Exam 4 - practice 2

1\. A nurse is assessing a client who has a diagnosis of colon cancer. Which of the following should the nurse expect?

c) Hematochezia – Passage of blood through Anus

2\. A nurse is assessing a client admitted with peripheral vascular disease. Which of the following findings indicates a venous vascular disorder?

d) Edema of the ankle

3\. A nurse is assessing a client who has pericarditis. In which of the following areas of the client’s chest should the nurse place the stethoscope to best hear a pericardial friction rub? (select HOT spot)

D

4\. A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?

d) “Your breathing pattern causes this”

5\. A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure. Which of the following is the priority topic for the nurse to review with the client?

c) Changes in weight

6\. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) unit. Which of the following statements should the nurse include?

d) “adjust the dial until you feel a ‘pins and needles’ sensation”

7\. A nurse is providing teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?

a) “use raised toilet seat to maintain your hips above the knees”

8\. A nurse finds a client in bed, unresponsive and breathing. Which of the following action should the nurse take first?

c) Palpate for the client’s carotid pulse

9\. A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?

b) Perform neurological assessments

10\. A nurse is providing discharge teaching about blood sugar monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to obtain which of the following supplies?

a) Sterile lancets

11\. A nurse is completing discharge teaching who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching?

c) Use 10 mL syringe to flush line

12\. A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lbs. the amount available is 0.4 mg/mL. How many mL should the nurse administer? (round to the nearest tenth)

2\.5ml

13\. A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?

d) Limit family member visits to 30 min per day

14\. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

b) Cloudy effluent

15\. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications?

c) Furosemide

16\. A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take?

c) Insert a large bore nasogastric tube

17\. A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take?

a) Instruct client to avoid eating raw fruit

18\. A nurse is caring for a patient who has hypotension, cool and clammy skin, tachycardia and tachypnea. Which of the following positions should the nurse place the client?

d) High – fowler’s

19\. A nurse is caring for a client who weighs 190 lb. and is receiving Total parenteral Nutrition. If the RDA Protein is 0.8g/kg of body weight, how many grams of protein should the client receive daily (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

69g

20\. A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care?

a) Flush a catheter using a 10 mL syringe

21\. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

d) Thrombocytopenia

22\. A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking?

a) What is meant by saying “don't beat around the bush?”

23\. A Nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care?

c) support bony prominences with pillows

24\. A nurse is reviewing a cardiac rhythm strip of a client who has atrial flutter. Which of the following findings should the nurse expect?

d) Sawtooth pattern with atrial rate of 252 400 / minutes

25\. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions?

b) ask the client to empty his bladder prior to the procedure

26\. A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

a) diminished breath sounds

27\. A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching?

a) Monitor urinary output for retention

28\. A nurse is providing discharge teaching for a client who has asthma and a new prescription for a metered dose inhaler. Which of the following client statements indicates an understanding of the teaching?

b) I should shake the inhaler before I use it

29\. A nurse is providing preoperative teaching for a client who is having left-sided cardiac catheterization. Which of the following information should the nurse include in the teaching?

d) you should expect warm sensation after the injection of the contrast dye during the procedure

30\. A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?

b) Headache

31\. A nurse is teaching a client who has a new prescription for Warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following Foods interact with this medication?

kale

32\. A nurse is monitoring an older adult client who has an extrapolation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin which of the following actions should the nurse take?

d) Institute bleeding precautions

33\. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?

b) I should apply antibiotic ointment to the lesions

34\. A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg / DL. Which of the following actions is the nurse’s priority?

a) Insert an NG Tube

35\. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

a) Cool, clammy skin

36\. A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when finding the clients meals?

d) offer frequent High carbohydrate meals

37\. A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the information diagnosis, which of the following clients requires a private room?

a) A client service port reports having fever, night sweats, and call for 2 days

38\. A nurse in an emergency department is assessing a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? (select all the apply)

b) reports of nausea and vomiting

c) Serum glucose 380 mg / DL

e) fruity smelling breath

39\. A nurse is planning a staff education session about hepatitis A. Which of the following information should the nurse include?

