NURS 120 Brownie Recipe 2_Latest ,100% CORRECT

NURS 120 Brownie Recipe 2_Latest WEEK 3 1. Consequence of too much O2 → dry & cracking oral mucosa 2. PE s/sx → petechiae, pleural rub, tachycardia (not bradycardia, hypertension) 3. 1 day post surgery (thora ...

NURS 120 Brownie Recipe 2_Latest WEEK 3 1. Consequence of too much O2 → dry & cracking oral mucosa 2. PE s/sx → petechiae, pleural rub, tachycardia (not bradycardia, hypertension) 3. 1 day post surgery (thoracotomy), what should the nurse do? → teach about incentive spirometer and high fowler’s position (not give O2 nasal cannula) 4. CVP increase → possible right ventricular failure 5. Digoxin toxicity s/sx → nauseous with loss of appetite [REPEAT] 6. Apical pulse location → (image) mitral location 7. PaO2 50 mm → severe hypoxia (anything > 60 mm) WEEK 4 1. Hypokalemia → “U” wave formation on EKG 2. Client’s partner will suction, ready to be sent home? → they perform it independently 3. Best indicator for heart damage → troponin I 4. Patient is on coumadin, what is concerning → PT 45 seconds (normal: 11-12.5) 5. Suspected MI, what do you do first → oxygen WEEK 5 1. Type I patient insulin therapy, barriers? → literacy, dexterity, culture, motivation 2. Give Lispro, when do you wanna give insulin → 15 minutes before breakfast 3. Give furosemide, what do you teach → give foods high in potassium 4. What does coumadin do → prevent stroke in patients with atrial fibrillation 5. SIADH → fluid restriction 6. DKA, blood sugar goes down to 240 → change to D5 NS IV fluid 7. Cushing’s SATA → buffalo hump, purple striation, moon face 8. tPA (tissue plasminogen), what is the most concerning → LOC (not oozing blood) WEEK 6 1. Teaching of Hep B → increase appetite (anorexia) 2. Allergic reaction of blood transfusion → generalized urticaria 3. Asthma exacerbation, priority intervention → nebulizer (not high-fowler's position) 4. +4 edema intervention → pressure relieving mattress 5. Warfarin, contraindication → cabbage (green leafy) 6. Severe cirrhosis → nose bleeding & bruising *bleeding priority* 7. Acute pancreatitis teaching → no cheddar cheese 8. Intervention for ascites → (NOT 3in above umbilicus) 9. Cirrhosis, further teaching → “I can eat anything I want” 10. Acute pancreatitis, after pain med → keep them NPO 11. TPN at home teaching (SATA) → keep refrigerated, start D10 if feeding is finished, keep infusion rate if behind on feeding (3) 12. Patient is falling asleep as nurse is talking to them → increased ammonia levels 13. Cholecystitis (SATA) → back rub, incisional splinting, identify pain level, change client position (4) WEEK 7 1. Spinal cord injury, what will occur? → flaccid paralysis 2. What contributes to ICP → sodium 110 (hyponatremia) *always think sodium!* 3. Hep A, early indication → anorexia 4. Acute pancreatitis, where is the pain → epigastric radiating to back 5. What should be reported → ICP of 19 6. Left HH, teaching → put tray & items on patient’s right side 7. Cane teaching with AP → move cane first before legs 8. Stroke teaching → put the patient semi fowlers to facilitate swallowing 9. Associated with embolic stroke → chronic a fib 10. L1, what should you do? → give anticoagulants (they are paralyized → not active ROM exercises) 11. TIA where will you monitor, symptoms go away → go to neurotele & monitor 12. Embolic stroke → it travels 13. Most concern to nurse → unresponsive with arousal 14. ICP sata → headache, slurred speech, eye changes, disorientation 15. Trauma, s/sx hypovolemia → increased HR (tachycardia) Quiz 1 1. SATA AP a. Record Urinary Output b. Assist ambulation pt. Who has a cane c. Move pt to stretcher d. NOT irrigate wound e. NOT eye drops 2. Best position for getting IAP a. Supine 3. PCA a. Pain scale b. IV bolus before lock out c. 30 min lock d. Let fam do it 4. Heparin a. PLT 73,000 b. NOT PTT 65 sec c. Hct 45% d. 5. Holistic care SATA a. Legal members b. Non legal partners c. Anyone the patient identifies as support system d. Siblings 6. Ibuprofen a. Take with food 7. Aspirin a. Expect dark stools b. Monitor tinnitus c. 8. Football on a hot day a. Dehydration Na 152 9. increased CVP what would be the level a. 7 10. What reflects L SIDE afterload a. SVR 11. What would you expect in L HF a. JVD b. Abdominal girth c. Weak peripheral pulses d. dependent edema 12. Suction SATA - Only 3 a. Spontaneous cough b. Cyanosis c. Secretions d. Tachypnea e. …... 13. Increase preload, Fluids a. Crackles 14. Family member in ICU a. Tell fam injuries and plan of care 15. 5.4 K a. Call MD b. Omit med 14. New nurse is showing doctor that they have knowledge about using arterial line a. Same level as the phenobarbital axis b. Lay patient supine with head flat c. Recalibrate level after pt moves 15. Adverse effect of digoxin a. Nausea and vomiting 16. What situation do you call RRT for a. Right calf pain and SOB 17. First intervention when patient’s low pressure alarm is ringing? a. Assess cardiac dysrhythmias b. Assess hand for pallor 18. Picture of heart a. The solo on are the right side Quiz 2 1. HR increasing (80-110) and irregular HR a. Hyperoxygenation 2. Requires immediate intervention a. 92% No response to verbal stimuli (i think this was the answer, -KL) 3. Apical pulse a. 5th ICS 4. TB 5. ET a. Private room special ventilation a. Hand Gestures b. Various tech 6. Digoxin a. N/ no appetite 7. CVP a. Right ventricular failure 8. PaO2 50 a. Severe hypoxic 9. SATA PE a. Tachypnea b. Priatial rub c. Petechiae 10. Prevent PE quadraplegic, SATA a. Passive ROM b. SVC c. Assess redness 12. Left arterial line a. Left is cooler than right 11. Thrombus a. Homan’s sign b. (dull aching calf pain) 12. Slow bubbling in water seal chamber a. Monitor resp 13. Oxygen toxicity a. Cracks on mucous membranes 14. Chest tube water chamber norm finding a. Fluctuation 15. Hyperventilation & hypoxic a. CO2 30 pO2 50 16. ET Tube Complication uneven chest rise a. Went to R heart 17. Dyspnea, Deviated... a. Tension Pneumothorax 18. PE 1st RN action a. Oxygenate 19. On Mechanical ventilator risk for infection prevention Don't remember answer a. Drain chamber b. Suction c. Clamp? 20. Tracheal shift a. Tension pneumonia 21. Post op bronchoscopy a. Withhold food and fluids until gag reflex 22. 1 day post op a. High fowlers, Use IS, encourage coughing 23. Blood transfusion - febrile, chills, blood in urine a. Hemolytic reaction 24. Quiz 3 1. What should patient report to provider? a. Crepitus b. Tracheal shift to unaffected side c. Bubbling... 2. SATA O2 therapy N/V a. NOT petroleum, and NOT assessing flow rate every other day b. Inspect ears c. Hang no smoking sign in house d. Check positioning regularly 3. rapid irregular pulse, Pulse deficit a. A-Fib 4. Image on ECG, Hyperkalemia a. T wave 5. Cholesterol diet a. Beans 6. Needs further teaching a. I ate two eggs 7. Come to ER, indigestion, calf pain a. ECG 8. P wave a. Atrial depolarization 9. Cardiac enzymes a. Injury to heart muscle 10. Cardiac enzyme question a. Troponin I 11. Hypokalemia a. Prominent u wave 12. Ventricular depolarization, repolarization a. QT interval 13. Pt on coumadin, enoxaprin, etc a. PT of 45 14. Glipizide for DM 2 15. Hx of coronary artery disease a. Increasing LDL 16. First intervention for MI a. Oxygen (ABC) 17. DVT SATA a. HTN b. Immobility c. Increased Ca+ intake d. Oral contraceptives 18. Patient has a-fib, what vitals are most important a. Apical and radial pulse Quiz 4 1. Warfarin for afib a. Prevents stroke in afib 2. First DKA intervention a. 0.9% Sodium chloride w/ IV drip insulin 3. DKA pt, <260 mg/dL now what do you do a. Add glucose to IV fluids 4. Contributors to noncompliance for diabetes regime a. Dexterity b. Literacy c. Culture d. Motivation 5. SATA of cushings a. Striae b. Moon face c. Buffalo hump 6. tPa priority to look out for a. Decreased loc 7. Dehydration clinical manifestation a. tachycardia 8. Expected finding of addisons a. hyperpigmentation 9. Rapid insulin a. Give food 15min after 10. Thyroidectomy w. Tingling of hands a. Check chvosteck sign 11.Levothyroxine overdose a. insomnia 12. DI given vasopressin how do you know its working a. Urine specific gravity 1.015 13.Prevent thyroid storm a. Provide low stimuli environment 14.Why is nitroglycerin given a. To dilate cardiac blood vessels to deliver more oxygen rich blood back to heart 15. SIADH a. Hyponatremia 16. Stopping prednisone taper down pt teaching a. Adrenal insufficiency 17.Mixing NPH first step a. Inject 20 units of air into NPH vial 18. Statement needing clarification by diabetic woman & CAD about diet a. “I will need to increase intake of trans-fats” 19.Digoxin don’t want to eat a. Check vitals 20. Which insulin do you use for DKA a. Humulin R (regular insulin) 21. Lasix pt teaching a. Eating foods with K 22. What to do for hella hypoglycemic pt with 60mg/dL a. glucagon 23. 