1. Client reports having jaundice, dark urine, abdominal distention, and some dull right upper quadrant pain. Which additional assessment does the nurse make? Select all
Information about weight loss
Amt of alcohol co
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1. Client reports having jaundice, dark urine, abdominal distention, and some dull right upper quadrant pain. Which additional assessment does the nurse make? Select all
Information about weight loss
Amt of alcohol consumption
Report of changes in mental status
Any petechiae on arms or legs
2. A client is diagnosed with graves disease. Client has temp of 104, pulse 120, abdominal pain, vomiting, diarrhea. The nurse anticipates which treatment will be prescribed?
a. Proplthiouracil
3. A client asks the nurse how a family emmber could have contracted hep a. which statement by the nurse is best?
a. Tell me what u know about hep a
4. A client experiences shoulder pain following a laparoscopic surgery. Which is the most important nursing action at this time?
a. Give pain meds
5. Client recovers after a nephrectomy. Client weights 176.5 lbs. Nurse measures 85ml of urine after 2 hours. Which action does the nurse implement on current data?
a. Meausre in 2 hours
6. Nurse teaches a client in preparation for an upper GI xray. Which information is given to client?
a. No smoking for 6-8 hours before procedure
7. Client is diagnosed with diabetes mellitus type 1. Client reports nausea and vomiting for 12 hours. Which question is most important for the nurse to ask the client?
a. When did u check your blood glucose last?
8. A client is diagnosed with cholecystitis and is scheduled for surgery in a week. The nurse teaches the client which measure to prevent pain until surgery?
a. Low fat diet
9. Symptoms- joint pain in the knee that gets worse with activity, knee stiffness in morning, etc. Client has osteoarthritis. Nurse anticipates which treatment will be recommended initially?
a. Rest when joint inflamed
b. Acetaminophen and capsaicin cream
c. Alternate heat and cold
d. Muscle strength exercise
10. Client sustained deep partial-thickness burn to both arms and upper part of torso. Nurse adds new nursing care plan. (got this wrong)
a. Decreased nutrition
b. Infection risk
c. Skin integrity (maybe not this)
d. Injury risk (maybe not this?)
e. Inadequate fluid volume risk
11. Client as possible UTI. What does nurse expect client to say that is relevant to infection
a. I have to urinate and it hurts
b. I use a diaphragm when I have sex
c. I get hold and cold and shiver
12. A client is diagnosed with hypothyroidism. Client tells nurse the symptoms have resolved and has stopped taking meds.
a. Client will comply with medication regimen
13. Client diagnosed with hep b. Nurse identifies a nursing diagnosis based on which prority concern?
a. Possible changes in liver function because of viral infection
14. Client diagnosed with end stage kindey disease has been approved for kidney transplant. Which statement?
a. I may need dialysis assistance as the new kidney recovers.
15. Client is hospitalized with acute pancreatitis. Which is most important nursing intervention for client?
a. Adequate pain relief
16. Client diagnosed with DM2. Which info does nuse teach to client?
a. Balanced diet planning
b. Plan for eye exam
c. Blood glucose monitoring techniques
d. Sign of hypo/hyperglycemia
17. HIV question- tell me what u know about HIV
18. Nurse prepares a client for extracorporeal lithotripsy. Nurse determines the client understands and procedure when which statement is made?
a. My urine may be bloody for a while after procedure
19. ……An ordered ACTH stim test is abdmonal. Which underlying disease is the cause of the symptoms?
a. Addison’s
20. Client is diagnosed with urinary calculi. The client goal is to prevent further calculi. Which info does nurse give the client?
a. Drink atleast 3000 mL daily
21. Client diagnosed with DM. at 0600 client reports hunder, headache, numb toes, feeling cold and clammy. Nurse check glucose. Which action does the nurse anticipate?
a. Provide orange juice and breakfast
22. Client diagnosed with cushings syndrome caused by ACTH secreting tumor. What is included in plan of care?
a. Possibility of infections because immune system is suppressed
23. Client undergoes lumbar laminectomy. Nurse identifies a nursing diagnosis for which priority client problem?
a. Difficulty with urinary elimination
24. Client diagnosed with chronic kidney disease. Client keeps gaining weight, legs swell, bp is up etc..Most important for nurse to communicate to client
a. You need to tell the heath care provider what you told me
25. Client diagnosed with psoriasis is treated with etanercept.
a. I will take this medication until I come to clinic again
26. Client diagnosed with central diabetes insipidus. Which symptom does the nurse expect to see?
a. Decreased skin turgor
b. Hypernatremia
c. Drinking a lot of fluids
27. Client received full thickness burns to both legs. Client shows no indication of lung involvement. Immediate care for client?
a. Establish 2 IV access sites
28. Client diagnosed with peptic ulcer diease. Client understands teaching?
a. I will stop drinking alcohol and smoking
29. Client recovers following a cystoscopy. Client tells the nurse about burning and pink colored urine.
a. Tell the client its normal
30. Client recovers following thyroidectomy. Nursing diagnosis based on which initial potential complication?
a. Surgical site edema
31. Client tells nurse of latex food allergy. Which is the nurses responsibility to client. (I got this wrong)
a. It is NOT: notify health care provider or request foods not wrapped in plastic
32. Nurse presents a program on lyme disease. Additional teaching when?
a. I will make sure I get the vaccine for lyme disease
33. Client diagnosed with acute kidney injury. Fluid restrictions enforced. Client asks why?
a. Restricting fluid prevents a fluid buildup in your body
34. Client diagnosed with type 2 diabetes. Nurse knows the dieticians teaching is effective when?
a. I will read food labels when I plan my meals
35. Sustained a left subtrochanteric fracture. Most important preop care?
a. Client will state satisfactory pain control
36. Client recovers from surgery to create ileostomy. What does the nurse understand about client?
a. Client shows understanding of new body image and situation
37. Client had abdominal surgery 36 hours ago…..
a. NPO and instert NG tube
38. Client diagnosed with hyperthyroidism. Suspects Graves disease. Assessment data?
a. Hypertension
b. Agitation
c. Clubbing fingers
39. Client with fiberglass cast.
a. Use plastic bag when shower
b. Keep arm above heart for 2 days
c. Report burning or tinglings
40. Client experiences anaphylactic shock caused by reaction to medication. Monitor what?
a. Respirations
41. Client has hyperglycemia. Goal is to reduce gluose to normal level. A1C is 5.8.
a. You are doing a great job
42. Recovers from above knee amputation. Most concerned with what statement?
a. I will always need a wheelchair
43. SIADH question
a. Chew sugarless gum between meals
44. 62 year old comes for annual exam. Which vaccine?
a. Herpes zoster
45. Client diagnosed with chrons disease. Nurse teaches ways to prevent exacerbation.
a. I will talk about my feelings
46. Clients blood glucose is 675. Most important nursing action for client?
a. Monitor blood glucose levels
47. Client has RA.
a. Help verbalize thoughts and feelings
48. Nurse cares for colonoscopy. Which action does nurse take first?
a. Vital signs
49. Client is diagnosed with ascites secondary to metastatic liver cancer. Nurse prepares to do paracentesis. What position? (got wrong!)
a. NOT- supine or semi fowlers
50. Ulcerative colitis- don’t know answer but its not effective coping strategies
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