practice questions - final
A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside? 1) Bag valve mask device 2) Defibrillator machine 3) Chest tube equipment 4) Central venous catheter tray
1) Bag valve mask device
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) (Select All that Apply.) Absence of bowel sounds Difficulty regulating body temperature Hypotension Polyuria Weakened gag reflex Respiratory complications
difficulty regulating body temperature, hypotension, weakened gag reflex, respiratory complications
2. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) (Select All that Apply.) Bradycardia Deep respirations Dyspnea Barrel chest Clubbing of the fingers
dyspnea, barrel chest, clubbing of the fingers
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? 1) "Large incisions will be made in the eschar to improve circulation." 2) "This procedure involves placing the client into a shower and removing the dead tissue." 3) "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." 4) "Dead tissue will be non-surgically removed."
1) "Large incisions will be made in the eschar to improve circulation."
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?pH 7.22PaCO2 68 mm HgBase excess -2PaO2 78 mm HgSaturation 80%Bicarbonate 26 mEq/L 1) Respiratory acidosis 2) Metabolic acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis
1) Respiratory acidosis
the nurse should use the Rule of Nines to estimate the percentage of burned surface area:
Head 9% Torso 36% (front 18% and back 18%) Arm 9% eachLeg 18% Perineum 1%
11. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?pH 7.22PaCO2 68 mm HgBase excess -2PaO2 78 mm HgSaturation 80%Bicarbonate 26 mEq/L 1) Respiratory acidosis 2) Metabolic acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis
1) Respiratory acidosis
22. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? 1) Urticaria 2) Stridor 3) Vomiting 4) Hypotension
2) Stridor
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? 1) Calcium 2) RBC count 3) Magnesium 4) Amylase
4) Amylase
35. 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.) (Select All that Apply.) Severe dyspnea Nausea Decreased level of consciousness Hypotension Bradycardia Decreased pulse oximetry
Answer: severe dyspnea, decreased LOC, hypotension, hypotension, decreased pulse oximetry
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? 1) "These tests help determine if there is damage to the heart tissues." 2) "Cardiac enzymes will identify the location of the MI." 3) "These tests will enable the provider to determine the heart structure and mobility of the heart valves." 4) "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."
1) "These tests help determine if there is damage to the heart tissues."
A nurse is reviewing the EKG strip of a client who has CKD. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hyperkalemia? 1) A peaked T wave 2) Depressed ST segment 3) An irregular heart rate 4) Inverted P wave
1) A peaked T wave
26. A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? 1) Airway protection 2) Decreasing intracranial pressure 3) Stabilizing cardiac arrhythmias 4) Preventing musculoskeletal disability
1) Airway protection
27. A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? 1) Breathing ranging from very deep to very shallow with periods of apnea 2) Shallow to normal breaths alternating with periods of apnea 3) Rapid respirations that are unusually deep and regular 4) An inability to breathe without dyspnea unless sitting upright
1) Breathing ranging from very deep
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? 1) Check the client's vital signs. 2) Request a dietitian consult. 3) Suggest that the client rests before eating the meal. 4) Request an order for an antiemetic.
1) Check the client's vital signs.
A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? 1) Decreased blood pressure 2) Increase of HDL cholesterol 3) Prevention of bipolar manic episodes 4) Improved sexual function
1) Decreased blood pressure
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? 1) Dehydration 2) Polyphagia 3) Hyperglycemia 4) Bradycardia
1) Dehydration
25. The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? 1) Evaluate chest expansion. 2) Check pupillary response to light. 3) Assess the capillary refill. 4) Check client's response to questions about place and time.
1) Evaluate chest expansion.
4. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? 1) Fluid imbalance 2) Infection 3) Airway obstruction 4) Paralytic ileus
1) Fluid imbalance
13. A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? 1) Increased respiratory rate from 18 to 44/min. 2) Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). 3) Increased blood pressure from 112/68 to 120/72 mm Hg. 4) Increased heart rate from 68 to 72/min.
1) Increased respiratory rate from 18 to 44/min.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? 1) Increased respiratory rate from 18 to 44/min. 2) Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). 3) Increased blood pressure from 112/68 to 120/72 mm Hg. 4) Increased heart rate from 68 to 72/min.
