Exam Review

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?
A)Assess the pulses proximal to the fracture site.
B)Assess the pin sites for signs of infection.
C)Administer pain medication at designated intervals around the clock.
D)Remove traction every shift and provide skin care.
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
A)Corticosteroid cream was applied to eczema.
B)A grandson and his new dog recently visited.
C)Recently received an influenza immunization.
D)An old friend with eczema came for a visit.
The nurse is caring for a client in the postanesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the vital signs as a heart rate of 140 beats/minute, respirations 26 breaths/minute, and a blood pressure 140/90 mm Hg. Which intervention is most important for the nurse to implement?
A)Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
B)Medicate for pain and monitor vital signs according to protocol.
C)Administer intravenous fluid bolus as prescribed by the healthcare provider.
D)Encourage the client to splint the incision with a pillow to cough and deep breathe.
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?
A)Bronze pigmentation.
B)Uneven hair distribution.
C)Lower leg edema.
D)Bounding peripheral pulse.

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Exam Review

The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
A)Have the client sign the surgical and transfusion permits.
B)Notify the healthcare provider of the client's medication history.
C)Ensure that the potential for bleeding is explained to the client.
D)Observe the heparin injection sites for signs of bruising.
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?
A)Monitor urine and stool for occult blood regularly.
B)Ensure a large gauge catheter is used to obtain blood samples.
C)Remove cold and frozen foods from dietary trays.
D)Wrap bruised areas with elastic bandage dressings.
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)
A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?
A)Elevated creatinine and blood urea nitrogen (BUN).
B)Hypovolemia and electrocardiographic (ECG) changes.
C)Uremic irritation of mucous membranes and skin surfaces.
D)Side effects of total parenteral nutrition (TPN) and intralipids.

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Exam Review

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
A)Activity level of bowel sounds.
B)Level and amount of physical activity.
C)Color and consistency of feces.
D)Eating patterns of dietary intake.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
A)Hemoglobin levels.
B)Red blood cell count.
C)White blood cell count.
D)Platelet count.
A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?
A)Wear braces on both wrists during the night.
B)Notify the healthcare provider as soon as possible.
C)Elevate the hands on two pillows at night.
D)Apply cold compresses for 30 minutes before bedtime.
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
A)Select another finger.
B)Apply pressure to the site.
C)Assess radial pulse volume.
D)Collect the blood sample.

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Exam Review

An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
A)Avoid frequent eye pressure measurements.
B)Maintain prescribed eye drop regimen.
C)Wear prescription glasses.
D)Eat a diet high in carotene.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
A)Visible swelling of the neck, with no pain.
B)Warm, soft, moist, salmon-colored skin.
C)Husky voice and troubled by hoarseness.
D)Central type obesity, with thin extremities.
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
A)Obtain a sample of the drainage to send to the laboratory.
B)Auscultate the abdomen for bowel sound activity.
C)Prepare the client to return to the operating room.
D)Bring additional sterile dressing supplies to the room.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
A)Sip fluids with each meal.
B)Reduce intake of fatty foods.
C)Eat small frequent meals.
D)Chew slowly and thoroughly.

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Exam Review

The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL. How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
An older adult client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
A)Clear, dark amber-colored urine.
B)Prothrombin time within normal limits.
C)Decreased abdominal girth.
D)Improved level of consciousness.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
A)Internal bleeding.
B)Right-sided heart failure.
C)Left ventricular dysfunction.
D)Cardiac tamponade.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
A)Discontinue infusing solution.
B)Irrigate the catheter manually.
C)Monitor catheter drainage.
D)Decrease the flow rate.

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