every 1 to 2 hr. b. Minimize the amount of pain medication the client receives to prevent sedation. c. Advise the client to splint the surgical incision when coughing and deep breathing. d. Reposition the client every 8 hr for the first 48 hr.
c
A nurse is caring for a client who is receiving moderate sedation with midazolam. The the client's respiratory rate decreases from 16/min to 6 /min, and their oxygen saturation decreases from 92% to 85%. Which of the following medications should the nurse administer? a. Atropine b. Acetylcysteine c. Flumazenil d. Protamine sulfate
c
A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? a. "I'll wait to use the device until it's absolutely necessary." b. "I'll be careful about pushing the button so I don't get an overdose." c. "I should tell the nurse if the pain doesn't stop after I use this device." d. "I will ask my son to push the dose button when I am sleeping."
c
A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? a. Decrease the client's fluid intake b. Apply pressure to the puncture site c. Place the head of the bed flat d. Instruct the client to lie prone
c
A nurse is planning care for a client who is post operative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include? a. Check the patency of the drain every 12 hr. b. Clamp the drain while the client is ambulating. c. Cleanse the drain plug with alcohol after emptying. d. Secure the drain to the client's bed sheet.
c
A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include? a. "Lie on your side when resting for the first week after surgery." b. "Limit intake to clear fluids after the first 24 hr after surgery." c. "Use cool compresses on your eyes, nose, and face." d. "Close your mouth when you are about to sneeze."
c
A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include? a. Inject the insulins intramuscularly b. Shake the insulins vigorously prior to administration c. Draw up the insulins into separate syringes d. Expect the insulins to appear cloudy
c
A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements by the client indicates an understanding of the teaching? a. "I should stop taking my insulin if I feel nauseous." b. "I will test my urine for protein when I start to feel ill." c. "I will call my doctor if my blood sugar is more than 250." d. "I should check my blood sugar level every 8 hours."
c
A patient has had changes in facial structure. Which lab should be ran? a. Testosterone b. Estrogen c. Growth hormone d. ACTH
c
Hypothermic patients require gradual rewarming in PACU to prevent: a. Fluid loss b. Nausea c. Hypotension d. Bradycardia
c
Hypothyroidism can lead to: a. DKA b. Cushing's disease c. Myxedema com d. Grave's disease
c
Lubricating eye drops would be used for: a. Goiter b. Hyperosmolar hyperglycemia c. Exophthalmos d. Moon face
c
Midazolam (Versed) is in the following drug family: a. Opioid b. NSAID c. Benzodiazepines d. Antihistamine
c
Risks of oral antiglycemic medications (Glipizide) run the risk of: a. UTI b. Bronchitis c. Hypoglycemia d. Stress response
c
The doctor places an order to decompress the stomach. You will plan to: a. Administer Reglan b. Insert a Foley catheter c. Insert a nasogastric tube d. Insert an IV
c
The nurse is monitoring a patient who is receiving moderate sedation. An expected outcome for conscious outcome is: a. Blocked multiple peripheral nerves in a specific region b. Decreased motor function in the targeted limb c. Decreased level of consciousness, yet able to respond to verbal commands d. CNS depression, resulting analgesia and amnesia, with loss of muscle tone and reflexes
c
Treatment for malignant hyperthermia is prompt administration of: a. Narcan b. Dilaudid c. Dantrolene c. Cyclobenzaprine
c
Type 2 diabetics will: a. Never be on insulin b. Effect mainly children c. Sometimes reverse their condition with diet and exercise d. Not respond to oral medicines for glycemic control
c
When positioning to decrease pain in the postoperative patient, which intervention is most appropriate? a. Raise the knee gatch of the bed. b. Place pillows under the patient's knees. c. Reposition the patient at least every 2 hours. d. Allow the patient to get out of bed as soon as possible.
