Care Management Post-Test

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a. A 65-year-old with hemi-paralysis and incontinence b. A 78-year-old requiring assistance to ambulate with a walker c. A 44-year-old prescribed IV antibiotics for pneumonia d. A 26-year-old who is bedridden with a fractured leg

a. A 65-year-old with hemi-paralysis and incontinence

An older client is hospitalized with Myasthenia Gravis. A family member tells the nurse the client is much more restless and seems confused which is new. What action by the nurse takes priority? a. Assess the client's oxygen saturation b. Place the client on a bed alarm c. Check the medication list for interactions d. Put the client on safety precautions

a. Assess the client's oxygen saturation

A client is on their cell phone in the pre-op holding area when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Exaplin the rationale for giving the medicine now b. Leave the room and come back in 15 minutes c. Tell the client you must start the medication d. Provide holistic client care and come back later

a. Exaplin the rationale for giving the medicine now

A nurse assesses a client's recent memory. Which client statement confirms that the client's memory is intact? a. "I ate oatmeal with wheat toast and orange juice for breakfast." b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "A young girl wrapped in a shroud fell asleep on a bed of clouds." d. "Apple, chair, and pencil are the words you just stated."

a. "I ate oatmeal with wheat toast and orange juice for breakfast."

A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (select all that apply) a. Hypocalcemia - Diarrhea b. Hypomagnesemia - Kidney failure c. Hypophosphatemia - Calcium deficit d. Hyperkalemia - Salt substitutes e. Hypernatremia - Hyperaldosteronism

a. Hypocalcemia - Diarrhea d. Hyperkalemia - Salt substitutes e. Hypernatremia - Hyperaldosteronism

A nurse cares for a dying client. Which manifestations of dying should the nurse treat first? a. Pain b. Hair loss c. Anorexia d. Nausea

a. Pain

A 50-year-old client is receiving an infusion of tissue plasminogen activator (t-PA) for acute coronary syndrome since the cath la is down and they can't go immediately to the cath lab. The nurse assesses the client to have newly altered mental status since the infusion started and is disoriented to person, place, and time. What action by the nurse is best? a. Stop the infusion and call the provider b. Assess the client's pupillary responses c. Take and document a full set of vital signs d. Request a neurologic consultation

a. Stop the infusion and call the provider

A nurse cares for a middle-aged female with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, "What can I do to help prevent these infections?" How should the nurse respond? a. "Test your urine daily for the presence of ketone bodies and proteins." b. "Drink more water and empty your bladder more frequently during the day." c. "Use tampons rather than sanitary napkins during your menstrual period." d. "Keep your hemoglobin A1C under 9 % by keeping your blood sugar controlled."

b. "Drink more water and empty your bladder more frequently during the day."

A 50-year-old client is scheduled for a leg bone biopsy in the surgicenter. What action by the nurse takes priority? a. Administering the preoperative medications b. Ensuring that informed consent is on the chart c. Answering any questions about the procedure d. Showing the client's family where to wait

b. Ensuring that informed consent is on the chart

After teaching a patient who is prescribed a restricted sodium diet, a nurse assesses the patient's understanding. Which food choice for lunch indicates that the patient correctly understood the teaching? a. Sliced of smoked ham with potato salad b. Grilled chicken breast with glazed carrots c. Bowl of tomato soup with a grilled cheese sandwhich d. Salami and cheese on whole-wheat crackers

b. Grilled chicken breast with glazed carrots

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? (select all that apply) a. Have a padded tongue blade at the bedside b. Have suction equipment at the bedside c. Permit only clear oral fluids d. Keep bed rails up at all times e. Maintain the client on strict bedrest f. Ensure that the client has IV access

b. Have suction equipment at the bedside d. Keep bed rails up at all times f. Ensure that the client has IV access

A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 4 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 65 mm Hg Blood pressure = 135/45 PaCO2 = 65 mm Hg Respiratory rate = 6 breaths/min HCO3- = 26 mEq/L O2 saturation = 78% Which action should the nurse take first? a. Decrease the flow rate of oxygen to 2 L/min, and reassess b. Notify the Rapid Response Team and provide ventilation support c. Change the nasal cannula to a mask and reassess in 10 minutes d. Place the client in Fowler's position if he or she is able to tolerate it

b. Notify the Rapid Response Team and provide ventilation support

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. "Remember you should not drink alcohol for a year." b. "Have a wonderful time and enjoy your vacation!" c. "Avoid getting salt water on the radiation site." d. "Do not expose the radiation area to direct sunlight."

d. "Do not expose the radiation area to direct sunlight."

Ten hours after surgery, a postoperative client who has had a radical prostatectomy reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. "Let me call the surgeon to see if you really need them." b. "Ok, we can remove them since you are stable now." c. "No, you have to use those for 24 hours after surgery." d. "Please wear them as you need them to help prevent blood clots."

d. "Please wear them as you need them to help prevent blood clots."

The nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old clonet who has a longer expiratory phase then inspiratory phase d. A 27-year-old cllient with a heart rate of 135 beats/min

d. A 27-year-old client with a heart rate of 135 beats/min

The following data relates to an older patient who is 2 hours postoperative after an esophagogastrostomy: Physical Assessment: Skin dry Urine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless Vital Signs: Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hour Vital signs every hour Vancomycin (Vancocin) 1 g IV every 8 hr What action by the nurse is best? a. Consult the surgeon about a different antibiotic b. Administer the prescribed pain medication c. Have respiratory therapy reduce the respiratory rate d. Consult the surgeon about increased IV fluids

d. Consult the surgeon about increased IV fluids

A nurse is caring for a client on a patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety? a. Instruct the client to report any unrelieved pain b. Assess and record vital signs every 4 hours c. Monitor for abnormal neuro findings d. Have another nurse independently verify or double-check the pump settings

d. Have another nurse independently verify or double-check the pump settings

A client has a platelet count of 9800/mm3 . What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness b. Obtain cultures as per the facility's standing policy c. Place the client on protective isolation precautions d. Instruct the client to call for help to get out of bed

d. Instruct the client to call for help to get out of bed

A patient has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the patient is in bed? a. Remind the patient to do quad-setting exercises b. Change the settings based on range of motion c. Assess the distal circulation in 30 minutes d. Raise the lower side-rail on the affected side

d. Raise the lower side-rail on the affected side

A nurse reviews laboratory results for a patient with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL (31.1 mmol/L). Which laboratory result would the nurse correlate with the patient's polyuria? a. Presence of urine ketone bodies b. Serum creatinine: 1.6 mg/dL (141 umol/L) c. Serum sodium: 163 mEq/L (163 mmol/L) d. Serum osmolarity: 375 mOsm/kg (375 mmol/kg)

d. Serum osmolarity: 375 mOsm/kg (375 mmol/kg)