Exam Review
- The nurse is caring for an older client with severe obstructive sleep apnea (OSA) who is reluctant to wear a bi-level positive airway pressure (BIPAP) mask. Which condition has been identified that is often associated with OSA?A)Weight loss.B)Hypotension.C)Gastroesophageal reflux disease.D)Insomnia.
- The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?A)Notify the nurse of a client's readiness for discharge.B)Remove a client's discontinued nasogastric tube.C)Assist clients on the unit with using incentive spirometer devices.D)Irrigate a urinary catheter with normal saline.
- Patient Data The client has not been seen in the clinic for several months and did not follow up after having annual laboratory testing done nine months ago as requested by the healthcare provider (HCP). Which factor(s) is/are the most important for the nurse to include in an initial assessment of the client? Select all that apply.(SATA)A)Medication list from homeB)RelationshipsC)Travel historyD)Substance use (drugs or alcohol)E)Vaccination statusF)Recent losses experiencedG)Sleep patternsH)Work responsibilities
- Patient data (Highlight — findings requiring follow-up are marked)
Patient data
Click to highlight the information that should inform the nurse about the client's mental health.
During the initial assessment, the nurse observes the client has poor hygiene and has dried food on his mouth with food stains on his clothing. He reports living his near job. He reports trouble sleeping. He reports smoking one-half pack of cigarettes a day. He denies pain. He denies thoughts of self-harm or thoughts of suicide.
Exam Review
- Patient Data For each nursing action, click to indicate whether the action is a therapeutic communication or a nontherapeutic communication. Each row must have only one response option selected.
Therapeutic communication Nontherapeutic communication Point out misfortunes of other people ✓ Discuss client's appearance and daily activities ✓ Inform client of medication times ✓ Allow client to verbalize feelings. ✓ - Patient Data The client has been diagnosed with depression by the healthcare provider (HCP). Prescriptions are received for discharge. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse instructs the client that sertraline can cause ▾ dry mouth and that the client can manage this side effect with ▾ sips of waterDropdown 1:Option 1: hypernatremiaOption 2: elevated blood pressureOption 3: dry mouthDropdown 2:Option 1: sips of waterOption 2: frequent restOption 3: elevation of legs
- Patient Data The client returns to the clinic for his four week follow up appointment. Which 3 statements made by the client indicate his depression is improving?(SATA)A)My sister came over and helped me clean my apartment. She is coming over for dinner this week.B)There were several people in the support group who lost a parent, too. We were sad together.C)I went back to work the day after my last appointment and have not missed any work since my appointment.D)I have switched from drinking beer to vodka.E)Sometimes friends are hard to get a hold of, so I have not spoken with them for a while.
- Patient Data The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?A)A peanut butter sandwich with soda and cookies.B)A salad with three kinds of lettuce and fruit.C)Vegetable soup, crackers, and milk.D)A tuna fish sandwich with chips and ice cream.
Exam Review
- The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?A)Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.B)Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg.C)Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.D)Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C).
- A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?A)Any level of fever is serious and should be reported right away.B)Keep the child home from daycare for the next two days.C)Chewable children's aspirin will help prevent inflammation.D)Apply a cool pack to the injection site to reduce discomfort.
- A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow a return to work. When the nurse administrator approaches the charge nurse with the impaired nurse's request, which action is best for the charge nurse to take?A)Ask to meet with the impaired nurse's therapist before allowing the nurse back on the unit.B)Allow the impaired nurse to return to work and monitor medication administration.C)Meet with staff to assess their feelings about the impaired nurse's return to the unit.D)Since treatment is completed, assign the nurse to routine registered nurse (RN) responsibilities.
- A client who is currently receiving azithromycin for an infection reports flu-like symptoms for the past couple of days and a new onset of red and purplish rash with blisters on the skin and mucous membranes of the mouth, nose, eyes, and genitals. Which condition presents with these findings?A)Endocarditis.B)Stevens-Johnson syndrome.C)Pityriasis rosea.D)Anaphylactic reaction.
Exam Review
- The nurse is caring for a client with a subarachnoid hemorrhage (SAH) complicated by a cerebral aneurysm. Which component of care is key to SAH management?A)Blood pressure control.B)Temperature maintenance.C)Prophylactic antiepileptic initiation.D)Glucose stabilization.
