NURS 306 MC questions part uno
A client with a spinal cord injury is being prepared for discharge. Because of the risk for autonomic dysreflexia, the nurse should instruct the client and family to report which symptoms to the healthcare provider? A. Headache and facial flushing B. Dizziness and tachypnea C. Circumoral pallor and lightheadedness D. Pallor and itching of the face and neck
A
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? A. Increase the oxygen flowrate B. Teach the patient to cough and deep breathe C. Help the patient to sit in a more upright position D. Suction the patient's oropharynx
A
A patient is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? A. Assessing the IV site every hour B. Educating the patient on side effects C. Monitoring the patient for nausea D. Providing warm packs for comfort
A Chemotherapy is a vesicant and extravasation is common.
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different area B. Administer an analgesic PO C. Request a prescription for placement of a central venous access device D. Administer a local anesthetic
A It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere
Which nursing interventions are appropriate to help decrease the development of increased intracranial pressure for a client with a head injury? Select all that apply. A. Maintain head in midline neutral position with HOB in semi-fowler's B. Keep the client's room quiet and dark C. Assessment of the client's neurological status D. Administration of acetaminophen (Tylenol) for a temperature of 100.1 F E. Position the client with HOB supine
A, B, D
Which discharge instructions would the nurse include for a patient with a new pacemaker? Select all that apply A. Do not lift the arm above the level of your shoulder for 4 weeks B. Until your incision is healed, do not submerge your pacemaker in water C. Have your pacemaker turned off before having magnetic resonance imaging (MRI) D. If you feel weak, apply pressure over your generator
A, B
A patient's family members are concerned that telling the patient about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the patient. What actions but he nurse are most appropriate? Select all that apply. A. Ask the family to describe their concerns more fully B. Consult with social worker, chaplain, or ethics committee C. Explain the patient's right to know and ask for their assistance D. Have the unit manager take over the care of this patient and family E. Tell the family that this secret will be kept from the patient
A, B, C
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? Select all that apply A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Place pillows under the client's knees when in bed E. Massage the calves every shift.
A, B, C D is incorrect because it places pressure under the popliteal space E is incorrect because that can dislodge a thrombus and avada kedavra you just caused a PE and killed a man
The nurse is caring for an oncologic client. The nurse recognizes the following as possible manifestations of tumor lysis syndrome. (Select all that apply) A. Acute renal failure B. Cardiac dysrhythmia C. Renal calculi D. Hyperphosphatemia E. Hypokalemia F. Hyperuricemia
A, B, C, D, F
The nurse is caring for a patient who was recently extubated. Upon assessment, the nurse notes the patient has difficulty coughing up secretions, dyspnea, and has a high-pitched crowing sound. What are the priority nursing action(s)? Select all that apply. A. Notify healthcare provider immediately B. Prepare for intubation C. Reassure the patient these are expected findings D. Administer racemic epinephrine E. Encourage the patient to cough and deep breath more
A, B, D "High pitched crowing sound" is also called stridor D is for the stridor "What does racemic mean?" Racemic epinephrine is just a type of epi that we give through a nebulizer
The client receiving TPN via a central venous catheter (CVC) is scheduled for an IV antibiotic. The nurses' first action is to: A. Turn off the TPN for 30 minutes to run the antibiotic B. Ensure that the client has a separate line for the antibiotic C. Check the TPN for compatibility with the antibiotic D. Flush the TPN line with normal saline then run the antibiotic
B
A client who has been diagnosed with lung cancer complains of increasing shortness of breath and difficulty swallowing. The client has facial swelling and jugular venous distention (JVD). What is the priority nursing action? A. Encourage the client to cough and deep breathe B. Ensure the client has a patent airway C. Assist the client to a tripod position D. Prepare the client for a swallow evaluation
