RN ADULT MEDICAL SURGICAL NURSING, Exams of Nursing

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A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following actions should the nurse take to promote client compliance? (SATA)

A. Ask the dietitian to assist with meal planning B. Contact the client's support system C. Assess for age-related cognitive awareness D. Encourage the use of a daily medication dispenser E. Provide educational materials for home use

A. Ask the dietitian to assist with meal planning B. Contact the client's support system D. Encourage the use of a daily medication dispenser E. Provide educational materials for home use

A nurse in a health care clinic is evaluating the level of wellness for clients using the illness-wellness continuum tool. The nurse should identify which of the following clients as being at the center of the continuum?

A. A college student who has influenza B. An older adult who has a new diagnosis of type 2 diabetes mellitus C. A new mother who has a urinary infection D. A young male who has a long history of well-controlled rheumatoid arthritis

D. A young male who has a long history of well-controlled rheumatoid arthritis

A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable? (SATA)

A. Smoking on social occasions B. BMI of 28 C. Alopecia D. Trisomy 21 E. History of reflux

A. Smoking on social occasions B. BMI of 28 E. History of reflux

A nurse is caring for a client who was just informed of a new diagnosis of breast cancer. The nurse evaluates the client's response. Which of the following statements by the client reflects a lack of understanding of an illness perspective?

A. "I have no family history of breast cancer." B. "I need a second opinion. There is no lump." C. "I am glad we live in the city near several large hospitals." D. "I will schedule surgery next week, over the holidays."

B. "I need a second opinion. There is no lump."

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients?

A. Client who has a pressure injury of the right heel whose blood glucose is 300 mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal pulse

B. Client who reports right calf pain and shortness of breath

A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (SATA)

A. Induce vomiting B. Instill activated charcoal C. Perform a gastric lavage with aspiration D. Administer syrup of ipecac E. Infuse IV fluids

B. Instill activated charcoal C. Perform a gastric lavage with aspiration E. Infuse IV fluids

A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (SATA)

A. Remove wet clothing B. Maintain normal room temperature C. Apply warm blankets D. Use a rapid rewarming water of 40º C (104º to 108º F) E. Infuse warmed IV fluids

A. Remove wet clothing C. Apply warm blankets D. Use a rapid rewarming water of 40º C (104º to 108º F) E. Infuse warmed IV fluids

A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway?

A. Head-tilt, chin-lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head

A. Head-tilt, chin-lift

A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency?

A. Perform defibrillation B. Prepare for transcutaneous pacing C. Administer IV epinephrine D. Elevate the client's lower extremities

C. Administer IV epinephrine

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (SATA)

A. Use the Glasgow Coma Scale when assessing the client B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake E. Instruct the client to perform deep breathing and coughing exercises

B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

A. Headache B. Infection C. Aphasia D. Hypertension

B. Infection

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document?

A. E2 + V3 + M5 = 10 B. E3 +. V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2+ M4 = 8

B. E3 + V4 + M4 = 11

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (SATA)

A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."

A. "I think I might be pregnant." B. "I take warfarin." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching?

A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure."

B. "Try to stay awake most of the night prior to the procedure."

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer?

A. Ketorolac B. Ketamine C. Meperidine D. Methadone

A. Ketorolac

A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain?

A. Phantom limb pain B. Mixed pain C. Breakthrough pain D. Neuropathic pain

C. Breakthrough pain

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device?

A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose

C. "I should tell the nurse if the pain doesn't stop after I use this device."

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include?

A. Most clients exaggerate their level of pain B. Pain must have an identifiable source to justify the use of opioids C. Objective data are essential in assessing pain D. Pain is whatever the client says it is

D. Pain is whatever the client says it is

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (SATA)

A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C. Bradypnea D. Orthostatic hypotension E. Nausea

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?

A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights

B. Implement droplet precautions

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (SATA)

A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend the client's head toward chest E. Straighten the client's flexed leg at the knee

A. Place client in supine position C. Place hands behind the client's neck D. Bend the client's head toward chest

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (SATA)

A. Implement seizure precautions B. Perform neurological checks four times a day C. Administer morphine for the report of neck and generalized pain D. Turn off room lights and television E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently

A. Implement seizure precautions D. Turn off room lights and television E. Monitor for impaired extraocular movements

A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include?

A. The vaccine is indicated to reduce the risk of respiratory infection B. The vaccine is administered in a series of four doses C. The vaccine is recommended for adolescents before starting college D. The vaccine is initially given at 2 months of age

C. The vaccine is recommended for adolescents before starting college

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (SATA)

A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment E. Keep the head of the bed flat

B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment

A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? (SATA)

A. Provide privacy B. Ease the client to the floor if standing C. More furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding F. Restrain the client

A. Provide pricacy B. Ease the client to the floor if standing C. More furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?

