NURS 221 FINAL EXAM Iggy & D2L questions

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1-hour time period?

A. Plasma volume osmolarity increases; blood pressure increases

B. Plasma volume osmolarity decreases; blood pressure increases

C. Plasma volume osmolarity increases; blood pressure decreases

D. Plasma volume osmolarity decreases; blood pressure decreases

Answer: A

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply.

A. Blood pressure

B. Deep tendon reflexes

C. Hand-grip strength

D. Pulse rate and quality

E. Skin turgor

F. Urine output

Answer: A, D, F

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?

A. Foot and ankle

B. Forehead

C. Sacrum

D. Chest

Answer: C

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia to prevent harm?

A. 72-year-old taking the diuretic spironolactone for control of hypertension

B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hr

C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours

D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

Answer: D

In reviewing the electrolytes of a client, the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm?

A. Deep tendon reflexes

B. Oxygen saturation

C. Pulse rate and rhythm

D. Respiratory rate and depth

Answer: C

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse’s best first action to prevent harm?

A. Hold the next dose of the prescribed antidiarrheal drug

B. Assess bowel sounds in all four abdominal quadrants C. Assess the client’s response to the Chvostek test

D. Increase the IV flow rate of the normal saline infusion

Answer: C

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply.

A. Calcium

B. Chloride

C. Hydrogen

D. Potassium

E. Sodium

F. Sulfate

Answer: A, D

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss?

A. The client has calf muscle cramping.

B. The serum chloride level is low.

C. The urine specific gravity is high.

D. The hematocrit is 52%.

Answer: D

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour?

A. 12 mEq (mmol)

B. 15 mEq (mmol)

C. 18 mEq (mmol)

D. 20 mEq (mmol)

Answer: B

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L?

A. Asking about the use of sugar substitutes

B. Determining what drugs are taken daily

C. Measuring the client’s response to Chvostek testing D. Asking about a history of kidney disease

Answer: B

Which normal physiologic process contributes most to the need for acid base balance?

A. Continuous

B. Continuous alveolar exchange of oxygen and carbon dioxide

C. Continuous metabolic production of free hydrogen ions

D. Continuous kidney formation of urine from blood

C

Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acidbase imbalance?

A. pH 7.42; Pao2

B. pH 7.46; Pao2 98 mm Hg; CO2 38 mm Hg; HCO3 − 30 mEq/L (mmol/L)

C. pH 7.22; Pao2 60 mm Hg; CO2 80 mm Hg; HCO3 − 22 mEq/L (mmol/L)

D. pH 7.29; Pao2 78 mm Hg; CO2 82 mm Hg; HCO3 − 36 mEq/L (mmol/L)

D

With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply.

A. Client who has been NPO for 36

B. Client receiving a rapid infusion of normal saline

C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate

D. Client who has had continuous gastric suction for 48 hours

E. Client having a sudden and severe asthma attack

F. Client with uncontrolled diabetes mellitus

.

C, D

1. How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance?

A. Carbon dioxide loss through exhalation can raise arterial pH levels.

B. Carbon dioxide retention during exhalation can lower arterial pH levels.

C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance.

D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

A

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action?

A. Measure the client's pulse and blood pressure

B. Apply humidified oxygen by nasal cannula

C. Assess the client's oxygen saturation

D. Notify the Rapid Response Team

C

Why are the terminal bronchioles more prone to collapse than are the other airways? Select all that apply.

A. The cartilage is an incomplete C shape rather than a true ring.

B. The mucous membrane lining contains minimal active cilia.

C. Lung elastic recoil is the only force that keeps them patent.

D. Their walls are too thick to permit gas exchange.

E. They are surrounded by capillaries.

F. The lumens have a small diameter.

G. Their walls contain no cartilage.

C, F, G

The nurse assessing an 88-year-old client notices a severe kyphosis that curves the client's spine to the right and bends her forward. Which change in respiratory function does the nurse expect as a result of this age-related change?

