Synthesis Practice Exam 1
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? SATA: A) Poor skin turgor B) Bradycardia C) Hypotension D) Pale yellow urine E) Flat neck veins
A) Poor skin turgor C) Hypotension E) Flat neck veins
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? SATA: A) Contractures of the extremities B) Polyuria C) Diarrhea D) Crackles in the lungs E) Pressure ulcers
A) Contractures of the extremities D) Crackles in the lungs E) Pressure ulcers
A nurse is caring for a group of clients on a medical surgical unit. Which of the following situations requires that the nurse wear gloves? SATA: A) Emptying urine from an indwelling urine collect bag B) Providing oral care C) Changing an ostomy bag D) Delivering a food tray to a client who has AIDS E) Placing oral medication tablets into a client's hand
A) Emptying urine from an indwelling urine collect bag B) Providing oral care C) Changing an ostomy bag
The nurse is caring for the client with a non-healing wound due to osteomyelitis. The client is ready for discharge home. The nurse should consult the case manager if the client experiences the following? A) Wound drainage B) Edema in hip C) Inability to ambulate to the bathroom D) Decreased appetite
C) Inability to ambulate to the bathroom
Calculate the client's intake for the 7 am to 3 pm shift. Record your answer using a whole number. 1 -- 8 oz cup of coffee, 1 -- 4 oz carton of milk, 1 -- 4 oz bowl of applesauce, 1 -- 4 oz glass of cranberry juice. Additional information for 8-hour shift: IV of normal saline is running at 100 mL/hr. A 1500mg vancomycin injection in 200 mL 50% dextrose was administered q12h.
1480
An 86-year-old client with dementia is being discharged after treatment for a hip fracture. In reviewing the notes, the nurse identifies that the sole caregiver at home is an adult daughter with a moderate intellectual disability. Which is the most important action the nurse should ensure is in place before discharging the client home? A) Physical therapy service has been coordinated in the home B) Social work support has been established for the caregiver C) The insurance company is aware of the need for increased services D) An immediate home visit is arranged with the visiting nurse service and the social worker
D) An immediate home visit is arranged with the visiting nurse service and the social worker
A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength? A) Ask the client how string she feels today B) Ask the client to touch her finger to her nose C) Palpate the client's pedal pulses D) Ask the client to push her feet against the nurse's palms
D) Ask the client to push her feet against the nurse's palms
The nursing team on a medical surgical unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN? A) a 52-year-old client with lung cancer admitted for acute dyspnea B) a 26-year-old client being evaluated for a bone marrow transplant C) a 45-year-old client receiving tube feedings D) a 65-year-old client diagnosed with endometrial cancer who underwent abdominal hysterectomy 3 days ago
A) a 52-year-old client with lung cancer admitted for acute dyspnea
The nurse is assessing a client who has fallen twice in the last 2 days. The client has been diagnosed with delirium tremens (DTs) following withdrawal from alcohol use. The nurse should further evaluate the client for which complications? SATA: A) disorientation B) paralysis C) Bradycardia D) diaphoresis E) visual or auditory hallucinations
A) disorientation D) diaphoresis E) visual or auditory hallucinations
A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must: A) ensure that health education is begun as early as possible B) ensure that this information is specified in the client's informed consent document C) administer prophylactic antibiotics for to six hours prior to surgery D) ensure that the client is safe to drive before being discharged
A) ensure that health education is begun as early as possible
A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications...... hen caring for a client who will be discharged shortly after a procedure, the nurse must: A) ensure that health education is begun as early as possible B) ensure that this is specified in the client's informed consent document C) administer prophylactic antibiotics four to six hours prior to surgery D) ensure that the client is safe to drive before being discharged
A) ensure that health education is begun as early as possible
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A) Observe client's respiratory status B) Elevate the head of the client's bed 30-45 degrees C) Monitor intake and output every 8 hours D) Check residual volume every 4 to 6 hours
B) Elevate the head of the client's bed 30-45 degrees
A nurse is planning care for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physical restraints? SATA: A) Elevate all side rails on the bed B) Ensure effective pain management C) Attend to the client's needs for toileting D) Assign the client to a room near the nurse's station E) Orient client frequently to the environment
