NM422 Final Exam Practice Questions

A nurse in the ED is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Slow the rate to 50 mL/hr

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Small drops of clear fluid in left ear

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A young adult female patient who is HIV positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

Continue to use contraception while taking this medication

A nurse in the ED is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply)

Hypotension Absence of Bowel Sounds Weakened gag reflex

Which action will the ED nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Provide discharge instructions about monitoring neurological status

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimuli is expected?

Pushes the painful stimuli away

The following interventions are part of the ED protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Remove the patient's rings

A patient admitted with a diffuse axonal injury has systemic BP of 106/52 mm Hg and an ICP of 14 mm Hg. Which action should the nurse take?

Report the BP and ICP to the HCP

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

Staff have entered the patient's room without a mask

During the primary survey of a patient with severe leg trauma, the nurse observes the patient's left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next?

Start normal saline fluid infusion with a large-bore IV line

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

Systolic blood pressure increased

A patient who uses injectable illegal drugs asks the nurse about preventing AIDS. Whish response by the nurse is best?

"Consider participating in a needle-exchange program"

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the ED. The nurse determines that discharge teaching has been affected when the patient makes which statement?

"I need to drink extra fluids when working outside in hot weather"

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

"You might have to stop taking this medication 5 days before any planned surgeries"

A nurse is admitting a client who has acute heart failure following MI. The nurse recognizes that which of the following prescriptions by the provider requires clarification?

0.9% NS IV at 50 mL/hr continuous

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not response to a verbal command to move but attempts to push away painful stimulus. The nurse records the patient's GCS score as:

11

A nurse is caring for a client who reports a new onset of chest pressure severe epigastric distress. The physician prescribes monitoring of creatine kinase (CK) isoenzymes. When should the nurse anticipate the CK isoenzymes will begin to rise if the client has had a MI? Select all that apply.

2 hour 3 hour

A male patient who has possible cerebral edema has a serum sodium level of 116 and a decreasing level of consciousness. He is now complaining of a headache. Which prescribed intervention should the nurse implement first?

Administer IV 5% hypertonic saline

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the UAP who regularly work in the intensive care unit?

Check cap blood glucose level every 6 hours

A 68-year-old male patient is brought to the ED by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?

Check oxygen saturation

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?

Check the drainage for glucose content

A nurse is caring for a client who had an evaluation of a subdural hematoma. Which of the following actions should the nurse take first?

Check the oximeter

After endotracheal sunctioning, the nurse notes that the ICP for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

Ensure that the patient's neck is in neutral position

A patient who is unconscious after a fall from a ladder is transported to the ED by emergency medical personnel. During the primary survey of the patient, the nurse should:

Obtain a Glasgow Coma Scale score

A 19-year-old patient is brought to the ED with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving:

TIG and tetanus-diphtheria toxoid and pertussis vaccine (T-dap)

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?

Teach the patient the reason for the use of prophylactic antibiotics

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

Temperature of 101.4 F

After evacuation of an epidural hematoma, a patient's ICP is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the HCP?

Temperature of 101.6 F

A nurse is caring for a client who as ICP following a closed-head injury. Which of the following actions should the nurse take?

Use log rolling to reposition the client

When planning the response to the potential use of smallpox as a biological weapon, the ED nurse manager will plan to obtain adequate quantities of

Vaccine

The ED triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?

A patient with paradoxical chest movements

While auscultating a client's heart sounds, the nurse hearts turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

A systolic murmur

An unresponsive 79-year-old patient is admitted to the ED during a summer heat wave. The patient's core temperature is 105.4 F, BP is 88/50 mm Hg, and pulse is 112/min. The nurse will plan to

Apply wet sheets and a fan to the patient

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?

Ask the family members whether they would prefer to remain in the patient's room or wait outside the room

A triage nurse in a busy ED assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.F at home." The nurse's first action should be to

Assess the patient's current vital signs

A 22-year-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?

Auscultate breath sounds

Admission vital signs for a brain-injured patient are BP 128/68 mm Hg, pulse of 110, and resps of 26/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

BP of 154/68, pulse 56, respis 12/min

A patient arrives in the ED after topical exposure to powdered lime at work. Which action should the nurse take first?

Brush off any visible powder on the skin and clothing

The following four patients arrive in the ED after a motor vehicle collision. In which order should the nurse assess them? A. a 74-year-old patient with palpitations and chest pain. B. A 43-year-old patient complaining of a 7/10 abdominal pain. C. A 21-year-old patient with multiple fractures of the face and jaw. D. A 37-year-old patient with misaligned lower left leg with intact pulses

C, A, B, D

A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Decrease in systolic pressure by more than 10 mm Hg during inspiration

A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?

