Exam Review

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.(SATA)
A)Effective coping with illness related anxiety
B)Infection prevention related to illness
C)Relief of acute pain
D)A review of diet progression postoperatively
E)Promotion of bowel routine
F)Prevention of deep vein thrombosis (DVT) related to immobility
G)Fluid volume management
H)Client education about diagnosis and plan of care
Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.(SATA)
A)Encourage sitting up and ambulation
B)Monitor for bleeding once daily
C)Use Incentive spirometer every 1 hour
D)Promote adequate hydration
E)Assess for sedation after pain medications
F)Complete neurologic assessment every 2 hours
G)Administer pain medication after activity
Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?(SATA)
A)Heart rate 121 beats/minute
B)Capillary refill 2 seconds
C)Respirations 28 breaths/minute with shallow breathing
D)Radial and pedal pulses 2+
E)Severe abdominal pain in right lower quadrant
F)Feels anxious
G)Temperature 100.8° F (38.2° C)
H)Vomiting small amounts of green bile
I)Blood pressure 115/76 mm Hg
Which is the best approach for the nurse to use when interviewing a client about sexual abuse?
A)Begin with questions that are less sensitive in nature.
B)Share personal values to put the client at ease.
C)Get the most difficult questions over with first.
D)Ask questions in a vague, non-specific format.

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Exam Review

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)
A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?
A)IV administration of benztropine.
B)PO administration of divalproex.
C)PO administration of lorazepam.
D)IV administration of isotonic crystalloid fluid.
The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.(SATA)
A)Determine if the client has recently experienced a fall.
B)Instruct the adult child to check the client's temperature.
C)Ask if the client is experiencing any pain with urination.
D)Encourage increased intake of high protein foods.
E)Review the client's current food and medication allergies.
A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?
A)A resting respiratory rate of 35 breaths/minute.
B)Flaring of the nares.
C)Diaphragmatic respirations.
D)Bilateral bronchial breath sounds.

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Exam Review

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?
A)Report when hematuria becomes pink tinged.
B)Restrict all physical activities.
C)Use the incentive spirometer.
D)Monitor urinary stream for decreased output.
A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?
A)Regression.
B)Suppression.
C)Compensation.
D)Sublimation.

Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

	Promotes safety	Does not promote safety
Place all client belongings out of reach		✓
Instruct the client to call before getting up	✓
Initiate use of the bed alarm	✓
Complete a swallow study before giving anything by mouth	✓
Place the client in a room near the elevator		✓
Provide a call button kept within reach	✓

Patient Data Exhibits The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery. What interdisciplinary team member(s) should assist the client in recovery? Select all that apply.(SATA)
A)Case Manager
B)Occupational Therapist
C)Speech Therapist
D)Respiratory Therapist
E)Chief Nursing Officer
F)Medical Assistant
G)Pharmacy Technician
H)Physical Therapist

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Exam Review

Patient Data Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of ▾ Stroke as evidenced by▾ Neurological defects. neurological defects as evidenced by
Dropdown 1:
Option 1: Malignant hypertension
Option 2: Stroke
Option 3: Allergic reaction
Option 4: intoxication
Dropdown 2:
Option 1: Report of alcohol consumption
Option 2: Neurological defects
Option 3: Vital signs
Option 4: Garbled speech
A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?
A)Defibrillate with one shock.
B)Prepare for external pacing.
C)Administer atropine IV.
D)Give a dose of amiodarone IV.
A client who was admitted with rapid atrial flutter is receiving amiodarone 1 mg/minute via a peripheral IV infusion in the left hand. The unlicensed assistive personal (UAP) reports to the nurse that the client's heart rate is 90 beats/minute and blood pressure is 110/50 mm Hg. Which intervention should the nurse implement?
A)Tell the UAP to turn off the amiodarone.
B)Evaluate rhythm of client's heat rate.
C)Determine regularity of peripheral pulses.
D)Restart the IV infusion in another site.
Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow-up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep at night. Which intervention is most important for the nurse to implement?
A)Ask the spouse if the client seems to be depressed.
B)Tell the spouse to wait outside so the client can be assessed for depression.
C)Explain that depression often occurs after a life-threatening experience.
D)Encourage the client to further describe his feelings.

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Exam Review

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?
A)Propose that the nurse use the antecubital site for IV access.
B)Send an unlicensed assistive personnel to gather equipment.
C)Direct the nurse to remove the needle before the procedure.
D)Suggest starting a secondary infusion at the IV tubing
Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.(SATA)
A)Oxygen saturation 98% on room air
B)Urine output 20 mL in the last hour
C)Basilar crackles
D)Heart rate 72 beats/minute
E)Respiratory rate 26 breaths/minute
F)Blood pressure 126/76 mm Hg
G)Electrocardiogram Tall T wave and widened QRS complex
H)Temperature 98.9° F (37.1° C) orally
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
A)Length of time of the exposure to tuberculosis.
B)Current diagnosis of hepatitis B.
C)History of intravenous drug abuse.
D)Conversion of the client's purified protein derivative (PPD) skin test from negative to positive.
A client is receiving "Heparin Sodium 25,000 Units in 250 mL 5% Dextrose" IV at 7 mL/hour. The healthcare provider changes the prescription to 900 units/hour. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only.)

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Exam Review

Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

	Indicated	Contraindicated
IV 0.9% normal saline continuous infusion at 100		✓
Daily weights	✓
Calculation of intake and output	✓
IV potassium sparing diuretic		✓
Continuous pulse oximetry monitoring	✓
Electrocardiogram monitoring	✓

Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?(SATA)
A)Administering antipyretic medication as needed
B)Educating client and family on the importance of fluid restrictions
C)Collaborating with dietician to prepare low protein diet
D)Monitoring fluid status
E)Investigating acid/base complication
F)Assessing for worsening respiratory status
G)Performing diagnostic testing to determine cause of fever
H)Reassessing vital signs
I)Identifying cardiac arrhythmias
Patient Data Exhibits After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic. Drag from Word Choices to complete the sentence. The nurse determines that the findings are reflective of▾ Uremic encephalopathy and▾ Fluid volume overload
Dropdown 1:
Option 1: Depression
Option 2: Uremic encephalopathy
Option 3: Fluid volume overload
Option 4: Pernicious anemia
Dropdown 2:
Option 1: Depression
Option 2: Uremic encephalopathy
Option 3: Fluid volume overload
Option 4: Pernicious anemia
Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.(SATA)
A)Skin pale and diaphoretic
B)Respiratory rate 36 breaths/minute
C)Blood pressure 140/86 mm Hg
D)Temperature 101.1° F (38.4" C) orally
E)Bilateral basilar crackles
F)Bilateral radial pulses bounding
G)Heart rate 117 beats/minute and irregular
H)Oxygen saturation 98% on room air

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