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    Exam Review

    1. The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?

      A)
      Assess the client for pain
      B)
      Assess the client's oxygen saturation
      C)
      Assess the client with the Glasgow Coma Scale (GCS)
      D)
      Assess the client's lung sounds

    2. The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute.

      ➢ The nurse should document this finding as

      A)
      a widened pulse pressure.
      B)
      a pulse deficit.
      C)
      pulsus paradoxus.
      D)
      an expected finding.

    3. The nurse is teaching a client about newly prescribed doxycycline. Which of the following statements, if made by the client, would require further teaching? Select all that apply.

      (SATA)
      A)
      “I should take this medication with milk or cheese.”
      B)
      “If I develop foul-smelling diarrhea I should contact my doctor.”
      C)
      “I need to wear sunscreen outdoors while taking this medication.”
      D)
      “I can stop this medication when I feel better.”
      E)
      “I should take this medication on an empty stomach.”

    4. The nurse is caring for a client with a sodium level of 130 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which of the following medications may cause this abnormality?

      Select all that apply.

      (SATA)
      A)
      Spironolactone
      B)
      Hydrochlorothiazide
      C)
      Prednisone
      D)
      Sodium polystyrene
      E)
      Tolvaptan
    Page 1 of 38

    Exam Review

    1. The nurse is caring for a client scheduled for an amniocentesis. Which of the following statements would require follow-up? Select all that apply.

      (SATA)
      A)
      “This test may tell me the gender of my baby.”
      B)
      “I will receive intravenous (IV) sedation for this test.”
      C)
      “I may have cramping after this procedure.”
      D)
      “I may be given a medicine to stimulate contractions.”
      E)
      “The results will tell me how my baby will handle labor.”

    2. The nurse is providing teaching to the mother of an infant with a diagnosis of heart failure. Which of the following educational points would be helpful for optimizing feedings for this infant?

      Select all that apply.

      (SATA)
      A)
      Small, frequent feedings.
      B)
      Feeding every 5 hours.
      C)
      Feed for a maximum of 30 minutes.
      D)
      Increased calorie formula.
      E)
      Switching from breastfeeding to formula.

    3. The nurse has attended a staff education program about pressure ulcers.

      ➢ Which of the following would the nurse recognize as an accurate statement regarding pressure ulcers? Select all that apply.

      (SATA)
      A)
      "In a stage II pressure ulcer, part of the dermis and epidermis are lost."
      B)
      "In a stage I pressure ulcer, there is a loss of integrity of the epidermis only."
      C)
      "In a stage III pressure ulcer, a deep tissue injury can expose fat."
      D)
      "In a stage IV pressure ulcer, the base of the wound is covered by eschar."
      E)
      "Stage III involves extensive tissue damage and can lead to bone and muscle involvement."

    4. The client is diagnosed with acute pancreatitis. Which preventative intervention should the nurse implement to reduce the client's risk of developing a respiratory infection?

      Select all that apply.

      (SATA)
      A)
      Assist the client to turn and reposition frequently
      B)
      Document the respiratory rate and oxygen saturation
      C)
      Place the client in a semi-fowlers position
      D)
      Encourage deep breathing and coughing.
      E)
      Obtain a prescription for prophylactic antibiotics
    Page 2 of 38

    Exam Review

    1. When the nurse is educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following should the nurse emphasize as early signs of heart failure?

      Select all that apply.

      (SATA)
      A)
      Diaphoresis
      B)
      Sudden weight gain
      C)
      No wet diapers
      D)
      Hypoxia
      E)
      Increased appetite

    2. Outpatient Clinic Nurses' Notes

      1030: A 20-year-old female and her mother present to the clinic reporting a 3-day fever and diarrhea with nausea and vomiting (N/V). She has been unable to eat and has tolerated only sips of fluid. Because she has been unable to eat, she has not taken her insulin. Her mother stated, "I thought she was getting better, but it happened so suddenly that she started feeling like this." Her mother reports she recently arrived back from an international trip. On assessment, the client is weak and has to be assisted to the examination table. She is very lethargic and is slow to respond to any question. She has tachypnea, and respirations are deep and rapid with an acetone-type of odor. Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants, and the client reports nausea. Skin is warm and very dry. Capillary refill > 3 seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP 96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was obtained at 374 mg/dL (normal 70-110 mg/dL).

