RLE REV Part 2

Question 1

A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last?

a) ultrasound
b) colonoscopy
c) barium enema
d) computed tomography

Answer 1

c) barium enema

Question 2

A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client?

a) diarrhea
b) risk for aspiration
c) risk for deficient flid volume
d) imbalanced nutrition, less than body requirements

Answer 2

b) risk for aspiration

Question 3

A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to:

a) obtain vital signs
b) ask the client about the precipitating events
c) complete an abdominal physical assessment
d) insert a nasogastric (NG) tube and Hematest the emesis

Answer 3

a) obtain vital signs

Question 4

A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client’s arrival, the client’s therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for:

a) interaction with peers
b) the presence of suicidal thoughts
c) the amount of food intake for the past 24 hours
d) information regarding the past medication regimen

Answer 4

b) the presence of suicidal thoughts

Question 5

A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern?

a) peer support through structured groups
b) finding affordable housing for the group
c) setting up a 24-hour crisis center and hotline
d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available

Answer 5

d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available

Question 6

A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider?

a) contacting the older resident’s families
b) attending to the emotional needs of the older residents
c) arranging for ambulance transportation for the oldest residents
d) attending to the nutritional status and basic needs of the older residents

Answer 6

d) attending to the nutritional status and basic needs of the older residents

Question 7

A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure?

a) vital signs
b) intake and output
c) height and weight
d) allergy to iodine or shellfish

Answer 7

d) allergy to iodine or shellfishq

Question 8

A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on:

a) the comfort level
b) activity tolerance
c) the level of consciousness
d) the hydration and nutrition status

Answer 8

d) the hydration and nutrition status

Question 9

A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client?

a) age
b) hypertension
c) hyperlipidemia
d) glucose intolerance

Answer 9

b) hypertension

Question 10

A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action would the nurse implement to assist in preventing a sickle cell crisis from occurring during labor?

a) continually reassure and coach the client
b) administer the prescribed oxygen throughout labor
c) maintain strict asepsis throughout the labor process
d) increase the intravenous (IV) fluids if the client complains of feeling thirsty

Answer 10

b) administer the prescribed oxygen throughout labor

Question 11

A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action would be to:

a) check the fetal heart rate
b) check the maternal blood pressure
c) maintain an open airway
d) administer oxygen to the mother by face mask

Answer 11

c) maintain an open airway

Question 12

A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints?

a) providing range-of-motion exercises to the wrists
b) removing the restraints periodically per agency guidelines
c) applying lotion to the skin under the restraints
d) assessing color, sensation, and pulses distal to the restraint

Answer 12

d) assessing color, sensation, and pulses distal to the restraint

Question 13

A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client’s blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next?

a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy
b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively
c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic
d) the RN assesses the client, checks the client’s surgical notes, and gathers addition data before calling the surgeon

Answer 13

d) the RN assesses the client, checks the client’s surgical notes, and gathers addition data before calling the surgeon

Question 14

A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action?

a) examine and treat the wound sites
b) obtain and record a detailed history
c) encourage and assist the client to ventilate feelings
d) administer an anti-anxiety agent

Answer 14

a) examine and treat the wound sites

Question 15

A nurse has just administered a dose of hydralazine hydrochloride (Apresoline) intravenously to a client. Based on the action of this medication, the nurse would initially assess the client’s:

a) cardiac rhythm
b) oxygen saturation
c) blood pressure
d) respiratory rate

Answer 15

c) blood pressure

Question 16

A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client’s vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check:

a) lung sounds
b) vital signs
c) the chest tube connections
d) the amount of drainage

Answer 16

c) the chest tube connections

Question 17

A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, the nurse would first:

a) inspect the client for injuries resulting from the incident and initiate appropriate treatment
b) document the behavior leading to seclusion
c) document the time and the client is placed in seclusion
d) make sure that there is a written order by the physician allowing for the seclusion

Answer 17

a) inspect the client for injuries resulting from the incident and initiate appropriate treatment

Question 18

A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first?

a) active bowel sounds
b) adequate urine output
c) orientation to the surroundings
d) a patent airway

Answer 18

d) a patent airway

Question 19

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 38 C orally. Which action should the nurse take?

1) Begin the transfusion as prescribed.
2) Administer an antihistamine and begin the transfusion.
3) Delay hanging the blood and notify the health care provider.
4) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.

Answer 19

3) Delay hanging the blood and notify the health care provider.

Question 20

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which INITIAL question?

1) “Have you ever had a transfusion before?”
2) “Why do you think that you need the transfusion?”
3) “Have you ever gone into shock for any reason in the past?”
4) “Do you know the complications and risks of a transfusion?”

Answer 20

1) “Have you ever had a transfusion before?”

Question 21

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client’s blood pressure is 90/50 from a baseline of 125/78. The client’s temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?

1) Septicemia
2) Hyperkalemia
3) Circulatory overload
4) Delayed transfusion reaction

Answer 21

1) Septicemia

Question 22

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item?

1) An air vent
2) Tinted tubing
3) An in-line filter
4) A microdrip chamber

Answer 22

3) An in-line filter

Question 23

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken NEXT?

1) Remove the intravenous (IV) line.
2) Run a solution of 5% dextrose in water.
3) Run normal saline at a keep-vein-open rate.
4) Obtain a culture of the tip of the catheter device removed from the client.

Answer 23

3) Run normal saline at a keep-vein-open rate.

Question 24

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?

1) 5 minutes
2) 15 mintues
3) 30 minutes
4) 45 mintues

Answer 24

2) 15 mintues

Question 24

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which PRIORITY item?

1) Vital signs
2) Skin color
3) Urine output
4) Latest hematocrit level

Answer 24

1) Vital signs

Question 25

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST?

1) Maintain bed rest with legs elevated
2) Place the client in high-Fowler’s position
3) Increase the rate of infusion of intravenous fluids
4) Consult with the HCP regarding initiation of oxygen therapy.

Answer 25

2) Place the client in high-Fowler’s position\

Question 26

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion?

1) Hematocrit level
2) Erythrocyte count
3) Hemoglobin level
4) White blood cell count

Answer 26

4) White blood cell count

Question 27

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client?

1) To treat the loss of platelets
2) To promote rapid volume expansion
3) Because a transfusion must be done slowly
4) Because it will increase the hemoglobin and hematocrit levels

Answer 27

2) To promote rapid volume expansion

Question 28

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?

1) Expiration date
2) Presence of clots
3) Blood group and type
4) Blood identification number

Answer 28

1) Expiration date

Question 29

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

1) Infusion pump
2) Pulse oximeter
3) Cardiac monitor
4) Blood-warming device

Answer 29

4) Blood-warming device

Question 29

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? SELECT ALL THAT APPLY.

1) Ask a family member to donate blood ahead of time.
2) Give an autologous blood donation before the surgery.
3) Take iron supplements before surgery to boost hemoglobin levels.
4) Request that any donated blood be screened twice by the blood bank.
5) Take adequate amounts of vitamin C several days prior to the surgery date.

Answer 29

1, 2

Question 30

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client’s bedside?

1) Lactated Ringer’s
2) 0.9% sodium chloride
3) 5% dextrose in 0.9% sodium chloride
4) 5% dextrose in 0.45% sodium chloride

Answer 30

2) 0.9% sodium chloride

Question 31

A client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 3pm. The nurse making rounds at 3:45 pm finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The IV bag has 400 mL remaining. The nurse should take which action first?
1. Call the physician
2. Slow the IV infusion
3. Sit the client up in bed
4. Remove the IV catheter

Answer 31

2. Slow the IV infusion

Question 32

A client with the recent diagnosis of MI and impaired renal function is recuperating on the step-down cardiac unit. The client’s blood pressure has been borderline low and IV fluids have been infusing at 100 mL /hr via a central line catheter in the right internal jugular for approx 24 hours to increase renal output and maintain the blood pressure. Upon entering the client’s room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy.
1. Hematoma
2. Air embolism
3. Systemic infection
4. Circulatory overload

Answer 32

4. Circulatory overload

Question 33

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred.
1. Infection
2. Phlebitis
3. Infiltration
4. Thrombosis

Answer 33

3. Infiltration

Question 34

The nurse is inserting an IV line into a client’s vein. After the initial stick, the nurse continues to advance the catheter if:
1. The catheter advances easily
2. The vein is distended under the needle
3. The client does not complain of discomfort
4. Blood return shows in the backflash chamber of the catheter.

