Practice Test 1

The wife of a client is concerned because her husband is requiring increasingly high doses of analgesia. She states, "He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasn't just raised and raised." What would be the nurse's best response?

"Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the client relief."

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.

5% DW

A 75-year-old client had surgery for a hip fracture yesterday. The client is under stress because of the pain, the medications, sleep deprivation, and hospital surroundings. Which nursing intervention to treat the client's pain should the nurse question when ordered by the doctor?

Advil for pain management

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level Electrolyte imbalance

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply.

Arteriography Open reduction of a fracture Cystoscopy Paracentesis

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

Which action by the nurse indicates understanding of one basic principle of providing effective pain management?

Awakening a new postoperative client to take pain medication

Solu-medrol and prednisone are glucocortico steroids used to prevent or control inflammation in the lungs and airways. As such, which lab value would take priority in the coordination of care for a patient receiving this therapy?

Bedside blood glucose reading of 388 mg/dL

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.

Chills Crackles Tachypnea

A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections?

Chlorhexidine

Why should the nurse be vigilant with assessment of perioperative risks on the older adult patient? (Select all that apply.)

Ciliary action decreases, reducing the cough reflex. Fatty tissue increases, prolonging the effects of anesthesia. Liver size decreases, reducing the metabolism of anesthetics.

The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this client, what variables should the nurse consider? Select all that apply.

Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply.

Cyanosis Shoulder pain Dyspnea Tachycardia

The circulating nurse is preparing a patient for a surgical procedure. What primary responsibility does the circulating nurse have in the perioperative experience?

Discussing the complications of the surgical procedure with the patient

The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply.

Explanation of procedure Potential risks Benefits of surgery Description of alternatives

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply.

Extravasation Hematoma Phlebitis

Which factor increases blood urea nitrogen (BUN)?

Gastrointestinal bleeding

A client who has developed a painless penile ulcer is diagnosed with syphilis. What treatment would physician prescribe?

IV penicillin G; single dose

A patient is complaining of a headache after receiving spinal anesthesia. What does the nurse understand may be the cause of the headache related to the spinal anesthesia? (Select all that apply.)

Leakage of spinal fluid from the subarachnoid space Size of the spinal needle used Degree of patient hydration

During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?

Metabolic acidosis When a patient's temperature falls, glucose metabolism is reduced. As a result, metabolic acidosis may develop.

A nurse would implement droplet precautions for a client with which condition? Select all that apply.

Mumps Parvovirus B 19 Pertussis

A nurse implements aseptic technique as a means to break the chain of infection at which element?

Portal of entry The use of aseptic technique interrupts the chain of infection at the portal of entry. Employee health, environmental sanitation, and disinfection and sterilization interfere with the reservoir element. Hand hygiene, control of secretions, and excretions and proper trash and waste disposal interfere with the portal of exit. Isolation, proper food handling, airflow control, standard precautions, sterilization, and hand hygiene interfere with the means of transmission.

An obese client is scheduled for open abdominal surgery. What priority education should the nurse provide to this client?

Prevention of respiratory complications

An older adult has been medicated with an oral opioid for postoperative pain. To make the pain medication more effective, the nurse first

Provides the client with a fresh gown and changes the bed linens

When assessing a client with infectious diarrhea, which of the following would lead the nurse to suspect that the client is experiencing severe dehydration?

Rapid, thready pulse

The nurse is providing an education program to reduce the incidence of infection currently on the rise in the community. What areas should the nurse focus on when presenting this program? (Select all that apply.)

Regulated health practices Sanitation techniques Immunization programs

The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to:

Remove the patch after 12 hours.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Reorient the client. Assess for hypoxia. Assess urine output.

A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply.

Scrub clothes Caps Scrub clothes and caps are worn in the semi-restricted area. Street clothes are worn in the unrestricted area. Scrub clothes, caps, shoe covers, and masks are worn in the restricted area.

A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.

The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past.

How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.)

The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.

The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure?

Up to 2 hours before surgery

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply.

Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed.