rev finals part 2

Question 1

A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client?

a.Repeated syncope
b.New-onset confusion
c.Spontaneous ecchymosis
d.Abdominal distention

Answer 1

c.Spontaneous ecchymosis

Question 2

The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client?

a.Position the client with the unaffected side down.
b.Apply sequential compression stockings.
c.Instruct the client to turn the head from side to side.
d.Teach the client to touch and use both sides of the body.

Answer 2

b.Apply sequential compression stockings.

Question 3

A client has experienced a stroke resulting in damage to Wernicke’s area. Which clinical manifestation does the nurse monitor for?

a.Inability to comprehend spoken words
b.Communication with rote speech only
c.Slurred speech
d.Inability to make sounds

Answer 3

a.Inability to comprehend spoken words

The client with damage to Wernicke’s area cannot understand spoken or written words.

Question 4

A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, “Why do I need rehabilitation?” How does the nurse respond?

a.”Rehabilitation will reverse any physical deficits caused by the stroke.”
b.”If you do not have rehabilitation, you may never walk again.”
c.”Rehabilitation will help you function at the highest level possible.”
d.”Your doctor knows best and has ordered this treatment for you.”

Answer 4

c.”Rehabilitation will help you function at the highest level possible.”

Question 5

When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is most important for the nurse to carry out?

a. Irrigate the peritoneal catheter with saline.
b. Send a specimen for culture and sensitivity.
c. Document the finding in the client’s chart.
d. Change the dialysate solution and catheter tubing.

Answer 5

b. Send a specimen for culture and sensitivity.

Question 6

A client has end-stage kidney disease (ESKD). The nurse observes tall, peaked T waves on the client’s cardiac monitor. Which action by the nurse is best?

a. Check the serum potassium level.
b. Document the finding in the client’s chart.
c. Prepare to give sodium bicarbonate.
d. Call the health care provider to request an electrocardiogram (ECG).

Answer 6

a. Check the serum potassium level.

Question 7

The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed?

a. Adding potassium and antibiotic to the dialysate bags
b. Positioning the client on either side
c. Using sterile technique when hooking up dialysate bags
d. Warming the dialysate fluid in a microwave oven

Answer 7

c. Using sterile technique when hooking up dialysate bags

Question 8

A student nurse is preparing blood for an A Positive patient who needs to receive a blood transfusion. The nurse intervenes after which statement?

A. “ Since you are A positive, you are considered a “universal recipient”, therefore you can receive any type of blood.
B. “A positive blood types can receive A+, A-, O+ and O-“
C. “Testing your blood type helps us determine what type of blood you need. Not all blood types are the same and can cause a reaction”
D. “Only certain people who meet a certain criteria can donate blood, but if you have any types of symptoms during transfusion, let a health care staff member know”

Answer 8

A. “ Since you are A positive, you are considered a “universal recipient”, therefore you can receive any type of blood.

Question 9

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

1. “Aspirin can cause bleeding after surgery.”
2. “Aspirin can cause my ability to clot blood to be abnormal.”
3. “I need to continue to take the aspirin until the day of surgery.”
4. “I need to check with my HCP about the need to stop the aspirin before the scheduled surgery.”

Answer 9

3. “I need to continue to take the aspirin until the day of surgery.”

Question 10

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

1. Inhale as rapidly as possible
2. Keep a loose seal between the lips and the mouthpiece
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

Answer 10

4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

Question 11

The nurse assess a client’s surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm tender skin

Answer 11

2. Serous drainage

Question 12

A client who has had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply:

1. Contact the surgeon
2. Instruct the client to remain quiet
3. Prepare the client for wound closure
4. Document the findings and actions taken
5. Place a sterile saline dressing and ice packs over the wound
6. Place the client in a prone position without a pillow under the head.

Answer 12

1, 2, 3, 4

Question 13

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

1. Assess the patency of the airway
2. Check tubes or drains for patency
3. Check the dressing to assess for bleeding
4. Assess the vital signs to compare with preoperative measurements

Answer 13

1. Assess the patency of the airway

Question 14

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

1. Urine output of 20ml/hour
2. Temperature of 37.6 C
3. Blood pressure of 114/70
4. Serous drainage on the surgical dressing

Answer 14

1. Urine output of 20ml/hour

Question 15

A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?

