Med Surg 1 (part 1)

3

A client admitted in the emergency department has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia. Which condition of the client will be given the highest priority? 1 Hypoglycemia 2 Chest wall trauma 3 Airway obstruction 4 External hemorrhage

8 (The client having pain opening the eyes scores 2 points, abnormal flexion motor response scores 3 points, and inappropriate words scores 3 points, which adds up to 8. A client scoring 8 points on the Glasgow Coma Scale after trauma requires medium priority.)

A client after a trauma has difficulty opening his or her eyes to pain, has abnormal flexion motor response, and speaks inappropriate words. What is the status of the client utilizing the Glasgow Coma Scale? Record your answer using a whole number._________

3

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? 1 "This is a decision you alone can make." 2 "Do not tell your partner unless asked." 3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."

1,3

A client comes to the primary healthcare provider with reports of pain due to an insect bite on the hand. The primary healthcare provider notices swelling at the site of insect bite. Which insect bites may cause this condition? Select all that apply 1 Bees 2 Ticks 3 Wasps 4 Bed bugs 5 Pediculosis

3 (In respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the PCO2 level is low because carbon dioxide is lost through hyperventilation. An elevated pH, elevated PCO2 is partially compensated metabolic alkalosis. A decreased pH, elevated PCO2 is respiratory acidosis. A decreased pH, decreased PCO2 is metabolic acidosis with some compensation.)

A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? 1 An elevated pH, elevated PCO2 2 A decreased pH, elevated PCO2 3 An elevated pH, decreased PCO2 4 A decreased pH, decreased PCO2

3

A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data? 1 Loss of battery power 2 Functioning as expected 3 Failure to stimulate the heart 4 Ignoring the client's heartbeat

1

A client is admitted with a diagnosis of stage 0 cervical cancer (carcinoma in situ). What does the nurse emphasize while helping the client understand her diagnosis and prognosis? 1 Five-year survival rates for this cancer are nearly 100% with early treatment. 2 Radiation therapy is as successful as surgery in the treatment of this type of cancer. 3 Cancer has probably extended into the vaginal wall and may require a radical hysterectomy. 4 Stage 0 indicates that the cancer is invasive and may require surgery in addition to radiation therapy.

2,3,1,5,4

A client is admitted with a sudden onset of dyspnea and chest pain. What are the interventions in the order in which the nurse will perform them to provide comfort to the client? 1. Elevating the head of the bed 2. Notifying the Rapid Response Team 3. Reassuring the client and family members 4. Monitoring and assessing for other changes 5. Preparing for oxygen therapy and blood gas analysis

3

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1 Skeletal and nervous 2 Circulatory and urinary 3 Respiratory and urinary 4 Muscular and endocrine

1 (Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.)

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? 1 Sodium and chloride levels 2 Bicarbonate and sulfate levels 3 Magnesium and protein levels 4 Calcium and phosphate levels

3

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? 1 Chronic pain 2 Risk for injury 3 Electrolyte imbalance 4 Inadequate gas exchange

3

A client receiving chemotherapy for cancer develops sores in the mouth and asks the nurse why this happened. What is the nurse's best response? 1 "The sores occur because of the direct irritating effects of the drug." 2 "These tissues are poorly nourished because you have a decreased appetite." 3 "The frequently dividing cells of the gastrointestinal tract are damaged by the drug." 4 "This side effect occurs because it targets the cells of the gastrointestinal system."

1

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis

4

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate? 1 Ulnar 2 Radial 3 Brachial 4 Femoral

1,2,3

A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse share in the client's preoperative teaching plan? Select all that apply. 1 "The kidney may not function immediately." 2 "Precautions are needed to prevent infection." 3 "A urinary catheter will be present postoperatively." 4 "Immunosuppressive medications will be given preoperatively." 5 "The arteriovenous fistula will be used for drawing blood specimens preoperatively."

3

A client who is recovering from a motor vehicle accident is discharged from the health care agency and transferred to an extended care facility for rehabilitation. What kind of health care service does this client receive? 1 Preventive care 2 Continuing care 3 Restorative care 4 Tertiary health care

4

A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. What does the nurse include when teaching the client about the purpose of the antibiotics? 1 They prevent incisional infection. 2 Antibiotics prevent postoperative pneumonia. 3 These drugs limit the risk of a urinary tract infection. 4 They are given to eliminate bacteria from the gastrointestinal (GI) tract.

