799 RN Exit Exam799 correctly answered Answered Questions LATEST UPDATE 2023/2024, Exams of Nursing

Download 799 RN Exit Exam799 correctly answered Answered Questions LATEST UPDATE 2023/2024 and more Exams Nursing in PDF only on Docsity! UPDATE 2023/2024[Fortis College], Answered Questions LATEST 799 RN Exit Exam 100% Correctly 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Nursing Exams for Nursing 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for 799 RN Exit Exam Terms in this set (798) Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea. b. Suggest that the client also plan to eat frequent small meals to reduce discomfort c. Review with the client the need to avoid foods that are rich in milk and cream. d. Reinforce this teaching by asking the client to list a dairy food that he might select. Review with the client the need to avoid foods that are rich in milk and cream Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be avoided. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a. Blindness secondary to cataracts b.Acute kidney injury due to glomerular damage c. Stroke secondary to hemorrhage d. Heart block due to myocardial damage Stroke secondary to hemorrhage Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? a. Ensure that the UAP has placed the pillows effectively to protect the client. b. Instruct the UAP to obtain soft blankets to secure to the side rails instead 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for a. Encourage the client to take deep breaths b. Remove the mask to deflate the bag c. Increase the liter flow of oxygen d. Document the assessment data Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first? a. Respiratory apnea of 30 seconds b. Oxygen saturation rate of 88% c. Eight premature ventricular beats every minute d. Disconnected monitor signal for the last 6 minutes. Respiratory apnea of 30 seconds Rationale: The priority is the client whose alarm indicating respiratory apnea that should be assessed first. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? a. Give the client 4 ounces of orange juice b.Call 911 to summon emergency assistance c. Check the client for lacerations or fractures d.Asses clients blood sugar level Check the client for lacerations or fractures Rationale: After the client falls, the nurse should immediately assess for the possibility of injuries and provide first aid as needed At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a. Ensure preoperative lab results are available b.Start prescribed IV with lactated Ringer's c. Inform the anesthesia care provider d. Contact the client's obstetrician. Inform the anesthesia care provider Rationale: Surgical preoperative instruction includes NPO after midnight the day of surgery to decrease the risk of aspiration should vomiting occur during anesthesia. While it is possible the C-section will be done on schedule or rescheduled for later in the day, the anesthesia provider should be notified first. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for action should the 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for b. "My throat hurts when I swallow" c. "I feel sick to my stomach and am going to throw up" d. I have a headache that gets worse when I sit up" "I have a headache that gets worse when I sit up" Rationale: A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bedrest, analgesic, and hydration. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement a.Auscultate for renal bruits b. Obtain a clean catch mid-stream specimen c. Use a dipstick to measure for urinary ketone d. Begin to strain the client's urine. Obtain a clean catch mid-stream specimen Rationale: This elderly is experiencing symptoms of urinary tract infection. The nurse should obtain a clean catch mid-stream specimen to determine the causative agent so an anti-infective agent can be prescribed. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? a. Wheat products b. Foods sweetened with aspartame. c. High fat foods d. High calories foods. Foods sweetened with aspartame Rationale: Aspartame should not be consumed by a child with PKU because ut is converted to phenylalanine in the body. Additionally, milk and milk products are contraindicated for children with PKU. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? a.Ask a more experience nurse to perform that scrub since it is the first time of the day b. Validate the nurse is implementing the OR policy for surgical hand scrub c. Inform the nurse that hand scrubs should be 3 minutes between cases. d. Direct the nurse to continue the surgical hand scrub for a 5- minute duration. Direct the nurse to continue the surgical hand scrub for a 5 minute duration Rationale: The surgical hand scrub should last for 5 to 10 mints, so the nurse should be directed to continue the vigorous scrub using a reliable agent for the total duration of 5 mints. It is not necessary to reassign staff (A). The 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for length of the hand scrub and 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for subsequent scrubs during the day require the same process for the same amount of time, (B and C) Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? a. Egg whites, toast and coffee. b.Bran muffin, mixed fruits, and orange juice. c. Granola and grapefruit juice d. Bagel with jelly and skim milk. Bagel with jelly and skim milk Rationale: D includes dairy products which contain calcium and does not include any foods that inhibit calcium absorption. The primary dietary implication of osteoporosis is the need for increased calcium and reduction in foods that decrease calcium absorption, such as caffeine and excessive fiber. The charge nurse of critical care unit informed at beginning of shift that less than optimal number registered nurses be working that shift. In planning assignments, which client should receive most care hours by a registered nurse a.A 34 yo admitted today after emergency appendendectomy who has peripheral intravenous catheter, Foley catheter. b.A 48 yo marathon runner w/a central venous catheter experiencing nausea, vomiting due to electrolyte disturbance following a race. c.A 63 yo chain smoker w/ chronic bronchitis receiving O2 nasal cannula and a saline- locked peripheral intravenous catheter. d.An 82 yo client with Alzheimer's disease newly-fractures femur w/Foley catheter and soft wrist restrains applied An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied Rationale: (D) describe the client at the most risk for injury and complications because of the factor listed. (A) has complete the recovery period form anesthesia but requires critical care because of the invasive lines and new abdominal incision. (B) is likely to be in excellent physical condition and has one invasive line needed for rehydration. (C) is essentially stable, despite having a chronic condition. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? a. Cleanse the foot with soap and water and apply an antibiotic ointment b.Provide teaching about the need for a tetanus booster within the next 72 hours. c. have the mother check the child's temperature q4h for the next 24 hours d. transfer the child to the emergency department to receive a gamma globulin injection 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for with the blood turbulence created by the heart or valvular defect. B is associate with Heart Failure. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth. 0.4 0.4 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? a.Auscultate the client's bowel sounds b. Observe for edema around the ankles c. Measure the client's capillary glucose level d. Count the apical and radial pulses simultaneously Auscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? Ask the client to discuss "do not resuscitate" with her healthcare provider A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? a.Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour b. Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr. c. Maintain the present feeding until diarrhea subsides and the begin the next new prescription. d. Withhold any further feeding until clarifying the prescription with healthcare provides. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour Rationale: Diluting the formula can help alleviate the diarrhea. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes including hyperosmolar formula. A female client reports that her hair is becoming coarse and breaking off, 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? a. "Is there a history of female baldness in your family?" 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for b. Encourage the client to verbalize his feelings about the nurse c. Reassure the client that his request will be met whenever possible. d.Advise the client that assignments are not based on client requests Advise the client that assignments are not based on clients requests Rationale: Those with antisocial personality disorders are manipulative in order to meet their own needs. The charge nurse must set limits on this behavior. The client's superficial charm and emotional maturity prevent effective therapeutic communication and (A and B) will be used to the client's advantage. C encourage further manipulative behavior. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? a. Call the radiology department b.Reinsert the implant into the vagina c.Apply double gloves to retrieve the implant for disposal. d. Place the implant in a lead container using long- handled forceps Place the implant in a lead container using long-handled forceps Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent tumor tissues. If the radiation source or the applicator become dislodged long-handled forceps should be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then placed in the lead container. The client with which type of wound is most likely to need immediate intervention by the nurse? a. Laceration b.Abrasion c. Contusion d. Ulceratio n Laceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? a. Record urine output every hour b. Monitor blood pressure frequently c. Evaluate neurological status d. Maintain seizure precautions 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? a. To reduce abdominal pressure on the diaphragm b. to promote retraction of the intercostal accessory muscle of respiration c. to promote bronchodilation and effective airway clearance d. to decrease pressure on the medullary center which stimulates breathing To reduce abdominal pressure on the diaphragm Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? a.The client is too obese b.Palpating in the wrong abdominal quadrant c. The gallbladder is normal d. Deeper palpation technique is needed The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? a. Describe the transmission of drugs to the infant through breast milk b.Encourage her to use stress relieving alternatives, such as deep breathing exercises c. Inform her that some antianxiety medications are safe to take while breastfeeding d. Explain that anxiety is a normal response for the mother of a 3- week-old. Inform her that some antianxiety medications are safe to take while breastfeeding Rationale: There are several antianxiety medications that are not contraindicated for breastfeeding mothers. The woman is apparently aware that drugs can be transmitted through breast milk, so A is not helpful. C might be helpful, but the client's history suggest that nonpharmacological methods of anxiety management do not produce the best outcome. (D) the 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for mother's history places her at risk for severe anxiety. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for b. urine specific gravity 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for c. Serum calcium d. white blood cell count Serum calcium Rationale: Numbness and tingling of the fingers and around the mouth, along with muscle cramps are signs of hypocalcemia What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? a. working together can decrease the risk for back injury b.The technique is intended to maintain straight spinal alignment. c. Using two or three people increases client safety. d. turning instead of pulling reduces the likelihood of skin damage The technique is intended to maintain straight spinal alignment. Rationale: The main rationale for use of the long-rolling technique is to maintain the client's spine straight alignment. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? a. Plain yogurt with sweetened with raw honey b.Peanuts in the shell, roasted or un-roasted. c.Aged farmer's cheese with celery sticks d. Baked apples topped with dried raisins Baked apples topped with dried raisins Rationale: A patient with chemotherapy-induced severe neutropenia is at high risk for infection. A low bacteria diet is required D is a healthy snack for a client receiving chemotherapy. A, B and C have a high bacterial count and should be avoided. Which action should the school nurse take first when conducting a screening for scoliosis? a. Compare dorsal measurement of trunk b. Extend arms over head for visualization c. Inspect for symmetrical shoulder height. d. Observe weight-bearing on each leg. Inspect for symmetrical shoulder height. Rationale: Children between 9 and 15 years old should be screening for scoliosis, which is exhibited Vertebral column. Screening for scoliosis should begin with inspection of shoulder height An Unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for beat/ minutes. What action should the charge nurse implement? 