c
When should a pre-operative antibiotic be given? a. Within 2 hours of surgery b. Within half an hour of surgery c. Within 1 hour of surgery d. During surgery
c
Which INCREASES sensitivity to insulin? a. Eating every 4 hours b. Taking lantus insulin c. Exercise d. Increasing fiber intake
c
Which client would be at greatest risk for fractures? a. Hyperglycemia b. Hyperthyroidism c. Hyperparathyroidism d. Hyperaldosteronism
c
Which client would need a calm, quiet environment? a. Hypothyroidism b. SIADH c. Pheochromocytoma d. DM I
c
Which is a probable complication of thyroidectomy? a. Diabetes b. Diabetes insipidus c. Needing life-long thyroid supplementation d. Increased caloric need
c
Which is an independent nursing intervention for monitoring fluid balance? a. Serum osmolarity, BUN b. 24-hour urine collection c. Daily weights, I&Os d. Specific gravity, urinal weighing
c
Which is specific to type 1 diabetes? a. Thirst b. Hunger c. Ketones d. Lethargy
c
Which type of diabetic is a client with hyperosmolar hyperglycmia? a. Type 1 b. DI c. Type 2 d. Gestational diabetes
c
Which usually precedes an adrenal crisis? a. Dieting b. Maintaining social networks c. Stressful event d. Meth usage
c
Why would a client need calcium supplementation following a thyroidectomy? a. Thyroid crisis b. Calcitonin changes c. Removal of parathyroid gland d. R/t weight gain
c
You are caring for a patient s/p knee replacement receiving opioids who has N/V. What should you do first? a. Hold the opioid medication at the next dose. b. Palpate the abdomen. c. Auscultate the abdomen. d. Administer Zofran 4 mg, IVP.
c
You are caring for a pre-operative patient who is scared, crying, and shaking. You can anticipate an order for: a. Opioid b. Hypnotic c. Benzodiazepine d. Paralytic
c
Your patient has arrived from PACU and is complaining of hunger, what should you do? a. No bowel sounds = no food b. Provide phone for dining menu c. Check diet order in EHR d. Ignore patient's statement
c
Your patient needs a blood transfusion. You can anticipate an order for: a. CBC b. BMP c. Type and Crossmatch d. hCG
c
A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all that apply.) a. Potassium 3.9 mEq/L b. Sodium 145 mEq/L c. Creatinine 2.8 mg/dL d. Blood glucose 235 mg/dL e. WBC 17,850/mm3
c, d, e
A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply.) a. Urinary incontinence b. Diarrhea c. Bradypnea d. Orthostatic hypotension e. Nausea
c, d, e
A nurse is caring for a client who has cancer and has a prescription for transcutaneous electrical nerve stimulation (TENS) for pain management. Which of the following actions should the nurse take? a. Remove hair before applying the electrodes from the TENS unit on the skin. b. Apply alcohol to the client's skin before attaching the electrodes from the TENS unit. c. Attach the electrodes from the TENS unit over painful incisions or skin damage. d. Avoid other pain medications when using the TENS unit.
a
A nurse is caring for a client who is 12 hr postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse? a. Gastric distention b. Absent bowel sounds c. Urine output of 150 mL over the last 4 hr d. Yellow drainage in the NG tube
a
A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer? a. Ketorolac b. Ketamine c. Meperidine d. Methadone
a
A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39 C orally. Which of the following actions should the nurse take? a. Inform the surgeon of the elevated temperature b. Transfer the client to the preoperative unit c. Apply ice packs to the groin d. Encourage the client to increase intake of clear liquids
a
A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? a. Assess bowel sounds. b. Administer antiemetic medication. c. Restart prescribed IV fluids. d. Insert a prescribed nasogastric tube.
a
A nurse is caring for a client who will undergo a neurolytic ablation. The client asks the nurse the reason for this procedure. Which of the following responses should the nurse make? a. "It should provide permanent pain relief." b. "It reduces the adverse effects of your pain medication." c. "It increases your ability to fight infections." d. "It increases cells that stop bleeding."
