NursGuru

    Exam Review

    1. A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute. Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.
      (SATA)
      A)
      Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
      B)
      Stat ventilation/perfusion (V/Q) of chest.
      C)
      Stat 2 views chest x-ray.
      D)
      Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
      E)
      Send sputum for culture & sensitivity.
    2. A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?
      A)
      Instruct the client to avoid foods with gluten, such as wheat bread.
      B)
      Describe the use of an elimination diet to find trigger foods.
      C)
      Advise the client to limit foods that are high in calcium and iron.
      D)
      Explain that the need to restrict fluids is the primary limitation.
    3. The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer.The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?
      A)
      Chronic pain related to tissue destruction by tumor.
      B)
      Anxiety and grieving related to progression of disease.
      C)
      Risk for aspiration related to difficulty swallowing.
      D)
      Imbalanced nutrition: less than body requirements.
    4. The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?
      A)
      Measure oxygen saturation.
      B)
      Auscultate bowel sounds.
      C)
      Assess body temperature.
      D)
      Check serum creatinine.

    Exam Review

    1. The patient is a 51-year-old male with pneumonia.The patient has a history of hypertension and takes enalapril and a multivitamin daily.His surgical history includes adenoid removal at age 4 and a surgical repair of a fractured tibia at age 20. Based on the information that the nurse has about the patient, what condition is he likely to have?
      A)
      Dysrhythmia
      B)
      Toxicity
      C)
      Anemia
      D)
      Pneumonia
    2. Patient Data shows that on Day 1, there were no active processes.On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side.What is the likely diagnosis?
      A)
      Pneumonia
      B)
      Tuberculosis
      C)
      Bronchitis
      D)
      Pulmonary Embolism
    3. A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?
      A)
      Auscultate the patient's bowel sounds and measure the abdominal girth.
      B)
      Confirm that the patient is taking the medication one hour after meals.
      C)
      Notify the healthcare provider that the patient may need a change in dosage.
      D)
      Advise the patient that healing typically takes several weeks to occur.
    4. The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?
      A)
      Diabetes Mellitus
      B)
      Hypoglycemia
      C)
      Hyperglycemia
      D)
      Prediabetes

    Exam Review

    1. A client receives a prescription for ophthalmic ketorolac.Prior to administering the medication, the nurse should review the medical record for which condition?
      A)
      Radiation exposure
      B)
      Corneal abrasion
      C)
      Chemical burn
      D)
      Foreign body
    2. While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound.Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?
      A)
      Culture for sensitive organisms.
      B)
      C-reactive protein level.
      C)
      Blood pH level.
      D)
      Serum blood glucose level.
    3. The antitubercular drug isoniazid is prescribed for a client with active tuberculosis.To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?
      A)
      Decreased appetite and weight loss.
      B)
      Decreased cough and sputum.
      C)
      Vertigo and tinnitus.
      D)
      A positive sputum smear and culture.
    4. Exhibits A nurse is reviewing the client’s condition. Based on the exhibits provided, what is the most likely diagnosis for this client?
      A)
      . Hypovolemic shock and Puerperal infection
      B)
      . Pulmonary embolism and postpartum hemorrhage
      C)
      Acute myocardial infarction and postpartum hemorrhage
      D)
      Pneumonia and Acute myocardial infarction

    Exam Review

    1. Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?
      A)
      Observe the skin for lesions.
      B)
      Palpate the lymph nodes.
      C)
      Palpate large joints for nodules.
      D)
      Observe the client’s fingers.
    2. The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?
      A)
      Observe for edema around the ankles.
      B)
      Count the apical and radial pulses simultaneously.
      C)
      Measure the patient’s capillary glucose level.
      D)
      Auscultate the patient’s bowel sounds.
    3. The nurse is performing a routine dressing change for a patient with a stage 3 pressure injury that is red with significant granulation.The wound has a gauze dressing covering the area. Which action should the nurse implement?
      A)
      Leave the dressing off until consulting with the healthcare provider.
      B)
      Apply a hydrocolloidal gel dressing.
      C)
      Increase the frequency of the dressing changes.
      D)
      Replace the gauze with a transparent dressing.
    4. The patient is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy.He has a past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cholangitis. Which physician orders would the nurse anticipate being prescribed after reporting findings? Select all that apply.
      A)
      Obtain arterial blood gases (ABGs) prior to procedure.
      B)
      Explain that the patient may be placed in five positions.
      C)
      Perform the drainage immediately after meals.
      D)
      Instruct the patient to breathe shallow and fast.

    Exam Review

    1. When performing postural drainage on a patient with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?
      A)
      Obtain arterial blood gases (ABGs) prior to procedure.
      B)
      Explain that the patient may be placed in five positions.
      C)
      Perform the drainage immediately after meals.
      D)
      Instruct the patient to breathe shallow and fast.
    2. The patient is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy. He has a past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cholangitis. Which physician orders would the nurse anticipate being prescribed after reporting findings? Select all that apply.
      A)
      Stat ventilation/perfusion (V/Q) of chest.
      B)
      Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
      C)
      Stat 2 views chest x-ray.
      D)
      Send sputum for culture & sensitivity stat.
      E)
      Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
      F)
      Start the patient on antibiotic therapy.
    3. A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions.When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?
      A)
      Leave the old ties in place until the new ones are secure.
      B)
      Secure tracheostomy ties by making knots close to the tube.
      C)
      Remove ties to secure a disposable, soft foam collar with self-adhesive fastening.
      D)
      Place knots of the ties laterally to prevent irritation and pressure.
    4. The patient’s vital signs are as follows: Temperature 97.5 F (36.4 C), Heart rate 104 beats/minute, Respirations 29 breaths/minute, Blood pressure 119/82 mm Hg, Oxygen saturation 89%. Oxygen mask applied.What should the nurse do next?
      A)
      Check the patient’s temperature again.
      B)
      Monitor the patient’s heart rate.
      C)
      Observe the patient’s breathing.
      D)
      Check the patient’s blood pressure.

    Exam Review

    1. A patient with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting.Which finding should the nurse report to the healthcare provider?
      A)
      Amber urine.
      B)
      Belching.
      C)
      Flatulence.
      D)
      Yellow sclera.
    2. A patient is being cared for in the emergency department with acute abdominal pain and a provisional diagnosis of pancreatitis.The nurse assesses the patient and obtains the results from laboratory studies.Which information is most valuable in reporting the patient’s status to the healthcare provider?
      A)
      Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts.
      B)
      Reports of chronic constipation and serum gastrin levels.
      C)
      Severity of nausea and vomiting and serum amylase results.
      D)
      Presence of bowel sounds and degree of abdominal pain.
    3. A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection.Which response should the nurse provide?
      A)
      Explain to the client that antibiotics are not useful in treating viral infections such as influenza.
      B)
      Advise the client that once symptoms occur it is too late to receive an influenza vaccination.
      C)
      Refer the client to the healthcare provider at the clinic to obtain a medication prescription.
      D)
      Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms.
    4. The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?
      A)
      Wild rice.
      B)
      Oatmeal.
      C)
      Corn chips.
      D)
      Potatoes.