a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas

40\. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client?

serum ammonia

41\. A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include?

c) turn the client to the lateral position during seizure activity

42\. A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation?

d) place two bed pillows between the legs when in bed

43\. A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN) The crane infusion is almost complete and the new solution is not available. Which of the following actions should the nurse take?

a) Infuse dextrose 10% in water

44\. A nurse is caring for a client who is 6 hours postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?

c) palpate the dorsalis pedis pulse ---(priority neurovascular assessment)

45\. A nurse is caring for a client in the emergency department who experienced a full thickness burn injury to the lower torso 1 hour ago. Which of the following findings should the nurse expect?

Hypotension

46\. A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan?

d) encourage the client to change position slowly

second option

48\. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?

d) Glasgow Coma Scale score changes from 14 to 9

49\. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take when performing a closed intermittent irrigation?

d) inject the irrigation solution slowly into the catheter

50\. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?

c) I will be sure to wear gloves and wash my hands when I change my cat's litter box

51\. A nurse is caring for a client who is post-operative following an endoscopy with moderate (conscious) Sedation. Which of the following assessment findings is the nurse’s priority?

b) Gag reflex

52\. Nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse’s priority?

d) Obtain a blood specimen for culture and sensitivity testing

53\. A nurse is caring for a client who has just undergone a total laryngectomy. Which of the following findings is the nurse’s priority for immediate intervention?

b) Tachypnea

54\. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?

a) Administer IV fluids to the client

55\. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?

b) The client's capillary refill in the left toe is 6 seconds

56\. A nurse in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has a first-degree heart block?

b) Prolonged PR intervals

57\. A nurse is reviewing the medication list of a client who is being admitted with diabetes insipidus. Which of the following medications places the client at an increased risk for developing diabetes insipidus?

d) Lithium (nephrotoxicity)

58\. A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?

a) Place a plate guard on the client’s meal tray

59\. A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take?

c) Monitor the client for adequate urine output

60\. A nurse in the PACU is caring for a client. Which of the following assessments is the nurse’s priority?

c) Respiratory status

61\. A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media. Which of the following medications should the nurse instruct the client to withhold for 48 hours following the procedure?

metformin

62\. Nurse is caring for a client who has pancreatitis and has been receiving total parenteral Nutrition. Which of the following Laboratory tests should the nurse monitor for overall nutritional status?

prealbumin

63\. A nurse is teaching a client who has endometriosis about the adverse effects of leuprolide. Which of the following manifestations should the nurse include in the teaching?

bone loss

64\. A nurse is caring for a client who had an arterial revascularization of the right lower extremity. Which of the following is the priority action the nurse should plan to take after contacting the provider? (Click on the “exhibit” button for additional information about the client)

c) Start an IV fluid bolus of 0.9% sodium chloride 500 ml to infuse over 1 hour

65\. A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy?

Antithrombotic

66\. A nurse is caring for a client who has a new colostomy. The nurse notes that the client appears withdrawn and looks away during ostomy care. Which of the following actions should the nurse take?

a) Ask the client how they feel about the stoma

67\. A nurse is preparing to perform ocular irrigation for a client following a chemical Splash to the eye. Which of the following actions should the nurse plan to take first?

c) Collect information about the irritant that caused an injury

68\. A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?

b) Initiate a referral for the client to a home health agency

69\. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report?

c) platelets 70,000 / mm3

70\. A home health nurse is providing nutrition education for a client who has trigeminal neuralgia. Which of the following foods should the nurse recommend?

c) vanilla pudding

71\. A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium?

c) 1 Cup white rice

72\. A nurse is planning care for a client who has a full thickness burns on the lower extremities. Which of the following interventions should the nurse include?

d) Apply new gloves when alternating between wound care sites

73\. A nurse is caring for a client who has cancer. The client tells the nurse, “I would prefer to try vitamins and minerals instead of chemotherapy” which of the following responses should the nurse make?