a
A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take? a. Administer IV hydrocortisone sodium b. Give oral spironolactone c. Infuse 1 unit of platelets d. Restrict daily fluid intake
a
A nurse is monitoring a client who is 24 hr postoperative after a total thyroidectomy. Which of the following findings should the nurse report to the provider? a. Laryngeal stridor b. Productive cough c. Pain with hyperextension of the neck d. Hoarse, weak voice
a
A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia? a. Administer dantrolene. b. Institute seizure precautions. c. Remove the endotracheal tube. d. Administer IV atropine.
a
A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? a. Fasting blood glucose 96 mg/dL b. Postprandial blood glucose 195 mg/dL c. Random blood glucose 210 mg/dL d. Preprandial blood glucose 60 mg/dL
a
A nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (Select all that apply.) a. Urine output less than 25 mL/hr b. Hematocrit 53% c. BUN 24 mg/dL d. Tenting of skin over the sternum e. Apical pulse rate 62/min
a, b, c, d
Rank the following opioid agonists in order of strength (strongest first): • Codiene • Dilaudid • Morphine • Fentanyl
1. Fentanyl 2. Dilaudid 3. Morphine 4. Codiene
True or False: The purpose of a PCA is to provide clients with analgesia at a therapeutic level without having to rely on the nurse for pain relief.
True
True or False: You should obtain the culture specimen before you administer antibiotics.
True
True or False: It is okay for the patient's spouse to administer the PCA medication for the patient.
False
True or False: Penrose drains are active drains.
False
True or False: The unconscious post-operative patient should be positioned supine in semi-Fowlers.
False
True or False: Opioids should be given on a PRN basis and not scheduled.
It depends!
23. A nurse is reviewing the medical record for a client who has a prescription for general anesthesia prior to surgery. Which of the following findings should the nurse report to the provider? a. Potassium 2.8 mEq/L b. Sodium 140 mEq/L c. INR 1.5 d. BUN 12 mg/dL
a
A 70-year-old patient is ordered Norco 500/5 q6h and Tylenol 650 q8h. Is this safe? a. Nope, a provider should be contacted. b. Yep! No worries here! c. Can I see some hepatic labs first? d. Can I phone a (pharmacist) friend?
a
A nurse administered propranolol by IV bolus to a client who is having a thyroid storm. Which of the following findings indicates that the client is having a therapeutic response? a. Reduction of the effects of thyroid hormone on the heart b. Blockage of the release of thyroid hormone from the thyroid gland c. Increase in the heart's sensitivity to the thyroid hormone d. Increase in the uptake of thyroid hormone by the thyroid gland.
a
A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? a. Sodium 110 mEq/L b. 2+ deep-tendon reflexes c. Potassium 3.7 mEq/L d. Urine specific gravity 1.025
a
A nurse is receiving an evening shift report on four clients who returned from the PACU that morning. Which of the following clients should the nurse assess first? a. A client who is postoperative following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr. b. A client who is postoperative following a small bowel recession and has a temporary colostomy along w/ absent bowel sounds in all four quadrants. c. A client who is postoperative following a tonsillectomy and has had one episode of coffee-ground emesis. d. A client who is postoperative following a total knee arthroplasty and is reporting a pain level of 7 on a scale from 0 to 10
a
A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect? a. pH 7.32, PaCO2 36 mm Hg, HCO3 14 mEq/L b. pH 7.38, PaCO2 55 mm Hg, HCO3 22 mEq/L pH 7.44, PaCO2, 40 mm Hg, HCO3 24 mE1/L pH 7.50, PaCO2 42 mm Hg, HCO3 30 mEq/L
a
A patient has had bowel surgery. Which symptom, assessed by the nurse, is the best indicator of intestinal activity? a. Passage of flatus or stool b. Patient's report of hunger c.Abdominal cramping with distention d. Detection of bowel sounds upon auscultation
a
A pre-operative patient receives glycopyrrolate, an anti-cholinergic medication. What is the best response to "Why do I need this medication?" a. "It decreases respiratory secretions during surgery." b. "It helps you breathe better during surgery." c. "It increases urinary output during surgery." d. "It will help maintain BP during surgery."
