N2 Final
A client is newly diagnosed with sickle cell anemia. Which information does the nurse include in the client's discharge instructions?
"Be aware of the early symptoms of crisis."
A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause?
"Do you take diuretics or use laxatives?"
The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure?
"I have to stop halfway up the stairs to catch my breath and I'm not urinating as much."
The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the nurse's best response?
"Let's see if the occupational therapist can provide you with some utensils that are easier for you to use."
The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin sodium. What instruction is a priority for the nurse to provide to this client?
"Notify your health care provider if your stools appear tarry."
A nurse is preparing a teaching plan for a client with migraine headaches who is receiving a beta blocker daily to help manage this disorder. Which instruction would be appropriate to relay to this client?
"Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache."
A client who is receiving Combination Antiretroviral Therapy (cART; formerly HAART) tells the nurse, "The doctor said that my viral load is reduced. What does this mean?" What is the nurse's best response?
"The medications are working well right to suppress the viral load."
Which statement indicates that a client understands teaching about the correct use of a long acting beta-2 agonist medication for asthma?
"This drug is effective in decreasing the frequency of my asthma attacks."
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."
The nurse reviews the nutritional teaching for a client with Crohn's disease. Which instruction does the nurse provide for the client?
"You should eat a diet that is high in calories and protein."
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? ____ Tablets (Round the answer to the nearest tenth. Use a leading zero if it applies. Type only the numbers, not the units.)
0.5
A nurse is preparing to administer intravenous famotidine 30 mg IV every 6 hr for a client who has GERD. Available is famotidine 40 mg/2 mL. How many mL should the nurse administer? ____ mL (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero. Type only the numbers, not the units.)
1.5
You are the nurse caring for a client newly diagnosed with a deep vein thrombosis. You receive an order to infuse heparin 1250 units/hr. The IV bag contains 25,000 units of heparin in 250mL D5W. Calculate the IV rate in mL/hr. ____ mL/hr (Round the answer to the nearest tenth. Type only the numbers, not the units.)
12.5
You are the nurse caring for a client newly diagnosed with a deep vein thrombosis. You receive an order to infuse heparin 1350 units/hr. The IV bag contains 25,000 units of heparin in 250mL D5W. Calculate the IV rate in mL/hr. ____ mL/hr (Round the answer to the nearest tenth. Type only the numbers, not the units.)
13.5
A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer? ____ mL. (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero. Type only the numbers, not the units.)
2.5
A nurse is assessing four female clients for obesity. Which of the following clients have manifestations of obesity?
A client who has a BMI of 33%
The nurse assesses a client's legs. Which assessment finding indicates arterial insufficiency?
Absent pedal pulses and muscle pain with physical activity.
Which action by the nurse is most effective to prevent becoming exposed to the Human Immunodeficiency Virus?
Always use Standard Precautions with all clients in the workplace.
Which of the following activities cannot be delegated to an unlicensed assistive personnel (UAP)?
Assess for pain while eating.
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a DVT (deep vein thrombosis)? (Select all that apply.)
Assess legs for redness or swelling. Apply sequential compression device (SCDs). Administer ordered subcutaneous Heparin. Massage the calves every day.
The nurse assesses a client with pneumonia and notes no audible lung sounds on the left side and decreased lung expansion. What is the nurse's initial action?
Assess oxygen saturation and notify the health care provider.
The nurse is caring for a client who was started on total parenteral nutrition 2 days previously. The client reports blurred vision, dry mouth, and frequent urination. Which is the nurse's most appropriate action?
Assess the client's blood sugar.
A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority assessment?
Assess the respiratory rate and depth.
Which of the following disorders are associated with the acid-base imbalance of respiratory acidosis? (Select all that apply.)
Asthma Pneumonia COPD
A client suspected to have myasthenia gravis is scheduled for the edrophonium chloride test. Which prescribed medication does the nurse prepare to administer if complications of this test occur?
Atropine sulfate
A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?
BUN 21 mg/dL and creatinine 1.0 mg/dL
A client being treated for a spinal cord injury needs immediate ventilator support. The nurse realizes that this client's level of injury is most likely:
C3
A nurse is caring for a client who has HIV. Which of the following laboratory values should the nurse recognize as priority?
CD4-T-cell count of 180 cells/mm3
A client receiving care for a spinal cord injury complains of a pounding headache, flushed skin, cardiac dysrhythmias and has a blood pressure of 220/125 mmHg. What is the first action the nurse should take?
Check the bladder for distension.
Which risk factor does the nurse assess for to determine a client's cause of anemia?
Chronic alcoholism
A client was admitted to the ICU with a diagnosis with hypokalemia. Which of the following assessment findings would cause the nurse to become concerned? (Select all that apply.)
Coma Lethargy
A client is admitted with severe diarrhea. Arterial blood gas results are pH 7.30, PaCO2 35, HCO3 18. The nurse concludes this client has which acid-base imbalance?
Compensated Metabolic Acidosis
A client has the following Arterial Blood Gases: pH 7.43, HCO3- 19 mEq/L, PCO2 30mm Hg, PO2 98mm Hg. As the nurse you interpret the Arterial Blood Gas as which of the following?
