Exam Review
- An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and reports a dry mouth. Which intervention should the nurse implement?A)Encourage client to drink water.B)Assist client to an upright position.C)Apply a high-flow venturi mask.D)Administer a prescribed sedative.
- An older adult client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?A)Explain that weight loss will be reversed after the acute phase of the stroke has ended.B)Demonstrate the use of visual scanning during meals to the client and family.C)Suggest that the family bring foods from home that the client enjoys eating.D)Encourage the family to offer to feed the client when she does not eat her entire meal.
- Exhibits Click to indicate if the listed symptoms are consistent with angina, myocardial infarction, or both. Each column must have at least one response option selected.
Myocardial infarction Angina Occurring without cause ✓ Feelings of fear ✓ ✓ Pain relieved by nitroglycerin ✓ Pain only relieved by opioids ✓ Epigastric distress ✓ Chest pain radiating down arm ✓ ✓ - Exhibits The client was given oxygen, sublingual nitroglycerin, and aspirin. After one dose of nitroglycerin, the client's pain decreased to a reported 2 on a 0 to 10 scale with squeezing pain. The client was admitted for observation and percutaneous coronary intervention (PCI) to be completed later within the evening. The client asks the nurse to explain why a PCI is being completed. select word choices to complete the sentence. If healthcare providers see a narrowed heart vessel while performing a percutaneous coronary intervention (PCI), they may perform a balloon angioplasty to compress the plaque against the vessel wall and hold it there with a stent, which will lessen ▾ pain and ▾ dysrhythmiasDropdown 1:Option 1: heart blocksOption 2: dysrhythmiasOption 3: vasospasmsOption 4: painDropdown 2:Option 1: heart blocksOption 2: dysrhythmiasOption 3: vasospasmsOption 4: pain
Exam Review
- Exhibits The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?(SATA)A)I will wear a medication alert bracelet to indicate my history of heart problems.B)I will lie down or sit if I start to feel any chest discomfort.C)I will take the nitroglycerin 1 or 2 more times 10 minutes apart if pain does not get better.D)I will call 911 if there is no improvement in my chest pain after taking nitroglycerinE)I will chew my nitroglycerin tabs as soon as pain begins.F)I will keep my nitroglycerin tablets with me all the time.G)I will wait 5 minutes after taking my nitroglycerin to see if the pain improves
- A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement?A)Teach client to use pursed lip breathing when episodes occurB)Review the client's routine asthma management prescriptions.C)Assess client for signs and symptoms of upper airway infection.D)Determine if the client is using an inhaler before exercising.
- While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?A)Observe the color of the extremity.B)Document the neurovascular assessment as normal.C)Discontinue elevating the client's affected extremity.D)Notify the healthcare provider of assessment finding.
- A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?A)Pulmonary function test.B)Endotracheal intubation.C)Chest tube insertion.D)Bronchoscopy.
Exam Review
- A client with a gram positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% sodium chloride with daptomycin 500 mg/100 mL to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter the numerical value only.)Correct Answer:200 mL/hour.
- Exhibits Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.✓Begin anticoagulation therapy✓Early ambulation✓Deep vein thrombosis✓Development of pulmonary embolus✓Laboratory valuesAction to take Choices✓Begin anticoagulation therapy✓Early ambulation✕Prep for return to surgery✕Massage the calf area✕Culture hip woundPotential Conditions Choices✕Surgical site infection✕Osteomyelitis✕Displaced hip✓Deep vein thrombosisParameters to Monitor Choices✓Development of pulmonary embolus✓Laboratory values✕Intake and output✕Wound drainage✕Nutritional intake
- The nurse observes that a client with Parkinson's disease (PD) has a mask like face. Which follow up assessment is most important for the nurse to implement?A)Note frequency of drooling.B)Determine ability to chew and swallow.C)Observe appearance of oral mucosa.D)Assess patterns of speech.
- An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that applyA)Signs of respiratory tract infection.B)Sensation in feet and legs.C)Skin condition of lower extremities.D)Visual acuity.E)Scrum creatinine and blood urea nitrogen (BUN)
Exam Review
- A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?A)Visualize the abdominal incision.B)Obtain sterile towels soaked in saline.C)Assure the client that such feelings occur with wound infections.D)Notify the healthcare provider
- The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client? Reference Range: Glycosylated hemoglobin (A1C) [Good diabetic control: less than 7%A)The client's hemoglobin A1C will be less than 7% in 3 months.B)The nurse will encourage the client to walk thirty minutes every day.C)The client's blood pressure readings will be less than 160/90 mm Hg.D)The nurse will demonstrate the procedure for accurate eye care.
- Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?A)Chicken, rice, and wheat products.B)Oatmeal, raisins, and fruit with skin.C)Potatoes, low-fat breads, and applesauce.D)Lean beef, salads, and baked potatoes.
- A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?A)Substitute natural fruit juices for carbonated drinks.B)Limit use of mobility equipment to avoid muscle atrophy.C)Return for periodic liver function studies.D)Massage joints to relax muscles and decrease pain.
Exam Review
- Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires Immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]A)Surgical consent form is not signed.B)Preoperative chest x-ray report is not available.C)Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L)D)Client's pulse oximeter reading is 96%
- A client is to receive progesterone 10 mg IM daily. The medication is labeled "Progesterone 50 mg/mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
- The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?A)Thready pulse, hypotension, and chest or back pain.B)Urticaria, itching, and wheezing.C)Bounding pulse, hypertension, and distended neck veins.D)Chills, fever, and tachycardia.
- Exhibits Highlight the assessment findings that require follow-up by the nurse. The client is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is client-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL an hour. General: Alert, oriented to person, place, and time. Eyes Pupils round, reactive to light and accommodation (PERRLA). Lungs: Lungs clear all lobes. Heart Telemetry monitor displaying sinus rhythm (SR). Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow. Right leg: Right leg incision is open to air skin to the area is cool to touch and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 ml of drainage present on right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area. Left leg 2+ pedal pulse loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toe nails noted, and capillary refill is greater than 4 secondsA)cool to touch and edema noted along the incisionB)wound drain with approximately 100 ml of drainage presentC)loss of hair on the lower legD)right residual limb area.E)capillary refill is greater than 4 seconds
Exam Review
- Exhibits Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client.A)Pale skinB)Capillary refillC)Blood pressureD)Oxygen saturationE)Edema
- Exhibits Select the Word Choices to complete the sentence. The client is at risk for dropdown and dropdown
- Exhibits For each action, click to indicate whether the actions are indicated or contraindicated for postoperative amputation. Each column must have at least one response option selected.A)Conditioning exercises of residual limbB)Instructions on equipmentC)Collaborative careD)Assessment for grievingE)Strengthening exercisesF)Obtaining soft mattress overlay
- Exhibits Which item(s) should the nurse teach the client? Select all that apply.A)Soaking baths for pain managementB)Circular wrapping of the residual limbC)Prevention of skin breakdownD)Therapeutic copingE)Keeping a positive outlookF)Use of equipmentG)Fine motor skillsH)Alternating positions