NursGuru

    Exam Review

    1. A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
      A)
      A raised red rash around the fistula site
      B)
      Cold and numb sensation distal to the fistula site
      C)
      Foul-smelling drainage from the fistula site
      D)
      Pain in the right arm proximal to the fistula site
    2. A client's 24-hour urine for creatinine clearance reveals the client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m². What stage of chronic kidney disease is the client in?
      A)
      Stage 4
      B)
      Stage 3
      C)
      Stage 2
      D)
      Stage 1
    3. In an emergency department, a nurse is presented with four clients. Which client should the nurse prioritize based on the ABCDE approach?
      A)
      A 40-year-old with a headache following a stressful day at work
      B)
      A 30-year-old with a minor laceration on the arm
      C)
      A 50-year-old with suspected sepsis displaying altered mental status
      D)
      A 25-year-old with a sprained ankle
    4. Which of the following is a clinical symptom most commonly associated with Acute Respiratory Distress Syndrome (ARDS)?
      A)
      Hypercapnia with respiratory alkalosis
      B)
      Pulmonary hypertension
      C)
      Severe hypoxemia despite supplemental oxygen
      D)
      Pleural effusion

    Exam Review

    1. A patient is admitted to the intensive care unit after a motor vehicle accident. On the second day of hospital admission, the patient develops acute renal failure. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patient's hypervolemia and hyperkalemia. Which of the following therapies will the patient's hemodynamic status best tolerate?
      A)
      Hemodialysis
      B)
      Peritoneal dialysis
      C)
      Continuous venovenous hemodialysis (CVVHD)
      D)
      Plasmapheresis
    2. A client is diagnosed with a large pulmonary embolism. When explaining what has happened to cause respiratory distress to the client's family, which information will the nurse include?
      A)
      Thick secretions in your small airways are blocking air from moving into the small air sacs in your lungs
      B)
      Blood flow through some areas of your lungs is decreased even though you are taking adequate breaths
      C)
      Large areas of your lungs are getting good blood flow but are not receiving enough air to fill the small air sacs
      D)
      Oxygen transfer into the blood is slow because of thick membranes between the small air sacs and the lung circulation
    3. While the client's full-thickness burn wounds to the face and body are exposed, what is the best nursing action to prevent cross-contamination?
      A)
      Wear gowns, caps, masks, and gloves during care of the client
      B)
      Turn the room temperature up to at least 70°F (20°C) during dressing changes
      C)
      Use sterile gloves when removing old dressings
      D)
      Administer IV antibiotics to prevent bacterial colonization of wounds
    4. A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
      A)
      Heart rate 122/min
      B)
      Urinary output 25 mL/hr
      C)
      Pain of 6 on a scale of 0 to 10
      D)
      Difficulty swallowing

    Exam Review

    1. Which intervention should be prioritized for a client experiencing acute hypoxemic respiratory failure?
      A)
      Starting antibiotic therapy
      B)
      Initiating bronchodilator therapy
      C)
      Providing supplemental oxygen
      D)
      Administering diuretics
    2. A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?
      A)
      A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around
      B)
      A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically
      C)
      A client who has severe head injuries, respiratory rate 8/min, and is unresponsive
      D)
      A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound
    3. A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
      A)
      Cause of the burn
      B)
      Associated medical history
      C)
      Location of the burn
      D)
      Age of the client
    4. Before weaning a client from a ventilator, which assessment parameter(s) is most important for the nurse to assess?
      A)
      Fluid intake for the last 24 hours
      B)
      Baseline arterial blood gas (ABG) levels
      C)
      Blood pressure and heart rate
      D)
      Electrocardiogram (ECG) results

    Exam Review

    1. A client who has broken his femur presents to the emergency department with the following signs and symptoms: cool, moist skin, increased heart rate, and falling blood pressure. The nurse suspects the client is experiencing:
      A)
      Low blood glucose
      B)
      High blood glucose
      C)
      Hemorrhage
      D)
      Fluid volume excess
    2. A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
      A)
      Atelectasis
      B)
      Flail chest
      C)
      Hemothorax
      D)
      Pneumothorax
    3. A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?
      A)
      Administer pain medication
      B)
      Administer IV fluids
      C)
      Clean and dress the wound
      D)
      Administer a tetanus booster
    4. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
      A)
      Infection
      B)
      Paralytic ileus
      C)
      Airway obstruction
      D)
      Fluid imbalance

    Exam Review

    1. A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
      A)
      Start an IV infusion of lactated Ringer’s
      B)
      Give morphine IV
      C)
      Administer oxygen therapy
      D)
      Initiate cardiac monitoring
    2. The critical care nurse recognizes that which of the following conditions may indicate the need for a client to have a tracheostomy?
      A)
      A client with a respiratory rate of 10 breaths/min
      B)
      A client who requires permanent ventilation
      C)
      A client who exhibits symptoms of dyspnea
      D)
      A client with respiratory acidosis
    3. The nurse in a trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
      A)
      Evaluate chest expansion
      B)
      Assess the capillary refill
      C)
      Check pupillary response to light
      D)
      Check client's response to questions about place and time
    4. A client is unable to take a deep breath and does not want to get out of bed due to chest tube discomfort. To increase the client's compliance with ambulation and deep breathing, the nurse should:
      A)
      Administer pain medication before ambulation
      B)
      Tell the patient the importance of lung expansion
      C)
      Arrange a care schedule to provide rest periods
      D)
      Teach the patient how to use an incentive spirometer

    Exam Review

    1. A client in severe pulmonary edema is being intubated by the resident. What action by the nurse will assist in the confirmation of the endotracheal tube placement in the proper position?
      A)
      Observe for mist in the endotracheal tube
      B)
      Call for a chest x-ray
      C)
      Attach a pulse oximeter and document O2 saturation
      D)
      Check the pH of secretions
    2. Which clinical finding is most indicative of hypoxemic respiratory failure?
      A)
      PaCO2 greater than 50 mm Hg
      B)
      Bradycardia
      C)
      PaO2 less than 60 mm Hg
      D)
      Peripheral edema
    3. A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations?
      A)
      Hypervolemia
      B)
      Hypovolemia
      C)
      Hyperkalemia
      D)
      Hyponatremia
    4. A nurse in the PACU is assessing a client who has an endotracheal tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
      A)
      Passage of the endotracheal tube into the esophagus
      B)
      Infection of the vocal cords
      C)
      Movement of the endotracheal tube into the right main bronchus
      D)
      Blockage of the endotracheal tube by the client's tongue