A. Decreased gas exchange as a result of reduced airway elasticity

B. Decreased gas exchange as a result of ineffective chest movement

C. Reduced pulmonary perfusion as a result of decreased alveolar diffusion capacity

D. Reduced pulmonary perfusion as a result of decreased blood return to the right atrium

B

When assessing the client 2 hours after a thoracentesis, the nurse notes the skin around the puncture site is swollen and a crackling is felt and heard when pressure is applied to the area. What is the nurse's best action?

A. Assess the client's SPO 2 levels at two separate sites. B. Obtain a prescription to culture the site.

C. Document the finding as the only action.

D. Notify the respiratory health care provider.

D

Which respiratory side effect does the nurse teach the client who is now prescribed an angiotensin-converting enzyme (ACE) inhibitor to expect?

A. Wheezing on exertion

B. Increased secretions

C. Persistent dry cough

D. Orthopnea

C

While responding to questions in a health history, the client reports that he usually expectorates about 2 ounces of thin, clear, colorless sputum daily, usually on getting up in the morning. What is the nurse's best action related to this finding?

A. Document the report as the only action.

B. Arrange for the client to have tuberculosis testing.

C. Collect a sputum specimen for laboratory analysis.

D. Alert the primary health care provider about this funding.

A

When answering the call light for a client on bedrest, the nurse finds the client’s visitor unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at least 2 minutes have passed since the client’s light first came on. What is the nurse’s priority action?

A. Initiate CPR with chest compressions.

B. Perform an abdominal thrust maneuver.

C. Assess the visitor for the presence of a head injury

D. Ask the client what event led up to the visitor’s fall.

A

Which information is most relevant for the nurse to teach a client about CPAP therapy for OSA? Select all that apply.

A. Avoid alcoholic beverages or drugs that make you sleepy within 3 hours of bed time.

B. Clean the mask device daily.

C. Ensure your mask device fits tightly enough to prevent air leaks.

D. Keep open flames such as candles out of the room when CPAP is in use.

E. Seal the mask edges to your face with petroleum jelly. F. Use only sterile water in the humidifier tank.

G. Use the CPAP during all sleep periods, especially in bed.

H. Do not share your mask or tubing system with others.

B, C, G, H

Which nursing action has the highest priority when caring for a client with any type of facial or laryngeal trauma?

A. Managing pain

B. Providing nutrition

C. Assessing self-image

D. Maintaining a patent airway

D

A client who underwent radical neck surgery for head and neck cancer 5 days ago tells the nurse that he is worried because his right shoulder is lower than the left and does not go back into place when he tries to raise it. What is the nurse's best response?

A. "I will notify the surgeon right away because some leftover tumor must be pressing on the nerve."

B. "The nerve to the shoulder was removed during surgery. Physical therapy will help you to use other muscles to regain some motion."

C. "This problem is not related to your surgery. If it persists after you go home you will need to see your primary health care provider about it."

D. "Your time under anesthesia was long and you are not yet fully recovered. It is likely you will regain full motion in that shoulder by the end of the week."

B

When making rounds, the nurse observes that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse’s priority action?

A. Place the bed in reverse Trendelenburg position and apply humidified oxygen by nasal cannula.

B. Check the flow sheet to assess for trends in the client’s oxygen saturation paĴerns.

C. Determine which assistive personnel (AP) provided this client’s morning care today.

D. Immediately provide complete oral care to this client.

D

2. A client with severe angioedema and tongue swelling from a drug allergy has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare?

A. Nasal CPAP

B. Tracheotomy

C. Cricothyroidotomy

D. Endotracheal intubation

C

3. A client has just come to the floor after undergoing inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse’s priority action?

A. Administer the prescribed antiemetic by the intravenous or rectal route.

B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team.

C. Cut the wires holding his jaws together, and carefully remove them from the mouth.

D. Reposition the client to the side and suction the mouth with a large bore catheter.

D

4. In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply.

A. Scalp and eyebrow alopecia

B. Taste sensation loss or changes

C. Bloody and purulent sinus drainage

D. Increased risk for skin breakdown

E. Moderate weight gain

F. Increased risk for cavities

G. Gastroesophageal reflux

H. A persistent blue tinge to the skin and mucous membranes around the mouth

B, D, F

When performing a medication reconciliation for a newly admiĴed client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm?

A. Record and display the information in a prominent place within the client's medical record.

B. Ask the client how long the drugs have been prescribed and how well the asthma is controlled.

C. Collaborate with the surgeon to arrange for continuation of this therapy in the perioperative period

D. Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.

C

A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm?

A. “This year I will get the pneumonia vaccination in addition to a flu shot.”

B. “Now I will try to rest as much as possible and avoid any unnecessary exercise.”

C. “Maybe drinking a supplement will help me retain weight and have more energy.”

D. “Perhaps using a spacer with my metered dose inhaler will make the drug work better.”

B

Which statement about the genetics of cystic fibrosis is true?

A. Recessive disorder affecting chloride transport

B. Recessive disorder affecting alpha1 -antitrypsin levels

C. Dominant disorder inhibiting alveoli formation

D. Dominant disorder increasing production of interleukin-5

A

A client with primary pulmonary arterial hypertension (PAH) receiving treprostinil by continuous IV infusion now has a fever of 101.6°F (38.7°C). Which actions will the nurse perform to prevent harm? Select all that apply.

A. Administer the prescribed antipyretic

B. Ask the client whether a productive cough is present

C. Apply oxygen by nasal cannula

D. Culture the IV site

E. Determine whether a durable power of aĴorney has been signed

F. Increase the treprostinil flow rate

G. Initiate a second IV access and administer prescribed antibiotic

H. Place the client in protective isolation

D, F, G

The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first?

A. Immediately notify either the Rapid Response Team or the thoracic surgical resident.

B. Assist the client to a side-lying position and reassess the water seal chamber for bubbling.

C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system.

D. No action is needed because these responses are normal for the first postoperative day after lobectomy.

B

1. Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy?

A. Avoid breathing into the inhaler or getting it wet.

B. The drug can only be given by a health care professional.

C. Do not chew, crush, or split the tablet containing this drug.

D. The drug must be taken at bedtime because of the extreme drowsiness it causes.

B

2. A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm?

A. pH from 7.21 to 7.20

B. HCO3 - remains the same at 31 mEq/L

C. Paco2 from 45 mm Hg to 68 mm Hg

D. Pao2 from 88 mm Hg to 86 mm Hg

C

Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy?

A. Examine your skin and the whites of your eyes daily for a yellow appearance.

B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum.

C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination.

D. Go to your primary health care provider immediately if you develop a fever or other signs of infection.

A

The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply.

A. ambrisentan

B. bosentan

C. epoprostenol

D. iloprost

E. macitentan

F. riociguat

G. selexipag

H. sildenafil

I. tadalafil

J. treprostinil

A, B, E, F

A client newly diagnosed with stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response?

A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it."

B. "This drug is approved for use in clients whose lung cancer has metastasized not for early-stage cancers."

C. "Why would you want to take a drug for months when you may be cured by surgery alone?"

D. "You need to talk about this with your oncologist and your surgeon."

B

The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for cardiovascular disease? Select all that apply.

A. BMI of 26

B. BP of 120/66 mm Hg

C. Triglycerides 140 mg/dL

D. Moderate exercise for 20 to 30 minutes weekly

E. Exposure to secondhand cigarette smoke

F. History of repeated streptococcal tonsillitis

G. Family history of cardiovascular disease

A, D, E, G

The nurse is assessing a client with heart failure. Which assessment data are the best indicator of fluid balance?

A. Blood pressure 144/79 mm Hg

B. Urine output 200 mL in the last 4 hours

C. Weight increase of 9 lb in the past week

D. Generalized edema in the lower extremities

C

The nurse is caring for a client immediately following a cardiac catheterization. Which assessment data require immediate nursing intervention?

A. Blood pressure 146/70 mm Hg

B. Hematoma developing at insertion site

C. Client reports headache pain

D. Client reports extreme thirst

B

1. The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply.

A. “If you tend to get angry easily, then your risk for heart disease is higher.”

B. “To reduce your overall risk, it is important to keep your BMI greater than 30.”

C. “Do not eat more calories on a daily basis that you are able to burn.”

D. “Decreasing the amount that you smoke will decrease your overall cardiovascular risk.”

E. “Secondhand smoke creates a significant risk to others for cardiovascular disease.”

F. “Exercise moderately at least 2 days per week for a total of 150 minutes.”

A, C, E, F

The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds?