- An adult client experiencing pain associated with maxillofacial surgery receives a prescription for acetaminophen and codeine phosphate oral solution 25 mL PO every 6 hours PRN. The bottle is labeled: "Acetaminophen and Codeine Phosphate Oral Solution, USP: 120/12 mg per 5 mL." How many mg of codeine will the client receive with each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
- Patient Data The nurse is evaluating the interventions completed by the team during the delivery. Click to highlight the findings that would indicate that the client and/or newborn are not stable at this time. Vacuum-assisted vaginal delivery of a viable male infant over a second- degree perineal laceration repaired under local anesthesia. There is maternal quantitative blood loss of 1,100 mL. The newborn is attended by the neonatal team. Apgar scores are 3/4/7. The newborn's oxygen saturation is 84%. Caput succedaneum and acrocyanosis are noted.A)Vacuum-assisted vaginal delivery of a viable male infant over a second- degree perineal laceration repaired under local anesthesia.B)There is maternal quantitative blood loss of 1,100 mLC)Apgar scores are 3/4/7D)The newborn's oxygen saturation is 84%.E)Caput succedaneum and acrocyanosis are noted.
- The nurse is providing client teaching on the correct administration of ophthalmic ointment with an older adult client. Which response by the client indicates further education is needed?A)"I should avoid driving until the ointment has dissolved."B)"I will check the name, strength, and expiration date of the ointment."C)"I will apply a small thin strip of ointment into the pocket of the bottom eyelid."D)"I will pull upward on the upper lid to instill the ointment."
Exam Review
- The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?A)Supervise the UAP in the next client's room to evaluate hand hygiene.B)Advise the UAP to wear gloves when obtaining vital signs for all clients.C)Instruct the UAP to return to the client's room to perform handwashing.D)Remind the UAP to continue rubbing the hands together until they are dry.
- The healthcare provider prescribes cefazolin 800 mg intramuscularly every 6 hours. The available vial is labeled, "Cefazolin 1 gram," and the instructions for reconstitution state, "For IM use, add 2.5 mL sterile water for injection to provide a total volume of 3.0 mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
- The nurse is monitoring a client with Cushing's disease in the post anesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care (POC)?A)Provide frequent mouth care.B)Maintain nasal packing.C)Monitor intake and output.D)Keep head of bed at 30".
- A client with Alzheimer's disease (AD) is receiving trazodone, a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?A)Explain that it may take several weeks for the medication to be effective.B)Notify the healthcare provider that a change in dosage may be needed.C)Confirm that the desired effect of the medication has been achieved.D)Evaluate when and how the medication is being administered to the client
Exam Review
- A client diagnosed with psychosis arrives at the emergency department and is communicating non-verbally through gesture-like actions. To encourage the client's verbal communication, which question would be best for the nurse to ask?A)"Tell me about what's been bothering you lately."B)"How did you get to the hospital?"C)"Are you in pain?"D)"What happened before you came here?"
- A client treated for type 2 diabetes mellitus for eight years arrives to the clinic describing elevated blood glucose readings intermittently for the past two months. Which information requires further assessment by the nurse? Reference Range: Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)] White Blood Cell (WBC) 15,000 to 10,000/mm3 (5 to 10 x 109/L)] Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]A)Fasting serum glucose 140 mg/dL (7.8 mmol/L).B)White blood cell count 11,000/mm3 (11 x 109/L).C)Blood urea nitrogen 26 mg/dL (9.28 mmol/L).D)Potassium 3.5 mEq/L (3.5 mmol/L).
- The nurse is assessing a client who was admitted with diabetic ketoacidosis (DKA). Which finding should the nurse expect?A)Jaundice.B)Peripheral edema.C)Respiratory depression.D)Hypotension.
- A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. Which action should the nurse take?A)Explain that this normal secretion can be assessed at the next visit.B)Recommend that the client start wearing a supportive brassiere.C)Reschedule the client's prenatal appointment for the following day.D)Tell the client to begin nipple stimulation to prepare for breast feeding.