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A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was a.) dysphagia b.) ¢.) dyspnea d.) weight loss A nurse is caring fora client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red- tinged urine. Which of the following transfusion reactions should the nurse suspect? a. Febrile b. Allergic c. Acute Pain d. Hemiolytié A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T- cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions? Select one or more: a. Gingivitis b. Caniisis c. Xerostomia d. Halitosis A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? Select one or more: a. b. c.Hyperthermia «Hypotension e, Weakend gag reflex f. Polyuria A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? Select one or mo A. b. c. Reposition the client from side to side every 2 hr. d, e. 6. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? Select one or more: question a. — c. Polydipsia d. Polyunia 6 7. A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored? Select one or more: a. b. Skin color c. Cardiac rhythm. d. Urine output 8. A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? Select one: a. Respiratory rate 18/min b, Straw-colored urine from an indwelling urinary catheter question c. d. Blood pressure 102/66 mm Hg 9. A nurse is caring fora client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Select one or more: a. Irrigate the catheter. b. Adjust the rate of the bladder irrigant. c. Notify the provider d. 10. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Select one: a. b. Wide QRS c. Elevated ST segment d. Inverted P wave 11. A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital A. Inform the client that privileges are related to participation in therapy B. Limit visiting hours until the client begins to participate in therapy C. Allow the client to control the timing and frequency of the therapy D. Establish a plan of care with client that sets attainable goals 17. 18. 19. 20. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. The medical management of the patient's condition is aimed toward cone: a. limiting fluids to minimize the possibility of congestive heart failure. bi canadian: ¢, administering vasodilator gubstances to increase blood flow to vital organs. d. discontinuing invasive monitoring as a possible cause of sepsis, A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? Select one: a. BP b. Urine output e. d. Weight A nurse enters a client's room and find the client on the floor having a seizure. Which of the ae a should the nurse take? Select one or more: a. b. Place the client back in bed. ce. Hold the client's arms and legs from moving. d. Insert a tongue blade in the client's mouth. A nurse is caring fora client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? Select one or more: a. Delay in disease progression b. Relief of depression c. Improved bladder function. a. Decreased tremors 21, 23. 24. 25. Av.nurse has been floated from the medical unit to the postpartum unit. Which client should be assigned to this nurse? Select one: a. b. The 8-hour postpartum client who has saturated 3 peri-pads in 1 hour. e. The 14-hour postpartum client who experienced eclampsia during delivery. d. The 23-hour postpartum client who is being discharged home this morning. . A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? Select one or more: a. b. c. d. Normal heart rate e. Vesicular breath sounds f. 8. A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? Select one or more: a. b, Monitor for an irregular heart rate ¢, Monitor for postural hypotension A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? Select one or more: a, Pertussis b. Respiratorysyncytial virus c de e. Pneumonia A nurse Is caring fora client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? Select one or more: a. b. c. Hepatomegaly d. Small hands ¢, Obtain a urine specimen, d. 32. A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction? question Select one: a. "Pursed-lip breathing will help relieve my shortness of breath.” b. "should rest before I eat." 0: d. "I should use my bronchodilator 30 minutes before I eat." 33. A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3. days. What is likely to happen to this patient? Select one: a. He could go into thyroid storm, b. He could go into adrenal crisis. cA d. Nothing: it is appropriate to stop the medication for 3 days. 34, A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client. Select one or more: a. displays compulsive and ritualistic behaviors b. refuses to leave home to see a provider. o. d. reminisces about the past. 35. A nurse has given a client with viral hepatitis instructions about home care. Which statement by the client indicates to the nurse that the client needs further teaching? Select one: a. "I need to rest during the day and get enough sleep at night." b."Lean't drink aleohol." c. d. "have to avoid having sex until the test for antibodies comes back negative.” a. Question 1 Correct ‘Mark 1.00 out of 1.00 Flag question Question text A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? Select one: Subarachnoid hemorrhages b. Ischemic stroke Ce Hemorrhagic stroke d, Intracerebral hemorrhages ry Feedback lechemisstrokeresalia feontd Jon of ised Aowes dig bein and for 80% to 859 of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (smal!