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    Exam Review

    1. A nurse is caring for a client who has a below-the-knee amputation. Which of the following statements should indicate to the nurse that the client has adapted to role changes after their injury?
      A)"I don't think I will ever be a whole person again."
      B)"I don't feel comfortable socializing with my friends."
      C)"My spouse and I both accept that I am no longer capable of taking care of myself."
      D)"I will have to work with a vocational counselor to find out what kinds of jobs I can do.
    2. A nurse is assessing a client's response to receiving morphine for postoperative pain management. Which of the following findings is the nurse's priority?
      A)Bradypnea
      B)Bradycardia
      C)Hypotension
      D)Pruritus
    3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)(SATA)
      A)Verify the solution with another RN prior to infusion.
      B)Monitor serum blood glucose during infusion.
      C)Increase the rate of infusion: administration is delayed
      D)Infuse 0.9% sodium chloride if the solution is not available
      E)Obtain the client's weight daily
    4. A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse Include in the plan of care? (Select all that apply.)(SATA)
      A)Place a tongue blade at the bedside.
      B)Dim the overhead lights.
      C)Assist the client to ambulate every 4 hr.
      D)Apply a warming blanket.
      E)Have suction equipment at the bedside.
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    Exam Review

    1. A nurse is caring for a client who is postoperative following ambulatory surgery requiring general anesthesia. Which of the following actions should the nurse take?
      A)Offer the client oral fluids when awake
      B)Discontinue IV fluid infusion on arrival to the PACU
      C)Check the client's vital signs once every hour until awake
      D)Maintain the client in a supine position.
    2. A nurse is performing chest percussion on a client who has severe COPD. Which of the following actions should the nurse take?
      A)Ask the client to take shallow, rapid breaths.
      B)Place a towel over the area to be percussed.
      C)Percuss over each area for 10 min.
      D)Maintain client positioning for 45 min.
    3. A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?
      A)Clamp the tubing to check for air leaks.
      B)Raise the drainage system to the client's chest level.
      C)Gently squeeze the tubing to remove excess drainage.
      D)Empty the collection chamber.
    4. A nurse manager is evaluating a quality improvement initiative for reducing health care-associated infections. Which of the following findings indicate the initiative is effective?
      A)Central lines are inserted into the femoral vein for clients who are obese.
      B)Nurses perform hand hygiene for 10 seconds before completing tasks.
      C)Clients who have an indwelling urinary catheter are assessed daily to determine if it is still needed.
      D)Clients who are intubated are kept in the supine position.
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    Exam Review

    1. A nurse is reviewing the laboratory results of a female client who has cirrhosis. Which of the following findings should the nurse identify as a complication?
      A)Platelets 325,000/mm3 (150,000 to 400,000/mm3)
      B)Albumin 4.8 g/dl (3.5 g/dL to 5 g/dL)
      C)RBC count 4 million/mm (4.2 to 5.4 million/mm)
      D)WBC count 8,000/mm3 (5,000 to 10,000/mm3)
    2. A nurse is caring for a client who is at risk for respiratory alkalosis. Which of the following alterations should the nurse identify as an increased risk for this condition?
      A)Acute respiratory distress syndrome
      B)Hyperventilation
      C)Excessive intake of bicarbonate
      D)Kyphosis
    3. A nurse is providing teaching for a client who received a prescription for an epinephrine autoinjector to treat anaphylaxis. Which of the following Information should the nurse include in the teaching?
      A)Inject into the buttock or deltoid.
      B)Hold the autoinjector firmly down for 10 seconds while injecting.
      C)Use the autoinjector if shortness of breath is the only symptom of anaphylaxis.
      D)Use the second autoinjector immediately after the first dose.
    4. A nurse is caring for a client who has end-stage kidney disease. Which of the following dietary instructions should the nurse give to the client's partner?
      A)"Limit your partner's potassium intake to 60 mEq/L per day.
      B)"Encourage foods high in protein for your partner.”
      C)"Help your partner consume foods containing phosphorus.
      D)Restrict your partner's oral fluid intake to 450 mL/day"
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    Exam Review

