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ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which of the following instructions should the nurse include A. "Wait at least 5 minutes between puffs from the same inhaler" B. "Breathe in rapidly when inhaling the medication" C. "Clean the plastic inhaler cap weekly with cold water" D. "Shake the inhaler vigorously prior to use" - ANSWER-D .) "Shake the inhaler vigorously prior to use" Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan A. Provide the client with a means of communication B. Maintain the head of the client's bed in a flat position C. Suction the client's endotracheal tube every 4 hr D. Perform oral hygiene for the client every 8 hr - ANSWER-A.) Provide the client with a means of communication
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effectiveness of the treatment A. Sodium 165 mEq/L B. Potassium 5.2 mEq/L C. Urine specific gravity 1. D. Hct 62% - ANSWER-C Urine specific gravity 1. Within the expected range of 1.005-1. A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for bleeding A. PT 11.5 seconds B. aPTT 35 seconds C. Platelets 80, D. RBC 4.0 million - ANSWER-C Platelets 80, platelet range is 150,000-400, A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which of the following interventions is the nurse's priority while caring for this client A. Change the client's position every 2 hours B. Pad pressure points at the edges of the client's cervical collar C. Palpate the client's abdomen for bladder distention D. Assist the client with quad coughing - ANSWER-D Assist the client with quad coughing
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS D. Verify the client's blood type with a second nurse E. Use a 20 gauge IV needle for venous access - ANSWER-A, D, E A, complete assessment prior to transfusion D, verify identification, blood compatibility, and expiration of product with second nurse E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect A. 3.6 mg/dl B. 8 mg/dL C. 18.7 mg/dL D. 26 mg/dL - ANSWER-D 26 mg/dL Normal range is 10 - 20, and elevated levels indicates renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse identify as atrial fibrillation (cannot insert pictures, read description) A. multiple irregular and variable waves at the baseline and irregular R to R intervals B. a rate of 140 - 180/min
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than the ventricles. Rate between 100-280/min D. a P wave for every QRS, rate is 60 - 100/min - ANSWER-A.) multiple irregular and variable waves at the baseline and irregular R to R intervals A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which of the following items is the priority for the nurse to have available in the client's room upon admission A. Obturator B. Hydrogen peroxide C. Sterile gloves D. Inner cannula - ANSWER-A.) Obturator The obturator can be inserted in the stoma in the even of dislodgment or decannulation to maintain an airway until a new trach tube can be placed. For the first 72 hr following the insertion of a trach, dislodgement or decannulation is considered an emergency A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2 days ago. Which of the following statements should the nurse use to assess how the client is coping with this change in their body image A. "Tell me how the changes to your leg make you feel" B. "What potential changes do you think you'll need to make when doing your job" C. "Let's discuss how you can adjust once you have a prosthesis" D. "What are some possible issues that you foresee when completing self-management tasks" - ANSWER-A .) "Tell me how the changes to your leg make you feel" A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a colonoscopy for colon cancer screening. Which of the following information should the nurse provide
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (select all that apply) A. Monitor peripheral pulses in the affected extremity B. Position weights against the foot of the bed C. Adjust the prescribed weights every 24 hrs D. Examine the skin under the traction bood E. Assess the temperature of the affected extremity - ANSWER-A, D, E -- A, closely monitor the neurovascular integrity. Circulation can be compromised from the fracture as well as the traction device D, monitor skin integrity at least every 8 hr E, Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure, paresthesia, and paralysis A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer's disease. Which of the following instructions should the nurse include in the teaching A. Lock doors leading to stairways B. Instruct the client not to use the stove C. Place a throw rug in front of the toilet D. Provide a darkened room for the client to sleep - ANSWER-A) Lock doors leading to stairways
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS This pt is at an increased risk for falls d/t difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan A. Keep the client's room dark and quiet B. Perform a vascular assessment for the client every 6 hr C. Maintain the head of the client's bed at 15 degrees at all times D. Place the client on contact precautions - ANSWER-A) Keep the client's room dark and quiet Meningitis often causes photophobia and phonophobia. Reduce stimuli A nurse is caring for a client who has a right subclavian central venous catheter. Which reconnecting a new intravenous infusion administration set, which of the following actions should the nurse take A. Ask the client to exhale slowly B. Turn the client's head to the right C. Place the client in a semi fowlers position D. use aseptic technique - ANSWER-D use aseptic technique aseptic= sterile prevents central line related blood infections when disconnecting and reconnecting the new set A nurse is educating an older adult client about immunizations. Which of the following immunizations should the nurse include in the recommendation for the client A. Recombinant herpes zoster B. Human papillomavirus C. Live attenuated influenza