      • Diabetes mellitus, type I
      • Borderline personality disorder
      • Multiple suicide attempts
      • Major depressive disorder
      • Acne vulgaris
      • Direct admission to the intensive care unit (ICU) immediately via EMS
      • Establish peripheral vascular access devices
      • Two liters of 0.9% saline to run concurrently over one hour
      • Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
      • Acetaminophen 1 gram every eight hours PRN pain
      • 5 units of regular insulin intravenous (IV) push x 1 dose
      • CBC with differential
      • Complete metabolic panel (CMP)
      • Blood cultures × 2 sites
      • Arterial blood gas on room air
      • Obtain glycated hemoglobin A1C level
      • NPO
      • Consult endocrinology reason: DKA management

      Intensive Care Unit Nurses' Note

      1145: Client arrives at ICU and is severely lethargic. Physician orders reviewed. Vital signs: T 102° F (39° C), P 136, RR 29, BP 92/60, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 379 mg/dL (normal 70-110 mg/dL). The client had one episode of emesis of opaque fluid upon arrival. Reports nausea.

      1250: Intravenous fluids administered. Vital signs: T 100° F (37.8° C), P 113, RR 29, BP 101/70, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 360 mg/dL (normal 70-110 mg/dL). Headache was reported as 8 on a scale of 0 (no pain) to 10 (severe pain). Reports nausea. The endocrinology consult was notified, and regular insulin was administered as prescribed.

      Which of the following three (3) assessment findings requires immediate follow-up?

      (SATA)
      A)
      lung sounds
      B)
      reports of dizziness
      C)
      previous suicide attempts
      D)
      pulse, respirations, blood pressure
      E)
      abdominal assessment findings
      F)
      pulse oximetry reading
      G)
      capillary blood glucose result

    3. Outpatient Clinic Nurses' Notes

      1030: A 20-year-old female and her mother present to the clinic reporting a 3-day fever and diarrhea with nausea and vomiting (N/V). She has been unable to eat and has tolerated only sips of fluid. Because she has been unable to eat, she has not taken her insulin. Her mother stated, "I thought she was getting better, but it happened so suddenly that she started feeling like this." Her mother reports she recently arrived back from an international trip. On assessment, the client is weak and has to be assisted to the examination table. She is very lethargic and is slow to respond to any question. She has tachypnea, and respirations are deep and rapid with an acetone-type of odor. Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants, and the client reports nausea. Skin is warm and very dry. Capillary refill > 3 seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP 96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was obtained at 374 mg/dL (normal 70-110 mg/dL).

      • Diabetes mellitus, type I
      • Borderline personality disorder
      • Multiple suicide attempts
      • Major depressive disorder
      • Acne vulgaris
      • Direct admission to the intensive care unit (ICU) immediately via EMS
      • Establish peripheral vascular access devices
      • Two liters of 0.9% saline to run concurrently over one hour
      • Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
      • Acetaminophen 1 gram every eight hours PRN pain
      • 5 units of regular insulin intravenous (IV) push x 1 dose
      • CBC with differential
      • Complete metabolic panel (CMP)
      • Blood cultures × 2 sites
      • Arterial blood gas on room air
      • Obtain glycated hemoglobin A1C level
      • NPO
      • Consult endocrinology reason: DKA management

      Intensive Care Unit Nurses' Note

      1145: Client arrives at ICU and is severely lethargic. Physician orders reviewed. Vital signs: T 102° F (39° C), P 136, RR 29, BP 92/60, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 379 mg/dL (normal 70-110 mg/dL). The client had one episode of emesis of opaque fluid upon arrival. Reports nausea.

      1250: Intravenous fluids administered. Vital signs: T 100° F (37.8° C), P 113, RR 29, BP 101/70, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 360 mg/dL (normal 70-110 mg/dL). Headache was reported as 8 on a scale of 0 (no pain) to 10 (severe pain). Reports nausea. The endocrinology consult was notified, and regular insulin was administered as prescribed.

