Nursing 428 Trends Exit Exam Questions & Answers
1. The nurse assesses a client one hour after starting a transfusion of packed RBC and determines
... [Show More] that there are no indicators of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel UAP who is working with the nurse?
a. Notify the nurse when the transfusion has finished, so further client assessment can be done
b. Monitor the client carefully for the next three hours and report the onset of the reaction immediately
c. Continue to measure the client’s vital signs every thirty minutes until transfusion is complete
d. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
2. An older client is brought to the clinic for appointment by a grandson. The client is withdrawn and allows the grandson to answer the nurse’s questions. The nurse observes the grandson makes frowning facial expressions and shakes his head sighing when speaking to the client. Which action the nurse take next?
a. Ask the client if an assisted living facility has been considered
b. Request social services to make a home visit
c. Interview the client privately without the family member present
d. Complete a neurological and musculoskeletal assessment
3. The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected?
a. Skin of palms of the hand
b. Current height and weight c. Condition of tooth enamel
d. Length of the last menses
4. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-guage needle. Which action should the charge nurse implement?
a. Prompt the nurse to apply povidone to the site
b. Suggest the nurse use a 20-guage needle
c. Direct the nurse to change the IV tubing d. Instruct the nurse to remove the needle
5. After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? SATA
a. Location of the initial IV site
b. Swollen lymph nodes in the groin c. White blood cell count (WBC)
d. Core body temperature
e. Red blood cell count (RBC)
6. A client has an abdominal wound dehiscence when the surgical staples are removed. What intervention should the nurse implement first.
a. Place the client in protective (reverse) isolation
b. Notify the surgeon immediately
c. Place a saline dressing over the wound
d. Assess the client’s bowel sounds
7. After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client ‘s serum creatinine is 0.3mg/dL (22.9 micro….). which action should the nurse implement?
a. Assess the client for signs of hypokalemia
b. Initiate the urine collection as prescribed
c. Notify the healthcare provider of the results
d. Evaluate the client’s serum BUN level
8. The nurse is preparing to administer histamine 2 -receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug?
a. Destroys microorganisms causing stomach inflammation
b. Neutralizes hydrochloric acid (HCl) in the stomach
c. Inhibits action of acetylcholine by blocking parasympathetic nerve endings d. Decreases the amount of HCI secretion by the parietal cells in the stomach
9. The nurse is working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse do first?
a. Assess the level of consciousness and vital signs for both clients
b. Complete a head-to-toe assessment of the client with pneumonia
c. Change the surgical dressing to observe the appearance of the incision
d. Review the plan of care and the medications that are due to both clients
10. Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?
a. An adult client in remission after a series of chemotherapy treatments who is receiving intramuscular iron injections for anemia
b. A middle-aged male client who has just undergone an excisional biopsy and has been told that his tumor appears to be benign
c. A young adult client who is experiencing fatigue while undergoing a series of external beam radiation treatments for stage one cancer
d. An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease Control
11. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?
a. Peripheral edema
b. Ketonuria
c. Elevated blood pressure
d. Hypokalemia
12. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic pain. A nasogastric tube and left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds on the left side, and chest movement that occurs only on the right side of the thorax. Which procedure should the nurse prepare for first?
a. Insertion of a left-sided chest tube
b. Set-up of patient-controlled analgesia
c. Retraction of the nasogastric tube
d. Placement of an endotracheal tube
13. A older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?
a. Destruction of joint cartilage
b. Infectious process in the synovial fluid
c. Systemic inflammatory response
d. loss of bone mineral density
14. The father of a four year old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his health care provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?
a. Reassure the client that his child will be allowed to visit
b. Provide the client written information about end-of-life care
c. Obtained a detailed report from the nurse transferring the client
d. Mark the chart with the client’s request for no heroic measures
15. In evaluating the effectiveness of postoperative client’s intermittent pneumatic compression
device, which assessment is most important for the nurse to complete?
a. Evaluate the client ability to use an incentive spirometer b. Observe both lower extremities for redness and swelling
c. Palpate a peripheral pulse points for volume and strength
d. Monitor the amount of drainage from the client’s incision
16. The nurse implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective
a. Average client scores improved on specific risk factor knowledge tests
b. Healthcare providers prescribed 40% more human papillomavirus (HPV) vaccines
c. Condoms were provided in all health clinics in the community colleges
d. More than 50% of at-risk clients were diagnosed early in their disease process
17. The nurse is preparing discharge instruction for an older client with heart failure who will be starting a new prescription medications. Which action should the nurse take when reviewing the instructions with the client?
a. Stand behind the client to avoid intimidation
b. Provide handouts written at 12th grade reading level c. Turn on the overhead light when giving instructions
d. Use background music to promote relaxation
18. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the healthcare provider?
a. Pruritus and muscle aches
b. Vomiting and diarrhea
c. Decreased white blood cell count d. Elevated liver function tests
19. The nurse on the pediatric unit observes a distraught mother in the hallway scolding her 3-year- old son for wetting his pants. What initial action should the nurse take?
a. Inform the mother that toilet training is slower for boys
b. Refer the mother to a community parent education program
c. Suggest that the mother consult a pediatric nephrologist
d. Provide disposable training pants while calming th [Show Less]