Decreased blood pressure

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Defibrillation

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

Different apical and radial pulses

A nurse is caring for a client who is post-op following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

Dull, aching calf pain

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?

Dyspnea

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor?

Dyspnea

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP)

Eight years after seroconversion, a HIV infected patient has a CD4+ cell count of 800/uL and an undetetable viral load. What is the priority nursing intervention at this time?

Encourage adequate nutrition, exercise, and sleep

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Exercise at least 3 times per week

A nurse is caring for a client who is taking digoxin for heart failure and develops indications of severe digoxin toxicity. Which of the following medications should the nurse prepare to administer?

Fab antibody fragments

A home health nurse is making a home visit to a client who takes daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Fatigue

A nurse is obtaining a medical history from a client who is to start warfarin therapy and currently uses herbal supplements at home. The nurse should inform the client that which of the following herbal supplements can interact adversely with warfarin?

Feverfew

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy Sputum

A patient arrives in the ED several hours after taking "25 to 30" acetaminophen (Tyenol) tablets. Which action will the nurse plan to take?

Give N-acetylcysteine

A patient who is suspected of having an epidural hematoma is admitted to the ED. Which action will the nurse expect to take?

Prepare the patient for craniotomy

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

Pressure of oxygen in brain tissue is 14 mm Hg

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

Spironolactone

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my medications at the first sign of an attack"

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for ICP monitoring. Which response by the nurse is best for this situation?

"The monitoring system helps show whether blood flow to the brain is adequate"

A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching?

"The pacemaker can be checked from home by using the telephone"

A nurse is preparing to perform a 12-lead ECG. Which of the following instructions should the nurse provide to the client?

"Try to remain still once I have attached the gel pads"

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?

"Use elastic stockings"

Which patient is most appropriate for the ICU charge nurse to assign to an RN who has floated from the medical unit?

A 45-year-old patient receiving IV antibiotics for meningococcal meningitis

Following an earthquake, patients are triaged by emergency medical personnel and transported to the ED. Which patient will the nurse need to assess first?

A patient with a red tag

Which information about a patient population would be most useful to help the nurse plan for HIV testing needs?

Age

An unconscious patient is admitted to the ED with a head injry. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take?

Allow the family to stay with the patient and briefly explain all procedures to them

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Check the patient's class schedule to help decide when the drugs should be taken

According to the CDC guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for C. diff? (Select all that apply)

Gown Gloves

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as a manifestation of which of the following conditions?

Heart Failure

A nurse in an ED is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: BP 198/110, resps 24/min, temp of 38.2 C (100.8 F). Which of the following neurologic disorders should the nurse expect?

Hemorrhagic stroke

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnosis should the nurse identify as being the priority in the client's care?

Impaired tissue perfusion

A nurse in the ICU is caring for a client who has heart failure and receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

Increased urine output

A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect?

Increased urine output

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?

Insert NG tube to low suction

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head

The nurse has administered prescribed IV mannitol to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

Intracranial pressure

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Keep the HOB elevated to 30 degrees

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?

LDL 172 mg/dL

A nurse is assessing a client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

Leg pain at rest

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by a severe headache

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Mannitol 25%

Which patient exposure by the nurse is most likely to require post-exposure prophylaxis when the patient's HIV status is unknown?

Needle stick with a needle and syringe used for a venipuncture

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper-socks for the client

A nurse on a med-surg unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

Obtain an EKG

The nurse is caring for a patient who has a head injury. Which finding, when reported to the HCP, should the nurse expect will result in a new prescribed intervention?

Pale yellow urine output of 1200mL over the past 2 hours

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to:

Perform ROM exercises every 4 hours

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

Prothrombin time (PT)

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Respiratory status

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the ED. Which action prescribed by the HCP should the nurse question?

Restrict oral fluids to 1000mL/day

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

Systolic blood pressure is increased

A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the reading?

The client is experiencing premature atrial contractions

A nurse is receiving a transfer report for a client who has a head injury. The client has a GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

The client should hold his cell phone on the side opposite the ICD

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

The left second intercostal space

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse?

The patient is more difficult to arouse

The nurse is caring for a patient who is HIV positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

The patient reports missing some doses of zidovudine (AZT)

While admitting a 42-year-old patient with a possible brain injury after a car accident to the ED, the nurse obtains the following information. Which finding is most important to report to the HCP?

The patient takes warfarin daily

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

The staff nurse suctions the patient routinely every 2 hours