      ➢ For each client finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process

      • A. hyperglycemia
      • B. fluid volume deficit
      • C. urine ketones
      • D. abrupt onset of symptoms
      • E. altered level of consciousness

    4. Outpatient Clinic Nurses' Notes

      1030: A 20-year-old female and her mother present to the clinic reporting a 3-day fever and diarrhea with nausea and vomiting (N/V). She has been unable to eat and has tolerated only sips of fluid. Because she has been unable to eat, she has not taken her insulin. Her mother stated, "I thought she was getting better, but it happened so suddenly that she started feeling like this." Her mother reports she recently arrived back from an international trip. On assessment, the client is weak and has to be assisted to the examination table. She is very lethargic and is slow to respond to any question. She has tachypnea, and respirations are deep and rapid with an acetone-type of odor. Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants, and the client reports nausea. Skin is warm and very dry. Capillary refill > 3 seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP 96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was obtained at 374 mg/dL (normal 70-110 mg/dL).

      • Diabetes mellitus, type I
      • Borderline personality disorder
      • Multiple suicide attempts
      • Major depressive disorder
      • Acne vulgaris
      • Direct admission to the intensive care unit (ICU) immediately via EMS
      • Establish peripheral vascular access devices
      • Two liters of 0.9% saline to run concurrently over one hour
      • Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
      • Acetaminophen 1 gram every eight hours PRN pain
      • 5 units of regular insulin intravenous (IV) push x 1 dose
      • CBC with differential
      • Complete metabolic panel (CMP)
      • Blood cultures × 2 sites
      • Arterial blood gas on room air
      • Obtain glycated hemoglobin A1C level
      • NPO
      • Consult endocrinology reason: DKA management

      Intensive Care Unit Nurses' Note

      1145: Client arrives at ICU and is severely lethargic. Physician orders reviewed. Vital signs: T 102° F (39° C), P 136, RR 29, BP 92/60, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 379 mg/dL (normal 70-110 mg/dL). The client had one episode of emesis of opaque fluid upon arrival. Reports nausea.

      1250: Intravenous fluids administered. Vital signs: T 100° F (37.8° C), P 113, RR 29, BP 101/70, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 360 mg/dL (normal 70-110 mg/dL). Headache was reported as 8 on a scale of 0 (no pain) to 10 (severe pain). Reports nausea. The endocrinology consult was notified, and regular insulin was administered as prescribed.

      ➢ Complete the sentence below by choosing from the list of options

      The client is at highest risk of developing [suicide / diabetic ketoacidosis / hyperglycemic hyperosmolar state] as evidenced by the client's [history of suicide attempts. / recent international travel. / fluid volume deficit.]

    Page 3 of 38

    Exam Review

    1. Outpatient Clinic Nurses' Notes

      1030: A 20-year-old female and her mother present to the clinic reporting a 3-day fever and diarrhea with nausea and vomiting (N/V). She has been unable to eat and has tolerated only sips of fluid. Because she has been unable to eat, she has not taken her insulin. Her mother stated, "I thought she was getting better, but it happened so suddenly that she started feeling like this." Her mother reports she recently arrived back from an international trip. On assessment, the client is weak and has to be assisted to the examination table. She is very lethargic and is slow to respond to any question. She has tachypnea, and respirations are deep and rapid with an acetone-type of odor. Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants, and the client reports nausea. Skin is warm and very dry. Capillary refill > 3 seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP 96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was obtained at 374 mg/dL (normal 70-110 mg/dL).

