Exam Review

The nurse is teaching a group of students about renal disorders.
➢ Which statement, if made by the student, requires follow-up? Select all that apply.
(SATA)
A)
"Pyelonephritis causes a client to have massive amounts of proteinuria."
B)
“Acute kidney injury may be caused by nephrotoxic medications."
C)
“Bacterial cystitis is diagnosed using a 24-hour urine collection.”
D)
“Polycystic kidney disease may cause hematuria after a cyst rupture.”
E)
“Diabetic nephropathy is prevented by increasing the hemoglobin A1C.”
The nurse is providing discharge instructions to a client prescribed lisinopril.
➢ Which of the following instructions should the nurse include? Select all that apply.
(SATA)
A)
"You will need to take your pulse for one minute before each dose."
B)
"You may notice the need to go to the bathroom more often."
C)
"Limit your intake of foods such as avocados and apricots."
D)
"You may notice a decrease in your ability to taste foods."
E)
"The goal of this medication is to lower your cholesterol."
The nurse is assessing a client with suspected Lyme disease.
➢ Which of the following findings would support a diagnosis of Lyme disease? Select all that apply.
(SATA)
A)
lymphadenopathy
B)
fatigue
C)
petechial rash
D)
arthralgias
E)
hemoptysis
The nurse is providing education to a group of pregnant women regarding the prevention of postpartum thrombophlebitis. Which statement by one of the expecting mothers would indicate a correct understanding of the teaching?
Select all that apply.
(SATA)
A)
“After giving birth, we are at an increased risk of clots for 6 to 8 weeks.”
B)
“We shouldn’t go on car rides longer than 4 hours for a few weeks after giving birth.”
C)
“After delivery, we should get up and walk as soon as we are able.”
D)
“Avoiding crossing our legs will help prevent clots from forming.”
E)
“Having a vaginal delivery will increase the risk for postpartum clots”

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Exam Review

The nurse is caring for a client with atrial fibrillation who takes prescribed warfarin. Which alternative therapies should the nurse advise this client to avoid? Select all that apply.
(SATA)
A)
Ginger root
B)
Aloe vera
C)
Garlic
D)
Ginko biloba
E)
Saw palmetto
When caring for an Amish patient, what does the nurse know to be true?
Select all that apply.
(SATA)
A)
They use traditional and alternative health care.
B)
Funerals are conducted in the home.
C)
The authority of women and men are equal.
D)
Many choose to live without health insurance.
E)
Health is believed to be a gift from God.
The nurse is caring for a client who has a prescribed regular insulin sliding scale before meals. The client has the following capillary blood glucose (CBG) levels and insulin orders.
The nurse should do which of the following interventions at 1730? Select all that apply.

(SATA)
A
B
A)
Administer 8 units of regular insulin
B)
Administer 6 units of regular insulin
C)
Notify the primary health care provider (PHCP)
D)
Withhold the prescribed insulin
E)
Modify the client’s prescribed diet to low sodium
1300 – Client is here for a prescribed chemotherapy infusion (four of eight infusions). Client receiving treatment for stage IV breast cancer with metastasis to the liver. Client reports significant fatigue, which has caused her to nap more and procrastinate on her activities of daily living. She reports that no matter how much she sleeps, she never feels rested. The client stated that her hands and feet feel like 'pins and needles' and have worsened since the previous treatment. She reports using topical ointments and creams with no relief. Finally, the client reports experiencing night sweats that started last night and feeling 'hot' today. On assessment, the client is alert and completely oriented. Lung sounds are clear bilaterally, and respirations are unlabored. Skin hot and pale pink in tone; peripheral pulses 2+ and regular. Capillary refill is 3 seconds. Vital signs: T 101.1° F (38.4° C), P 92, RR 18, BP 133/76, pulse oximetry reading 95% on room air.
➢ Complete the following sentence by choosing from the list of options
The nurse is ****highly**** concerned about the client's risk for [neuropathic pain / infection / fatigue] based on the client's [reports of peripheral sensations. / vital signs. / altered sleep pattern.]

