NR 226 EXAM 1 2024 ACTUAL EXAM AND STUDY GUIDE 180 QUESTIONS WITH DETAILED VERIFIED ANSWE, Exams of Nursing

Download NR 226 EXAM 1 2024 ACTUAL EXAM AND STUDY GUIDE 180 QUESTIONS WITH DETAILED VERIFIED ANSWE and more Exams Nursing in PDF only on Docsity!

NR 226 EXAM 1 2024 ACTUAL EXAM AND STUDY GUIDE 180

QUESTIONS WITH DETAILED VERIFIED ANSWERS (100%

CORRECT) AND RATIONALES /A+ GRADE ASSURED

The RN is assessing a client who has hypercalcemia. Which of the following findings would the nurse expect? Select all that apply. A .Nausea and vomiting B. Confusion C. Hyperreflexia D. Numbness/tingling E. Pallor A. Nausea and vomiting B. Confusion The RN is reviewing lab values for a group of clients and notices a sodium level of 130 mEq/L. The nurse understands that which client is at highest risk for the development of this lab value? A. The client who is taking furosemide (a diuretic) B. The client who is in renal failure C. The client who takes a multi-vitamin D. The client who was admitted to hospice A. The client who is taking furosemide (a diuretic) The body's fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements shows an understanding of this mechanism? A. "The pituitary secretes aldosterone." B. "The kidneys secrete antidiuretic hormone." C. "The adrenal cortex secretes antidiuretic hormone." D. "The pituitary gland secretes antidiuretic hormone." D. "The pituitary gland secretes antidiuretic hormone." While reviewing a client's progress notes, the RN reads "insensible fluid loss of approximately 700 mL daily". The RN understands that this type of fluid loss can occur through: A. The GI tract B. Urine output C. Wound drainage D. The skin E. Emesis D. The skin

A senior student nurse delegates the task of intake and output to a new unlicensed assistive personnel (UAP). The student will verify that the UAP understands the task of I&O when the UAP states A. "I will record the amount of all voided urine." B. "I will not count liquid stools as output." C. "I will not record a café mocha as intake." D. "I will notate perspiration and record it as a small or large amount." A. "I will record the amount of all voided urine. " A nurse is inserting an IV line into a client's vein. After the initial stick the nurse continues to advance the catheter if the nurse notes that: A. The catheter advances easily B. Blood returns shows in the flashback chamber C. The vein is distended under the needle D. The client does not complain of discomfort B. Blood returns shows in the flashback chamber You are caring for a client who is depressed because the only child has gone away to college. The nurse will assess this type of depression as: A. actual loss B. perceived loss C. situational loss D. maturational loss D. maturational loss Which of the following is an example of disenfranchised grief? A. A newly-widowed individual does not want to remove her husband's clothes from the closet B. A teenage client dies from a car accident and the client's mother is crying loudly in the hospital hallway C. A client verbalizes being upset by voluntarily giving a newborn up for adoption D. A person is unwilling to discuss the loss of a child for several months after the death C. A client verbalizes being upset by voluntarily giving a newborn up for adoption A client has been told by the healthcare provider that remaining life expectancy is approximately 3 months. The client tells the immediate family that the doctor is incorrect and that he "will get better by my birthday in a month". Which stage of grieving is this client experiencing?

A. Acceptance B. Denial C. Depression D. Anger B. Denial Which of the following are appropriate in regard to postmortem care? Select all that apply. A. Provide privacy and time for the family to be with the deceased client. B. Maintain respect and dignity for the deceased client. C. Consider cultural preferences, state laws, and facility policies when providing care. D. Follow appropriate procedures related to organ donation. E. Allow for family to participate in care if requested and allowed per policy. All answers are correct As a first-year nursing student, you are assigned to care for a dying client. To best prepare you for this assignment, you will want to: A. complete a course on death and dying B. control your emotions about death and dying C. compare this experience to the death of a family member D. develop a personal understanding of your own feelings about grief and death D. develop a personal understanding of your own feelings about grief and death You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A. an increased appetite B. an increased heart rate C. a decrease in perspiration D. a decrease in respiratory rate B. an increased heart rate A client comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the client is depressed because of the loss of a job. This type of crisis can be classified as: A. maturational B. situational C. sociocultural D. posttraumatic