      • Diabetes mellitus, type I
      • Borderline personality disorder
      • Multiple suicide attempts
      • Major depressive disorder
      • Acne vulgaris
      • Direct admission to the intensive care unit (ICU) immediately via EMS
      • Establish peripheral vascular access devices
      • Two liters of 0.9% saline to run concurrently over one hour
      • Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
      • Acetaminophen 1 gram every eight hours PRN pain
      • 5 units of regular insulin intravenous (IV) push x 1 dose
      • CBC with differential
      • Complete metabolic panel (CMP)
      • Blood cultures × 2 sites
      • Arterial blood gas on room air
      • Obtain glycated hemoglobin A1C level
      • NPO
      • Consult endocrinology reason: DKA management

      Intensive Care Unit Nurses' Note

      1145: Client arrives at ICU and is severely lethargic. Physician orders reviewed. Vital signs: T 102° F (39° C), P 136, RR 29, BP 92/60, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 379 mg/dL (normal 70-110 mg/dL). The client had one episode of emesis of opaque fluid upon arrival. Reports nausea.

      1250: Intravenous fluids administered. Vital signs: T 100° F (37.8° C), P 113, RR 29, BP 101/70, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 360 mg/dL (normal 70-110 mg/dL). Headache was reported as 8 on a scale of 0 (no pain) to 10 (severe pain). Reports nausea. The endocrinology consult was notified, and regular insulin was administered as prescribed.

      The outpatient clinic nurse gives the intensive care unit nurse a telephone handoff report

      The client arrives at the ICU, and the ICU nurse reviews the nurses' notes, medical history, and physician orders

      ➢ Complete the sentences below from the list of options

      The nurse understands that the rationale for the prescribed intravenous fluids is to [increase urinary output. / lower blood glucose. / restore circulatory volume.] The nurse understands that the rationale for the prescribed intravenous regular insulin is to [rapidly drop the blood glucose. / treat the ketoacidosis. / restore circulatory volume.]

    2. Outpatient Clinic Nurses' Notes

      1030: A 20-year-old female and her mother present to the clinic reporting a 3-day fever and diarrhea with nausea and vomiting (N/V). She has been unable to eat and has tolerated only sips of fluid. Because she has been unable to eat, she has not taken her insulin. Her mother stated, "I thought she was getting better, but it happened so suddenly that she started feeling like this." Her mother reports she recently arrived back from an international trip. On assessment, the client is weak and has to be assisted to the examination table. She is very lethargic and is slow to respond to any question. She has tachypnea, and respirations are deep and rapid with an acetone-type of odor. Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants, and the client reports nausea. Skin is warm and very dry. Capillary refill > 3 seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP 96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was obtained at 374 mg/dL (normal 70-110 mg/dL).

      • Diabetes mellitus, type I
      • Borderline personality disorder
      • Multiple suicide attempts
      • Major depressive disorder
      • Acne vulgaris
      • Direct admission to the intensive care unit (ICU) immediately via EMS
      • Establish peripheral vascular access devices
      • Two liters of 0.9% saline to run concurrently over one hour
      • Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
      • Acetaminophen 1 gram every eight hours PRN pain
      • 5 units of regular insulin intravenous (IV) push x 1 dose
      • CBC with differential
      • Complete metabolic panel (CMP)
      • Blood cultures × 2 sites
      • Arterial blood gas on room air
      • Obtain glycated hemoglobin A1C level
      • NPO
      • Consult endocrinology reason: DKA management

      Intensive Care Unit Nurses' Note

      1145: Client arrives at ICU and is severely lethargic. Physician orders reviewed. Vital signs: T 102° F (39° C), P 136, RR 29, BP 92/60, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 379 mg/dL (normal 70-110 mg/dL). The client had one episode of emesis of opaque fluid upon arrival. Reports nausea.

      1250: Intravenous fluids administered. Vital signs: T 100° F (37.8° C), P 113, RR 29, BP 101/70, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 360 mg/dL (normal 70-110 mg/dL). Headache was reported as 8 on a scale of 0 (no pain) to 10 (severe pain). Reports nausea. The endocrinology consult was notified, and regular insulin was administered as prescribed.

      The intensive care unit (ICU) nurse obtains vital signs, reviews the physician's orders, and makes an entry into the nurses' note

      ➢ It would be a priority for the nurse to implement which two (2) physician orders based on the 1145 nursing note entry?

