Exam Review
The nurse in the medical-surgical unit is observing the telemetry monitor for assigned clients. Which client condition change requires immediate notification to the primary healthcare provider (PHCP)? A client
A)with normal sinus rhythm (NSR), who has had three premature ventricular contractions (PVCs) in the past hour.B)recovering from cardiac catheterization and has had two brief runs of ventricular tachycardia (VT).C)with atrial fibrillation, whose heart rate decreased from 113 to 95 beats per minute.D)who has developed sinus tachycardia (ST) following the application of nitroglycerin paste.0700 - Handoff report received. On assessment, the client’s breathing appears regular without any distress, and clear lung sounds are noted in all lung fields. Skin is warm to the touch and pink in tone; pulses 2+ and regular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. Two peripheral venous access devices (VAD) were noted in the right and left antecubital spaces. The right VAD had 0.9% saline infusing at 100 mL/hr, and the left had regular insulin infusing at 4 units/hr.
- Continuous infusion of regular insulin per DKA protocol
- 0.9% saline at 100 mL/hr
- Basic metabolic panel (BMP) every 3 hours
- Obtain capillary blood glucose hourly
- Daily complete blood counts (CBC)
The nurse reviews the physician's orders and plans care
➢ Complete the sentences below from the list of options
The nurse understands that the [complete blood count / basic metabolic panel / capillary blood glucose] needs to be monitored due to the client's risk for [hyperglycemia / hypokalemia / hemoconcentration]
- (SATA)
The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following complications should the nurse assess for during the therapy? Select all that apply.
A)HyperglycemiaB)InfectionC)Air embolismD)Cardiac tamponadeE)Dehydration - (SATA)
The nurse is caring for a client experiencing an acute episode of severe anxiety. The nurse should plan to take which appropriate action? Select all that apply.
A)Discuss previous coping skillsB)Stay and observe the clientC)Maintain an environment with low stimuliD)Plan to ambulate with the client in the hallwayE)Instruct the client to identify what triggered the eventF)Assess the client for possible hypoventilationG)Obtain a prescription for haloperidol
Exam Review
- (SATA)
The nurse is assessing a client who has developed cardiac tamponade. Which of the following findings would the nurse expect to observe?
Select all that apply.
A)unilateral cracklesB)systolic murmurC)bradycardiaD)jugular venous distentionE)hypotension - (SATA)
The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply.
A)Decreased painB)Increased urinary outputC)Decreased blood pressureD)Decreased temperatureE)Increased muscle coordination - (SATA)
The nurse is developing a plan of care for a client with a wet-suction chest tube prescribed wall suction.
➢ Which interventions would be appropriate to include? Select all that apply.
A)Apply clamps to the tubing to secure it to the bed.B)Strip the tubing at least once every eight hours.C)Report any bubbling in the suction control chamber.D)Ambulate the client with the device below the insertion site.E)Palpate around the insertion site for any crackles or popping. - (SATA)
The nurse is assessing a child with iron deficiency anemia.
➢ Which assessment findings would support a diagnosis of iron deficiency anemia? Select all that apply.
A)TachycardiaB)PicaC)PallorD)ParesthesiaE)Fatigue
Exam Review
- (SATA)
The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply.
A)drawing a line through the erroneous documentation.B)using correction tape and write over the error.C)writing over the error in darker ink.D)completely black out the error with a black marker.E)discarding the documentation in the trash and starting over.F)writing your initials, date, and time above the erroneous documentation with the word' error.' - (SATA)
The nurse is working with a client with a neural tube defect. Which of the following statements are true regarding neural tube defects?
Select all that apply.
A)"Types of neural tube defects include spina bifida occulta, spina bifida cystica, meningocele, and myelomeningocele."B)"The nurse should protect the exposed sac by covering with a sterile, moist, non-adherent dressing."C)"Left-lateral is the optimal position to minimize tension on the sac."D)"Neurological deficits are always present in clients with neural tube defects."E)"Adequate prenatal Vitamin D intake can prevent neural tube defects." The nurse is teaching a client who is scheduled for a thoracentesis.
➢ Which of the following information should the nurse include? Select all that apply.
A)“This procedure will require you to receive general anesthesia.”B)“You will need to report any shortness of breath following the procedure.”C)“You will need to empty your bladder before this procedure.”D)“A follow-up chest x-ray will be done after the procedure.”E)“You will need to be on a clear liquid diet one day before the procedure.”The nurse is reviewing septic shock with a group of nursing students. It would be correct if the student identifies which causes increased lactate production?
A)Decreased anaerobic glycolysisB)Elevated serum bicarbonate levelsC)Improved tissue oxygenationD)Inadequate tissue perfusion
Exam Review
The nurse is creating a care plan for a child recovering from a hematopoietic stem cell transplant. The nurse is most concerned about the client's risk for
A)infection.B)delirium.C)nutritional imbalance.D)oral mucositis (OM).The nurse is assisting in discharging a client who was treated for digoxin toxicity. While reinforcing teaching on ways to prevent future toxicity, the nurse should recommend the client have an adequate dietary intake of which electrolyte?
A)chlorideB)potassiumC)phosphorusD)sodium0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
The nurse reviews the clinical data and plans the client's care.