B. situational What is the best way to monitor fluid balance? Monitoring daily weight What is isotonic and when would we see this solution used? A solution with the same salt concentration as in cells 0.9% NS & Lactated Ringers (LR) What is hypotonic and when would we see this solution used? A solution that is diluted (makes the cell swell) Dextrose 5% in Water & 0.45% NS What is hypertonic and when would we see this solution used? A solution that is concentrated (makes the cell shrink) TPN, 3% NS, Dextrose 50% What is osmolality? A measure of the number of particles per kilogram of water What is the I&O calculation? Intake = Output 1L of fluid = 2.2 lbs = 1kg What is the normal lab value for acid base balance? normal pH is 7.35-7. What is an example of fluid overload? Hypervolemia (fluid volume excess) What are some manifestations of hypervolemia?

• Dyspnea (crackles or rhonchi)
• Change in vitals (Tachycardia/pnea, HYPERtension)
• JVD
• Edema
• Altered mental status/confusion What is an example of fluid deficit? Hypovolemia (dehydration) What are some manifestations of hypovolemia?

• Thirst/dry mucous membranes/poor skin turgor
• Change in vitals (Tachy, HYPOtension, fever)
• Flattened neck veins
• Weight loss
• Altered mental status/confusion What are some treatments for hypervolemia?
• Monitor fluid overload in lungs
• Restrict sodium/fluid intake
• Diuretics
• Monitor daily weight/I&O
• Patient education What are some treatments for hypovolemia?
• Monitor for hypovolemic shock
• Encourage PO fluids
• IV fluids
• Monitor daily weight/I&O
• Patient education What are some risk factors for fluid and electrolyte imbalances?
• Age
• Medical diagnosis
• Intake & Output imbalance
• Medications What is the electrolyte range for Hyponatremia? less than 136 What is the electrolyte range for Hypernatremia? more than 145 What is the electrolyte range for Hypokalemia? less than 3. What is the electrolyte range for Hyperkalemia? more than 5. What is the electrolyte range for Hypophosphatemia? less than 3. What is the electrolyte range for Hyperphosphatemia? more than 4.

What is the electrolyte range for Hypocalcemia? less than 9. What is the electrolyte range for Hypercalcemia? more than 10. What is the electrolyte range for Hypomagnesemia? less than 1. What is the electrolyte range for Hypermagnesemia? more than 2. How does Potassium effect an ECG? Causes a peaked T-wave (could lead to V-fib) Hyperkalemia What is the ABG interpretation method? ROME- Respiratory Opposite, Metabolic Equal What is the normal Respiratory PaCO2 level (ABG)? PaCO2= 35- 45 What is the normal Metabolic HCO3 level (ABG)? HCO3= 21- 28 What is General Adaptation Syndrome? A model of the body's stress response, consisting of three stages what are the 3 stages of the General Adaptation Syndrome?

• Alarm
• Resistance
• Exhaustion How does general adaptation syndrome affect the body? It causes stress on the body and if not resolved, it can cause to physical and mental harm to the body What is chronic stress? Occurs in stable conditions and results from stressful roles What is acute stress? Time-limited events that threaten a person for a brief period What is a crisis?

a sudden event in one's life, during which usual coping mechanisms cannot resolve the problem; the crisis disturbs homeostasis What is compassion fatigue and how can you combat it? A state of burnout and secondary traumatic stress. Can be overwhelming to healthcare providers and cause physical/mental/emotional health issues or emotional exhaustion What is PTSD? Begins when a person experiences or witnesses a traumatic event and responds with intense fear or helplessness What are the 5 types of grief?

• Normal (uncomplicated)
• Anticipatory
• Disenfranchised
• Ambiguous
• Complicated What is normal grief? Universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death What is anticipatory grief? Unconscious process of "letting go" before the actual loss/death occurs What is disenfranchised grief? Grief or mourning that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Situations in which this occur often relate to a socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption. What is ambiguous grief? Person is who lost is physically present but not psychologically available What is complicated grief? May take years, struggle through stages of grief, a prolonged or difficult time moving forward after a loss What are the stages of dying?
• Denial
• Anger
• Bargaining

• Depression
• Acceptance What factors influence loss and grief?
• human development
• personal relationships
• nature of the loss
• coping strategies
• socioeconomic status
• culture
• spiritual and religious beliefs A nurse is caring for a client whose partner passed away 4 months ago and has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction C. Alarm reaction A nurse is caring for a client who has left sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role conflict B. Role overload

