a.
2. Request the client’s reserved unit if packed red blood cells. A male client with stomach cancer returns to the unit following a total
... [Show More] gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a.
b. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer’s solution.
Add sterile water to the suction control chamber.
3. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? a.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal.
4. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client’s fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
5. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)
Headache and tremors
a.
Irregular heart rate
b.
c. Skin hyperpigmentation
d. Postural hypotension
Pallor and diaphoresis
e.
6. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
Skin tenting occurs when the client’s forearm is pinched.
d.
File a detailed incident report with the specific hiring facility.
7. After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a.
b. Warn the colleague that their actions are unprofessional.
c. Comment anonymously about the action of a staf discussion board.
d. Communicate the colleague’s actions to the unit charge nurse.
8. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is efective?
a. At-risk clients received an increased number of routine health screenings.
Clients who incurred disease complications promptly received rehabilitation.
b. Clients reported having new confidence in making healthy food choices. c.
d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
9. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client’s bilateral lung sounds and oxygen saturation.
Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
c. Notify the healthcare provider about the client’s distress. d.
10. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?
“When I get out of bed quickly, I feel a little dizzy.”
a.
b. “The dressing over my incision feels like it is too tight.”
c. “I’m most comfortable when the head of the bed is raised.”
d. “This IV infusion makes me urinate more often than usual.”
11. An older adult male who is in his early 70’s is admitted to the emergency department because ofa COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which action should the nurse take?
a. Facilitate a family meeting with the palliative care team.
b. Notify the healthcare provider of the client’s wishes.
c. Place a certified copy of the living will in the client’s record.
d. Alert the nursing staf of the client’s don’t resuscitate status.
12. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?
a. Determine the client’s level of mobility and need for assistance.
Advice the client to maintain bedrest so that safety can be ensured.
b. Instruct the UAP that all clients deserve equal care. c.
d. Assign another UAP to care for the client.
13. A nurse determines that more than 25% of the students at a middle school are overweight. Thenurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents’ degree of concern about their children’s weight.
14. After several months of chronic fatigue, morning stifness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone?
a. Take prednisone doses before meals on an empty stomach.
If sequential doses are missed, notify the healthcare provider.
b. Wear sunglasses when exposed to bright sunlight. c.
d. Schedule a monthly laboratory visit for a complete blood count.
15. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires thenurse’s immediate attention?
a. A 16-year-old client diagnosed with major depression who refuses to participate in group.
b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
16. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
a. Positive Epstein-Barr, and malaise.
b. Ear pain and fever.
c. Elevated WBC and sedimentation rate.
d. Increased BUN and serum creatinine.
17. A client arrives for an annual physical exam and complains of having calf pain. The client’s healthhistory reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms?
a. Were your legs ever suddenly swollen, red, warm, and painful? b. Does the calf pain occur when walking short distances? c. Did you receive treatment for weeping ulcers on lower legs?
d. Have you experienced ankle edema and varicose veins?
18. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure?
a. Drank a glass of water in the past 2 hours.
b. Reports left chest wall pain prior to admission.
c. Verbalize a fear of being in a confined space.
d. Experience facial swelling after eating crab.
19. The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?
a. Keep the nails trimmed short.
Apply baby lotion to the skin twice daily.
b.
c. Bathe the child daily with bath oil.
d. Allow the child to wear only 100% cotton clothing.
20. A new mother on the postpartum unit runs out of the room screaming that her newborn infant’scrib is empty and the baby is missing. What action should the nurse take first?
a. Determine if the newborn is in the nursery.
b. Activate the lockdown procedure.
c. Ask the mother if any visitors were expected to arrive.
d. Match ID bands of all infants and mothers on the unit.
21. While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask?
a. “Do you often have feeling of sadness?”
b. “Are you having problems concentrating?”
“Have you though about taking your life?”
c.
d. “What problems are you facing right now?”
22. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “kill, kill.” What question should the nurse ask the client next?
a. “When did these voices begin?”
b. “Have you taken any hallucinogens?”
“Are you planning to obey the voices?”
c.
d. “Do you believe the voices are real?”
23. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?
a. The client will express acceptance of their newly diagnosed health status.
b. The nurse will encourage the client to walk thirty minutes everyday.
c. The client’s blood pressure readings will be less than 160/90 mmHg.
d. The client’s skin on the lower legs will be intact at the next clinical visit.
. Fruits without sauce
24. When conducting diet teaching for a client who was diagnosed with hypertension, which foodshould the nurse encourage the client to eat? (select all that apply.) a.
b. Canned soup.
Fresh or frozen vegetables without sauce.
c.
d. Cottage cheese.
e. Pickled olives.
25. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication tothe nurse that the client is experiencing a therapeutic response to the phenytoin?
a. Increased time of ambulation between periods of rest.
b. Decrease in intracranial pressure and cerebral edema.
c. Absence of seizure activity for the duration of treatment.
d. Normal electroencephalogram after drug administration.
26. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely?
(Select all that apply)
a. Brings a heavy can close to body before lifting.
b. Locks knees while preparing food on the counter.
c. Widens stance while working near the sink.
d. Bends from the waist to pick trash of the floor.
e. Leans forward to pull a pan from a high shelf.
27. An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first?
a. Document neurologic changes.
b. Reduce environmental stimuli.
c. Administer prescribed neuroleptic.
d. Review medications for interactions. [Show Less]