B
A client who is receiving chemotherapy develops stomatitis. Which of the following actions is appropriate for the nurse to incorporate into the plan of care? A. Avoid using dental floss until the client's stomatitis is resolved B. Encourage the client to use a soft-bristled toothbrush after each meal C. Rinse the client's mouth with full-strength hydrogen peroxide every 4 hours D. Provide hot tea with honey to soothe the client's painful oral mucosa
B
A client with a spinal cord injury (SCI) at level C3-4 is being triaged by the nurse in the emergency department. What is the priority nursing assessment? A. Determine Glasgow Coma Scale (GCS) score B. Assess respiratory effort, rate, and oxygen saturation level C. Obtain blood pressure, heart rate, and temperature D. Assess motor function, sensory function, and deep tendon reflexes
B
A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What its he priority nursing concern at this time? A. Muscular weakness B. Fatigue C. Decreased mobility D. Joint pain
B
A patient has a platelet count of 9800/mm^3. What action by the nurse is most appropriate? A. Assess the patient for calf pain, warmth, and redness B. Instruct the patient to call for help to get out of bed C. Obtain cultures as per the facility's standing policy D. Place the patient on protective isolation precautions
B They're at high risk of bleeding episodes
The nurse on the medical-surgical unit receives hand-off report on four patients. Which patient is the priority to assess first? A. Patient with rib fractures, respiratory rate 23 breaths/min, heart rate 106 beats/min, oxygen saturation 96% on high-flow nasal cannula, complaining of chest discomfort B. Patient who is one day postoperative femur repair and suddenly complains of shortness of breath, heart rate 125 beats/min, oxygen saturation 71% on nasal cannula 6 L/min C. Patent with sepsis, respiratory rate 22 breaths/min, heart rate 112 beats/min, blood pressure 113/79 (90), oxygen saturation 88% on non-rebreather 15 L/min D. Patient who is recovering from opioid overdose, respiratory rate 14 breaths/minute, heart rate 90 beats/min, oxygen saturation 96% on nasal cannula 2 L/minute
B They're giving pulmonary embolism. HR high, Oxsat super low B&C are both unstable but B takes priority because of the low oxsat "For questions asking you to chose between patients always think "UUAR" (pronounced "you are") meaning you are looking for someone who is unstable, unexpected, acute, and real problem."
A nurse is caring for a client with manifestations of Parkinson's disease. Which of the following are expected findings for PD? Select all that apply. A. Decreased vision B. Pill-rolling tremors of the fingers C. Drooling D. Bilateral ankle edema E. Lack of facial expressions
B, C, E
A client is admitted with severe headache, fever, vomiting, photophobia, drowsiness and stiff neck associated with viral meningitis. What is the priority action? A. Encourage client to breath slowly B. Place a large, soft pillow under the head C. Dim the lights in the room D. Offer sips of warm liquids
C
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia? A. Epinephrine B. Magnesium C. Atropine D. Sodium bicarbonate
C
A nurse is caring for a client woh has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A. The client's ECG tracing shows irregular heart rate without P waves B. The client has an aPTT of 80 seconds C. The client experiences sudden weakness of one arm and leg D. The client's urine output is cloudy and odorous
C
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is the best? A. Increase the IV flow rate to 250 mL/hr B. Measure intake and output every 4 hours C. Place the client in a high-Fowler position D. Assess the client further for fall risk
D
A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could: A. Counteract the effects of antibiotics B. Stimulate the central nervous system C. Elevate the blood pressure D. Mask symptoms of increasing intracranial pressure
D
A nurse cares for a patient who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? A. Make certain that your bath water is warm B. Limit your intake of caffeinated drinks to one a day C. Avoid strenuous exercise such as running D. Avoid straining while having a bowel movement
D
The registered nurse (RN) in the intensive care unit is caring for a patient with a myocardial infarction. What nursing action can the registered nurse delegate to the unlicensed assistive personnel (UAP)? A. Apply oxygen via nasal cannula B. Assess chest pain C. Obtain vital signs D. Administer sublingual nitroglycerin
C