- vessel thrombotic strokes), Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes), In 30% of the cases, the Sunes y eg cate tei eure enterica perigee sesh, hates ane enn Question text The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? Select one: . "Thave been drinking more water than usual." "| have experienced blurred vision on several occasions.” - "have to ns halfway = the stairs to catch my breath.” d. "Lhave been awakened by the need to urinate at night." b. Assess for bilateral breath sounds. c. Tape the tube securely in place. d. Assure the client that alternative communication means will be provided. Correct answer: Assess for bilateral breath sounds. ‘The first action by the nurse is to assess for bilateral breath sounds as an initial indication of confirm tube placement. Once the client's airway and breathing have been attended to, then the nurse can assure the client about alternative communication means. Question 5 Correct ‘Mark 1.00 out of 1.00 Flag question Question text An 8-year-old is being admitted in vaso-occlusive crisis, When creating the care plan, to which of the following actions should the nurse give priority? Select one: a. Replacing Factor VIII b. Evaluating the acid-base status and administering sodium bicarbonate as necessary c, Administering high concentration of oxygen to provide adequate oxygenation d. Assessing pain and administering pain medication as necessary fe a ; Correct answer: 3. a caaula a,g a agas cagt erase ieaciculanciina ane men idl. Nike taoc blac siget used ulemaeued te a ae occlusive crisis. Factor VIII replacement therapy is utilized with hemophilia. ‘The correct answer is: Assessing pain and administering pain medication as necessary Question 6 Correct ‘Mark 1.00 out of 1.00 Flag question Question text Aclient on bedrest for the past 48 hours secondary to a fractured femur presents with tachycardia and a petechial rash. ‘he nurse attributes these symptoms to a(n): Select one: a. Deep vein thrombosis (DVT). ‘b. Hypovolemic shock. c. Fat Emboli. ——— d. Allergic reaction to medication. Feedback Correct answer: 2 A fat embolus is a common complication following the fracture of a long bone. Symptoms of fat emboli include tachycardia, a petechial rash, and tachypnea. ‘The correct answer is: Fat Emboli. Question 7 Correct Mark 1.00 out of 1.00 Flag question Question text A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which substance does the nurse ensure is readily available? Select one: . Vitamin K . Potassium chloride Protamine sulfate aor gs . Calcium gluconate c Rationale; Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsia to help prevent seizures (eclampsia). [t also causes central nervous system depression, however, so toxicity is a concern. Calcium gluconate should be available at the bedside of a client receiving an intravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest if the serum magnesium level becomes too high. Vitamin K is the antidote for warfarin sodium (Coumadin), Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency. The correct answer is; Calcium gluconate Question B Incorrect Mark 0.00 out of 1.00 Flag question Question text Ans: A 72-year-old patient who needs teaching about the use of incentive spirometry Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted fora high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs dependent patient needs a nurse who is familiar with ventilator care. Both patients need experienced nurses. The correct answer is: A 72-year-old patient who needs teaching about the use of incentive spirometry Question 10 Incorrect Mark 0.00 out of 1.00 Flag question Question text A client with myasthenia gravis is taking neostigmine bromide. The nurse determines that the client is experiencing the intended therapeutic effect from the medication after noting: Select one: a. Improved swallowing function b. Decreased blood pressure c. Bradyeardia d. Increased heart rate Feedback Rationale: Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would monitor the client fora therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. Bradycardia, increased heart rate, and decreased blood pressure are signs of an adverse reaction to the medication. The correct answer is; Improved swallowing function Question 11 Correct Mark 1.00 out of 1.00 Flag question Question text The nurse is caring for a client with continuous ECG monitoring. The nurse observes that the client's rhythm has changed to ventricular fibrillation, After activating the emergency response system, the next best action by the nurse is to: Select one: a. Immediately defibrillate the client. b. Call the physician to report the change in rhythm. c. Administer intravenous lidocaine. d. Check the client's blood pressure. Feedback Correct answer: 4 ‘The rhythm shown in the figure is ventricular fibrillation. This is a cardiac emergency, and immediate defibrillation is the recommended response. Administration of intravenous lidocaine is recommended for ventricular tachycardia, Checking vital signs and calling the ‘The correct answer is: Immediately defibrillate the client. Question 12, Correct Mark 1.00 out of 1.00 Remove flag Question text The nurse in the labor and delivery department is caring for a client whose abdomen remains hard and rigid between contractions and the fetal heart rate is 100. Which client problem is priority? Select one: a. Alteration in comfort. b. Fluid and electrolyte imbalance. c. Ineffective breathing pattern. d, Risk for fetal death. ———— —————————————————————————————— Feedback ANSWER 1. Pain for the mother isa priority, but it is not priority over potential death of the fetus. 