      A)
      Establish peripheral vascular access devices
      B)
      Two liters of 0.9% saline to run concurrently over one hour
      C)
      Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
      D)
      Acetaminophen 1 gram every eight hours PRN pain
      E)
      5 units of regular insulin intravenous (IV) push x 1 dose
      F)
      Obtain laboratory testing
      G)
      Consult endocrinology
      H)
      Educate the client that they are NPO

    3. Outpatient Clinic Nurses' Notes

      1030: A 20-year-old female and her mother present to the clinic reporting a 3-day fever and diarrhea with nausea and vomiting (N/V). She has been unable to eat and has tolerated only sips of fluid. Because she has been unable to eat, she has not taken her insulin. Her mother stated, "I thought she was getting better, but it happened so suddenly that she started feeling like this." Her mother reports she recently arrived back from an international trip. On assessment, the client is weak and has to be assisted to the examination table. She is very lethargic and is slow to respond to any question. She has tachypnea, and respirations are deep and rapid with an acetone-type of odor. Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants, and the client reports nausea. Skin is warm and very dry. Capillary refill > 3 seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP 96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was obtained at 374 mg/dL (normal 70-110 mg/dL).

      • Diabetes mellitus, type I
      • Borderline personality disorder
      • Multiple suicide attempts
      • Major depressive disorder
      • Acne vulgaris
      • Direct admission to the intensive care unit (ICU) immediately via EMS
      • Establish peripheral vascular access devices
      • Two liters of 0.9% saline to run concurrently over one hour
      • Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
      • Acetaminophen 1 gram every eight hours PRN pain
      • 5 units of regular insulin intravenous (IV) push x 1 dose
      • CBC with differential
      • Complete metabolic panel (CMP)
      • Blood cultures × 2 sites
      • Arterial blood gas on room air
      • Obtain glycated hemoglobin A1C level
      • NPO
      • Consult endocrinology reason: DKA management

      Intensive Care Unit Nurses' Note

      1145: Client arrives at ICU and is severely lethargic. Physician orders reviewed. Vital signs: T 102° F (39° C), P 136, RR 29, BP 92/60, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 379 mg/dL (normal 70-110 mg/dL). The client had one episode of emesis of opaque fluid upon arrival. Reports nausea.

      1250: Intravenous fluids administered. Vital signs: T 100° F (37.8° C), P 113, RR 29, BP 101/70, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 360 mg/dL (normal 70-110 mg/dL). Headache was reported as 8 on a scale of 0 (no pain) to 10 (severe pain). Reports nausea. The endocrinology consult was notified, and regular insulin was administered as prescribed.

      The nurse reviews the nurses' note entries from 1250 [ICU Nurses' Notes (2)] and compares them to the 1030 entry [clinic nurses' notes]

      ➢ For each assessment finding, click to specify if it is improved, unchanged, or worsening

      Note: Each row must have 1 response option selected.

      • A. Pulse rate
      • B. Blood pressure
      • C. Capillary blood glucose
      • D. Pain level
      • E. Reports of nausea
      • F. Peripheral pulses

    4. The nurse is caring for a child experiencing anaphylactic shock. The nurse should prioritize administering

      A)
      nasal cannula oxygen.
      B)
      intramuscular (IM) epinephrine.
      C)
      intravenous (IV) dexamethasone.
      D)
      intravenous (IV) diphenhydramine.
    Page 4 of 38

    Exam Review

    1. 1540: A 59-year-old male who was doing home repairs fell from the top of an 8-foot stepladder. He experienced a brief loss of consciousness, which he regained once his wife checked on him. The client's wife drove him to the ED to get further care. A large laceration over the right parietal area with a large amount of bloody drainage. The client endorses a headache rated 6 on a scale of 0 (no pain) to 10 (severe pain). The client reports right lower arm pain, rated 2 on a scale of 0 (no pain) to 10 (severe pain). A full range of motion was noted in the right arm, with slight bruising and discomfort with movement.