C. Role ambiguity D. Role strain A. Role conflict A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply): A. Suggest coping skills for the client to use in this situation B. Allow the client to provide input in the treatment plan C. Assist the client with time management, and address the client's priorities. D. Provide extensive instructions on the client's treatment regimen E. Encourage the client in the expression of feelings and concerns B. Allow the client to provide input in the treatment plan C. Assist the client with time management, and address the client's priorities. E. Encourage the client in the expression of feelings and concerns We have an expert-written solution to this problem! A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting D. Convening a family meeting A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscles and promote hearing B. The client needs to be given privacy at all times for self-reflecting and organizing her life C. The client's sense of loss can be lessened through retaining control of certain areas of her life D. Performing ADLs is required prior to discharge from an acute facility C. The client's sense of loss can be lessened through retaining control of certain areas of her life A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if i Could just live long enough to attend my daughter's wedding." Based on Kubler-Ross' model, which

stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance C. Bargaining A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? A. "Would you like me to contact the chaplain to come speak to you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling." A. "Would you like me to contact the chaplain to come speak to you?" D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling." A nurse is caring for a client who has a terminal illness. Death is expected within 24hr. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone D. Decreased muscle tone A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following findings should the nurse include in this discussion? (Select all that apply): A. "I will remove the dentures from the body." B. "I will make sure the body is lying completely flat." C. "I will apply fresh linens and place a clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room C. "I will apply fresh linens and place a clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply): A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor C. Tachycardia D. Syncope E. Decreased skin turgor A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an overdose of sodium bicarbonate antacids A. A client who has nasogastric suctioning A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (Select all that apply): A. Hematocrit 55% B. Serum osmolarity 260 mOsm/kg C. Serum sodium 150 mEq/L D. Urine specific gravity 1. E. Serum creatinine 0.6 mg/dL A. Hematocrit 55% C. Serum sodium 150 mEq/L D. Urine specific gravity 1. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites B. A client who has heart failure

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 30 mL/hr D. Encourage independent ambulation four times a day B. Check the client's weight each morning A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene A. Infuse hypotonic IV fluids A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism A. Crohn's disease A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should anticipate which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage C. Initiating continuous cardiac monitoring A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply): A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting

B. Confusion D. Bone pain E. Nausea and vomiting A nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. The client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "You will receive magnesium in a series of intramuscular injections." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate who grains from your diet until your magnesium level increases." D. "You will have your deep-tendon reflexes monitored while you are receiving magnesium." D. "You will have your deep-tendon reflexes monitored while you are receiving magnesium." What organs compensate for respiratory imbalances? Kidneys Deep tendon reflexes will be absent with this electrolyte disorder Hyper magnesemia This test will be positive with hypo calcemia Chvosteks pH: 7. PaCO2: 46 HCO3: 28 Metabolic Alkalosis A solution more dilute than blood Hypo tonic ECV deficit and hyper natremia that occur at the same time Clinical dehydration Fluid with the same osmolality as blood Isotonic Decreased vascular volume Hypo volemia Abnormal accumulation of interstitial fluid Second spacing What system compensates for metabolic imbalances?

Respiratory system What is an example of second spacing? Edema An example of isotonic fluid Lactated Ringers or 0.9% NS This acid-base imbalance can occur with significant diarrhea Metabolic Acidosis pH: 7. PaCO2: 28 HCO3: 21 Respiratory Alkalosis Occurs when lungs are are unable to blow off enough CO Respiratory Acidosis Fluid accumulates in portion of the body (trapped) and unavailable for use Third spacing A solution more concentrated than blood Hyper tonic 2.2 lbs (1 kg) is equivalent to how many liters of fluid? 1 L A peaked T wave will be present on an EKG with this electrolyte imbalance Hyper kalemia An acid produced by the respiratory system Carbon dioxide (CO2) pH of 7. Acidosis What is an example of third spacing? Ascites A base produced and regulated by the kidneys Bicarbonate (HCO3)

