AH Exam 2 Practice Questions

A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. B. Explain the procedure for an upper gastrointestinal series. C. Administer pain medication. D. Test the client's emesis for blood.

A. Assess orthostatic blood pressure.

A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm? Select all that apply a. Fever b. Nausea c. Lethargy d. Tremors e. Confusion f. Bradycardia

A,B,D,E- Thyroid storm is an acute and life-threatening condition. Symptoms include fever, nausea, tremors, and confusion.

A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this medication? Select all that apply a. Administer methimazole with food b. Place client on low-calorie, low-protein diet c. Assess client for unexplained bruising or bleeding d. Instruct client to report side effects such as sore throat, fever, or headache e. Use special radioactive precautions when handling urine for the first 24 hours following initial administration

A,C,D- Common side effects include nausea, vomiting, diarrhea: reduced by taking with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client should consume a high-caloric diet. Sore throat, fever, headache, or bleeding may indicate agranulocytosis (caused by antithyroid meds) and the HCP should be notified immediately.

The community health nurse visits a client at home. Prednisone 10mg orally daily has been prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary? a. "I can take aspirin or my antihistamine if I need it" b. "I need to take the medication every day at the same time" c. "I need to avoid coffee, tea, cola, and chocolate in my diet" d. "If I gain more than 5 pounds a week, I will call my health care provider"

A- "I can take aspirin or my antihistamine if I need it." Aspirin and other OTC medications should not be taken unless the client consults with the health care provider.

A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide? A. "Crushing the medication might cause you to have a stomachache or indigestion." B. "Crushing the medication is a good idea, and I can mix it in some ice cream for you." C. "Crushing the medication would release all the medication at once, rather than over time." D. "Crushing is unsafe, as it destroys the ingredients in the medication."

A. "Crushing the medication might cause you to have a stomachache or indigestion."

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis? A. "You will do special exercises in advance of getting your prosthesis." B. "You will be fitted for your prosthesis at the time of surgery." C. "A special pressure dressing will remain on to cushion your prosthesis." D. "The prosthesis will be adjustable depending on what shoe you are wearing."

A. "You will do special exercises in advance of getting your prosthesis."

.A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? A. Check the client's medical record for the provider's prescription. B. Explain to the client that the provider prescribed the procedure. C. Assure the client that enemas are commonly prescribed for constipation. D. Inform the charge nurse that the client refused the enema.

A. Check the client's medical record for the provider's prescription.

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first? A. Checking capillary refill B. Discussing cast care C. Managing pain D. Performing range of motion

A. Checking capillary refill

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? A. Decrease the client's fluid intake. B. Increase the client's saturated fat intake. C. Increase the client's sodium intake. D. Decrease the client's carbohydrate intake.

A. Decrease the client's fluid intake.

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment. B. Explain the discharge instructions to the client and parents. C. Provide reassurance to the client and parents. D. Apply an ice pack to the casted leg.

A. Perform a neurovascular assessment.

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? A. Pitting edema around the stump dressing B. Looseness of the stump dressing C. The dressing forms a cone shape over the stump D. Figure-eight wrapping around the stump

A. Pitting edema around the stump dressing

A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high-flow oxygen. B. Check the client for a positive Chvostek's sign. C. Administer an IV vasopressor medication. D. Monitor the client for headache.

A. Provide high-flow oxygen.

A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic? A. Relief of heartburn B. Cessation of diarrhea C. Passage of flatus D. Absence of constipation

A. Relief of heartburn

A client is admitted to an emergency department and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? a. Warm the client b. Maintain a patent airway c. Administer thyroid hormone d. Administer fluid replacement

B- Maintain a patent airway. The initial nursing action would be to maintain a patent airway. Oxygen would be first followed by fluid replacement, keeping the client warm, monitoring vitals, and administering thyroid hormones.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? a. Diarrhea b. Polyuria c. Polyphagia d. Weight gain

B- Polyuria. Hypercalcemia is the hallmark of hyperparathyroidism. Elevated calcium levels produce osmotic diuresis and thus polyuria.

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? a. Lower the head of the bed b. Test the drainage for glucose c. Obtain a culture of the drainage d. Continue to observe the drainage

B- Test the drainage for glucose. This could indicate a cerebrospinal fluid leak. Cerebrospinal fluid contains glucose. Regular mucous does not.

