Exam #1
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?
Presence of sudden peripheral edema.
A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals?
The client will receive medication to minimize episodes of breakthrough pain
A nurse is providing teaching for a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates the need for further teaching
"Fibromyalgia causes joint inflammation."
A nurse is completing discharge instructions with a client following hospitalization for an acute onset of gout. Which of the following client statements should indicate to the nurse that the client understands the treatment regimen?
"I will limit my alcohol intake"
A nurse is preparing a client who has AIDS for discharge . Which of the following statements should the nurse include in the discharge instructions?
"Prevent the spread of infection with good household cleaning practices"
A charge nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room?
A client who is neutropenic
A nurse is admitting a client who has active tuberculosis to a room on a medical -surgical unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment
A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the client will require teaching about which of the following medications?
Acetaminophen
The nurse reviews the medication orders for an older patient with arthritis in both hips who reports level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse offer as initial therapy?
Acetaminophen 650mg
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
Age obesity smoking
A nurse is assessing a client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should identify which of the following as a cutaneous manifestation of SLE?
Butterfly rash on the face
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority
CD4-T cells count 180 cells/mm3
A nurse in a clinic is caring for a client requiring a hysterectomy who states that she has decided to delay having this surgery for several months. Which of the following statements should the nurse make?
Can you elaborate on your reasons for delaying the surgery?
A nurse in a clinic is assessing client who has AIDS and a significantly decreased CD4 -T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?
Candidiasis
A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from to 10. Which of the following actions should the nurse take first?
Check the display on the PCA pump
The nursing instructor is discussing the chain of infection to a group of student nurses. What is the most important information about identifying the chain of infection for the health care provider?
Determination of points at which the infection can be stopped or prevented can be made by identifying the chain of infection
A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings?
Document the findings in the client's medical record
A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask?
Does the pain keep you from doing things you enjoy?
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
Encourage the use of a incentive spirometer
A nurse is caring for an older adult client who has RA and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
Erythrocyte's sedimentation rate (ESR)
A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs?
Establish baseline for postoperative assessment
A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE
Exercise
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?
Fatigue
A nurse is caring for a client who received a diagnosis of the systemic scleroderma 5 years ago. The nurse plans to assess the clients to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect?
Fingers contractures
A nurse is presenting a community- based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection Which of the following manifestations should the nurse include the explanation of initial symptoms?
Flu like symptoms and night sweats
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
It is primarily transmitted through direct contact with infected body fluids
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
Have the client void immediately before going into surgery
When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient's pain?
How would you describe your pain
A nurse a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching?
I can use either heat or ice to help relieve the discomfort
A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?
I will avoid people who have just received an immunization
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?
I will call for pain medication before the previous dose wears off
A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. It is 0830 and the client will begin physical therapy at 0900. Which of the following is an appropriate nursing intervention for this client at this time?
Identify the client's pain level and medicate if needed
A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test ( RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?
Immunoglobin IgE
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?
Obtain a telephone consent from a family member, following agency policy
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?
Phlebotomist who collects blood from clients who have HIV
A nurse is assessing a client who returned to the unit 4 hr ago after a partial colectomy. Which of the following findings should the nurse attend to first?
Report of severe incisional pain
a nurse is assessing a client for a suspected anaphylactic reaction following a ct scan with contrast media. for which of the following client finding should the nurse intervene first.
Stridor
A nurse is reviewing the medication administration records for four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify with as contradiction to this medication?
The client has paralytic ileus
The nurse assesses that a home hospice patient with terminal cancer who complains of severe pain has a respiratory rate of 11breaths/min. Which action should the nurse take?
Titrate the prescribed morphine does up until the patient indicates adequate pain relief.
A nurse is teaching a client who has chronic tophaceous gout about his new prescription for allopurinol. The nurse should explain that the purpose of this medication is to reduce blood levels of which of the following substances
Uric Acid
An Absolute Neutrophil Count (ANC) of less than 1000 means that neutropenic precautions are needed. Which of the following are examples of neutropenic precautions SELECT ALL THAT APPLY?
Visitor restrictions No potted or live plants No fresh fruits
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the include in the teaching?
You may experience drowsiness while taking this med
Which is the nurse's PRIORITY action when managing a client experiencing a Type hypersensitivity
airway management
A nurse is caring for a client who has developed gout. Which of the following medications should the nurse prepare to administer?
allopurinol
A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16, 000 /mm3 with increased immature neutrophils (bands) and monocytes Which of the following is the appropriate analysis of the results?
an acute infectious process
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
complete the dressing change
A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?
connective tissue
is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication?
decreases inflammation
The nurse is working in a clinical medical area with a census of 15 Each patient has a different illness. When planning care, the nurse recognizes which of the following as the most important action to provide protection to each patient from health care-associated infections?
hand hygeine
A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection
performing hand hygiene before, during, and after direct contact
A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy?
quantitative RNA assay
A nurse is caring for a client who has chemotherapy induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms?
tingling feelings in the extremities
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?
western blot analysis