    1. A nurse is teaching a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all apply.)(SATA)
      A)"You will take medication for this condition for several months."
      B)"This condition can cause you to gain weight."
      C)"We will perform laboratory tests to monitor the effect of your medication."
      D)"You might notice that you perspire more with this condition
      E)"You will need to eat a higher amount of iodine rich foods
    2. A nurse is monitoring a client who recently had an esophagogastroduodenoscopy procedure. Which of the following findings should the nurse identify as an indication that the client is recovering after the procedure as expected?
      A)SpO2 92%
      B)Heart rate 110/min
      C)Temperature 38.7° C (101.7° F)
      D)Respiratory rate 14/min
    3. A nurse is caring for a client following the placement of a chest tube drainage system for a pneumothorax. Which of the following findings should the nurse expect?
      A)Serous drainage noted in the collection chamber
      B)Tidaling in the water seal chamber with respirations
      C)Movement of the trachea toward the unaffected side
      D)Diminished breath sounds in the lung base
    4. A nurse is instructing a client on the maintenance of their cast. Which of the following instructions should be given to the client?
      A)"You might feel tightness and pain with the cast and that is a normal feeling."
      B)Trim off the rough edges of the cast if it bothers you in order to promote comfort."
      C)"You might feel itchy under the cast, and it is okay to scratch under the cast with a very slim tool."
      D)"Once the cast is dry, you can shower if you cover it with a plastic covering."
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    Exam Review

    1. A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
      A)Blood glucose 230 mg/dL (74 to 106 mg/dL)
      B)pH 7.5 (7.35 to 7.45)
      C)Serum bicarbonate 9 mEq/L (21 to 28 mEq/L)
      D)Partial pressure of CO, 50 mm Hg (35 to 45 mm Hg)
    2. A nurse is teaching a client who is scheduled for a procedure with moderate (conscious) sedation. Which of the following information should the nurse include in the teaching?
      A)"You will be able to hear verbal commands during this procedure."
      B)"You will be fully awake during this procedure."
      C)"You will have a breathing tube inserted for this procedure."
      D)"You will receive a medication to paralyze your muscles."
    3. A nurse is caring for a client who is 2 hr postoperative following orthopedic surgery and reports pain as 10 on a scale of 0 to 10. Which of the following prescriptions should the nurse expect to administer?
      A)Oxycodone 10 mg PO
      B)Fentanyl 12.5 mcg/hr transdermal
      C)Acetaminophen 1,000 mg PO
      D)Ketorolac 30 mg IV
    4. A nurse is assessing a client's response to receiving morphine for postoperative pain management. Which of the following findings is the nurse's priority?
      A)Bradypnea
      B)Bradycardia
      C)Hypotension
      D)Drowsiness
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    Exam Review

    1. A nurse is assessing a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is having a hemolytic transfusion reaction?
      A)Bounding pulses
      B)Low back pain
      C)Distended jugular veins
      D)Pretension
    2. A nurse is caring for a client who has an arterial line inserted in the radial artery. Which of the following actions should the nurse take?
      A)Infuse 0.9% sodium chloride at 150 mL/hr.
      B)Maintain the pressure bag at 300 mm Hg of pressure.
      C)Align the transducer to the level of the client's radial artery.
      D)Have the client bear down when checking their blood pressure
    3. A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
      A)Cleanse the catheter site using a side-to-side motion.
      B)Tape down the corners of the dressing.
      C)Place a mask on the client during the procedure.
      D)Secure an occlusive dressing over the gauze pads
    4. A nurse is caring for a client who has pulmonary edema and a new prescription for furosemide 40 mg IV twice daily. Which of the following client findings indicates the prescription is appropriate?
      A)Bilateral coarse, crackle breath sounds
      B)Vesicular breath sounds over the peripheral lung fields
      C)Blood pressure 100/70 mm Hg
      D)Potassium 3.2 mEq/L (3.5 mEq/L to 5.0 mEq/L)
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