A. Keeping the client in a side-lying position B. Document the duration of the seizure C. Reorient the client to the environment D. Provide client hygiene

A. Keeping the client in a side-lying position

A nurse is proving discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include?

A. Consider taking an antacid when on this medication B. Watch for receding gums when taking the medication C. Take the medication at the same time every day D. Provide a urine sample to determine therapeutic levels of the medication

C. Take the medication at the same time every day

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (SATA)

A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet C. Limit looking at flashing lights D. Perform aerobic exercise E. Limit episodes of hypoventilation F. Use of aerosol hairspray is recommended

A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet C. Limit looking at flashing lights

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching?

A. "It is safe to use microwaves that are 1,200 watts or less." B. "You should avoid the use of CT scans with contrast." C. "You should place a magnet over the implantable device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain managem

C. "You should place a magnet over the implantable device when you feel an aura occurring."

A nurse is caring for a client who displays manifestations of stage III Parkinson's disease. Which of the following actions should the nurse include?

A. Recommend a community support group B. Integrate a daily exercise routine C. Provide a walker for ambulating D. Perform ADLs for the client

C. Provide a walker for ambulating

A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include? (SATA)

A. Provide three large balanced meals daily B. Record diet and fluid intake daily C. Document weight every other week D. Offer cold fluids such as milkshakes E. Offer nutritional supplements between meals

B. Record diet and fluid intake daily D. Offer cold fluids such as milkshakes E. Offer nutritional supplements between meals

A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include?

A. Rise slowly when standing B. Expect urine to become dark-colored C. Avoid foods containing tyramine D. Report any skin discoloration

A. Rise slowly when standing

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (SATA)

A. Decreased vision B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression

B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling F. Lack of facial expression

A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?

A. Teach the client to walk more quickly when ambulating B. Complete passive range-of-motion exercises daily C. Place the client on a low-protein, low-calorie diet D. Give the client extra time to perform activities

D. Give the client extra time to perform activities

A nurse is providing teaching to the partner of a client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching was effective?

A. "This medication should increase my husband's appetite." B. "This medication should help my husband sleep better." C. "This medication should help my husband's daily function." D. "This medication should increase my husband's energy level."

C. "This medication should help my husband's daily function."

A nurse working in a long-term care facility is planning care for a client who has moderate Alzheimer's (mild or moderate stage). Which of the following interventions should be included in the plan of care?

A. Use a gait belt for ambulation

B. Thicken all liquids C. Provide protective undergarments D. Reorient the client to self and current events

D. Reorient the client to self and current events

A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (SATA)

A. Remove floor rugs B. Have door locks that can be easily opened C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

A. Remove floor rugs C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe?

A. Keep the call light near the client B. Place the client in a room close to the nurses' station C. Encourage the client to ask for assistance D. Remind the client to walk with someone for support

B. Place the client in a room close to the nurses' station

A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurses's response? (SATA)

A. Exposure to metal waste products B. Long-term estrogen therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection

A. Exposure to metal wast products D. Previous head injury E. History of herpes infection

A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (SATA)

A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures

A. Increased intracranial pressure C. Hydrocephalus E. Seizures

A nurse is caring for a client who has just undergone a craniotomy for. A supratentorial tumor and has a respiratory rate of 12. Which of the following postoperative prescriptions should the nurse clarify with the provider?

A. Dexamethasone 30 mg IV bolus BID B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain C. Ondansetron 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin 100 mg IV bolus TID

B. Morphine sulfate 2 mg bolus PRN every 2 hr for pain

A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (SATA)

A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP 15 mm Hg E. Headache

A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils E. Headache

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (SATA)

A. "It is given to reduce swelling of the brain." B. "You will need to monitor for low blood sugar." C. "You might notice weight gain." D. "Tumor growth will be delayed." E. "It can cause you to retain fluids."

A. "It is given to reduce swelling of the brain." C. "You might notice weight gain." E. "It can cause you to retain fluids."

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if this same type of tumor can occur in other areas of the body. Which of the following responses should the nurse make?

A. "It can spread to breasts and kidneys." B. "It can develop in your gastrointestinal tract." C. "It is limited to brain tissue." D. "It probably started in another area of your body and spread to your brain."

C. "It is limited to brain tissue."

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this finding?

A. Stroke the lateral aspect of the sole of the foot B. Ask the client to blink both eyes C. Observe for facial drooping D. Have the client stand erect with eyes closed

D. Have the client stand erect with eyes closed

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids

B. Loss of cognitive function

A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (SATA)

A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia

A. Areas of paresthesia B. Involuntary eye movements E. Ataxia

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?