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Which instruction should the nurse provide a pregnant client who is complaining of heartburn? a. Limit fluids between meals to avoid over distension of the stomach b.Take an antacid at bedtime and whenever symptoms worsen c. Maintain a sitting position for two hours after eating. d. Eat small meal throughout the day to avoid a full stomach. Eat small meal throughout the day to avoid a full stomach. Rationale: Eating small frequent meals throughout the day decreases stomach fullness and helps decrease heartburn. Fluids should not be consumed with foods because they further distend the stomach, but fluids not be limited between meals (A) because this puts the client at risk for dehydration. (B) is not recommended during pregnancy unless prescribed by the health provider because they place the client at risk for electrolyte imbalance (sodium), constipation (aluminum, or diarrhea (magnesium) (C) is less effective than (D) preventing heartburn. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? a. Hypokalemia b. Ketonuria. c. Peripheral edema d. Elevated blood pressure Hypokalemia Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? Digitally check the client for a fecal impaction After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? Bilateral Wheezing. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? Inflammation of the mucous membrane & bronchospasm 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? a. "Your mother & father will be here soon. Talk to them about that." b. "Why do you want to know about what will happen to your body when you die?" c. "The heart will stop beating & you will stop breathing." d. "Are you concerned about where your spirit will go?" "The heart will stop beating & you will stop breathing." The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: a. Restlessness b. Clenched Fist c. Increased pulse rate d. Increased respiratory rate. e. Increased temperature f. Peripheral pallor of the skin a. Restlessness b. Clenched Fist c. Increased pulse rate d. Increased respiratory rate. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication a.Ask the client about soft foods preferences b.Auscultate the client's breath sounds c. Obtain and record the client's vital signs d. Determine which side of the body is weak. Determine which side of the body is weak. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? a. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. b. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson- pratt drain. c. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container d.Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for a. Blood alcohol level of 0.09% b. Serum lithium level of 1.6 mEq/L or mmol/l (SI) 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for c. Six hours of sleep in the past three days. d. Weight loss of 10 pounds (4.5 kg) in past month. Serum lithium level of 1.6 mEq/L or mmol/l (SI) Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? a. Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock b.Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. c. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzymes levels. d.Notify the healthcare provider of the client's increase chest pain a call for the defibrillator crash cart. Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. Rationale: Administer morphine sulfate can increase oxygen supply are the priority intervention for symptoms of acute MI and should be supplemented with nitroglycerin and aspirin administration. A may result in overload that the impaired myocardium cannot handdle effectively. C and D are helpful but after. B The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? a. Literacy level b. Prevalent learning style c. Median age d. Percent with internet access. Literacy level Rationale: Reading ability, or literacy level is the most important population characteristic in choosing strategies for implementing teaching plan. If the population cannot read it would be useless to reinforce teaching with written material. A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? a. Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. b.Avoid eating all foods that contain any vitamin K because it is an antagonist 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for of 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for a. Evaluate the client's orientation to time and place b. Place the client on fall precautions c. Encourage the client to drink milk with meals d.Assess the client's breath sounds daily. Place the client on fall precautions Rationale: Osteoporosis causes bone to become brittle, fragile and less dense with age, which increases an older client's risk for falls and fractures which increases their risk for another pathology. Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) a.Apply oxygen 10 l/mask b. Stop the oxytocin infusion c. Turn the client to the right lateral position. d. Continue to monitor the progress of labor. Continue to monitor the progress of labor Rationale: Early deceleration are indicative of head compression as the fetus descends in the birth canal, which is a normal patter during active labor, so labor progression should continue to be monitored An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.) 1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. Rationale: Noting the date and time of the behavior is the first action that is important in providing factual information. The unit manager should discuss the behavior with the UAP and describe the problems the behaviors causes for the staff, when a problem is identified, it is important to plan and implement solutions, such as scheduled break times during the shift. These interventions should be evaluated based on the UAP's signs of improvements. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? a. Gastric output of 900 mL in the last 24 hours b. Serum potassium level of 3.1 mEq/L or mmol/L (SI) c. Increased blood urea nitrogen (BUN) 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for d. 24-hour intake at the current infusion rate. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Serum potassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L). Rationale: The normal potassium level in the blood is 3.5-5.0 mill Equivalents per liter (mEq/L). Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? a. Neutrophils b. Lymphocytes c. Eosinophils d. Monocyt es Eosinophils Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat a. Vanilla-flavored yogurt b. Low fat chocolate milk. c. Calcium fortified juice d. Cinnamon applesauce d. Cinnamon applesauce RATIONALE: Dairy products and calcium fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection. Since other options contains calcium, these snacks should be avoided by a client who is taking ciprofloxacin. Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond? a. Explain the healing from injury can take many months b.Assist the client in developing a goal of managing the pain. c. Encourage the client to verbalize her fears about the pain d. Complete an assessment of the client's functional ability. Assist the client in developing a goal of managing the pain Rationale: Neuropathic pain is chronic pain and the nurse should first help the client understand the need to learn to manage the pain. One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? a. Slow increasing intracranial pressure (ICP) b.Decerebrate posturing c. Rapid onset of decreased level of consciousness. d. Coup contrecoup signs Rapid onset of decreased level of consciousness. Rationale: Epidural hematomas results from arterial bleeds that cause a rapid increase in ICP, which initially manifested by an early and rapid onset of decreased consciousness. Slowly increasing ICP is more likely to occur with a venous subdural hematoma. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? a.Apply oxygen by mask after opening the airway b. Position a firm wedge to support pelvis and thorax at 30-degree tilt. c. Give continuous compression with a ventilation ratio at 20:3 d.Apply less compression force to reduce aspiration Position a firm wedge to support pelvis and thorax at 30 degree tilt. Rationale: To relieve aortocaval compression caused by the gravid uterus, left lateral uterine displacement (LUD) should be maximized using a firm wedge to support the pelvis and thorax at 30- degree tilt to optimize maternal hemodynamic during CPR. Maternal modification should include ventilation with 100% oxygen, not A. Pregnant adults should be resuscitated using a compression-ventilation ration of 30:2 not C without interruption of continuous compressions. Effective chest compression should be forceful rhythmic application of pressure (fast and hard) at 100 compressions/minutes at the depth of 2 inches (5cm) to generate myocardial and cerebral blood flow. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan? a. Report any signs of cloudy urine output. b. Seek counseling for body image concerns c. Follow instruction for self-care toileting d. Frequently empty bladder to avoid distension. Report any signs of cloudy urine output. Rationale Infection can be life-threatening and cloudy urine output is a sign of urinary tract infection, which should be reported immediately. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Which finding requires the nurse to take further action? 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for a. Loss of appetite b. Serum K 4.0 mEq/or mmol/dl (SI) c. Loose, runny stool d. Tented skin turgor. Tented skin turgor. Rationale: D indicate dehydration, a serious complication following prolonged diarrhea that requires further interventions by the nurse. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? a. Note the skin color around the area b.Measure the degree of... c.Apply light pressure over the area. d. Palpate the temperature of the area. Apply light pressure over the area. Rationale: To assess for blanching the nurse should apply pressure to the area of hyperemia with one finger and when the finger is removed evaluate for return of erythema (blanching hyperemia) The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take? a. Use a full knot to secure the restrain tie. b. Reposition the restraint tie onto the bedframe. c. Raise the button side rail of the client's bed d. Document that the restrain is secured. Reposition the restraint tie onto the bedframe. Rationale: Restraints should be secured to the bedframe, which is more stable than the side rails. A is difficult to release quickly. The restrain should be removed from the side rail before the position of the side rail is changed. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? a. Premature atrial contractions (PAC) b.Hemoccult-positive nasogastric fluid c. Diminished left lower lobe sounds. d. Increasing endotracheal secretions. Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Rationale: Frequently, the client is placed in five positions (head down, prone, right and 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for left lateral, and sitting upright) to aid in drainage of each of the five lobes of the lungs (D). Postural drainage should be performed before meals to prevent nausea, vomiting and aspiration(A). The client should breath slow and exhale through pursed lips to help keep airway open so that secretions can be drained while assuming the various positions. C is not required A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? a. Slow onset of facial drooping associated with headache b. Inability to close the affected eye, raise brow, or smile c.A flat nasolabial fold on the right resulting in facial asymmetry. d. Drooling is present on right side of the mouth, but not on the left. Inability to close the affected eye, raise brow, or smile Rationale: Because the motor function controlling eye closure, brow movement and smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment of all branches of the facial nerve indicate that Bell's palsy has occurred. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? a. Turns to left the side to instill the irrigating solution into the stoma b. Keeps the irrigating container less than 18 inches above the stoma c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d. Inserts irrigating catheter deeper into stoma when cramping occurs Keeps the irrigating container less than 18 inches above the stoma Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to flow slowly with little excessive peristalsis does not cause immediate release of stool. The nurse should teach the client to observe which precaution while taking dronedarone? a. Stay out of direct sunlight b.Avoid grapefruits and its juice c. Reduce the use of herbal supplements d. Minimize sodium intake. b. Avoid grapefruits and its juice Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility of serious side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias and should be avoided. D does not directly affect those taking dronedarone. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for c. Determine if she can ask for support from family, friend, or the baby's father. d. Explain the differences between postpartum blues and postpartum depression. Determine if she can ask for support from family, friend, or the baby's father Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety about transitioning to parenthood. The nurse should ask the client who is available to support her. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? a. Establish the second IV site b.Asses the IV for blood return c. Stop the normal saline infusion. d. Discontinue the 24- gauge IV Stop the normal saline infusion. Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the pain, and a large gauge needle is preferable. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care? a. Evaluate her response to narcotic analgesia b.Asses the skin under the traction moleskin c. Place a pillow under the involved lower left leg d. Ensure proper alignment of the leg in traction. Ensure proper alignment of the leg in traction. Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the application of Buck's skin traction proper alignment ensures the transaction S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize muscle spasms and surrounding tissue injury related to the fracture. A should be implement but improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but the greatest risk is improper alignment of the traction. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for a. Immediately apply a pressure dressing b. Document the ongoing wound healing. c. Irrigate the wound with sterile saline d. Obtain a capillary INR, measurement Document the ongoing wound healing Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and ongoing wound healing At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? a. Knowledge deficit b.Anxiety c.Anticipatory grieving d. Pain (acute) anxiety Rationale: The client is demonstrating only anxiety. There is no indication that the client is presenting signs of A, C or D The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? a.Administer oxygen by face mask at 6L/mint b.Transport the client for a cesarean delivery c. Elevate the presenting part off the cord. d. Place the client to a knee-chest position. Elevate the presenting part off the cord Rationale: The nurse should immediately elevate the presenting part off the cord because when the cord prolapses, the presenting part applies pressure to the cord, especially during each contraction, and reduces perfusion to the fetus. A can be delayed until pressure is removed from the cord. B and D are important but do not have priority. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? a. Reassess readiness for SNF transfer. b. Obtain specimens for culture analysis c. Confer with family about home care plans d.Arrange physical therapy for strengthening. Reassess readiness for 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) a. Recommend a 24-hour caregiver on discharge to the long-term facility. b.Notify the healthcare provider of the client's change in mental status. c. Include q2 hour's reorientation in the client's plan of care. d.Request immediate evaluation by Rapid Response Team e.Apply soft wrist restraints so that the operative site is protected. b. Notify the healthcare provider of the client's change in mental status. c. Include q2 hour's reorientation in the client's plan of care. An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first a.Ask the family member to answer the questions. b.Provide a printed health care assessment form c.Assess the surroundings for noise and distractions. d. Defer the health history until the client is less anxious. Assess the surroundings for noise and distractions.\ The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? a. Treatment for acute uremic symptoms within 24 hours b. Change to a regular diet c. Large amounts of fluid and electrolyte replacement. d. Unrestricted sodium intake Large amounts of fluid and electrolyte replacement. Rationale: This client, whose output is significantly high will need fluids and electrolyte replacement. The diuretic stage of ARF begins when the client has greater than 500 ml of urine in 24 hrs. A is associated with the oliguric and anuric stage of ARF. B and D should not occur until the client's BUN and electrolytes indicate a significant improvement that will allow for such changes. Which intervention should the nurse include in the plan of care for a child with tetanus? a. Open window shades to provide natural light b.Reposition side to side every hour. c. Minimize the number of stimuli in the room. d. Encourage coughing and deep 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for breathing Minimize the amount of stimuli in the room 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for significant and the concomitant use of NSAID and other anticoagulants should be avoided. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse? a.A client who is leaking clear fluid b.A mother who just delivered a 9 pounds boy c. A mother with an infected episiotomy. d. A client at 28- weeks' gestation in pre- term labor. A mother with an infected episiotomy Rationale: An infected episiotomy is essentially an infected surgical incision, and an experienced emergency room nurse is likely be able to care for such a client. A, B and D required specialized maternity nursing care. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? a. Spironolactone b.Potassium c.Ampicillin sodium parental d. Digoxi n. Digoxin. Rationale: This infant is demonstrating early signs of heart failure due to an increase right ventricular workload caused by a left to right shunt through the VSD, son an inotropic, such as digoxin should be administered first to improve the efficiency of myocardial contractility. Next a high ceiling diuretic to reduce fluid volume and workload of the heart. If hypokalemia occurs as result of potassium-wasting diuretic, should be given to reduce the risk of digoxin toxicity. