Exam Review
- The nurse is caring for a client with herpes zoster virus who reports painful, red blisters that align from the back along the thoracic curvature to the anterior chest. Which intervention is the highest priority for the nurse?A)Place wet compresses to ruptured vesicles.B)Administer antiviral medications.C)Administer narcotic analgesics.D)Place the client on contact precautions.
- Four days following an abdominal aortic aneurysm (AAA) repair, the client is exhibiting edema of both lower extremities and pedal pulses are not palpable. Which action should the nurse implement first?A)Wrap the feet with warmed blankets.B)Evaluate edema for pitting.C)Elevate extremities on pillows.D)Assess pulses with a vascular Doppler.
- The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?A)Platelet count.B)Red blood cell count.C)White blood cell count.D)Hemoglobin levels.
- The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?A)Prepare to sit forward with arms propped on a table.B)Expect a persistent cough after the procedure.C)Limit activity for a day or two after returning home.D)Anticipate a stinging feeling during needle insertion.
Exam Review
- A client has a leg cast following an open reduction for a fractured tibia. Approximately two hours after returning to the unit, the client reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blanched. Which action should the nurse perform first?A)Record the observations and check the limb every 15 minutes.B)Release the traction and notify the healthcare provider.C)Notify the healthcare provider of the assessment findings.D)Administer a PRN pain medication routinely as prescribed.
- A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?A)Albumin.B)Glucose.C)Osmolarity.D)Platelets.
- The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral tissues. Which is the best initial nursing action?A)Obtain a soft diet for the client.B)Encourage frequent mouth care.C)Administer a topical analgesic per protocol.D)Cleanse the tongue and mouth with swabs.
- A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain rated 8 on a 0 to 10 scale. Which intervention should the nurse implement?A)Educate the client on signs and symptoms of narcotic dependency.B)Give maximum dosage when score reaches 10.C)Alternate IV and IM analgesic medications.D)Administer opioid and non-opioid medication simultaneously.
Exam Review
- A client who works as a data entry clerk is concerned about how a recent diagnosis of Raynaud's syndrome will affect their job performance. Which instruction should the nurse provide to this client?A)Obtain a keyboard designed to limit wrist flexion.B)Keep both hands elevated during work breaks.C)Use a space heater to keep the workspace warm.D)Take a multivitamin that contains vitamin D daily.
- The nurse reports that a client is at risk for a stroke based on which assessment finding?A)Nuchal rigidity.B)Carotid bruit.C)Jugular vein distention.D)Palpable cervical lymph node.
- A client who had a C5 spinal cord injury (SCI) 2 years ago is admitted to the emergency department (ED) with a diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?A)Profuse diaphoresis and severe, pounding headache.B)Pain and a burning sensation upon urination and hematuria.C)Reports of chest pain and shortness of breath.D)Hypotension and venous pooling in the extremities.
- A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells (PRBCs). When notifying the healthcare provider (HCP), which information should the nurse provide first using the Situation, Background, Assessment, and Recommendation (SBAR) communication process?A)Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).B)Explain specific reason for urgent notification.C)Communicate the pretransfusion temperatures.D)Begin the report by stating the client’s name and admitting diagnosis.
Exam Review
- When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?A)Vital signs.B)Bowel sounds.C)Level of consciousness.D)Daily weight.
- A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells (PRBCs). When notifying the healthcare provider (HCP), which information should the nurse provide first using the Situation, Background, Assessment, and Recommendation (SBAR) communication format?A)Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).B)Explain specific reason for urgent notification.C)Communicate the pretransfusion temperatures.D)Begin the report by stating the client's name and admitting diagnosis.
- The nurse is assessing a client who is one day postoperative from a parathyroidectomy and finds that the client is experiencing tenderness. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?A)Central line insertion.B)Nasogastric tube (NGT) insertion.C)Pacemaker placement.D)Tracheostomy placement.
- The healthcare provider (HCP) prescribes penicillin G benzathine 1,800,000 units intramuscularly (IM) for a client with a bacterial infection. The prefilled syringe is labeled, "Penicillin G benzathine 1,200,000 units/2 mL." How many mL should the nurse administer to this client? (Enter numerical value only, rounded to the nearest whole number.)
Exam Review
- The healthcare provider (HCP) prescribes diagnostic tests for a client whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation to guide the most therapeutic treatment of the pneumonia?A)Blood cultures.B)Computerized tomography (CT) of the chest.C)Sputum culture and sensitivity.D)Arterial blood gas (ABG).
- The nurse obtains a fingerstick blood glucose using a bedside glucose meter for a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). Which intervention should the nurse implement first?A)Document the glucose reading in the electronic medical record (EMR) as the only action needed.B)Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis.C)Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.D)Give the client six ounces (180 mL) of non-diet carbonated soda and instruct the client to drink it entirely.
- The nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?A)Dyspnea and sinus tachycardia.B)Productive cough and fever.C)Low, concentrated urine output.D)Reports of a bad taste in the mouth.
- A male client who fractured his right femur from a fall at home is placed in Buck’s skin traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?A)Log roll the client and place adult disposable briefs beneath the client.B)Release the traction so the client can use a bedpan.C)Insert an indwelling urinary catheter preoperatively.D)Maintain traction while the client uses a urinal.
Exam Review
- The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?A)Abdominal striae.B)Rapid weight gain.C)Moon facies.D)Gastric irritation.
- A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to awaken during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?A)Tap the client's wrists to locate the pain.B)Apply firm pressure over the ulnar artery.C)Compare the capillary refill in the hands.D)Determine the client's sleeping position.
- A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia care unit (PACU). Before selecting which medication to administer, which action should the nurse implement?A)Compare the client's pain scale rating with the prescribed dosing.B)Determine which prescription will have the quickest onset of action.C)Document the client's report of pain in the electronic medical record.D)Ask the client to choose which medication is needed for the pain.
- The nurse is assessing a group of older adult clients. Which factor in a client's history places the client at greatest risk for developing colon cancer?A)Eats a high-fat diet.B)Is excessively exposed to sunlight.C)Smokes cigars.D)Has intestinal polyps.