NursGuru

    Exam Review

    1. A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet count [150,000 to 400,000/mm3 (150 to 400 x 109/L)]
      A)
      Monitor for signs of activity intolerance.
      B)
      Require visitors to wear respiratory masks.
      C)
      Assess urine and stool for occult blood.
      D)
      Obtain client's temperature every 4 hours.
    2. A client reports that the 30 mg extended release form of cyclobenzaprine has been the only medication that provided relief from lower back pain in the past. The client asks the nurse if the medication for chronic back pain could be prescribed on a monthly basis. Which is the best response from the nurse?
      A)
      The medication has been recalled by the FDA and can no longer be prescribed.
      B)
      You will have to have labs drawn monthly to renew your prescription.
      C)
      You may build up a tolerance to that dose so it may have to be increased.
      D)
      This medication is usually prescribed for a maximum use of 3 weeks.
    3. Following a total knee arthroplasty, the client is discharged from the hospital with a prescription for warfarin. In reviewing discharge teaching, the client recounts to the nurse the need to avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond?
      A)
      Discuss necessary fluid restrictions as well as food restrictions.
      B)
      Review teaching about the effects of foods rich in Vitamin K.
      C)
      Explain that no dietary restrictions are needed with warfarin.
      D)
      Provide a written list of additional foods high in potassium.
    4. The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first?
      A)
      Irrigate the dialysis catheter.
      B)
      Check the client's blood pressure and serum bicarbonate.
      C)
      Continue to monitor intake and output with next exchange.
      D)
      Change the client's position.

    Exam Review

    1. The licensed nurse is unable to complete medication administration within the accepted time limits. The licensed nurse reviews time management strategies with the lead nurse and reports difficulty with interruptions and call-lights. Which strategy should the lead nurse recommend to improve on-time medication administration?
      A)
      Avoid procrastination.
      B)
      Decrease distractions.
      C)
      Set boundaries.
      D)
      Set goals.
    2. A history is completed by the healthcare provider (HCP) with a rapid assessment, and vital signs completed by the nurse
      (Highlight — findings requiring follow-up are marked)

      A history is completed by the healthcare provider (HCP) with a rapid assessment, and vital signs completed by the nurse

       Click to highlight the findings that require follow up.

      • Neurological: Alert and oriented person, place, time, and situation. Agitated. Denies headaches.
      • Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
      • Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
      • Gastrointestinal: Within normal limits (WNL).
      • Genitourinary: WNL
      • Musculoskeletal: WNL
      • Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
    3. Click to indicate if the listed symptoms are consistent with angina, myocardial infarction, or both. Each column must have at least one response option selected
      Myocardial infarctionAngina
      Pain relived by nitroglycerin✓
      Epigastric distress✓✓
      Pain only relieved by opioids✓
      Chest pain radiating down arm✓
      Occurring without cause✓✓
      Feelings of fear✓
    4. Initial testing is complete, and the nurse is reviewing the results. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse determines that the client has ▾ new onset anginaevidenced by ST depression on electrocardiogram and normal ▾ Troponinlevel.
      Dropdown 1:
      Option 1: new onset angina
      Option 2: aortic aneurysm
      Option 3: myocardial infarction
      Dropdown 2:
      Option 1: Troponin
      Option 2: Prothrombin time (PT)
      Option 3: C-reactive protein (CRP)

    Exam Review

    1. Drag and drop word choices to complete the sentence. If healthcare providers (HCPs) see a narrowed heart vessel while performing a percutaneous coronary intervention (PCI), they may perform a balloon angioplasty to compress the plaque against the vessel wall and hold it there with a stent, which will lessen ▾ painand▾ dysrhythmias
      Dropdown 1:
      Option 1: vasospasms
      Option 2: dysrhythmias
      Option 3: heart blocks
      Option 4: pain
      Dropdown 2:
      Option 1: vasospasms
      Option 2: dysrhythmias
      Option 3: heart blocks
      Option 4: pain
    2. The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?
      (SATA)
      A)
      I will chew my nitroglycerin tabs as soon as pain begins.
      B)
      I will lie down or sit if I start to feel any chest discomfort.
      C)
      I will keep my nitroglycerin tablets with me all the time.
      D)
      I will call 911 if there is no improvement in my chest pain after taking nitroglycerin.
      E)
      I will wear a medication alert bracelet to indicate my history of heart problems.
      F)
      I will take the nitroglycerin 1 or 2 more times 10 minutes apart if pain does not get better.
      G)
      I will wait 5 minutes after taking my nitroglycerin to see if the pain improves.
    3. A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement? Reference Range: pH [7.35 to 7.45] PaCO2 [35 to 45 mm Hg] PaO2 [80 to 100 mm Hg]
      A)
      Increase rate of ventilation.
      B)
      Decrease expiratory pressure.
      C)
      Decrease expiratory flow time.
      D)
      Increase ventilator tidal volume.
    4. A client arrives at the emergency department after blunt chest trauma with severe shortness of breath, distended neck veins, hypotension, and deviation of the trachea to the left. Which statement should the nurse provide about this condition?
      A)
      "The trachea shifts toward the injured side because the lung overexpands and pushes air outward."
      B)
      "Air in the pleural space increases intrathoracic pressure, collapsing the lung and reducing cardiac output."
      C)
      "Blood in the pleural space compresses the unaffected lung, increasing oxygen diffusion."
      D)
      "Loss of negative pleural pressure decreases lung expansion, limiting oxygen delivery to tissues."

