NCLEX Prep Exam 2
The home care nurse provides care to a client diagnosed with alcoholic cirrhosis. Which caregiver statement requires intervention by the nurse? (SATA) "I will give the low-dose aspirin with breakfast" "Elastic-waist pants are more comfortable for my client" "Im trying to prepare more salads and leafy green vegetables" "We often have to wake the client for meals" "Sometimes the client doesn't make it to the toilet sometimes for his bowel movements" "The clients appetite is not good, so I am glad to see an increased weight"
"I will give the low-dose aspirin with breakfast" "We often have to wake the client for meals" "The clients appetite is not good, so I am glad to see an increased weight"
Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): 1) blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing. 2) rectal temperature was 97.9°F in the morning and 99.2°F in the evening. 3) heart rate was 76 beats/minute before eating and is 60 after eating. 4) respiratory rate was 14 breaths/min when standing and is 22 breaths/min after walking.
1) blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing. 3) heart rate was 76 beats/minute before eating and is 60 after eating.
The nurse instructs a client diagnosed with a fractured and casted left ankle how to use crutches. Which action by the client indicates the client understands the correct technique for using crutches. 1)The client moves the crutches and the left leg forward while standing on the right leg. Then, the client moves the right leg forward while balancing on the crutches 2) The client moves the left crutch and the left foot forwards while balancing on the right leg. Then, the client moves the right crutch and right foot forward while balancing on the left leg. 3) the client moves the right crutch and the left foot, and then the left crutch and the right foot 4) the client bears partial weight on the left foot and moves the crutches forward. Then the client moves the left foot forward while balancing on the crutches.
1)The client moves the crutches and the left leg forward while standing on the right leg. Then, the client moves the right leg forward while balancing on the crutches
A client who underwent surgery for colon cancer 6 weeks earlier has an appointment with a wound care nurse. After correctly demonstrating the changing of the stoma pouch, the client asks the nurse for advice regarding how to deal with gas coming from the stoma. To respond to the client's concern, the nurse should ask the client to do which of the following? SATA 1. Describe the usual dietary intake, including types of foods 2. Include cruciferous vegetables in the diet daily 3. Decrease fluid intake to 1,200 mL per 24 hours 4. Prick the colostomy stoma pouch with a pin 5. Limit intake of gas-producing beverages such as carbonated sodas 6. Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp
1. Describe the usual dietary intake, including types of foods 5. Limit intake of gas-producing beverages such as carbonated sodas 6. Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp
A patient with acute kidney injury has a serum potassium level of 7.0 mEq/L. The nurse should plan which actions as a priority? Select all that apply. 1. Place the patient on a cardiac monitor 2. Notify the health care provider 3. Put the patient on NPO status except for ice chips. 4. Review the patient's medications to determine whether any contain or retain potassium. 5. Allow an extra 500 mL of IV fluid intake to dilute the electrolyte concentration.
1. Place the patient on a cardiac monitor 2. Notify the health care provider 4. Review the patient's medications to determine whether any contain or retain potassium.
Which medication will the primary care provider will most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin
2) Furosemide
The nurse is caring for a client who is 1 day post-operative for a total hip replacement. Which is the best position in which the nurse should place the client? 1) Head elevated lying on the operative side 2) On the nonoperative side with the legs abducted 3) Side-lying with the affected leg internally rotated 4) Side-lying with the affected leg externally rotated
2) On the nonoperative side with the legs abducted
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 35 seconds. On the basis of the PT, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin
2. Holding the next dose of warfarin
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? 1) Begin the transfusion as prescribed. 2) Administer an antihistamine and begin the transfusion. 3) Delay hanging the blood and notify the health care provider. 4) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.
3) Delay hanging the blood and notify the health care provider.