a
A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. For which of the following findings should the nurse intervene? a. The scrub technologist is wearing a watch under their scrubs. b. The circulating nurse opens dressing packages before applying sterile gloves. c. The surgeon has their hands folded 5 cm above their waist d. The holding area nurse is performing client education.
a
During a preoperative assessment, the nurse asks the patient about allergies. Which allergy cited by the patient would be of greatest concern during the surgical procedure? A. Kiwi B. Codeine C. Shellfish D. Sulfa drugs
a
During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What is the priority nursing intervention? a. Communicate the discrepancy to the surgical team immediately b. Complete appropriate documentation concerning the error in the sponge count. c. Examine the environmental distractions, refocus, and count the sponges again d. Anticipate that the surgeon will order an x-ray to look for the sponge postoperatively
a
Precautions of Ondansetron (Zofran) are: a. Cardiac arrhythmia risk b. Renal impairment c. Intestinal obstruction d. Hepatic impairment
a
TED stockings and sequential compression devices both: a. Prevent blood from pooling in legs b. Break up clots in the legs c. Prevent atelectasis d. Reduce surgical site infections
a
The nurse is aware that a patient having surgery is at risk for infection if which additional factor is present? a. Diabetes mellitus b. Age greater than 65 c. Impaired liver function d. Insertion of a surgical drain
a
To detect anemia, the nurse will review the: a. HGB + HCT b. WBC c. PT/PTT d. Platelets
a
What is the main reason for doing a thorough pre-operative assessment? a. Obtain baseline data b. Calm the patient and their family members c. Provide it to the patient's workplace d. Teach others the proper technique
a
What type of drain is a Jackson-Pratt? a. Active b. Passive
a
Which is NOT a sign of DKA? a. Overhydrated b. Hypotension c. Flu-like symptoms d. Thready pulse
a
Which is contraindicated with metformin? a. Contrast dye b. Iodide c. Aspirin d. Oxygen
a
Which of the following is inaccurate education about diabetic foot care? a. Try one shoes first thing in the morning for the best fit b. Don't use heat or ice on your feet c. Wear cotton socks d. Have nails trimmed by a podiatrist
a
Which of the following should be included in post-operative pain management education? a. The patient will call for a dose before the prior dose stops working. b. Addiction counseling. c. The nurse is qualified to determine when I need another dose of pain medications. d. The patient should call for a dose when the pain starts to increase.
a
Interventions for painful diabetic neuropathy? (Select all that apply.) a. Elevate feet off the bed with a pillow b. Giving gabapentin as ordered c. Applying compression stockings d. Soaking the feet in warm water
a, b
A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following adverse effects should the nurse include? (Select all that apply.) a. Osteoporosis b. Moon-shaped face c. Increased risk of infection d. Hearing loss e. Weight loss
a, b, c
How can we best assess pain in a non-verbal patient? (Select all that apply.) a. Use a visual report aid that the patient can point to. b. Ask the patient to hold up fingers (1-10) related to pain level. c. Use the FACES scale to have them indicate which one best matches the pain. d. The nurse can match the patient's appearance to the FACES pain scale.
a, b, c
What may cause post-operative hypoventilation? (Select all that apply.) a. Pain b. Depressed respiratory drive 2/2 drowsiness c. Poor muscle tone d. Anxiety
a, b, c
Which of the following nursing interventions reduce the risk of wound dehiscence? (Select all that apply.) a. Limit physical activity and lift weights (> 10 lbs) b. Splinting incision site while coughing, sneezing, baring down c. Utilization of an abdominal binder d. Educate the patient to get out of bed quickly rather than slowly
a, b, c
A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (Select all that apply.) a. "Take your heart medication with a sip of water before surgery." b. "Splint the abdominal incision with a pillow when coughing and deep breathing." c. "Bed rest is recommended for the first 48 hours." d. "Anti-embolism stockings are applied before surgery." e. "You can eat solid foods up to 4 hours before surgery."
a, b, d
Opioids can cause: (Select all that apply.) a. Constipation b. Hypotension c. Hypertension d. Respiratory depression
a, b, d
Why would we schedule opioids for a patient's pain? (Select all that apply.) a. The patient will be participating in therapy or other painful activity. b. The patient has had a major injury or surgery and pain is expected. c. The nurse needs to schedule their care of their assignment. d. In hopes of preventing breakthrough pain.