Answer 34

4. Blood return shows in the backflash chamber of the catheter.

Question 35

The nurse nostes that the site of a client’s peripheral IV catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced:
1. Phlebitis of the vein
2. Infiltration of the IV line
3. Hypersensitivity to the IV solution
4. Allergic reaction to the IV catheter material

Answer 35

1. Phlebitis of the vein

Question 36

A client involved in a motor vehicle crash presents to the ER with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will most likely be prescribe to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure?
1. 5% dextrose in lactated ringers
2. 0.33% sodium chloride (1/3 normal saline)
3. 0.225% sodium chloride (1/4 normal saline)
4. 0.45% sodium chloride (1/2 normal saline)

Answer 36

1. 5% dextrose in lactated ringers

Question 37

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter. The nurse determines that the client needs further instructions if the client made which statement?
1. I need to wear a medic-alter tag or bracelet
2. I need to have a repair kit available in the home for use if needed.
3. I need to keep the insertion site protected when in the shower or bath.
4. I need to keep my activity level to a minimum while this catheter is in place.

Answer 37

4. I need to keep my activity level to a minimum while this catheter is in place.

Question 38

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? SATA
1. Notifies the physician
2. Removes the IV catheter at that site
3. Applies warm moist packs to the site
4. Starts a new IV line in a proximal portion of the same vein
5. Documents the occurence, actions taken, and the client’s response

Answer 38

1, 2, 3, 5

Question 39

The nurse is caring for a post-op client that has had nausea, vomiting, and a urine output of 200 mL in the past 8 hrs. The client’s BP is 90/60. Which of the following orders would the nurse implement first?

A. Increase IV rate to 150 mL/hr
B. Administer 750 mL IV bolus of normal saline
C. Administer Ondansetron (Zofran) IV for vomiting
D. Discontinue the PRN IV Morphine

Answer 39

B. Administer 750 mL IV bolus of normal saline

Question 40

The nurse is caring for a client with nausea, vomiting and diarrhea for 3 days. The nurse would anticipate which of the following fluid choices as best for this client?

A. D5 ½ NS
B. D5W
C. LR
D. D5LR

Answer 40

D. D5LR

Question 41

The nurse is caring for a diabetic client who has been npo for surgery. The nurse would question which of the following iv fluid choices?
A. LR
B. D5LR
C. NS
D. ¼ NS

Answer 41

B. D5LR

Question 42

The nurse is preparing to administer IV fluids to a client with a serum potassium of 6.2. The nurse would question the order if it was for which of the following fluids?

A. D5W
B. 0.9% NS
C. D51/2 NS
D. LR

Answer 42

D. LR

Question 43

The nurse hears the physician stating that the client needs a hypotonic iv solution. Which of the following solutions would the nurse expect to administer?

A. LR
B. D5W
C. 0.45% NS
D. D51/2 NS

Answer 43

C. 0.45% NS

Question 44

The nurse is caring for a client that is hypovolemic and plasma expanders are not available. The nurse would correctly anticipate that which type of solution would be ordered?

A. TPN
B. Isotonic
C. Hypertonic
D. Hypotonic

Answer 44

B. Isotonic

Question 45

The nurse is planning to administer a hypertonic fluid to a client. WhicH of the following fluids would the nurse anticipate being ordered?

A. 0.22% NS
B. LR
C. D10W
D. 0.9% NS

Answer 45

C. D10W