1) Increased respiratory rate from 18 to 44/min.
7. A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? 1) Movement of the trachea toward the unaffected side 2) Bubbling of the water in the water seal chamber with exhalation 3) Crepitus in the area above and surrounding the insertion site 4) Eyelets are not visible
1) Movement of the trachea toward the unaffected side
3. A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? 1) Prevent aspiration. 2) Ensure adequate nutrition. 3) Promote oral hygiene 4) Relieve the client's pain.
1) Prevent aspiration.
23. A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? 1) Provide high-flow oxygen. 2) Check the client for a positive Chvostek's sign. 3) Administer an IV vasopressor medication. 4) Monitor the client for headache.
1) Provide high-flow oxygen.
28. A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? 1) Respiratory acidosis 2) Respiratory alkalosis 3) Metabolic acidosis 4) Metabolic alkalosis
1) Respiratory acidosis
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? 1) Stop the infusion of blood. 2) Inform the provider. 3) Obtain a urine specimen. 4) Notify the laboratory.
1) Stop the infusion of blood.
33. A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? 1) Stridor 2) Copious oral secretions 3) Hoarseness 4) Sore throat
1) Stridor
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? 1) Suction two to three times with a 60-second pause between passes. 2) Perform chest physiotherapy prior to suctioning. 3) Lubricate the suction catheter tip with sterile saline. 4) Hyperventilate the client on 100% oxygen prior to suctioning.
1) Suction two to three times with a 60-second pause between passes.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? 1) Test the drainage for glucose. 2) Suction the nostril. 3) Notify the physician. 4) Ask the client to blow his nose.
1) Test the drainage for glucose.
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? 1) The client states having a severe headache. 2) The client's bladder becomes distended. 3) The client's blood pressure becomes elevated. 4) The client states having nasal congestion.
1) The client states having a severe headache.
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? 1) Turn the on their side. 2) Check the client's motor strength. 3) Loosen the clothing around the client's waist. 4) Document the time the seizure began.
1) Turn the on their side.
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? 1) pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg 2) pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg 3) pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg 4) pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
1) pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? 1) "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs." 2) "What do you think your spouse would have wanted?" 3) "Most religions support organ donation, so don't let that stand in the way." 4) "Don't you think you will feel a little better about the situation if you donate your spouse's organs?"
2) "What do you think your spouse would have wanted?"
16. A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? 1) Prepare for mechanical ventilation. 2) Administer oxygen via face mask. 3) Prepare to administer a sedative. 4) Assess for indications of pulmonary embolism.
2) Administer oxygen via face mask.
A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? 1) Glucose. 2) Ammonia 3) Potassium 4) Bicarbonate
2) Ammonia
31. A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? 1) Urinary output 25 mL/hr 2) Difficulty swallowing 3) Heart rate 122/min 4) Pain of 6 on a scale of 0 to 10
2) Difficulty swallowing
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? 1) BP 2) Heart rate 3) Urine output 4) Weight
2) Heart rate
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? 1) Transient ischemic attack (TIA) 2) Hemorrhagic stroke 3) Thrombotic stroke 4) Embolic stroke
2) Hemorrhagic stroke
15. A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms in a house fire. Which of the following is the priority action the nurse should take? 1) Insert an indwelling urinary catheter. 2) Inspect the mouth for signs of inhalation injuries. 3) Administer intravenous pain medication. 4) Draw blood for a complete blood cell (CBC) count.
2) Inspect the mouth for signs of inhalation injuries.
6. A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? 1) It decreases the client's level of anxiety. 2) It facilitates the client's deep breathing. 3) It enhances the client's ability to sleep. 4) It reduces the client's blood pressure.
2) It facilitates the client's deep breathing.
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? 1) It decreases the client's level of anxiety. 2) It facilitates the client's deep breathing. 3) It enhances the client's ability to sleep. 4) It reduces the client's blood pressure
2) It facilitates the client's deep breathing.
