Comprehensive Exam 2 Questions With Answers for Nursing, Exams of Nursing

Download Comprehensive Exam 2 Questions With Answers for Nursing and more Exams Nursing in PDF only on Docsity! Comprehensive Exam 2 Questions With 100% Correct Answers 2024-2025 Updated Graded A+. 1. Which type of management style is a case management model for nursing care delivery? a. Patient focused and primary nursing. b. Clinically oriented and business oriented. c. Centralized and decentralized systems models. d. Clinical pathways and patient classifications - Exact answerA 2. The nurse is assessing a client with multiple trauma from a motorcycle crash who is being ventilated due to multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse monitor as an indicator of MODS progression? a. Cardiac function. b. Renal function. c. Hepatic function. d. Coagulation system. - Exact answerB 3. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? a. Dismiss the staff nurse's report about the float nurse because it may be just gossip. b. Call the nursing supervisor and request a different employee be sent to the unit. c. Assign the float nurse to function as an unlicensed assistive personnel (UAP) for the day. d. Arrange for someone to be available to assess and assist the float nurse. - Exact answerD 4. Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide? a. Give the toddler nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so the child is hungry at mealtimes. d. Explain to the child in a firm manner what is expected. - Exact answerA 5. Which action should the nurse implement when implementing a physical assessment of an older client? a. Avoid unnecessary touching while interacting with the client. b. Apply additional pressure to palpate the hepatic edge. c. Arrange the exam sequence to minimizes position changes. d. Speak loudly and slowly when telling the client how to assist. - Exact answerC 6. When culturing a wound, the nurse should obtain the sample from which part of the wound? a. The outer edges of the wound. b. All necrotic sections of the wound. c. Areas containing purulent or pooled exudates. d. Any particularly painful area of the wound. - Exact answerC 7. An adult male with a history of heart failure tells the nurse that his lower extremities and feet swell when he sits at his computer all day. Which response is best for the nurse to provide? a. Limit the amount of table salt that you add to your meals. b. Take a daily vitamin with minerals to correct imbalances. c. Get up and walk around frequently during the day. d. Elevate your feet every night to reduce swelling. - Exact answerC 8. A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU). What is the priority nursing action? a. Determine the client's pain. b. Take the client's vital signs. a. Goniometer. b. Wood's lamp. c. Reflex hammer. d. Transilluminator. - Exact answerC 18. Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)? a. Type 1 DM and a serum hemoglobin-A1c of 3.5%. b. Type 1 DM and retinopathy and mild vision loss. c. Type 2 DM and hypertension controlled by metoprolol. d. Type 2 DM and a history of morbid obesity for 5 years. - Exact answerB 19. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? a. Encourage the student to associate with non-smokers only while attempting to stop smoking. b. Tell the student that he is still young and should continue to try various smoking cessation methods. c. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. d. Provide the student with the latest research data describing the long- term effects of tobacco use. - Exact answerA 20. The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN? a. A client receiving Lactated Ringer's solution requests pain medication. b. A client with a history of falls needs assistance to the bathroom. c. A client's indwelling urinary catheter requires manual irrigation. d. A client with an epidural infusion reports lower extremity parasthesia. - Exact answerD 21. An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first? a. Counsel the girl regarding hygiene. b. Ask if she is going to the bathroom frequently. c. Teach the girl the importance of practicing safe sex. d. Encourage the girl to see the school counselor. - Exact answerB 22. A 6-year-old boy says he does not like the food at the hospital. A review of the child's intake reveals that he has eaten very little for the past 2 days. The nurse formulates a nursing problem of, "Imbalanced nutrition, less than body requirements." What action should the nurse implement? a. Select nutritious foods on the menu for the child. b. Provide the child with any snack foods between meals. c. Encourage family members to bring foods from home. d. Arrange the child's meal tray with generous portions of food. - Exact answerC 23. After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take? a. Replace the empty tank without reporting the situation to any members of the agency. b. Complete an adverse occurrence report and submit it to the nurse- manager. c. Send an anonymous letter explaining the situation to the family of the client. d. Advise the flight crew of the situation, then suggest that no further discussion be held. - Exact answerB 24. Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa? a. Improve the client's body perception. b. Consume at least 50% of all meals. c. Exercise no more than one hour daily. d. 5% decrease in serum potassium levels. - Exact answerB 25. Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis? a. Jaundice. b. Vomiting. c. Peripheral edema. d. Left upper quadrant pain. - Exact answerC 26. While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first? a. Unexplained weight gain. b. Current hair care practices. c. Family history of alopecia. d. Absence of axillary hair. - Exact answerB 27. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? a. Use an electronic sphygmomanometer to take the BP every 30 minutes. b. Retake the blood pressure in the same arm, deflating the cuff slowly. c. Ask another nurse to recheck the blood pressure to compare results. d. Obtain another blood pressure cuff and retake the blood pressure. - Exact answerB 28. Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder? a. Describes success in dismissing persistent thoughts that used be bothersome. b. Reports that the obsessions and compulsions experienced are silly. c. Avoids obsessive verbalizations while interacting with family and staff. d. Participates in one social or recreational activity each morning and afternoon. - Exact answerD 29. Which biological practices are federally regulated for healthcare workers? (Select all that apply.) d. A female client with angina and ectopy noted on the telemetry monitor. - Exact answerB 37. A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid replacement at 20 ml/kg. How many ml should the nurse administer? (Enter numeric value only.) - Exact answer400 38. The nurse calculates the mean arterial pressure (MAP) for a client whose blood pressure is 152/90. What is the MAP in mm Hg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - Exact answer111 39. A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement? a. Refer for further diagnostic evaluation. b. Determine exposure of others to the tuberculosis. c. Begin anti-tubercular drug therapy. d. Quarantine or isolate to control communicability. - Exact answerA 40. During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention should the nurse implement? a. Prepare a written schedule to remind the client when to take each dose of aspirin. b. Observe the client place each dose in the correct boxes of her pill container. c. Contact the client's healthcare provider to report the assessment findings. d. Ask a family member to ensure that the client takes the medication as prescribed. - Exact answerC 41. A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? (Enter numeric value only.) - Exact answer90 42. Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion of packed red blood cells? a. Skin turgor. b. Weight. c. Oxygen saturation. d. Vital signs. - Exact answerD 43. The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement? a. Prepare for intubation. b. Defibrillate at 200 joules. c. Insert intravenous catheter. d. Obtain arterial blood gases. - Exact answerB 44. When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? a. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. b. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption. c. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping. d. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. - Exact answerD 45. When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? a. Record these findings in the client's record. b. Observe closely for possible dehiscence. c. Notify the healthcare provider that the client's wound is producing a sanguineous drainage. d. Increase the IV fluid rate and encourage the client to eat more ice chips. - Exact answerA 46. When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement? a. Lower the extremity below the level of the client's heart. b. Gather the supplies needed to discontinue the IV fluid. c. Obtain an intravenous infusion pump to regulate the rate of infusion. d. Convert the IV to a saline lock until the healthcare provider is notified. - Exact answerB 47. An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids? a. Begin wearing the aids in quiet environments to experiment with adjustments. b. Wear the hearing aids for an hour a day at first, gradually increasing the time. c. Keep the volume on low until the conditions with noises are audible. d. Use one hearing aid until comfortable, then add the second aid. - Exact answerA 48. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? a. Place a sterile drape under the client's buttocks. b. Instruct the client to inhale and then exhale slowly. c. Discard the gloves and apply new sterile gloves. d. Apply a sterile lubricant to the end of the catheter. - Exact answerD 49. A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response? a. "You need to stop thinking negative thoughts. They get in the way of your recovery." b. "You are no bother to me or to the staff. We want you to get well and not feel sad anymore." a. Determination of the compatibility of the intravenous fluids and prescribed antibiotics. b. Provision of nursing staff education about safe administration of IV antibiotics. c. Maintenance of data related to the number of IV infiltration occurrences in the hospital. d. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. - Exact answerD 57. Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first? a. Assess the client's current oxygen saturation level. b. Auscultate the client's breath sounds bilaterally. c. Prepare to administer a dose of naloxone (Narcan) IV. d. Attempt to arouse the client to stimulate respirations. - Exact answerD 58. A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part of preoperative teaching, what information should the nurse provide? a. The transverse loop ostomy is permanent. b. Easily removable appliances allow independence in self-care. c. Daily irrigation is started after the J pouch heals. d. Stool is eventually expelled through the rectum. - Exact answerD 59. Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse implement? a. Avoid any intramuscular medications to prevent localized bleeding. b. Have vitamin K available in the event the client begins to bleed. c. Notify the healthcare provider if the partial thromboplastin time is greater than 50 seconds. d. Start instruction for self-administered SC heparin injections for long-term home therapy. - Exact answerA 60. A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? a. Obstruction at the urinary bladder neck. b. Ureteral calculi obstruction. c. Ureteropelvic junction stricture. d. Partial post-renal obstruction due to ureteral stricture. - Exact answerA 61. Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional? a. "I really wish that my birthday wasn't so soon." b. "I don't talk about things like that anymore." c. "The doctor won't talk with me about this." d. "I think I should talk about this in group." - Exact answerB 62. A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct? a. "An antibiotic ointment is placed in each newborn's eyes to prevent infection." b. "Conjunctivitis neonatorum is common in newborns." c. "This type of question should be discussed with your pediatrician." d. "Most infants have drainage from their eyes which usually resolves within 2 to 3 days of life." - Exact answerA 63. While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take? a. Notify respiratory therapy immediately for a PRN bronchodilator treatment. b. Obtain a prescription to increase the tidal volume setting on the ventilator. c. Stop mechanical ventilation and re-assess the client's lung sounds bilaterally. d. Suction the client's endotracheal tube and auscultate following suctioning. - Exact answerD 64. The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? a. An older man who is always happy and chooses to view only the good in every situation. b. A single mother who seeks the support of her two teenage daughters during difficult times. c. A successful businessman who is accustomed to handling highly- stressful situations. d. A teacher who seeks information about her disease and wants to continue teaching. - Exact answerD 65. A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of labor. The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction. What action should the nurse implement at this time? a. Discontinue the oxytocin (Pitocin) infusion. b. Notify the healthcare provider. c. Administer 10 L of oxygen via face mask. d. Place the client on her left side. - Exact answerD 66. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? a. Page the unit manager to address the situation. b. Close the demographic screen on the computer. c. Instruct the UAP to end the phone call immediately. d. Send a UAP into the client's room to relieve the nurse. - Exact answerB 75. A client who has been taking a diuretic and ACE inhibitor for hypertension has a blood pressure of 160/90. Today a new drug, carvedilol (Coreg), is prescribed, and the client expresses concern about receiving so many different medications. What action should the nurse implement? a. Explain the rationale for the administration of all three medications to the client. b. Withhold the newly prescribed medication until contacting the healthcare provider. c. Administer the newly prescribed medication and withhold the other two medications. d. Document the client's BP and refusal to take the newly prescribed medication. - Exact answerA 76. Which client requires the most immediate intervention by the nurse? a. A client with low back pain who is experiencing tolerance to the effects of an analgesic. b. An adolescent with a history of drug addiction who is requesting a sedative. c. A client with a chronic renal disease who is demonstrating a therapeutic response to a diuretic. d. A young adult who is reporting an anaphylactic response to an antibiotic. - Exact answerD 77. The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement? a. Limit visitors to immediate family to decrease exposure to infection. b. Maintain "clean" technique in the change of wound dressing and IV site. c. Assess and document skin condition around the incision and IV site at each shift. d. Require the use