d) Tell me what you know about chemotherapy

74\. a nurse is planning to teach a client whose provider has prescribed a low purine diet. The nurse should plan to instruct the client that he can include which of the following Foods in his diet (select all that apply)

b) Nuts

c) Apricots

75\. Nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?

c) apply an ice pack to the client’s knee

76\. A nurse is caring for a client who has lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?

a) I will need to have my partner take over shopping for groceries and cooking the meals for us

77\. A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

latex

78\. A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?

c) a client who has thrombocytopenia and reports a nosebleed

79\. A nurse is monitoring a client who is receiving two units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

back pain

80\. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

c) Wear cotton rather than nylon socks

81\. A nurse is providing teaching to a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse identify as a risk factor for the development of the DVTs?

c) oral contraceptive use

82\. A nurse is administering furosemide 80 mg PO twice-daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

c) weight loss of 1.8 kg (4 lb) in the past 24 hours

83\. A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contradiction for receiving the medication?

c) potassium 3.2 meq / L

84\. A nurse in an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?

b) wear a lead apron when providing client care

85\. A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following results should the nurse monitor to determine long-term glycemic control?

a) Glycosylated hemoglobin level -(HbA1c 4-6, acceptable DM 6.5-8

86\. A nurse is reviewing the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse anticipate including in the plan? (click on the exhibit button for additional information about the client)

b) Hold the client’s phenytoin

87\. A nurse is preparing to administer two units of packed RBC to a client. Which of the following actions should the nurse take?

d) Prime the tubing with 0.9% sodium chloride

88\. A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH: 7.24 paCO2: 44 mm Hg, paO2: 84 mmHg, HCO3: 18 mEq/ L base excess - 2 and O2 saturation 95% The nurse should include that the client has which of the following acid-base balances?

d) metabolic acidosis

89\. A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?

b) sleep with the head of your bed elevated 6 inches

90\. A nurse is monitoring a client's heart rhythm following insertion of a permanent pacemaker. Which of the following images should the nurse expect?

answer B

91\. A nurse is assessing a client who has heart failure. Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?

b) I am too tired to brush my teeth

92\. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take?

c) flush the catheter manually with 0.9% sodium chloride

93\. A nurse is discussing nutrition options with a client who has a new diagnosis of COPD. Which of the following statements should the nurse take?

a) Plan to include high protein foods in each of your meals ----------(red meat, pork, chicken, potatoes)

94\. A nurse is teaching a client who has asthma about the use of a peak flow meter. After setting the meter to the zero baseline, what is the sequence of steps the nurse should instruct the client to take? put them by order of performance

D- stand upright (1)

B-fill your lungs with a deep breath (2)

A- seal your lips around the mouthpiece (3)

C- exhale forcefully and quickly (4)

E-record the highest of three consecutive readings (5)

95\. A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suction. The nurse should recognize these assessment findings as indicating which of the following?

d) fluid volume excess

96\. A nurse in a clinic is providing for preventive teaching to an older client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after age 60 (select all that apply)

b) pneumococcal polysaccharide (older than 65 y/o/not immunized)

c) Meningococcal-------(MPSV4 only to adults older than 55 years of age)

d) Influenza ---------(18 yo and older)

e) herpes zoster------(50 and older)

97\. A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first?

d) Motor responses -------(non invasive and impair neurologic response )

98\. A nurse is preparing to administer piperacillin 3.375 grams by intermittent IV bolus every 6 hours. Available is piperacillin 3.375 grams in dextrose 5% in water 100 ml to infuse over 30 minutes. the nurse should set the IV pump to deliver how many ml /hr? (round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

200 ml/hr

99\. Nurse in the emergency department is caring for a client who was involved in an explosion. Which of the following actions should the nurse plan to take first question (click on the exhibit button for additional information about the client)

c) notify the rapid response team

100\. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find?

c) Pitting edema (leg, feet and ankles)