Final Exam Review practice questions

A client receiving packed red blood cells starts complaining of right flank pain and dyspnea. The nurse understands this is a sign of which type of transfusion reaction? a. Fluid overload b. Hemolytic c. Allergic d. Febrile

b

The client is exhibiting sinus bradycardia, complains of synocpe and weakness, BP 98/60. Which collaborative treatment should the nurse anticipate to implement? a. Administer a thrombolytic medication b. Assess the client's cardiovascular status c. Prepare for the insertion of a pacemaker d. Obtain a permit for synchronized cardioversion

c

A nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? a. Notify the healthcare provider to have chest tubes reinserted STAT b. Instruct the client to take slow shallow breaths until the tube is reinserted c. Take no action and assess the client's respiratory status every 15 minutes Tape a petroleum jelly occlusive dressing on three sides to the insertion

d

The 29-year-old client is admitted to the medical floor diagnosed with menningitis. Which assessment by the nurse has priority? a. Assess lung sounds b. Assess the six cardinal fields of gaze c. Assess apical pulse d. Assess level of consciousness

d

What indicates to the nurse that a patient with AKI is in the recovery phase? a. Weight loss b. Urine output of 3700 mL/day c. Decreasing sodium and potassium levels d. Decreasing BUN and creatinine levels

d

When a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the client's left ventricular pressure? a. Right ventricular pressure b. Central venous pressure c. Pulmonary artery diastolic pressure d. Pulmonary artery wedge pressure

d

Which client rhythm will the nurse anticipate for the healthcare provider to prescribe synchronized cardioversion? a. Third degree heart block b. Sinus tachycardia 140 beats per minute c. Ventricular fibrillation d. Ventricular tachycardia with a pulse

d

Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? a. Obstructive b. Neurogenic c. Cardiogenic d. Hypovolemic

d

What are intrarenal causes of acute kidney injury? Select all that apply a. Anaphylaxis b. Renal stones c. Bladder cancer d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin

d, e

Identify the labels on the chest drainage device pictured:

air leak/water seal is where you see intermittent bubbling

After the initial assessment, which earthquake survivor with chest trauma would the disaster management nurse treat first? a. Client with muffled distant heart sounds and neck vein distention b. Client with paradoxical movement of chest wall and respiratory distress c. Client with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side d. Client with hyperresonance to percussion, diminished or absent breath sounds on the affected side

c

A client who sustained a closed head injury is being monitored for increased intracranial pressure. ABG gas results are pH 7.36, PCO2 38 mmHg, HCO3 21 mmHg. Which action should the nurse take? a. Suction the client's oropharynx b. Encourage the client to slow their breathing rate c. Continue to monitor for signs of increasing intracranial pressure d. Notify the health care provider that the client needs more

c

A health care provider prescribes mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of this medication? a. Decreasing the production of cerebrospinal fluid b. Limiting the metabolic requirements of the brain c. Drawing fluid from brain cells into the bloodstream d. Preventing uncontrolled electrical discharges in the brain

c

A nurse is caring for a client diagnosed with septic shock. Which assessment data warrants immediate intervention by the nurse? a. Vital signs: T 100.4 F, P 104, RR 26, BP 102/60 b. WBC of 18,000/mm3 c. Urinary output of 90 mL in the last four hours d. Client complains of increased thirst

c

A nurse is reviewing the laboratory values of a client with a myocardial infarction 3 hours ago. The nurse should expect which lab value to be elevated? A. Creatinine 1.5 B. Amylase 20 C. Troponin 0.06 ng/mL D. CK-MB 20 IU/L

c

After insertion of a central venous catheter through the left subclavian vein, a client reports chest pain and has decreased breath sounds on the left side. Which action should the nurse take first? a. Administer oxygen as prescribed b. Activate the Rapid Response Team c. Give the prescribed as needed morphine sulfate d. Assist the client to cough and deep breathe

a

In which order would the assessments of a client who is severely injured with burns and has sustained major trauma from a fire incident occur according to priority? 1. Monitoring systolic blood pressure 2. Assessing the score of eye opening 3. Removing the clothing with scissors 4. Using a jaw-thrust maneuver to establish airway 5. Palpating for the presence of a radial pulse 6. Providing bag-valve-mask ventilation a. 4, 5, 6, 1, 3, 2 b. 4, 6, 3, 2, 5, 1 c. 1, 3, 4, 2, 6, 5

a

The client has full-thickness burns to 65% of the body including the chest area. After establishing a patent airway, which collaborative intervention is priority? a. Replace fluids and electrolytes b. Prevent contractures of extremities c. Monitor urine output hourly d. Prepare to assist with escharotomy

a

When should the nurse check for leaks in the chest tube and pleural drainage system? a. There is continuous bubbling in the water-seal chamber b. There is constant bubbling of water in the suction control chamber c. Fluid in the water-seal chamber fluctuates with the patient's breathing d. The water levels in the water-seal and suction control chambers are decreased

a

A client is admitted to the ED with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply a. Bradycardia b. Hypotension c. Spastic paralysis d. Urinary retention e. Increased pulse pressure

a, b, d

Which event(s) cause increased intracranial pressure? Select all that apply a.Hydrocephalus b. Necrotic brain tissue c. Blood vessel compression d. Edema from initial brain insult e. Brainstem herniation

a, b, d

A nurse is caring for a client receiving mechanical ventilation. Which nursing action(s) is appropriate for the nurse to implement in order to prevent complications? Select all that apply a. Elevate the head of the bed to at least 30 degrees b. Suction ETT every two hours c. Apply restraints if the client shows signs of agitation d. Administer pantoprazole as prescribed e. Assess skin surrounding ETT for color, tenderness, and skin irritation

a, d, e

A client was in a motor vehicle crash with loss of function above C4. Which effect must the nurse be aware of to provide priority care? a.Diaphragmatic breathing can occur b. Loss of all respiratory function c. Hypomotility with paralytic ileus d. Decrease in sympathetic nervous system response

b

A nurse is caring for a client during endotracheal tube placement. Which assessment finding indicates the enodtracheal tube is in the right mainstem bronchus? A. Air is auscultated over the abdomen B. No breath sounds over the left chest C. End-tidal CO2 detector turns from purple to gold D. Air is auscultated over the carina

b

A client is brought to the ED with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply a. Restrict fluids b. Assess for airway patency c. Administer oxygen as prescribed d. Place a cooling blanket on the client e. Elevate extremities if no fractures are present f. Prepare to give oral pain medications as prescribed

b, c, e