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? a. Supervise a newly hired graduate nurse during an admission assessment. b.Transport a client who is receiving IV fluids to the radiology department. c.Administer PRN oral analgesics to a client with a history of chronic pain d.Complete ongoing focused assessments of a client with wrist restrain. Supervise a newly hired graduate nurse during an admission assessment. Rationale: The admission assessment of a client should be completed by a professional nurse. A graduate nurse should be supervised by the RN to 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for ensure that the graduate nurse understand and performs within the expected scope of practice. The UAP transport a stable client. (B) The PN can complete C and D 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take a. Remind the client that a rescue inhaler might save his life b. Leave the client alone so that he can grieve his illness c.Ask the client what he is thinking about at his time. d. Gently touch the client then continue with teaching. Ask the client what he is thinking about at his time. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) a.Apply oxygen via nasal cannula b.Administer PRN nebulizer treatment. c. Obtain 12 lead electrocardiogram. d.Monitor continuous oxygen saturation. e. Give PRN dose of regular insulin b. Administer PRN nebulizer treatment. c. Obtain 12 lead electrocardiogram. d. Monitor continuous oxygen saturation. Rationale: A nebulizer treatment may improve the wheezing. Chest tightness is most likely to coughing, but a 12-lead electrocardiogram is needed to assess for cardiac ischemia. Oxygen saturation monitors for adequate oxygenation. The nurse caring for a 3-month-old boy one day after a pylorostomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? a.Administer a prescribed analgesia for pain. b. Increase IV infusion rate for rehydration c. Provide additional blankets to increase body temperature d. Feed one ounce of formula to correct hypoglycemia. Administer a prescribed analgesia for pain Rationale: Since this child is exhibiting signs of pain, the prescribed analgesic should be administered. The behavioral signs of pain in an infant are facial grimaces, restlessness or agitation, and guarding the area of pain, in this case by pulling the knees to the chest A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for c. Explain that relief of the signs/symptoms of hyperthyroidism will occur immediately d. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? a.Assess the client's dressing for bleeding b. Determine client's pulse, blood pressure, and respirations c.Administer a PRN dose of IV Morphine d. Check the client's orientation to time and place. Determine client's pulse, blood pressure, and respirations Rationale: Colon resection, a major abdominal surgical procedure, causes severe pain in the immediate postoperative period and requires administration of IV morphine regularly to maintain analgesic serum level. Before administering a central nervous system depressing analgesia, the client's vital signs should be assessed to determine the client's current level of CNS depression. In the immediate postoperative period, during administration to PACU (A, C and D) should be evaluated. The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply) a. Change a saturated surgical dressing for a client who had an abdominal hysterectomy. b.Take postoperative vital signs for a client who has an epidural following knee arthroplasty c. Start a blood transfusion for client who had a below-the knee amputation. d.Collect a sputum specimen for a client with a fever of unknown origin e.Ambulate a client who had a femoral-popliteal bypass graft yesterday b. Take postoperative vital signs for a client who has an epidural following knee arthroplasty d. Collect a sputum specimen for a client with a fever of unknown origin e. Ambulate a client who had a femoral- popliteal bypass graft yesterday Rationale: Measuring vital signs, collecting specimens, and ambulating a mobile client are within the scope of practice for a UAP A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi-Fowler position with his arms at his sides. What action should the nurse implement? a. Reposition the client in a side-lying position and support his abdomen with 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for pillows. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for b. Elevate the client's feet on a pillow while keeping the head of the bed elevated. c. Raise the head of the bed to a Fowler's position and support his arms with a pillow Place the client in a shock position and monitor his vital signs at frequent intervals Raise the head of the bed to a Fowler's position and support his arms with a pillow Rationale: The Ascites is the accumulation of fluid in the peritoneal or abdominal cavity, and this fluid pushes on the diaphragm, limiting the client's lung expansion and causing dyspnea. To relieve pressure, the head of the bed should be elevated with the arms supported for comfort. A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness but can bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? . d. Crutches with 4-point gait. Crutches with 4- point gait. Rationale: Crutches using a 4-point gait provide stability and require weight bearing on both legs, which this client should be able to provide. A is used when is partial or complete leg paralysis or some hemiplegia. B requires at least partial weight bearing on each foot but does not provide the stability of D. C is useful when the client must bear all the weight on one foot and this is not the problem experienced by this client. The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) 12,160 Answer: 12,160 Rationale: 4ml x 76kg x 40 (bsa) =12,160 ml A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a.Assess body temperature b.Monitor skin elasticity c. Observe aspiration site. d. Measure urinary output Observe aspiration site. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? a. Tell the client that the vaccine for HPV is not indicated 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for d. Encourage the client to eat finger foods. Encourage the client to eat finger foods 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Rationale: Eyes-hand coordination is often affected with dementia. Providing a way to eat without using utensils is likely to help the client maintain independence while obtaining adequate nutrition. A: increase frustration. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? a. Pupillary response b.Oxygen saturation c. Peripheral pulses d. Bowel patterns Bowel patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement? a. Place the records in a separate trash bag and tie the bag securely closed b.Point out the record to a worker in the medical records department c. Contact the medical records department supervisor. d. Immediately remove and shred the records. Contact the medical records department supervisor Rationale: Notify the department supervisor of a Privacy officer alerts the appropriate people to a possible internal procedural problem and provides an opportunity of education a prevention of recurrence. A 16-year-old adolescent with meningococcal meningitis (83) is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 83 Answer 83 Rationale: 1000 ml-12hr. 1000/12 = 83.33 While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for getting in and out of the bed than she did previously. Which action should the nurse implement first? a. Inquire about an electric bed for the client's home use 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Ask the older brother how he felt during the incident Rationale: The brother's change in demeanor may indicate that he is experiencing post- traumatic stress that warrants further investigation, so the nurse should address the older brother's feeling. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? a.Administer PRN medication b.Titrate the oxygen to keep saturation above 92% c. Hold oral intake until swallow evaluation is done. d. Elevate the head of his bed at least 45 degrees. Hold oral intake until swallow evaluation is done. Rationale: After oral intubation, the client is at high risk for swallowing difficulties. A swallowing evaluation should be done to determine what consistency of liquids the client can tolerate without aspirating. A, B and D helps but does not have the priority. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply) a. Report feeling sad b. Interacts with a flat affect. c.Avoids eye contact. d. Has a disheveled appearance. e. Express suicidal thoughts. b. Interacts with a flat affect. c. Avoids eye contact. d. Has a disheveled appearance. Rationale: Observed finding are objective and include the client's appearance, such as flat affect, lack of eyes contact, and disheveled appearance. A and E are subject only the client can express verbally. A client in the postanesthesia care unit (PACU) has an eight (8) (Normal) on the Aldrete postanesthesia scoring system. What intervention should nurse implement a. The client should be kept in the recovery room b.Assess the client's respiratory status immediately c. Notify the client's surgeon immediately d. Transfer the client to the surgical floor. Transfer the client to the surgical floor. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Rationale: A score of 7 to 8 is normal and indicates that the client can be discharge from PACU. The PACU assessment form includes 5 mints areas of assessment: muscle 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for activity, circulation, consciousness level, and oxygen saturation. Each of these 5 areas receives two points for normal. A, B, C are interventions that are not indicated for a score of 8. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Place personal religious artifacts on the body. b.Confirm the client's wishes for tissue donation c. Observe consent for autopsy signature by family. d.Attach identifying name tags to the body. e. Follow cultural beliefs in preparing the body. a. Place personal religious artifacts on the body. d. Attach identifying name tags to the body. e. Follow cultural beliefs in preparing the body. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions? a. Be alert for possible cross-sensitivity to cephalosporin agents. b.Monitor peak ad trough levels whenever taking any antibiotic c. Watch daily urine output and weight gain while taking antibiotics d.Wear sun block and protective clothing to avoid exposure to sun. Be alert for possible cross-sensitivity to cephalosporin agents Rationale: Cross-sensitivity with cephalosporin can occur in those who are allergic to penicillin, so the nurse should provide this warning. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? a. The impending signs of death should be documented b.The client's need for pain medication should be determined. c. The nurse manager should be updated on the client's status d.The client's status should be conveyed to the chaplain The client's need for pain medication should be determined. Rationale: Palliative care includes nursing interventions that provide relief for the dying client's suffering by assessment and treatment of pain and other problems that are physical, psychosocial and spiritual. After the family is notified for the client's impending death, the client's need for pain medication should be assessed. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) a. Monitor abdominal girth. b. Increase oral fluid intake to 1500 ml daily. c. Report serum albumin and globulin levels. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for d. Straining on urination and nocturia Fever and dysuria. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? a. Maintain both lower extremities elevated on pillows. b. Remove the contracting antiembolic stocking c.Administer diuretics in the morning hours d. Restrict PO fluid intake to 500 ml per shift Maintain both lower extremities elevated on pillows Rationale: Hepatocellular failure and hypertension contribute to third spacing of fluids. The clients complain best addresses by maintaining both extremities in an elevated position on pillows, which uses gravity to facilitate venous return and decrease peripheral edema. Stockings should be reapplied evenly to relieve constriction, but no removed. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? a. Elevate lower extremities while out of bed b.Teach family proper range of motion exercises. c. Maintain proper body alignment when in bed d. Encourage diaphragmatic breathing exercises. Teach family proper range of motion exercises. Rationale: Performing proper range of motion exercised helps maintain maximum mobility by preventing excessive muscle atrophy and joint contractures. Elevating lower extremities decreases the amount of peripheral edema. Proper body alignment reduces strain on joints, tendons, ligaments and muscles and minimizes contractures in an abnormal position. Diaphragmatic breathing exercises may decrease the risk of pulmonary complications. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? a. Family history is more important than calcium intake in determining the occurrence of osteoporosis b.Calcium should be taken once a day, preferable at the same time of day c. Smoking cessation is more important than calcium intake in preventing osteoporosis. d. Postmenopausal women need an intake of at least 1,500 mg of calcium daily. Postmenopausal women need an intake of at least 1,500 mg of calcium daily 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for When evaluating a client's rectal bleeding, which findings should the nurse document? 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for d.Encourage the client to keep a diary of his food intake until his next visit to the clinic. 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Remind the client to keep his appointments to have his cholesterol level checked. Rationale: Ezetimibe lowers cholesterol and LDL levels, so it is important for the nurse to remind the clients to keep his appointments at the laboratory. D may influence his serum levels, but A provide better indicator. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? a.Application of joint splints b.Effective body mechanisms c. Fall prevention measures. d. Low fat, high protein diet Fall prevention measures Rationale: Client instruction should include measures to prevent falls, because elderly clients with decrease bone density are at high risk for bone fractures and impaired bone healing in fracture should occur. A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? a. Infection b. Increase intracranial pressure c. Shock d. Head Injury. Shock Rationale: This client has symptoms of shock. Two signs of shock are decreased BP, and increased (often weak and thread) pulse, this client has both symptoms. A temperature of 98.6 F is average normal. An increase of temperature. D is correct but is vague and is not specifically related to the assessment date describe, so it is not the best answer. An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? a. Obtain a medical history b.Record pain evaluation c.Assess blood glucose d. Identify pills in the bag. Identify pills in the bag 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for Rationale: Comorbidity places the client at risk for multiple drug interaction and side effects, and the client's gout therapy may need to be modified. A review of the medication in the bag (D) is the most important way to analyze the client's polypharmacy. And therapeutic response for comorbidities. Obtain a medical history (A), pain evaluation (B), and assessing blood glucose level (C) should be done in a timely manner. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? a. Dark yellow-brown colored urine b.Nonspecific muscle and joint pain c. New onset of purple skin lesions. d. Weakness when getting up to walk. New onset of purple skin lesions. Rationale: During the convalescence period of hepatitis A, the client major complain is malaise and fatigability. Purple skin lesions may be indicative of the liver's impaired ability to produce clothing elements and should be reported to the healthcare provider (C) for further analysis. Urine may become dark when excess bilirubin is excreted by the kidney, which is expected even when the client is not jaundice during the acute phase hepatitis (A). Myalgia and arthralgia (B) are intermittent complains with ongoing malaise, fatigue and weakness (D) during convalescence of hepatitis A. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? a. Increase the rate of the continuous bladder irrigation b. Manually irrigate the catheter with sterile normal saline c. Clamp the catheter above the drainage. d. Ensure that no dependent loops are present in the tubing. Ensure that no dependent loops are present in the tubing. Rationale: The nurse should ensure that the tubing is not kinked, and adequate flow is maintained to prevent bladder distention. Clear pale pink urine is desirable following TURP and indicates the absence of clots or excessive hemorrhage. A is implemented if the flow is dark red to prevent clot formation, and B if clots is present, to prevent obstruction. C is not a useful action in this situation and causes bladder distention while the bladder irrigation is still infusing The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which foods should the nurse encourage this client to eat? a. Yogurt and/or buttermilk. b.Avocados and cheese 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for b. Death anxiety related to concern about prognosis 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for c.Anxiety related to fear of suffocation. d. Ineffective coping related to knowledge deficit about COPD Anxiety related to fear of suffocation. Rationale: A common problem with clients who have COPD is anxiety. These clients cannot aerate their bodies, so they feel a perpetual state of suffocation which is worse during exacerbation of their COPD. A classic descriptor of COPD id impaired gas exchange (A). Because the client has typically adapted to impaired gas exchange over a long period of time, and the nurse has assessed a change in her appearance (A) is not the primary diagnosis at this time. Based on the data presented (B and D) are not the best diagnoses in this situation. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? a. Provide daily care of tong insertion sites using saline and antibiotic ointment b.Modify the client's diet to prevent constipation c. Encourage active range of motion q2 to 4 hours. d. Instruct the client to report any symptoms of upper extremity paresthesia. Provide daily care of tong insertion sites using saline and antibiotic ointment Rationale: Crutchfield tongs, a skeletal traction device for cervical immobilization, requires daily care of the surgically inserted tongs to minimize the risk of infection of the insertion site and cranial bone. Daily cleansing with normal saline solution and antibiotic applications minimizes bacterial colonization and helps to prevent infection. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? a.Administer prescribed pain medication b.Assess surgical site c. Determine the client's vital sign. d.Apply warmed blankets Determine the client's vital sign. Rationale: The First priority must be to obtain baseline vital signs. A and B should also be accomplished soon, but not until the initial vital signs are determined. C is a nice thing to do. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? a.An apical pulse of 120 beats per minute 799 RN Exit Exam 100% Correctly Answered Questions LATEST UPDATE 2023/2024[Fortis College], Exams for b.Extreme agitation with staff and family