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    Exam Review

    1. A nurse is assessing a client with acute pancreatitis. Which of the following findings should be the nurse's highest priority?
      A)Fever
      B)Hypotension
      C)Abdominal distention
      D)Elevated serum lipase levels
    2. A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which assessment finding is the greatest concern?
      A)PaO2 of 46 mm Hg (80-100 mm Hg)
      B)lack of adventitious lung sounds
      C)respirations of 20 breaths/min (12-20 breaths/min)
      D)oxygen saturation of 95% on room air (95-100%)
    3. The nurse assesses a client with cirrhosis who is prescribed diuretics for ascites. Which assessment findings are most important for the nurse to evaluate related to diuretic therapy? Select all that apply.(SATA)
      A)Renal function tests.
      B)Body image disturbances.
      C)Gastrointestinal bleeding
      D)Electrolyte laboratory results.
      E)increased clotting tendencies.
    4. A nurse is assessing a client with acute pancreatitis who reports increased shortness of breath and has an oxygen saturation level of 88%. What should the nurse assess first?
      A)Neurological status for changes in level of consciousness
      B)Lung sounds for the presence of crackles or diminished breath sounds.
      C)Abdominal girth and tenderness
      D)Vital signs for hypotension and tachycardia.
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    Exam Review

    1. The nurse cares for a client with cirrhosis who is experiencing variceal bleeding. What should the nurse do first?
      A)Obtain a type and crossmatch for blood administration
      B)Insert two large bore intravenous lines
      C)Suction the airway
      D)Prepare the client for endoscopy
    2. The nurse suspects that a client who presented to the emergency department is experiencing bleeding from liver trauma, Which cues support the nurse's suspicion? Select all that apply.(SATA)
      A)New onset of lightheadedness
      B)Complaints of right shoulder pain
      C)Heart rate of 116 beats per minute
      D)Requesting more water to drink
      E)A wide pulse pressure
      F)Respiratory rate of 28 breaths per minute
    3. A student nurse is completing an internship in the emergency department. The student asks the preceptor. "How is emergency department nursing different from other areas of nursing practice? How should the experienced emergency department nurse respond? Select all that apply.(SATA)
      A)"We focus on primary care."
      B)"Most of what we do is acute care or critical care."
      C)"Emergency department nurses provide care to patients of all ages."
      D)"Most of the time we are providing care to patients without a medical diagnosis."
      E)"it is episodic
    4. A nurse manager is making morning assignments for the nursing team. Which duties can be assigned to the nursing assistant/unlicensed worker? Select all that apply.(SATA)
      A)Changing the linen of a client on a pressure-releasing mattress
      B)Repositioning a client on complete bed rest
      C)Teaching a client on an anticoagulant about using an electric razor
      D)Transferring a client from the bed to the chair using a mechanical lift
      E)Totaling the oral intake and output for the entire unit.
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    Exam Review

    1. A client is admitted to the emergency department with abdominal pain. Which data should the nurse document regarding a client's complaint of abdominal pain? Select all that apply.(SATA)
      A)The client describes the pain as sharp and stabbing
      B)The pain began 24 hours ago
      C)The client fears losing her job if pain causes another absence
      D)Belching has lessened the pain
      E)Walking exacerbates the pain
    2. Which client admitted to the emergency department should the nurse see first?
      A)A client with a blood pressure of 170/95 mm Hg
      B)A client experiencing a "ripping" sensation in the chest.
      C)A client taking anticoagulants with bloody stool.
      D)A client with a urine output of 240 mL in 12 hours.
    3. The nurse changes the subclavian dressing of a client receiving total parenteral nutrition and notes the presence of yellow drainage around the sutures anchoring the catheter. What should the nurse do first?
      A)Obtain a culture of the drainage
      B)Clean the insertion site and redress the area.
      C)Check the client's temperature.
      D)Document the findings in the chart
    4. A nurse attempts to administer lactulose to a client who has cirrhosis. The client refuses to take the medication because it causes diarrhea. The nurse provides teaching about the medication, but the client continues to refuse the medication. Which action should the nurse take first?
      A)Explain again to the client the consequences of refusing to take the medication.
      B)Document in the client's clinical record the client's refusal to take the medication.
      C)Notify the primary health-care provider of the client's refusal to take the medication.
      D)Discuss with a family member the need for the client to take the medication.
    Page 3 of 21