640

A client who weighs 176 pounds (80 kg) is being immunosuppressed by daily maintenance doses of cyclosporine to prevent organ transplant rejection. The dose prescribed is 8 mg/kg each day. How many milligrams should the nurse plan to administer each day? Record your answer using a whole number. ___ mg

4 (With emphysema, it is believed that the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe [1] [2] but rather to lowered oxygen levels; therefore, the oxygen being delivered must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe)

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? 1 Question the client about the confusion. 2 Change the method of oxygen delivery. 3 Percuss and vibrate the client's chest wall. 4 Discontinue or decrease the oxygen flow rate.

1,5

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply 1 Headache 2 Thready pulse 3 Decreased blood pressure 4 Dizziness when standing up 5 Crackles on lung auscultation

2

A client with bone cancer is receiving hospice care at home. The hospice program also provides respite care. What is the purpose of respite care? 1 Assisting the client with meals and personal care 2 Providing short-term relief to the family caregiver 3 Providing skilled nursing interventions for the client 4 Providing counseling and treatment for behavioral problems

1

A client with colon cancer is receiving hospice care at home. What is the focus of hospice care? 1 To ease the pain from illness 2 To provide curative treatment 3 To assist with activities of daily living 4 To adapt to the limitations due to illness

2

A client with coronary artery disease is scheduled for a cardiac catheterization. What should the client be able to describe if the nurse's preoperative teaching is considered effective? 1 What will occur if there is an emergency 2 What will be experienced during the procedure 3 The risks associated with this invasive procedure 4 The importance of immediate postoperative exercises

2

A client with radiation therapy for neck cancer reports, "I feel a lump while swallowing and foods get stuck." What does the nurse document in the client's medical history? 1 Dysgeusia 2 Dysphagia 3 Xerostomia 4 Odynophagia

0.4

A client with terminal cancer is to receive 4 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. It is supplied at 10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place and leading zero if applicable. ___ mL

1

A client's laboratory report reveals a CD4+ T-cell count of 520 cells/mm3. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

1,3,2,4

A disaster management team is planning a protocol for survivors of a winter storm who present with frostbite. How would the nurse order the interventions in the protocol? 1. Give pain medication. 2. Apply sterile and loose dressings. 3. Immerse the feet in warm water. 4. Remove the victim from the cold environment.

3 (Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated)

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? 1 Headache 2 Pallor 3 Paresthesias 4 Blurred vision

1

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? 1 Attempt to identify the client's concerns. 2 Reassure the client that the surgery is routine. 3 Report the client's anxiety to the healthcare provider. 4 Provide privacy by pulling the curtain around the client.

2,4

A nurse is assessing a client for dehydration. The client has had diarrhea and vomiting for 48 hours. Which assessment findings alert the nurse that the client is dehydrated? Select all that apply. 1 Protruding eyeballs 2 Postural hypotension 3 The client reporting eating an average of three meals daily 4 The skin on the client's forehead remains tented after being pinched 5 Within four days, the client gained two pounds (0.9 kg) of weight

1

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? 1 Visceral pain 2 Somatic pain 3 Referred pain 4 Intractable pain

1 (Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis)

A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? 1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2 Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3 Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4 Impaired glomerular filtration, causing retention of sodium and metabolic waste products

2,3,5

A nurse is caring for a client who underwent surgery for laryngeal cancer. Which nursing action may help to communicate effectively with the client? Select all that apply. 1 Asking the client open-ended questions 2 Providing the client with praise and encouragement 3 Collaborating with a speech and language pathologist 4 Using a high-pitched tone of voice to speak with the client 5 Asking the client to make noise when immediate attention is required

4

A nurse is caring for a client with end-stage kidney disease after a kidney transplant. Which finding indicates the transplant is successful? 1 Increased specific gravity 2 Correction of hypotension 3 Elevated serum potassium 4 Decreasing serum creatinine

3

A nurse is caring for a client with pain after surgery. The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. Which standard of practice does the nurse perform? 1 Planning 2 Diagnosis 3 Assessment 4 Implementation

1

A nurse is caring for a client with pain due to muscle spasm. Which nursing action is beneficial for the client? 1 Providing heat compresses at the site 2 Providing a massage to the affected area 3 Encouraging the client to perform isometric exercises 4 Encouraging the client to do active-passive range-of-motion (ROM) exercises

4

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1 Skin turgor 2 Intake and output results 3 Client's report about fluid intake 4 Blood lab results

2,3

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1 Dementia 2 Multiple losses 3 Declines in health 4 A milestone birthday 5 An injury requiring hospitalization

3

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? 1 Increased skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties

2

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? 1 Get an additional IV infusion pump for the medication. 2 Check the compatibility of the medication and the continuous IV solution. 3 Disconnect the continuous IV solution while administering the piggyback medication. 4 Flush the client's venous access device to ensure patency.