A. "Please roll onto your left side."

B. "Lay all the way down on your back."

C. "Please hold your breath while I use my stethoscope."

D. "I will just take your pulse instead."

A

3. Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse?

A. "My allergies are bothering me, so I took some Benadryl last night before bed."

B. "I was nervous last night, but I still remembered to take my warfarin."

C. "I sure am hungry. I haven't had anything to eat since I went to bed last night."

D. "I don't know what I will do if they find a blockage in my heart."

B

A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply.

A. Peripheral edema

B. Crackles in both lungs

C. Tachycardia

D. Ascites

E. Tachypnea

F. S3 gallop

B, C, E, F

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education?

A. "I may need to take this drug every other day according to lab values."

B. "I need to take potassium supplements with this medication."

C. "I will try my best not to use table salt on my food."

D. "This medication will cause me to urinate more often."

B

A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching?

A. "I need to brush my teeth at least twice daily and rinse with water."

B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg leĴuce."

C. "I need to take a full course of antibiotics prior to my colonoscopy."

D. "I will take my blood pressure every day and call if it is too high or low."

C

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complication will the nurse suspect?

A. Pulmonary embolus

B. Renal infarction

C. Transient ischemic attack

D. Splenic infarction

B

1. The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply.

A. "Visual changes with exposure to light are expected initially."

B. "Be sure to take this medication with food."

C. "Call your health care provider if your pulse rate is low or irregular."

D. "Use caution when driving in the sunlight."

E. "Check your BP regularly and notify the health care provider if elevated."

A, B, C, D, E

2. The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first?

A. Contact respiratory therapy.

B. Increase the oxygen to 4 L.

C. Place the client in a high-Fowler position.

D. Draw arterial blood for arterial blood gas analysis.

C

The nurse is admiĴing an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning?

A. Digoxin therapy daily

B. Daily metoprolol

C. Furosemide twice daily

D. Currently taking an antacid for upset stomach

A

The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply.

A. "This drug may cause a dry, nagging cough."

B. "Take this drug with a snack, right before bed."

C. "Try to increase your intake of potassium in your diet."

D. "This drug can affect your glucose control."

E. "Increased urination is expected with this drug.

C, D, E

Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease?

A. Carotid artery bruit

B. HDL 60 mg/dL

C. Palpable peripheral pulses

D. BP 120/58 mm Hg Peripheral Arterial

A

The nurse is caring for a client with intermittent claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management?

A. "I need to reduce the number of cigarettes that I smoke each day."

B. "I'll elevate my legs above the level of my heart."

C. "I'll use a heating pad to promote circulation."

D. "I'll start to exercise gradually, stopping when I have pain."

D

A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate?

A. "You will need both drugs long-term to provide long-term anticoagulation."

B. "Warfarin is easier on your stomach so you can take it long-term."

C. "It takes several days for warfarin to begin working, so both drugs are required for a shortime."

D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."

C

The nurse is admitting a client with an ulcer on the right foot. Which client statement indicates venous insufficiency to the nurse? Select all that apply.

A. "My ankles swell up all the time."

B. "My leg hurts after I walk about a block."

C. "My feet are always really cold."

D. "My veins really stick out in my legs."

E. "My ankles have been discolored for years."

A, D, E

1. The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications?

A. "I will reduce my sodium intake to 2500 mg per day."

B. "I will restrict my intake of daily dietary lean protein."

C. "I am only going to drink one cup of coffee to start my day."

D. "I will drink a glass of low-fat milk with my breakfast."

D

A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured?

A. Shortness of breath and hemoptysis

B. Sudden, severe low back pain and bruising along the flank

C. Gradually increasing substernal chest pain and diaphoresis

D. Rapid development of patchy blue mottling on feet and toes

B

The nurse is caring for a client receiving intravenous heparin for treatment of DVT who begins to begins to vomit blood. What action should the nurse be prepared to take?