Which statement about blood transfusion capabilities is correct? A. Donor type B can donate to recipient blood type O B. Donor type AB can donate to anyone C. Donor type O can donate to anyone D. Donor type A can donate to recipient blood type AB E. Donor type A can donate to recipient blood type B
C
A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? A. Apply oxygen at 100% B. Assess the respiratory rate C. Ensure a patent airway D. Administer 1L crystalloid fluid bolus
C ABC's bruh. Airway takes priority always
A nurse prepares to defibrillate a patient who is in ventricular fibrillation. Which priority intervention would the nurse perform prior to defibrillating this patient? A. Ensure that everyone is clear of contact with the patient and the bed B. Set the defibrillator to the synchronous mode C. Test the equipment by delivering a smaller shock of 100 J D. Administer epinephrine 1 mg intravenous
A
A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? A. Tying a square knot at the back of the neck B. Holding the device securely when changing ties C. Suctioning the patient first if secretions are present D. Using half-strength peroxide for cleansing
A
The nurse completed health promotion teaching about skin cancer prevention. What statement by the client indicates the teaching as effective? A. "I need to let my doctor know if I develop a spot on my skin that has different colors." B. "As long as I wear sunscreen, I will not develop skin cancer." C. "Since I have dark-colored skin, I do not need to worry about developing skin cancer." D. "Indoor tanning booths are safer than being in the sun."
A
The nurse in the neurology unit is admitting a young adult client with a closed head injury. The client is sleepy and arousable, oriented to person, place, time and situation, and has clear liquid draining from the nose. What is the priority nursing intervention? A. Maintain the head of bed (HOB) at least 30 degrees B. Reposition the client from side to side C. Apply packing in the nose to prevent further damage D. Encourage the client to blow their nose to remove secretions
A
A 19-year-old student comes to the student health center at the end of the semester stating, "My heart is skipping beats." An ECG shows occasional univocal premature ventricular contractions (PVCs). What action should the nurse take next? A. Ask the patient about current stress level and caffeine use B. Insert an IV catheter for emergency use C. Start supplemental O2 at 2 to 3 L/min via nasal cannula D. Have the patient taken to the nearest emergency department
A
A client with cancer who is receiving radiation therapy develops thrombocytopenia. The priority nursing goal is to prevent which of the following? A. Bleeding related to the decreased platelet count B. Altered nutrition related to anemia C. Skin breakdown related to decreased tissue perfusion D. Pain related to spontaneous bleeding episodes
A
A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? A. Call the emergency response team B. Seek immediate help from the risk manager C. Call the provider for a stat DNR order D. Respect the family's wishes and do nothing
A
The nurse is caring for a client who just had a peripherally inserted central catheter (PICC) insertion. Which of the following actions tells the nurse that a student nurse understands the care of the client with a PICC line? A. Use 10 mL normal saline to flush the line B. Cover the insertion site with a 4x4 gauze to prevent bleeding C. May perform blood pressure monitoring on the affected arm D. Able to shower at home without restrictions
A
The nurse is preparing to administer a blood transfusion. Which action is the most important? A. Put on a pair of gloves B. Document transfusion C. Place the client in isolation D. Place the client on NPO status
A
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? A. Sudden lethargy B. Muffled heart sounds C. Flattened neck veins D. Bradycardia
B Muffled heart sounds are a key indicator of cardiac tamponade because of the excess amount of fluid surrounding the heart
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? A. Extremities that turned blue when exposed to cold B. Tingling feelings in the extremities C. Jerking movements of the extremities D. Spasms of the extremities
B Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness, tingling, burning, or a loss of feeling in the extremities
The nurse is caring for a client with an acute MI. Which medication should be given to cause vasodilation and reduce anxiety and pain? A. Nitroglycerin B. Morphine C. Lorazepam D. Furosemide
B That's just what it does. bleh.