Compensated Respiratory Alkalosis
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?
Decrease in tissue perfusion
A client has received diphenhydramine and now states she is drowsy. Upon further assessment the nurse notes the patient is alert and oriented to person, place, time and situation. What is the best action for the nurse to take?
Document the response and continue to monitor.
The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client?
Dyspnea with activity
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following interventions by the nurse is best for preventing aspiration?
Elevate the head of the client's bed 30° to 45°.
The nurse is caring for a client post spinal cord injury. What interventions will the nurse provide to minimize the risk of autonomic dysreflexia?
Ensure strict adherence to a bowel retraining program.
The nurse is caring for a client who is experiencing a seizure that is continuing after 5 minutes. What is the nurse's priority action?
Establish airway
The nurse is caring for a client with ulcerative colitis. Which nursing assessment is the highest priority?
Heart rate and rhythm
Isoniazid (INH) and Rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following noted in the client's history would require the nurse to question the order for these medications?
Hepatitis B
A client presented to ER with decrease level of consciousness, polydipsia, hyperthermia, dry mucous membranes. Blood glucose result was critical high of 600 mg/dl and serum Na= 155, K= 6, and no serum ketones. The nurse determines the physician will diagnosis this client with which of the following conditions?
Hyperglycemic Hyperosmolar State (HHS/HHNK)
The nurse is caring for a client with a history of chronic renal failure. The nurse should assess the client's electrocardiogram rhythm for signs of which electrolyte abnormality?
Hypernatremia
The nurse is assessing the patient who has started to complain of muscle cramps and paresthesias in his hands and feet. The nurse notes a positive Chvostek sign upon assessment and knows this result is associated with which electrolyte disorder?
Hypocalcemia
A client is taking triamterene-hydrochlorothiazide and furosemide. What assessment finding requires action by the nurse? a. Cough
Hypokalemia
A nurse suspects anaphylaxis when caring for a client following the initial administration of an intravenous infusion of an antibiotic. Which of the following would the nurse likely assess in this client? (Select all that apply).
Hypotension Angioedema Tachycardia
Which nursing diagnoses is a priority for the client with autonomic dysreflexia?
Impaired Urinary Elimination related to neurogenic bladder
A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen?
In the client's peripheral view.
The nurse assesses for which clinical manifestations in a client with suspected diabetic ketoacidosis?
Increased rate and depth of respirations.
A new nurse demonstrates their understanding of a proper physical assessment of an abdomen when the four techniques of examination are completed in which order?
Inspect, auscultate, percuss, palpate
A nurse is teaching a group of nursing students about dissecting abdominal aortic aneurysm. Which of the following statements should the nurse include in the teaching?
It is a medical emergency requiring immediate treatment.
A client is receiving treatment for the diagnosis of hemophilia A. Which of the following is the most appropriate to include in the assessment of this client?
Joint pain and bruising
A client has metabolic alkalosis due to renal failure. Which laboratory results is the nurse most likely to assess as consistent with this condition?
K+ 3.0
Which medication will the nurse prepare to administer to the client who is experiencing status epilepticus?
Lorazepam
.The daughter of an older adult client diagnosed with dry macular degeneration asks the nurse to explain the signs of worsening of the disorder. In formulating a response, the nurse would include which characteristics of this condition?
Loss of central vision with peripheral vision intact
The nurse is reviewing the physician's orders for a client newly admitted with a diagnosis of Meniere's disease. Which diet will most like be prescribed?
Low-sodium diet.
Which information is most important for the nurse to provide to the client to prevent sickle cell crisis?
Maintain an oral fluid intake of at least 4500 mL/day.
A client is demonstrating signs of an anaphylactic reaction. Which of the following should the nurse do? (Select all that apply.)
Maintain patent airway Begin administering ordered intravenous fluids
The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent aspiration related respiratory complications in the client?
Maintain the head of the bed at least 30 degrees or greater.
The nurse has admitted to the intermediate care unit a client who sustained a spinal cord injury at T1 in a motor vehicle accident. Which nursing care activity can the nurse delegate to the unlicensed assistive person (UAP) working with this client? (Select all that apply.)
Measure oxygen saturation level every hour Provide mouth care
A client is complaining of dizziness, unilateral ringing in the ear, feeling of pressure or fullness in the ear, and unilateral hearing loss. Which would the nurse suspect the client is experiencing?
Meniere's disease
A client who experienced a spinal cord injury 1 hour ago is brought to the emergency room. Which medication will the nurse prepare to administer to this client?
Methylprednisolone
A nurse is caring for a client who has been admitted for an exacerbation of Crohn's disease. An NG tube has been placed and is to suction, and the client is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC) line. Which of the following interventions should the nurse recognize as the priority intervention in the care of this client?
Monitor laboratory values and assess for abnormal respiratory or cardiac functioning.
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide for pulmonary edema. Which is the priority nursing intervention?
Monitor the client's blood pressure.
The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client?