      Past medical history:

      • Hyperlipidemia

      • Hypothyroidism

      • Benign prostatic hyperplasia

      • Coronary artery disease

      • Venous thromboembolism

      Current medications -

      • Apixaban

      • Tamsulosin

      • Multivitamin

      • Levothyroxine

      • Atorvastatin

      • Gemfibrozil

      1540: Oral temperature 97.7° F (36.5° C), P 98, RR 18, BP 130/85, pulse oximetry 95% on room air

      Clinical illustration

      1619: The client's wife alerted RN to the bedside, where she stated, 'he is getting confused.' The client was assessed and is not oriented to person, place, or situation. The client kept repeating, "Where am I"? Reoriented the client. The pupillary assessment showed the right pupil at 4 mm and the left at 2 mm. Both were sluggish to light. Notified the physician of the condition change at this time.

      1655: Head CT scan

      • Axial head computed tomography scan shows a frontoparietal large subdural hematoma

      1655: Radiograph (x-ray) of the right radius and ulna

      • No evidence of fracture, significant soft tissue swelling

      ➢ Which of the following assessment findings require immediate follow-up? Select all that apply.

      A)
      pulse, respirations, and blood pressure
      B)
      neurological assessment
      C)
      temperature and pulse oximetry reading
      D)
      current medications
      E)
      reports of dizziness
      F)
      lung sounds
      G)
      reports of nausea
      H)
      arm pain

    2. 1540: A 59-year-old male who was doing home repairs fell from the top of an 8-foot stepladder. He experienced a brief loss of consciousness, which he regained once his wife checked on him. The client's wife drove him to the ED to get further care. A large laceration over the right parietal area with a large amount of bloody drainage. The client endorses a headache rated 6 on a scale of 0 (no pain) to 10 (severe pain). The client reports right lower arm pain, rated 2 on a scale of 0 (no pain) to 10 (severe pain). A full range of motion was noted in the right arm, with slight bruising and discomfort with movement.

      Past medical history:

      • Hyperlipidemia

      • Hypothyroidism

      • Benign prostatic hyperplasia

      • Coronary artery disease

      • Venous thromboembolism

      Current medications -

      • Apixaban

      • Tamsulosin

      • Multivitamin

      • Levothyroxine

      • Atorvastatin

      • Gemfibrozil

      1540: Oral temperature 97.7° F (36.5° C), P 98, RR 18, BP 130/85, pulse oximetry 95% on room air

      Clinical illustration

      1619: The client's wife alerted RN to the bedside, where she stated, 'he is getting confused.' The client was assessed and is not oriented to person, place, or situation. The client kept repeating, "Where am I"? Reoriented the client. The pupillary assessment showed the right pupil at 4 mm and the left at 2 mm. Both were sluggish to light. Notified the physician of the condition change at this time.

      1655: Head CT scan

      • Axial head computed tomography scan shows a frontoparietal large subdural hematoma

      1655: Radiograph (x-ray) of the right radius and ulna

      • No evidence of fracture, significant soft tissue swelling

      ➢ Click to specify the issues the client is at risk of developing

      Each row must have one (1) response selected

      • A. pulmonary embolism
      • B. abdominal aortic aneurysm rupture
      • C. traumatic brain injury
      • D. bacterial meningitis
      • E. ischemic stroke
      • F. arm injury

    3. 1540: A 59-year-old male who was doing home repairs fell from the top of an 8-foot stepladder. He experienced a brief loss of consciousness, which he regained once his wife checked on him. The client's wife drove him to the ED to get further care. A large laceration over the right parietal area with a large amount of bloody drainage. The client endorses a headache rated 6 on a scale of 0 (no pain) to 10 (severe pain). The client reports right lower arm pain, rated 2 on a scale of 0 (no pain) to 10 (severe pain). A full range of motion was noted in the right arm, with slight bruising and discomfort with movement.

      Past medical history:

      • Hyperlipidemia

      • Hypothyroidism

      • Benign prostatic hyperplasia

      • Coronary artery disease

      • Venous thromboembolism

      Current medications -

      • Apixaban

      • Tamsulosin

      • Multivitamin

      • Levothyroxine

      • Atorvastatin

      • Gemfibrozil

      1540: Oral temperature 97.7° F (36.5° C), P 98, RR 18, BP 130/85, pulse oximetry 95% on room air

      Clinical illustration

      1619: The client's wife alerted RN to the bedside, where she stated, 'he is getting confused.' The client was assessed and is not oriented to person, place, or situation. The client kept repeating, "Where am I"? Reoriented the client. The pupillary assessment showed the right pupil at 4 mm and the left at 2 mm. Both were sluggish to light. Notified the physician of the condition change at this time.

