NURSING 265 exam 2 Questions with Answers
1. The nurse is assessing a client who is suspected of having a pulmonary embolism (PE). Which of the following
... [Show More] findings is consistent with this diagnosis?
• Cough
2. The nurse is caring for a client who is 4 days postoperative and suddenly develops difficulty breathing and sharp chest pain. The nurse has called the rapid response team (RRT), raised the head of the bed (HOB), and applied oxygen to the client. Which actions from the box below should the nurse take next?
o Auscultate the client’s lung sounds.
o Initiate continuous cardiac monitoring.
o Prepare to administer intravenous (IV) alteplase.
o Connect the client to a continuous pulse oximeter.
o Apply bilateral antiembolism stockings to the legs.
o Assess the client’s skin color.
• 1, 2, 4, 6
3. The nurse has provided discharge teaching to a client who developed a pulmonary embolism (PE) following a surgical procedure. The client will be taking newly prescribed warfarin at home. Which of the following client statements indicates a correct understanding of the teaching?
• I should avoid anything rectally, such as enemas or suppositories.
4. The nurse is caring for a client who appears to have developed a pulmonary embolism (PE). Which of the following arterial blood gas (ABG) results would the nurse expect the client to initially have?
• Ph = 7.50; PaO2 = 79mm Hg; PaCO3 = 32 mm Hg; HCO3 = 23 mEq/L; SaO2 = 88%
5. The nurse is caring for the following assigned clients. The nurse should first see the client who has?
• Received a heparin infusion for the last 10 days and has a platelet count of 90,000
6. The nurse is caring for a client who has a chest tube. Which assessment findings from the box below requires the nurse to immediately notify the primary health care provider (PHCP)?
a. Continuous bubbling in the suction control chamber
b. Tracheal deviation
c. Tidling in the water seal chamber with breathing
d. 100 mL of drainage within an hour
e. Visibility of the eyelets of the chest tube
f. Low water level in the water seal chamber
• 2, 4, 5
7. The nurse is assessing a client who had a chest tube placed 36 hours ago for the treatment of a pneumothorax. The nurse observes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?
• Inform the primary health care physician (PHCP) that there is a leak in the system
8. The nurse working in the emergency department (ED) is caring for a client who was in a boating crash 3 hours ago and has the following data: The nurse concludes that the client is developing?
a. Reports a headache
b. Restless and irritable
c. (ABG) pH: 7.28, PaO2 60mm Hg, PaCO2 52 mm Hg, HCO3 24 mEq/L, SaO2 84%
d. Pulse 110
e. Respirations 10 and dyspneic
f. Blood pressure 145/86 mm Hg
• Acute respiratory failure (ARF)
9. The nurse is assessing clients for the risk of developing acute respiratory distress syndrome (ARDS). The nurse should identify at greatest risk the client who?
• Has sepsis and is receiving nutrition via continuous tube feeding
10. The nurse working on a medical surgical unit is caring for assigned clients. It indicates appropriate clinical judgement if the nurse initially assesses the client who has?
• An arterial oxygen (PaO2) level of 59 mm Hg while receiving 100% oxygen
11. The nurse is caring for a client who developed acute respiratory distress syndrome (ARDS) and has been placed on mechanical ventilation. Which of the following is a priority action for the nurse to take?
• Obtain a special bed that will turn the client
12. The nurse has attended a continuing education program on interdisciplinary care. It would indicate a correct understanding of the program if the nurse identifies that an interdisciplinary conference would be most important for the client who is
• 21-year-old, is a college student, and has been receiving mechanical ventilation for 14 days for the treatment of acute respiratory distress syndrome (ARDS)
13. The nurse working in the emergency department (ED) is assessing a client who has a left pneumothorax. Which of the following assessment findings should the nurse expect?
• Limited chest expansion
14. The nurse is caring for a client who is receiving mechanic ventilation. It indicates a correct understanding about managing a client on a ventilator if the nurse
• Determines if the client needs to be suctioned when the high-pressure alarm sounds
15. The nurse is caring for a client who is receiving mechanical ventilation via an endotracheal (ET) tube and is unable to speak. The client’s family is frightened that the client has permanently lost their voice. Which of the following responses should the nurse make?