An adult client with cirrhosis has been prescribed a diet with optimal amounts of protein. The nurse evaluates the client's status as being most satisfactory if the total protein is which value? 1. 0.4 g/dL 2. 3.7 g/dL 3. 6.4 g/dL 4. 9.8 g/dL
3. 6.4 g/dL
A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process?1)Perception 2)Transduction 3)Transmission 4)Modulation
4)Modulation
An emergency room nurse is giving discharge instructions to a 15-year-old male who has suffered an orthopedic injury during a soccer game. He has been instructed to use crutches and limit weight bearing until further evaluation by a specialist. When instructing this patient, which of these is the correct way to describe the proper use of crutches? 1. Keeping the arms slightly bent, place the crutches as far as you can in front of you, and allow your body weight to rest on the armpit pads while you swing your uninjured leg to meet the crutches. 2. Straighten the arms and place your body weight on either the hand grips or armpit pads as you swing your uninjured leg as far as you can in front of you. 3. Straighten the arms and allow your body weight to rest on the armpit pads as you swing your uninjured leg in front of you, then pull the crutches to your standing leg. 4. Keeping the arms slightly bent, place the crutches about one foot in front of you, shifting your body weight to the hand grips as you swing your uninjured leg to, or just in front of, the crutches.
4. Keeping the arms slightly bent, place the crutches about one foot in front of you, shifting your body weight to the hand grips as you swing your uninjured leg to, or just in front of, the crutches.
Identify possible complications of a PICC. (Select all that apply.) A) Air embolism B) Thrombosis C) Occlusion D) Fat embolism E) Sepsis F) Phlebitis G) Immunosuppression
A) Air embolism B) Thrombosis C) Occlusion E) Sepsis F) Phlebitis
The nurse administers insulin glulisine by subcutaneous injection at 0900 to a client diagnosed with diabetes mellitus (DM). Which time after the injection will the nurse expect the greatest risk for hypoglycemia A. 1000 B. 0930 C. 0915 D. 0912
A. 1000
The nurse is beginning to administer blood product to a patient who has lost alot of blood in the ER. Before administering the blood what must the nurse have to safely run the blood? SATA A. 18 g IV B. NS 1000ml C. y set tubing D. primary tubing E. LR
A. 18 g IV B. NS 1000ml C. y set tubing
You are caring for four clients who are receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infections? A. A client who has nontunneled central line in the left internal jugular vein. B. A client with an implanted port in the right subclavian vein. C. A client with a peripherally inserted central catheter (PICC) line in the right upper arm. D. A client who has a midline IV catheter in the left antecubital fossa.
A. A client who has nontunneled central line in the left internal jugular vein.
Which patient is at more risk for an electrolyte imbalance? A. An 8 month old with a fever of 102.3 'F and diarrhea B. A 55 year old diabetic with nausea and vomiting C. A 5 year old with RSV D. A healthy 87 year old with intermittent episodes of gout
A. An 8 month old with a fever of 102.3 'F and diarrhea
What are possible complications from immobility? SATA A. Atelectasis B. Orthostatic Hypertension C Diabetes D. Cardiovascular Diseases E. Constipation
A. Atelectasis E. Constipation
Immobility can lead to the following conditions: (Select All That Apply) A. Decreased bladder muscle tone B. Increased depth of respirations C. Increased risk for DVT's D. Skin breakdown E. Increased appetite F. Decreased muscle strength
A. Decreased bladder muscle tone C. Increased risk for DVT's D. Skin breakdown F. Decreased muscle strength
A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? A. Midline catheter B. Peripherally inserted central catheter C. Short peripheral catheter D. Tunneled central catheter
A. Midline catheter
A client has just voided 50mL, but reports that his bladder still feels full. The nurse's next actions should include: (select all that apply) A. Palpating the bladder height B. Obtaining a clean catch urine specimen C. Performing a bladder scan D. Asking the patient about his recent voiding history E. Encouraging the patient to consume cranberry juice daily F. Inserting a straight catheter to measure residual urine
A. Palpating the bladder height C. Performing a bladder scan D. Asking the patient about his recent voiding history
The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP), and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. A. Peas B. Nuts C. Cheese D. Cauliflower E. Processed oat cereals
A. Peas B. Nuts D. Cauliflower
This term is known as the production of excessive amounts of urine of 2.5 liters over a 24-hour period of time. A. Polyuria B. Oliguria C. Anuria D. Dysuria
A. Polyuria
A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock? A. Restlessness B. Pale, warm, dry skin C. Heart rate of 110 beats/minute D. Urine output of 30 ml/hour
A. Restlessness
A client must follow a high-protein, low-sodium, and low-potassium diet. Which menu selection by the client requires follow-up teaching by the nurse (Select all that apply) A. Roast beef sandwich, coleslaw, and baked beans B. Broiled chicken breast, spinach salad, and green beans. C. Poached salmon fillet, broiled cabbage, and lemonade. D. Steel-cut oatmeal with brown sugar, fresh blueberries, and black coffee. E. Grilled chicken Caesar salad and whole-grain roll with iced tea.
