Main version priority one exit exam 2021| Rated +

1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? A. Capillary refill less than 2 seconds B. Boun ...

1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? A. Capillary refill less than 2 seconds B. Bounding distal pulses C. Intense pain with movement D. Erythema of the toes 2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? A. Chills ? (think fever, you get cold when your body is hot) B. Hypertension C. Bradycardia D. Back pain 3 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? A. Remove the wedge device when turning B. Place two bed pillows between the legs when in bed C. Encourage the client to lean forward when attempting to stand D. Elevate the knees higher than the hips when sitting 4 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 A. Povidone-iodine B. Adhesive tape C. Latex D. Anesthetics 5 A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? A. Place hands on the upper abdomen during inhalation. B. Position the mouthpiece 2.5 cm (1 in) from the mouth C. Exhale slowly through pursed lips D. Hold breaths about 3 to 5 seconds before exhaling6 A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client’s serum potassium level is 2.8mEq/L. Which of the following interventions should the nurse implement first? Priority question remember, what can I do first, you can start a K+ drip without knowing how their heart is affected. A. Check the clients hand grasps B. Administer an IV potassium drip C. Listen to the client’s bowel sounds D. Initiate cardiac monitoring for the clients This is a priority!!! 7 A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? A. Chill the dialysate before administration B. Hang the drainage bag below the client’s abdomen C. Place the client in high-Fowlers position D. Use clean technique to access the catheter 8 A nurse is preforming a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? A. Inability to smell B. loss of peripheral vision C. Disequilibrium with movement D. Deviation of the tongue from midline 9 A nurse is planning care for a client who is one day postoperative Following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? A. Place pillows under the clients knees B. Avoid use of anticoagulants C. Discourage leg exercises while in bed D. apply compression stockings to the lower extremities 10 A nurse is caring for a male client who has an exacerbation of heart failure. Which of the following prescriptions should the nurse expect to receive from the provider? (click on the “exhibit” button for additional information about the client. There are 3 tabs that contain separate categories of data.) A. Atropine 1mg IV bolus every 5 min up to 3 mg ? B. Adenosine 6mg rapid IV bolus now C. Verapamil 80 mg PO TID D. Furosemide 40 mg IV bolus every 6 hr.11 A nurse is providing a discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? A. “I will keep my left arm flexed at the elbow as much as possible” ? B. “ I should expect less than 25 mL of secretions per day in the drainage devices” C. “I will perform strength building arm exercises using a 15 pound weight” D. “ I will have to wait 2 months before additional saltine can be added to my breast expander” 12 A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include I the first teaching? A. “Do not shake your inhaler before use” B. “Exhale Fully before bringing the inhaler to your lips “ C. “Use Peroxide to clean the mouthpiece of your inhaler” D. “Depress the canister after you inhale” 13 A nurse is caring for a client who has been receiving total parental nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider? A. Calcium level 11.5 mg/dL B. Serum albumin level 3.9g/dl C. Output 200 mL more than intake over the past 12 hr. D. Fasting blood glucose level 105 mg/dL 14 A nurse is preparing to discharge a client who has