Exam Review
- A nurse is caring for a postoperative patient receiving opioid analgesics for pain management. Which assessment would alert the nurse to contact the provider?A)Blood pressure of 104/72 mm Hg, pulse rate of 80, respiratory rate of 16B)Blood pressure of 110/60 mm Hg, pulse of 70, respiratory rate of 14C)Blood pressure of 90/50 mm Hg, pulse of 120, respiratory rate of 18D)Blood pressure of 120/80 mm Hg, pulse of 100, respiratory rate of 20
- A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?A)BradypneaB)HypotensionC)BradycardiaD)Increased urine output
- A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?A)Blood pressure of 84/50 mm HgB)ConfusionC)AnuriaD)Petechiae
- A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?A)Partial thickness skin loss with red tissue in wound bedB)Full thickness skin loss with visible boneC)Full thickness skin loss with visible adipose tissueD)Intact skin with localized non-blanchable redness
Exam Review
- A nurse is interviewing a preoperative patient scheduled for a total hip replacement. Which of the following failings would require the nurse to collaborate with the surgeon immediately before sending the patient to the operating room?A)The client took warfarin 2.5 mg with a sip of water at 6 a.m.B)The client took metoprolol 25 mg with a sip of water at 6 a.m.C)The client took phenytoin 100 mg with a sip of water at 6 a.m.D)The client took half their morning dose of insulin at 6 a.m.
- A nurse is caring for a client who developed a wound infection. Despite aggressive fluid resuscitation, the client has a blood pressure of 78/50 mm Hg and a heart rate of 136 beats per minute. The nurse contacts the provider. Which of the following orders does the nurse expect to receive from the provider?A)Start intravenous norepinephrine 0.1 mcg/kg/minB)Administer intravenous vancomycin 1 g every 12 hoursC)Administer intravenous furosemide 40 mgD)Start intravenous dopamine 5 mcg/kg/min
- A nurse is working on a surgical unit and is caring for a client who returned from the Post Anesthesia Care Unit (PACU) 90 minutes ago. Which interventions will decrease the client’s risk of developing a pulmonary embolism? (Select all that apply)(SATA)A)Encourage client to do active leg exercisesB)Maintain the head of the bed at 90 degreesC)Ambulate the client earlyD)Administer aspirin and warfarinE)Apply compression stockings
- A provider tells the nurse a client with a peptic ulcer is being placed on a proton pump inhibitor. Which medication would the nurse anticipate the provider ordering?A)OmeprazoleB)RanitidineC)SucralfateD)Metronidazole
Exam Review
- Which interventions can reduce the incidence of pressure injuries in hospitalized clients? (Select all that apply)(SATA)A)Frequent skin assessmentsB)Frequent turning and positioningC)Optimizing nutritionD)Maintaining the head of the bed at a 45-degree angleE)Inspect the sacrum for blanching
- A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?A)MethylprednisoloneB)EpinephrineC)DobutamineD)Furosemide
- The nurse is assessing a patient with peritonitis. What findings should they expect? (Select all that apply)(SATA)A)Frequent bowel movementsB)Rigid abdomenC)Decreased urinary outputD)Inability to pass stoolsE)Hyperactive bowel sounds
- 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?A)Blood pressureB)Heart rateC)Urine outputD)Weight
Exam Review
- A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?A)Provide a sputum specimen every 2 weeks to the clinic for testingB)Expect your sputum cultures to be negative after 6 months of therapyC)Drink at least 8 ounces of water when you take the pyrazinamide tabletD)Take isoniazid with an antacid
- You are caring for a patient with a positive TB skin test (15 mm), productive cough for two months, and unintentional weight loss. Which of the following orders will assist with the diagnosis of active tuberculosis? (Select all that apply)(SATA)A)Collect specimen three mornings for acid-fast bacilliB)Vital signs every shiftC)Complete blood count, basic metabolic panel, HIV viral load, VDRLD)Chest X-rayE)Admit to a negative pressure room
- An occupational health nurse provides monthly lunch and learn sessions to employees of a rail transportation manufacturer. This month, they are providing education on the risk factors for peptic ulcer disease. Which risk factors should the nurse include in the educational session?A)Six-month history of H. pylori infectionB)Eating spicy foods and laid-back lifestyleC)Active lifestyle and smokingD)Alcohol abuse and smoking
- A client is admitted with the diagnosis of Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?A)Impaired gas exchangeB)Activity intoleranceC)Imbalanced nutrition: less than body requirementsD)Impaired oral mucous membranes
Exam Review
- A client is admitted with the diagnosis of Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?A)Impaired gas exchangeB)Activity intoleranceC)Imbalanced nutrition: less than body requirementsD)Impaired oral mucous membranes
- Which interventions should the nurse implement to prevent a catheter-associated urinary tract infection (CAUTI)? (Select all that apply)(SATA)A)Flush catheter system dailyB)Obtain a urine specimen for culture every 24 hoursC)Secure the catheter to prevent movementD)Inspect urine for color, odor, and consistencyE)Maintain a closed drainage system
- A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication?A)Bone marrow suppressionB)Metabolic alkalosisC)HypoglycemiaD)Hyperkalemia
- A nurse is caring for a client who has a suspected myocardial infarction. Which of the following laboratory values is a strong indicator of massive cell destruction?A)Elevated troponinB)Decreased hemoglobinC)Elevated creatinineD)Decreased sodium