A. Roast beef sandwich, coleslaw, and baked beans B. Broiled chicken breast, spinach salad, and green beans. C. Poached salmon fillet, broiled cabbage, and lemonade. E. Grilled chicken Caesar salad and whole-grain roll with iced tea.
A patient started receiving their first unit of blood at 1000. It is now 1010 and the patient is reporting itching, chills, and a headache. In addition, the patient's temperature is now 99.8'F from 98'F. Your next nursing action is: A. Stop the transfusion B. Notify the physician C. Decrease the rate of the transfusion D. Reassure the patient that this is normal and will resolve in 30 minutes.
A. Stop the transfusion
Which of the following are signs and symptoms commonly seen in patients experiencing a hemolysis reaction from a blood transfusion? Select All That Apply. A. Tachycardia B. Flank pain C. Pruritic erythema D. Chills E. Chest pain F. Swelling of the lips
A. Tachycardia B. Flank pain E. Chest pain
The nurse prepares discharge teaching for a client going home with a walker for the first time. Which assessment of the home most concerns the nurse? A. The client describes having multiple pets in the home. B. The client describes living in a ranch-style home. C. The client describes living with an adult child and infant grandchild. D. The client describes financial constraints that affect access to prescription medications.
A. The client describes having multiple pets in the home.
The nurse reviews the use of incident reports with a novice nurse. Which examples require an incident report to be completed? (SATA) A. The health care provider prescribes ampicillin 900 mg and the client is administered 1000mg. B. Vancomycin hydrochloride is inducing via peripheral IV and the IV site becomes red and swollen. C. Famotidine is scheduled to be administered at 0900, the client received it at 1130 due to a pharmacy delay D. A left knee arthroscopy is schedules but a right knee arthroscopy is completed. E. An UAP falls due to a liquid spill on the floor.
A. The health care provider prescribes ampicillin 900 mg and the client is administered 1000mg. B. Vancomycin hydrochloride is inducing via peripheral IV and the IV site becomes red and swollen. C. Famotidine is scheduled to be administered at 0900, the client received it at 1130 due to a pharmacy delay D. A left knee arthroscopy is schedules but a right knee arthroscopy is completed. E. An UAP falls due to a liquid spill on the floor.
A client's blood pressure is 180/85 mmhg. The health care provider prescribes hydralazine 10 mg IV PRN for blood pressure readings greater than 160 mm Hg systolic or 100 mm Hg diastolic. Which action by the nurse is appropriate related to PRN medication administration? SATA A. The nurse administers Iv hydralazine slowly over 2 minutes B. The nurse reports to the next nurse at shift change that hydralazine PRN was prescribed. C. The nurse documents the heart rate prior to administering hydralazine D. The nurse assesses and documents the blood pressure after hydralazine is administered E. The nurse holds the prescribed hydralazine and passes the information on to the next nurse at shift change.
A. The nurse administers Iv hydralazine slowly over 2 minutes B. The nurse reports to the next nurse at shift change that hydralazine PRN was prescribed. D. The nurse assesses and documents the blood pressure after hydralazine is administered
Your patient attempts to sit down in the bedside chair after ambulating in the hallway with crutches. What finding requires you to re-educate the patient on how to sit down in the chair correctly while using crutches? A. The patient places both crutches on the non-injured side before sitting down in the chair. B. The patient backs up to the chair's seat until he feels it with his non-injured leg and stops. C. The patient keeps the injured leg extended out in front of him while sitting down. D. The patient holds both crutches on one side and reaches for the hand grips on the crutches and places weight on them while sitting down.
A. The patient places both crutches on the non-injured side before sitting down in the chair.
The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. The patient's blood pressure changes from 75/48 to 110/82. B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed. D. Patient's urinary output is 20 mL/hr.