3,000 IV in 24h started 1,000 at 0800 when would you start the next 1,000 a. 1600 24. DM 2 pt teaching priority a. Evaluate pt understanding of DM 2 25. Quiz 5 1. Cholecystitis SATA a. Everything but ambulation 2. TPN SATA - refigerate when not used a. keep TPN even after goal weight, dextrose 10 3. Asthma exacerbation, PRIORITY a. b2 nebulizer 4. Cirrhosis, what not to give a. ham sandwich 5. Acites diet a. high carbs, low protein 6. Bile duct cholecystitis a. fatty stool 7. Pancreatitis, pain is addressed what next a. keep NPO status 8. Wafarin, contradiction a. cabbage 9. African American a. check hard palate 10. Cardiac cath a. L radial pulse 11. Levothyroxine toxicity a. insomnia 12. Cirrhosis, what to intervene a. “I take tylenol q4hr” 13. Homeless with hep B a. bedrest with commode privilege 14. Liver cirrhosis, avoid a. chedder cheese 15. Wound healing a. protein 16. Heb B teaching to pt a. promote appetite 17. Blood transfusion, allergic reaction a. Generalized urticaria 18. Pt with edema 4+ a. Give pressure bed 19. Advanced cirrhosis a. Frequent nosebleed and bruises 20. Pt teaching with cirrhosis a. Go not strain when pooping 21. Pancreatitis lab a. increased amylase Quiz 6 1. Increased ICP SATA a. HA b. Disorientation c. Slurred speech d. Dilated pupils 2. Pancreatitis a. Severe pain in RUQ radiating to back 3. CSF leakage a. Check for presence of glucose 4. Fever, nuccal rigidity, HTN a. Meningeal irritation 5. Internal flexion a. deCORticate 6. Decerebrate a. Downward and outward 7. CT scan a. To see what kind of stroke it is 8. L5 SCI rehab, nursing care a. Admin SQ anticoags (I put this, this is correct) b. Give o2 c. Active ROM on lower extremities 9. Increased ICP, what concerns MD a. HTN 10. Cane pt teaching a. Move Cane first 11. What to report to MD? a. ICP 19 12. Lumbar puncture a. Contraindicated with increased ICP 13. SATA a. Admin antihypertensives b. Elevate HOB c. Loosen restrictive clothing d. Assess for urinary retention and bowel impaction 14. Hep A a. Anorexia 15. Pt comes into ED dx with TIA, what next? a. Monitor pt for 24hr in neurotele 16. Embolic stroke, whos at highest risk? a. Pt w Chronic a-fib 17. Homonoymous hemisomething a. Put their things on the R side 18. Post-op, DVT prevention a. SCDs bil 19. Injury at T5 a. Neuro shock 20. Hypovolemia a. Tachycardia 21. Spinal shock a. Flaccid paralysis 22. Communicating w a pt w aphasia a. Use nonverbal cues 1. A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to intervene? a. Crackles in bilateral lower lobes b. WBC count 13,000/mm3 c. Right upper quadrant pain d. Capillary blood glucose level 164 mg/dL 2. Don’t have! 3. A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client’s immobility? a. Blurred vision b. Diarrhea c. Confusion d. Polyuria 4. A nurse is assessing a client who has pericarditis. In which of the following area of the client’s chest should the nurse place the stethoscope to best hear a pericardial friction rub? (hot spot) a. i. Erbs Point 5. A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse take? a. Begin an IV infusion of 0.9% sodium chloride b. Insert another 22-gauge IV catheter c. Administer the unit through secondary IV tubing d. Verify the blood product with an assistive personnel 6. A nurse is assessing a client who reports numbness and tingling and exhibits a positive Trousseau’s sign. Which of the following electrolyte imbalances should the nurse suspect? a. Hyponatremia b. Hyperchloremia c. Hypermagnesemia d. Hypocalcemia 7. A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? a. “I plan to take this medication for 1 week.” b. “I will have my liver function tested while I am taking this medication.” c. “This medication may cause my blood pressure to increase.” d. “I should take an antacid with each dose of this medication.” 8. A nurse is planning care for a client who has a pulmonary embolism and a prescription for enoxaparin via subcutaneous injection. Which of the following interventions should the nurse include? a. Assess the client’s stools for occult blood. b. Instruct the client to limit vitamin K intake. c. Monitor the client’s PT levels. d. Massage the injection site for 1 minute. 9. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse? a. The client has an oral temperature of 38.3 C (100.9 F) b. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site. c. The client has 100 ml blood in the closed-suction drain. d. The client’s capillary refill in the left toe is 6 seconds. 10. A community health nurse is reviewing home care instructions with an older client who has a new diagnosis of heart failure. Which of the following is the priority topic for the nurse to review with the client? a. Daily sodium restrictions b. Daily exercise routine c. Changes in weight d. Fluid intake record 11. A nurse is providing 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 should expect less than 25 mL of secretions per day in the drainage devices.” b. “I will keep my left arm flexed at the elbow as much as possible.” c. “I will have to wait 2 months before additional saline can be added to my breast expander.” d. “I will perform strength-building arm exercises using a 15 pound weight.” 12. A nurse is planning care for a client who has a chest drainage system set to low suction following a thoracotomy. Which of the following nursing actions is appropriate to include in the plan of care? a. Empty the collection chamber every 8 hr. b. Check for bubbling in the water seal chamber. c. Loop excess tubing below the chest wall. d. Keep the water seal chamber at chest level. 13. A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax? a. Diminished breath sounds b. Irregular heart rate c. Itching over the incision d. Distended neck veins 14. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client as risk for bleeding? a. Digoxin b. Captopril c. Phenytoin d. Ibuprofen 15. A nurse is caring for a client who is receiving total parenteral nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take? a. Switch the infusion to a 10% dextrose solution. b. Start an infusion of 0.45% sodium chloride solution. c. Decrease the rate of infusion to last until the new bag is available. d. Discontinue the infusion and flush the line. 16. A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? a. “I’ll cut a slit in a clean gauze pad to use as a stoma dressing.” b. “I’ll insert the obturator after cleaning my stoma.” c. “I’ll cleanse the cannula with half-strength hydrogen peroxide.” d. “I’ll remove the soiled tracheostomy ties prior to cleaning my stoma.” 17. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? a. Mental confusion b. Palmar erythema c. Yellow sclera d. Spider angiomas 18. A nurse is planning care of a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care? a. Insert a saline lock into a site 10 cm (4 in) distal to the graft. b. Instruct the client to avoid lifting the right arm for 72 hours. c. Check blood pressure in the right arm. d. Palpate the site for a thrill. 19. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? a. “I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash.”*** b. “I will increase the amount of fresh fruits and vegetables I consume.” c. “I will be sure to wear gloves and wash my hands when I change my cat’s litter box.” d. “I will need to take my clothes to the dry cleaners to sterilize them.” 20. A nurse is preparing instructions for a client who is prescribed metoprolol. Which of the following should the nurse plan to include in the teaching? a. Expect excess production of saliva after taking the medication. b. Monitor for hyperglycemia when taking the medication. c. Notify the provider if hearing loss occurs. d. Take a radial pulse before administering the medication. 21. A nurse is caring for a client who has atrial fibrillation. Which of the following medications should the nurse expect to administer? b. Dobutamine c. Lidocaine d. Atropine 22. Don’t have! 23. A nurse is teaching a client who has Graves’ disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching? a. Decreased heart rate b. Lethargy c. Hypotension d. Increased temperature 24. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesics. Which of the following actions should the nurse implement to help facilitate the client’s recovery? a. Provide analgesic medication prior to physical activities. b. Inform the client to monitor for loose stools while taking opioid analgesia. c. Withhold analgesic medication unless the client reports pain. d. Administer naloxone if the client’s respiratory rate if greater than 24/min. 25. A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. “Depress the canister after you inhale.”** b. “Use peroxide to clean the mouthpiece of your inhaler.” c. “Do not shake your inhaler before use.” d. “Exhale fully before bringing the inhaler to your lips.” 26. A nurse is caring for a client who has ulcerative colitis and was admitted to the medical-surgical unit for management of diarrhea. Which of the following food items should the nurse select for the client’s breakfast tray? a. Poached egg b. Fresh peaches c. Whole grain toast d. Oatmeal 27. A nurse is caring for a client who develops third-degree heart block with a heart rate of 30/min. Which of the following actions should the nurse take? a. Instruct the client to perform the Valsalva maneuver. b. Administer digoxin by IV bolus. c. Perform carotid sinus massage. d. Prepare the client for temporary pacing. 28. A nurse in the emergency department admitted a client who is having a myocardial infarction. The client has been placed on the heart monitor. Which of the following electrocardiogram strips is indicative of a myocardial infarction? a. 29. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? a. “I will eat a high-fiber diet.” b. “I will empty my bag when it is full.” c. “I will expect my stools to be loose.”*** d. “I will take a laxative when I’m constipated.” 30. A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following? a. Fluid volume excess*** b. Pleural effusion c. Increased cardiac output d. Aspiration 31. A nurse is caring for a client who is 5 days postoperative following a total abdominal hysterectomy. Which of the following findings indicates dehiscence? a. Inflammation of incision edges b. Serous crusting along the incision line c. Increased serosanguineous drainage from the wound*** d. Incision pain when coughing or breathing deeply 32. A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? a. Obtain a blood specimen for type and crossmatch. b. Monitor urine output. c. Administer IV therapy. 33. 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? b. Remove the wedge device when turning. c. Encourage the client to lean forward when attempting to stand. d. Elevate the knees higher than the hips when sitting. 34. A nurse is assessing a client who has malnutrition. Which of the following should the nurse expect to find? a. Hyperproteinemia b. Hypermagnesemia c. Diplopia d. Cachexia*** 35. A nurse is providing discharge teaching to a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) a. “I will use cosmetics without moisturizer.” b. “I will increase my intake of sodium.” c. “I will wear long sleeves when outdoors.”** d. “I will disinfect skin lesions with rubbing alcohol.” e. “I will use NSAIDS to treat aches and pains.” 36. A nurse is caring for a client who has been diagnosed with myxedema coma. Which of the following assessment findings indicate that the prescribed interventions have been effective? a. Heart rate 56/min c. PaCO2 49 mm Hg d. Blood pressure 80/50 mm HG 37. A charge nurse receives a call from the house supervisor requesting room assignments for four new patients. Based on the admission diagnoses, which of the following clients requires a private room? a. An older client who was admitted with aspiration pneumonia b. A client who reports having fever, night sweats, and a cough for 2 days c. A client who has a compound fracture of the right femur d. A client who has diabetes mellitus and is presenting with acute ketoacidosis 38. A nurse is caring for a female client who has toxic shock syndrome. Which of the following should the nurse expect? a. Generalized rash ** b. Hypertension c. Elevated platelet count d. Decreased total bilirubin 39. A nurse is caring for a patient who has thrombocytopenia. Which of the following laboratory results should the nurse expect? a. INR of 1.0 b. PT 11 seconds c. aPPT 40 seconds 40. A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the following findings should the nurse identify as an indication of a complication at the vascular access site? a. 2+ left radial pulse b. Dilated appearance of the AV site c. Presence of a palpable thrill 41. A A nurse is assessing an older adult client who has right hemiplegia. The nurse notes 3 cm (1.2 in) pink-red areas on both the client’s scapulae. Which of the following actions by the nurse is appropriate? a. Place the client in supine position. b. Massage the pink-red areas gently. c. Provide the client with protein supplements. d. Apply a calcium alginate dressing to the client’s scapulae. *** 42. A nurse is caring for a client who has acute pancreatitis and a new prescription for a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? a. Check the client’s respiratory rate every 4 hours while using the PCA. b. Program the client’s PCA dosage parameters with another nurse*** c. Set the client’s PCA lockout demand time for every 3 min. d. Instruct the assistive personnel how to push the PCA button for the client. 43. A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? a. “I use my heating pad on a low-setting to keep my feet warm.” b. “I rest my recliner with my feet elevated for about an hour every afternoon.”*** c. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.” d. “I soak my feet in hot water before trimming my toenails.” 44. A nurse is teaching a client who has asthma about the use of a peak flow meter. After setting the meter to the zero baseline, what is the sequence of steps the nurse should instruct the client to take? a. 1“Stand upright.” b. 4“Exhale forcefully and quickly.” c. 3“Seal lips around the mouthpiece.” d. 2“Fill your lungs with a deep breath.” e. 5“Record the highest of three consecutive readings.” 45. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? a. Flush the catheter manually with 0.9% sodium chloride. ** b. Decrease traction on the catheter. c. Administer ibuprofen 400 mg for pain relief. d. Remove the indwelling urinary catheter. 46. A nurse is caring for a client in the emergency department following a myocardial infarction. Which of the following actions should the nurse anticipate if the client develops asystole? b. Start a continuous lidocaine infusion. c. Defibrillate with 200 joules. d. Administer atropine via IV bolus. 47. A nurse is caring for an older adult client who is prescribed packed RBCs. Which of the following actions is appropriate for the nurse to take? a. Infuse lactated Ringer’s solution while transfusing the blood product. b. Use a 24-gauge needle for the transfusion. c. Obtain vital signs every hour during the transfusion. d. Administer the transfusion over a 4-hour period*** 48. A nurse is teaching a group of young adults clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? a. Born with a high birth weight b. Perforation of the eardrum c. Chronic infections of the middle ear d. Frequent exposure to low-volume noise e. Use of a loop diuretic 49. A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold? a. Metoprolol b. Metformin c. Valproic acid d. Fluticasone 50. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? a. “The elastic bandage will keep you from seeing the surgical site.” b. “The elastic bandage will prevent a postoperative wound infection.” c. “The elastic bandage will prevent excessive edema.”*** d. “The elastic bandage will will keep the sutures from loosening.” 51. A nurse in the intensive care unit is caring for a patient who has the following ABG results: pH, 7.30; HCO3 19 mEq/L; PaO2 and PaCO2 within the expected reference ranges. The nurse should expect to provide treatment for which of the following conditions? a. Metabolic alkalosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic acidosis 52. A nurse is preparing a client who is to undergo a thoracentesis. The nurse should place the client in which of the following positions? a. On her affected side with her head lowered b. In high-fowler’s position with her arms at her side c. Prone position with her arms above her head d. Upright on the edge of the bed leading over the bedside table 53. A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take this medication with fiber to prevent constipation.” b. “I will notify my provider if I experience muscle weakness.” c. “I will increase my dose if my vision becomes blurry.” d. “I will take my digoxin if my pulse is less than 50 beats per minute.” 