• The tube is causing a temporary loss of the voice
16. The nurse has been made aware of the following client situations. The nurse should
initially follow up with the client who is receiving.
• mechanical ventilation with PEEP and develops left tracheal deviation.
17. The nurse is reviewing chest radiography (x-ray) results on an assigned client. The x-ray reveals 3 rib fractures. Based on these findings, the nurse should
• Place suction set up at the bedside
18. The nurse is caring for a client who has been admitted for suspected diabetes insipidus (DI). Which of the following assessment findings is a priority for the nurse to follow-up on?
• Bounding peripheral pulses with a decrease in thirst
19. The nurse has taught a client who has diabetes insipidus (DI) about self-care at home. Which of the following client statements indicates the need for further teaching?
• I will test urine daily for positive ketones and report any findings.
20. The nurse is providing discharge instructions to a client who has permanent diabetes insipidus. Which of the following client statements would indicate a correct understanding of discharge instructions?
• I should report if I develop increased thirst or urination.
21. The nurse caring for a client who has developed diabetes insipidus (DI). Which of the following should the nurse correlate to the development of this condition?
• Recent craniotomy
22. The nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a serum sodium level of 114 mEq/L. Which of the following actions is most important for the nurse to take?
• Reduce environmental noise and lighting
23. The nurse is reviewing the below data for a client who has syndrome of inappropriate antidiuretic hormone (SIADH): Which of the following actions should the nurse take first?
a. Chief complaint: fell and hit head 2 days ago
b. Neurological status: reports a dull headache, drowsy
c. Temperature: 97.8 F
d. Pulse: 100
e. Respirations: 18
f. Blood pressure: 140/95 mm Hg
g. Sodium level: 120 mEq/L
h. 24-hour intake: 3500 mL
i. 24-hour output: 1500 mL
• Perform a complete neurological assessment
24. The nurse is performing a health history on a 45-year-old female client who is suspected of having Cushing’s syndrome. Which of the following questions is a priority for the nurse to ask the client?
• What prescribed medications do you take?
25. The nurse has taught a client who has Cushing’s disease about changes in dietary habits. Which of the following meal choices indicates a need for further teaching?
• Bacon, lettuce, and tomato sandwich on wheat toast and a glass of apple juice
26. The nurse is assessing clients for the risk of developing Cushing’s syndrome. The nurse should identify of greatest risk the client who is a
• 44-year-old female and has frequent exacerbations of chronic obstructive pulmonary disease (COPD).
27. The nurse working in the emergency department (ED) is caring for a client who has Addison’s disease and was brought in by emergency medical services (EMS). The client has the following admission date: which of the following actions by the nurse is priority?
a. Temperature: 101.8 F
b. Pulse: 64
c. Respirations: 22
d. Blood pressure: 94/56 mm Hg
e. ECG: Atrial fibrillation (AF)
f. Potassium level: 6.2 mEq/L
g. Sodium level: 122 mEq/L
h. Reports of nausea
• Initiate an infusion of 20 units of regular insulin with 20 mg of dextrose in normal saline (NS).
28. The nurse is caring for a client who has adrenal insufficiency and is experiencing an exacerbation. Which of the following actions should the nurse plan to take?
• Monitor the client’s sodium level
29. The nurse is caring for a client who was admitted with a pheochromocytoma. Which of the following assessment findings should the nurse expect in this client?
• Palpitations
30. The nurse preceptor is observing a newly hired nurse care for a client with suspected pheochromocytoma. Which of the following actions by the newly hired nurse requires the nurse preceptor to intervene?
• Avoid palpitating and percussion of the client’s abdomen
31. The nurse is assessing a client who has Grave’s disease and notes that the client’s temperature has increased by 1 F. After notifying the primary health care physician (PHCP), the nurse should first
• Administer prescribed oral anti-thyroid
32. The nurse has instructed a male client who has hyperthyroidism and is scheduled to receive radioactive iodine (RAI) therapy. Which of the following client statements indicates a correct understanding of the instructions?
• I will use disposable tissues rather than a cloth handkerchief
33. The nurse is caring for a client who is 12 hours postoperative from a total thyroidectomy and has developed stridor. Which of the following actions should the nurse take?