    Exam Review

    1. The client with esophageal varices was admitted with hypovolemic shock secondary to upper gastrointestinal bleed. Which intervention is not appropriate for this client?
      A)Administer lactulose as prescribed for the client with liver failure.
      B)Ensure that the balloon of an esophagogastric balloon tube is in place no longer than 12 hours
      C)Closely monitor respiratory and neurological status.
      D)Prepare for emergent surgery
    2. The nurse assesses a client being evaluated for viral hepatitis. Which finding is not expected in viral hepatitis?
      A)Pruritus
      B)Arthralgia
      C)Polyphagia
      D)Skin abrasions
    3. The nurse assesses a client with a pleural chest tube inserted to treat a pneumothorax. Which findings require immediate notification to the provider? Select all that apply.(SATA)
      A)The client complains of chest pain when breathing deeply.
      B)New onset of subcutaneous emphysema
      C)Constant bubbling in the water seal chamber,
      D)The eyelets of the chest tube are visible.
      E)An occasional bubble appears in the water seal chamber when the client exhales
    4. A nurse is caring for a client who has acute pancreatitis. Complete the following sentence by using the list of options. When prioritizing client needs, the nurse should first address the client's ▾ glucose level  followed by notifying the provider of the client's ▾ Hgb & Hct level  
      Dropdown 1:
      Option 1: lipase level
      Option 2: glucose level
      Option 3: Hgb & Hct level
      Option 4: amylase level
      Dropdown 2:
      Option 1: lipase level
      Option 2: glucose level
      Option 3: Hgb & Hct level
      Option 4: amylase level
    Page 4 of 21

    Exam Review

    1. A nurse is preparing a teaching plan for a newly married female client with a cervical spinal cord injury who would like to have children someday. The client does not want to become pregnant at this time. What information would be important for the nurse to include? Select all that apply.(SATA)
      A)Explain that is not possible for her to become pregnant
      B)Suggest she take oral birth control pills
      C)suggest the couple use condoms
      D)Instruct the client's husband how to properly insert a diaphragm
      E)Provide her husband with a vasectomy referral
    2. A nurse is caring for a newly admitted client. A nurse notes the client's condition and initiates the following action. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
      ✓Monitor hematemesis
      ✓Administer lactulose as prescribed
      ✓Encephalopathy
      ✓Safety measures
      ✓Intake and output
      Actions to Take Choices
      ✓Monitor hematemesis
      ✕Educate the client about protein intake
      ✕Prepare for a paracentesis
      ✓Administer lactulose as prescribed
      Potential Condition choices
      ✓Encephalopathy
      ✕Esophageal varices
      ✕Ascites
      ✕pruritus
      Parameters to Monitor Choices
      ✕Bleeding
      ✕Skin integrity
      ✓Safety measures
      ✓Intake and output
    3. A client with end-stage liver failure presents with confusion, lethargy, and asterixis. Which laboratory result is most likely associated with these symptoms?
      A)Elevated platelet count
      B)Normal albumin levels
      C)Elevated ammonia levels
      D)Decreased bilirubin levels
    4. A nurse assesses a client who is a possible candidate for a liver transplant for contraindications of a liver transplant. Which findings should the nurse report to the provider? Select all that apply.(SATA)
      A)End-stage Chronic Obstructive Pulmonary Disease
      B)Advanced cardiac disease
      C)Inability to follow instructions regarding drug therapy and self-management
      D)Hepatitis C
      E)Metastatic tumors
    Page 5 of 21

    Exam Review

    1. What should the emergency department nurse identify as a PRIMARY survey clinical priorities for the treatment of a client with a gunshot wound? Select all that apply.(SATA)
      A)Obtaining medical history.
      B)Hypothermia prevention
      C)Hemorrhage control.
      D)Airway maintenance.
      E)Ventilation assistance.
    2. The nurse teaches a client about strategies for reducing the risk of hepatitis B transmission, which statements by the client indicate understanding? Select all that apply.(SATA)
      A)" will avoid contact with blood and body fluids."
      B)"will avoid eating all fish.
      C)"I will avoid contaminated food and water."
      D)will wash my hands frequently to prevent fecal-oral transmission."
      E)"I will use safe sex techniques."
    3. A client presents to the emergency department with bee stings to the hand. Which action should the nurse take first?
      A)Apply ice packs to both hands.
      B)Apply calamine lotion to itching areas.
      C)Remove the client's rings.
      D)Give diphenhydramine 50 mg by mouth.
    4. The nurse prepares to administer dobutamine 2.5 mcg/kg/min IV for a client who weighs 193 pounds. The nurse receives dobutamine 250 mg in 250 mL of 5% dextrose from the pharmacy. The IV pump should be set to deliver how many mL/hr? Round to a whole number.
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