Final Exam ( Disregard the first 30-40 Questions, as I started creating this set before the final, and added the remaining questions after the final.)

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism? A.) Sudden onset of dyspnea B.) Tracheal deviation C.) Bradycardia D.) Difficulty swallowing

A.) Sudden onset of dyspnea

The HCP has scheduled a debridement for a pt who has partial thickness burns on his chest and right upper leg. Which nursing intervention is important?

Administer an opioid analgesic intravenously before debridement

A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions should be done? Select all that apply.

Administer humidified oxygen Instruct on the use of the incentive spirometer Monitor vital signs and pulse oximetry frequently

Burn wound is periodically debrided using hydrotherapy. Which nursing intervention is essential either before or after the therapeutic modality?

Administering a prescribed analgesic.

A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?

Albuterol (Proventil)

1. A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is

C. Confirming the gag reflex

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect the client to experience?

Hyperinflated lungs on chest x-ray

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

I need to avoid sun exposure before 10:00 am and after 4:00 am."

What would help the child with a serious burn meet nutritional needs during the subacute phase of recovery?

Increase calories and protein to compensate for the healing process.

On the first day following a severe burn, the body's fluid reserves have left the circulating volume and entered the interstitial space, causing massive edema. What should the nurse monitor for very closely in the burn victim?

Reduced urine output

The nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux tuberculin skin test. Which action by the nurse is the priority?

Report the findings

A nurse is reinforcing teaching about possible treatments with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? Select all that apply?

Tar preparations UV light therapy Corticosteroids

A nurse is caring for a client who has bacterial pneumonia. The nurse should expect what assessment finding?

Temp 101.8 degrees F Rat.: an elevated temp is an expected finding for a client who has bacterial pneumonia

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client?

The best results are achieved when sitting at least halfway or fully upright

A client has a closed-chest tube drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. How does the nurse interpret this finding?

The tube is patent

A nurse is caring for a client with second and third degree burns who is prescribed a high calorie, high protein diet. Which of the following is the appropriate meal for the practical/vocational nurse to assist the client in selecting?

Turkey and cheese sandwich, scalloped potatoes

A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with refampin. The nurse should plan to include what in the client's discharging teaching plan?

Urine and other secretions will be orange.

What should the nurse do when administering a therapeutic bath to a patient who has severe pruritis?

Use Barrow's solution to help promote healing

A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug?

Use gloves.

An adolescent girl with acne is being treated with an antibiotic in addition to topical applications. What side effect does the nurse caution the girl to expect?

Vaginitis

A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?

Within 12 hours after burn trauma

A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?

You should wear glasses instead of of contacts while taking this medication.

Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from

hypovolemic shock and renal failure.

A nurse treatment plan includes using open method of burn wound management. It is most appropriate to use this method for which of the following complications?

infection

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

large incisions will be made in the burned tissue to improve circulation

What is the most common symptom of scabies?

nocturnal pruritus

The nurse debriding a burn wound explains that the purpose of debridement is to:

prevent infection and promote healing.

hen the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of:

pulmonary embolus

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area.

Which of the following are nursing interventions and patient teaching for the treatment of head lice and scabies?

1.) Clothing, linens, and bath articles thoroughly cleaned in hot water 2.) Stress nature and transmission of the disease

Prioritize the intervention of the first responder to the victim during the emergent phase of burn management. 1.) Stop, drop, and roll. 2.) Provide an open airway. 3.) Control any bleeding. 4.) Remove all nonadherent clothing and jewelry. 5.) Cover victim with clean cloth or sheet. 6.) Transport victim to hospital.

1.) Stop, drop, and roll, is the answer.

A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (tb). Which of the following actions should the nurse plan to take? Select all that apply?

1.)Remind the client to cover her mouth with a tissue when coughing 2.)determine whether the client lives alone or with others. 3.)Use an alchol-based hand cleaner unless hands are visibly solied

The nurse is caring for a client with emphysema receiving oxygen. The nurse should check the oxygen flow rate to ensure the client does not exceed how many L/min of oxygen?

2

A nurse is collecting data from a client who has severe burn injuries. The nurse shades in the diagram indicating the burned surfaces. What percentage of the body surface area should the nurse estimate the client has burned?

31.5 ( round up to 32). This is for the shading question regarding the rule of 9's.

the nurse reinforces home care instructions with a client diagnosed with impetigo. Which statements indicate understanding about the measures that will prevent the spread of infection? select all that apply?

