Exam Review

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?
A)Dilated pupils, tachycardia, elevated blood pressure, elation.
B)Excessive eating, constipation, headache.
C)Nausea, vomiting, diaphoresis, anxiety, tremors.
D)Mood lability, poor hand coordination, fever, drowsiness.
While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?
A)Report any increase in the white blood cell count.
B)Change the surgical dressing readily when soiled.
C)Instruct the family to adhere to contact precautions.
D)Wear a face mask while performing wound care.
A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.(SATA)
A)Use standard precautions and wear a mask.
B)Explain the purpose of a low bacteria diet.
C)Send wound drainage for culture and sensitivity.
D)Institute contact precautions for staff and visitors.
E)Monitor the client's white blood cell count.
The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?
A)Hold the client at arm's length while transferring to better distribute the body weight.
B)Place the client's locked wheelchair on the client's strong side next to the bed.
C)Pull the client into position by reaching from the opposite side of the bed.
D)Apply a gait belt around the client's waist once a standing position has been assumed.

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Exam Review

The nurse is caring for a client who receives a prescription for parenteral lidocaine. Prior to administering the medication, the nurse should review the medical record for which condition?
A)Diabetes mellitus.
B)Heart block.
C)Gastric ulcers.
D)Glaucoma.
Exhibits Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.(SATA)
A)Occupation of legal secretary
B)Stiffness in hands for 3 months
C)Radial and pedal pulses 2+
D)Pain in bilateral hands and wrists
E)History of asthma using albuterol inhaler PRN
F)Capillary refill 2 seconds
G)Body mass index (BMI) of 31 kg/m2
H)Client's hobbies
Exhibits The nurse reviews the history and physical, the nurses' notes, and the flow sheet to help determine what is causing the client's symptoms. For each listed finding, click to indicate whether the finding is associated with arthritis or carpal tunnel syndrome. Each column must have at least one response option selected.
Arthritis Carpal Tunnel Syndrome
Can be caused by aging ✓ ✓
Inflammatory disease process ✓
Finger numbness ✓
Experience difficulty with fine motors movements ✓ ✓
May have a genetic component ✓
Exhibits The healthcare provider (HCP) is reviewing the client's laboratory results and imaging and has diagnosed the client with rheumatoid arthritis. Drag from Word Choices to complete the sentence. Due to the new diagnosis of rheumatoid arthritis, the nurse should recognize that the client is at risk for▾ impaired physical mobility,▾ acute painand▾ knowledge deficit.
Dropdown 1:
Option 1: impaired physical mobility
Option 2: electrolyte imbalance
Dropdown 2:
Option 1: electrolyte imbalance
Option 2: acute pain
Dropdown 3:
Option 1: electrolyte imbalance
Option 2: knowledge deficit

	Arthritis	Carpal Tunnel Syndrome
Can be caused by aging	✓	✓
Inflammatory disease process	✓
Finger numbness		✓
Experience difficulty with fine motors movements	✓	✓
May have a genetic component	✓

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Exam Review

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.(SATA)
A)Perform aggressive weight bearing exercises.
B)Anticipate dry eyes and mouth; no intervention is needed.
C)Take hot showers to help relieve stiffness.
D)Observe skin for any lesions.
E)Watch for gastrointestinal upset with medication administration.
F)Discuss body image feelings with a trusted friend or therapist.
G)Avoid fluids, to decrease trips to the bathroom.
H)Prioritize rest, with short periods of activity.
Exhibits The nurse is preparing the client's plan of care. A major component of the clients at home care is pain management. Select the 3 most important interventions the nurse can educate the client with rheumatoid arthritis (RA) about to help with pain management.(SATA)
A)Consult a dietitian to support nutrition and weight loss.
B)Perform fine motor activities for the client to decrease pain.
C)Avoid movement, as it will increase pain.
D)Eat a diet high in refined carbohydrates.
E)Apply ice packs to inflamed joints.
F)Facilitate paraffin wax dips to help soothe joints.
Exhibits The nurse evaluates the client and the flow sheet.
(Highlight — findings requiring follow-up are marked)
Exhibits

The nurse evaluates the client and the flow sheet.

Click to highlight the findings that indicate the client is progressing as expected.

The client presents to the office for reevaluation of rheumatoid arthritis after methotrexate 25 mg PO weekly was started at the last visit. The client reports she has been balancing periods of activity with rest. She recently attended a large family wedding and became fatigued quickly. She has continued to garden, and read, but crocheting is too painful. She is tolerating weekly medication without side effects. She describes pain as 1 to 2 on a 0 to 10 pain scale in bilateral hands. She has noticed "heartburn" about an hour after using ibuprofen for pain relief. The client is pleased with the improvements.
A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care?
A)Maintain strict intake and output.
B)Assess warmth of extremities.
C)Keep head of bed raised 45 degrees.
D)Monitor blood glucose level.

