EXAM PREP STUDY GUIDE COMPREHENSIVE
REVIEW
◉ A nurse is preparing to administer a unit of packed RBCs to a
client. Which of the following actions should the nurse take?
Answer: Remain with the client for the first 15 min of the infusion.
Rationale: remaining with the client for the first 15 to 30 minutes of
infusion because hemolytic reactions usually occur during the
infusion of the first 50 mL of blood
◉ A nurse is evaluating a client who has a new diagnosis of type 1
diabetes mellitus. Which of the following client statements indicates
the client is successfully coping with the change? Answer: "I used to
never worry about my feet. Now, I inspect my feet every day with a
mirror."
◉ A nurse is caring for a client who has a closed head injury and has
an intraventricular catheter placed. Which of the following findings
indicates that the client is experiencing increased intracranial
pressure (ICP)? (Select all that apply.) Answer: Sleepiness, Widening
pulse pressure, Decerbrate posturing
, ◉ A nurse is planning to provide discharge teaching for the family of
an older adult client who has hemianopsia and is at risk for falls.
Which of the following instructions should the nurse include?
Answer: Remind the client to scan their complete range of vision
during ambulation.
Rationale: this practice can accommodate for the loss of vision and
help to reduce risk for falls.
◉ A nurse in an emergency department is caring for a client who
reports vomiting and diarrhea for the past 3 days. Which of the
following findings should indicate to the nurse that the client is
experiencing fluid volume deficit? Answer: Heart rate 110/min
Rationale: the client should have an elevated heart rate, have
hypotension, have a urine specific gravity greater than 1.030, and a
BUN greater than 20 mg/dL.
◉ A nurse is caring for a client who is on bed rest and has a new
prescription for enoxaparin subcutaneous. Which of the following
actions should the nurse take? Answer: Inject the medication into
the anterolateral abdominal wall.
◉ A nurse in a provider's office is caring for a client who requests
sildenafil to treat erectile dysfunction. Which of the following