??

A nurse is inspecting a lesion on the client who has basal cell carcinoma. Which of the following findings should the nurse expect?

A pearly, shiny nodule

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following pieces of information should the nurse include in the teaching? A.) Use pursed-liped breathing during periods of dyspnea B.) Limit fluid intake to 1,500mL per day C.) Practice chest breathing each day D.) Wear home oxygen to maintain an SaO2 of at least 94%

A) Use pursed-liped breathing during periods of dyspnea

The main components of the skin are the: A) epidermis and dermis. B) dermis and hypodermis. C) epidermis, dermis, and hypodermis. D) epidermis, dermis, hypodermis, and the subcutaneous layer.

A) epidermis and dermis.

The nurse is obtaining the history from the parents of an infant who suffered an episode of apnea. If the apnea was an acute life threatening event, what would the nurse expect the parents to report? Select all that apply? A.)Coughing B.) Change in color C.) Altered muscle tone D.) Tachycardia E.) Bradycardia

A, B, C, E

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A.) Stabbing chest pain B.) Calf tenderness C.) Elevated temperature D.) Bradycardia

A.) Stabbing chest pain

What should the nurse examine in assessing a patient for tinea corporis?

Abdomen

A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?

Ablative

A frail, older adult home heath patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

Access frequently for herpes zoster.

A pt is admitted with herpes zoster. The nurse should plan to administer which medication in a frequent basis?

Acyclovir (Zovirax)

A nurse is caring for a client who has partial-thickness and full thickness burns of his head, neck and chest. The nurse should recognize which of the following is the priority risk to the client?

Airway obstruction

Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery?

Anticoagulant agent

When transferring a client to a chair, a nurse notices the pressure relieving mattress overlay has deep imprints of the client's buttocks, heels and scapulae. Which action should the nurse implement?

Apply a different pressure relieving device.

In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially?

Apply a medical alert band to patient's wrist

A nurse is contributing to a plan of care with a client who has herpes zoster. Which of the following actions should the nurse recommend in the plan of care?

Apply cold compresses to the effected area

A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Assess respiratory status

What should the nurse do to minimize the potential for venous stasis?

Assist with early ambulation

nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?

Athletes foot

A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide?

Avoid caffeine while taking this medication

A patient with severe eczema is starting a coal tar derivative treatment. What should the nurse include in the teaching plan for the patient relative to this treatment?

Avoid exposure to sunlight for 72 hours after use

A pt complains that he has basal cell carcinoma and is going to die. When planning the best response to make the nurse should include what knowledge?

Basal cell carcinoma us rarely terminal

The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma?

Bilateral wheezing

A nurse is caring for a client who has active TB and is to be started on IV rifampin therapy. The nurse should instruct that this medication can cause which of the following adverse effects?

Body secretions turning a red-orange color

It is important to teach a pt the warning signs of skin cancer. Which is a warning sign of skin cancer?

Border irregularity and delayed or prolonged lesional healing

What should be included in the assessment of a pt with an electrical burn?

Cardiac irregularities

A client is at risk of developing a pulmonary embolism. The nurse monitors for which initial sign/symptom?

Chest pain that occurs suddenly

The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection?

Chills and night sweats

A pt is admitted with partial and full thickness burns on his right lower extremity. What is likely to be included in the plan of care?

Closed dressing change every 3 hours

Which of the following early postoperative observations should be reported immediately?

Coffee ground" emesis

The home health nurse discovers a family infected with pediculosis. What information can the nurse provide to the mother to start eradication of the lice?

Comb though hair with a vinegar-water solution

The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding?

Complaints of night sweats

Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?

Curling Ulcer.

The nurse is discussing signs of severe airway obstruction with a group of nursing students. Which sign should the nurse emphasize as one that indicates severe airway obstruction?

Cyanosis

The nurse is assisting a health care provider with the insertion of a wet-suction chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action?

Document the accurate functioning of the tube

The nurse understands that a patient with human immunodeficiency virus (HIV) starts to develop immune problems when their CD4 count:

Drops below 200

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? Select all that apply?

Dyspnea Barrel chest Clubbing of the fingers shallow respirations

which of the following are early signs and symptoms of an hiv infection? select all that apply

Dyspnea Sore Throat Weight loss

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.

Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking

The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply.