A. The patient's blood pressure changes from 75/48 to 110/82.
Which of these typically does not factor into a patient's perception of and response to pain? A. Treatment options available B. fatigue C. past experience with pain D. support system
A. Treatment options available
A client is receiving a blood transfusion and experiences a hemolytic reaction. The nurse will anticipate which of the following assessment findings? (SATA) A. hypotension B. shortness of breath C. fever D. pain E. itching
A. hypotension C. fever D. pain
The normal range for C-reactive protien is: A. less than 10 mg/L B. greater than 15 mg/L C. between 11 -14 mg/L D. between 20-30 mg/L
A. less than 10 mg/L
The nurse reviews the use of incident reports with a novice nurse. Which examples require an incident report to be completed? (SATA) The health care provider prescribes ampicillin 900 mg and the client is administered 1000mg. Vancomycin hydrochloride is inducing via peripheral IV and the IV site becomes red and swollen. Famotidine is scheduled to be administered at 0900, the client received it at 1130 due to a pharmacy delay A left knee arthroscopy is schedules but a right knee arthroscopy is completed. An UAP falls due to a liquid spill on the floor.
ALL of the choices
You are an emergency department nurse working the night shift in the emergency room when you get a 9 year old child admitted alone with a black eye and broken ribs. What is the best question to ask the child as you do your assessment? Are you afraid of anyone at home? How did you injure yourself? Did your dad hit you? What did you do to get in trouble?
Are you afraid of anyone at home?
A client has been admitted to the hospital for a urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value? A. 3 mg/dL B. 15 mg/dL C. 29 mg/dL D. 35 mg/dL
B. 15 mg/dL
An elderly client was admitted to the hospital in a coma. Analysis of the arterial blood gave the following values: PCO2 16 mm Hg, HCO3- 5 mmol/L, and pH 7.1. As a well-rounded nurse, you know that the normal value for HCO3 is: A. 20 mmol/L B. 24 mmol/L C. 29 mmol/L D. 31 mmol/L
B. 24 mmol/L
Which of the following patients is at greatest risk for developing pressure ulcers? A. An alert, chronic arthritic patient treated with steroids and aspirin B. An 88-year-old incontinent patient with gastric cancer who is confined to his bed at home C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed
B. An 88-year-old incontinent patient with gastric cancer who is confined to his bed at home
The nurse understands the primary reason for maintaining a constant rate of infusion with parenteral nutrition (PN) is to prevent which complication? A. The risk of fluid overload B. An unstable blood glucose level C. Potential clotting of the catheter D. Electrolyte Imbalance
B. An unstable blood glucose level
A patient is being weaned from TPN and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. The nurse anticipates that which prescription regarding the TPN solution will accompany the diet prescription? A. Discontinue the TPN B. Decrease the TPN rate to 50 mL/hr C. Start 0.9% NS at 25 mL/hr D. Continue the current infusion rate for TPN
B. Decrease the TPN rate to 50 mL/hr
The nurse provides education to an adult client to facilitate bowel elimination. Which action should the nurse encourage? A. Engaging in a sedentary lifestyle B. Increasing dietary bulk C. Decreasing fluid intake D. Using oral laxatives
B. Increasing dietary bulk
What is the main benefit of a Tunnel Central Venous Catheter? A. Shorter dwell times B. Lower incidences of infections C. Can utilize multiple lumens D. Lower risk of pneumothorax
B. Lower incidences of infections
The nurse checks the laboratory result for a serum digoxin level that was prescribed for a client earlier in the day and notes that the result is 2.4 ng/mL. The nurse should take which immediate action? A. Check the client's last pulse rate B. Notify the health care provider C. Record the normal value on the client's flow sheet D. Administer the next dose of the medication as scheduled
B. Notify the health care provider
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires Nasogastric suction C. Has a history of Addison's disease D. Is taking a potassium-retaining diuretic
B. Requires Nasogastric suction
Your patient will be using crutches for mobility. After educating the patient on how to adjust the crutches to fit correctly, you assess how well the patient understood the instructions. What findings demonstrate that the crutches were adjusted correctly by the patient? Select all that apply. A. The hand grips of the crutches are even with the mid-forearm. B. When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees. C. The patient has about a 2-3 finger width distance between the axillae and the crutch rest pad. D. The patient places weight on the axillae rather than the hands while ambulating.
B. When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees. C. The patient has about a 2-3 finger width distance between the axillae and the crutch rest pad.
A patient arrives back to the unit postop. The physician has ordered a clear liquid diet for the patient and it is explained to the patient. Which of the following responses by the patient suggests a need for further teaching? A. "I can drink iced tea" B. "I cannot drink milk" C. "I cannot eat jello" D. "I can drink water"
C. "I cannot eat jello"
The nurse is recommending guided meditation as a nonpharmacological pain intervention for a client experiencing chronic pain. What information should the nurse include when teaching the client about nonpharmacological pain interventions? A. "Guided meditation will replace your pain medication." B. "Guided meditation is only available at the hospital using licensed therapists." C. "You may require lower doses of your pain management medications." D. "Pain medications will only need to be given on an as needed basis."