2. The client is not having trouble breathing; therefore, this would not be a priority problem. Altered gas exchange would be an appropriate problem for the fetus. 3. The client is exhibiting signs of abruptio placentae, and a decreased heart rate indicates a compromised fetus. This problem will lead quickly to the death of the ferus. Therefore, it is the priority problem. 4. All pregnant women experience an increase in fluid volume status and some resulting electrolyte imbalance; therefore, this is not a priority problem. The correct answer is: Risk for fetal death. Question 13 Correct ‘Mark 1.00 out of 1.00 Flag question FEI{: ie e Question text The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. Select one or more: a. Reposition the newborn every 2 hours. b. Monitor skin temperature closely. ¢. Expose all the newborn's skin. d. Avoid stimulation. e. Cover the newborn's eyes with eye shields or patches. f. Decrease fluid intake. Feedback 4,5,6 Rationale: Phototherapy (bili-light or bili-blanket), is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the after therapy is discontinued. hours., Cover the newborn's eyes with eye shields or patches. Question 16 Correct Mark 1.00 out of 1.00 Flag question Question text Which of the following actions taken by the nurse is specific to caring for a client with methicillin-resistant Staphylococcus aureus (MRSA)? Select one: a. Keeping the client's door closed b. — sai when it vital ia c. Wearing a mask when administering medications d. Instructing the client to wear a mask when being transported to other departments Feedback Correct answer: 3 Methicillin-resistant Staphylococcus aureus is transmitted by direct contact. Options 1, 2, and 4 are not appropriate because the microorganism is not transmitted by airborne or particulate droplets. Gloves (option 3) are necessary when providing nursing care. ‘The correct answer is: Wearing gloves when taking vital signs Question 17 Correct Mark 1.00 out of 1.00 Remove flag Question text When opening the airway of an unresponsive trauma patient in the emergency department, which of the following considerations is correct? Select one: a. Airway patency takes priority over cervical spine immobilization. b. Hyperextension of the neck is always recommended. c. Airway assessment must incorporate cervical spine immobilization. d. Flexion of the neck protects the patient from further injury. Feedback d. Bradycardia, hypotension, and respiratory acidosis. Feedback ANS: Tachycardia, mental status change, and low urine output (D) includes the earliest signs and symptoms of shock. Decreased tissue oxygenation in early shock first affects the brain, which is dependent on a high concentration of oxygen for optimum functioning. The earliest signs of shock include mental status changes accompanied by subtle cardiovascular compensatory mechanisms, including tachycardia, which increases blood flow to the organs, and reduces volume excretion through the kidneys, thereby conserving the body's circulatory volume. (A, B, and C) do not describe early symptoms of shock, although several of these symptoms occur in later stages of shock. ‘The correct answer is: Tachycardia, mental status change, and low urine output Question 20 Incorrect Mark 0.00 out of 1.00 Flag question Question text Aftera client experiences spontancous rupture of the membranes during labor, the nurse notes a visible prolapse of the umbilical cord. What intervention should the nurse implement immediately? Select one: a. Prepare the client fora cesarean delivery. b. Turn the client to a supine position. c, Push the presenting part off the cord. d. Administer ee bi face mask at 6 L/min. Feedback ANS: Push the presenting part off the cord. To assess functional ability, the nurse needs to observe the client's ability to perform tasks, such as meal preparation (A). (B,C, and D) all provide data relevant to the nursing diagnosis, but will not provide information about the client's ability to function. ‘The correct answer is: Push the presenting part off the cord. Question 21 Incorrect Mark 0.00 out of 1.00 Flag question Question text The nurse is caring for a patient with hemophilia A who is admitted with hemarthrosis. The nurse anticipates that which of the following will be a priority in therapeutic management of this patient? Select one: a. application of warm soaks for pain control b. administration of Vitamin K (phytonadione) 2 c, administration of aspirin as an analgesic d. immobilization of the affected joint Feedback (D); The nurse anticipates assisting with management of pain associated with the administration of analgesics (no aspirin because of its effects on coagulation). The correct answer is: immobilization of the affected joint Question 22 Incorrect ‘Mark 0.00 out of 1.00 Flag question Question text The nurse determines that the highest priority action when caring for a client who has alcohol-withdrawal delirium would be: Select one: a. Reality orientation. See b. Restraint application. c. Referral to Aleoholics Anonymous. d. Replacement of fluids and electrolytes Feedback maintain life. Fluid and electrolyte loss caused by nausea and vomiting can be a life- threatening condition during alcohol withdrawal, requiring replacement by intravenous therapy The correct answer is: Replacement of fluids and electrolytes Question 23 ‘Correct ‘Mark 1.00 out of 1.00 Flag question Question text 