Normal range is 135-145 for this electrolyte Sodium What electrolyte is important when mental status changes occur? Sodium Which should a nurse do to encourage a confused client to drink more fluid? A. Serve fluid at a tepid temperature B. Explain the reason for desired intake C. Offer the client something to drink every hour D. Leave a pitcher of water at the client's bedside. C. Offer the client something to drink every hour A nurse is caring for two clients; one has oliguria and the other has polyuria. Which is the priority problem that is a concern for the nurse regarding both of these clients? A. Diarrhea B. Cachexia C. Deficient Fluid Volume D. Impaired Skin Integrity C. Deficient Fluid Volume A client is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis; dry, sticky mucous membrane; weakness; disorientation; and a decreasing level of consciousness. Which electrolyte imbalance do these data support? A. Hyperkalemia B. Hypercalcemia C. Hypernatremia D. Hypermagnesemia C. Hypernatremia An assessment of which of the following is most important when a nurse is caring for an adult client experiencing vomiting? A. Electrolyte values B. Bowel function C. Body weight D. Oral Mucosa A. Electrolyte values A client receiving an enteral feeding develops diarrhea. Which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea?

A. Hypertonic B. Hypotonic C. Isotonic D. Icteric A. Hypertonic If a client receiving an infusion of magnesium presents with these signs and symptom, the infusion should be stopped because their magnesium levels are elevated. Which of the following indicates this electrolyte imbalance? A. Hyperactivity of the deep tendon reflexes B. Loss of deep tendon reflexes C. Seizures D. Muscle spasms B. Loss of deep tendon reflexes This IV solution will have the same osmolality of blood: A. 0.9 Normal Saline B. D5W C. D10W D. 0.45 Normal Saline A. 0.9 Normal Saline Which of the following acid-base imbalance is the following?PaCO2→ 55P H--> 7. HCO3→ 22 A. Respiratory Alkalosis B. Metabolic Acidosis C. Respiratory Acidosis D. Metabolic Alkalosis C. Respiratory Acidosis Which of the following acid-base imbalance is the following? PaCO2---> 36 PH---> 7. HCO3 ---> 30 A. Respiratory Alkalosis B. Metabolic Acidosis C. Respiratory Acidosis D. Metabolic Alkalosis

D. Metabolic Alkalosis Which of the following acid-base imbalance is the following?PaCO2→ 47 PH→ 7. HCO3→ 29 A. Respiratory Alkalosis B. Metabolic Acidosis C. Respiratory Acidosis D. Metabolic Alkalosis C. Respiratory Acidosis A client with a terminal illness tells the nurse, "I have lived a long life. I am ready to go." Which is the nurse's best response? A. Offer the client a back rub B. Sit quietly by the client's bedside C. Tell the family about the client's statement D. Discuss with the client how dying is part of the life cycle. B. Sit quietly by the client's bedside A man with a heart condition continues to perform strenuous sports against medical advice. Which defense mechanism does the nurse identify the client is using? A. Denial B. Repression C. Introjection D. Dissociation A. Denial Which statement by a dying client reflects Kubler Ross's stage of depression in the grief process? A. I am upset that I will not be here for my daughter's wedding B. I wrote a letter to be read by my daughter on the day of her wedding C. I just need to get a little stronger so I can go to my daughter's wedding D. I don't care if I die as long as I live long enough to see my daughter married A. I am upset that I will not be here for my daughter's wedding A 16 year old girl is upset due to not making the cheerleading team. What type of loss is she experiencing? A. Actual B. Maturational

C. Situational D. Perceived D. Perceived A terminally ill patient is talking to his family members in the hospital room. The family members are outwardly grieving. What type of grief is the family experiencing? A. Normal grief B. Anticipatory grief C. Disenfranchised grief D. Complicated grief B. Anticipatory grief A patient diagnosed with lung cancer states " If I stop smoking, then my lung cancer will start to ease up." What Kubler-Ross stage is being expressed? A. Denial B. Anger C. Bargaining D. Acceptance C. Bargaining A nurse identifies that a client's colostomy stoma is pale. Which should the nurse do? A. Notify the surgeon B. Listen for bowel sounds C. Wash the area with warm water D. Gently massage around the stoma A. Notify the surgeon A client is admitted with lower gastrointestinal tract bleeding. Which characteristic of the client's stool should the nurse assess for that supports this medical diagnosis? A. Tarry stool B. Orange stool C. Green mucoid stool D. Bright red-tinged stool D. Bright red-tinged stool A nurse is collecting a bowel elimination history from a newly admitted client with a medical diagnosis of possible bowel obstruction. Which question takes priority? A. Do you use anything to help you move your bowels? B. When was the last time you moved your bowels?