      1655: Head CT scan

      • Axial head computed tomography scan shows a frontoparietal large subdural hematoma

      1655: Radiograph (x-ray) of the right radius and ulna

      • No evidence of fracture, significant soft tissue swelling

      ➢ The client is at highest risk of developing

      A)
      pulmonary embolism.
      B)
      right arm contracture.
      C)
      ischemic stroke.
      D)
      traumatic brain injury.

    4. 1540: A 59-year-old male who was doing home repairs fell from the top of an 8-foot stepladder. He experienced a brief loss of consciousness, which he regained once his wife checked on him. The client's wife drove him to the ED to get further care. A large laceration over the right parietal area with a large amount of bloody drainage. The client endorses a headache rated 6 on a scale of 0 (no pain) to 10 (severe pain). The client reports right lower arm pain, rated 2 on a scale of 0 (no pain) to 10 (severe pain). A full range of motion was noted in the right arm, with slight bruising and discomfort with movement.

      Past medical history:

      • Hyperlipidemia

      • Hypothyroidism

      • Benign prostatic hyperplasia

      • Coronary artery disease

      • Venous thromboembolism

      Current medications -

      • Apixaban

      • Tamsulosin

      • Multivitamin

      • Levothyroxine

      • Atorvastatin

      • Gemfibrozil

      1540: Oral temperature 97.7° F (36.5° C), P 98, RR 18, BP 130/85, pulse oximetry 95% on room air

      Clinical illustration

      1619: The client's wife alerted RN to the bedside, where she stated, 'he is getting confused.' The client was assessed and is not oriented to person, place, or situation. The client kept repeating, "Where am I"? Reoriented the client. The pupillary assessment showed the right pupil at 4 mm and the left at 2 mm. Both were sluggish to light. Notified the physician of the condition change at this time.

      1655: Head CT scan

      • Axial head computed tomography scan shows a frontoparietal large subdural hematoma

      1655: Radiograph (x-ray) of the right radius and ulna

      • No evidence of fracture, significant soft tissue swelling

      The nurse reviews the Nurses' Note from 1619

      ➢ For each potential order, click to specify whether the potential order is indicated or not indicated for the client

      Each row must have at least one (1) option selected

      • A. intravenous fluid boluses
      • B. wound care
      • C. computed tomography scan (CT) of the head
      • D. right arm radiograph
      • E. seizure precautions
      • F. intravenous glucocorticoids
      • G. neurological assessment once every six hours
    Page 5 of 38

    Exam Review

    1. 1540: A 59-year-old male who was doing home repairs fell from the top of an 8-foot stepladder. He experienced a brief loss of consciousness, which he regained once his wife checked on him. The client's wife drove him to the ED to get further care. A large laceration over the right parietal area with a large amount of bloody drainage. The client endorses a headache rated 6 on a scale of 0 (no pain) to 10 (severe pain). The client reports right lower arm pain, rated 2 on a scale of 0 (no pain) to 10 (severe pain). A full range of motion was noted in the right arm, with slight bruising and discomfort with movement.

      Past medical history:

      • Hyperlipidemia

      • Hypothyroidism

      • Benign prostatic hyperplasia

      • Coronary artery disease

      • Venous thromboembolism

      Current medications -

      • Apixaban

      • Tamsulosin

      • Multivitamin

      • Levothyroxine

      • Atorvastatin

      • Gemfibrozil

      1540: Oral temperature 97.7° F (36.5° C), P 98, RR 18, BP 130/85, pulse oximetry 95% on room air

      Clinical illustration

      1619: The client's wife alerted RN to the bedside, where she stated, 'he is getting confused.' The client was assessed and is not oriented to person, place, or situation. The client kept repeating, "Where am I"? Reoriented the client. The pupillary assessment showed the right pupil at 4 mm and the left at 2 mm. Both were sluggish to light. Notified the physician of the condition change at this time.

