Exam Review
The nurse is planning a staff development conference about changing the process of how clients are seen at a clinic to a first come, first served basis.
➢ This proposed change will model which ethical principle?
A)NonmaleficenceB)VeracityC)PaternalismD)JusticeThe nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take?
A)Keep the stretcher's side rails raised during the transferB)Instruct the client to fold their arms over their chestC)Apply gloves and gown for this procedureD)Unlock the wheels on the stretcher and wheelchair- (SATA)
0730 – The client arrives at the preoperative area with his family. He reports that he is anxious about the procedure. The pre-operative assessment was completed at this time. 20-gauge peripheral vascular access established in the right antecubital space. + blood return and flushes without resistance. The client reports no pain at the insertion site.
The nurse reviews the completed pre-operative assessment
➢ Click to highlight the findings on the assessment that require follow-up
A)ID band applied and verifiedB)Informed consent not yet obtained by surgeonC)Client states NPO since midnight (8 hours ago)D)Client plans to drive self home after procedureE)Taken phenytoin with a sip of waterF)20-gauge IV in right antecubital 1400: Follow-up assessment after the infusion of 30 mL/kg of 0.9% saline bolus (1850 mL total) was infused. Vital signs: T 103.4° F (39.7° C), P 104, RR 22, BP 90/61, pulse oximetry reading 95% on room air.
1410: The physician was notified of the vital signs, and a verbal order for a dopamine drip was received for 5 mcg/kg/minute to titrate to a MAP of 65 mm Hg. The order was read back and verified.
1415: Dopamine infusion started in the client's right antecubital peripheral vascular access device.
1445: The client reports 'stinging' pain at the vascular access site. The site had erythema, swelling, and tenderness when touched. The infusion was stopped.
The nurse reviewed all nursing note entries and notified the physician of the vascular access device assessment findings
➢ 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
Action to Take: Obtain a prescription for phentolamine | Flush the vascular access device | Aspirate any residual medication | Restart the infusion at a lower rate
Potential Condition: Extravasation | Hematoma | Infiltration | Phlebitis
Parameters to Monitor: Urinary output | Neurovascular status of affected extremity | Drainage at vascular access site | Pain level
Action to Take: Obtain a prescription for phentolamine | Flush the vascular access device | Aspirate any residual medication | Restart the infusion at a lower rate
Parameters to Monitor: Urinary output | Neurovascular status of affected extremity | Drainage at vascular access site | Pain level
Exam Review
- (SATA)
The nurse is preparing to obtain a prescription for Rho(D) Immune Globulin. The nurse understands that this medication may be administered through which route? Select all that apply.
A)IntradermalB)IntramuscularC)SubcutaneouslyD)OralE)Intravenous - (SATA)
The nurse is developing a plan of care for a client diagnosed with Kawasaki disease. Which of the following should the nurse include in the client's plan of care?
Select all that apply.
A)Initiate contact precautionsB)Obtain a 12-lead electrocardiogramC)Offer soft foods and liquidsD)Implement fluid restrictionE)Administer aspirin, as prescribed - (SATA)
The nurse is caring for a client who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse?
Select all that apply.
A)administer prescribed carbamazepineB)notify the rapid response team (RRT)C)obtain a prescription for lorazepamD)loosen any restrictive clothingE)review the client's most recent phenytoin level - (SATA)
The nurse provides oral care to clients in the ICU. What are the benefits of providing oral care to a client in critical care? Select all that apply.
A)It promotes the patient’s sense of well-being.B)It prevents deterioration of the oral cavity.C)It decreases the incidence of aspiration pneumonia.D)It eliminates the need for regular flossing.E)It decreases oropharyngeal secretions.F)It compensates for an inadequate diet.
Exam Review
- (SATA)
The nurse has obtained assistance from a licensed practical/vocational nurse (LPN/VN). Which tasks would be appropriate for the RN to delegate to the LPN/VN?