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS B. 1/2 cup cooked navy beans C. 1/2 cup cooked asparagus D. 1/2 cup watermelon - ANSWER-B) 1/2 cup cooked navy beans navy beans contain 5g of fiber per 1/2 cup A nurse is providing teaching to a client who has venous insufficiency. Which of the following statements by the client indicates an understanding of the teaching A. "I will wear my graduated compression stockings while sleeping" B. "I will elevate my legs for 10 minutes 3 times per day" C. "I will limit the time I spend sitting down during the day" D. "I will cross my legs at my knees when sitting" - ANSWER-C) "I will limit the time I spend sitting down during the day" Avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis A nurse is providing teaching to a client who is undergoing radiation therapy and wants to go for a walk outside. Which of the following recommendations should the nurse include in the teaching? A. "Try to avoid sun exposure by waiting until after sunset to go outdoors" B. "Gently was the irradiated area to remove the markings before going outside" C. "Protect exposed skin with an over the counter sunscreen" D. "Wear form sitting clothing when going outside" - ANSWER-A) "Try to avoid sun exposure by waiting until after sunset to go outdoors" Protect the skin from exposure to sunlight during treatment and for 1 year after the last treatment. Stay in the shade, go outside in the early morning or evening to avoid the more intense sun rays to allow the pt to stay outside for a longer period
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS A nurse in an emergency department is monitoring a client who reports angina. Which of the following findings should indicate to the nurse that the client might have experienced a myocardial infarction (MI) A. Increased troponin B. Decreased creatinine kinase MB C. Cholesterol 300 mg/dL D. C- reactive protein 1.2 mg/dL - ANSWER-A ) Increased troponin Troponin is a myocardial muscle protein released into the blood stream as a result of injury to the heart muscle. Troponin levels increase within 2-3 hr following an MI A nurse is preparing to obtain blood cultures from a client's central venous catheter (CVC). Which of the following actions should the nurse take when accessing the catheter A. Flush the lumen with heparin solution before each use B. Aspirate for blood return prior to each use C. Perform a 5 second scrub to the catheter hub before accessing the catheter D. Apply firm pressure to the syringe plunger when flushing the lumen - ANSWER-B) Aspirate for blood return prior to each use A nurse on a medical surgical unit has received shift report for a group of clients. Which of the following interventions should the nurse plan to complete first A. Perform a dressing change on a client who is 24 hr postoperative following abdominal surgery and has sanguineous drainage on the dressing B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV antibiotics due in 30 minutes C. administer a prescribed opioid pain medication to a client who is reporting back pain as a 5 on a numeric pain scale of 0 to 10
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS B, distended neck veins indicates fluid overload in a pt with heart failure D, acute weight gain is the most reliable indicator of fluid volume overload in a client who has heart failure A nurse is teaching the caregiver of a client who has mild alzheimer's disease about progression of the disease. Which of the following should the nurse include as a manifestation of moderate alzheimer's disease A. Short term memory loss B. misplacement of household items C. Episodes of wandering D. loss of mobility - ANSWER-C) Episodes of wandering Wandering occurs in the moderate stage of AD A nurse is providing discharge teaching to a client who was admitted to the medical surgical unit due to heart failure. Which of the following statements by the client indicates an understanding of the teaching A. "I will limit my dietary sodium intake to 4 grams per day" B. "I should weigh myself once a week" C. "I plan to wait 2 hours after eating to take my walk" D. "I will take my diuretic before going to bed at night" - ANSWER-C To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in exercise -- A, limit sodium to 2 - 3g per day to prevent fluid retention in a heart healthy diet
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS B, weigh daily! Report a weight gain of more than 1.4kg (3lb) in 1 day or more than 2.3 kg (5lb) per week D, take diuretics in the morning to avoid having to get up during the night to void A nurse is reviewing the laboratory reports of a client who has cirrhosis. Which of the following results should the nurse report to the provider immediately A. BUN 22 mg/dL B. Sodium 134 mEq/L C. Platelet count 18,000 mm D. WBC 4,500 mm - ANSWER-C) Platelet count 18,000 mm The greatest risk to this client is injury from hemorrhage, and 18,000 is critically lower than the range of 150,000-400,000. A level <20,000 is a critical value representing thrombocytopenia and the potential for spontaneous bleeding A nurse is preparing to transfuse 1 unit of packed RBC to a client. Which of the following actions should the nurse take first A. Verify the label on the blood product with 2 client identifiers B. Check the client's medical record to verify the provider's prescription C. Flush the blood tubing with 0.9% sodium chloride D. Instruct the client to report itching or shortness of breath - ANSWER-B) Check the client's medical record to verify the provider's prescription The greatest risk to this client is injury from a transfusion reaction, so the first action is to check the medical record to verify the providers order. This reduces the risk for client injury form receiving incompatible packed RBCs A nurse is providing discharge teaching to a client who is postoperative following glaucoma surgery. Which of the following instructions should the nurse include to prevent increased intraocular pressure