1

A nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is essential before the nurse administers the medication? 1 Verify the consent. 2 Have the client void. 3 Check the vital signs. 4 Remove the client's dentures.

3

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1 "Inhale completely and exhale in short, rapid breaths." 2 "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3 "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." 4 "Exhale halfway, then inhale a rapid, small breath; repeat several times."

2,3,5

A nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply 1 Mosquito bites 2 Sharing syringe needles 3 Breastfeeding a newborn 4 Dry kissing the infected partner 5 Anal intercourse

4

A nursing student is recalling information about hospice care. What is hospice care? 1 Hospice care is a resident's temporary or permanent home, where the surroundings have been made as homelike as possible. 2 Hospice care offers an attractive long-term care setting with an environment akin to the client's home, which offers the client greater autonomy. 3 Hospice care is a service that provides short-term relief for people providing home care to an ill, disabled, or frail older adult. 4 Hospice care is a system of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness.

4

A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients? 1 Reviewing the past is depressing. 2 Stimulating new situations are ideal. 3 Dependency increases as age progresses. 4 Staying healthy promotes a quality retirement.

3

A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? 1 Add a placebo to the morphine to appease the spouse. 2 Discuss with the spouse the risk for morphine addiction. 3 Assess the client's pain before increasing the dose of morphine. 4 Check the client's heart rate before increasing the morphine to the next level.

4

After abdominal surgery a client reports pain. What action should the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.

2

After surgery for cancer, a client is to receive chemotherapy. When teaching the client about the side effects of chemotherapy, what advice should the nurse share about alopecia characteristics? 1 Usually rare 2 Not permanent 3 Frequently prolonged 4 Sometimes preventable

2

An adolescent visits the allergy clinic because of seasonal environmental allergies, and blood is drawn for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress? 1 Decreased platelet count 2 Increased eosinophil level 3 Increased lymphocyte count 4 Decreased immunoglobulin leve

3

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? 1 Moving the client's bedside table closer to the bed 2 Encouraging the client to take an available sedative 3 Instructing the client to call the nurse before going to the bathroom 4 Assisting the client to telephone home to say goodnight to the spouse

950 (Rationale: The client received 150 mL from the first bag, 200 mL from IVPBs, and 600 mL from the current bag. The sum of these volumes is 950 mL.)

At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000-mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration. How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ___ mL (400 left in bag)

3

During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mcmol/L). What should the nurse do first in response to this laboratory result? 1 Notify the primary healthcare provider. 2 Obtain current blood test results. 3 Assess for decreased urine output. 4 Check the intravenous (IV) infusion.

3

For which type of injury would the nurse classify a client with a black tag during a disaster situation? 1 Young adult with closed fractures of the right leg 2 Young adult with bruises and superficial lacerations 3 Older adult with massive head trauma and multiple open fractures 4 Middle-aged adult with third-degree burns over 20 percent of his body

1

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? 1 Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. 2 Arrange for a supply of heparin for the client to take to the rehab center. 3 Explain to the client that anticoagulant therapy will no longer be needed. 4 Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.

4

On a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response? 1 5-mm erythema with no induration 2 No erythema with 3-mm induration 3 7-mm erythema with 5-mm induration 4 5-mm erythema with 10-mm induration

4

Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching? 1 "I'll get pillows for you. I want you to be as rested as possible." 2 "It's not a good idea, but you do look uncomfortable. I'll get one." 3 "We don't allow pillows under the legs because you will get too warm." 4 "A pillow under the knees can result in clot formation because it slows blood flow."

2 (Carbohydrates provide 4 kcal/g; therefore 3 L × 50 g/L × 4 kcal/g = 600 kcal, only about a third of the basal energy needed. Four hundred kilocalories is less than the kilocalories provided by the prescribed (IV) fluid. Eight hundred kilocalories and 1000 kilocalories are more than the kilocalories provided by the prescribed IV fluid)

Routine postoperative intravenous fluids are designed to supply hydration, electrolytes, and limited energy. One liter of 5% dextrose solution contains 50 grams of sugar. The nurse calculates that 3L solution/day will supply approximately how many kilocalories? 1 400 2 600 3 800 4 1000

3

Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (25 mmol/L). Which action should the nurse take? 1 Obtain a prescription for a diuretic. 2 Have the client breathe into a rebreather bag. 3 Encourage the client to take deep, cleansing breaths. 4 Request a prescription for the administration of sodium bicarbonate.

