Exam Review

The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on botom.)
A)
A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
1
B)
A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness
2
C)
A 10-year-old child with bleeding lacerations on both knees after falling on the playground
3
D)
A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
4
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)
(SATA)
A)
Remove the medication from the dispensing system.
B)
Compare the client’s wristband to the medication administration record.
C)
Document administration of the medication.
D)
Open the medication package.
E)
Obtain the client’s apical heart rate.
Patient Data History and Physical A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just could not catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working. The nurse reviews the client's history of the presenting illness in the electronic medical record. Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
A)
The client reports using a rescue inhaler three times, but he just could not catch his breath
B)
The client reports that symptoms seem worse when outdoors and when exercising
C)
episodes like this make him extremely nervous
D)
it has been a couple of months since he had an asthma attack
E)
noticed that his inhaler was expired and was worried the medication was not working
Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
(SATA)
A)
Administer medications as ordered.
B)
Provide client teaching.
C)
Place the client in Trendelenburg position
D)
Ask the client for a list of current medications.
E)
Notify the healthcare provider of the client's need for intubation
F)
Apply oxygen via nasal cannula

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Exam Review

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.
(SATA)
A)
Administer additional nebulizer treatment as ordered.
B)
Take and monitor vital signs.
C)
Apply a nonrebreather oxygen mask.
D)
Increase oxygen flow.
E)
Raise the head of the bed.
F)
Provide client incentive spirometer and instruct on use.

Patient Data Exhibits The nurse performs an initial focused assessment of the client. Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

	Neither disease process nor medication use	Disease process	Medication use
Blood pressure 130/86 mmHg	✓
Respirations 28 breaths/minute		✓
Temperature 98.9" F (37.1°C)	✓
Heart rate 112 beats/minute			✓
Oxygen saturation 88% on room air		✓

Patient DataThe nurse has Implemented additional needed actions. Exhibits Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

	No Indication that the Interventions Were Successful	Indicates the Interventions Were Successful
Lung sounds clear		✓
Client can now speak in full sentences without pausing		✓
Respirations 16 breaths/minute		✓
Client reports, "It's a lot easier to breathe now."		✓
Blood Pressure 122/84 mmHg	✓

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
A)
Administer pain medication at designated Intervals around the clock.
B)
Assess the pulses proximal to the fracture site.
C)
Remove traction every shift and provide skin care.
D)
Assess the pin sites for signs of infection.

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Exam Review

Patient Data Exhibits For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.

	Decreases pain	Reduces inflammation	Lowers uric acid levels	Minimize alcohol consumption.	If a dose is missed, double the amount in the subsequent dose.
Colchicine	✓			✓
Naproxen		✓		✓
Prednisone		✓		✓
Allopurinol			✓		✓

Patient Data Exhibits here The healthcare provider places orders to determine the extent of the client condition. Drag from Word Choices to complete the sentence. Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for ▾ Inflammation and ▾ Discoloration in his affected joint.
Dropdown 1:
Option 1: Swelling
Option 2: Bruising
Option 3: Infection
Option 4: Inflammation
Option 5: Rash
Dropdown 2:
Option 1: Discoloration
Option 2: Erythema
Option 3: Cyanosis
Option 4: Pallor
Option 5: Ecchymosis
Patient’s Data Exhibits Select the 3 dietary choices that are not part of the recommended diet gout.
A)
Shrimp
B)
Sardines
C)
Quinoa
D)
Oranges
E)
Oatmeal
F)
Spinach
G)
Liver
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
A)
Uneven hair distribution.
B)
Lower leg edema.
C)
Bronze pigmentation.
D)
Bounding peripheral pulse.

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Exam Review

A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3 (25 x 109/L), which intervention should the nurse include in the plan of care? Reference Range Platelets [150,000 to 400,000/mm3 (150 to 400 × 109/L)]
A)
Ensure a large gauge IV catheter is used to obtain blood samples.
B)
Monitor urine and stool for occult blood regularly.
C)
Remove cold and frozen foods from dietary trays.
D)
Wrap bruised areas with elastic bandage dressings.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
A)
Hemoglobin levels.
B)
White blood cell count.
C)
Red blood cell count.
D)
Platelet count.
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
A)
Activity level of bowel sounds.
B)
Eating patterns of dietary intake.
C)
Level and amount of physical activity.
D)
Color and consistency of feces.
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
A)
Palpate the right flank for tenderness.
B)
Evaluate the urine for a strong odor.
C)
Test the urine for the presence of hematuria.
D)
Measure the temperature and pulse rate.

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Exam Review

The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
A)
Notify the healthcare provider of the client's medication history.
B)
Have the client sign the surgical and transfusion permits.
C)
Observe the heparin injections sites for signs of bruising.
D)
Ensure that the potential for bleeding is explained to the client.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
A)
Right-sided heart failure.
B)
Left ventricular dysfunction.
C)
Cardiac tamponade.
D)
Internal bleeding.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
A)
Educate client on signs and symptoms of narcotic dependency.
B)
Administer opioid and non-opioid medication simultaneously.
C)
Give maximum dosage when score reaches 10.
D)
Alternate IV and IM analgesic medications.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
A)
Do your family members share combs and brushes?
B)
Do you have any dry patches on your feet and hands?
C)
Has everyone at home already had varicella?
D)
Have the antifungal creams been effective?

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Exam Review

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
A)
Hematocrit.
B)
Platelet count.
C)
White blood cell (WBC) count.
D)
Blood pH level.
A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?
A)
Notify the healthcare provider as soon as possible.
B)
Wear braces on both wrists during the night.
C)
Elevate the hands on two pillows at night.
D)
Apply cold compresses for 30 minutes before bedtime.
A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
A)
Withhold next scheduled dose of treatment.
B)
Maintain the prescribed fluid restriction.
C)
Assess for increasing fluid volume overload.
D)
Increase neurologic checks to every 2 hours.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
A)
Visible swelling of the neck, with no pain.
B)
Warm, soft, moist, salmon colored skin.
C)
Central type obesity, with thin extremities.
D)
Husky voice and troubled by hoarseness.

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