The nurse receives hand-off report on four patients who all have endotracheal intubation and mechanical ventilation. Which patient is the priority to assess first? A. Patient with head of bed at 25 degrees B. Patient with bilateral wrist restraints who is calm and cooperative C. Patent with decreased right-side lung sounds D. Patent with bilateral crackles and increased oral secretions
C ETT tube might be in the wrong place or pneumothorax
The nurse is caring for a patient with a right-sided chest tube in place. At 0800, the chest tube drainage was 30 mL and serous. At 0900, the chest tube drainage from the tube was 110 mL and sanguineous. What is the nurse's best action? A. Check the chest tube system for leaks B. Gently "milk" the tubing to remove clots C. Notify the provider immediately D. Instruct the patient to cough and deep breathe
C That's a lot of drainage at 0900 and it's frank red blood, so new bleed so...ya know, no bueno.
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? A. Administer the chemoteherapy through a small-bore catheter B. Infuse the medication over a short period of time C. Stop the infusion if swelling is observed at the site D. Hold the medication unless a central venous line is available
C That's giving extravasation my dude
A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? A. Attending a class given about tracheostomy care B. Verbalizing all steps in the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning
C The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.
A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client? A. Piperacillin/tazobactam B. Levothyroxine C. Levodopa/carbidopa D. Carbamazepine
C This is a cornerstone of Parkinson's treatment. The nurse should prepare to instruct the client on the use of this medication.
A patient is found pulseless, and the cardiac monitor shows a rhythm that has no recognizable deflections, but instead has coarse "waves" of varying amplitudes. What is the priority intervention for this rhythm? A. Noninvasive temporary pacing B. Administer epinephrine IV push C. Immediate defibrillation D. Endotracheal intubation
C V-fib = d-fib
The nurse is caring for an older adult who is receiving multiple packed red blood cell transfusions. Which assessment findings indicate possible transfusion circulatory overload? Select all that apply. A. Bradycardia B. Acute confusion C. Dyspnea D. Hypertension E. Depression F. Bounding pulse
C, D, F
A nurse is teaching a client who has stomatitis. Which of the following instructions should the nurse include? A. Rinse with a commercial mouthwash B. Use toothpaste that contains sodium laurel sulfate C. Cleanse the mouth with lemon-glycerine swabs D. Brush teeth with a soft toothbrush
D The client should use a soft toothbrush and gently brush after each meal to reduce mouth irritation and prevent superinfections
Which of these clients should be seen immediately after hand-off shift report? A. A client complaining of feeling fatigued following chemotherapy B. A client complaining of nausea and vomiting following chemotherapy C. A client with a temperature of 99.0 F and heart rate 88 beats/minute D. A client complaining of discomfort at the IV insertion site during chemotherapy
D
The nurse is caring for a patient admitted for pneumothorax. The patient has a chest tube, does not follow commands, and is becoming more agitated and confused despite having oxygen via nonrebreather at 15 L/min. Based on this assessment, an arterial blood gas is drawn: pH = 7.21, CO2 = 58, O2 = 59, HCO3 = 19. What is the priority nursing action? A. Notify healthcare provider, prepare for BiPAP B. Administer oxygen via nonrebreather at 25 L/min C. Administer normal saline (0.9%) 1L IV bolus D. Notify healthcare provider, prepare for intubation
D They're not breathing, giving them more oxygen will do nothin
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should thenurse take? A. Have the client lie flat in bed. B. Keep the affected leg slightly flexed. C. Elevate the head of the bed 45°. D. Keep the client NPO for 4 hr.
A
The nurse is assessing a client with Parkinson's disease who was prescribed Carbidopa-levodopa. What is the highest priority assessment question? A. "Are you having any side effects of the medication?" B. "Are you having less stiffness and rigidity?" C. "Have you had any difficulty with urination?" D. "Are you experiencing fewer tremors in your hands?"
