AH2 Exam 3
A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy sign c. Clay-colored stools d. Upper abdominal pain after eating
C
0. A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever
A
10. The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding
A
13. A nurse receives hand-off report from the emergency department on a new admission suspected of having septic shock. The client's qSOFA score is 3. What action by the nurse is best? a. Plan to calculate a full SOFA score on arrival. b. Contact respiratory therapy about ventilator setup. c. Arrange protective precautions to be implemented. d. Call the hospital chaplain to support the family.
A
3. The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg)
A
3. The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours
A
5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."
A
6. The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."
A
A client is receiving norepinephrine for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denies chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours
A
3. The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration f. Use of diuretics
A, B, C, D, F
The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."
A
The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.) a. "Avoid alcohol ingestion." b. "Be sure and balance rest with activity." c. "Avoid caffeinated beverages." d. "Avoid green, leafy vegetables." e. "Eat small meals and high-calorie snacks."
A, B, C, E
9. The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure
A, B
4. The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine
A, B, C, D, E, F
6. The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"
A, B, C, D, E, F
3. The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) a. Thinner skin b. Slower healing time c. Decreased mobility d. Hyperresponsive immune response e. Increased risk of unnoticed sepsis f. Pre-existing conditions
A, B, C, E, F
5. The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids.
A, B, C, E, F
The nurse is caring for a client who was recently diagnosed with pancreatic cancer. What factors present risks for developing this type of cancer? (Select all that apply.) a. Diabetes mellitus b. Cirrhosis c. Smoking d. Female gender e. Family history f. Older age
A, B, C, E, F
1. A nurse assesses a client with an injury to the medulla. Which clinical manifestations would the nurse expect to find? (Select all that apply.) a. Decreased respiratory rate b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex
A, B, D, E
4. A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance
A, B, D, E
The nurse in the emergency department would arrange to transfer which burned clients to a burn center? (Select all that apply.) a. 15% partial-thickness burn b. Lightening injury c. 7% partial-thickness burn d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum
A, B, D, E, F
1. The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection b. GI bleeding c. Irritable bowel syndrome d. Constipation e. Anemia f. Hypovolemia
A, B, D, F
1. The nurse studying shock understands that the common signs and symptoms of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased systemic perfusion
A, C
6. A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age-group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.
A, C, D
The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the patient." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."
A, C, D
The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures f. Limiting the client's visitors until more stable
A, C, D, E
5. The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. prone position c. feet elevated on pillows d. daily weights e. physical therapy f. respiratory therapy
A, C, D, F
3. The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian nutritionist b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Primary health care provider
A, C, E
6. After teaching a client who has chronic pancreatitis and will be discharged with enzyme replacement therapy, a nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? (Select all that apply.) a. "I will take the enzymes between meals." b. "The enteric-coated preparations cannot be crushed." c. "Swallowing the tables without chewing is best." d. "I will wipe my lips after taking the enzymes." e. "Enzymes should be taken with high-protein foods."
A, E
5. The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) a. Ascites b. Weight gain c. Steatorrhea d. Jaundice e. Polydipsia f. Polyuria
A. C, D, E, F
The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client (Select all that apply) a. elevated amylase b. elevated lipase c. elevated glucose d. decreased calcium e. elevated bilirubin f. elevated leukocyte count
ALL of the above A, B, C, D, E, F
11. A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."
B
12. A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider? a. Creatinine: 0.9 mg/dL (68.6 mcmol/L) b. Lactate: 5.4 mg/dL (6 mmol/L) c. Sodium: 150 mEq/L (150 mmol/L) d. White blood cell count: 11,000/mm3 (11 109/L)
B
2. A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess using the MEWS score. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.
B
2. The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.
B
3. A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers.
B
A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"
B
A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the side. d. Stay with the client and reassure him or her.
B
7. The nurse is assessing a client who has hepatitis C. What extra-hepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis
B, C, D
A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer. b. Is allergic to acetaminophen. c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends. e. Plans to have a beer and go to bed once home.
B, D, E
2. A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)
B, E, F
When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client's current level of consciousness? a. Alert b. Lethargic c. Stuporous d. Comatose
B. Lethargic
A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP
B. Lowe blood volume lowers MAP
7. The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis
B. polyarthritis C. heart disease D. myalgia
A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching e. elevated temperature
B. severe boring abdominal pain
10. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome (MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the nurse causes the charge nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs
C
14. The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."
C
5. After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? a. "The capsules can be opened and the powder sprinkled on applesauce if needed." b. "I will wipe my lips carefully after I drink the enzyme preparation." c. "The best time to take the enzymes is immediately after I have a meal or a snack." d. "I will not mix the enzyme powder with food or liquids that contain protein."
C
A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment Btestbanks.com Btestbanks.com b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment
C
A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine
C
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3 (3.8 109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the primary health care provider immediately. d. Prepare to administer insulin per sliding scale.
C
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."
C
The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French
C
6. The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? a. Electrolyte imbalance b. Pleural effusion c. Internal bleeding d. pancreatic pseudocyst
C. internal bleeding
11. A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following: Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C) Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best? a. Transfer the client to the Intensive Care Unit. b. Continue monitoring every 30 minutes. c. Notify the unit charge nurse immediately. d. Call the Rapid Response Team.
D
13. The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.
D
17. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)
D
3. A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider? a. Mild temporal headache b. Pupils equal and react to light c. Alert and oriented 3 d. Decreasing level of consciousness
D
3. After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice
D
8. The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment
D
A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive form the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. Btestbanks.com Btestbanks.com c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.
D
The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C
D
The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug."
D
9. A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? a. Assess the 24-hour intake and output. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Increase the infusion rate of the TPN
A
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.
A
7. A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.
B
7. After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."
B
5. The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."
B
8. A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain a pulse oximetry reading d. Start two large-bore IV catheters.
B