C. "You may require lower doses of your pain management medications."
Your patient needs 1 unit of packed red blood cells. You've completed all the prep and the blood bank notifies you the patient's unit of blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know that you must start transfusing the blood within _________. A. 5 minutes B. 15 minutes C. 30 minutes D. 1 hour
C. 30 minutes
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client? A. A percutaneous, non tunneled subclavian catheter B. A peripheral intravenous catheter that is 20 gauge C. A multi lumen implanted tunneled and cuffed central venous catheter D. A peripherally inserted central venous catheter
C. A multi lumen implanted tunneled and cuffed central venous catheter
You are caring for a post-operative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client? A. A cleansing enema B. A retention enema C. A return-flow enema D. A laxative
C. A return-flow enema
During medication administration how can the nurse properly confirm he or she has the right patient? A. Ask the patient to state their last name and compared this to the patient's ID arm band. B. Ask the patient to state their full name and compare this information to the medication administration record and the patient's ID arm band. C. Ask the patient to state their full name along with their date of birth and compare this information to the medication administration record and the patient's ID arm band. D. Ask the patient to state their full name and compare this to the patient's ID arm band.
C. Ask the patient to state their full name along with their date of birth and compare this information to the medication administration record and the patient's ID arm band.
The nurse is administering augmentin to her patient with a sinus infection. Which is the best way for her to ensure that she is giving it to the right patient? A. Call the patient by name. B. Read the name of the patient on the patient's door. C. Check the patient's wristband. D. Check the patient's room number on the unit census list.
C. Check the patient's wristband.
2. You're providing care to a 36 year old male. The patient experienced abdominal trauma and recently received 2 units of packed red blood cells. You're assessing the patient's morning lab results. Which lab result below demonstrates that the blood transfusion was successful?* A. Hemoglobin level 7 g/dL B. Platelets 300,000 µl C. Hemoglobin level 15 g/dL D. Prothrombin Time 12.5 seconds
C. Hemoglobin level 15 g/dL
You received a new medication order on a patient for the treatment of glaucoma. The patient has no other health history and is allergic to Penicillin. The order says to administer Timolol 0.25% 1 gtt twice a day. Your NEXT action is to: A. Administer the medication as ordered. B. Confirm you have been dispensed with the right medication before administering the medication and then administer the medication. C. Hold the order until you can obtain an order clarification from the prescribing physician. D. Educate the patient on how to perform punctual occlusion before administering the medication.
C. Hold the order until you can obtain an order clarification from the prescribing physician.
A patient with gout should follow what type of diet? A. High calcium diet B. Potassium modified diet C. Low purine diet D. Renal diet
C. Low purine diet
What is the nurse's highest priority to prevent life-threatening complications related to a CVAD? A. Monitor arterial blood pressure. B. Obtain correct central venous pressure readings. C. Maintain aseptic care of the access device and system. D. Ensure that medications continue infusing during blood sampling.
C. Maintain aseptic care of the access device and system.
A patient diagnosed with AIDS has recurrent bouts of diarrhea, nausea, and vomiting. Which is the MOST important goal for this patient? A. Decreased sense of social isolation B. Improved activity tolerance C. Maintenance of fluid and electrolyte balance D. Expression of grief
C. Maintenance of fluid and electrolyte balance
A pediatric nurse has been assigned to assist with a bone marrows biospy for a 7 year old patient. Conscious sedation will be used for the procedure. What is the nurse primary responsibility? A. Communicate with the childs parents B. Apply topical anesthetic ointment C. Monitor the child during the procedure Documentation of the entire process
C. Monitor the child during the procedure
In which of the following patients is acetaminophen preferred over aspirin ? A. Patients with severe pain B. Patients with high fever C. Patients with bleeding tendencies D. Patients with inflammatory disorders
C. Patients with bleeding tendencies
The nurse assesses an older adult client and prepares to administer a prescribed intravenous potassium supplement. Which assessment finding concerns the nurse? A. The client has a normal electrocardiogram B. The client reports experiencing dizziness C. The client reports history of low urine output D. The client is experiencing muscle cramps
C. The client reports history of low urine output
Your patient is prescribed to use crutches for ambulation. The patient can bear partial weight and needs to be taught how to use the two-point gait while using crutches. Which description below best describes this type of gait with crutches? A. The patient moves both crutches forward and then moves both legs forward to the same point as the crutches. B. The patient moves the right crutch (injured side), then moves the left foot (non-injured side), then moves the left crutch (non-injured side), and then moves the right foot (injured side). C. The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward together. D. The patient moves both crutches and injured leg forward together, and then moves the non-injured leg forward.