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS phantom limb pain is a type of neuropathic pain resulting from damage to peripheral and central nervous system pathways. Gabapentin is an anticonvulsant medication that helps treat neuropathic pain A nurse is reviewing the laboratory findings for a client who has a urinary tract infection. Which of the following laboratory findings should the nurse identify as an indication the client is in the initial stages of systemic inflammatory response syndrome (SIRS)? A. WBC count 14,000/mm B. Platelets 110,000/ mm C. Lactic acid 19 mg/dL D. C reactive protein 2.8 mg/L - ANSWER-A. ) WBC count 14,000/mm WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms the body's defenses, resulting in a widespread inflammation. WBCs might increase initially, but depending on the bone marrow's ability to produce neutrophils and WBCs, the WBC count can become extremely low A nurse is caring for a client who is receiving brachytherapy. Which of the following actions should the nurse take? A. Limit visitation time to 2 hr per day, per visitor B. Wear a dosimeter film badge when caring for the client C. Open the door toe the client's room when visitors are present D. Double bag bed linens and remove them daily from the client's room - ANSWER-B ) Wear a dosimeter film badge when caring for the client the badge does not protect the nurse form the effects of radiation, it does record the amount of individual exposure to the radiation A nurse is panning care for a client who has been newly diagnosed with acute pancreatitis. Which of the following interventions should the nurse include in the plan of care A. Encourage liquid nutritional supplements
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS B. Administer opioid medications via a PCA C. Assess for signs of hypercalcemia D. Administer hypotonic IV fluids - ANSWER-B) Administer opioid medications via a PCA pain mangement is important in the care of a client who has pancreatitis. Clients are most often started on opioid medication via PCA in the early stages of pancreatitis to mange pain A nurse is reviewing the current laboratory findings for a client who has a pulmonary embolism and is receiving heparin therapy by continuous IV infusion. Which of the following prescriptions should the nurse anticipate for an aPTT of 110 seconds A. Increase the rate of the heparin infusion B. Stop the heparin infusion C. Administer vitamin K to the client D. Administer atropine to the client - ANSWER-B) Stop the heparin infusion Therapeutic range of aPTT for client on heparin is 1.5-2.5 times the normal value. A value greater than 2.5 times the expected reference range of 20 - 40 seconds is critical! If the aPTT is > 100 seconds, anticipate a prescription to stop or decrease the heparin infusion rate A nurse in the emergency department is caring for a client who has a traumatic brain injury (TBI). Which of the following assessment findings should the nurse recognize as a late manifestation of increased intracranial pressure (ICP) (select all that apply) A. Tachypnea B. Increased restlessness C. Bradycardia D. Asymmetric pupils E. Widened pulse pressure - ANSWER--Bradycardia
- Asymmetric pupils
- Widened pulse pressure
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS A BMI of 38.6 indicates the client is obese and is at a greater risk for developing DVT as a surgical complication A nurse is caring for a client who has neutropenia following cyclosporine therapy. Which of the following actions should the nurse take? A. Monitor the client's vital signs every 8 hr B. Keep a designated blood pressure cuff in the client's room C. Inspect the client's mucous membranes daily D. Avoid the use of alcohol based hand sanitizers prior to client care - ANSWER-B. Keep a designated blood pressure cuff in the client's room Designate equipment to keep in the client's room to limit exposing the equipment to micro- organisms from other clients. Patients with neutropenia have an increased risk for infection and sepsis due to a reduction in their leukocyte count A nurse is completing a preoperative assessment on a client who is scheduled for surgery in the morning. Which of the following findings should indicate to the nurse that the client is at risk for increased bleeding A. History of smoking B. Shellfish allergy C. Uses St John's wort D. Takes a garlic supplement - ANSWER-D. Takes a garlic supplement Garlic supplements increase the client's risk for bleeding due to garlic's ability to inhibit blood clotting by decreasing platelet aggregation A nurse is assessing a client who has a calcium level of 12.3 mg/dL. Which of the following findings should the nurse expect A. lethargy
ASSESSMENT 2 |ACTUAL LATEST STUDY | QUESTIONS AND ANSWERS B. muscle spasms C. positive chvostek's sign D. shortened P-R interval - ANSWER-A. lethargy 12.3 calcium indicates hypercalcemia (range is 9 - 10.5). A nurse in the ICU is caring for a client who is reporting heart palpitations. The nurse notes ventricular tachycardia on the ECG monitor. Which of the following actions should the nurse take A. Defibrillate the client B. Prepare the client for cardioversion C. Initiate CPR D. Administer digoxin - ANSWER-B. Prepare the client for cardioversion cardioversion is a synchronized countershock that uses a pulse to help convert vtach back to sinus rhythm for a client who is STABLE AND RESPONSIVE A nurse is providing discharge teaching to a client who has lithotripsy for calcium phosphate renal calculi. Which of the following instructions should the nurse give to the client A. Limit intake of animal protein to 6 oz per day B. Increase fluid intake to 1.5L/ day C. Expect pain in the kidneys and bladder D. Expect difficulty urinating for up to 1 week - ANSWER-A. Limit intake of animal protein to 6 oz per day To prevent further kidney stones, the client should limit animal protein intake to 5 servings per week. Animal protein contains purine, which produces uric acid that can accumulate as stones in the kidney