A
The nurse on the medical-surgical unit receives hand-off report on four patients. Based on the arterial blood gases below, which patient is the priority to assess first? A. pH = 7.21, CO2 = 58, O2 = 59, HCO3 = 19 B. pH = 7.33, CO2 = 44, O2 = 81, HCO3 = 24 C. pH = 7.59, CO2 = 23, O2 = 79, HCO3 = 20 D. pH = 7.40, CO2 = 36, O2 = 86, HCO3 = 23
A It's giving respiratory acidosis. That O2 is hella low
A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? A. Pushes the painful stimulus away B. Extends her body toward the painful stimulus C. Shows no reaction to the painful stimulus D. Flexes the upper and extends the lower extremities in response to the painful stimulus
A This is an expected response. This rationale is amazing.
The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? A. The patient's respiratory rate is 32 breaths/min B. The patient's PaO2 is 45 mmHg C. The patient's respirations are shallow D. The patient's PaCO2 is 33 mmHg
B
Patients with tracheostomy or endotracheal tube need suctioning as needed to keep the airway patent. Which nursing actions demonstrate proper suctioning technique? Select all that apply. A. Preoxygenate the patent for at least 30 seconds before suctioning B. Quickly insert the suction catheter until resistance is met C. Suction the patient for at least 30 seconds to remove secretions D. Repeat suctioning as needed for four to five total suction passes E. Apply suction when withdrawing the suction catheter
A, B, E C is incorrect because you should only suction for 10-15 seconds. 30 is too long D is incorrect because only 2-3 passes The resistance you meet is the carina, and that's where you wanna be
The nurse is caring for a client 1 hour post-op cardiac catheterization in the left femoral artery. What is the priority nursing assessment? Select all that apply. A. Pulses in the left foot B. The client's ability to ambulate C. Heart rate and blood pressure D. Drainage on the dressing E. Capillary refill in the left hand
A, C, D
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? Select all that apply A. Severe dyspnea B. Nausea C. Decreased level of consciousness D. Headache E. Hypotension
A, C, D, E A is correct because hypoxemia C and D are correct because of hypercapnia E is correct because acidosis B is just wrong.
A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply) A. A non healing sore B. Bloating C. Change in bowel pattern D. Change in moles E. Nagging cough
A, C, D, E These are all s/s in C A U T I O N C: Change in bowel or bladder habits A: A sore that does not heal U: Unusual bleeding or discharge T: Thickening or lump in the breast or elsewhere I: Indigestion or difficulty swallowing O: Obvious change in a wart or mole N: Nagging cough or hoarseness
The nurse started the transfusion of 1 unit of PRBs. Which clinical findings indicate a complication of allergic reaction? (Select all that apply) A. Urticaria B. Lower back pain C. Pruritus D. Chills E. Wheezing
A, C, E
The nurse is caring for a client with a head injury who has developed increased intracranial pressure. Which of the following actions should the nurse plan to take? Select all that apply. A. Implement seizure precautions B. Perform neuro checks QID C. Administer morphine for head and neck pain D. Turn off room lights and TV E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently
A, D, E
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (select all that apply) A. Elevate the head of the bed to at least 30 degrees B. Verify the prescribed ventilator settings daily C. Apply restraints if the client becomes agitated D. Administer pantoprazole as prescribed E. Reposition the endotracheal tube to the opposite side of the mouth daily
A, D, E B is incorrect because ventilator checks should be done every 8 hours C is incorrect because a client who becomes agitated or restless might be experiencing air hunger. The nurse should assess the flow settings. If the client continues to be restless or agitated, a chemical restraint, such as midazolam, may be administered. Physical restraints are a last resort and only applied to prevent accidental dislodgment of the endotracheal tube.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless and apneic. Which of the following actions is the nurse's priority? A. Defibrillation B. Airway management C. Epinephrine administration D. Amiodarone administration