C. The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward together.
Which patient has the highest risk for sudden changes in homeostasis? A. The patient who had a herniorrhaphy and is 12 hours postoperative. B. The patient on intravenous antibiotics every 8 hours with an infected leg ulcer. C. The patient with multiple fractures admitted after a motor vehicle accident earlier today D. The patient who is ambulating two days after a transurethral resection for benign hypertrophy of the prostate.
C. The patient with multiple fractures admitted after a motor vehicle accident earlier today
Your patient is getting ready to begin walking a couple days after a left leg operation. The doctor has ordered some crutches and wants the patient to ambulate in the halls. Which of the following is the correct way for this patient to use their crutches? A. the patient first steps with the affected leg then the two crutches together follow for stability B. The patient steps with the unaffected leg first then the two crutches follow. Using the unaffected leg to balance C. both crutches and the affected leg move first then the unaffected leg follow behind D. both crutches with the unaffected leg then using the affected leg for stability which follows behind
C. both crutches and the affected leg move first then the unaffected leg follow behind
A 70 year old patient has recently undergone a surgery and is immobile. The patient has history of dysphagia and is a type two diabetic. To ensure proper nutrition following discharge, which of the following diets would the nurse recommend to the patient's family? A. A diet low in sodium, consisting of all foods except frozen and canned foods. B. a mechanical soft diet consisted of ground meats, soft vegetables, and ice cream C. dysphagia diet with carbohydrate restrictions D. high protein diet, following foods with eggs, fish, and dairy products.
C. dysphagia diet with carbohydrate restrictions
You are the nurse taking care of a patient receiving digoxin. As the nurse you understand that you must review digoxin levels to determine if the patient is receiving therapeutic treatment. You take a look at your client's digoxin levels and note that the lab value is 3.2. What action would the nurse take next? A. Administer the dose B. call the provider C. hold the dose D. explain to the patient that the treatment is working
C. hold the dose
Which one defines anuria: A. painful burning upon urination B. less than normal amount of urinary output at less than 400 mLs over the course of 24 hrs C. lack of production of urine or a severely scant amount of urine of less than 50 mLs in 24-hrs D. excessive amount of urine production in excess of 2.5 liters over a 24 hrs.
C. lack of production of urine or a severely scant amount of urine of less than 50 mLs in 24-hrs
The nurse providers care for a client 8 hours after abdominal surgery. The client reports pain, and the nurse administers morphine 4 mg intravenously. Ninety minutes later, the client reports no relief from the pain. Which action by the nurse is appropriate? Assess the client's mental status. Contact the health care provider. Ask the client about participation in yoga. Explain that abdominal wounds are painful.
Contact the health care provider.
Which patient below is experiencing leukopenia based on their complete blood count? A. A patient with a platelet level of 100,000. B. A patient with a WBC level of 9,000. C. A patient with a platelet level of 150,000. D. A patient with a WBC level of 3,000.
D. A patient with a WBC level of 3,000.
A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will A. Stop the blood transfusion and administer the IV antibiotics, and when the antibiotic is done resume the blood transfusion. B. Adminiter the IV antibiotic via secondary tubing into the blood transfusion's y tubing. C. Hold the antibiotic until the blood transfusion is done. D. Administer the IV antibiotic as scheduled in a second IV access site.
D. Administer the IV antibiotic as scheduled in a second IV access site.
Packed red blood cells (PRBCs) have been prescribed for female client with anemia who has a hemoglobin level of 7.6 g/dL and a hematocrit level of 30%. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F (38.1° C) orally. Which action should the nurse take? A. Begin the transfusion as prescribed. B. Administer an antihistamine and begin the transfusion. C. Administer 2 tablets of acetaminophen and begin the transfusion. D. Delay hanging the blood and notify the primary health care provider (PHCP).