1

The client has arrived at the medical surgical unit after discharge from the post anesthesia care unit. Which areas should the nurse observe when making a focused assessment of the airway? 1 The nurse should monitor if the neck is in proper alignment. 2 The nurse should observe the rate and the depth of the respirations. 3 The nurse should look at the quality and the pattern of the breathing. 4 The nurse should see if the client is using accessory muscles to breathe.

3

The emergency room nurse is training to be a member of a direct response team to respond to community emergencies. Which new triage level would this nurse be required to learn? 1 Urgent 2 Emergent 3 Expectant 4 Nonurgent

31

The healthcare provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at what rate? Record your answer using a whole number. ____ gtts/minute.

3

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1 Sunken eyes 2 Dry, flaky skin 3 Change in mental status 4 Decreased bowel sounds

3

The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? 1 Class I 2 Class II 3 Class III 4 Class IV

2

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? 1 Measure other vital signs. 2 Stop administering the medication. 3 Elevate the head of the client's bed. 4 Report to the primary healthcare provider.

3

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? 1 PO2 value is 80 mm Hg. 2 PCO2 value is 60 mm Hg. 3 HCO3 value is 50 mEq/L (50 mmol/L). 4 Serum potassium value is 4 mEq/L (4 mmol/L).

3 (Kussmaul respirations are the regular, rapid, and deep respirations observed in clients who have metabolic acidosis. Therefore client 3 may have metabolic acidosis. Respiratory rate >20 breaths/min indicates tachypnea (client 1), which is a sign of fever, hypoxemia, and restrictive lung disease)

The nurse is assessing four clients in a healthcare setting who have respiratory disorders. Which client's findings indicate possible metabolic acidosis? 1. Tachypnea 2. Pursed lip breathing 3. Kussmaul respirations 4. Abdominal paradox

2,4

The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. 1 Pruritus 2 Sedation 3 Constipation 4 Respiratory rate 5 Nausea and vomiting

2

The nurse is caring for an older adult client. Which genitourinary factor that contributes to urinary incontinence in older adults should the nurse consider when planning care? 1 Sensory deprivation 2 Urinary tract infection 3 Frequent use of diuretics 4 Inaccessibility of a bathroom

2

The nurse is counseling a client infected with human immunodeficiency virus (HIV) regarding prevention of HIV transmission. Which statement by the client indicates the nurse needs to follow up? 1 "I should abstain from sexual activity." 2 "I can safely have anal sex without any barriers." 3 "I should get HIV counseling if planning for pregnancy." 4 "I will use condoms while having sexual intercourse."

2

The nurse is delivering abdominal and chest thrusts to clear a client's airway obstruction. Which environmental emergency requires this priority emergency treatment? 1 Frostbite 2 Drowning 3 Hypothermia 4 Lightening injury

2

The nurse is performing a rewarming procedure on a client with severe hypothermia by administering warmed intravenous fluids. The nurse carefully monitors the client's core temperature while performing this procedure. What is the lowest temperature at which the nurse will stop the rewarming? 1 86° F (30°C) 2 91.4° F (33°C) 3 96.8° F (36°C) 4 100.4° F (38°C)

4

The nurse is planning to triage clients after a disaster. Which client does the nurse categorize into the green-tagged category? 1. Client A: Airway obstruction 2. Client B: Open fractures 3. Client C: Massive head trauma 4. Client D: bruises and lacerations on skin

3,4

The nurse is teaching a client about management of low back pain. Which statements made by the client indicate effective learning? Select all that apply 1 "I should sleep in a prone position." 2 "I should sleep with my legs out straight." 3 "I should keep a check on my body weight." 4 "I should stop exercising if the pain gets severe." 5 "I should exercise by leaning forward without bending the knees."

1,4,5

The nurse is trained to work as a member of a disaster preparedness team. Which activities should the nurse be prepared to perform if a disaster were to occur? Select all that apply. 1 Triage 2 Palliative care 3 Home visits to newborns 4 Decontamination procedures 5 Evaluation of the disaster plan

4

The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client makes which statement? 1 "The healthcare provider is going to use a laser to destroy all of the cancer cells. I will have oxygen in place to help me breathe after the surgery." 2 "I don't even need the lobe they are taking out. I still have three lobes in my left lung to help me breathe after the surgery." 3 "I know that my entire right lung will be removed. I will have chest tubes to help with drainage after surgery." 4 "The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."