Early onset cough Purulent mucous production Mild episodes of dyspnea

patient is admitted for pain and tenderness in his lower right leg. The nurse's assessment reveals the extremity is warm, swollen, and has a slightly pitted appearance. Which measure would the nurse use to relieve the discomfort?

Elevate the leg with pillows to reduce edema.

A nurse is checking a school age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?

Firmly attached white particles on the hair

A client complains of burning pain in his lower thoracic area. Upon inspection, there is an area that is found to be erythematous and edematous with a cluster of vesicles on one side of the body. What do you suspect?

Herpes Zoster

A pt complains of a burning pain on his lower thoracic area. On inspection, the area is found to be erythematous and edematous with a cluster of vesicles. What condition is most likely to be diagnosed?

Herpes zoster

The nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a Pao2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client?

Ineffective oxygen and carbon dioxide exchange

Which may indicate a malignant melanoma in a nevus on a patient's arm?

Irregular border of the mole

What is Pityriasis Rosea?

Is a rash that usually begins as a large circular or oval spot on your chest, abdomen or back. Called herald patch, this spot can be up to 4 inches across.

A client receiving a full thickness graft to a burn on the hand. The nurse understands that a full thickness graft is being applied instead of a split thickness graft because of which reason?

It provides better cosmetic results.

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse should monitor the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

Which patient instruction should the nurse include in the teaching plan relative to the management of systemic lupus erythematosus?

Maintain a balance between rest and activity

A nurse is reviewing the urinalysis results of a client who reports urinary frequency and burning. Which of the following finding should the nurse report to the provider?

Microscopic hematuria

A nurse is caring for a client who comes to a provider's office for treatment of acne vulgaris on her cheeks. Which of the following instructions should the nurse

Minimize sun exposure

nurse is caring for a client who has recurring herpes simplex type 1 lesions. A nurse should perform focused assessment on which of the following areas of the client's body

Mouth

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action?

Notify the registered nurse

client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Which prescription should the nurse complete first?

Obtain a culture and sensitivity of sputum

A nurse is collecting data from a client who has herpes zoster or shingles. Which of the following is an expected finding?

Painful vesicles following a nerve pathway

A nurse is collecting data from a client who has herpes zoster or shingles. Which of the following is an expected finding?

Painful vesicles following a nerve pathway.

A health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the health care provider asks the client to do which action?

Perform the Valsalva maneuver

A pt has a rash in her back that began about 10 days ago with a raised, scaly border and a pink center. Now she has similar eruptions on both sides of her back. What condition are these manifestations most consistent with?

Pityriasis rosea

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis?

Po2 of 60 mmHg and Pco2 of 50 mmHg

A nurse is collecting data from a client with SLE. Which of the following is the highest priority to report to the provider?

Presence of peripheral edema

A nurse is caring for a child who has atopic dermatitis. Which of the following finding should the nurse expect?

Rashes with thick skin

When examining the client's skin who has psoriasis, which finding would the nurse expect to observe?

Red skin patches covered with silvery scales

In a patient admitted with cellulitis of the left foot, which clinical manifestation or symptoms would the nurse expect to find on assessment of the left foot?

Redness and swelling

A client phones the clinic and tells the nurse that a family member has been diagnosed with ringworm (tinea corporis). The client asks the nurse if ringworm is contagious. Which of the following would be an appropriate response by the nurse?

Ringworm is a fungal skin infection that is contagious with direct, skin-to-skin contact

A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?

Scaling and redness between the toes

A nurse is collecting data from a client who has systemic lupus erythematousus (SLE). Which of the following laboratory values should the nurse review to determine the client's renal function?

Serum creatinine

The home health nurse is assessing skin lesions using the PQRST mnemonic as a guide. What does the "S" in this guide indicate?

Severity of the symptoms

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume?

Sitting on the side of the bed, leaning on an overbed table

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

Sitting, leaning forward over the bedside table.

The nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse should review the results of which diagnostic test to confirm this diagnosis?

Sputum culture

A pt with thermal burns over 30 percent of his body has maintained a urinary output of 250 ml for the past 8 hours. what can the nurse infer for this information?

Stage of hypovolemic shock is resolving

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?

Stridor

A nurse arrives at an accident scene where the victim has just received an electrical burn. What is the nurse's primary concern?

The likelihood of cardiac arrest.

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position in which to place the client, which information should the nurse ascertain?

The lung areas involved

In which situation might surgery be delayed?

The patient is still taking anticoagulants

The nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that this is indicative of which occurrence?