Muscle weakness that worsens with use and improves with rest.
The nurse is concerned that a client with a gastrostomy feeding tube is developing a complication. Which of the following are considered complications associated with this type of feeding tube? (Select all that apply.)
Nausea Vomiting Abdominal distention
Which risk factor does the nurse recognize that may predispose an individual to back pain?
Obesity
A nurse is assessing a male client who has a new diagnosis of peripheral artery disease (PAD). Which of the following findings should the nurse expect to find on the affected extremity? (Select all that apply)
Pain Paresthesia Pallor
The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a deep, painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with?
Peripheral arterial disease
A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action?
Place the client in a high Fowler's position.
A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?
Placing the client in at least Semi-Fowlers position during meals
The nurse is preparing to transfuse a third unit of red blood cells to a client. Which laboratory result is the nurse most concerned about?
Potassium level of 6.2 mg/dL
A client who is taking Spironolactone at home arrives in the emergency department complaining of unrelieved edema in the legs. The nurse share what data with the physician that indicates a need to withhold the medication?
Potassium of 6 mEq/L
A client has the following arterial blood gases: pH 7.30, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg. Which intervention by the nurse is most appropriate?
Prepare to give rapid intravenous of sodium bicarbonate.
A client has a BUN of 68 mg/dL and a creatinine level of 6.0 mg/dL. The IV fluid is 5% Dextrose in 0.9% sodium chloride with 40 mEq KCL @100 mL/hour. Which action would be most appropriate for the nurse to take?
Question the use of potassium in the IV fluids.
A nurse is caring for a client with hypertension and diabetic nephropathy about a newly prescribed medication, Perindopril. Which of the following manifestations does the nurse recognize as a hypersensitivity or toxicity?
Rebound hypertension
A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?
Red meat
A client is admitted to the emergency room with a respiratory rate of 6/min. Arterial blood gasses (ABGs) have been drawn and reveal to following values: pH 7.22, PaCO2 68, HCO3 26, PaO2 74. Which of the following is an appropriate analysis of these ABGs?
Respiratory acidosis
Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?
Respiratory status and airway patency.
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions is the highest priority for the nurse to take?
Review the client's electrolyte values.
47. assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis?
Severe, steady right lower quadrant pain
A nurse is reviewing the labs for a newly admitted heart failure patient and notes a K+ level of 6.1. Upon reviewing the patient's medications, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance?
Spironolactone
The nurse is providing medication instructions to a client. The nurse informs client that hyperkalemia can result from taking which newly prescribed diuretic?
Spironolactone
A client with acquired immunodeficiency syndrome (AIDS) who has cellulitis is being admitted to the nursing unit. The nurse should institute which of the following?
Standard precaution
The nurse is caring for a client who is about to have immunotherapy initiated due to severe allergies. Knowing that this patient is being exposed to a known allergen, what intervention does the nurse implement to provide for client safety this allergy treatment?
Stay with the client and ensure that emergency equipment is in the room.
A nurse assessing a client that states she has leakage of small amounts of urine when attempting to get up out of bed. The nurse should associate these findings with which of the following types of urinary incontinence?
Stress incontinence
The nurse is assessing a client diagnosed with asthma. The client's initial breath sounds heard by the nurse consisted of wheezing but are now clear to auscultation. This has occurred due to which of the following?
The client's albuterol inhaler treatment was effective.
A client is diagnosed with glaucoma and is prescribed medication to treat it. The nurse knows that which of the following best explains the purpose of the medication?
This medication lowers intraocular pressure.
A client with epilepsy develops loss of consciousness and incontinence, then breathing cessation for 25 seconds. The nurse expects this type of seizure is which of the following?
Tonic-clonic seizure
Which of the following conditions should the nurse recognize as a type II hypersensitivity reaction?
Transfusion with the improper blood type
A client is admitted with arterial blood gas (ABGs) results of pH 7.30, PaCO2 60, HCO3 22. The nurse concludes this client has which acid-base imbalance??
Uncompensated Respiratory Acidosis
A nurse is caring for a client and observes that the client's urine is cloudy and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?
Urinary tract infection
A client has notified the nurse that she has completely eliminated fats from her diet. The nurse recognizes this type of diet places the client at risk for a deficiency of which fat-soluble vitamins and/or minerals?
Vitamins A, D, E, and K.
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
a. Check the client's vital signs.
The nurse assesses a client who has Myasthenia Gravis. Which clinical manifestation does the nurse expect to find in this client?
mild diplopia and unilateral ptosis
A client is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which arterial blood gas (ABG) lab value would the nurse expect to see with this client?
pH 7.29; PaCO2 32; HCO3 18
A client with uncompensated metabolic acidosis is admitted. Which laboratory value would the nurse expect to find in this client?
pH 7.2; serum potassium 6.2 mEq/L
Of the following blood gas values, which would indicate the nurse needs to further evaluate the client?
pH 7.49, PO2 82, CO2 31, HCO3 23
Which arterial blood gas (ABG) values are expected with hyperventilation?
pH, 7.55; PaCO2, 32 mm Hg