Select all that apply.
A)performing tracheostomy careB)initiate a transfusion of packed red blood cellsC)flushing a peripherally inserted central catheter (PICC)D)inserting an indwelling urinary catheterE)administer enteral feedings via nasogastric tubeF)titrate a medication - (SATA)
The nurse is caring for a client and suspects the client is experiencing domestic violence at home.
➢ What health issues may the nurse expect to see in this client? Select all that apply.
A)Upper respiratory infectionsB)Bruises and broken bonesC)Unintended pregnanciesD)Repetitive strain injuriesE)AlcoholismF)Depression A patient has completed a living will stating that he does not want intubation, mechanical ventilation, or artificial nutrition/hydration should he become unable to communicate his preferences related to medical care. However, the patient’s adult children have expressed their opposition to the patient’s wishes. Which are appropriate nursing actions?
Select all that apply.
A)Notify the patient’s physician, the nursing supervisor, and the risk manager.B)Explain to the patient’s family that the living will cannot be changed at this point.C)Encourage the family to discuss their feelings to try to resolve this issue.D)Request a consult with the facility ethics committee if needed.E)Advise the patient to just go along with the wishes of his adult children.The nurse is planning a staff development conference about pain management. Which statement would be appropriate to include? Select all that apply.
A)Infants do not have developed pain sensors.B)A lack of behavioral signs of pain indicates there is no pain.C)The amount of pain has a positive correlation with the extent of tissue damage.D)Self-report is the most reliable method of pain assessment.E)Analgesics should be administered via the oral route when possible.
Exam Review
Chief Complaint – 23-year-old male presents with his mother, who insists, 'he needs some help; all he does is work and play video games and doesn't socialize with anyone.'
History of Present Illness – 23-year-old Caucasian male presents with his mother with reports of his asociality starting to impact his life. He reports that while in high school, he had a degree of anxiety about socializing with his peers. He thought that as the years passed, it would get better.
He states his anxiety has declined, but he gets paranoid around individuals because they may want to 'do him wrong.' He cannot point to an example of maleficence caused by his friends. He states he doesn't have a problem with his self-esteem, but sometimes social situations are avoided because 'I can see ahead into the future, and I want to avoid people who can bring me harm through their negative energy.' The client reports that he spends his time playing video games, stating he likes games that are fantasy related because 'they take me a while.' He states he has a strong interest in tarot card readings, and for his close friends, he does provide readings. He did offer the examiner a tarot card reading. His interest in tarot cards came from his self-described ability to interpret the spirits of individuals and their auras.
He states that occasionally, he will browse social media and identify a quote or lyric that he feels 'was directed towards me.' The client is employed as an overnight hotel clerk, and his highest level of education is a high school diploma. The client has never been married and has no children. His last relationship was seven years ago, which was brief. He identifies himself as heterosexual. He has a distant criminal history of petty theft and identity theft. No history of violent crimes. He has never been incarcerated. He denies drinking alcohol. However, he does smoke marijuana 2-3x a week. He lives in the basement with his Mother and declines to move out because he has no plans.
Medical History – No past medical history, no past psychiatric history. The client has never been hospitalized—no family history of psychiatric illness.
Mental Status Examination – Alert and fully oriented; Fair concentration; No psychomotor retardation or agitation; Cooperative behavior; Adequately groomed; unkept hair that is bright green in color. He has multiple facial piercings (nose, eyebrow, lip). Speech is at a normal rate with a slightly increased volume. Affect is bright, and he describes his mood as 'okay.' Denies suicidal or homicidal ideations. Intact insight and judgment
➢ Complete the sentence below by choosing from the list of options
The client is at highest risk of developing [antisocial personality disorder / bipolar disorder / schizotypal personality disorder / dependent personality disorder] as evidenced by the client's [illogical thought content. / criminal history. / self-esteem. / living situation.]