There is an air leak somewhere in the system

A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complaints of pain and pruritus. Why would the nurse use a Woods lamp?

To cause fluorescence of the infected hairs.

A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax?

Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Turn your patient every two hours

A nurse is reviewing the plan of care for client who has cellulitis of the leg. Which of the following interventions should the nurse recommend?

Wash daily with an antibacterial soap

A nurse is instructing a mother about caring for a child who has impetigo contagiosa. Which of the following should the nurse care plan include?

Wash the child's clothes in tepid water.

After PaO2 for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber

In report, the nurse finds the assigned client is suspected of having scabies. Which precaution will the nurse institute during the care of the client?

Wearing gown and gloves

Which of the following are considerations for the older adult surgical patient? (Select all that apply.)

a.) The need for specific clear preoperative and postoperative teaching b.) Presence of coexisting conditions c.) Increased risk of respiratory complications

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

administer oxygen therapy

A nurse in urgent care is caring for a patient who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

administering a nebulizer beta-adrenergic

A patient is on postoperative day 2 after a nephrectomy. The nurse is aware that the most effective way to increase her peristalsis is

ambulation.

an african american patient is seen with impending shock after an accident. how would the nurse expect the skin to appear during the assessment of the patient?

ashen, gray, or dull

A nurse in a provider's office is collecting data from a client who has systemic lupus erythematosus (SLE) and takes hydroxychloroquine (Plaquenil) to reduce skin inflammation. The nurse should identify the adverse effects of taking hydroxychloroquine.

blurred vision

which of the following is composed of loose connective tissue? a. Epidermis b. Reticular layer of dermis c. Hypodermis d. Both a and b e. Both b and c

c. Hypodermis

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

can stain the skin & hair.

When caring for a client who has emphysema, which of the following findings should the nurse expect to assess in the patient? Dyspnea, bradycardia, barrel chest, clubbing of fingers, shallow respirations (select all that apply)

dyspnea, barrel chest, clubbing, shallow respiration

A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is:

infection.

a parent tells the dermatologist that her doughter seems to be losing interest in school. which medication could have caused the patient's change in behavior?

isotretinoin (accutane)

which conditions would predipose the patient to cellulitis

malnutrition treatment with steroids or chemotherapy alcoholism

the nurse planning to care for a patient who has impetigo expects to administer which topical drug to the patient?

retapamulin

when teaching home care to a patient with recurrent genital herpes infection, it is important to include that:

the patient will need to use protection even when no lesions are evident

What would the nurse stress to the 17 year old girl who has been prescribed isotretinoin (Accautane) for her acne?

use dependable birth control to avoid pregnancy.

The school nurse recognizes the signs of scabies when a child presents with:

wavy threadlike lines on the body and pruritus.

A nurse is caring for a client who has partial thickness to full thickness burns to his head, neck, and chest. The nurse should recognize which of the following is a priority risk to the client?

Airway obstruction

The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94° F?

Cover with a warm blanket

7: A pt is admitted with partial thickness burns on his upper chest and face. What is the most important thing for the nurse to initially monitor in the pt?

Respiratory problems

The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to:

Support the surgical site with a pillow

A nurse is reinforcing teaching with a 20 year old patient who has atopic dermatitis. Which of the following information should the nurse include?

he doctor might recommend an antihistamine to control your symptoms.

In reviewing the medical records, the nurse notes the client's medications include isotretinoin (Accutane). The nurse recognized the client is being treated for what?

Acne

A nurse in the PACU is collecting data from a newly admitted client and ovserves intervostal retractions and a high-pitched inspiratory sound. The nurse should identify that these findings are mainfestations of which of the following complications? A.) Pulmonary edema B.) Tension pneumothorax C.) Flail chest D.) Respiratory obstruction

Respiratory Obstruction

Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage?

Restlessness

A nurse is reinforcing discharge instructions for a client who has asthma and is about to start taking theophylline. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of the medication?

Tachycardia

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35ml of purulent drainage. Which of the following findings indicate a tension pneumothorax? ( select all that apply.) A.) Tracheal deviation to the left B.) Temperature of 38.8 C.) Absent breath sounds of the right side D.) Neck vein distention E.) Bradypnea

A, C, D

A nurse is caring for a patient with partial and full thickness burns to 65% of the body. When planning nutritional intervention for the patient, what dietary choices should the nurse implement?

High calorie and high protein foods