Mock 2

The nurse has completed a teaching session on self-administration of sublingual nitroglycerin. Which client statement indicates that the teaching has been effective?

"I can take nitroglycerin before sex so I won't develop chest pain".

A client with an acute myocardial infarction is receiving nitroglycerin by continuous I.V. infusion. Which client statement indicates that this drug is producing its therapeutic effect?

"My chest pain is decreasing."

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

"You must have the second one in 1 month and the third in 6 months."

The nurse working on a pulmonary unit has an order to administer zafirlukast 20 mg twice a day to a client who was admitted with an exacerbation of asthma. Order: Accolate 20 mg oral (po) two times a day (bid) Dose on hand: 10 mg/tablet How many tablets should the nurse give at each dose?

2

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

3 hours

At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.

45

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80

The nurse is caring for a patient with dementia in the long-term care facility when the patient has a change in cognitive function. What should the nurse suspect this patient may be experiencing?

A UTI

You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect?

Aortic aneurysm

A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?

Avoid heavy lifting.

A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply.

Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Brain CT scan or MRI

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?

Carotid endarterectomy

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

Chest pain and dyspnea

A patient comes to the clinic suspecting a possible UTI. What symptoms of a UTI would the nurse recognize from the assessment data gathered?

Cloudy urine

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling blood pressure

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?

Crackles at lung bases

A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication?

Deep vein thrombosis

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace?

Disposing of sharps appropriately and not recapping needles

Which instruction would be included in a teaching plan for a client diagnosed with a urinary tract infection?

Drink liberal amount of fluids.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

Effective breathing at a rate of 16 breaths/minute through the established airway

Giger and Davidhizar created an assessment model to guide nurses in exploring cultural phenomena that might affect nursing care. When using this model in the care of a client who has had a transurethral prostate resection (TUPR), what area of care would be influenced most directly?

Explaining the rationale for continuous bladder irrigation (CBI)

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke?

Facial droop

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Following proper hand-washing techniques

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

Incontinence and right-sided hemiparesis

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

Initiate oxygen therapy.

A female patient is being seen in the ER complaining of fatigue and shoulder blade discomfort. She is also short of breath. Based on these symptoms, what will the nurse suspect?

Myocardial infarction (MI)

A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include?

Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication?

Pulmonary embolism

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a client who is postoperative day 1 following total laryngectomy. What is the nurse's best action?

Rapidly assess the client and notify the surgeon about the client's bleeding

A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?

Relieved by rest and nitroglycerin

The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?

Shortness of breath

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?

Stabilizing heart rate and blood pressure and easing anxiety

The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response?

Stop the test and monitor the client closely.

Which statements would be considered appropriate interventions for a client with an endotracheal tube? Select all that apply.

The cuff is deflated before the tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize?

The importance of adhering closely to the prescribed medication regimen

A patient taking corticosteroids for exacerbation of Crohn's disease comes to the clinic and informs the nurse that he wants to stop taking them because of the increase in acne and moon face. What can the nurse educate the patient regarding these symptoms?

The moon face and acne will resolve when the medication is tapered off.

The nurse is caring for a client with Addison disease who is scheduled for discharge. When teaching the client about hormone replacement therapy, the nurse should address what topic?

The need for lifelong steroid replacement

The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding?

This is an accurate indicator of myocardial injury.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

To remove air from the pleural space

When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina?

Unstable

A client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which nursing intervention is appropriate?

Use sterile technique when irrigating the catheter.

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine

The nurse is teaching a client with recurrent urinary tract infections (UTIs) ways to decrease risk for additional UTIs. The nurse includes which information?

Void immediately after sexual intercourse.

A client is placed in isolation for suspected tuberculosis. Which action should the nurse take when entering the client's room?

Wear an N95 respirator

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

pleural effusion

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura?

pneumothorax