Exam Review

A nurse is caring for a postpartum client who is breastfeeding their newborn and reports feeling well overall but being extremely fatigued. The nurse should recognize that the client is demonstrating manifestations of which of the following disorders?
A)
Postpartum depression.
B)
Iron deficiency anemia.
C)
Sickle cell anemia.
D)
Postpartum hemorrhage.
A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following secondary conditions should the nurse anticipate the client might develop?
A)
Development of emotional disorders and acute pain.
B)
Decreased appetite and a lack of sleep.
C)
Body dysmorphia and neurofibrillary tangles.
D)
Loss of sensation and cognitive difficulties.
A nurse is planning care for a client who has a severe traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care? (Select all that apply)
(SATA)
A)
Assess for cough reflex.
B)
Assess for abnormal posturing.
C)
Assess for Cushing's Triad.
D)
Assess palmar reflex.
E)
Assess the ability to follow simple commands.
A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia? (Select all that apply)
(SATA)
A)
Constipation.
B)
Loose clothing.
C)
Nausea.
D)
Surgery below level of injury.
E)
Urinary tract infections.
F)
Pressure on the testicles.

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Exam Review

A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
A)
Slurred speech.
B)
Confusion.
C)
Pain.
D)
Fatigue.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
A)
Blood pressure 184/92 mm Hg.
B)
Bilateral flank pain.
C)
Distended jugular veins.
D)
Generalized urticaria.
A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?
A)
Administer acetaminophen by mouth for pain control.
B)
Perform a thorough health history.
C)
Prepare for a STAT non-contrast CT scan.
D)
Insert an indwelling urinary catheter to monitor output.
A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following groups should the nurse understand has a higher risk of sustaining TBI?
A)
People who play contact sports.
B)
People who are in their 30s.
C)
People who live in rural areas.
D)
People who abstain from alcohol.

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Exam Review

A nurse is planning care for a client who has multiple sclerosis and is receiving methylprednisolone. Which of the following adverse effects should the nurse anticipate? (Select all that apply.)
(SATA)
A)
Hypotension.
B)
Bladder spasms.
C)
Hyperglycemia.
D)
Delayed wound healing.
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
A)
Progressive increase in platelet production.
B)
Excessive thrombosis and bleeding.
C)
Increased clotting factors.
D)
Immediate sodium and fluid retention.
A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?
A)
The client should maintain systolic BP between 136 and 140 mm Hg.
B)
The client should maintain systolic BP between 141 and 145 mm Hg.
C)
The client should maintain systolic BP between 120 and 129 mm Hg.
D)
The client should maintain systolic BP between 130 and 135 mm Hg.
A nurse is caring for a client who has a subarachnoid hemorrhage and asks why they are having a CT angiography. Which of the following should the nurse understand about CT angiography?
A)
A CT angiogram will reveal any overproduction of cerebrospinal fluid (CSF).
B)
A CT angiogram will reveal any decreased blood flow related to vasospasm.
C)
A CT angiogram will reveal any detailed, minimal changes in the brain tissue.
D)
A CT angiogram will reveal any edema within the brain tissue.

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Exam Review

A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?
A)
Keep lights turned to a medium level in the evening.
B)
Reposition the client every shift.
C)
Maintain the head of the bed between 30 and 45 degrees.
D)
Administer hypotonic intravenous solutions.
A nurse is reviewing the electronic medical record of a middle-aged client who was admitted following a stroke. Which of the following findings should the nurse identify as a modifiable risk factor for stroke?
A)
Client’s age.
B)
History of sickle cell disease.
C)
Parent who has cardiovascular disease.
D)
Hypertension.
A nurse is caring for a client who experienced severe head trauma. The client's partner asks the nurse why they are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of the following?
A)
The client's intake and output needs.
B)
Resorption of cerebrospinal fluid.
C)
Cerebral blood flow.
D)
Regulation of blood pressure.
A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand the type of reaction. Which of the following information should the nurse confirm about this condition?
A)
Humoral immune response is mediated by T-lymphocytes.
B)
Anaphylaxis defends only against viral infections.
C)
Anaphylaxis involves phagocytic natural killer cells.
D)
It can be triggered by antibodies reacting with proteins in the transfused blood, including IgA deficiency with anti-IgA antibodies.

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Exam Review

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
A)
Blood pressure 184/92 mm Hg.
B)
Bilateral flank pain.
C)
Distended jugular veins.
D)
Generalized urticaria.
A nurse is caring for a client who has sickle cell anemia. The client asks, "Why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?
A)
You have an autoimmune disease.
B)
You have a low ferritin level.
C)
You have had a gastrointestinal bleed.
D)
You have fewer red blood cells.
A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following actions should the nurse take?
A)
Prepare the client for mechanical ventilation.
B)
Prepare to administer a vasoconstrictor.
C)
Instruct the client to perform pursed-lip breathing.
D)
Administer prescribed sedatives.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
A)
Blood pressure 184/92 mm Hg.
B)
Bilateral flank pain.
C)
Distended jugular veins.
D)
Generalized urticaria.

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Exam Review

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply.)
A)
Check the expiration date of the blood product with a second nurse.
B)
Prime the blood tubing with dextrose 5% in water.
C)
Insert an IV with a 20-gauge or larger needle.
D)
Transfuse the blood product within 5 hours after removing it from refrigeration.
E)
Check vital signs before transfusion.
A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.)
A)
Brush teeth with a soft toothbrush.
B)
Blow nose gently.
C)
Limit fruit consumption.
D)
Use a straight-edge razor to shave.
E)
Lubricate lips with water-soluble ointment.
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?
A)
Quadriplegia.
B)
Paresthesia.
C)
Paraplegia.
D)
Hemiplegia.
A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis?
A)
Not exercising enough.
B)
Eating a diet high in protein.
C)
Developing a respiratory infection.
D)
Taking too much prescribed medication.

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