54. 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.) a. Monitor serum blood glucose during infusion. b. Infuse 0.9% sodium chloride if the solution is not available. c. Verify the solution with another RN prior to infusion. d. Obtain the client’s weight daily. *** e. Increase the rate of infusion if administration is delayed. 55. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? a. Limit the client’s fluid intake to 1 L per day. b. Change the client’s dressing every 8 hours. c. Keep the client on bedrest for 24 hours. d. Maintain the client’s affected extremity in extension. 56. A nurse is reviewing the laboratory results of a client who has COPD and severe dyspnea. Which of the following ABG values should the nurse expect? a. pH 7.4 b. PaCO2 50 mm Hg c. PaO2 95 mm Hg d. HCO3 20 mEq/L 57. A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding of the teaching? a. “I will monitor my blood glucose every 8 hours.” b. “I will check my urine for ketones if my blood glucose is greater than 240 mg/dL.” c. “I will consume 250 grams of carbohydrates daily while I’m sick.” d. “I will not take my diabetes medication while I am sick.” 58. A nurse on an acute care unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who had a colon resection 24 hr ago and has a hemoglobin level of 14 g/dL b. A client who had an acute kidney injury and has a potassium level of 6.5 mEq/L c. A client who received morphine 10 mg IV bolus 30 minutes ago and has a respiratory rate of 14/min d. A client who had total hip arthroplasty and is reporting a pain level of 5 on a scale of 0 to 10 59. A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching? a. “I should lie down before taking a dose of isosorbide dinitrate.” b. “I should take my daily aspirin on an empty stomach.” c. “I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses.” d. “I should withhold my metoprolol if my heart rate is above 100 beats per minute.” 60. A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? a. Monitor for hypokalemia as a manifestation of acute rejection. b. Administer opioids PO. c. Check the client’s blood pressure every 8 hr. d. Assess urine output hourly. 61. A nurse is providing teaching to a client who has diabetes mellitus. Which of the following instructions should the nurse provide to the client to help prevent the development of nephropathy? a. Limiting protein intake. b. Controlling hypertension c. Voiding every 2 hr d. Decreasing potassium intake 62. A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? a. Limit family member visits to 30 min per day. b. Remove soiled linens from the room after each change. c. Apply a second pair of gloves before touching the client’s implant if it dislodges. d. Give the dosimeter badge to the oncoming nurse at the end of the shift. 63. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching? a. “I will spread my protein allowance over the entire day.” b. “I should limit my intake of hard cheese to 3 ounces each day.” c. “I will season my food with lemon pepper rather than salt.” d. “I should increase my intake of canned salmon to three times per week.” 64. A nurse working in the emergency department is assessing a client admitting with atrial fibrillation. Which of the following findings should the nurse report to the provider immediately? a. Shortness of breath b. Ventricular rate 120/min c. Syncope d. Atrial rate of 350/min 65. A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider immediately? a. Hemoglobin 10 mg/dL b. WBC count 8,400/mm3 c. Reports pain of 4 on a scale from 0 to 10 when coughing d. Serosanguineous exudate noted on dressing change 66. A nurse is caring for a client who has rheumatoid arthritis and reports increased fatigue. The nurse should instruct the client to take which of the following actions to conserve energy? a. Avoid using large muscle groups b. Determine priority activities to accomplish c. Allow others to perform her self-care activities d. Limit iron intake 67. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate? a. Your cough should go away in time b. Sucking on a lozenge may reduce the frequency of your cough c. Your cough may require that you stop or change your medication d. Increasing your daily fluid intake may eliminate your cough 68. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. Change the water in your drinking glass every 4 hours b. Wash your perineal area two times each day with antimicrobial soap c. Wash your toothbrush in the dishwasher once each month d. Change your pet’s litter box daily 69. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? a. Hold the transfusion if the client is actively bleeding b. Transfuse the plasma over 4 hours c. Administer the transfusion through a 25-gauge saline lock d. Administer the plasma immediately after thawing 70. A nurse is providing teaching to a client who has tuberculosis. Which of the following is appropriate for the nurse to include in the teaching? a. You will need to continue to have yearly tb skin tests b. You will no longer to contagious after three consecutive negative sputum specimens c. You should expect to take the prescribed medication therapy for 2 months d. You should avoid consuming fresh fruit and vegetables during therapy 71. A nurse is an emergency department is receiving the medical record of a client who is experiencing chest pain. Which of the following findings should the nurse recognize as an indication the client has recently experienced a myocardial infarction? a. Echocardiogram b. Serum marker c. Serum lipids d. 12-lead ECG 72. A nurse is caring for a client who has dumping syndrome following a gastrectomy. Which of the following actions should the nurse take? a. Provide the client with four full meals a day b. Offer the client high-carbohydrates meal options c. Have the client lie down for 30 min after meals d. Encourage the client to drink at least 30 mL (12 oz) of fluids with meals 73. A nurse in the PACU is caring for a client. Which of the following assessments is the nurse’s priority? a. Pain level b. Respiratory status c. Level of consciousness d. Surgical site 74. A nurse is preparing to administer piperacillin 3.375 g by intermittent IV bolus every 6 hours. Available is piperacillin 3.375 in dextrose 5% water. 100 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr. a. 200 75. A nurse is caring for a client who has traumatic brain injury. The client, who has been quiet and cooperative. Becomes agitated and restless. Which of the following assessments should the nurse perform first? a. Blood glucose b. Blood pressure c. Motor responses d. Urinary output 76. A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect? a. Hyperalbuminemia b. Proteinuria c. Decreased serum lipid levels d. Decreased coagulation 77. A home health nurse is teaching a client how to care for a peripherally inserted central catheter in his right arm. Which of the following statements should the nurse include in the teaching? a. “Use a 10-milliliter syringe when flushing the catheter.” b. “ Clean the insertion site with mild soap and water.” c. “Measure your right arm circumference once weekly.” d. “Change the transplant dressing over the insertion site every 48 hours.” 78. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider? a. BUN 22 mg/dL b. Blood glucose of 120 mg/dL c. WBC count of 16,000/mm3 d. RBC count of 4.7 million/mm3 79. A nurse is preparing a client for an ECG. The client is anxious and says that he is afraid the equipment will give him an electric shock. Which of the following is an appropriate response by the nurse? a. “The machine voltage delivery is low enough that you won’t feel any discomfort.” b. “The machine only senses and records electrical current coming from your heart.” c. “The lead wires and cables are insulated for your safety.” d. “The electrodes pads will prevent the conduction of electricity to your skin.” 80. A nurse is teaching a client who has heart failure about self-management techniques. Which of the following statements by the client indicates an understanding of the teaching? a. “ I will weigh myself every other day.” b. “I will expect swelling in my feet and ankles. c. “I will take ibuprofen for mild pain.” d. “I will keep an exercise diary.” 