➢ 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: insert a peripheral venous access device (VAD) | obtain a stool specimen for culture and sensitivity (C & S) | prepare the client for surgery | request an order for a clear liquid diet
Potential Conditions: peritonitis | diverticulitis | appendicitis | gastroenteritis
Parameters to Monitor: lung sounds | pulse | temperature | hemoglobin and hematocrit
Action to Take: insert a peripheral venous access device (VAD) | obtain a stool specimen for culture and sensitivity (C & S) | prepare the client for surgery | request an order for a clear liquid diet
Parameters to Monitor: lung sounds | pulse | temperature | hemoglobin and hematocrit
1709: 58-year-old African American male presents to the office looking to establish primary care. The client has not had a primary healthcare provider in over eleven years. The client requests a physical examination. The client reports that two months ago, he started noticing changes in his bowel habits, which alternate between diarrhea and constipation. The symptoms are accompanied by occasional dark, tarry stools. This past week, he has had constant abdominal pain that has ranged from a 5/10 to a 7/10 on the Numerical Rating Scale. He describes the pain as 'dull.' He reports that his diet has not changed, and he primarily eats red meat and sandwiches made with luncheon meats and occasionally vegetables. Currently, the client takes a daily aspirin and a multivitamin. He reports a medical history of oral herpes simplex and high blood pressure. He is overweight. He smokes cigarettes daily. On assessment, the client is alert and fully oriented, skin is warm and dry. Lung sounds are clear; the apical pulse is regular. Bowel sounds are active in all quadrants, with no abdominal distention. Capillary refill less than 3 seconds. Peripheral pulses palpable, 2+. Vital signs: T 97.5° F (36.4° C), P 97, RR 18, BP 161/92, pulse oximetry reading 96% on room air.
1741:
1719:
- Point of care (POC) hemoglobin and hematocrit
- Guaiac-based fecal occult blood test (gFOBT)
The nurse is reviewing the client's assessment data to prepare the client's plan of care.
➢ 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: obtain an order for serum type and screen | obtain an order for a colonoscopy | educate the client on adopting a high fiber diet | request a prescription for an oral corticosteroid.
Condition Most Likely Experiencing: bowel obstruction | ulcerative colitis | colon cancer | peptic ulcer disease
Parameter to Monitor: pain level | serum glucose level | bowel elimination pattern or habits | white blood cell (WBC) count
Actions to Take: obtain an order for serum type and screen | obtain an order for a colonoscopy | educate the client on adopting a high fiber diet | request a prescription for an oral corticosteroid.
Parameter to Monitor: pain level | serum glucose level | bowel elimination pattern or habits | white blood cell (WBC) count
Exam Review
The nurse has attended a staff education program about immunizations.
➢ Which of the following statements by the nurse would indicate a correct understanding of the teaching?
A)"The rotavirus vaccine is a live attenuated vaccine type."B)"The hepatitis B vaccine is an example of a toxoid vaccine type."C)"Polio vaccination is recommended during pregnancy"D)"The Human papillomavirus vaccine (HPV) reduces the risk for ovarian cancer."The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
A)Hepatitis CB)Cryptococcosis meningitisC)Clostridium difficileD)ScabiesE)Rheumatic feverF)BotulismG)Hepatitis BH)PediculosisI)Infectious mononucleosisJ)Human immunodeficiency virus (HIV)A nurse is caring for a client prescribed tiotropium bromide inhalation capsules. What action by the client indicates a potential safety concern?
A)Disposing of the tiotropium capsules in the regular household trash.B)Sharing the tiotropium capsules with a family member who has Chronic obstructive pulmonary disease (COPD).C)Inhaling the tiotropium medication while lying down in bed.D)Storing the tiotropium capsules in their original blister pack in a cool, dry place away from moisture and sunlight.The nurse is caring for a client with an indwelling urethral catheter.
➢ Which of the following actions should the nurse take? Select all that apply.
A)Empty drainage bag when ½ full.B)Provide perineal hygiene using mild soap and hot water.C)Ensure tubing is clipped onto the edge of the linens.D)Wear sterile gloves while cleaning the urinary meatus.E)Clean catheter starting at meatus and moving downward while holding it securely.
Exam Review
The nurse is preparing a continuing education course on blood transfusion reactions.
➢ The nurse recognizes which intervention would prevent an ABO incompatibility (hemolytic) transfusion error.
A)Priming a Y-tubing blood administration set with 0.9% sodium chloride (normal saline).B)Ensure that the client has a patent 20-gauge peripheral vascular access device.C)Accurately label the client's blood specimen for crossmatching.D)Review the client's medication allergies.The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question?
A)Iron sucroseB)EnoxaparinC)SucralfateD)HydroxyureaThe nurse in the behavioral health clinic is preparing to discharge a client who has been admitted multiple times for psychosis because of non-adherence to their prescribed antipsychotic medications.
➢ Which statement would be most effective in promoting medication adherence?
A)"Staying in treatment will help you keep your job and stay out of the hospital."B)"I've struggled with staying adherent to my own medications."C)"Do you recognize how many times you've stopped taking your medications?"D)"Can you tell me about the purpose of your medication?"The nurse is assisting the primary health care provider (PHCP) with an elective electrical cardioversion for a chronic atrial fibrillation client. Prior to this procedure, the nurse should perform which action?
A)Remove the client's peripheral vascular access device.B)Review the client's risk factors for post-procedure bleeding.C)Ensure that a water-seal chest tube drainage device is readily available.D)Verify that the informed consent has been obtained by the health care provider (HCP).