A nurse is providing discharge teaching to a client following hip arthroplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home? A. A reclining chair with an ottoman B. A straight-backed chair with an elevated seat C. A couch with plush cushions D. A rocking chair with a curved back

B. A straight-backed chair with an elevated seat

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? A. Change in temperature of the toes. B. Pallor of the toes. C. Edema of the toes. D. Inability to move toes.

B. Pallor of the toes.

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 assessing a client who is in skeletal traction. The nurse should correct which of the following findings? A. The ropes are in the center of the wheel grooves. B. The weights rest against the foot of the bed. C. The weights are equal on each side. D. The ropes are securely attached to the pins.

B. The weights rest against the foot of the bed.

A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures? A. "The pain will disappear soon." B. "It's likely that you will have only a tingling sensation." C. "Your pain will gradually become less severe." D. "Phantom pain is mostly psychological."

C. "Your pain will gradually become less severe."

The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell the client that which occurrence is a side effect of the medication? a. Headache b. Vulval pain c. Runny nose d. Flushed skin

C- DDAVP administered intranasal can cause runny or stuffy nose. The other options are side effects if taken IV.

After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptoms is most indicative of this disorder? a. Fatigue b. Diarrhea c. Polydipsia d. Weight gain

C- Polydipsia. Diabetes insipidus is characterized by hyposecretion of antidiuretic hormone, and the kidney tubules fail to reabsorb water. Polydipsia and polyuria are classic symptoms.

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "Skeletal traction has less risk for infection than skin traction." B. "Clients with skin traction have more mobility than those with skeletal traction." C. "Skeletal traction is more appropriate than skin traction for reducing a fracture." D. "Clients with skin traction have more discomfort than those with skeletal traction."

C. "Skeletal traction is more appropriate than skin traction for reducing a fracture."

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 completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? A. Remain on bedrest for the first 24 hr. B. Keep the leg in a dependent position. C. Apply ice to the affected area. D. Begin active range of motion.

C. Apply ice to the affected area.

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 gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? A. Limit fluid intake not related to meals B. Chew on mint leaves to relieve indigestion. C. Avoid eating within 3 hr of bedtime. D. Season foods with black pepper.

C. Avoid eating within 3 hr of bedtime.

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? A. Avoid covering sores with bandages. B. Avoid handwashing after eating. C. Avoid foods prepared with tap water. D. Avoid eating meat. Rationale: Clients sh

C. Avoid foods prepared with tap water.

A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? A. You may donate blood 6 months after completing the medication regimen. B. Consume a high-protein diet. C. Rest frequently throughout the day. D. Take acetaminophen every 4 hr, as needed, for discomfort

C. Rest frequently throughout the day.

A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy? A. 56-year-old who had a colonoscopy 6 years ago B. 34-year-old who reports a new onset of constipation C. 32-year-old who has a sister who died of colon cancer D. 51-year-old who is being seen for an annual physical examination

D. 51-year-old who is being seen for an annual physical examination

A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in which of the following positions? A. Adduction. B. External rotation. C. Internal rotation. D. Abduction.

D. Abduction.

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? A. Calcium B. RBC Count C. Magnesium D. Amylase

D. Amylase

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? A. Serosanguineous drainage B. Mild erythema C. Warmth D. Fever

D. Fever

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? A. Measure the circumference of the thigh. B. Palpate the femoral pulse. C. Monitor the client's calf for edema. D. Instruct the client to wiggle his toes.

D. Instruct the client to wiggle his toes.

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first? A. Administer an opioid analgesic. B. Obtain a prescription to adjust the weight amount. C. Offer a muscle relaxant to the client. D. Realign the client's position.

D. Realign the client's position.

.A nurse is caring for four clients for whom she has to administer oral medications in the morning. The nurse should administer which of the following medications before breakfast? A. Alendronate B. Digoxin C. Mycostatin mouthwash D. Divalproex

A. Alendronate

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A. Evaluate chest expansion. B. Check pupillary response to light. C. Assess the capillary refill. D. Check client's response to questions about place and time.

A. Evaluate chest expansion.

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min. B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). C. Increased blood pressure from 112/68 to 120/72 mm Hg. D. Increased heart rate from 68 to 72/min.