81. A nurse is caring for a client who has deep partial-thickness burns over 15% of her body. Which of the following laboratory findings should the nurse expect during the first 24 hr? a. Hypoalbuminemia b. Hypoglycemia c. Decreased hematocrit d. Decreased BUN 82. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? a. Initiate a continuous IV insulin infusion b. Begin bicarbonate continuous IV infusion c. Check potassium levels d. Administer 0.9% sodium chloride 83. A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock? a. PaCO2 37 mm Hg b. Potassium 5.2 mEq/L c. Urine output 45 mL/hr d. Capillary refill 1.5 seconds 84. A nurse is performing a venipuncture on an older adult client whose veins are difficult to locate. Which of the following actions should the nurse take? a. Tap the skin around the insertion site b. Apply a cool compress to the extremity c. Elevate the client’s extremity using pillow d. Raise the angle of the catheter to 30 degrees above the insertion site. 85. A nurse is assessing the extremities of a client who has Raynaud’s disease. Which of the following findings should the nurse expect? a. Vitiligo on affected extremities b. Blanching of the hands c. Hyperactive reflexes d. Calf pain with foot dorsiflexion 86. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first? a. Administer an opioid analgesic b. Check the color of the client’s skin. c. Remove all of the client’s clothing. d. Prepare the client for peritoneal lavage. 87. 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. Exhale slowly through pursed lips. b. Place hands on the upper abdomen during inhalation. c. Position the mouthpiece 2.5 cm (1in) from the mouth. d. Hold breaths about 3-5 seconds before exhaling. 88. A nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include? a. Inspect the feet every other day. b. Apply lotion between the toes. c. Soak the feet twice a day. d. Trim toenails straight across. 89. A nurse is reviewing a medical record of a client who has heat exhaustion with nausea and vomiting. Which of the following prescriptions should the nurse expect to administer? a. 0.9% sodium chloride IV solution b. Dextrose 5% in water c. Metoprolol d. Spironolactone 90. A nurse is caring for a client who had peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? a. Verify placement with an x-ray prior to the initial dose. b. Change the transparent membrane dressing daily. c. Flush the catheter using a 5-mL syringe. d. Administer 20 mL of 0.9% sodium chloride after each dose of medication. 91. A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? a. A client who has peritonitis reports generalized abdominal pain. b. A client who has angina reports substernal chest pain. c. A client who has pancreatitis reports pain in the left shoulder. d. A client who is postoperative reports incisional pain. 92. A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? a. Sodium 130 mg/dL b. BUN 8 mg/dL c. Hematocrit 35% d. WBC count 15,000/mm3 93. A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse? a. Administer a sedative medication b. Reinforce the importance of lying still during the procedure. c. Determine whether the client has an allergy to local anesthetics. d. Describe the sensations the client will feel during the procedure. 94. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glascow Coma Scale scores should the nurse assign the client? a. 2 b. 5 c. 10 d. 13 95. A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment findings is the nurse’s priority? a. Hypotension b. Weakness to lower extremities c. Bladder distension d. Hypoactive bowel sounds 96. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color, which of the following responses should the nurse take? a. “You will need to increase your fluid intake to resolve this problem.” b. “This finding may indicate possible medication toxicity.” c. “This is an expected adverse effect of this medication.” d. “Your provider will prescribe a different medication regimen.” 97. A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications? a. Epinephrine b. Desmopressin c. Furosemide d. Nitroprusside 98. A nurse is planning care for a client who is receiving mechanical ventilation through an endotracheal (ET) tube. Which of the following actions should the nurse take? a. Suction the tube of the low-pressure alarm sounds. b. Provide the client with a communication board. c. Change the client’s position every 4 hrs. d. Keep the ET tube on the client’s left side. 99. A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? a. Headaches b. Lymphedema c. Mouth sores d. Urticaria 100. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? a. Feet elevated b. Side-lying c. High-fowler’s d. Reverse trendelenburg ATI Seizures and epilepsy= place patient on the floor during a seizure Spinal cord injury=clarify with doctor if patient can drive Non pharm methods for pain relief= Osteoporosis Aldendronte med= teach patient to wait for 30 before getting up Arthroplasty pain question= use pillow Peritoneal dialysis= keep the outflow bag lower than the clients abdomen Sinus bradycardia= treat if the client symptomatic. Pacemaker or fluids for asymptomatic Pacemaker safety?= Parkinsons= dopamine deficiency ATI Adv. Med-surg FINAL EXAM 1. A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escharotomy. The client’s spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? a. “large incisions will be made in the eschar to improve circulation” b. “ I can call the doctor back here if you want me to” c. “a piece of skin will be removed and grafted over the burned area” d. “dead tissue will be surgically removed” 2. A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury? a. 5% dextrose in water b. 5% dextrose in normal saline c. normal saline d. lactated ringers 3. A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system? a. auscultate cuff blood pressure b. palpate pulse pressure c. obtain a central venous pressure d. monitor the pulmonary artery pressure 4. A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn? a. Age of the client b. Associated medical history c. Location of the burn d. Cause of the burn 5. A client arrives at the emergency dept following an explosion at the chemical plant. He has deep partial and full-thickness chemical burns over more than 25 % of his body surface area. What is the nurse’s priority intervention? a. Initiate fluid resuscitation b. Medication for pain c. Administer antibiotics d. Maintain a patent airway 6. A nurse is caring for a client who came the emergency dept reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client’s troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is a. An enzyme that indicates damage to brain, heart, and skeletal muscle tissues b. A protein whose levels reflect the risk for coronary artery disease c. A heart muscle protein that appears in the bloodstream when there is damage to the heart d. A protein that helps transport oxygen throughout the body 7. A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following should the nurse expect in the findings? a. Excessive thrombosis and bleeding b. Progressive increase in platelet production c. Immediate sodium and fluid retention d. Increased clotting factors 8. A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what his medication will do, which of the following is an appropriate nursing response? a. It helps convert atrial fibrillation to sinus rhythm b. Is dissolves clots in the bloodstream c. It slows the response of the ventricles to the fast atrial impulses d. It prevents strokes in clients who have atrial fibrillation 9. A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the following findings should the nurse expect? a. Decreased brain natriuretic peptide (BNP) b. Elevated central venous pressure (CVP) c. Decreased pulmonary pressure d. Increases urinary output 10. A client comes into the ED reporting nausea and vomiting that worsens when lying down and without relief from antacids. The provider suspects acute pancreatitis. Which of the following lab test results should the nurse expect to see if the client has acute