• Prepare the client for an emergency tracheostomy
34. The nurse has instructed a female client who has hyperthyroidism about a newly prescribed medication, methimazole. Which of the following client statements indicates a need for further teaching?
• I might have heat intolerance or hot flashes while taking this medication
35. The nurse has become aware of the following client situations. It would be a priority for the nurse to follow up with the client who
• Had a subtotal thyroidectomy 12 hours ago and reports tingling of the fingers
36. A patient presents with these signs. Which of the following should the nurse suspect that the client is experiencing?
a. Difficulty with memory
b. Facial edema
c. Dry skin
d. Amenorrhea
e. Pulse: 60
f. Decreased peripheral pulses
g. Blood glucose: 64 mg/dL
h. Sodium level of 135 mEq/L
i. Weight gain of 5 lbs in 1 week
• Myxedema coma
37. The nurse is caring for a client who was recently diagnosed with hypothyroidism and is receiving the initial doses of levothyroxine. During the initiation of this medication therapy, it is a priority for the nurse to assess the client for the development of
• Chest pain and dyspnea
38. The nurse is teaching a client who has hypothyroidism about self-management. Which of the following should the nurse include in the teaching plan?
• Avoid the use of any fiber supplements with thyroid replacement medications
39. The nurse is developing a plan of care for a client who has hyperparathyroidism and an increased calcium level of 12.0 mg/dL. Which of the following prescriptions should the nurse question?
• Hydrochlorothiazide 25 mg IV twice a day.
40. The nurse is caring for a client who has hyperparathyroidism. It requires follow-up if the client
• Develops epigastric pain
41. The nurse is providing care to a client who has hypoparathyroidism and has developed a positive Trousseau’s sign. Which of the following actions is a priority for the nurse to take?
• Implement seizure precautions for the client
42. The nurse is admitting a client who has hyperglycemic hyperosmolar state (HHS). Which of the following complications is the client at increased risk for developing?
• Dehydration
43. The nurse is caring for a client who is being treated for hyperglycemic hyperosmolar state (HHS). The client has been receiving intravenous normal saline (NS) and is now adequately rehydrated. Which of the following interventions should the nurse be prepared to implement next?
• Initiate a prescribed insulin drip
44. The nurse is preparing to administer a regular insulin iv bolus to a client who has HHS. The primary health care provider has prescribed an initial dose of bolus 0.1 units/kg. the client weighs 120lb. how much regular insulin should the nurse administer to the client as an IV bolus.
• 5 units
45. The nurse is caring for a client who is being treated for HHS. Which of the following findings indicates to the nurse that treatment needs to be adjusted?
• Serum osmolarity
46. The nurse is reviewing prescriptions for newly admitted clients. It would require immediate follow-up by the nurse if the PHCP prescribed?
• 3% normal chloride at 100ml/hr. for a client receiving treatment for HHS.
47. The nurse is caring for a client who has DKA. Which of the following should the nurse expect to assess in the client?
• ABG results of PH 7.22, PaCO2 42, HCO3 15. (metabolic acidosis)
48. The nurse is teaching a client who is newly diagnosed with diabetes mellites type 1 about sick day rules. Which of the following instructions from the box below should the nurse include?
a. Check blood glucose levels q 4hrs.
b. Hold insulin injections if vomiting occurs
c. Get plenty of rest and sleep
d. Drink 8-12 ounces of sugar free liquids everyday while awake
e. Attempt to eat meals at regular times
f. Test urine for ketones with every void if blood glucose is greater than 200.
• 1,3,4,5
49. Which of the following actions should the nurse take next, with findings?
a. Blood pressure 90/60
b. Urine output 160 ml/8hrs
c. Potassium level 5.3
d. Blood glucose 350
e. Increase IV fluid rate to 10ml/kg/hr.
• Increase rate of the IV fluids as prescribed
50. The nurse has provided discharge instructions to a client who is postoperative from a transsphenoidal hypophysectomy. Which of the following client statements indicates a need for further teaching?
• I will wash the incision everyday with hydrogen peroxide and cover with a dressing. [Show Less]