Exam Review

A client has been diagnosed with a tumor classified as T2 N1 M0 according to the TNM staging system. Which statement best describes this classification?
A)
The tumor is small, there is no lymph node involvement, and metastasis to distant sites has occurred.
B)
The tumor is large, there is regional lymph node involvement, and no distant metastasis has occurred.
C)
The tumor is localized with no regional lymph node involvement or distant metastasis.
D)
The tumor is in situ, with no lymph node involvement and the presence of distant metastasis.

A nurse is caring for a client in the emergency department. The client exhibits signs of altered mental status and has a history of decreased fluid intake. The healthcare team is assessing the client's condition for potential underlying issues. Indicate whether the following nursing actions are anticipated or contraindicated.

	Anticipated	Contraindicated
Initiate vasopressor therapy to manage hypotension		✓
Administer IV fluids to increase intravascular volume	✓
Administer diuretics to reduce fluid overload		✓
Provide antibiotics for suspected septic shock	✓

A nurse is caring for a client on a mechanical ventilator. The client was admitted for respiratory support following a significant pulmonary event. The nurse will monitor vital signs and observe alarms to ensure the stability of the client's condition. The ventilator alarm is sounding intermittently, and the nurse is reviewing potential interventions to maintain airway patency and ensure adequate ventilation.

	Anticipated	Contraindicated
Ignore ventilator alarms temporarily to reduce noise.		✓
Increase ventilator settings without provider confirmation.		✓
Assess ventilator tubing for disconnection or leaks.	✓
Suction the endotracheal tube to clear potential airway obstructions.	✓

What is the primary goal of administering lactulose to a client with hepatic encephalopathy?
A)
To decrease blood pressure
B)
To improve liver function tests
C)
To enhance the excretion of ammonia from the body
D)
To increase sodium levels in the body

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Exam Review

Which of the following statements about internal radiation therapy (brachytherapy) are accurate? Select All that Apply
(SATA)
A)
Brachytherapy is only used for tumors in the prostate gland.
B)
Limited visitation is typically required during the treatment period.
C)
Body fluids may be contaminated with radiation during this treatment.
D)
The client may emit radiation for a short time after treatment.
E)
The client can safely be in close proximity to pregnant individuals and children.
A client is experiencing angina and has just taken one sublingual nitroglycerin tablet. After 5 minutes, the client still reports chest pain. What should the nurse include in their teaching about the next steps? Select all that apply.
(SATA)
A)
Continue with normal activity and avoid resting.
B)
Call for emergency medical assistance before taking a second tablet.
C)
Take two more sublingual tablets at the same time to expedite relief.
D)
Stop all medications if the pain does not subside with the first tablet.
E)
Take a third sublingual tablet if the pain is still not relieved after the second tablet and 5 minutes have passed.
A nurse is caring for a client with pneumonia who is on mechanical ventilation and exhibits a respiratory rate of 34 breaths per minute. The client's ABG results show a pH of 7.5, PaCO2 of 28 mm Hg, and HCO3 of 22 mEq/L. Which nursing action should be prioritized?
A)
Administer an anxiolytic.
B)
Administer sodium bicarbonate.
C)
Increase oxygen concentration.
D)
Decrease the respiratory rate of the mechanical ventilator.
Which of the following statements best describes the characteristics of malignant tumors compared to benign tumors?
A)
Benign tumors can spread to distant organs and invade surrounding tissues.
B)
Malignant tumors are well-defined, slow-growing, and typically have localized effects.
C)
Malignant tumors are characterized by rapid growth, abnormal cell structure, and the ability to invade surrounding tissues.
D)
Benign tumors are more likely to cause severe systemic symptoms than malignant tumors.

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Exam Review

Which of the following complications can arise after a Trans jugular Intrahepatic Portosystemic Shunt (TIPS) procedure?
A)
Cholecystitis
B)
Biliary obstruction
C)
Ascites
D)
Hepatic encephalopathy
Which of the following statements regarding the storage of sublingual nitroglycerin is accurate?
A)
It can be stored in an open bottle or pill organizer at room temperature.
B)
It should be stored in a light-resistant container.
C)
Nitroglycerin tablets should be refrigerated to enhance their potency.
D)
It should be discarded after one month after opening, regardless of its appearance.
A nurse is caring for a client in a cardiac unit. The client presents with intermittent chest discomfort that varies in intensity and duration. The nurse conducts an assessment to gather pertinent clinical information. Based on the clinical findings, which characteristics are consistent with unstable angina or stable angina.
A)
Chest pain that occurs at rest and increases in severity and duration over time
B)
Chest pain triggered by physical activity and relieved by rest or nitroglycerin
C)
Pain typically resolves within minutes and does not require emergent medical attention
D)
May progress to myocardial infarction if not treated promptly
A client who has sustained a spinal cord injury above the level of T6 presents with bradycardia, hypotension, and warm, flushed skin. Which of the following findings is most indicative of neurogenic shock rather than spinal shock?
A)
Hypothermia
B)
Warm, flushed skin
C)
Increased heart rate
D)
Persistent hypertension

