Exam Review

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)(SATA)
A)Send blood for a complete blood count, electrolytes
B)Enalapril 10 mg every morning
C)C Ibuprofen 400 mg every 4 to 6 hours PRN for temperature greater than 100.5°F (38° C)
D)Admit to the medical floor
E)Supplemental oxygen 10 L/min via nasal cannula
F)Vital signs every 4 hours
G)Continuous pulse oximetry
H)Chest x-ray
Patient Data Exhibits What should the nurse do before applying the face mask? Select that apply.(SATA)
A)Perform hand hygiene
B)Identify the client using Z client identifiers
C)Determine if the client needs to go to the bathroom
D)Check the skin around the face
E)Don gloves
F)Brush the client's teeth
G)Assess respiratory function
Patient Data Exhibits According to the client's vital signs, he is experiencing ▾ Tachypnea and ▾ Tachycardia
Dropdown 1:
Option 1: Eupnea
Option 2: Hypothermia
Option 3: Bradycardia
Option 4: Tachypnea
Option 5: Hyperthermia
Dropdown 2:
Option 1: Bradycardia
Option 2: Tachycardia
Option 3: Arrhythmia
Option 4: Hypertension
Option 5: Atrial Fibrillation
Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.(SATA)
A)Avoid treating fever with antipyretics
B)Encourage the client to take breaks from the oxygen mask every few hours
C)Providing suctioning so the client does not have to cough
D)Assist the client in ambulating safely
E)Asking the client do quick, shallow breaths
F)Positioning the client with the head of the bed elevated
G)Teaching the client to cough at least once an hour

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Exam Review

Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

	Effective	Ineffective
Rhonchi in the right lung		✓
Symmetric chest expansion	✓
Oxygen saturation greater than 949%	✓
PaCO2 55 mm Hg on a blood gas		✓
Client ambulates without shortness of breath	✓
Diminished breath sounds in the right lung		✓

Patient Data Exhibits Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?
A)Palpate the lymph nodes.
B)Observe the client's fingers.
C)Palpate large joints for nodules.
D)Observe the skin for lesions.
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?
A)Observe pupil response of the right eye.
B)Turn, cough, and deep breathe every 2 hours.
C)Sleep flat in a supine position.
D)Administer a stool softener.
A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?
A)Hematemesis
B)Brown, foarmy urine.
C)Clay-colored stool.
D)Anorexia.

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Exam Review

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?
A)Prevent esophageal reflux.
B)Increase intestinal peristalsis.
C)Promote effective swallowing.
D)Maintain intact oral mucosa.
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
A)Topical analgesics.
B)Topical corticosteroids.
C)Topical antifungal.
D)Colloidal oatmeal-based lotion.
The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)
A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the lies of the tracheostomy tube, which action is most important for the nurse to take?
A)Secure tracheostomy ties by making knots close to the tube.
B)Leave the old ties in place until the new ones are secure.
C)Remove ties to secure a disposable, soft foam collar with self-adhesive fastening.
D)Place knots of the ties laterally to prevent irritation and pressure.

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Exam Review

A client presents to the emergency department vomiting dark brown emesis and in severe abdominal pain. The client reports to the nurse of recently being diagnosed with adenocarcinoma of the small intestine. After auscultating bowel sounds and obtaining vital signs, which prescription should the nurse implement next?
A)Insert a nasogastric tube (NGT) and attach to low intermittent suction.
B)Place an indwelling urinary catheter and attach a bedside drainage unit.
C)Send the client to x-ray for a flat plate of the abdomen.
D)Give a prescribed analgesic for temperature above 101°F (38.3°C).
A client has a nasogastric (NG) tube placed during abdominal surgery. During postoperative convalescence, the nurse identifies that the client is manifesting a hand tremor, muscle twitching, and confusion. Which arterial blood gases consistent with metabolic alkalosis should the nurse report to the healthcare provider? Reference Range pH 17.35 to 7.45] PaCO2 135 to 45 mm Hg] HCO3 [21 to 28 mEq/L or 21 to 28 mmol/L] PaO2 [80 to 100 mm Hg]
A)pH 7.30, PCO, 20 mm Hg, HCO, 22 mEq/L (22 mmol/L), PO, 85 mm Hg.
B)pH 7.46, PCO, 55 mm Hg, HCO, 36 mEq/L (36 mmol/L), PO, 95 mm Hg.
C)pH 7.49, PCO, 45 mm Hg, HCO, 32 mEq/L (32 mmol), PO, 90 mm Hg.
D)pH 7.29, PCO, 35 mm Hg, HCO, 25 mEq/L (25 mmol/L), PO, 99 mm Hg.
A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?
A)Ability to ambulate independently.
B)Improved mental status.
C)Reduction in number of liquid stools.
D)Increase in urine output.
The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?
A)Measure oxygen saturation.
B)Assess body temperature.
C)Auscultate bowel sounds.
D)Check serum creatinine.

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Exam Review

An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?
A)Raise voice volume to a shout.
B)Exaggerate nonverbal expressions.
C)Decrease speaking speed.
D)Over-enunciate word syllables.
An adult client is admitted with AIDS and oral Candide albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?
A)Offer the client mouthwash for thorough cleansing after brushing teeth.
B)Assist with personal case, but leave oral care for the nurse to complete.
C)Provide a soft-bristled toothbrush for the client to use during oral care.
D)Wear sterile gloves when cleansing any areas of infected mucosa.
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?
A)Explain that the need to restrict fluids is the primary limitation.
B)Instruct the client to avoid foods with gluten, such as wheat bread.
C)Describe the use of an elimination diet to find trigger foods.
D)Advise the client to limit foods that are high in calcium and Iron.
A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in "500 mg per 100 mL of dextrose 5% in water." To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

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