A. Defibrillation The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.
A nurse is an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A. First-degree AV block B. Atrial fibrillation C. Sinus bradycardia D. Sinus tachycardia
B
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? A. Defibrillation B. Elective cardioversion C. CPR D. Radiofrequency catheter ablation
B
A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? A. Bradycardia B. Pulmonary embolism C. Peripheral vascular Disease D. Hypertension
B
A patient is apnea and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next? A. Give atropine per agency dysrhythmia protocol. B. Start cardiopulmonary resuscitation (CPR) C. Perform synchronized cardioversion D. Apply supplemental O2 via non-rebreather mask
B
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? A. Insertion of a mini-tracheostomy B. Endotracheal intubation and positive pressure ventilation C. Initiation of continuous positive pressure ventilation (CPAP) D. Administration of 100% O2 by non-rebreather mask
B
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia has become increasingly agitated. Which action should the nurse take first? A. Offer reassurance and reorient the patient B. Use pulse oximetry to check the oxygen saturation C. Give the prescribed PRN sedative drug D. Notify the health care provider about the patient's status
B
The nurse is caring for a client who was receiving IV fluid at 125 mL/hr and now has a BP of 90/60. The nurse notices the IV was turned off accidentally. What is the priority action by the nurse? A. Call the doctor B. Begin the IV again at 125 mL/hr and continue to monitor blood pressure C. Begin TPN therapy for more volume D. Obtain an order for a blood transfusion
B
The nurse is caring for an older patient who was hospitalized 2 days earlier with community acquired pneumonia. Which assessment information is most important to communicate to the health care provider? A. Persistent cough of blood tinged sputum B. Oxygen saturation 90% on 100% O2 by non-rebreather mask C. Temperature 101.5 F (38.6 C) after 2 days of IV antibiotics D. Scattered crackles in the posterior lung bases
B
Which of these nursing actions by the LPN for a client who is in protective isolation following chemotherapy indicates a need for immediate intervention by the charge nurse? A. The LPN refuses to take in a moist potted plant to the client B. The LPN delivers a fruit tray including apples, pears, and bananas to the client C. The LPN requires UAP to practice effective hand hygiene when providing care to the client D. The LPN notifies the healthcare provider that the client's temperature is 100.8 F
B
Which of these statements made by a client receiving external radiation therapy indicates a need for further teaching? A. "I will notify the provider if I have difficulty swallowing." B. "I will expose the radiated area to sunlight to help the skin heal." C. "I can use prescribed lotions on the radiated area." D. "I must leave the ink or dye markings on my skin."
B
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet
B A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction.
The nurse is caring for a client who complains of a severe headache, stiff neck and fever. The nurse's assessment reveals a positive Kerning and Brudzinski's signs. Which of the following actions should the nurse do first? A. Administer ordered antibiotics B. Implement droplet precautions C. Educate the client about the condition and treatment plan D. Decrease bright lights
B It's giving meningitis and could be bacterial. Want to decrease the risk of spreading to both yourself and other patients.
A client presents to the emergency department with a 3-day history of nausea, headache and stiff neck. Nursing assessment reveals a rash on the client's lower extremities. Vital signs: BP 142/88, temperature 102.2 F, heart rate 100 and respirations 22. What is the priority nursing action? A. Place the client in a darkened room to decrease stimuli B. Place the client on droplet precautions C. Apply ointment to the client's rash D. Administer prescribed pain medications
B It's giving meningitis. Could be bacterial.
A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse? A. Bounding pulsations B. Irregular pulsations C. Tachycardia D. Bradycardia
B PVCs are early ventricular depolarizations with a pause immediately afterwards. That pause in the usual heart rhythm results in an irregular force and rate on palpation of a peripheral pulse and an irregular beat on auscultation of the apical pulse. PVCs have a wide variety of causes. Clients typically perceive them as "palpitations" and can feel lightheaded if they occur frequently.