D. Delay hanging the blood and notify the primary health care provider (PHCP).
Which selection is a serious form of infiltration that occurs when a caustic medication, like some chemotherapeutic medications, infiltrates into the tissue, which can lead to necrosis and the loss of an affected limb A. Infection B. Phelbitis C. Embolus Formation D. Extravasation
D. Extravasation
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime. B. Ask the client each morning to describe the quantity of sleep during the previous night. C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation. D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
A nurse is conducting a follow-up home visit to a client who has been discharged with a parenteral nutrition(PN). Which of the following should the nurse most closely monitor in this kind of therapy? A. Blood pressure and temperature. B. Blood pressure and pulse rate. C. Height and weight. D. Temperature and weight
D. Temperature and weight
Which intervention should the nurse include as a nonpharmacologic pain relief intervention for chronic pain. A. Referring the client for hypnosis B. Administering pain medication as prescribed C. Removing all glaring lights and excessive noise D. Using transcutaneous electric nerve stimulation
D. Using transcutaneous electric nerve stimulation
You are the ED nurse working night shift. After three hours of quiet 4 patients come into the emergency room needing attention. As the nurse, which patient would you tend to first? A. an elderly patient who is having trouble retaining their urine and reports peeing when they cough B. a 20 year old who was just in a MVA and appear to have a dislocated shoulder C. a 40 year old pregnant woman complaining of having contractions that subside D. a 75 year old client with extreme chest pain, RR of 32 and SOB
D. a 75 year old client with extreme chest pain, RR of 32 and SOB
You've started the first unit of packed red blood cells on a patient. You stay with the patient during the first 15 minutes and: A. run the blood at 100 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. B. run the blood at 20 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. C. run the blood at 200 mL/min and then decrease the rate after 15 minutes, if tolerated by the patient. D. run the blood at 2 mL/min and then increase the rate after 15 minutes, if tolerated by the patient
D. run the blood at 2 mL/min and then increase the rate after 15 minutes, if tolerated by the patient
A patients D-dimer result is <500 ng/mL. The nurse knows that D-dimer assess _____ and this result means? A. platelet degradtation protein; negative for a blood clot B.fibrin degradation fragment; positive for a blood clot C. clotting factors; postives for a blood clot D.fibrin degradation fragment; negative for a blood clot
D.fibrin degradation fragment; negative for a blood clot
The nurse has obtained a unit of blood from the blood bank and has checked the bag properly with another RN. Just before begining the transfusion, the nurses assess which priority item? A.urine output B.skin color C. latest hematocrit level D.vital signs
D.vital signs
A client is being weaned off from parenteral nutrition (PN) and is given a go-signal to take a regular diet. The ongoing solution rate has been 120ml/hr. A nurse expects that which of the following prescriptions regarding the PN solution will accompany the diet order? Decrease the PN rate to 60 ml/hr Start 0.9% normal saline at 30 ml/hr Maintain the present infusion Discontinue the PN
Decrease the PN rate to 60 ml/hr
Packed red blood cells (PRBCs) have been prescribed for female client with anemia who has a hemoglobin level of 7.6 g/dL and a hematocrit level of 30%. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F (38.1° C) orally. Which action should the nurse take? Begin the transfusion as prescribed. Administer an antihistamine and begin the transfusion. Administer 2 tablets of acetaminophen and begin the transfusion. Delay hanging the blood and notify the primary health care provider (PHCP).
Delay hanging the blood and notify the primary health care provider (PHCP).
The nurse providers care to a client diagnosed with asthma. The client's plan of care includes respiratory treatments administered via nebulizer. The nurse recognizes which condition as a potential complication of prolonged respiratory treatments, such as nebulizer use? Hypovolemia Metabolic Acidosis Hypervolemia Metabolic Alkalosis
Hypervolemia
What is the primary advantage of a central vascular access device over the use of a peripheral IV? It can remain in place longer. It is unaffected by movement. Sterile technique is unnecessary. Sepsis is less likely to develop. Increase likelihood of extravasation.
It can remain in place longer.
The nurse is reviewing the laboratory result of a client receiving digoxin (Lanoxin) and notes that the result is 2.5 ng/mL. The nurse plans to do which of the following? Give the next dose. Notify the physician. Check the client's pulse rate. Increase the next dose as ordered.
Notify the physician.
