Exam Review
- A nurse is assessing a client who is receiving radiation therapy to the head and neck. Which of the following findings should the nurse expect?A)XerostomiaB)EpistaxisC)DiplopiaD)Tinnitus
- A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?A)"Eat a light meal 1 hour before bedtime."B)"Increase your caloric intake by 250 calories per day."C)“Sleep with the head of your bed elevated 6 inches."D)"Lie down for 30 minutes after each meal."
- A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings indicates the client is experiencing fluid volume overload?A)+1 pedal pulsesB)Urinary output of 20 mL in the past hourC)S3 heart soundD)Temperature of 38° C (100.4° F)
- A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?A)StridorB)Sore throatC)RhonchiD)SaO2 92%
Exam Review
- A nurse is preparing discharge teaching for a client who has Crohn's disease and a new ileostomy. Which of the following community resources should the nurse include in the teaching?A)Long-term care facilityB)Rehabilitation centerC)Visiting nurse servicesD)Hospice care services
- A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?A)25-Hydroxyvitamin D 92 ng/mL (25 to 80 ng/mL)B)Albumin 3.1 g/dL (3.5 to 5 g/dL)C)WBC 12,000/mm3 (5,000 to 10,000/mm3)D)Hgb 18 g/dL (12 to 16 g/dL)
- A nurse is caring for a client who has diabetes insipidus and has had a urinary output of 3,000 mL in the past 12 hr. Which of the following medications should the nurse expect to administer to the client?A)SpironolactoneB)Desmopressin acetateC)DopamineD)Furosemide
- A nurse is caring for a client who has diabetes mellitus and cool, clammy skin. The client begins having a seizure. Which of the following treatment s should the nurse administer?A)Continuous IV infusion of regular insulinB)Glucagon 1 mg IMC)1 L bolus of 0.45% sodium chloride over 1 hrD)10 g of oral glucose gel
Exam Review
- A nurse is caring for a client who has chronic kidney failure. The client received hemodialysis 1 hr ago. The nurse should identify that which of the following findings is a manifestation of a complication related to the procedure?A)A palpable thrill at the fistula siteB)HyperglycemiaC)Altered mental statusD)Decrease in weight
- A nurse is caring for a client who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?A)Maintain the affected extremity in a dependent position.B)Adjust the clamps on the fixator frame.C)Wrap sterile gauze on the sharp point of the pins.D)Palpate the dorsalis pedis pulse.
- A nurse is providing education to a client who has a prescription for incentive spirometry. Which of the following instructions should the nurse include in the teaching?A)"Place the mouthpiece in your mouth and inhale slowly."B)"Remove the mouthpiece and exhale quickly."C)"Use the incentive spirometer every 4 hours."D)"Avoid coughing during and after the session."
- A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?A)QRS durationB)ST segmentC)PR intervalD)T wave
Exam Review
- A nurse is providing preventive education to a client who has diabetes mellitus. Which of the following statements made by the client indicates they understand proper foot care?A)"I should plan to remain barefoot while I am at home."B)"I should apply lotion between my toes twice a day."C)"I should file the edges of my toenails after trimming them."D)"I should use a heating pad when my feet are cold."
- A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider?A)Purulent drainageB)EdemaC)Ecchymotic skinD)Erythema
- A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect?A)Increased body hairB)HypocalcemiaC)Decreased blood urea nitrogen levelD)Hyperpigmentation of the skin
- A nurse is caring for a client who has an evisceration of an abdominal incision. Which of the following actions should the nurse take first?A)Cover the protrusion with a dressing soaked in 0.9% sodium chloride.B)Raise the head of the bed to 20°.C)Obtain the client's vital signs every 5 min until the provider arrives.D)Prepare the client for surgery.
Exam Review
- A nurse is caring for a client who has end stage cancer and is receiving chemotherapy. The client tells the nurse “I want to discontinue treatment, but my children insist I continue”. Which of the following responses should the nurse make?A)"It is your decision whether to continue chemotherapy."B)"Your provider would not prescribe this treatment if it weren't necessary."C)"Why don't you want to continue treatment?"D)"Chemotherapy is your best chance for survival."
- A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take?A)Obtain bottles of warm, sterile 0.9% sodium chloride solution.B)Attempt to reinsert the protruding viscera.C)Apply a firm pressure dressing across the client's abdomen.D)Place the client in left lateral recumbent position.
- A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?A)Perform range-of-motion exercises to the client's knee.B)Place pillows under the client's knee.C)Apply an ice pack to the client's knee.D)Gently massage the area around the client's incision.
- A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?A)Projectile vomitingB)PapilledemaC)RestlessnessD)Decorticate posturing
Exam Review
- A nurse is admitting a client who reports tightness in their chest that radiates to left arm. The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.A)Blood glucose levelB)Bowel soundsC)Blood pressureD)Pain levelE)Electrocardiogram findingsF)Lung soundsG)Troponin T level
- A nurse is admitting a client who reports tightness in their chest that radiates to left arm.Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again. Nurses' Notes: 1000: Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate is irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.A)Client reports tightness in chest that radiates to left arm.B)States pain as 7 on a scale of 0 to 10.C)Client is diaphoreticD)short of breathE)Heart rate is irregular and tachycardic.F)Alert and oriented to person, place, and time.G)Lungs clear to auscultation in all lobesH)+1 pedal pulses.I)Skin is cool to touch.J)Capillary refill less than 2 seconds.
- A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Complete the following sentence by using the lists of options. The nurse should first address the client's dropdown followed by the client's dropdown.
- The nurse is reviewing the client's medical record. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.A)Metoprolol 15 mg IV bolusB)Oxygen at 2 L/min via nasal cannulaC)Draw electrolytes along with Hgb and HctD)Morphine 6 mg IV bolus every 3 hr as needed for painE)Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 dosesF)Obtain daily weightG)Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate drops below 60