a, b, d
The circulating nurse: (Select all that apply.) a. Scrubs in b. Is the patient's advocate c. Is the communication link to other departments d. Checks electrical and mechanical equipment
b, c, d
Which of the following findings could indicate a post-operative ileus? (Select all that apply.) a. Fever b. Absent bowel sounds c. Absent flatus d. Abdominal distention
b, c, d
A client is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following statements indicates an understanding of the teaching? a. "I need to fast after midnight the night before the test." b. "This test's result is a good indicator of my average blood glucose levels." c. "A level of 8 to 10 percent suggests adequate blood glucose control." "I will use my hemoglobin A1c level to adjust my insulin doses."
b
A nurse finds their patient asleep and diaphoretic. Their first action may need to be: a. Check blood glucose b. Check random blood glucose c. No intervention needed at this time d. Get A1c
b
A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? a. Decreased heart rate b. Increased hematocrit c. High urine specific gravity d. Low BUN level
b
A nurse is assessing a client who is 2 days postoperative following a total prostatectomy. The nurse notes that the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take? a. Apply an ice pack to the client's right calf. b. Elevate the client's right extremity. c. Administer testosterone to the client. d. Gently massage the client's right calf.
b
A nurse is assessing a client who is preoperative. The nurse should identify which of the following factors reported by the client increases the risk for a postoperative wound infection. a. Frequent use of echinacea b. Long-term use of corticosteroids c. History of osteoporosis d. Diet high in vitamin C
b
A nurse is assessing a client who received a preoperative IV dose of metoclopramide 1 hr ago. For which of the following findings should the nurse notify the provider? a. Dry mouth b. Muscle rigidity c. Tinnitus d. Diarrhea
b
A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? a. Monitor blood creatinine levels b. Provide airway support c. Turn the client to the right side d. Administer a diuretic
b
A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? a. Cut a slit in a 4-inch square gauze pad to place around the drain. b. Use the sterile technique when performing dressing changes. c. Establish a clamping schedule prior to removal. d. Apply negative pressure when emptying the drain.
b
A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the client's feet? a. Examine the feet weekly for alterations in skin integrity. b. Monitor the temperature of bath water with a thermometer. c. Shop for shoes early in the day. d. Round the edges of toenails when trimming them.
b
A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a 0 to 10 scale. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first a. Draw the client's blood for electrolytes. b. Insert an NG tube. c. Administer pain medication. d. Initiate intake and output
b
A nurse is caring for a client who is postoperative and is asking multiple questions about the risks of the procedure. Which of the following actions should the nurse take? a. Explain the risks and benefits of the surgery to the client. b. Ask the surgeon to speak to the client for clarification. c. Reassure the client that the procedure is necessary for recovery. d. Notify the circulating nurse that the client has questions about the procedure.
b
A nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty. The client informs the nurse that they practice Judaism and adhere to a kosher diet. Which of the following interventions is the nurse's priority? a. Listen and allow the client to express feelings about the surgery. b. Determine if the client's faith conflicts with the treatment plan. c. Ensure the client's meal plan serves only kosher food following surgery. d. Teach the client how to perform various relaxation exercises.
b
A nurse is planning teaching for a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse plan to include? a. Consume no more than three servings of alcohol per day b. Ingest food with alcohol to reduce alcohol-induced hypoglycemia c. Increase insulin dosage before planned exercise d. Rest for 3 days between periods of vigorous exercise
b
A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching? a. "I will have an increase in yellow-colored drainage from my incision for 2 weeks." b. "I will eat foods that are high in protein and vitamin C during my recovery." c. "I should avoid taking over-the-counter pain medication if my pain is not severe." d. "I will remain on bed rest until my follow-up appointment with my doctor."
