Nurse Moose
    Sign In
    Review ModeExam ModePractice Mode

    Exam Review

    1. Which assessment would the nurse perform specific to the safe administration of intravenous mannitol?
      A)Urine output every 12 hours
      B)Neurological checks every 12 hours
      C)Daily weights.
      D)Vital Signs Hourly.
    2. A client has clear fluid leaking from the nose followed a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid (CSF) is present?
      A)Fluid is turbid and is positive for leukocytes
      B)Fluid separates into concentric rings and is positive for glucose
      C)Fluid is clear and tests positive for nitrates
      D)Fluid is sero-sanguinous and has a low pH of 6
    3. The nurse has just received shift report. Which client will the nurse assess first?
      A)The client with Guillain-Barre Syndrome who has ascending paralysis to the knees
      B)The client with Multiple Sclerosis who is scheduled physical therapy
      C)The client with a C-6 spinal cord injury whose foley catheter is not draining
      D)The client with Amyotrophic Lateral Sclerosis who is experiencing spasticity of the lower extremities
    4. A nurse assesses a client who experienced a spinal cord injury at the T5 level 20 minutes ago. Which assessment finding would the nurse correlate with neurogenic shock?
      A)Blood pressure 90/56
      B)Blood pressure 175/96
      C)Heart rate 34
      D)Heart rate 112
    Page 1 of 5

    Exam Review

    1. Which assessment findings would the nurse expect to find in a client diagnosed with amyotrophic lateral sclerosis (ALS)? Select all that apply.(SATA)
      A)Progressive muscle weakness
      B)Loss of central vision
      C)Mask-like face
      D)Cognitive decline
      E)Dysphagia
      F)Fatigue
    2. The nurse is assessing vital signs for a client on the neurological unit. Which set of vital signs is indicative of Cushing's triad?
      A)T: 99.6 P: 60 R: 14 BP: 166/58
      B)T: 97.9 P: 120 R: 24 BP: 160/100
      C)T: 98.6 P: 88 R: 18 BP: 130/64
      D)T: 98.7 P: 112 R: 20 BP: 148/78
    3. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse anticipate for the client? Select all that apply.(SATA)
      A)Maintain the client in a supine, flat position
      B)Maintain nothing by mouth status
      C)Monitor blood glucose levels
      D)Give intravenous medication as prescribed for pain
      E)Encourage coughing and deep breathing
      F)Give small, frequent high-calorie meals
    4. A client with a spinal cord injury at the T12 level is admitted to the rehabilitation unit one month post injury. Which intervention would the nurse include in the client's plan of care?
      A)Maintain head of bed in semi-Fowler's position
      B)Monitor blood pressure for neurogenic shock
      C)Calculate cerebral perfusion pressure every shift
      D)Reposition every two hours to prevent pressure injury
    Page 2 of 5

    Exam Review

    1. The nurse is caring for a client with peritonitis. Which collaborative interventions would the nurse anticipate? Select all that apply.(SATA)
      A)Intravenous fluids.
      B)Supine positioning.
      C)Nasogastric tube (NGT) to suction.
      D)Nothing by mouth (NPO) status.
      E)IV analgesic medications.
      F)Oral antibiotics.
    2. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease. Which statement made by the client indicates a need for further instruction?
      A)I can have exacerbations and remissions with Crohn's disease
      B)I will increase the fiber in my diet
      C)I'm going to learn some stress reduction techniques
      D)I will need to avoid caffeinated beverages
    3. A nurse is calculating the client's net fluid balance at the end of the 8 hour shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in the drainage container and 25 mL was emptied out of the Jackson-Pratt drainage tube. The patient is receiving 1/2 NS at 100 mL/hr. How many mL would the nurse record as the client's net fluid balance for this shift? Round to the nearest whole number. Record numeric answers only. Enter a + prior to the value if the value is positive, Enter a - prior to the answer if the value is negative.
    4. The nurse planning care for a client with a halo fixator. Which intervention would the nurse include in the plan of care for this client?
      A)Loosen the pins while sleeping
      B)Assess for bladder distention
      C)Remove the vest for client bathing
      D)Assess the pin sites for signs of infection
    Page 3 of 5

    Exam Review

    1. The nurse is assisting a neurologist conducting a Tensilon test with Edrophonium. Which antidote will the nurse ensure is available in case of an emergency?
      A)Glucagon
      B)Epinephrine
      C)Naloxone
      D)Atropine
    2. The nurse is caring for a 31 year old client admitted to the acute care unit. Complete the diagram by selecting from the choices below to specify what potential condition the client is likely experiencing. Select two nursing actions that are appropriate to take, and two clinical parameters to determine the effectiveness of the nursing actions.
      ✓Restrict free water intake
      ✓Administer hypertonic saline as prescribed
      ✓Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
      ✓Serum sodium level
      ✓Urine output and specific gravity
      Actions To Take
      ✓Restrict free water intake
      ✕Continue hypotonic IV fluids (5% D/0.45% NS)
      ✓Administer hypertonic saline as prescribed
      ✕Initiate seizure precautions
      ✕Encourage oral fluid intake aggressively
      Potential Condition
      ✕Neurogenic shock
      ✕Heat stroke
      ✓Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
      ✕Septic shock
      Parameters to Monitor
      ✓Serum sodium level
      ✓Urine output and specific gravity
      ✕Blood glucose level
      ✕Deep tendon reflexes
      ✕Serum calcium level
    3. The client is admitted to the hospital with a diagnosis of Guillain-Barre Syndrome (GBS). Which past medical event makes the client most at risk for the disease?
      A)Meningitis within the last five years
      B)Vaccine received during the previous month
      C)Seizures within the last year
      D)Spinal cord injury two years ago
    4. The nurse is caring for a client who is 24 hours postoperative for a craniotomy to remove a brain tumor. In what position would it be important for the nurse to maintain the client?
      A)Flat with blocks under the head of the bed
      B)On their back with the head of the bed elevated 35 degrees
      C)Prone with the head of the bed in Trendelenburg
      D)Lateral with pillows under the arms and knees
    Page 4 of 5

    Exam Review

    1. Which IV site is most appropriate for a client who is ordered to receive total parental nutrition?
      A)A
      B)B
      C)C
      D)D
    2. The client was admitted to the medical-surgical unit 24 hours ago with a diagnosis of an acute exacerbation of ulcerative colitis. What is the most appropriate intervention for the nurse to implement?
      A)Maintain nothing by mouth status
      B)Provide a low-residue diet
      C)Administer antacids orally
      D)Assess the client's vital signs daily
    3. The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions?
      A)I will be careful because the device alters balance
      B)I will carefully wash the skin under the brace daily
      C)I will use a straw when I drink
      D)I will drive only during the daytime
    4. The nurse is caring for a client diagnosed with acute pancreatitis experiencing abdominal pain. What order would be the most appropriate?
      A)Apply a transdermal fentanyl patch every 12 hours
      B)Administer intravenous hydromorphone using a patient-controlled analgesic (PCA)
      C)Administer intravenous push (IVP) morphine every 6 hours
      D)Administer oral oxycodone every 4-6 hours with food
    Page 5 of 5