A. Administer vitamin K

B. Stop the infusion of heparin

C. Administer an antiemetic

D. Insert a nasogastric tube

B

What is the most important precaution to prevent harm that a nurse will teach a client who is prescribed to take the anticoagulant drug warfarin?

A. Apply an ice pack to any body area that you bump or otherwise injure to reduce bleeding.

B. Check with your primary health care provider before taking any vitamin supplements.

C. Always take your medication within an hour of the same time every day and never with meals.

D. Avoid taking aspirin or any aspirin-containing product unless prescribed.

D

Which client history information is most relevant for the nurse to document when assessing for a possible hematologic problem? Select all that apply.

A. Eats a vegan diet

B. Participates in basketball twice weekly

C. Mother has pernicious anemia

D. Has a sister with Down syndrome

E. Sprays fertilizers and weed killers for a lawn care company

F. Takes aspirin or NSAIDs occasionally for minor muscle pain

G. Has used a vaping device instead of cigarette smoking for the past 2 years

A, C, E

When reviewing the laboratory results for a client in the emergency department, which finding does the nurse report immediately to prevent harm?

A. International normalized ratio (INR) is 5.2

B. Platelet count of 180,000/mm3 (180 × 109 /L)

C. Hematocrit of 27% (0.27 volume fraction)

D. Reticulocyte value of 4%

A

Which statement regarding erythrocytes is true?

A. Reticulocytes represent the final stage of mature erythrocytes.

B. The lack of a nucleus in a mature erythrocyte increases its life span.

C. Each erythrocyte can carry up to a maximum of four molecules of oxygen.

D. The main trigger for erythrocyte production is the secretion of thrombopoietin.

B

2. Which response or health problem does the nurse expect to be present in a client who has a lifelong deficiency of antithrombin III?

A. Chronic fatigue resulting from reduced production of normal hemoglobin

B. Failure to produce and maintain normal circulating levels of platelets

C. Prolonged bleeding and hematoma formation at sites of tissue injury

D. Increased risk for clot formation and disruption of perfusion

D

Which precaution has the highest priority for prevention of harm when the nurse teaches the client about home care after a bone marrow aspiration?

A. Clean the suture line daily with soap and water.

B. Drink at least 4 L of fluid to ensure adequate hydration.

C. Avoid taking any aspirin or aspirin-containing products

D. Stay in bed and get up only to use the bathroom for the next 2 days.

C

The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long-term pain control? Select all that apply.

A. "Take the prescribed drug before breakfast each day."

B. "Report any sign of bleeding, including bloody or dark, tarry stool."

C. "Do not take other NSAIDs while on celecoxib."

D. "Report any major changes in the amount of urine you excrete each day."

E. "Follow up with lab tests to assess liver function."

B, C, D

A client had a left noncemented posterolateral total hip arthroplasty 2 days ago. Which statements will the nurse include in health teaching for the client? Select all that apply.

A. "Practice leg exercises each day as instructed."

B. "Take deep breaths and use incentive spirometry every 2 hours."

C. "Be sure to cross your legs to be more comfortable in a chair."

D. "Report sudden increased hip pain or rotation immediately to the nurse."

E. "Stand on your right leg and pivot into the chair when getting out of bed."

A, B, D, E

Assistive personnel (AP) are assigned to care for a client who had a cemented total knee arthroplasty yesterday. Which observation by the AP indicates a need for follow-up by the nurse?

A. "The client's surgical knee is very swollen and discolored."

B. "The client states that the surgical knee is very painful when moving it."

C. "The client's lower leg on the surgical side is painful and red."

D. "The client needs assistance with walking to the bathroom."

C

Which assessment findings will the nurse expect for the client with early stage rheumatoid arthritis? Select all that apply.

A. Joint inflammation

B. Subcutaneous nodules

C. Severe weight loss

D. Fatigue

E. Thrombocytosis

F. Anorexia

A, D, F

The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client’s priority problem?