1. Pneumonia
2. Hypoxemia
3. Fluid imbalance
4. Pulmonary embolism

Answer 15

1. Pneumonia

Question 16

Which of the following are functions of dressings? (select all that apply)

A. promote hemostasis
B. keep wound bed dry
C. wound debridement
D. prevent contamination
E. increase circulation

Answer 16

A. promote hemostasis
C. wound debridement
D. prevent contamination

Question 17

The nurse is caring for a patient who had knee replacement surgery 5 days go. The patient’s knee appears red and warm to the touch and patient is requesting increased pain medication. What complication should the nurse be concerned about?

A. nothing, this is expected post operatively
B. patient is becoming dependent on pain medication
C. post operative wound dehiscence
D. post operative wound infection

Answer 17

D. post operative wound infection

Question 18

The nurse teaches the client how to change an abdominal wound dressing using aseptic technique. The client performs a return demonstration. Which action by the client shows an understanding of the procedure?

A) washing hands before changing the dressing
B) using tissue wipes to cleanse the skin adjacent to the wound.
C) donning sterile gloves before each dressing change.
D) keeping the dressing moist so it will not adhere to the wound.

Answer 18

A) washing hands before changing the dressing

Question 19

The nurse cares for the client who is 5’7 tall, weights 300 pounds, and is recuperating from an exploratory laparotomy. The client cooperates with coughing and deep breathing exercises and ambulates a distance of 25 feet in the hallway. For which postoperative complications should the nurse most vigilantly assess the client?

A) pneumonia
B) fat emboli
C) pulmonary emboli
D) wound dehiscence

Answer 19

D) wound dehiscence

Question 20

A client’s wound is draining thick yellow material. The nurse correctly describes the drainage as:

1. Sanguineous
2. Serous-sanguineous
3. Serous
4. Purulent

Answer 20

4. Purulent

(Drainage is described as purulent. Sanguineous and Serous-sanguineous contain blood. Serous is clear and watery.)

Question 21

You find that your newly assigned client has very shiny skin on their legs, has little or no leg hair, and the client reports that their skin damages easily. You would suspect that these signs and symptoms are related to:

1. Overuse of caustic products to strip the leg hair.
2. Chronic neurological pathology.
3. Impaired peripheral arterial circulation.
4. Inherited reduction in sweat glands and hair follicles.

Answer 21

3. Impaired peripheral arterial circulation.

Question 22

The nurse should observe for a Trousseau sign in the client with which of the following electrolyte abnormalities?

a. Hypokalemia
b. Hyponatremia
c. Hypochloremia
d. Hypocalcemia

Answer 22

d. Hypocalcemia

(Trousseau sign of latent tetany is a medical sign observed in patients with low calcium)

Question 23

One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances, is they:

a. Eat poor quality foods
b. Have a decreased thirst sensation
c. have more stress response
d. have an overly active thirst response

Answer 23

b. Have a decreased thirst sensation

Question 24

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved?

A. An oral temperature of 98.8 F
B. A urine specific gravity of 1.043
C. A urine output that is pale yellow
D. A blood pressure of 120/80 mmHg

Answer 24

B. A urine specific gravity of 1.043

Question 25

A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?

A. Tetany
B. Twitches
C. Positive Trousseau’s sign
D. Loss of deep tendon reflexes

Answer 25

D. Loss of deep tendon reflexes

Question 26

A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply:

A. Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
C. Encourage low fiber foods to prevent diarrhea.
D. Instruct the client about foods that contain
potassium.
E. Encourage the client to obtain assistance to
ambulate.

Answer 26

A, B, D, E

Question 27

Nurse would be most concerned about which lab values obtained from a client receiving furosemide (Lasix) therapy?

a. BUN 20
b. K 3.4
c. Creatinine 1.1
d. K 3.2

Answer 27

d. K 3.2

Question 28

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse?

A. “The fluid is an adverse reaction to chemotherapy.”
B. “A decrease in activity has allowed extra fluid to accumulate in the tissues.”
C. “Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues.”
D. “Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues.”

Answer 28

C. “Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues.”

Question 29

The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse?

A. Assess a client for metabolic acidosis
B. Evaluate the blood gases of a client with respiratory alkalosis
C. Obtain a glucose level on a client admitted with diabetes mellitus
D. Perform a neurological assessment on a client suspected of having hypocalcemia

Answer 29

C. Obtain a glucose level on a client admitted with diabetes mellitus

Question 30

The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following?