C. What color are your usual bowel movements? D. How often do you have a bowel movement? B. When was the last time you moved your bowels? A nurse performs a physical assessment of a newly admitted client who is incontinent of stool. For which characteristic related to bowel incontinence should the nurse assess the client? A. Frequent, soft stools B. Involuntary passage of stool C. Impaired anal sphincter control D. Greenish-yellow color to the stool B. Involuntary passage of stool What are somethings that should be monitoring acutely due to stressors on a patient who has been hospitalized? (Select-all-that-apply) A. Respiratory rate B. Elevated glucose C. Change in appetite D. Changes in GI system E. Wound healing A. Respiratory rate B. Elevated glucose C. Change in appetite D. Changes in GI system E. Wound healing When undergoing an elective surgery, it is essential that informed consent is attained. Which of the following actions should the nurse take regarding informed consent? (Select all that apply) A. Witness informed Consent B. Ensure that the client has no further questions regarding the procedure C. Explain the procedure to the client D. Explain the risk and benefits to the procedure E. Present the document to the patient to be signed. A. Witness informed Consent B. Ensure that the client has no further questions regarding the procedure A client is admitted to the post-anesthesia care unit. Which nursing action is most important during the client's stay in this unit? A. Monitoring urinary output B. Assessing level of consciousness

C. Ensuring patency of drainage tubes D. Suctioning mucus from respiratory passages D. Suctioning mucus from respiratory passages A client receiving conscious sedation during a colonoscopy. Which should the nurse expect regarding the client's experience with this procedure? A. Client will be unresponsive and pain free B. Client will be at risk for malignant hyperthermia C. Client will be sleepy but able to follow verbal commands D. Client will be positioned in the supine position to prevent headache. C. Client will be sleepy but able to follow verbal commands A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis? A. Utilization of compression stockings at night B. Deep breathing and coughing exercises daily C. Leg exercises 10 times per hour when awake D. Elevation of the legs on 2 pillows C. Leg exercises 10 times per hour when awake An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse be concerned about if exhibited by the client? A. Constipation B. Urinary Retention C. Shallow Breathing D. Inability to provide self-care C. Shallow Breathing A client arrives in the post-anesthesia care unit. Which is the most important information that the nurse needs to know? A. Anxiety level before surgery B. Type and extent of the surgery C. Type of intravenous fluids administered D. Special requests that were expressed by the client B. Type and extent of the surgery Which is the next most important assessment made by the nurse after ensuring a postoperative client has a patent airway? A. Condition of drains

B. Level of consciousness C. Stability of the vital signs D. Location of the surgical dressing C. Stability of the vital signs A nurse is to position a client in the post-anesthesia care unit. Which factor is most important for the nurse to consider? A. Allow for skeletal deformities B. Prevent pressure on bony prominences C. Provide for adequate thoracic expansion D. Avoid stretching of neuromuscular tissue. C. Provide for adequate thoracic expansion A postoperative client experiences tachycardia, sudden chest pain, and low blood pressure. Which complication associated with the postoperative period should the nurse conclude that the client most likely experience? A. Pulmonary embolism B. Hemorrhage C. Heart attack D. Pneumonia A. Pulmonary embolism nurse is caring for a client who is experiencing pain. For which common psychological response to pain should the nurse assess the client? A. Concerned about loss of control and independence B. Withdrawing from social interaction with others C. Asking for medication to provide for relief D. Experiencing nausea and vomiting A. Concerned about loss of control and independence A client requests pain medication for severe pain. Which should the nurse do first when responding to this client's request? A. Use distraction to minimize the client's perception of pain B. Place the client in the most comfortable position possible C. Administer pain medication to the client quickly D. Assess the various aspects of the client's pain. D. Assess the various aspects of the client's pain. A client has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this client?