pancreatitis? a. Decreased WBC b. Increased serum amylase c. Decreased serum lipase d. Increased serum calcium 11. A nurse in the ICU is caring for a client who has acute respiratory distress syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The provider plans to extubate her within the next 24 hour. Which of the following is an important criterion for extubating the client? a. Ability to cough effectively b. Adequate tidal volume without manually assisted breaths c. No indication of infection d. No need for supplemental oxygen 12. A nurse is caring for a client following a CT scan with dye who suffered from an anaphylactic reaction. Which of the following conditions requires a priority nursing response? a. urticaria b. stridor c. tachypnea d. angioedema 13. A nurse is caring for a female client who came in to the ED reporting SOB and pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80 m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Monitor for pulmonary embolism 14. A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicate a complication that requires notifying the provider immediately? a. Serosanguineous drainage from the puncture site b. Discomfort at the puncture site c. Increased heart rate d. Decreased temperature 15. A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is priority nursing action when the client is brought to the ED? a. cover the burned area with sterile gauze b. inspect mouth for signs of inhalation c. administer intravenous pain medication d. draw blood for a CBC 16. A triage nurse in an emergency dept is caring for a client who has gunshot wound to the right side of chest. The nurse notices thick dressing on the chest and sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take initially? a. Raise the foot of the bed to a 90 degree angle b. Remove the dressing to inspect the wound c. Prepare to insert a central line d. Administer oxygen via nasal cannula 17. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires which of the following? a. A cardiology consult b. Less frequent suctioning c. An antidysrhythmic medication d. Pre-oxygenation prior to suctioning 18. The nurse is caring for a client who is receiving a blood transfusion. The transfusion started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action? a. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution b. Slow the infusion and evaluate the vital signs and the client’s history of tranfusion reactions c. Slow the infusion of blood and begin infusion of normal saline solution from the Y connector. d. Recheck the unit of blood for correct identification numbers and crossmatch information 19. A client with a diagnosis of disseminated intravascular coagulation (DIC) has the following assessment findings: blood pressure of 76/56, temperature 102.6 degrees, resp. 24 breath/min., with complaints of severe neck and back pain. Which nursing action should the nurse implement first? a. Administer acetaminophen (Tylenol) PO. b. Administer ibuprofen (Motrin) PO. c. Draw coagulation study blood work in the AM d. Give morphine sulfate IV 20. The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client who has a history of coronary artery disease is now in congestive heart failure. What side effects will be particularly important to observe for when the client takes the medication? a. Tremors and central nervous system stimulation b. Tachycardia and chest discomfort c. Development of oral candidiasis d. An increase in blood pressure 21. The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea? a. Decreased breath sounds are heard over the left side of the chest b. Increased rhonchi are present at the lung bases bilaterally c. Ventilator pressure alarm continues to sound d. Client is able to speak and coughs excessively 22. What is the desired action of dopamine (Intropin) when administered in the treatment of shock? a. It increases myocardial contractility b. It is associated with fewer severe allergic reactions c. It causes rapid vasodilation of the vascular bed d. It supports renal perfusion by dilation of the renal arteries 23. The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes after the infusion is started, the client’s BP goes from 190/120 mm Hg to 120/90 mm Hg. What is the priority nursing action? a. Recheck the BP and call the doctor b. Decrease the infusion rate and recheck the blood pressure in 5 minutes c. Stop the medication and keep the IV open with D5W. d. Assess the client’s tolerance of the current level of BP 24. Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has: a. A heart rate of less than 120 beats/min b. Urine output of at least 30 mL/hr. c. Received adequate anticoagulation d. Been receiving adequate IV fluid replacement 25. The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present? a. CVP of 3 cm H20 and urine output of 20 mL/hr b. Jugular vein distention with the head elevated 45 degrees c. Chest tube drainage of 50 mL/hr in the first 2 hours d. Persistent increased BP and increased pulse pressure 26. The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary of 20 mL for the past hour. The nurse would interpret these findings as suggestive of which pathophysiology? a. Reduction of circulation to the coronary arteries, this increasing the preload b. Decreased glomeruli filtration rate, resulting in volume overload c. Stimulation of the sympathetic nervous system, causing severe vasoconstriction d. Decrease in the cardiac output and inadequate tissue perfusion 27. The nurse applies a Nitro-Dur patch on a client who has undergone cardiac surgery. What nursing observation indicates that a Nitro-Dur patch is achieving the desired effect? a. Chest pain is completely relieved b. Client performs activities of daily living without chest pain c. Pain is controlled with frequent changes of patch d. Client tolerates increased activity without pain 28) The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse 52, RR 16. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication? A. Pulse rate has increased to 70 beats/min B. systolic BP has increased by 20 C. pupils are dilated D. oral secretions have decreased 29) An older adult client comes into ER stating that he has no appetite, is nauseated, his heart feels funny and has noticed a haziness in his vision. The client states that he has been taking an antihypertensive drug and digitalis for more than a year. Based on the presenting symptoms, what would be the priority nursing action? A. Obtain an order for an EKG and serum potassium and digitalis levels B. Perform a neurological assessment to determine whether he has one side weakness. C. Assess lungs for decreased breath sounds and/or adventitious breath sounds. d. Obtain an order for an EKG 30) the nurse is administering alteplase to a client who has been diagnosed with acute coronary syndrome. What are important nursing implications for this medication? A. Monitor the ECG for dysrthymias B. Place the client on bleeding precautions C. monitor urine output hourly D. Monitor for activity tolerance 31) The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an important nursing measure at this time? A. Measure urinary output hourly and maintain continuous cardiac monitoring B. Encourage client to perform slow pressure exercise of the affected side to promote circulation. C. Maintain pressure over catheter insertion site and determine distal circulation status. D. Evaluate apical pulse and determine presence of pulse deficit. 32. The nurse in a cardiac stepdown unit has received a hand-off shift report for these clients. Which client should be assess first? A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent. B. A client who is in heart failure and has gained 2 pnds in the last 24 hours. C. a client with endocarditis who has temperature elevation of 100F and P 100 beats/min D. A client who was cardioverted from atrial fib 24 hours ago and has had 3 atrial premature 33) What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain? A. Prolonged PR interval B. Wide QRS complex C. ST- Segment elevation or depression D. Tall, peak T-waves 34) A new employee at a facility needs a hepatitis vaccine. Which statement reflects accurate understanding of the immunization? A. I need to get 6 shots of hep C B. Once I receive the Hep vaccine I will always been immune C. I will receive 3 injections over a period of months, which should protect me from hep B D. Hep vaccine is an oral vaccine with live attenuated Virus 35) While talking with a client with a diagnosis of end stage liver disease. The nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition? A. Hyperglycemia B. Increased Bile production C. Increased blood ammonia levels D. Hypocalcaemia 36) The nurse is caring for a client with chronic hep B. What will the teaching plan for this client include? A. use a condom for sexual intercourse B. Report any clay- colored stools. C. Eat a high protein diet D. Perform daily urine bilirubin checks 37. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. cool clammy skin b. inspiratory crackles c. apical heart rate of 48 beats/min d. temperature 101.2* F 38. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous and pulmonary artery wedge pressure are 4. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV b. increase normal saline infusion to 150 mL/hr c. Administer hydrocortisone (SoluCortef) 100 mg IV d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr 39. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of which of the following? a. Nitroglycerin (Tridil) b. Sodium nitroprusside (Nipride) c. Drotrecogin alpha (Xigris) d. Norepinephrine (Levophed) 40. Which of these findings is the best indicators that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. hemoglobin is within normal limits b. Urine output is 60 mL over the last hour c. Pulmonary artery wedge pressure (PAWP) is 10 mmHg d. Mean arterial pressure (MAP) is 55 mm Hg 41. Which interventions will the nurse include in the plan of the care for a patient who has cardiogenic shock? a. Avoid elevating head of bed b. Check temperature every 2 hours c. Monitor breath sounds frequently d. Assess skin for flushing and itching 42. Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation 43. When caring for the patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? (TB ch.67 Q.17) a. BP 92/56 mm Hg b. Skin cool and clammy c. apical pulse 118 beats/min d. Arterial oxygen saturation 91% 44. During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which findings is most important for the nurse to report to the HCP? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation 45. A patient is admitted to the burn unit with burns the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased ad no wheezes are audible. What is the best action for the nurse to take? a. encourage the patient to cough and auscultate the lungs again b. Notify the HCP and prepare for endotracheal intubation c. Document the results and continue to monitor the patient’s resp. rate d. Reposition pt in high-Fowler’s position and reassess breath sounds 46. During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor b. Monitor daily weight c. Assess mucous membranes d. Measures hourly urine output 47. After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain. d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hr 48. The RN observes all of the following actions begin taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a. The nurse uses latex gloves when applying antibacterial cream to a burn wound b. The float nurse obtains burn cultures when the patient has a temp of 101* F c. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes before a dressing change d. The float nurse calls the health care provider for an insulin order when a nondiabetic pt has an elevated serum glucose 49) A client with cervical neck fracture is admitted to the intensive care unit. Which findings would the nurse recognize as indicative of spinal shock? A. Spastically, neuromuscular irritability, hyperreflexia B. Flaccidity and lack of sensation below the level of spinal cord lesion. C. Automatic dysreflexia with neurogenic bladder symptoms D. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of spinal cord lesion. ****know T2-T3: paraplegic *************** 50) A client with T6 spinal cord injury is being discharged. The PT is concerned about autonomic dysreflexia. S/S include the following: A. Dialited pupils B. Sudden vomiting and diarrhea C. drop in BP and pulse D. Diaphoresis above the level of the lesion 51) A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want to get pregnant, but I don’t know how I will tolerate pregnancy because I have lupus. Which response is best? A. Most women find that they feel better when they are pregnant B. How long have you been in remission? C. Women with lupus frequently have slightly longer gestation D. Its best to become pregnant within the first 6 months of diagnosis 52. The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the fistula if which finding are noted? Select all that apply A. presence of a thrill on palpation over the fistula *B. Absence of a bruit on auscultation over the fistula C. Presence of a pulse in the extremity below the fistula *D. Complaints of tingling or discomfort in the extremity E. Warm hand and fingers in the extremity in which the fistula is located. 53. Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following? A. It is used to lower your blood pressure *B. It is used to treat anemia C. It will help to increase the potassium levels in your body D. It is an anticonvulsant medication given to all clients after dialysis to prevent seizure activity. 54. A client with and ECG reading showing sinus bradycardia has a blood pressure of 47/28 mmhg. Which drugs does the nurse expect the physician to order for this client? A. Lidocaine (Xylocaine) *B. Atropine sulfate C. Isoproterenol hydrochloride (Isuprel) D. Epinephrine 55. Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion will be needed? A. Nitroglycerin B Nifedipine (Procardia) C Lidocaine (Xylocaine) *D. Amiodarone (Cordarone) 56. A nurse assesses a comatose, head-injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. Which of the following describes these findings? A. Stroke B. Epileptic Seizure *C. Decorticate posturing D. Decerebrate posturing 57. The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? A Confirm that the ventilator settings are correct B Verify that the ventilator alarms are functioning properly *C. Assess the respiratory status and pulse oximeter reading. D Monitor the clients arterial blood gas results. 58. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? A. Administer oxygen B. Checks the client’s vital signs *C Ventilates the client manually D. Starts cardiopulmonary resuscitation 59. The client is admitted to the ED with chest trauma. Which signs/symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax? A. Bronchovesicular lung sounds and friction rub *B Absent breath sounds and tachypnea C Nasal flaring and lung consolidation D Symmetrical chest expansion and bradypnea. 60. A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply A. Clamping the chest tube intermittently *B. Changing the client’s position frequently *C. Maintaining the collection chamber below the client’s waist *D. Adding water to the suction control chamber as it evaporates. *E Taping the connection between the chest tube and the drainage system. 61. A client has a total serum calcium level of 7.5 mg/dl. Which clinical manifestations would the nurse expect to note on assessment of the client? Select all A Constipation *B Muscle twitches C Hypoactive bowel sounds *D Hyperactive deep tendon reflexes *E Positive Trousseau’s sign and positive Chvostek’s sign *F. Prolong ST interval and QT interval on ECG 62. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? A. Administer sublingual nitroglycerin. B Obtain a STAT electrocardiogram *C Have the client sit down immediately D Assess the clien’ts vital signs. 63. The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement. Select all *A Assess the client’s level of consciousness *B Monitor clients urine output *C Perform passive range of motion exercise *D maintain intravenous fluids as ordered E Place the client with the HOB flat 64. The nurse is assessing a client experiencing motor loss as a result of a left sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement. 65. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome? A. Increased blood pressure *B Increased urine output C Decreased pain D Decreased PVCs 66. A client arrives at the emergency department with deep partial thickness and burns over 15% of his body. At admission his vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute and respiratory rate 20 breaths/minute. Which nursing intervention are appropriate for this client? Select all that apply A. Starting an IV infusion of lactated Ringers solution B. Administering 6mg of morphine IV C. Administering tetanus prophylaxis as ordered 67. If dietary trays are usually brought to the nursing unit at 8:00am the nurse should plan to administer intermediate- acting insulin (Humlin N) 40 units SQ to the client between? ANSWER- 630am and 700 am 68. What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain? ANSWER- ST segment elevation or depression 69. The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse would plan which of the following as a priority action? ANSWER- Place the client on a cardiac monitor 67. The nurse is caring for a client who underwent cardiac catherization 1 hour ago. What is an important nursing measures at this time? ANSWER- MAINTAIN PRESSURE OVER CATHETER INSERTION SITE AND DETERMINE DISTAL CIRCULATION STATUS. 68. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s heart rate increases ??? to 110min and becomes irregular. The nurse should know that the client requires? ANSWER- OXYGENATE PRIOR TO SUCTIONING 69. A client comes into the ER with complains of midsternal chest pain radiating to the neck and left arm which is unrelieved by sublingual nitroglygen. An electrocardiogram (ECG) is obtained. What observation on the ECG or on the cardiac monitor would indicate to the nurse the need to immediately notify the physician? A. PR impulse 0.20 sec B. Tachycardia rate of 125 beat of premature C. premature ventricle beat D. An ST segment elevation from the isoelectric baseline. 70. A client begins complains of chills and discomfort after about 50ml of blood has packed red blood cells. The best nursing action at this time is to A. Discontinue the transfusion and move the IV and restart IV transfusion at another site. B. compare the VS now and what they were before the transfusion begin C. STOP THE TRANSFUSION AND MAINTAIN A PATENT LINE WITH NORMAL SALINE solution and new tubing D. slow down the transfusion blood and dilute with normal saline solution 71. The vital signs of a client with cardiac disease are as follows blood pressure of 103/78 mm Hg, heart rate ??? beats/min, and respiratory rate of 16 breaths/min. Atropine (atropine???? Administered IV push. What nursing assessment indicates a therapeutic response to the medication? ANSWER- Pulse rate has increased to 70 beats/min 72. Order rocephen 1g over 30minutes Q6H. Supply 1g/100mL. How many mL per hour will the nurse infuse? Round the nearest whole number. ANSWER- 200 ml/hr 73. The nurse is caring for client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40 percent. The 02 saturation measured by pulse oximeter was 83 ABG results are pH 7.31, PACO2 93mmHg, HCO3 25 meq/L. Which of the following is an appropriate action by the nurse? ANSWER- POSITION CLIENT IN HIGH- FOWLERS AND ENCOURAGE USE OF INCENTIVE SPIROMETER AND COUGHING. 74. The diabetic educator is teaching a class on Diabetes Type 1 and is discussing sick day rules. Which interventions should the diabetes counselor include in the teaching? Select all that apply ANSWER- A) Take diabetic medication even if unable to eat the client’s normal diet. B) If unable to eat, drink liquids equal to the client’s normal diet. D) Test the blood glucose levels and test the urine ketones once a day and keep a record. 75. The nurse is monitoring a client receiving pertional dialysis notes that the client’s outflow is less than inflow. What action should the nurse take? Select all that apply? ANSWER- (SELECT ALL ANSWERS EXPCEPT – CONTACT THE HEALTH CARE PROVIDER & INCREASE THE FLOW- DO NOT SELECT THOSE TWO ANSWERS) 76. The nurse is obtaining a health history from a client who is visiting the clinic with complaints of a severe headache. The client provides the following data to the nurse based on a review of systems. The nurse identifies the following as a modifiable risk for stroke? Select all the apply. A. SMOKING B. ALCOHOL CONSUMPTION C. DECREASED PHYSICAL ACTIVITY D. OBESITY 77. The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which intervention should the nurse implement? Select all that apply A. Assess the client’s level of consciousness. B. Monitor the client’s urine output C. Perform passive range of motion (ROM) exercise. D. Maintain intravenous fluids as ordered. 78. The nurse is performing an assessment on a client who has returned from dialysis unit following hemodialysis. The client is complaining of headache, nausea, and is extremely restless. Which of the following ?? the most appropriate nursing action? ANSWER- NOTIFY THE PHYSICANS 79. The nurse determines that a client with diabetes- mellitus is experiencing fat breakdown for conversion to glucose if the client has elevated levels of which substance in the urine? ANSWER- ketones 80. The client is admitted the ED with chest trauma. Which signs and symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax? ANSWER- ABSENT BREATHS SOUNDS TACHYPNEA 81. The nurse is caring for hospitalized clients. Which of the following clients is at greatest risk for fluid volume deficit? ANSWER- THE CLIENT WHO HAS JUST BEEN ADMITTED HAS SEVERE DIARRHEA AND IS febrile. 82. PT & INR for Coumadin, INR 2.8: continue medication 83. Hot spot: apical pulse 84. Hot spot: T wave 85. Hot spot: P wave 86. P wave: atrial depolarization 87. Assessing response in an unconscious patient: nail bed pressure (peripheral) 88. HbA1c considerations for about 3 months of glucose monitoring a. less than 6% for nondiabetic b. diabetic controlled should be less than 7% 89. Sengstaken-Blakemore tube prevents bleeding (esophageal varices) a. Triple lumen b. Have scissors at the bedside c. Provide oral and nasal care every 3 hours d. Used to reduce bleeding 90. Planning rehabilitation for a stroke patient a. Assess functional status before developing plan i. Walking, speaking, eating, ADLs 91. Cranial nerve II: Snellen test 92. T2-T3: Paraplegia 93. ICP: no lumbar puncture 94. A nurse observing a close chest tube drainage system is postop 1 day thoracotomy? Continue bubbling in the suction chamber? A. check the control outlet against the wall B. observe all the connection tubing C. Continue to monitor client respiratory status D. Notify MD of the oxidation 95. A client admit to hospital report recurrent flank pain, nausea, and vomiting within 24 hours. Which of the following priority nursing action? A. Administered pain medication B. Monitor intake and output C. Administered antiemetics D. Strain urine 96. A nurse is caring for client who have type 1 DM. The nurse misread client morning blood glucose level at 210 mg/dL instead of 120 mg/dL base on this error. She admitted insulin dose of 200 mg/dL before client breakfast. Which of the nursing priority? Monitor client for hypoglycemia 97. A nurse is caring a client who is schedule of colonoscopy. The client ask the nurse if there will be a lot of pain during procedure. Which of the following is appropriate nursing response? A. No, you shouldn’t feel any pain because your rectum will be anesthesia B. You may be sedated but you will feel discomfort during the instrument insertion C. Don’t worry ?? D. ??? 98. A nurse is performing teaching for client who have recently diagnosis type 2 DM. nurse should recognize that the client understood the teaching. Identify hypoglycemia? Select all A. Moist, clammy skin B. Tachycardia C. Polyuria D. Polydipsia E. Polyphagia F. ??? 99. A nurse admitted morphine 2 mg IV push after client report pain and evaluate client 15 min. later injection. Which follow adverse effect? A . pain scale level of 6 to 4 B. sleepy but arouse when name call C. O2 sat 94% D. RR 8 bpm 100. A nurse assess a client who 8 score using the Glasgow coma scale to elevate of consciousness. Describe the score. A. Reflex alert client B. Need of total nursing caring C. Client in deep coma D. Stable neurological status 101. client low sodium diet and reduce fluid intake to choose lunch. A. Tuna sandwich on wheat bread, can of cocktail fruit, salad, and soda B. Grill chicken sandwich on white bread, apple, salad, and ice tea C. Grill cheese sandwich, tomato soup D. Ham and bean 102. client acute MI. a cardiac enzyme obtain. Cardiac enzyme identify? A. damage to the myocardial B. determine the size MI C. help to determine the location MI D. ???? 104. administered DDAVP to client diagnosis DI. Therapeutic effect 1. Specific gravity (1.015)