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? 1) Hyperactive bowel sounds 2) Nausea and vomiting 3) Bradycardia 4) Increased urinary output
2) Nausea and vomiting
19. A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? 1) Oxygen saturation of 95% 2) No fluctuations in the water seal chamber 3) No reports of pleuritic chest pain 4) Occasional bubbling in the water-seal chamber
2) No fluctuations in the water seal chamber
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? 1) Insert a tongue blade in the client's mouth. 2) Place the client on his side. 3) Hold the client's arms and legs from moving. 4) Place the client back in bed.
2) Place the client on his side.
A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? 1) Hemoglobin (Hgb) 2) Prothrombin time (PT) 3) Bleeding time 4) Activated partial thromboplastin time (aPTT)
2) Prothrombin time (PT)
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium and neuormuscular blocking agent. The nurse recognizes that this medication is for which of the following purposes? 1) Decrease chest wall compliance 2) Suppress respiratory effort 3) Induce sedation 4) Decrease respiratory secretions
2) Suppress respiratory effort
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? 1) The client complains of pain. 2) The client develops a life-threatening situation. 3) The client needs to have an x-ray of the femur performed. 4) The client has to be repositioned in the bed.
2) The client develops a life-threatening situation.
Which electrolyte can be affected by lisinopril and which direction? 1. hypernatremia 2. hyperkalemia 3. hypomagnesemia 4. hypercalcemia
2. hyperkalemia
A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first? 1) A client who needs assistance with a bath 2) A client requesting a referral for home health services 3) A client asking about his PCA pump that contains morphine 4) A client who has questions about his new prescription
3) A client asking about his PCA pump that contains morphine
A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective? 1) A decrease in blood sugar 2) A decrease in blood pressure 3) A decrease in urine output 4) A decrease in specific gravity
3) A decrease in urine output
A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? 1) An upper respiratory infection 2) Pulmonary edema 3) Atelectasis 4) Delayed gastric emptying
3) Atelectasis
20. A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first? 1) Observe for cerebrospinal fluid (CSF) leaks from the evacuation site. 2) Assess for an increase in temperature. 3) Check the oximeter. 4) Monitor for manifestations for increased intracranial pressure.
3) Check the oximeter.
A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?Sodium 152 mEq/L Glucose 102 mg/dLPotassium 3.6 mEq/L BUN 18 mg/dLChloride 105 mEq/L Creatinine 0.7 mg/dL 1) Renal failure 2) Low-protein diet 3) Dehydration 4) Syndrome of inappropriate antidiuretic hormone (SIADH)
3) Dehydration
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? 1) Cleanse the perineum from back to front. 2) Obtain a prescription for an indwelling urinary catheter. 3) Encourage fluid intake at and between meals. 4) Offer the client the bedpan every 2 hr.
3) Encourage fluid intake at and between meals.
14. 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? 1) Perform range-of-motion exercises 2) Place suction equipment at the bedside 3) Encourage the use of an incentive spirometer 4) Administer an expectorant
3) Encourage the use of an incentive spirometer
30. A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? 1) Furosemide 2) Dexamethasone 3) Heparin 4) Atropine
3) Heparin
17. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? 1) Serosanguineous drainage from the puncture site 2) Discomfort at the puncture site 3) Increased heart rate 4) Decreased temperature
3) Increased heart rate
24. A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? 1) Blockage of the ET tube by the client's tongue 2) Passage of the ET tube into the esophagus 3) Movement of the ET tube into the right main bronchus 4) Infection of the vocal cords
3) Movement of the ET tube into the right main bronchus
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia? 1) Position the head of the client's bed in the flat position. 2) Turn the client every 4 hr. 3) Provide mouth care and use an antimicrobial mouth wash every 4-6 hours 4) Provide humidity by maintaining moisture within the ventilator tubing.
3) Provide mouth care and use an antimicrobial mouth wash every 4-6 hours
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? 1) Administer diuretics. 2) Restrict the client's intake of fluids. 3) Reduce the client's intake of protein. 4) Administer vitamin K.
3) Reduce the client's intake of protein.
18. A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis
3) Respiratory acidosis
A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include? 1) The nurse caring for the client at the time of death requests organ donation. 2) Donation costs are the responsibility of the donor's family and estate. 3) The nurse may serve as a witness to informed consent for organ donation. 4) Clients are placed on artificial life support before organ and tissue donation can occur.