    Exam Review

    1. A client with multiple cardiac diagnoses receives a prescription for verapamil. Which therapeutic response(s) should the nurse anticipate for a client taking this medication? Select all that apply.
      A)
      Presence of normal sinus rhythm.
      B)
      Decreased anginal pain.
      C)
      Potassium level within normal limits.
      D)
      Decreased hypertensive blood pressure.
      E)
      Increased frequency of urine output.
    2. The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?
      A)
      Instruct the UAP to return to the client's room to perform handwashing.
      B)
      Advise the UAP to wear gloves when obtaining vital signs for all clients.
      C)
      Remind the UAP to continue rubbing the hands together until they are dry.
      D)
      Supervise the UAP in the next client's room to evaluate hand hygiene.
    3. In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)
    4. A client is admitted following a motor vehicle collision. When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands. The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward. Which action should the nurse implement?
      A)
      Document the purposeful response to pain.
      B)
      Administer a prescribed PRN analgesic.
      C)
      Report the finding to the healthcare provider.
      D)
      Initiate seizure precautions immediately.

    Exam Review

    1. The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?
      A)
      Steak and baked potato with butter and cheese topping.
      B)
      Pasta with fish and an orange.
      C)
      Canned ham and green beans.
      D)
      Chicken, yams, pinto beans and pecans.
    2. The nurse is evaluating the intake data. Click to highlight the findings that require a priority follow-up. A 42-year-old female client presents to the emergency department experiencing indigestion, pain when swallowing, and aching pain in the middle upper abdomen. Additionally, the client is experiencing nausea and had one episode of emesis prior to arrival. Reports that the pain began shortly after she finished breakfast, but this is not the first time this has happened. She informs previous symptoms started 6 months ago with episodes occurring 1 to 2 times per month, but now symptoms occur multiple times per day. Has tried drinking milk which originally helped symptoms but no longer provides any relief. Was diagnosed with type 2 diabetes last year and takes metformin. She informs that she smokes 1 pack of cigarettes per week.
      A)
      client presents to the emergency department experiencing indigestion, pain when swallowing, and aching pain in the middle upper abdomen
      B)
      client is experiencing nausea and had one episode of emesis prior to arrival
      C)
      previous symptoms started 6 months ago with episodes occurring 1 to 2 times per month
      D)
      now symptoms occur multiple times per day
      E)
      diagnosed with type 2 diabetes last year and takes metformin
      F)
      smokes 1 pack of cigarettes per week
    3. The nurse is reviewing the assessment data. For each assessment finding, click to indicate if it is a symptom of gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), or gastritis. Each column must have at least one response option selected.
      A)
      Odynophagia
      B)
      Epigastric pain
      C)
      Dyspepsia
      D)
      Emesis
    4. Drag from Word Choices to complete the sentence. The nurse knows that, if left untreated, the client's condition could progress to developingdropdown,dropdownanddropdown

    Exam Review

    1. The nurse is considering the plan of care for this client. Click to highlight the outcomes the nurse should include in this client's plan of care. Select all that apply.
      A)
      Medications
      B)
      Surgical solutions
      C)
      Nutrition
      D)
      Lifestyle
      E)
      Endoscopic therapy
    2. The nurse is providing education to the client. For each teaching point, click to indicate whether it should be included or not included. Each row must have one response option selected.
      A)
      Avoid lying down at least 3 hours after a meal
      B)
      Avoid alcohol
      C)
      Eat 4 to 6 small meals
      D)
      Avoid eating spinach
      E)
      Increase intake of citrus
    3. The nurse is reviewing the information provided by the client in the follow up evaluation. Select the 4 client statements that indicate improvement in condition.
      A)
      Medication compliance
      B)
      Worse symptoms after late night meal consumption
      C)
      Minimal nausea noted after meals
      D)
      Reports adequate nutrition intake
      E)
      Denies vomiting
      F)
      Epigastric pain after coffee intake
    4. A client reports bloating and abdominal cramps after eating ice cream and foods with cheese. Which condition should the nurse suspect?
      A)
      Ulcerative colitis.
      B)
      Irritable bowel syndrome.
      C)
      Lactose intolerance.
      D)
      Diverticulitis.