4

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. Which urinary finding should the nurse conclude needs to be reported to the primary healthcare provider? 1 Acidic pH 2 Glucose negative 3 Bacteria negative 4 Presence of large proteins

3

The nurse should monitor for which involuntary physiologic response in a client who is experiencing pain? 1 Crying 2 Splinting 3 Perspiring 4 Grimacing

2

The registered nurse in a hospice is working with a new assistant who has prior experience working in a physician's office. Which action made by the registered nurse will promote a healthy working environment? 1 Encouraging the assistant to perform the registered nurse functions 2 Encouraging the assistant to adopt the philosophy of the organization 3 Asking open-ended questions and supervising the work by the assistant 4 Allowing the assistant to tackle various procedures and take accountability for the task performed

4

The registered nurse teaches the student nurse regarding the priority of care provided to clients with chest pain. Which activity performed by the student nurse indicates effective learning? 1 Placing the client in upright position 2 Auscultating heart and breath sounds 3 Administering oxygen via nasal cannula 4 Assessing airway, breathing, and circulation (ABC)

3

The survivors of an explosion develop heat stroke. Which intervention should be performed by the nurse on the disaster management team? 1 Start an intravenous infusion. 2 Assess the arterial blood gases. 3 Apply ice packs on the client's scalp. 4 Administer aspirin or any antipyretic drug.

1,2,5

What are the priorities of a circulating nurse when a surgery is taking place? Select all that apply. 1 The nurse protects the client's privacy. 2 The nurse assesses the client's blood loss and urine. 3 The nurse monitors ventilation for nonintubated clients. 4 The nurse monitors the level of anesthesia provided to the client. 5 The nurse provides supplies and equipment on the basis of the surgical team's needs.

2

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1 Rapid, thready pulse 2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

3

What is a nursing priority to prevent complications in clients with respiratory acidosis? 1 Assessing the nail beds 2 Listening to breath sounds 3 Monitoring breathing status 4 Checking muscle contractions

2

When changing a postoperative client's dressing, the nurse washes hands before changing the dressing. Which type of asepsis is the nurse using? 1 Wound asepsis 2 Medical asepsis 3 Surgical asepsis 4 Concurrent asepsis

2

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? 1 Sodium 2 Potassium 3 Calcium 4 Calcitonin

4

When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the priority nursing action? 1 Provide the client with information about the usefulness of herbal therapies 2 Inform the client about taking supplemental vitamins rather than herbs 3 Teach the client about herbal supplements 4 Ask the client which herbs have been taken

3,4,5

Which are extrinsic factors responsible for falls in older adults? Select all that apply 1 Impaired vision 2 Cognitive impairment 3 Environmental hazards 4 Inappropriate footwear 5 Improper use of assistive devices

1,2

Which intrinsic factors may contribute to falls in older adults? Select all that apply. 1 Deconditioning 2 Impaired vision 3 Inappropriate foot wear 4 Improper use of assistive devices 5 Unfamiliar environment of hospital room

1

Which tag color according to the disaster triage tag system is assigned to a client who has an immediate threat to life? 1 Red tag 2 Black tag 3 Green tag 4 Yellow tag

1

Which would the nurse consider to be a potential respiratory system-related complication of surgery? 1 Atelectasis 2 Hyperthermia 3 Wound dehiscence 4 Hypovolemic shock

3

Which would the nurse describe as an example of an internal disaster? 1 Tornado 2 Hurricanes 3 Fire or explosion 4 Terrorism attacks

1

Which would the nurse state is an example of a natural disaster? 1 Floods 2 Terrorism 3 Fire explosion 4 Building collapse

1 (alter platelet counts)

While assessing the medical reports of a client with upper respiratory tract infections, the nurse notices that there are alterations in the platelet count. The client has a history of recent nasal surgery. Which clinical condition does the nurse suspect? 1 Epistaxis 2 Rhinosinusitis 3 Allergic rhinitis 4 Acute pharyngitis

2

While providing palliative care, the nurse finds symptoms of dyspnea. What will be the priority nursing intervention in this situation? 1 Administering benzodiazepines 2 Providing prescribed oxygen by nasal cannula 3 Applying wet clothes on the client's face 4 Encouraging imagery and deep breathing