3) The nurse may serve as a witness to informed consent for organ donation.
34. A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? 1) Unequal pupils 2) Hypertension 3) Tympany upon chest percussion 4) Confusion
3) Tympany upon chest percussion
10. A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Continue to monitor the client as this is an expected finding. 2) Add more water to the suction control chamber of the drainage system. 3) Verify that the suction regulator is on and check the tubing for leaks. 4) Milk the chest tube and dislodge any clots in the tubing that are occluding it.
3) Verify that the suction regulator is on and check the tubing for leaks.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? 1) analgesic 2) anti-inflammatory 3) antiplatelet aggregate 4) antipyretic
3) antiplatelet aggregate
1. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) 1) Perform a Glasgow Coma Scale assessment. 2) Remove clothing for a thorough assessment. 3) Open the airway using a jaw-thrust maneuver. 4) Establish IV access 5) Determine effectiveness of ventilator efforts
3, 5, 4, 1, 2
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
31.5 %
A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? 1) "I can walk a mile a day." 2) "I've had a backache for several days." 3) "I am urinating more frequently." 4) "I feel nauseated and have no appetite."
4) "I feel nauseated and have no appetite."
21. A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? 1) A client who is scheduled for an abdominal x-ray and is awaiting transport 2) A client who has a prescription for discharge 3) A client who received oral pain medication 30 min ago 4) A client who told an assistive personnel he is short of breath
4) A client who told an assistive personnel he is short of breath
8. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? 1) Raise the foot of the bed to a 90° angle. 2) Remove the dressing to inspect the wound. 3) Prepare to insert a central line. 4) Administer oxygen via nasal cannula.
4) Administer oxygen via nasal cannula.
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? 1) Serosanguineous drainage 2) Mild erythema 3) Warmth 4) Fever
4) Fever
32. A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? 1) Intracranial pressure 2) Spinal cord perfusion 3) Renal function 4) Hemodynamic status
4) Hemodynamic status
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? 1) Paresthesia 2) Hemiplegia 3) Quadriplegia 4) Paraplegia
4) Paraplegia
9. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? 1) Obtain a cardiology consult. 2) Suction the client less frequently. 3) Administer an antidysrhythmic medication. 4) Perform pre-oxygenation prior to suctioning.
4) Perform pre-oxygenation prior to suctioning.
29. A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? 1) Administer low-flow oxygen continuously via nasal cannula. 2) Encourage oral intake of at least 3,000 mL of fluids per day. 3) Offer high-protein and high-carbohydrate foods frequently. 4) Place in a prone position.
4) Place in a prone position.
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)? 1) Tachycardia 2) Amnesia 3) Hypotension 4) Restlessness
4) Restlessness
A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed? 1) Prone 2) On the nonoperative side 3) supine 4) Semi-Fowler's
4) Semi-Fowler's
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? 1) The client who has a tracheostomy tube attached to humidified oxygen 2) The client who has an indwelling urinary catheter to gravity drainage 3) The client who has a chest tube to water seal 4) The client who has a nasogastric (NG) tube to suction
4) The client who has a nasogastric (NG) tube to suction
12. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? 1) The client who has been NPO since midnight for endoscopy. 2) The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. 3) The client who has end-stage renal failure and is scheduled for dialysis today. 4) The client who has gastroenteritis and is febrile.
4) The client who has gastroenteritis and is febrile.
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? 1) pulse and blood pressure findings 2) behavioral indicators and effect 3) scheduled treatments and client illness 4) a self-report pain rating scale
4) a self-report pain rating scale
Which disease process would the doctor most likely dc ace inhibitors. 1. Gout 2. Afib 3. Hyperthyroidism 4. CKD
4. CKD
5. A nurse is caring for a client who is unconscious and has a glucose level of 850. The patient has a breathing pattern characterized by rapid respirations that are unusually deep and regular. The nurse should document that the client has which of the following respiratory alterations? 1) Kussmaul respirations 2) Biot's respirations 3) Cheyne-Stokes respirations 4) Stridor
Kussmaul respirations
