Exam Review
- A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to awake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?A)Tap the client’s wrists to locate the painB)Compare the capillary refill in the handsC)Determine the client’s sleeping positionD)Apply firm pressure over the ulnar artery
- A client is admitted with sudden abdominal pain and possible acute pancreatitis. Which serum laboratory test result(s) should the nurse monitor? (Select all that apply)(SATA)A)AmylaseB)GlucoseC)Serum triglyceridesD)CalciumE)White blood cell count
- A client with Addison’s disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?A)PlateletsB)AlbuminC)GlucoseD)Serum electrolytes
- A client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for an oral temperature of 103°F (39.4°C), and an IV infusion of normal saline is initiated at 250 mL/hour. Which assessment finding should the nurse report to the healthcare provider (HCP) immediately?A)Severe headache with photosensitivityB)Right lower abdomen rebound tendernessC)Petechial hemorrhage under client’s eyesD)Dark green colored emesis
Exam Review
- The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?A)Measure the client’s intake and outputB)Increase the flow of the bladder irrigationC)Provide additional oral fluid intakeD)Administer a PRN dose of an antispasmodic agent
- A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?A)Determine which prescription will have the quickest onset of actionB)Ask the client to choose which medication is needed for the painC)Document the client’s report of pain in the electronic medical recordD)Compare the client’s pain scale rating with the prescribed dosing
- During a preoperative assessment phone call, a client reports taking several “pills” every day. Which response should the office nurse provide?A)Discuss with your healthcare provider which medications to take before surgeryB)Bring copies of all your prescription recordsC)Bring all of your medication containers to your preoperative appointmentD)Obtain a copy of your medication records from your healthcare provider (HCP)
- The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?A)The stoma mucosa is purple in colorB)The fecal matter is brown and has a solid consistencyC)The stoma has streaks of bright red bloodD)There are no bowel sounds in the left lower quadrant
Exam Review
- A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?A)Educate client on signs and symptoms of narcotic dependencyB)Give maximum dosage when score reaches 10C)Administer opioid and non-opioid medication simultaneouslyD)Alternate IV and IM analgesic medications
- The nurse is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?A)Inspect for distention of peripheral veinsB)Observe for change in breathing patternC)Palpate the volume of pedal pulsesD)Assess for inflammation of the calves
- The nurse reports that a client is at risk for a stroke based on which assessment finding?A)Palpable cervical lymph nodeB)Carotid bruitC)Nuchal rigidityD)Jugular vein distention
- A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care (POC)?A)Evaluate level of consciousnessB)Continuous cardiac monitoringC)Perform passive range of motionD)Assess burn depth and extent
Exam Review
- Four days following an abdominal aortic aneurysm (AAA) repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?A)Elevate both lower extremitiesB)Administer a PRN diuretic as prescribedC)Evaluate edema of the lower extremitiesD)Assess distal pulses with a Doppler device
- The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?A)Tenderness upon palpation and generalized erythemaB)Thick skin plaques topped by silvery white scalesC)Requires sunglasses because sunlight hurts eyesD)Brown, rough, greasy, wart-like papules on the face
- A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?A)Assess peripheral pulsesB)Administer PRN pain medicationC)Observe the leg for swellingD)Auscultate blood pressure
- A client with suspected increased intracranial pressure (ICP) exhibits clinical manifestations of Cushing’s triad. Which assessment finding would the nurse expect to observe?A)Hypertension with widening pulse pressure, bradycardia, and irregular respirationsB)Profuse diaphoresis and severe, pounding headacheC)Reports of chest pain and shortness of breathD)Pain and a burning sensation upon urination and hematuria
Exam Review
- A client is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA). Which interventions should the nurse include in the plan of care (POC)? (Select all that apply)A)Place the client in contact precautionsB)Administer vancomycin as prescribedC)Obtain a wound cultureD)Monitor white blood cell countE)Ensure hand hygiene compliance
- A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client’s spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?A)Apply the client’s home oxygenB)Take client to emergency department (ED)C)Ensure that the client avoids salt intake for the rest of the dayD)Check for a thrill and bruit at the client’s dialysis access site
- Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?A)Encourage the client to lie down and rest after mealsB)Instruct the client to use antacids only as a last resortC)Teach the client to elevate the head of the bed on blocksD)Remind the client to avoid high fiber foods
- A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells (PRBCs). When notifying the healthcare provider (HCP), which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?A)Explain specific reason for urgent notificationB)Obtain a PRN prescription for acetaminophen for fever over 101°F (38.3°C)C)Communicate the pretransfusion temperaturesD)Begin the report by stating the client’s name and admitting diagnosis
Exam Review
- A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800 mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?A)Avoid the consumption of wine, beer, and coffeeB)Take prescribed pain medication after exercising jointsC)Replace dietary table salt with salt substitutesD)Encourage active range of motion to limit stiffness
- A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?A)Teach a family member to administer eye dropsB)Provide an eye shield to be worn while sleepingC)Encourage deep breathing and coughing exercisesD)Obtain vital signs every 2 hours during hospitalization
- A female client reports that pain from carpal tunnel syndrome is beginning to affect her job performance. Which instruction should the nurse provide this client?A)Take a multivitamin that contains vitamin B6B)Use a space heater to keep hands warmC)Keep both hands elevated during work breaksD)Obtain wrist splints to wear during work
- A client with diabetes mellitus is admitted with an acute hyperglycemic episode. Which intervention should the nurse implement?A)Fewer fingerstick glucose checksB)Higher doses of insulinC)Restriction of caloric intakeD)Increased oral fluid intake