b
A nurse is providing discharge teaching to a client who has diabetes insipidus and a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? a. "Depress the pump once before using the nasal spray for the first time." b. "Blow your nose gently prior to using the nasal spray." c. "Administer the nasal spray while in a side-lying position." "Notify the provider if you develop numbness or tingling around the mouth."
b
A nurse is providing preoperative teaching for a client who is scheduled to have a below-the-knee amputation. Which of the following instructions should the nurse include? a. "You should avoid lying on your abdomen after surgery." b. "Your surgeon might prescribe an antibiotic before surgery." c. "It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia." d. "To promote wound healing, it is important to reduce your intake of carbohydrates once you return home."
b
A nurse is teaching a client who is in the immediate postoperative period about the use of a PCA pump. Which of the following statements should the nurse include in the teaching? a. "You will receive a dose of medication every time you push the button." b. "Do not allow visitors to push the PCA button if you are sleeping." c. "You cannot receive too much medication by pushing the button." d. "Do not push the PCA button until your pain reaches a severe level."
b
A patient with a 24-hour history of flank pain and nausea and vomiting has the following orders: 2 mg of Dilaudid, urinalysis, urine culture, and Zofran. Which action should the nurse take first? a. Give Zofran b. Give Dilaudid c. Do the urinalysis d. Strain the urine
b
Addison's crisis/adrenal insufficiency is induced by: a. Using corticosteroids b. Stress c. Illicit drugs d. A good day
b
Before administering levothyroxine, what should be assessed? a. Digoxin level b. Apical pulse c. Respiratory rate d. CBG
b
Corticosteroids should be: a. Have hard stop b. Be tapered c. Not be used d. Continued always for life
b
Signs of infection are typically seen on which post-operative day? a. 1st-2nd b. 3rd-5th c. 5th-6th d. 10th-14th
b
The BUN and creatinine levels will indicate the patient's: a. Liver function b. Renal function c. Neurologic status d. Bladder capacity
b
The acronym VTE means: a. vein to emboli b. venous thromboembolism c. variable thrombi d. vein tenderness
b
The patient is ordered acetaminophen/hydromorphone 325 mg/5mg, the floor stocks acetaminophen/hydromorphone 500 mg/5 mg. What should the nurse do? a. Call the provider and ask for an order change. b. Call the pharmacy and request the lesser concentration. c. Administer the stocked dose -- this is an acceptable substitution d. Seek assistance from an experienced nursing assistant
b
This route of Heparin administration is used for VTE prophylaxis: a. IM b. Subcutaneous c. PO d. IV
b
What is the most important aspect of diabetes care? a. Metformin b. Maintain stable glucose levels c. Quick amputation d. Monitor liver function
b
What is the most important assessment the nurse completes before administering an opioid agonist? a. Hepatic labs b. Respiratory rate c. Bowel sounds d. Pulse oximetry
b
What is the priority nursing assessment when a patient is admitted to the PACU? a. Level of consciousness b. Airway and gas exchange c. Dressing and incision status d. Vital signs and body temperature
b
What is the purpose of a surgical drain? a. Stop bleeding b. Prevent accumulation of excess fluid c. Prevent infection d. Provide sterile irrigation
b
What is the term for the separation of a surgical incision or rupture of a wound closure? a. Evisceration b. Dehiscence c. Slough d. Laceration
b
What should be kept at bedside following thyroidectomy? a. Chest tube b. Tracheostomy kit c. Intubation kit d. Suture kit
b
When assessing the laboratory work of a 65-year-old patient who is scheduled for surgery this morning, the nurse understand which laboratory value may result in cancellation of the surgery? A. Hemoglobin 10.5 g/dL B. Serum potassium 2.7 mEq/L C. Serum sodium level 149 mEq/L D. Fasting blood glucose 120 mg/dL
b
Which client experiences bronzing and weight loss? a. Cushing's syndrome b. Addison's disease c. Diabetes insipidus d. Pheochromocytoma
b
Which is NOT a sign of Cushing's syndrome? a. Mood swings b. Bulging eyes c. Buffalo hump d. Water weight gain
b
Which is NOT a sign of hypocalcemia? a. Tetany b. Hyperglycemia c. Arrhythmias d. Convulsions
b
Which is NOT a symptom of hypothyroidism? a. Dry skin b. Diarrhea c. Bradycardia d. Depression
b
Which is a symptom of Addison's disease? a. Pale skin b. Blood pressure 85/60 c. 10 lb weight gain from the last appointment d. Moon face
b
Which of the following are appropriate non-pharmacological interventions for PACU patients? a. 3 course dinner and drinks b. Warm blankets, dim lights, education, distraction, back rub c. IV opiates d. Early mobilization in the PACU
b
Which of the following is a S/S related to a deep vein thrombosis? a. Shortness of breath b. Unilateral lower extremity edema c. Bilateral lower extremity edema d. Decreased pulse in affected extremities
b
Which patient would likely NOT require an IVP opioid agonist? a. A 65-year-old woman with a history of ovarian cancer and COPD. b. A 24-year-old male s/p laparoscopic appendectomy ambulating in the hall with staff. c. A 44-year-old man s/p bowel resection with a history of substance abuse disorder. d. A 68-year-old male with s/p prostatectomy and a pulse ox of 94%.