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Exam Review

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?
A)Glucose and calcium levels.
B)Electrolytes and hemoglobin.
C)Renal and liver function tests.
D)Blood and urine cultures.
To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?
A)Remind the client to keep his appointments to have his cholesterol level checked.
B)Teach the client to weigh himself weekly and keep a log of the measurements.
C)Encourage the client to keep a diary of his food intake until his next visit to the clinic.
D)Assess the elasticity of the client's skin at the next scheduled clinic appointment.
The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?
A)Client exhibits a frequent productive cough.
B)Client reports using the incentive spirometer every hour while awake.
C)Client's breath sounds are clear to auscultation bilaterally.
D)Client demonstrates proper use of an incentive spirometer.
The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply. Reference Range: White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)](SATA)
A)Leakage of cerebral spinal fluid from the incisional site.
B)Poor feeding and vomiting.
C)Abdominal distention.
D)WBC of 10,000/mm3 (10 x 10^ 9/L).
E)Hyperactive bowel sounds.

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Exam Review

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?
A)Emphasize that using safe sex practices removes the risk of STIs.
B)Remain non-judgmental and assure the client of confidentiality.
C)Clarify that all STIs are transmitted through sexual intercourse.
D)Inform that follow-up may end after the treatment is finished.
Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?
A)Tie the knot with a double turn or square knot.
B)Ensure that the knot can be quickly released.
C)Move the ties so the restraints are secured to the side rails.
D)Ensure that the restraints are snug against the client's wrists.
Exhibits The nurse is reviewing nurses' notes to determine if there are any variations.
(Highlight — findings requiring follow-up are marked)
Exhibits

The nurse is reviewing nurses' notes to determine if there are any variations.

Click to highlight the findings that would indicate the client has developed a complication related to pregnancy.

The client is a 32-year-old multigravida at 28 weeks gestation, who presents to the healthcare provider's office for a routine prenatal visit. Obstetrical history reveals she has given birth three times; once at 35 weeks (twins), once at 38 weeks (singleton) and once at 41 weeks (singleton). All of these children are alive and well. She had one spontaneous abortion at 10 weeks' gestation. Her fourth child weighed 9 pounds (4.08 kg) at 41 weeks gestation.

Client is at 28 weeks. She has been receiving prenatal care since 8 weeks gestation. Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dL (9.1 mmol/L). Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).
The nurse is reviewing nurses' notes to determine what the client's obstetric history reveals in the form of GTPAL. Choose the most likely option for the information missing from the statement by selecting from the list of options provided. Based on the client's obstetrical history, what is the client's G-T-P-A-L designation?
A)4-2-1-1-4
B)5-2-1-1-4
C)4-3-1-0-4
D)5-3-1-0-4

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Exam Review

Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.(SATA)
A)"Hyperglycemia often results in weight loss."
B)"Hyperglycemia often presents as increased thirst and urination."
C)"Hyperglycemia causes an increased sensation of being hungry."
D)"Hyperglycemia causes a headache and flushed, dry skin."
E)"Hyperglycemia causes cool and clammy skin."
Exhibits The client asks the diabetic nurse educator to clarify what the Registered Dietician told her about the content and timing of her meals. Which 3 responses should the diabetic nurse educator provide?(SATA)
A)Drink between 8 to 10 cups (1.9 to 2.4 liters) of fluids daily.
B)Eliminate the bedtime snack if heartburn develops after eating.
C)Choose complex carbohydrates that are high in fiber content.
D)Increase the percentage of protein in the diet if anemia develops.
E)Avoid foods high in refined sugars.
Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The diabetic nurse educator instructs the client to perform fingerstick blood glucose (FSBG) monitoring ▾ before breakfastand▾ two hours after all meals.
Dropdown 1:
Option 1: two hours after all meals
Option 2: before bedtime
Option 3: only when symptomatic
Option 4: before breakfast
Dropdown 2:
Option 1: two hours after all meals
Option 2: before bedtime
Option 3: only when symptomatic
Option 4: before breakfast
Exhibits The postpartum nurse reviews the nurses' notes to determine if the outcomes were successful.
(Highlight — findings requiring follow-up are marked)
Exhibits

The postpartum nurse reviews the nurses' notes to determine if the outcomes were successful.

Click to highlight the notes that demonstrate a positive outcome.

The client is admitted to the hospital after her membranes rupture at 38 weeks gestation. A vaginal examination is done. The nurse determines that the client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station. The external monitor shows that contractions are occurring every 4 minutes and lasting 70 seconds, and the nurse palpates the quality as strong. Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L). The client is transferred to the labor-delivery-recovery (LDR) suite. The client dilates quickly to 10 cm and feels a strong urge to push. The fetal heart rate is reassuring with a baseline of 145 and moderate variability The nurse briefly reviews pushing techniques with her and her husband and notifies the obstetrician of the client's progress. After three cycles of open-glottis pushing, the baby's head is crowning. The head is born easily over an intact perineum. The infant weighs 9 lbs. 9 oz (4.34 kgs) and has an Apgar of 7 at 1 minute, then 9 at 5 minutes.

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