A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? A. The client cannot travel by air due to security screening B. The client should hold his cell phone on the side opposite the ICD C. The client should avoid the use of small electric devices D. The client can carry his ICD in a small pocket
B The client should keep his cell phone on the side opposite the ICD, as close proximity could interfere with the ICD's function.
An older adult patient arrives in the emergency department after falling off a roof. The nurse observes "sucking inward" of the loose chest area during inspiration and a "puffing out" of the same area during expiration. Arterial blood gasses (ABG) results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for? A. Chest tube insertion B. Endotracheal intubation C. Needle thoracostomy D. Tracheostomy
B They ain't breathing This is our first temporary advanced airway Tracheostomy for long term (longer than 7 days)
A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take? A. Obtain the client's blood glucose every 12 hours B. Change the IV tubing every 24 hours C. Change the IV site dressing every 4 days D. Weigh the client every other day
B This is to prevent bacteria from developing in the tubing A is incorrect because the nurse should obtain BG every 4 hours C is incorrect because the client's IV site dressing should be changed every 48 to 72 hours D is incorrect because the patient should be weighed daily
The nurse is caring for a client who sustained a spinal cord injury four days ago and now has quadriplegia. What assessments are priority in preventing pressure injuries? Select all that apply A. Auscultate the client's heart and lung sounds B. Assess bony prominences for actual or potential skin breakdown C. Complete the Braden Scale every shift D. Assess the client's total protein, albumin, and pre albumin levels E. Assess the client for constipation and urinary retention
B, C, D
A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? Select all that apply. A. Encourage a high fiber diet B. Eliminate standing water in the room C. Have a client wear a mask when leaving the room D. Have client-specific equipment remain in the room E. Eliminate raw foods from the client's diet
B, C, D, E These are all neutropenic precautions
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply) A. Confusion B. Bradycardia C. Hypotension D. Nonreactive dilated pupils E. Slurred Speech
B, D A & E are EARLY signs of ICP C is just straight incorrect. Severe hypertension is one of the three findings of Cushing's triad
A patient on a telemetry unit develops atrial fibrillation, rate 150, with associated dyspnea and chest pain. Which action should the nurse do first? A. Obtain a 12-lead ECG B. Assess the patient's blood pressure and discomfort level C. Apply supplemental O2 at 8 L/min via nasal cannula D. Notify the health care provider of the change in rhythym
C
After receiving change of shift report on a medical unit, which patient should the nurse assess first? A. A patient with cystic fibrosis who has thick, green-colored sputum B. A patient with emphysema who has an oxygen saturation of 90% to 92% C. A patient with sepsis who has intercostal and suprasternal retractions D. A patient with pneumonia who has crackles bilaterally in the lung bases
C
After starting IV access, what is best for the nurse to document immediately after the procedure? A. Type, amount, and flow rate of IV fluid. Condition of the IV site B. The type of IV fluid hung and equipment used C. The date, time, venipuncture site, type, the gauge of the catheter, and IV fluid hung D. The type of catheter used and the number of venipuncture attempts
C
An older adult is having frequent and severe chemotherapy-induced nausea and vomiting that seems to be anticipatory and acute. Which assessment is the most important to make? A. Fears and feelings associated with chemotherapy B. Patient's self-management of distressing symptoms C. Signs of dehydration or electrolyte imbalance D. Willingness to try complementary or alternative therapies
C
The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of thefollowing pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm
C
The nurse is taking a history and vital signs on a patient who has come to the clinic for a routine checkup. The patient has a pulse rate of 50 beats/min and denies any distress. What action does the nurse do next? A. Establish IV access B. Give supplemental oxygen C. Check blood pressure D. Complete the health history
C
The registered nurse (RN) in the intensive care unit is caring for a patient who is in acute respiratory failure. What nursing action can the registered nurse delegate to the licensed practical nurse (LPN)? A. Place patient in the prone position B. Assess breath sounds every hour C. Obtain arterial blood gases D. Insert an indwelling urinary catheter
C
The nurse completed health promotion teaching for a client at risk for developing lung cancer. Which statement by the client requires follow up by the nurse? A. "My mother who has been smoking for the past 40 years should have an annual CT scan." B. "I am less likely to get lung cancer since I have never smoked cigarettes." C. "I should have my house equipped with functioning carbon monoxide detectors." D. "I need to let my healthcare provider know if I have a cough that won't go away."