B) Ensure effective pain management C) Attend to the client's needs for toileting D) Assign the client to a room near the nurse's station E) Orient client frequently to the environment
A nurse is providing care for four clients on a medical surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? SATA: A) A client who is ambulatory following a cardiac catheterization 4 hours ago B) A client who has type 1 diabetes mellitus and is hyperglycemic C) A client who has protein calorie malnutrition D) A client who has right sided heart failure and 4+ edema to the lower extremities E) A client who has postoperative delirium
C) A client who has protein calorie malnutrition D) A client who has right sided heart failure and 4+ edema to the lower extremities E) A client who has postoperative delirium
A nurse is teaching. client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? SATA: A) Bacteria B) Diuretics C) Aging D) Obesity E) Smoking
C) Aging D) Obesity E) Smoking
A nurse is caring for a client who needs to increase his protein intake. The client tells the nurse some of the food he enjoys. Which of the following foods should the nurse recommend as the best source of protein among these suggestions? A) Yams B) Eggs C) Chicken D) Peanuts
C) Chicken
A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict? A) Implement a resolution B) Brainstorm solutions C) Identify the problem D) Evaluate the results
C) Identify the problem
The nurse at an outpatient surgical clinic witness's client signature. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? A) a 7-year-ole who need an open reduction internal fixation (ORIF) of the right arm B) a 62-year-ole with macular degeneration who is ordered a routine colonoscopy C) a married 17-year-ole who requires a cholecystectomy for relief of nausea and pain D) a 16-year-ole who is obtaining an elective breast reduction for back pain relief
C) a married 17-year-ole who requires a cholecystectomy for relief of nausea and pain
The nurse is caring fora client with an open tibia fracture. The nurse should closely monitor the client for which complication A) avascular necrosis B) compartment syndrome C) osteomyelitis D) dislocation
C) osteomyelitis
A client is in hypovolemic shock. In which position should the nurse place the client? A) supine B) semi-Fowler's C) supine with the legs elevated 15 degrees D) Trendelenburg's
C) supine with the legs elevated 15 degrees
A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? A) A client who has previously undergone a procedure that is to be performed for a second time B) A client who has been educated on treatment options and chooses alternative treatments C) A client who makes an informed decision not to participate in chemotherapy treatment D) An older adult client who has no family and is uncertain about moving to assisted living
D) An older adult client who has no family and is uncertain about moving to assisted living
A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? SATA: A) A client who requires placement in an assisted living facility B) A client who requests to secure an emergency notification system in the home C) A client who requests to get school assignments while hospitalized on a pediatric unit D) A client who requests to receive additional instructions on breastfeeding prior to discharge E) A client who requests to obtain information on the adverse effects of antidepressant medication therapy
A) A client who requires placement in an assisted living facility B) A client who requests to secure an emergency notification system in the home C) A client who requests to get school assignments while hospitalized on a pediatric unit
A nurse in an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider, which of the following nursing actions should the nurse perform? SATA: A) Apply ice to the affected areas B) Encourage range of motion of the foot C) Provide the client with a light snack D) Apply a compression bandage E) Elevate the foot
A) Apply ice to the affected areas D) Apply a compression bandage E) Elevate the foot
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? A) Apply the bag for 30 minutes at a time B) Reapply the bag 30 minutes after removing it C) Allow room for some air inside the bag D) Place the bag directly on the skin
A) Apply the bag for 30 minutes at a time
A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? SATA: A) Avoid prolonged sitting B) Apply heat for 10 minutes every hour C) Sleep in a side lying position with flexed knees D) Sleep on a soft mattress E) Try padded shoe insoles
A) Avoid prolonged sitting C) Sleep in a side lying position with flexed knees E) Try padded shoe insoles
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? SATA: A) Bathe a client who had an amputation 2 days ago B) Assist a client to ambulate using a go belt C) Review a low sodium diet for a client who has hypertension D) Explain oral hygiene to a client receiving chemotherapy E) Feed a client who had a stroke 3 months ago
A) Bathe a client who had an amputation 2 days ago B) Assist a client to ambulate using a go belt E) Feed a client who had a stroke 3 months ago
A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes clear liquid diet. Which of the following items should the nurse offer the client? SATA: A) Broth B) Grape juice C) Nonfat milk D) Custard E) Lemon gelatin
A) Broth B) Grape juice E) Lemon gelatin
A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. The ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take? A) Check that the client lifts the walker and then places it down in front of her B) Walk in front of the client to guide her in moving the walker C) Have the client move one leg forward with the walker D) Make sure that the upper bar of the walker is level with the client's waist
A) Check that the client lifts the walker and then places it down in front of her
A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status oh the client's affected extremity? SATA: A) Color B) Temperature C) Ecchymosis D) Skin integrity E) Sensation
A) Color B) Temperature E) Sensation
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? SATA: A) Decreased gastric motility B) Decreased skin elasticity C) Increased pain threshold D) Increased metabolic rate E) Increased cardiac output
A) Decreased gastric motility B) Decreased skin elasticity C) Increased pain threshold
The nurse is assessing a client with a hematoma and compartment syndrome the same extremity. Which symptoms would the nurse anticipate? SATA: A) Edema B) Increased venous pressure C) Decreased venous circulation D) Increased arterial circulation E)Decreased pain on movement
A) Edema B) Increased venous pressure
A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? SATA: A) Kidney beans B) Blackberries C) Refined cereals D) Whole wheat bread E) Lean turkey
A) Kidney beans B) Blackberries D) Whole wheat bread
A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? SATA: A) Monitor peripheral pulses in the affected extremity B) Position weights against the foot of the bed C) Adjust the prescribed weights every shift D) Examine the skin under the traction splint E) Assess the temperature of the affected extremity
A) Monitor peripheral pulses in the affected extremity D) Examine the skin under the traction splint E) Assess the temperature of the affected extremity
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? SATA: A) More difficulty seeing due to a greater sensitivity to glare B) Decreased cough reflex C) Decreased bladder capacity D) Decreased systolic blood pressure E) Dehydration of intervertebral discs
A) More difficulty seeing due to a greater sensitivity to glare B) Decreased cough reflex C) Decreased bladder capacity E) Dehydration of intervertebral discs
When assessing a client in the initial stage of hypovolemic shock, the nurse should observe for which early symptoms? A) New onset of mild confusion or restlessness B) Mottled extremities with diminished peripheral pulses C) Oliguria D) Bradycardia
A) New onset of mild confusion or restlessness
A client is brought to the emergency room after an automobile accident. He is unconscious with a blood pressure of 60/40. The nurse anticipates that the doctor will order which of the intravenous treatments first? A) Normal saline infused at "wide open" rapid rate of 500 mL/hr or more B) D5W fusion at 250 mL/hr C) Lactated Ringer's infusion at 125 mL/hr D) Norepinephrine (Levophed). IV infusion at a rate to maintain SBP>90mmHg
A) Normal saline infused at "wide open" rapid rate of 500 mL/hr or more
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? SATA: A) Poor nutritional state B) Altered mental status C) Obesity D) Pain medication administration E) Wound infection
A) Poor nutritional state C) Obesity E) Wound infection
When preparing a client for discharge from the hospital after a total hip replacement, the nurse should include which information in the discharge plan? A) Report signs of infection to health care provider (HCP) B)Sit in a low chair to avoid stress on the hip joint C) Remove anti embolism stockings when sleeping D) Change packed dressing daily
A) Report signs of infection to health care provider (HCP)
A nurse is caring for a client who is postoperative and I skeletal traction. When assessing the client, the nurse should expect which of the following findings? SATA: A) Slight pain at the insertion site B) Serous drainage on the dressing C) Movement of the pin at the insertion site D) Elastic bandages secure around the traction roes E) Minimal edema around the pin
A) Slight pain at the insertion site B) Serous drainage on the dressing E) Minimal edema around the pin
A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? SATA: A) The date of the incident B) The name of the provider who prescribed the medications C) The potential adverse effects of the medication D) The time the client was to receive the medication E) The client's vital signs
A) The date of the incident D) The time the client was to receive the medication E) The client's vital signs
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? A) A client who has lactose intolerance B) A client who has has a cerebrovascular accident C) A client who is 4 hours postoperative following a leg amputation with general anesthesia D) A client who has had prolonged diarrhea E) A client who has had radiation therapy for head and neck cancer
B) A client who has has a cerebrovascular accident C) A client who is 4 hours postoperative following a leg amputation with general anesthesia E) A client who has had radiation therapy for head and neck cancer
A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching? A) Buck's extension traction will reduce the fracture B) Buck's extension traction will relieve muscle spasms C) Buck's extension traction will maintain alignment of the pins D) Buck's extension traction will allow supported movement of the extremity
B) Buck's extension traction will relieve muscle spasms
A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? SATA: A) Apply full weight-bearing on the affected side B) Elevate the affected ankle above the level of the heart C) Apply a heating pad intermittently to the affected ankle after 48 hours D) Wrap the affected ankle with an elasticized compression bandage E) Apply intermittent ice to the affected ankle for the first 48 hours
B) Elevate the affected ankle above the level of the heart C) Apply a heating pad intermittently to the affected ankle after 48 hours D) Wrap the affected ankle with an elasticized compression bandage E) Apply intermittent ice to the affected ankle for the first 48 hours
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? SATA: A) Provide discharge instructions to a confused client's spouse B) Obtain vital signs from a client who is 6 hours post operative C) Administer a tap-water enema to a client who is preoperative D) Initiate a plan of care for a client who is postoperative from an appendectomy E) Catheterize a client who has not voided in 8 hours
B) Obtain vital signs from a client who is 6 hours post operative C) Administer a tap-water enema to a client who is preoperative E) Catheterize a client who has not voided in 8 hours
A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? SATA: A) BMI of 20 B) Oral contraceptive use C) Hypertension D) High calcium intake E) Immobility
B) Oral contraceptive use E) Immobility
A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse Which activity would be appropriate for the nurse to delegate? SATA: A) assessment of a client who has just returned from the post-anesthesia care unit B) vital sign monitoring of a client who is 3 days post surgical repair oh a fractured hip C) assistance with range of motion exercises for a client diagnosed with Alzheimer's disease D) education about how to administer a heparin injection to a client diagnosed with deep vein thrombosis E) administering a ritz-bath to a client who has had perineal surgery 2 days ago
B) vital sign monitoring of a client who is 3 days post surgical repair oh a fractured hip C) assistance with range of motion exercises for a client diagnosed with Alzheimer's disease E) administering a ritz-bath to a client who has had perineal surgery 2 days ago
A nurse has received change-of-shift report on the following four clients. Which client should the nurse assess first? A) Client with right-sided heart failure who has 4+ bilateral edema in the legs and feet B) Client with a recent lung transplant scheduled to begin pulmonary rehabilitation C) Client with a pneumonia who has chest pain from coughing D) Client experiencing tracheal deviation following a subclavian catheter insertion
D) Client experiencing tracheal deviation following a subclavian catheter insertion
The child weighs 44 lbs (20kg). The nurse has started an IV infusion of lactated Ringer solution and inserted an indwelling catheter. Which of the finding indicate that the child is going into hypovolemic shock? SATA: A) Urinary output is 30 mL/hr B) Specific gravity is within normal limits C) Pain is 7 on a pain scale of 1 to 10 D) Heart rate is elevated E) Blood pressure is dropping
D) Heart rate is elevated E) Blood pressure is dropping
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? A) One cup of brown rice B) One cup of orange juice C) One cup of pureed avocado D) One cup of lentils
D) One cup of lentils
A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? SATA: A) Bathtub with rails B) Electric cords behind the furniture C) Raised toilet seats D) Water heater temperature 54.4C (130F) E) Throw rugs
D) Water heater temperature 54.4C (130F) E) Throw rugs