b
Which would be a concerning sign of a patient with hyperthyroidism? a. BP 112/86 b. HR 120 c. RR 20 d. Temp 95.9 F
b
Why does Fentanyl cause hypotension? a. Vasoconstriction b. Vasodilation c. Dizziness d. Bradycardia
b
A cause of Cushing's could be: a. Diabetes b. Smoking c. Long-term use of corticosteroids d. Exercise
c
A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following complications of surgery? a. Malignant hyperthermia b. Blood clots c. Infection d. Hypoxia
c
A client received glycopyrrolate peri-op to dry secretions. The PACU nurse may note: a. A cough b. Respiratory wheezes c. Dysuria d. Diarrhea
c
A diabetic patient states their sugar has been running twice as high as normal the last few days: what should you do first? a. Check the glucose b. Advise the patient to double insulin c. Assess for ketones in the urine d. Assess for sugar in the urine
c
A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (Select all that apply.) a. Explain to the client the purpose of the having the procedure b. Inform the client of risks to having the procedure c. Ensure the client understands information about the procedure d. Witness the client signing the informed consent form e. Determine if the client is capable of understanding the reason
c, d, e
A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? a. Contact the anesthesiologist. b. Assist with endotracheal intubation. c. Increase the client's flow of oxygen. d. Use the head-tilt, chin-lift method to open the airway.
d
A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking the medication regularly. Which of the following findings should the nurse expect? a. Increased urine output b. Persistent diarrhea c. Tachycardia d. Hypotension
d
A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements by the client indicates an understanding of the teaching? a. "I will let my feet air dry after washing." b. "I will wear sandals to allow air to circulate around my feet." c. "I will buy over-the-counter medicine to treat the calluses on my feet." d. "I will apply lotion to the dry areas of my feet but not between my toes."
d
A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? a. Compare and contrast the peripheral pulses. b. Apply a warm blanket. c. Assess dressings. d. Place the client in a lateral position.
d
A nurse is caring for a client who had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? a. Go to the nurses' station to seek assistance. b. Reinsert the organs into the abdominal cavity. c. Place the client in a reverse Trendelenburg position. d. Obtain vital signs to assess for shock.
d
A nurse is caring for a client who has a prescription for gabapentin for neuropathic pain. The nurse should monitor the client for which of the following adverse effects of this medication? a. Constipation b. Urinary retention c. Insomnia d. Dizziness
d
A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client? a. Amiodarone b. Propanolol c. Methyldopa d. Epinephrine
d
A nurse is caring for a client who has type 2 diabetes mellitus and is experiencing a hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? a. Serum pH 7.32 b. Blood glucose 250 mg/dL c. Blood glucose 425 mg/dL d. Serum pH 7.45
d
A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? a. Most clients exaggerate their level of pain b. Pain must have an identifiable source to justify the use of opioids c. Objective data are essential in assessing pain. d. Pain is whatever the client says it is.