D
The nurse is caring for a patient in the emergency department with thoracic trauma from a motor vehicle collision. The patient is restless, confused, and agitated. The patient's ABG results are the following: pH - 7.30, PaCO2 - 59, PaO2 - 66, HCO3 - 28. Based on the ABG interpretation, what is the priority nursing action? A. Obtain a full set of vital signs and assess for pain B. Administer normal saline 0.9% at 100 mL/hour C. Administer oxygen 2L/in via nasal cannula D. Call healthcare provider and prepare to intubate
D
Which nursing action is most important for the nurse to implement to prevent nausea and vomiting in a client who is prescribed intravenous (IV) chemotherapy? A. Keep the client NPO while the chemotherapy is infusing B. Assess the client for manifestations of dehydration hourly during the infusion period C. Ensure that the chemotherapy is infused over a 4-to-6 hour period D. Administer antiemetic drugs before administering chemotherapy
D
A nurse is caring for a patient who is receiving mechanical ventilation via endotracheal tube. Which of the following actions should the nurse take? A. Apply mittens if self-extubation is attempted B. Perform oral care once per shift C. Monitor ventilator settings as needed D. Document tube placement in centimeters at the lips
D A is incorrect because soft restraints should be used, not mittens B is incorrect because oral care should be every 2 hours C is incorrect because ventilator settings should be checked every 8 hours against the computer
A nurse is caring for a client who is receiving a continuous IV infusion through a short-peripheral device. Which of the following actions should the nurse take? A. Ensure the client's IV solution is changed every 48 hours B. Replace the client's transparent IV dressing every 24 hours C. Check the client's IV site every 8 hours D. Change the client's IV tubing every 96 hours
D A is incorrect because the nurse should change the IV solution every 24 hours to reduce the risk of infection B is incorrect because the dressing should every 96 hours C is uncorrected because the nurse should check the client at least every 4 hours to monitor the IV insertion site for infection, phlebitis, or infiltration and to monitor the client's fluid status
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness
D ICP is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.
The nurse is caring for a patient who was extubated 30 minutes ago. What is an expected assessment finding? A. Stridor B. Dyspnea C. Restlessness D. Hoarseness
D It would make sense to me since they just had a tube shoved down their throat for who knows how long.
A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25%
D It's an osmotic diuretic that lowers ICP by promoting diuresis
A patient started on total parenteral nutrition (TPN) is complaining of thirst and states he has urinated 4 times over the past hour. Which action by the nurse is a priority? A. Obtain a urine specimen for culture and sensitivity B. Notify the provider C. Immediately stop the TPN infusion and notify the provider D. Check capillary glucose levels
D My dude is giving hyperglycemia
A nurse in the ED is caring for a client with jaw pain, heart pain, and nausea. What is the priority nursing action? A. Obtain a stat ECG B. Obtain a blood sample C. Start an IV D. Administer 2L oxygen via nasal cannula
D Remember ABC's! Oxygen first. Then place on a cardiac monitor. Place an IV and draw labs together.
What action should the nurse taken when witnessing a possible blood transfusion reaction? (Select all that apply) A. Send the blood bag and tubing to the blood bank for analysis B. Stop the transfusion C. Notify the primary care provider D. Maintain an IV infusion with 0.9% sodium chloride E. Check vital signs F. Obtain blood cultures
Everything but F