The nurse is caring for a hypercalcemic patient with a calcium level of 12 mg/dL. Which of the following orders would the nurse expect to find for this patient? Calcium administration and Fluid Restriction IV albumin Potassium replacement Phosphorous replacement
Phosphorous replacement
A client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the most appropriate nursing action if the client's IV infiltrates? Stop the IV and apply warm compress to the infiltrated area. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing. Call the health care provider and ask for an alternate oral medication. Restart new IV and continue the previous medication schedule.
Restart new IV and continue the previous medication schedule.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority interaction? Stop the intravenous flow Slow down the intravenous flow Notify the doctor Begin CPR
Stop the intravenous flow
Which of the following are signs and symptoms commonly seen in patients experiencing a hemolysis reaction from a blood transfusion? Select All That Apply. Tachycardia Flank pain Pruritic erythema Chills Chest pain Swelling of the lips
Tachycardia Flank pain Chest pain
The nurse is caring for several clients with central venous access devices (CVADs). While changing the tubing on the central lines, the nurse should complete which interventions? Select all that apply. Use strict aseptic technique Use clean technique for the tubing and dressing change Assess the insertion site for signs of redness and drainage Document the length of the external portion of the catheter Remove any sutures at the insertion site if the line has been in place for more than 5 days
Use strict aseptic technique Assess the insertion site for signs of redness and drainage Document the length of the external portion of the catheter
A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? a. Support weight on stronger leg and cane and advance weaker foot forward. b. Hold the cane in the same hand of the leg with the most severe deficit. c. Stand with as much weight distributed on the cane as possible. d. Do not use the cane to rise from a sitting position, as this is unsafe.
a. Support weight on stronger leg and cane and advance weaker foot forward.
A patient states they are experiencing an annoying, persistent dry cough that started once they begin taking an ACE Inhibitor. The patient is not experiencing any other signs and symptoms. As the nurse, your response is? a) Tell the patient to immediately stop taking the medication and seek medical treatment. b) Reassure the patient this is a harmless side effect of this medication and to not abruptly stop taking the medication. c) Recommend the patient start taking the medication at night to decrease the coughing. d) Reassure the patient that the cough will disappear within 6 months of taking the medication.
b) Reassure the patient this is a harmless side effect of this medication and to not abruptly stop taking the medication.
The nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse understands that which client would be the least likely candidate for parenteral nutrition (PN)? a. A 66 year-old client with extensive burns b. A 42 year-old client who has had an open cholecystectomy c. A 27 year-old client with severe exacerbation of Crohn's disease d. A 35 year-old client with persistent nausea and vomiting from chemotherapy
b. A 42 year-old client who has had an open cholecystectomy
A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living (ADL)? a. TENS unit b. High-seat commode c. Recliner d. Abduction pillow
b. High-seat commode
The nurse notes the discontinuation of a prescription for Total Parenteral Nutrition (TPN), which a client has been receiving for 2 weeks. Which type of intravenous fluid does the nurse expect to be prescribed for this client? a) Ringer lactate b) 0.9% sodium chloride c) 10% dextrose in water d) 0.45% sodium chloride
c) 10% dextrose in water
A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Aging decreases the amount of REM sleep a person experiences. d. Exercising decreases REM and NREM sleep.
c. Aging decreases the amount of REM sleep a person experiences.
A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.
c. Assess for bladder distention.
The nurse is caring for a patient who is unable to hold a cup or spoon. How should the nurse administer oral medications to the patient? a. Crush the pills and mix them in pudding before administering. b. Ask the pharmacist to change all of the medications to a liquid form. c. Use a small paper cup to put the pills into the patient's mouth. d. Place the pills on the table and have the patient take the pills by hand.
c. Use a small paper cup to put the pills into the patient's mouth.
The nurse teaches an adult patient to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. drinking 2000 to 3000 mL of fluid each day. d. choosing diuretic fluids such as coffee and tea
c. drinking 2000 to 3000 mL of fluid each day
The lab results for a 70 year-old postoperative client indicate that the serum blood urea nitrogen (BUN), creatinine ratio, and hematocrit (HCT) levels are all elevated. Sodium, chloride and potassium lab results are slightly elevated. Based on these findings, which of the following issues may be the actual problem? a) Impaired gas exchange b) Metabolic acidosis c) Renal insufficiency d) Fluid volume deficit
d) Fluid volume deficit