A. "This medication will help you with your tremors."

B. "This medication will help you with your bladder infection." C. "This medication can cause your skin to bruise easily." D. "This medication can cause you to experience dizziness."

D. "This medication can cause you to experience dizziness."

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods?

A. Baked salmon B. Salted cashews C. Frozen strawberries D. Fresh asparagus

B. Salted cashews

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching?

A. "This medication will relieve my symptoms by causing my blood vessels to dilate." B. "I should take this medication daily to prevent the headache from occurring." C. "I should expect facial flushing when I take this medication." D. "This medication will lower my sensitivity to food

C. "I should expect facial flushing when I take this medication."

A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (SATA)

A. Pain in bilateral across the posterior occipital area B. Client experiences altered sleep-wake cycle C. Headache occurs approximately 1 to 8 times daily D. Client describes headache pain as dull and throbbing E. Nasal congestion and drainage occur

B. Client experiences altered sleep-wake cycle C. Headache occurs approximately 1 to 8 times daily E. Nasal congestion and drainage occur

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include?

A. Use music therapy for relaxation with the onset of the headache B. Increase physical activity when a headache is present C. Drink beverages that contain artificial sweeteners to prevent headaches D. Apply a cool cloth to the face during a headache

D. Apply a cool cloth to the face during a headache

A nurse is obtaining a health history from a client who is being evaluate for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine headaches?

A. "Do the headaches occur multiple times each day." B. "Is your headache accompanied by profuse facial sweating?" C. "Does your headache occur on one side of your head?" D. "Do you have the same manifestations each time the headache occurs."

D. "Do you have the same manifestations each time the headache occurs."

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases?

A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

B. Open-angle glaucoma

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching?

A. "You can resume playing golf in 2 days." B. "You need to tilt your head back when washing your hair." C. "You can get water in your eyes in 1 day." D. "You need to limit your housekeeping activities."

D. "You need to limit your housekeeping activities."

A nurse is caring for a male older adult client who has a new diagnosis o glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (SATA)

A. Sex B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (SATA)

A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

C. Blurred vision D. White pupils

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching?

A. Increase intake of deep yellow and orange vegetables B. Administer eye drops twice daily C. Avoid bending at the waist D. Wear an eye patch at night

A. Increase intake of deep yellow and orange vegetables

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding?

A. Pearly gray tympanic membrane (TM) B. Malleus visible behind the TM C. Presence of soft Cerumen in the external canal D. Fluid or bubbles seen behind the TM

D. Fluid or bubbles seen behind the TM

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (SATA)

A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine

A. Enlarged adenoids B. Report of recent colds

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (SATA)

A. Reduce exposure to bright lightning B. Move head slowly when changing positions C. Do not eat fruit high in potassium D. Plan evenly-spaced daily fluid intake E. Avoid fluids containing caffeine

A. Reduce exposure to bright lightning B. Move head slowly when changing positions D. Plan evenly-spaced daily fluid intake

A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding?

A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss

D. Unilateral hearing loss

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching?

A. "I should restrict rapid movements and avoid bending from the waist for several weeks." B. "I should wait until the day after surgery to wash my hair." C. "I will remove the dressing behind my ear in 7 days." D. "My hearing should be back to normal right after my surgery."

A. "I should restrict rapid movements and avoid bending from the waist for several weeks."

A nurse caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time?

A. Keep neck stabilized B. Insert nasogastric tube C. Monitor pulse and blood pressure frequently D. Establish IV access and start fluid replacement

A. Keep neck stabilized

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment?

A. Glasgow Coma Scale B. Cranial nerve function

C. Oxygen saturation D. Pupillary responses

C. Oxygen saturation

A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (SATA)

A. Suction the endotracheal tube frequently B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows D. Administer a stool softener E. Keep the client well hydrated

B. Decrease the noise level in the client's room D. Administer a stool softener

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (SATA)

A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. Headache B. Dilated pupils D. Decorticate posturing

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?

A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

B. Hyponatremia

A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (SATA)

A. Impulse control B. Moving the left side C. Depth perception

D. Speaking E. Situational awareness

A. Impulse control B. Moving the left side C. Depth perception E. Situational awareness

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

A. Teach the client to scan to the right to see objects on the right side of the body B. Place the bedside table on the right side of the bed C. Orient the client to the food on the plate using the clock method D. Place the wheelchair on the client's left side

B. Place the bedside table on the right side of the bed

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (SATA)

A. Have suction equipment available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth D. Assign an assistive personnel to feed the client slowly E. Teach the client to swallow with the neck flexed

A. Have suction equipment available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth E. Teach the client to swallow with the neck flexed

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (SATA)

A. Speak to the client at a slower rate B. Assist the client to use cards with pictures C. Speak to the client in a loud voice D. Complete sentences that the client cannot finish E. Give instructions one step at a time

A. Speak to the client at a slower rate B. Assist the client to use cards with pictures E. Give instructions one step at a time

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke?