A. Increased respiratory rate from 18 to 44/min.

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain? A. Lower left quadrant B. Upper left quadrant C. Lower right quadrant D. Upper right quadrant

A. Lower left quadrant

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? A. Maintain immobilization and alignment. B. Provide optimal nutrition and hydration. C. Promote independence in activities of daily living. D. Provide relief from pain and discomfort.

A. Maintain immobilization and alignment.

1. A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client? A. Soy Milk B. Cheddar Cheese C. Low-fat yogurt D. Cottage cheese

A. Soy Milk

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions? A. Spontaneous bleeding B. Oliguria C. Hyperactive deep tendon reflexes D. Infection

A. Spontaneous bleeding

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever

A. Sudden decrease in abdominal pain

A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? A. Summon the code team. B. Begin chest compressions. C. Administer rescue breathing. D. Open the client's airway.

A. Summon the code team.

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry; most clients dislike the prep more than the procedure itself." B. "Before the examination, your provider will give you a sedative that will make you sleepy." C. "I know you're anxious, but this procedure is recommended for people your age." D. "After you have signed the consent form, we can talk more about this."

B. "Before the examination, your provider will give you a sedative that will make you sleepy."

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make? A. "Irregular bowel movements are an indication of poor intestinal health." B. "Excessive laxative use may cause an electrolyte imbalance." C. "Chronic use of laxatives can lead to a tear in the rectal mucosa." D. "Decrease your intake of foods high in fiber."

B. "Excessive laxative use may cause an electrolyte imbalance."

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 assessing a client who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice? A. Palms of the hands B. Hard Palate C. Conjunctiva D. Back of the neck

B. Hard Palate

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures? A. Diarrhea B. Hematuria C. Increased thirst D. Impaired taste

B. Hematuria

.A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome? A. Petechiae B. Hypoxemia C. Headache D. Precordial chest pain

B. Hypoxemia

A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take? A. Encourage the client to use full weight bearing. B. Identify the client's pain level and medicate if needed. C. Teach the client which positions to avoid during PT. D. Perform the client's morning care.

B. Identify the client's pain level and medicate if needed.

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for the client? a. Hypoglycemia b. Level of hoarseness c. Respiratory distress d. Edema at the surgical site

C- Respiratory distress. The thyroid is located in the anterior neck. Monitor airway status for swelling which could lead to respiratory distress.

The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication at which time? a. With food b. At lunchtime c. On an empty stomach d. At bedtime with a snack

C- oral doses should be taken on an empty stomach to enhance absorption. Best time is in the morning before breakfast.

A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include? A. "To prevent dehydration, drink an additional liter of fluid during preparation time." B. "Expect bowel movements to begin 3 hr following completion of solution." C. "Abdominal bloating might occur." D. "Drink 400 mL every hour until bowel movements are clear."

C. "Abdominal bloating might occur."

A nurse is teaching a client who has a new prescription for esomeprazole to manage his GERD. Which of the following statements by the client indicates an understanding of the teaching? A. "I won't pass gas as often now that I am taking this medication." B. "I will take this medication each morning with my breakfast." C. "I have an increased risk of getting pneumonia while taking this medication." D. "I will need to take a daily stool softener while taking this medication."

C. "I have an increased risk of getting pneumonia while taking this medication."

2. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? A. Request a prescription for a medication to ease the client's anxiety. B. Irrigate the NG tube with 100 mL of sterile water. C. Check to see if the suction equipment is working. D. Remove and reinsert the NG tube.

C. Check to see if the suction equipment is working.

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures? A. Impacted B. Transverse C. Comminuted D. Oblique

C. Comminuted

A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid? A. Rice B. Poached Eggs C. Fresh Apples D. White bread

C. Fresh Apples

3. A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority? A. Pain B. Nausea C. Gag reflex D. Level of consciousness

C. Gag reflex

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? A. Epigastric discomfort B. Dyspepsia C. Hematemesis

C. Hematemesis

5. A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. Auscultate B. Percuss C. Inspect D. Palpate

C. Inspect

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? A. Medicate the client for pain. B. Instruct the client on use of crutches. C. Perform neurovascular checks of the extremities. D. Direct the client to perform exercises of the ankle and toes

C. Perform neurovascular checks of the extremities.