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Exam Review

A client is assessed using the Glasgow Coma Scale (GCS) and demonstrates the following responses: eyes open to sound, incomprehensible sounds, and withdraws arm from pain. What is the total GCS score for this client?
A)
9
B)
10
C)
8
D)
11
A nurse is caring for a postoperative client who has shown a gradual decline in level of consciousness and reduced urine output over the past few hours. The client is most likely experiencing: Select answer choice
A)
hypotension
B)
hypertension
A nurse is documenting the Glasgow Coma Scale (GCS) assessment findings for a client who has experienced a severe head injury. The client opens their eyes only in response to painful stimuli, makes incomprehensible sounds, and exhibits no motor response to pain. What is the correct GCS score for this client?
A)
3
B)
6
C)
4
D)
5
A client presents to the emergency department following a chemical burn from an industrial solvent. What is the nurse's priority intervention?
A)
Initiate running water irrigation of the affected area.
B)
Administer liberal oral fluids to maintain hydration.
C)
Cover the burn with a sterile dressing immediately.
D)
Perform a pain assessment and administer analgesics.

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Exam Review

A client is being treated for a low-risk, stable pulmonary embolism (PE). Which of the following interventions should the nurse prioritize to provide effective management?
A)
Encourage the client to engage in physical therapy to strengthen leg muscles.
B)
Instruct the client to perform deep breathing exercises every hour.
C)
Administer low molecular weight heparin as ordered.
D)
Prepare the client for surgery to remove the embolus.
After a client has undergone coronary artery bypass graft surgery (CABG), which nursing intervention should be prioritized to minimize the risk of complications?
A)
Encouraging the client to eat a full meal shortly after the procedure.
B)
Assessing the client's vital signs regularly and monitoring for signs of surgical site infection.
C)
Encouraging the client to ambulate immediately after surgery.
D)
Administering pain medication on a fixed schedule regardless of the client's reported pain level.
A client diagnosed with Parkinson's disease is prescribed carbidopa-levodopa. What is the primary mechanism of action of this medication?
A)
It blocks acetylcholine release in the brain.
B)
It enhances the reuptake of dopamine in the synapses.
C)
It increases the production of dopamine in the brain.
D)
It inhibits the breakdown of serotonin in the brain.
What interventions should be included in the management of a client showing early signs of sepsis in order to align with the Surviving Sepsis Campaign guidelines? Select All that Apply.
A)
Delaying fluid resuscitation until the client is in septic shock.
B)
Drawing serum lactate and blood cultures
C)
Initiating fluid resuscitation of at least 30 mL/kg within the first 3 hours.
D)
Encouraging the client to maintain a high carbohydrate diet.
E)
Administering antibiotics within 1 hour of recognition of sepsis.

Page 5 of 23

Exam Review

A nurse is caring for a client with cirrhosis who is scheduled to undergo a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure. What is the primary purpose of this procedure in clients with cirrhosis?
A)
To decrease portal hypertension by providing an alternate pathway for blood flow.
B)
To allow for the delivery of chemotherapy directly to liver lesions.
C)
To perform a liver biopsy for assessing liver fibrosis.
D)
To facilitate liver transplant by improving liver function.
A nurse is caring for a client with a C4 spinal cord injury with an indwelling urinary catheter who exhibits signs of autonomic dysreflexia, including a severe headache and hypertension. What should the nurse do first?
A)
Administer an antihypertensive medication to the client.
B)
Place the client in a supine position.
C)
Check the urinary catheter for kinks.
D)
Perform digital rectal stimulation.
A nurse is reviewing the laboratory values of a client with bone marrow suppression and is receiving Oprelvekin. Which of the following values would indicate an improvement in the client's condition?
A)
WBC count of 1,800 mm3
B)
WBC count of 3,500 mm3
C)
Hemoglobin level of 11.5 g/dL
D)
Platelet count of 150,000 mm3
A client who has recently undergone a kidney transplant is prescribed cyclosporine. Which action should the nurse prioritize to prevent potential toxicity?
A)
Monitor the client's BUN and creatinine levels regularly.
B)
Advise the client to consume grapefruit juice to enhance the medication's effectiveness.
C)
Instruct the client to take cyclosporine with food to reduce gastrointestinal irritation.
D)
Encourage increased fluid intake to dilute the medication in the bloodstream.

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