A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception

C. Inability to recognize familiar objects

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurses's highest priority?

A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. Prevention of further damage to the spinal cord

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first?

A. Examine skin for irritation or pressure B. Sit the client upright in bed C. Check the urinary catheter for blockage D. Administer antihypertensive medication

B. Sit the client upright in bed

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greater risk for which of the following complications?

A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

D. Respiratory compromise

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider?

A. Anticoagulant B. Plasma expanders C. H2 antagonists D. Muscle relaxants

D. Muscle relaxants

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods?

A. Condom catheter B. Intermittent urinary catheterization C. Crede's method D. Indwelling urinary catheter

A. Condom catheter

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?

A. Position the client in an upright position, leaning over the bedside table B. Explain the procedure C. Obtain ABGs D. Administer benzocaine spray

A. Position the client in an upright position, leaning over the bedside table

A nurse at a provider's office is reviewing information with a client scheduled for pulmonary function tests (PFTs). Which of the following information should the nurse include?

A. "Do not use inhaler medications for 6 hr following the test." B. "Do not smoke tobacco for 6 to 8 hr prior to the test." C. "You will be asked to bear down and hold your breath during the test." D. "The arterial blood flow to your hand will be evaluated as part of the test."

B. "Do not smoke tobacco for 6 to 8 hr prior to the test."

A nurse is assessing a client following a bronchoscope. Which of the following findings should the nurse report to the provider?

A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms

D. Bronchospasms

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (SATA)

A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit

A. Oxygen equipment C. Pulse oximeter D. Sterile dressing

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risk for complications? (SATA)

A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site

A. Dyspnea C. Fever D. Hypotension

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (SATA)

A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing

A. Oxygen B. Sterile water C. Enclosed hemostat clamps E. Occlusive dressing

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?

A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess respiratory status

B. Apply sterile gauze to the insertion site

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (SATA)

A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

D Exposed sutures without dressing E. Drainage system upright at chest level

B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take?

A. Instruct the client to lie prone with arms by the sides B. Complete a surgical checklist on the client C. Remind the client that there is minimal discomfort during the removal process D. Place on occlusive dressing over the site once the tube is removed

D. Place an occlusive dressing over the site once the tube is removed

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (SATA)

A. Encourage the client to cough and deep breathe B. Check for continuous bubbling in the suction chamber C. Strip the drainage tubing every 4 hr D. Clamp the tube once a day E. Obtain a chest x-ray

A. Encourage the client to cough and deep breathe B. Check for continuous bubbling in the suction chamber E. Obtain a chest x-ray

A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV?

A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."

B. "It allows preset pressure delivered during spontaneous ventilation."

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (SATA)

A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B. Pale skin E. Elevated blood pressure

A nurse is caring for a client who has Dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?

A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

B. Venturi mask

A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? (SATA)

A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (SATA)

A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving mechanical ventilation F. Client who has myasthenia gravies

A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving mechanical ventilation F. Client who has myasthenia gravis

A nurse is caring for a client who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?

A. Obtain baseline vital signs and oxygen saturation B. Obtain a sputum culture

C. Obtain a complete history from the client D. Provide a pneumococcal vaccine

A. Obtain baseline vital signs and oxygen saturation

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8º C (100º F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions.

A. Administer antibiotics B. Administer oxygen therapy C. Perform a sputum culture D. Instruct the client to obtain a yearly influenza vaccination

B. Administer oxygen therapy C. Perform sputum culture A. Administer antibiotics D. Instruct the client to obtain a yearly influenza vaccination

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder?

A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjuctiva D. Palpation of the orbital areas

D. Palpitation of the orbital areas

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?

A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flu strains." D. "I should cover my mouth with my hand when I sneeze."

A. "I should wash my hands after blowing my nose to prevent spreading the virus."

A nurse in the emergency department is caring for a client who is experiencing an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (SATA)

A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Tachycardia

B. Wheezing C. Retraction of sternal muscles E. Tachycardia

A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer?

A. Antibiotic B. Beta-blocker C. Antiviral D. Beta2 agonist

D. Beta2 agonist

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates understanding?

A. "I will decrease my fluid intake while taking this medication." B. "I will expect to have black, tarry stools." C. "I will take my medication with meals." D. "I will monitor for weight loss while on this medication."

C. "I will take my medication with meals."

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma?

A. Sex B. Environmental allergies C. Alcohol use D. History of diabetes

B. Environmental allergies

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates understanding?

A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms."

B. "I take this medication to prevent asthma attacks."

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching?