205 Exam 3

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome. Which of the following questions should the nurse ask the client? A. "do you have a history of chronic alcohol abuse?" B. "have you had a recent influenza infection?" C. "have you traveled overseas recently?" D. "are you taking a multivitamin?"

B. "have you had a recent influenza infection?"

A nurse in the ER is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. airway obstruction B. infection C. fluid imbalance D. paralytic ileus

A. airway obstruction

A nurse suspects anaphylaxis when carig for a client following the initial administration of an oral antibiotic. WHich of the following should be the nurse's priority intervention? A. insert an IV line B. count the respiratory rate C. administer oxygen D. prepare equipment for intubation

B. count the respiratory rate

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. urinary output 25 ml/hr B. difficulty swallowing C. HR 122/min D. pain of 6/10

B. difficulty swallowing

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions? A. dehydration B. fungal infection C. compartment syndrome D. pleural effusion

B. fungal infection

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? A. urticaria B. stridor C. vomiting D. hypotension

B. stridor

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. hypotension B. anuria C. increased respiratory rate D. decreased level of consciousness

C. increased respiratory rate

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg base excess -2 PaO2 78 mm Hg Saturation 80% bicarbonate 26 mEq/L A. respiratory acidosis B. metabolic acidosis C. metabolic alkalosis D. respiratory alkalosis

A. respiratory acidosis

A nurse is caring for the client whose throat culture is positive for group A strep 24 hrs after a rapid strep test was negative. Which of the following actions is the nurse's priority? A. notify the client to return to the clinic for initiation of antibiotic therapy B. ask the client to identify friends and family who have been in close contact C. reinforce teaching about gargling with warm saline several times daily D. instruct the client to take antipyretics as directed for elevated temperature

A. notify the client to return to the clinic for initiation of antibiotic therapy

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? A. Prepare the client for mechanical ventilation B. Administer an anti-cholinesterase medication C. Instruct the client to perform the pursed lip breathing D. Prepare to administer a vasoconstrictor

A. Prepare the client for mechanical ventilation

A nurse is assessing a client who is postop and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. fatigue B. hypertension C. bradycardia D. diarrhea

A. fatigue

A nurse is teaching a group of clients about tick-borne illnesses. Which of the following information should the nurse include in the teaching regarding ticks? A. grasp the tick as close to the skin as possible B. use a twisting motion when removing the tick C. apply a pediculicide lotion to the area surrounding the tick D. use the hot ember from the tip of a match to remove the tick

A. grasp the tick as close to the skin as possible

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. insert an indwelling urinary catheter B. inspect the mouth for signs of inhalation injuries C. administer intravenous pain medication D. draw blood for a CBC

B. inspect the mouth for signs of inhalation injuries

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care? A. check the IV site for bleeding Q8 hours B. limit IM injections C. obtain a rectal temperature Q8 hours D. check the client for proteinuria

B. limit IM injections

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? A. chest x-ray B. sputum culture for acid-fast bacilus C. sputum smear D. mantoux test

B. sputum culture for acid-fast bacilus

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? A. assess the client's level of consciousness B. administer epinephrine C. auscultate for wheezing D. monitor for hypotension

C. auscultate for wheezing

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A. a family history increases your risk for acquiring hepatitis A B. hepatitis A infects the kidneys C. manifestations of the virus are similar to flu-like symptoms D. the incubation of the virus is 5 days

C. manifestations of the virus are similar to flu-like symptoms

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? A. avoid eating at fast food restaurants B. avoid serving raw foods C. practice effective hand hygiene D. wear barrier protection during vaginal intercourse

C. practice effective hand hygiene

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) indicated by which of the following findings? A. Nuchal rigidity B. Pupils reactive to light C. Widened pulse pressure D. Elevated temperature

C. widened pulse pressure

A nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider? A. platelets 156,000/mm3 B. PT 12 seconds C. PTT 64 seconds D. fibrinogen 85 mg/dL

D. fibrinogen 85 mg/dL

A nurse in the ZER is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? A. clean and dress the wound B. administer pain medication C. administer a tetanus booster D. administer IV fluids

D. administer IV fluids

A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care? A. insert an indwelling catheter to monitor sediment in the urine B. take the clients temperature once per shift C. provide the client with fresh fruit to avoid constipation D. limit the number of health care workers entering the room

D. limit the number of health care workers entering the room

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? A. initiate fluid resuscitation B. medicate for pain C. insert an indwelling urinary catheter D. maintain the airway

D. maintain an airway

A nurse is caring for a cleint who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biospy will hurt. Which of the following responses should the nurse make? A. "the biopsy can be uncomfortable, but I will try to keep you as comfortable as possible" B. "relax, you'll be asleep for most of the procedure and you won't remember a thing" C. "I will call your doctor and tell him you still have questions about the procedure" D. "I can understand because you must be very worried about what the biopsy will show"

A. "the biopsy can be uncomfortable, but I will try to keep you as comfortable as possible"

A nurse is reviewing the laboratory results of an adolescent female client snd notes a WBC count of 16,000/mm3 with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? A. an acute infectious process B. neutropenia C. allergic reaction D. a resolving inflammatory process

A. an acute infectious process

A nurse is teaching a client's family about lightening strike prevention following a lightening injury to the client. Which of the following information should the nurse include in the teaching? A. avoid using a corded landline telephone B. move out of the open area by standing by a tree C. lie down on the ground D. seek safety in an isolated shed

A. avoid using a corded landline telephone

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A. confusion B. blood pressure 84/50 mm Hg C. anuria D. petechiae

A. confusion

A nurse in the ER department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A. increased heart rate B. widening pulse pressure C. increased deep tendon reflexes D. pulse oximetry 96%

A. increased heart rate

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? A. measure the circumference of both upper arms B. notify the provider who inserted the PICC line C. remove the PICC line D. apply a cold pack to the client's upper arm

A. measure the circumference of both upper arms

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states "I always get a rash when I eat shellfish" Which of the following is the priority nursing action? A. notify the provider of the client's allergy B. attach a wristband indicating the client's allergy C. ask the client if any other foods cause such a reaction D. notify the dietary department of the client's allergy

A. notify the provider of the client's allergy

A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching? A. remove the stinger by scraping it off with a knife blade B. apply a tourniquet C. apply a warm pack D. suck the wound

A. remove the stinger by scraping it off with a knife blade

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her HR is 110/min, respiratory rate 40/min, and bloos pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. prepare for mechanical ventilation B. administer oxygen via face mask C. prepare to administer a sedative D. assess for indications of pulmonary embolism

B. administer oxygen via face mask

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? A. 9% B. 18% C. 36% D. 54%

D. 54%

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura. When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for A. side effects of immunosuppressants B. constipation C. fatigue D. bleeding

D. bleeding

A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include? A. take isoniazid with an antacid B. provide a sputum specimen every 2 weeks to the clinic for testing C. expect your sputum cultures to be negative after 6 months of therapy D. drink at least 8 ounces of water when you take the pyrazinamide tablet

D. drink at least 8 ounces of water when you take the pyrazinamide tablet

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan? A. administer antibiotics B. provide a diet high in fat C. restrict fluids D. encourage short periods of ambulation

D. encourage short periods of ambulation

A nurse is caring for a client who is experienceing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? A. dobutamine B. methylprednisolone C. furosemide D. epinephrine

D. epinephrine

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? A. fluid overload B. left ventricular failure C. intracardiac shunt D. hypovolemia

D. hypovolemia

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. cryoprecipitates B. Platelets C. Albumin D. Packed RBCs

D. packed RBCs

A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching? A. keep artificial nails trimmed B. use alcohol-based hand rubs before administering eye drops for a client C. wash hands with alcohol-based hand rubs when caring for a client who has C. Diff D. use chlorhexidine to wash hands if the client is immunosuppressed

D. use chlorhexidine to wash hands if the client is immunosuppressed