A. Joint pain

B. ADL dependence

C. Risk for falls

D. Muscle stiffness

A

The nurse is caring for a client who had an anterior total hip arthroplasty yesterday. For which commonly occurring postoperative complication will the nurse monitor for this client?

A. Pneumonia

B. Paralytic ileus

C. Wound dehiscence

D. Venous thromboembolism

D

The nurse is assessing a client who has late-stage rheumatoid arthritis. Which assessment findings would the nurse expect for this client? Select all that apply.

A. Joint inflammation

B. Severe weight loss

C. Bony nodules

D. Joint deformities

E. SjÖgren syndrome

B, D, E

The nurse is talking with a group of older clients about colorectal cancer (CRC) risk factors. Which of the following factors are considered to be common CRC risk factors? Select all that apply.

A. High-fat diet

B. Crohn's disease

C. Smoking

D. Alcoholism

E. Family history of cancer

F. Obesity

A, B, C, D, E, F

A client had an open partial colectomy and colostomy placement 6 hours ago. Which assessment would concern the nurse?

A. Purple, moist stoma

B. Stoma edema

C. Liquid stool collecting in the drainage bag

D. Serosanguineous fluid draining from the drain(s)

A

A nurse provides discharge teaching for a male client who had a minimally invasive hernia repair this morning. Which statement by the client indicates a need for further teaching?

A. “I should avoid coughing if at all possible.”

B. “I can shower in a day or two after I remove my surgical bandage.”

C. “I can’t go back to work for at least 6 weeks.”

D. “I should use an ice pack to help relieve my pain.”

C

The nurse is caring for a client with a complete large bowel obstruction. What assessment findings would the nurse expect? Select all that apply.

A. Obstipation

B. Dehydration

C. Metabolic alkalosis

D. Abdominal distention

E. Abdominal pain

F. Profuse vomiting

A, D, E

A client has a new diagnosis of irritable bowel syndrome (IBS) with diarrhea. What health teaching by the nurse is appropriate for this client?

A. "Take a stool softener every day to ease defecation."

B. "Avoid high-fiber foods in your diet."

C. "Avoid dairy products and caffeinated beverages."

D. "Ask your primary health care provider for an antidepressant."

C

A client had an exploratory laparotomy to treat the cause of peritonitis and has a large incision that is closed with staples and two abdominal drains. Which finding(s) would the nurse report immediately to the surgeon? Select all that apply.

A. Serosanguineous drainage

B. Increased abdominal distention

C. Fever and chills

D. Pain level 2 on a scale of 0 to 10

E. Passing flatus

B, C

The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea and rectal bleeding that have lasted a week. For which complication(s) will the nurse assess? Select all that apply.

A. Increased BUN

B. Hypokalemia

C. Leukocytosis

D. Anemia

E. Hyponatremia

A,B, C, D, E

The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the client to avoid?

A. Cucumber

B. Beans

C. Carrot

D. Radish Celiac Disease

A

The nurse is caring for a client with peritonitis from a perforated appendix. Which abdominal assessment finding will the nurse most likely expect?

A. Soft abdomen

B. Board-like abdomen

C. Slightly distended abdomen

D. Absent bowel sounds

B

A client had a colectomy with creation of an ileo-anal pouch and temporary ileostomy yesterday morning. The nurse assesses the ostomy and its functioning. Which assessment finding will the nurse report to the primary health care provider?

A. Client's report of abdominal pain of 3 on a 0 to 10 pain intensity scale

B. Slight abdominal distention

C. No drainage from the ileostomy

D. Serosanguinous effluent from the drain

C

Which hormones help prevent hypoglycemia? Select all that apply.

A. Aldosterone

B. Cortisol

C. Epinephrine

D. Growth hormone

E. Glucagon

F. Insulin

G. Norepinephrine

H. Proinsulin

B, C, D, E, G

The nurse reviewing the preadmission testing laboratory values for a 62- year-old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding?

A. The client's A1C is completely normal.

B. The client has type 1 diabetes mellitus.

C. The client has type 2 diabetes mellitus.

D. The client has prediabetes mellitus

D

Which precaution is a priority for the nurse to teach a client prescribed semaglutide to prevent harm?