of a face mask by staff when providing care requiring close contact. - Exact answerC 78. A client at 26-weeks gestation comes to the labor and delivery unit and complains, "Something is not right". Which finding should the nurse assess further? a. Estriol is absent from the maternal saliva. b. The cervix is effacing and dilated to 2 cm. c. Fetal fibronectin is absent in vaginal secretions. d. Irregular mild uterine contractions occurring daily. - Exact answerB 79. A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's first action? a. Hyperextend the client's neck. b. Call for emergency assistance. c. Document the finding as a normal expectation. d. Reassure the client that the voice change is temporary. - Exact answerB 80. What is the underlying pathophysiologic process between free radicals and destruction of a cell memb rane? a. Inadequate mitochondrial ATP. b. Enzyme release from lysosomes. c. Defective chromosomes for protein. d. Defective integral membrane proteins. - Exact answerB 81. A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question? a. Morphine sulfate 5 mg IV on call to operating room. b. Atropine sulfate 0.4 mg IM on call to operating room. c. Betaxolol (Betoptic) one drop in each eye the morning of surgery. d. Benzodiazepine (Valium) 5 mg by mouth the morning of surgery. - Exact answerB 82. During the initial home visit, the nurse performs a family assessment. Which component is most important for the nurse to consider? a. The legal definition of family in the United States. b. Members of the group that are direct descendents or bonded by marriage. c. An exploration of the group relationships, structure, functions, and roles. d. Cultural differences among members of the extended family. - Exact answerC 83. The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow? a. Check the pilot balloon to ensure that it is firm. b. Verify the healthcare provider's prescription for the required cuff pressure. c. Use a manometer to maintain cuff pressure between 25 and 30 mmHg. d. Inject air until no air is auscultated over the larynx during a deep breath. - Exact answerD 84. A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first? a. Notify the healthcare provider. b. Stop the irrigation flow. c. Document the finding and continue to observe. d. Irrigate the catheter with a large piston syringe. - Exact answerB 85. The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding perianal care is effective? a. Soaks in a sitz bath for 40 minutes after each diarrhea stool. b. Takes prescribed antidiarrheal medication after each diarrhea stool. c. Applies witch hazel compresses to provide relief from anal irritation. d. Cleans perianal area with mild soap and water after each diarrhea stool. - Exact answerD 86. The nurse is assessing an older adult client's living arrangements and care. Which situation should the nurse identify as contributing the most to the client's vulnerability for elder abuse? a. The caregiver's stress level is overwhelming. (LMP) as February 14, what expected date of birth (EDB) should the nurse calculate? a. January 7. b. October 17. c. November 21. d. December 11. - Exact answerC 95. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? a. Use disposable plates and utensils. b. Stay in a room with the door closed. c. Dispose of soiled dressings in plastic bags that are securely closed. d. Others who are in the same room with the client should wear a mask. - Exact answerC 96. Which assessment is most important for the nurse to implement when performing a comprehensive assessment for an older adult? a. Chronic illnesses. b. Functional abilities. c. Immunologic function. d. Physical signs of aging. - Exact answerB 97. Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.) a. Economics. b. Workforce. c. Technology. d. Interventions. e. Socio-economic status. f. Legislation/regulation. - Exact answerA, C, F 98. A client who delivered a 9 pound 2 ounce infant 3 hours ago is experiencing uterine atony. Which action should the nurse implement first? a. Massage the fundus. b. Catheterize the bladder. c. Establish venous access. d. Prep for surgical intervention. - Exact answerA 99. A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? a. Place the client in mechanical restraints until calm. b. Administer a PRN dose of haloperidol (Haldol) IM. c. Use a calm, soothing voice to diffuse the situation. d. Encourage the client to focus on his feelings of anger. - Exact answerA 100. A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? a. Write the correct prescription as a verbal order received from the healthcare provider. b. Correct the misspelled medication in the written prescription and initial the change. c. Consult with the pharmacist to determine the best medication for the client. d. Contact the healthcare provider to clarify the prescription intended for the client. - Exact answerD 101. The nurse is preparing to perform oral care for an unconscious client. In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.) a. Place an emesis basin under the client's chin. b. Position the client in a flat side-lying position. c. Raise bed to a comfortable working height. d. Lower the side rail between the nurse and the client. - Exact answerC, D, B, A 102. Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)? a. An older client with intestinal obstruction and septic shock. b. A near-drowning victim with a history of respiratory arrest. c. An adolescent with an autoimmune disease. d. An adult male with a myocardial infarction and pericarditis. - Exact answerA 103. While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? a. Continue the interview process and record the findings. b. Refer the client to a psychiatric outpatient clinic. c. Determine if there is a family history of emotional disorders. d. Encourage the woman to attend citizenship classes. - Exact answerA 104. A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first? a. Flush the catheter to maintain patency of the CVC access. b. Describe the placement and rationale for care of the catheter. c. Reassure the client that the TPN administration is temporary. d. Provide passive range of motion to the right arm and neck. - Exact answerB 105. Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? a. African-American women who are 30 to 35 years of age. b. Survivors of violence that occurred at least 5 years ago. c. Active armed forces reserve unit returning from Europe. b. Early contact is essential for optimum parent-infant relationships. c. The time immediately after birth is the critical period for human attachment. d. Bonding is a process that occurs over time and begins with the first parent-newborn contact. - Exact answerD 114. The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first? a. Document the change in pulse rate on the graphics sheet. b. Review the client's medical history for cardiac problems. c. Reassess the rate and characteristics of the client's pulse. d. Ask the UAP to recheck the client's pulse in thirty minutes. - Exact answerC 115. A child with nephrotic syndrome is receiving prednisone (Deltasone). Which priority nursing diagnosis should the nurse include in the plan of care? a. Nausea. b. Risk for Infection. c. Risk for Bleeding. d. Disturbed Body Image. - Exact answerB 116. Which responsibility best describes the role of a nurse as manager? a. Development of long range career goals. b. Maintenance of harmony within the agency. c. Assignment of nursing personnel and resources. d. Delivery of client care while meeting agency goals. - Exact answerD 117. The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase a. blood pressure to 140/80. b. urine output to 55 ml/hr. c. pulse to 132 beats/min. d. respirations to 24 breaths/min. - Exact answerB 118. A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? a. History of alcohol intake. b. Time of last meal. c. Frequency of vomiting. d. Intensity of pain. - Exact answerD 119. A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated, if the need arises. How should the nurse respond? a. Nurses use their best judgment based on the client's condition. b. The healthcare team must honor the written wishes of the client. c. Notify the healthcare provider of the family's wishes, so a decision can be made. d. Every effort must be made to honor the family's wishes about their loved one. - Exact answerB 120. The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider? a. Sinus bradycardia at 50 beats per minute. b. Flaccid paralysis below the level of the injury. c. Systolic blood pressure 80 mm Hg after 2 fluid boluses. d. SpO2 is 88% with shallow, slow respirations. - Exact answerD 121. A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding? a. Deep tendon reflexes 1+. b. Blood pressure of 140/90. c. Respirations of 10. d. Urinary output of 130 ml in 4 hours. - Exact answerC 122. A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? a. Ask the parents to participate in encouraging the child's fluid intake. b. Tell the child he can go outside after he drinks a full glass of water. c. Offer the child a popsicle and allow him to pick the flavor he prefers. d. Make a game of seeing who can finish a glass of water first--the nurse or the child. - Exact answerC 123. Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure 135/90, temperature 97.6 F, pulse rate of 98 beats/minute, and respiratory rate 22 breaths/minute. The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching. What action should the nurse take? a. Notify the healthcare provider of the client's status. b. Assess vital signs q15 minutes until stable. c. Place the client in a vest-type restraining jacket. d. Encourage the client to take a warm bath to help relax. - Exact answerA 124. The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first? a. Counsel the UAP about the inaccurate blood pressure readings. b. Observe the UAP performing blood pressure measurements. c. Make staff members aware of the possible errors in blood pressure readings. d. Ask the education department to provide additional training for the UAP. - Exact answerB 125. After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O 2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next? a. Collect blood for hemoglobin and hematocrit.