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Exam Review

The nurse has become aware of the following client situations.
➢ The nurse should first see the client who is receiving
A)
chemotherapy via a peripherally inserted central catheter (PICC) and reports blistering at the site.
B)
a chemotherapy infusion and develops nausea and vomiting.
C)
oral chemotherapy and reports burning in their mouth while drinking orange juice.
D)
external beam radiation therapy (EBRT) and sitting with visitors in the family waiting room.
The nurse cares for a client receiving fentanyl via patient-controlled analgesia (PCA). After the client reports increased pain, the nurse obtains a provider's order to adjust the PCA settings.
➢ While making the prescribed changes on the PCA device, the nurse should prioritize
A)
verifying the settings with a second nurse.
B)
educating the client about the medication's side effects.
C)
repositioning the client for nonpharmacological pain relief.
D)
reassessing the client's current pain level.
The nurse cares for a client scheduled for spinal surgery in one hour.
➢ The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
A)
gentamicin.
B)
enoxaparin.
C)
hydromorphone.
D)
cyclobenzaprine.
A nurse is conducting a dysphagia screening on a client who was recently extubated.
➢ Which assessment finding requires intervention?
A)
Slight cough after sipping water.
B)
Hoarseness of voice during speech.
C)
Reports of mild throat discomfort when swallowing.
D)
Presence of a wet, gurgling cough after drinking water.

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Exam Review

The nurse is performing teaching for a client scheduled for gastric bypass surgery. Which client statement requires follow-up by the nurse?
A)
"Once I am home, I can advance my diet as tolerated."
B)
"I will have to take a multivitamin after this surgery."
C)
"I will be encouraged to perform leg exercises while I am in bed."
D)
"My weight may increase if I do not change my eating habits."
The nurse is caring for a client with a confirmed pregnancy in her first trimester with hyperthyroidism.
➢ The nurse anticipates the physician will prescribe
A)
levothyroxine.
B)
calcitriol.
C)
methimazole.
D)
propylthiouracil (PTU).
The nurse is developing a plan of care for a child with severe acute glomerulonephritis (AGN). Which of the following should the nurse include in the client's plan of care? Select all that apply.
A)
Restrict the activity to strict bed rest.
B)
Offer snacks rich in potassium.
C)
Obtain daily weights.
D)
Monitor the client’s blood pressure closely.
E)
Obtain a prescription for sodium chloride (normal saline) fluid boluses.
The nurse is caring for a pregnant client at 28 weeks' gestation who presents to the emergency department with signs of preeclampsia. The primary healthcare provider (PHCP) orders magnesium sulfate. What potential complication should the nurse closely monitor for during magnesium sulfate administration?
A)
Pulmonary edema
B)
Hyperglycemia
C)
Hyporeflexia
D)
Increased fetal movement

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Exam Review

1100: Client was brought into the ED via emergency medical services (EMS) after he was found wandering the streets and completely disoriented. He was carrying a wallet and identification. His previous medical history was obtained from medical records—history of atrial fibrillation and diabetes mellitus (type two). On assessment, the client is lethargic, disoriented, and mumbling incoherent words. Breathing appears slightly labored, and wheezes with scattered rhonchi are noted in the bilateral lung fields—productive cough with a large amount of mucous. Skin is hot to touch, pale in tone; pulses 2+ and irregular. The client has an unkempt appearance and is malodorous. Peripheral venous access device (VAD) placed in right forearm. Vital signs: T 102° F (38.9° C), P 92, RR 24, BP 144/89, pulse oximetry reading 91% on room air. Orders received from the physician.
- Admit to the intensive care unit
- Incentive spirometry every 30 minutes while awake
- Notify radiology to obtain the portable chest radiograph (x-ray)
- Administer albuterol via nebulizer
- Apply supplemental oxygen via nasal cannula
- Collect ordered laboratory work (CBC, CMP, blood cultures)
- Perform a complete bed bath with chlorhexidine 2% solution
- Azithromycin 500 mg intravenous piggy-back (IVPB) daily
- Social services consultation
The nurse reviews the physician's orders and plans implementation.
➢ For each potential nursing action, click to specify whether the action is a high priority or a low priority.
- A. Educate the client on using the incentive spirometer
- B. Perform a head-to-toe skin assessment
- C. Notify radiology to obtain the portable chest radiograph (x-ray)
- D. Administer albuterol via nebulizer
- E. Apply supplemental oxygen via nasal cannula
- F. Collect ordered laboratory work (CBC, CMP, blood cultures)
- G. Perform admission medication reconciliation
- H. Perform a complete bed bath
- I. Administer prescribed azithromycin via intravenous infusion
- J. Social services consultation
The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
A)
Coarse tremors
B)
Intrajugular central vascular access device
C)
Wearing a wrist watch
D)
Cardiac pacemaker
The nurse is planning a staff education program about conflict resolution strategies.
➢ It is appropriate for the nurse to identify that compromising in a conflict may result in
A)
incomplete satisfaction of both parties’ concerns.
B)
appeasing an individual by self-sacrificing.
C)
suppression of thoughts and feelings.
D)
satisfaction of an individual’s interest regardless of the impact on others.
The nurse is caring for a client with symptomatic sinus bradycardia.
➢ The nurse recognizes the priority action is to
A)
document the findings.
B)
notify the rapid response team.
C)
continue monitoring the client's vital signs.
D)
review the client's most recent serum potassium level.

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Exam Review

The nurse is caring for a client who is postprocedure following an endoscopy.
➢ Which priority action should the nurse take prior to resuming the client's diet?
A)
assess the client's oxygenation level
B)
assess for the return of the client's gag reflex
C)
have the healthcare provider speak with the client regarding results of the procedure
D)
start with a soft diet to see if the client will tolerate
Which snack would be most appropriate for the nurse to recommend to the parents of a child with cystic fibrosis?
A)
Slices of pineapple
B)
Carrot sticks and fat-free ranch dressing
C)
Celery sticks and peanut butter
D)
Gelatin
The nurse reviews the client's intake and output throughout the twelve-hour shift.
- The client consumed three eight-ounce cups of water.
- The client received 0.9% sodium chloride at 70 mL/hr for 12 hours.
- The client received an infusion of 500 mg of azithromycin reconstituted in 250 mL of 0.9% sodium chloride to treat a bacterial infection.
- The client received 5 mg of morphine sulfate diluted in 0.9% sodium chloride, totaling an infused volume of 7 mL.
➢ When calculating the total intake for the client for the shift, the nurse would document how many milliliters?
A)
1817 mL
B)
1815 mL
C)
1810 mL
D)
1800 mL
0818: Client reports severe shortness of breath and swelling in his lower extremities. He reports a 3-day history of fatigue and decreased urine output. During the assessment, the client was alert and fully oriented. He has 2+ pitting pedal edema in the lower extremities. 2+ peripheral pulses in the upper extremities. Bibasilar crackles upon auscultation. Skin is warm, dry, and normal for ethnicity. Normoactive bowel sounds in all quadrants. Vital signs: T 98° F (36.7°C), P 89, RR 18, BP 164/95, pulse oximetry reading 96% on room air.
- Capillary blood glucose 121 mg/dL (6.72 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
- Serum creatinine 2.5 mg/dL (221 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
- Serum BUN 36 mg/dL (12.9 mmol/L) ([10–20 mg/dL (3.6–7.1 mmol/L)]
- Serum potassium: 5.2 mEq/L [3.5–5 mEq/L (3.5–5 mmol/L)]
- Urinalysis: Mild proteinuria, no hematuria
24 hour fluid intake: 1560 mL
24 hour fluid output: 250 mL
- hypertension
- hyperlipidemia
- coronary artery disease
- glaucoma
- diabetes mellitus (type two)
- carvedilol 6.25 mg p.o. daily
- multivitamin 1 tablet p.o. daily
- lisinopril 10 mg p.o. daily
- simvastatin 10 mg p.o. daily
- ergocalciferol 10000 units p.o. daily
- ethyl eicosapentaenoic acid 2 grams p.o. daily
The nurse is reviewing the client’s assessment data to prepare the client’s care plan.
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client’s progress.
Actions to Take: Prepare the client for peritoneal dialysis. | Request a prescription for sodium chloride (normal saline) 500 mL bolus. | Obtain an order to discontinue the lisinopril. | Obtain a prescription for a continuous infusion of regular insulin. | Request a prescription for a diuretic.
Potential Conditions: Nephrotic syndrome | Hyperglycemia hyperosmolar syndrome | Acute kidney injury | Chronic kidney disease
Parameters to Monitor: Peripheral pulses | Capillary blood glucose | Serum potassium | Temperature | Lung sounds
Actions to Take: Prepare the client for peritoneal dialysis. | Request a prescription for sodium chloride (normal saline) 500 mL bolus. | Obtain an order to discontinue the lisinopril. | Obtain a prescription for a continuous infusion of regular insulin. | Request a prescription for a diuretic.
Parameters to Monitor: Peripheral pulses | Capillary blood glucose | Serum potassium | Temperature | Lung sounds

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