      1655: Head CT scan

      • Axial head computed tomography scan shows a frontoparietal large subdural hematoma

      1655: Radiograph (x-ray) of the right radius and ulna

      • No evidence of fracture, significant soft tissue swelling

      The nurse reviews the diagnostic results

      ➢ Complete the following sentences by choosing from the list of options

      After reviewing the diagnostic imaging results, the nurse should [place a warm compress on the client's right lower arm. / communicate the results to the physician. / assess the client's swallowing ability by giving the client 240 mL of room temperature water.] The nurse should prepare the client for possible [surgical intervention. / admission to the medical-surgical unit. / casting of the right lower arm.] To reverse the anticoagulant effects, the nurse should obtain a prescription for [protamine sulfate. / platelet transfusion. / andexanet.]

    2. 1540: A 59-year-old male who was doing home repairs fell from the top of an 8-foot stepladder. He experienced a brief loss of consciousness, which he regained once his wife checked on him. The client's wife drove him to the ED to get further care. A large laceration over the right parietal area with a large amount of bloody drainage. The client endorses a headache rated 6 on a scale of 0 (no pain) to 10 (severe pain). The client reports right lower arm pain, rated 2 on a scale of 0 (no pain) to 10 (severe pain). A full range of motion was noted in the right arm, with slight bruising and discomfort with movement.

      Past medical history:

      • Hyperlipidemia

      • Hypothyroidism

      • Benign prostatic hyperplasia

      • Coronary artery disease

      • Venous thromboembolism

      Current medications -

      • Apixaban

      • Tamsulosin

      • Multivitamin

      • Levothyroxine

      • Atorvastatin

      • Gemfibrozil

      1540: Oral temperature 97.7° F (36.5° C), P 98, RR 18, BP 130/85, pulse oximetry 95% on room air

      Clinical illustration

      1619: The client's wife alerted RN to the bedside, where she stated, 'he is getting confused.' The client was assessed and is not oriented to person, place, or situation. The client kept repeating, "Where am I"? Reoriented the client. The pupillary assessment showed the right pupil at 4 mm and the left at 2 mm. Both were sluggish to light. Notified the physician of the condition change at this time.

      1655: Head CT scan

      • Axial head computed tomography scan shows a frontoparietal large subdural hematoma

      1655: Radiograph (x-ray) of the right radius and ulna

      • No evidence of fracture, significant soft tissue swelling

      The nurse prepares for the client to be transferred to the neurological intensive care unit

      ➢ Complete the sentence below by choosing from the list of options

      It is essential for the nurse to prioritize a [musculoskeletal / Glasgow coma scale / pain] assessment before transferring the client to the intensive care unit.

    3. The nurse is caring for a client with an ileostomy who reports an embarrassing odor.

      ➢ The nurse should recommend that the client avoid consuming

      A)
      buttermilk.
      B)
      parsley.
      C)
      yogurt.
      D)
      eggs.

    4. 1100 - Client presents for a routine follow-up and a medication refill. Client has no acute concerns and reports full adherence to his prescribed medications. Vital signs: T 97.5° F (36.4° C), P 90, RR 18, BP 138/88, pulse oximetry reading 96% on room air.

      Clinical illustration

      • diabetes mellitus (type 2)
      • hyperlipidemia
      • hypertension
      • irritable bowel syndrome
      • metformin 1 gram by mouth daily
      • glipizide 5 mg by mouth daily, before breakfast
      • lisinopril 40 mg by mouth daily
      • multivitamin 1 tablet by mouth daily
      • atorvastatin 80 mg by mouth daily

      The nurse reviews the client's medical record

      ➢ Please complete the sentence below from the list of options

      Based on the August glycated hemoglobin A1C results the client is [going to require a prescription for insulin. / having frequent episodes of hyperglycemia. / demonstrating evidence of good glucose control.]

    Page 6 of 38