A. Asking what is an acceptable level of pain B. Providing interventions that do not precipitate pain C. Focusing on pain management intervention before pain is excessive D. Determining the level of function that can be performed without pain C. Focusing on pain management intervention before pain is excessive Which concept should the nurse consider when assessing a client's pain? A. The expression of pain is not always congruent with the pain experienced B. Pain medication can significantly increase a client's pain tolerance C. The majority of cultures value the concept of suffering in silence D. Most people experience approximately the same pain tolerance A. The expression of pain is not always congruent with the pain experienced When assessing pain, if it is being described as stabbing or shooting, what part of the pain assessment does this correspond with? A. Intensity B. Quality C. Pattern D. Duration B. Quality A nurse is assessing a client in pain. Which word might the nurse use when documenting the pattern of a client's pain? A. Tenderness B. Moderate C. Episodic D. Phantom C. Episodic A nurse is assessing a client experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain? A. Self-focusing B. Sleep disturbances C. Guarding behaviors D. Variations in vital signs D. Variations in vital signs Sarah describes having 2/10 pain to the nurse. Before the nurse decides to implement pharmacological methods, she begins with non-pharmacological methods. Which of the following interventions are non-

pharmacological? (Select all that apply) A. Guided Imagery B. Herbal Analgesics C. Massage D. Transcutaneous Electrical Nerve Stimulation E. Biofeedback F. Distractions A. Guided Imagery C. Massage D. Transcutaneous Electrical Nerve Stimulation E. Biofeedback F. Distractions When removed on a pain medication, if the patient begins to demonstrate signs and symptoms of chills, shaking and sweating, what has the patient developed? A. Physical dependence B. Addiction C. Drug Tolerance D. Placebos A. Physical dependence When the nurse is assessing a client, the client states, "The pain moves from my chest down my left arm." Which characteristic of pain is associated with this statement? A. Pattern B. Duration C. Location D. Consistency C. Location A client presents to the hospital following a tornado. What type of crisis has the client experienced? A. Adventitious B. Situational C. Developmental D. Complicated A. Adventitious A mother with two children is trying to balance the care of her aging mother and work. What type of role is she experiencing? A. Role Strain

B. Role Overload C. Role Ambiguity D. Role Conflict B. Role Overload Two days ago, the grandfather of a client admitted to the hospital had lost his life in a car accident. Which of the following type of crisis is the client undergoing? A. Developmental Crisis B. Maturational Crisis C. Situational Crisis D. Adventitious Crisis C. Situational Crisis You are the nurse caring for a 72-year-old female who is recovering from abdominal surgery on the Medical Surgical unit. The surgery was very stressful and prolonged and you note on the chart that her blood sugars are elevated yet she in not been diagnosed with diabetes. To what do you attribute this elevation in blood sugars? A. It is a result of antidiuretic hormone B. She must have had diabetes prior to surgery C. She has become a diabetic from the abdominal surgery D. The blood sugars are probably a result of the "fight-or-flight" reaction. D. The blood sugars are probably a result of the "fight-or-flight" reaction. Which of the following is a physiological response experienced during the exhaustion stage of general adaptation syndrome? A. Increased mental alertness B. Vasoconstriction C. The initiation of neuroendocrine activity D. Decreased blood pressure D. Decreased blood pressure The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? A. Secondary stage B. Exhaustion stage C. Alarm stage D. Resistance stage B. Exhaustion stage

Which of the following nurses is most likely to experience the greatest amount of stress related to his or her position as a nurse? A. A graduate nurse working on a telemetry unit B. A nurse with 1 year of experience working on an oncology unit C. A nurse who is an editor of a nursing journal D. A nurse with 10 years of experience working as a nurse educator A. A graduate nurse working on a telemetry unit A mom is in distress as a result of her children leaving the home. What type of crisis is the mother experiencing? A. Developmental B. Situational C. Adventitious D. Perceived A. Developmental A graduate nurse who is going to start her first nursing job is feeling overwhelmed and uncertain. What type of role issue is she experiencing? A. Role Ambiguity B. Sick Role C. Role Conflict D. Role Strain A. Role Ambiguity When doing an assessment of a young woman who was in an automobile accident 6 months before, the nurse learns that the woman has vivid images of the crash whenever she hears a loud, sudden noise. The nurse recognizes this as: A. Acute Stress Disorder B. Anxiety Disorder C. Post-Traumatic Stress Disorder D. Hallucination C. Post-Traumatic Stress Disorder Which family member's comment about an older adult member of the family demonstrates ageism? (Select all that apply) A. She has outlived her usefulness B. She is elderly, but she is so cute C. She reads the newspaper with difficulty