d
A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include? a. "Drink at least 3 liters of fluid per day." b. "Weigh yourself weekly while wearing similar clothing at the same time of day." c. "Notify the provider of a weight loss of more than 1 pound or more per week." d. "Report nocturia because it requires a dosage adjustment."
d
A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client expresses anxiety about the upcoming surgery. Which of the following actions should the nurse take? a. Sympathize with the client's feelings. b. Reassure the client that the surgery will go fine. c. Change the topic of discussion. d. Provide concise, factual information.
d
A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching? a. "I should wait to take my pain medication until after I have completed my range-of-motion exercises." b. "I should wait until a week after surgery to start my hand-strengthening exercises." c. "I will be able to lift an object that weighs 10 pounds 2 weeks after my surgery." d. "I will be able to shower after the doctor removes the drain."
d
A nurse is reviewing the laboratory results of a client undergoing screening for primary Cushing's disease. The nurse should expect an elevation in which of the following laboratory findings? a. Lymphocyte count b. Potassium c. Calcium d. Glucose
d
A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk for complications? a. Cefazolin b. Digoxin c. Ondansetron d. Warfarin
d
A nurse is teaching a client about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders? a. Diabetes insipidus b. Hyperthyroidism c. Pheochromocytoma d. Addison's disease
d
A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of diabetic ketoacidosis (DKA)? a. Decreased urine output b. Weight gain of 0.45 kg in 24 hr c. Rapid, shallow respirations d. Blood glucose levels above 300 mg/dL
d
A nurse is teaching a client who is scheduled for a vanillylmandelic acid test to screen for pheochromocytoma. Which of the following statements should the nurse include in the teaching? a. "Start fasting at midnight prior to the day of the test." b. "Begin the 24-hour urine collection with the first morning urine, and then collect all urine after that for 24 hr." c. "Take low-dose aspirin for pain during the testing period." d. "Restrict coffee intake 2 to 3 days prior to the test."
d
A nurse providing teaching for a client who is scheduled to undergo moderate sedation for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? a. "I will need to complete a bowel prep the day before the procedure." b. "I will drink plenty of fluids the morning of the procedure." c. "I can eat as soon as the procedure is over." d. "I can expect to feel sleepy for several hours after the procedure."
d
A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? a. Encourage the client to void after preoperative medication administration b. Administer antibiotics 2 hr prior to surgical incision c. Remove hair using a manual razor d. Remove nail polish on fingers and toes
d
Corticosteroids are used to treat: a. Heart disease b. Cholesterol c. Anxiety d. Inflammationd
d
Desmopressin/vasopressin/DDAVP is a replacement for: a. Epinephrine b. Angiotensin c. Aldosterone d. ADH
d
Levothyroxine should be taken: a. at HS b. with meals c. immediately after meals d. on an empty stomach
d
Signs of thyrotoxic crisis does NOT include: a. Hypertension b. High fever c. Tachycardia d. Overhydration
d
This route of Heparin administration is used for VTE management: a. IM b. Subcutaneous c. PO d. IV
d
Treatment of Addison's disease involves: a. Removal of pituitary b. Removal of adrenal gland c. Thyroid blockers d. Corticosteroids
d
When does Lantus peak? a. 3 hours b. 12 hours c. 8 hours d. It doesn't
d
Which aspect of diabetic foot care is the MOST important? a. Lotion b. Avoiding shoes as much as possible c. Repetitive soaking of feet d. Inspection
d
Which is NOT a S/S of acromegaly? a. Aortic aneurysm b. Coarse facial features c. Enlarged distal extremities d. Moon face
d
Which of the following patients is at MOST at risk for developing VTE? a. A 45-year-old with hyperlipidemia and diabetes b. A 70-year-old with severe anxiety c. A 25-year-old with IV drug dependency d. A 60-year-old day 1 post-op knee replacement
d
Which should always receive immediate attention? a. Muscle spasm b. Sneezing c. Diarrhea d. Stridor
d
Which would be related to hypokalemia? a. Thyroid hormone b. PTH c. ADH d. Aldosterone
d
