NursGuru

    Exam Review

    1. The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. The client has T 100.4 F, P 100, R 24, and BP 102/60. The client is complaining of severe pain. Which assessment data is most concerning to the nurse?
      A)
      The client's pulse oximeter reading is 95 percent.
      B)
      The client's urinary output is 50 mL in two hours.
      C)
      The client reports a pain level of 9 out of 10.
      D)
      The client has localized edema around the burn site.
    2. A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. The nurse notes: HR increased from 88 to 118/min over 1 hour, BP decreased from 124/78 to 98/60 mm Hg, urine output is 20 mL/hr, skin is cool and pale, and the client reports incisional pain 6/10. Which finding is the most concerning for hypovolemic shock?
      A)
      Increased heart rate.
      B)
      Decreasing urine output.
      C)
      Increased incisional pain.
      D)
      Capillary refill less than 2 seconds.
    3. A client with pancreatitis develops hypocalcemia. Which ECG finding should the nurse anticipate?
      A)
      Peaked T-waves.
      B)
      Shortened QT interval.
      C)
      Widened QRS complex.
      D)
      Prolonged QT interval.
    4. A client with an electrical burn is brought to the emergency department. The entrance wound is on the right hand and the exit wound is on the left foot. The client reports chest tightness and feels lightheaded. Which action should the nurse take?
      A)
      Assess peripheral pulses in the affected extremities.
      B)
      Irrigate the entrance and exit wounds.
      C)
      Place the client on continuous cardiac telemetry monitoring.
      D)
      Administer IV opioid pain medication.

    Exam Review

    1. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
      A)
      A room with another nonsurgical client.
      B)
      A room with air exhaust directly to the outdoor environment.
      C)
      A room in the ICU.
      D)
      A room that is within view of the nurses' station.
    2. A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?
      A)
      Measure the circumference of both upper arms.
      B)
      Notify the provider who inserted the PICC line.
      C)
      Remove the PICC line.
      D)
      Apply a cold pack to the client's upper arm.
    3. A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? Round to the nearest whole number.
      Correct Answer:7 mL
    4. The nurse prepares to administer regular insulin to a diabetic client whose blood glucose level is 950. The provider prescribed regular insulin 1 unit/hr intravenously. Regular insulin is available in a bag containing 10 units of regular insulin in 100 mL solution. How many milliliters per hour should the nurse set the intravenous pump? Round answer to the nearest whole number.
      Correct Answer:10 mL

    Exam Review

    1. A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
      A)
      Administer oxygen therapy.
      B)
      Give morphine IV.
      C)
      Initiate cardiac monitoring.
      D)
      Start an IV infusion of lactated Ringer's
    2. A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?
      A)
      pH 7.26, HCO3 14, PaCO2 30.
      B)
      pH 7.26, HCO3 24, PaCO2 46.
      C)
      pH 7.49, HCO3 30, PaCO2 40.
      D)
      pH 7.49, HCO3 24, PaCO2 30.
    3. A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?
      A)
      Decompress the stomach.
      B)
      Supply nutrients via tube feedings.
      C)
      Determine the pH of the gastric secretions.
      D)
      Administer medications.
    4. A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
      A)
      "As a nurse, I am required by law to report any suspicion of child abuse.”.
      B)
      "The hospital policy requires all injuries to be reported.”.
      C)
      "I reported this because I believe abuse has occurred.”.
      D)
      "You should speak with the provider about this concern.”.