A. Only take this drug once weekly.

B. Report any vision changes immediately.

C. Do not mix in the same syringe with insulin.

D. This drug can only be given by a health care professional

A

How will the nurse modify insulin injection technique for a client who is 5 feet 10 inches tall and weighs 106 lb (48.1 kg)?

A. Use a 6-mm needle and inject at a 90-degree angle.

B. Use a 6-mm needle and inject at a 45-degree angle.

C. Use a 12-mm needle and inject at a 90-degree angle.

D. Use a 12-mm needle and inject at a 45-degree angle.

B

A client with diabetes who now has chronic albuminuria asks the nurse how this change will affect his health. How will the nurse answer this question?

A. "You will need to limit your intake of dietary albumin and other proteins to reduce the albuminuria."

B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage."

C. "Your risk for developing urinary tract infections is greatly increased, requiring the need to take daily antibiotics for prevention."

D. "From now on you will need to limit your fluid intake to just 1 L daily and completely avoid caffeine to protect your kidneys."

B

Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply.

A. Gluconeogenesis

B. Glycogenesis

C. Glycogenolysis

D. Ketogenesis

E. Lipogenesis

F. Lipolysis

A, C

Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm?

A. Only take this drug once weekly.

B. Do not drink alcohol when taking this drug.

C. Do not mix in the same syringe with insulin.

D. Report any genital itching to your primary health care provider.

C

Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply.

A. "Avoid all dietary carbohydrate and fat."

B. "Have your eyes and vision assessed by an ophthalmologist every year."

C. "Reduce your intake of animal fat and increase your intake of plant sterols."

D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise."

E. "Keep your feet warm in cold weather by using either a hot water boĴle or a heating pad."

F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home."

B, C

When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety?

A. Warm the vial in a bowl of warm water until it reaches normal body temperature.

B. Return the vial to the pharmacy and open a fresh vial of NPH insulin.

C. Roll the vial between the hands until the insulin is clear.

D. Check the expiration date and draw up the insulin dose

D

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm?

A. Call the pharmacy and order a STAT does of glucagon.

B. Immediately give the client 30 g of glucose orally.

C. Start an IV and administer a small amount of a concentrated dextrose solution.

D. Recheck the blood glucose level and call the Rapid Response Team.

B

Which nursing activities may be safely delegated to competent assistive personnel (AP)? Select all that apply.

A. Discharge teaching

B. Blood pressure monitoring

C. Gastrostomy feeding

D. Oxygen administration

E. Ambulation assistance

B, E

A nurse assures a client experiencing abdominal surgical pain that comfort measures, including drug therapy, will be provided as the client needs them. Which ethical principles apply in the situation? Select all that apply.

A. Beneficence

B. Social justice

C. Autonomy

D. Fidelity

E. Veracity

A, D, E

1. The nurse provides an SBAR hand-off communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format?

A. Situation

B. Background

C. Assessment

D. Recommendation

A

2. The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply.

A. Quality Improvement

B. Ethics

C. Health Care Disparities

D. Systems Thinking

E. Teamwork and Collaboration

A, D, E

9. The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic?

A. Administer at 8:00 a.m. as originally prescribed.

B. Adjust the administration time to be given at 10:00 a.m.

C. Do not administer, as preoperative prophylactic antibiotics are optional.

D. Hold the antibiotic until immediately following surgery, and then administer

B

The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply.

A. Blood pressure 130/72 mm Hg

B. Serum potassium 3.5 mEq/L

C. Diffuse rash on upper torso

D. Took 650 mg of aspirin yesterday

E. Has not had food or water since 9:00 p.m. last night

C, D

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply.

A. Begin practicing leg exercises prior to surgery.

B. Repeat leg exercises several times daily for each leg.

C. Push the ball of the foot into the bed until the calf and thigh muscles contract.

D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon.

E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

A, C, D, E

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority?

A. "When I eat shrimp, my tongue swells and I have trouble breathing."

B. "I'm feeling more anxious about my surgery than I thought I would be."

C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement."

D. "My sister had anesthesia a few months ago and she said she didn't like the way she felt."

A