A. Hypokalemia
B. Hypernatremia
C. Hypermagnesemia
D. Hypocalcemia

Answer 30

D. Hypocalcemia

Question 31

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?

A. Encourage fluids orally.
B. Administer 10% saline solution IVPB.
C. Administer antidiuretic hormone intranasally.
D. Place on seizure precautions.

Answer 31

D. Place on seizure precautions.

Question 32

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

a. Skin turgor

b. Daily weight

c. Presence of edema

d. Hourly urine output

Answer 32

b. Daily weight

Question 33

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.0 mg/dL. Which assessment would be most important for the nurse to make?

a. Daily alcohol intake

b. Intake of dietary protein

c. Multivitamin/mineral use

d. Use of over-the-counter (OTC) laxative

Answer 33

a. Daily alcohol intake

Question 34

The nurse is preparing a client for surgery . Which intervention should the nurse implement first?

1. Check the permit for the spouse’ s signature.
2. Take and document intake and output.
3. Administer the “on call” sedative.
4. Complete the preoperative checklist.

Answer 34

4. Complete the preoperative checklist.

Question 35

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation.

Answer 35

C. Schedule for A STAT computer tomography (CT) scan of the head.

Question 36

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures

Answer 36

A. Time of onset of current stroke

Question 37

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:

A. Pulse
B. Respirations
C. Blood pressure
D. Temperature

Answer 37

C. Blood pressure

Question 38

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
D. Echocardiogram

Answer 38

B. Pupil size and pupillary response

Question 39

What is the expected outcome of thrombolytic drug therapy?

A. Increased vascular permeability
B. Vasoconstriction
C. Dissolved emboli
D. Prevention of hemorrhage

Answer 39

C. Dissolved emboli

Question 40

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

A. A thrombolytic medication
B. A beta-blocker medication
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication

Answer 40

D. An oral anticoagulant medication

Question 41

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

A. A blood glucose level of 480 mg/dl.
B. A right-sided carotid bruit.
C. A blood pressure of 220/120 mmHg.
D. The presence of bronchogenic carcinoma.

Answer 41

C. A blood pressure of 220/120 mmHg.

Question 42

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

A. The assistant places a gait belt around the client’s waist prior to ambulating.
B. The assistant places the client on the back with the client’s head to the side.
C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.
D. The assistant praises the client for attempting to perform ADLs independently.

Answer 42

C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.

Question 43

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

A. Vomiting continues.
B. Intracranial pressure (ICP) is increased.
C. The client needs mechanical ventilation.
D. Blood is anticipated in the cerebrospinal fluid (CSF).

Answer 43

B. Intracranial pressure (ICP) is increased.

Question 44

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

A. To reduce intraocular pressure.
B. To prevent acute tubular necrosis.
C. To promote osmotic diuresis to decrease ICP.
D. To draw water into the vascular system to increase blood pressure.

Answer 44

C. To promote osmotic diuresis to decrease ICP.

Question 45

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

A. Urine output increases.
B. Pupils are 8 mm and nonreactive.
C. Systolic blood pressure remains at 150 mm Hg.
D. BUN and creatinine levels return to normal.

Answer 45

A. Urine output increases

Question 46

Which of the following values is considered normal for ICP?

A. 0 to 15 mm Hg
B. 25 mm Hg
C. 35 to 45 mm Hg
D. 120/80 mm Hg

Answer 46

A. 0 to 15 mm Hg

Question 47

Which of the following signs and symptoms of increased ICP after head trauma would appear first?

A. Bradycardia
B. Large amounts of very dilute urine
C. Restlessness and confusion
D. Widened pulse pressure

Answer 47

C. Restlessness and confusion

Question 48

Problems with memory and learning would relate to which of the following lobes?

A. Frontal
B. Occipital
C. Parietal
D. Temporal

Answer 48

D. Temporal

Question 49

While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?

A. Frontal
B. Occipital
C. Parietal
D. Temporal

Answer 49

C. Parietal

Question 50

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

A. Side-lying, with legs pulled up and head bent down onto the chest.
B. Side-lying, with a pillow under the hip.
C. Prone, in a slight Trendelenburg’s position.
D. Prone, with a pillow under the abdomen.

Answer 50

A. Side-lying, with legs pulled up and head bent down onto the chest.