    Exam Review

    1. A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
      A)
      "DIC is caused by abnormal coagulation involving fibrinogen.”.
      B)
      "DIC is characterized by an elevated platelet count.”.
      C)
      "DIC is controllable with lifelong heparin usage.”.
      D)
      "DIC is a genetic disorder involving a vitamin K deficiency.”.
    2. The nurse prepares a continuous aminophylline infusion at 0.3 mg/kg/hr for a client weighing 165 pounds. The bag is mixed with 500 mg of aminophylline in 250 mL of D5W. At which rate should the nurse set the pump in mL/hr? Round the answer to the tenths place.
    3. A client with chronic pancreatitis is being evaluated. Which findings are most consistent with this condition? Select all that apply.
      A)
      Increased Amylase.
      B)
      Decreased calcium related to binding of calcium.
      C)
      Increased Lipase.
      D)
      Decreased serum glucose.
      E)
      Elevated serum calcium.
    4. The emergency department nurse assesses a client with a head injury. The client lost consciousness at the time of the head injury and then regained consciousness but is now unconscious again. Which condition does the nurse suspect?
      A)
      Epidural hematoma.
      B)
      Concussion.
      C)
      Skull fracture.
      D)
      Subdural hematoma.

    Exam Review

    1. The nurse suspects that a client has decorticate posturing. Which findings support the nurse's suspicion?
      A)
      Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers.
      B)
      Back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet.
      C)
      Supination of arms and dorsiflexion of the feet.
      D)
      Arms are pronated, extended, and close to body with wrists rotated.
    2. The nurse evaluates a client's response to hemodialysis. Which finding indicates an expected outcome?
      A)
      Blood urea nitrogen (BUN) has decreased.
      B)
      White blood cells (WBC) have decreased.
      C)
      Calcium has decreased.
      D)
      Red blood cells (RBC) have decreased.
    3. A client is in the acute phase of a burn injury. The nurse notes a Mean Arterial Pressure (MAP) of 74 mm Hg, urine output of 95 mL/hr, and a temperature of 38.6°C (101.5°F). The white blood cell (WBC) count is 18,000/mm and the burn wound has increased drainage with a foul odor. What is the priority nursing action?
      A)
      Encourage increased oral protein intake.
      B)
      Administer prescribed opioid analgesic.
      C)
      Reduce IV fluid infusion rate.
      D)
      Notify the provider and obtain wound and blood cultures.
    4. A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
      A)
      Verify that the suction regulator is on and check the tubing for leaks.
      B)
      Milk the chest tube and dislodge any clots in the tubing that are occluding it.
      C)
      Continue to monitor the client as this is an expected finding.
      D)
      Add more water to the suction control chamber of the drainage system.

    Exam Review

    1. A client presents with a respiratory rate of 7/min. The ABG results are: pH 7.22, PaCO2 68 mm Hg, HCO3 26 mEq/L, PaO2 78 mm Hg, and Oxygen saturation 80 Which interpretation is most accurate?
      A)
      Metabolic acidosis with partial compensation.
      B)
      Respiratory alkalosis with hypoxia.
      C)
      Metabolic alkalosis without compensation.
      D)
      Respiratory acidosis with hypoventilation.
    2. A client is admitted with a closed head injury sustained in a motor vehicle accident. The nurse notes that the client's intracranial pressure (ICP) shows an upward trend. Which action should the nurse prioritize?
      A)
      Administer 100 mg of pentobarbital IV as ordered.
      B)
      Administer 1 g Mannitol IV as ordered.
      C)
      Increase the ventilator respiratory rate to 20 breaths/minute.
      D)
      Reposition the client to avoid neck flexion.
    3. The physician prescribes levofloxacin 300 mg IV every 6 hours for a client diagnosed with sepsis. The client weighs 43.5 kg. The nursing drug guide recommends a maximum of 5 - 7.5 mg/kg/dose. What is the maximum safe dose for this client in mg/dose? Round answer to the nearest hundredth.
    4. A client who experienced a myocardial infarction tells the nurse that he is fearful of dying. Which statement by the nurse will help validate this client's feelings?
      A)
      "It must be very frightening to be told that you've had a heart attack.”.
      B)
      "Why are you afraid? Can you explain your fear of dying?"
      C)
      "Please be assured that we're doing everything possible to prevent you from dying.”.
      D)
      "Facing death would certainly be a frightening experience for me.”.