A client with a peptic ulcer is prescribed sucralfate. Which statement by the client indicates an understanding of the medication?
A)"I should take sucralfate at least 1 hour before meals and at bedtime."B)"I will avoid taking antacids completely while I'm on sucralfate."C)"I should take sucralfate right before meals and at bedtime."D)"I can expect immediate relief of my ulcer symptoms after taking sucralfate."The nurse is teaching a parent of a child about immunization scheduling.
➢ Which immunization is administered to an infant before eight months of age?
A)human papillomavirus (HPV)B)tetanus, diphtheria, and pertussis (Tdap)C)Haemophilus influenzae type b (Hib)D)varicella1544: Received client to ICU immediately following percutaneous transluminal coronary angioplasty followed by stenting via right femoral artery. Notified primary health care provider about client status. Awaiting orders.
The nurse contacts the primary healthcare provider for admission orders.
➢ For each potential order, click to specify whether the potential order is indicated or not indicated for the client.
- A. maintain the head of the bed less than 30 degrees
- B. elevate the right leg on a pillow
- C. continuous cardiac monitoring
- D. serial troponin levels
- E. keep the client n.p.o.
- F. obtain serum glucose levels every two hours
Exam Review
The nurse is educating a client about the human papillomavirus (HPV) vaccine.
➢ Which group of clients is this vaccination primarily recommended for?
A)adults 65 years and olderB)pregnant womenC)ages 11–12 years oldD)infants at 6 months of ageThe nurse is establishing a care plan for a client with suicidal ideations.
➢ The priority for the nurse when caring for the client is to
A)maintain a therapeutic rapport.B)ensure that the room is secure by locking cabinet doors.C)obtain a prescription for an antidepressant.D)planning appropriate group therapy sessions.A nurse is assigned to care for a client with an internal radiation implant. The client's care plan should include each of the following except?
A)Wear gloves when handling the client's bedpanB)Leave soiled linens in the used linen bin within the client's roomC)Wear a lead apron when providing direct care to the clientD)Place the client in a semi-private room at the end of the hallwayThe nurse is performing a follow-up assessment on a client who was prescribed carbidopa/levodopa. Which assessment finding would indicate a therapeutic finding from this medication?
A)Decrease in tremorsB)Improvement in the excessive droolingC)Reduction in seizure activityD)Improvement in muscle spasticity
Exam Review
The nurse is caring for an infant client with gastroesophageal reflux. At the beginning of the shift, a new prescription for thickened feedings was received to help decrease the infant's passive regurgitation. Which of the following signs would indicate the effectiveness of the intervention?
A)Increased stoolsB)Decreased urine outputC)Absence or decrease of regurgitationD)Weight gainThe nurse is planning a presentation on teen pregnancy for high school students.
➢ Which of the following information should be included in the presentation?
A)There is a low risk of complications in teen pregnancies.B)Teenage pregnancies are commonly denied and concealed in the early stages.C)Teens are using contraceptives at a decreased rate.D)Teenage pregnancies are planned by teenagers as a form of rebellion.An emergency department nurse is caring for a client who presented with fatigue, muscular weakness, and dyspnea. Upon assessment, the client was noted to be coughing frequently and sitting in a tripod position. A subsequent diagnosis of left ventricular failure was made. The nurse understands that manifestations of left-sided heart failure present as respiratory issues because:
A)There is venous congestion in the liver.B)There is hypoperfusion of tissue cells.C)There is pulmonary congestion.D)Despite normal cardiac output, the heart cannot meet the accelerated demands of the body.The nurse is teaching a client with osteomalacia regarding ways to strengthen their bones. Which statement by the client would necessitate further teaching by the nurse?
A)“I’ve started to walk more frequently under the sun.”B)“I don’t like dairy products so I’ve stopped eating them.“C)“I’ve enrolled myself in an exercise program for seniors at the community center.”D)“I’ve been taking Vitamin D supplements lately.”