PN3 Final Exam 85%
1. The nurse, planning care for a mechanically ventilated client, would plan to administer pantoprazole. The nurse
understands this medication is to prevent the onset of which of the following complications?
Thrombophlebitis
Hypertension
Hyperglycemia
Stress Ulcers
2. A client is diagnosed with cardiogenic shock. The nurse should plan immediate interventions to address which of the
following complications of this disorder?
Pulmonary Embolism
Deep vein thrombosis
Acute renal failure
Disseminated intravascular coagulation
3. A patient in the emergency department is experiencing a hemorrhagic stroke. The nurse anticipates which of the
following symptoms may have been present at the onset. SATA
Vomiting
Limited mobility is worse in the morning
Severe, sudden headache
Increased appetite
Change in mental status
4. A nurse is caring for an end-of-life terminally ill client, experiencing very shallow and rapid breathing with periods of
apnea. After evaluating the client, which action by the nurse would be most appropriate?
Reduce the number of people in the client's room
Reorient the client as needed
Place the client in the supine position
Elevate the client's HOB
5. A nurse is admitted to the hospital with an infected postoperative surgical wound. The practitioner orders vancomycin
IV. Order: Vancomycin 1 gram in 500 ml dextrose 5% water (D5W) to infuse over 2 hours via infusion pump. Calculate
the flow rate in ml/hr. 250
6. A nurse assesses a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from
the client's right nostril. Which of the following actions should the nurse take first?
Palpate the client's head for the presence of fractures
Assess the drainage from eyes and ears
Assess the drainage and test the drainage to rule out cerebral spinal fluid
Ask the client to keep their head elevate
7. An emergency department nurse triages a client with diabetes mellitus who has fractured her wrist. Which action
would the nurse take first?
Remove the medical alert bracelet from the fractured arm
Place the client in a supine position with a warm blanket
Cover any open areas with a sterile dressing
Immobilize the arm by splinting the fracture
8. A nurse cares for a client who has obstructive jaundice. The client asks, " Why is my skin so itchy?" How would the
nurse respond?
"Bile salts accumulate in the skin and cause itching."
"Toxins released from an inflamed gallbladder led to itching."
"Itching is caused by the release of calcium into the skin."
"Itching is caused by a hypersensitivity reaction.
9. A nurse is caring for a client on mechanical ventilation and finds the client agitated and restless. What action by the
nurse is most appropriate?
Reassure the client that they are safe
Restrain the clients' legs and arms
Sedate the client immediately
Assess the cause of the agitation
, 10. A nurse obtains the health history of a client with a fractured femur. Which factor identified in the client's history
would the nurse recognize as an aspect that may delay healing?
Osteoporosis
Oral contraceptives
Sedentary lifestyle
Current smoking history
11. The nurse is notified that the client's monitor is showing artifacts. What does the nurse do next?
Troubleshoot the equipment
Check the status of the client
Monitor and document the artifact
Notify the physician of orders
12. A nurse is monitoring a client who has an acute kidney injury. Which of the following laboratory findings should the
nurse expect?
Hypokalemia
Metabolic acidosis
Hypercalcemia
Elevated BUN and creatinine
13. A client in the intensive care unit is scheduled for a lumbar puncture today. On assessment, the nurse finds the client
breathing irregularly with one pupil fixed and dilated. Which of the following nursing actions is the best?
Ensure that informed consent is on the chart.
Document these findings in the client’s record.
Give the prescribed preprocedural sedation.
Call a rapid response team
14. The nurse is concerned that a client may develop neurogenic shock when which of the following is assessed?
Decreased sympathetic nerve impulses cause a low mean arterial pressure (MAP)
Jugular vein distension caused by an elevated mean arterial pressure (MAP)
Fractured lower extremity
Sluggish bowel sounds
15. The nurse in the emergency department is using a triage system because this system ranks clients by
Name
Age
Body system involved
The severity of illness or injury
16. A nurse cares for a client who is recovering from a hypophysectomy. What action should the nurse take first?
Instruct the client to cough, turn, and deep breath
Assess for clear or light-yellow drainage from the nose
Keep the head of the bed flat and the client supine
Apply petroleum jelly to lips to avoid dryness
17. What is the rationale for chemotherapy as a cancer treatment?
Decreases the client's risk for life-threatening complications
To disrupt one or more steps necessary for cancer to develop
Less expensive and safer than radiation
Concentrates on secondary lymphoid tissues and prevents widespread metastasis.
18. A client diagnosed with cholecystitis asks the nurse what happened. The nurse correctly identifies which one of the
following risk factors?
A client with low body weight
A client on a vegetarian diet
An obese fertile client over the age of 40
A client on testosterone supplements
19. When educating clients on liver disease, the nurse correctly identifies the most common cause of cirrhosis in the
United States as being which of the following? SATA
Nonalcoholic steatohepatitis (NASH)
Chronic viral hepatitis
1. The nurse, planning care for a mechanically ventilated client, would plan to administer pantoprazole. The nurse
understands this medication is to prevent the onset of which of the following complications?
Thrombophlebitis
Hypertension
Hyperglycemia
Stress Ulcers
2. A client is diagnosed with cardiogenic shock. The nurse should plan immediate interventions to address which of the
following complications of this disorder?
Pulmonary Embolism
Deep vein thrombosis
Acute renal failure
Disseminated intravascular coagulation
3. A patient in the emergency department is experiencing a hemorrhagic stroke. The nurse anticipates which of the
following symptoms may have been present at the onset. SATA
Vomiting
Limited mobility is worse in the morning
Severe, sudden headache
Increased appetite
Change in mental status
4. A nurse is caring for an end-of-life terminally ill client, experiencing very shallow and rapid breathing with periods of
apnea. After evaluating the client, which action by the nurse would be most appropriate?
Reduce the number of people in the client's room
Reorient the client as needed
Place the client in the supine position
Elevate the client's HOB
5. A nurse is admitted to the hospital with an infected postoperative surgical wound. The practitioner orders vancomycin
IV. Order: Vancomycin 1 gram in 500 ml dextrose 5% water (D5W) to infuse over 2 hours via infusion pump. Calculate
the flow rate in ml/hr. 250
6. A nurse assesses a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from
the client's right nostril. Which of the following actions should the nurse take first?
Palpate the client's head for the presence of fractures
Assess the drainage from eyes and ears
Assess the drainage and test the drainage to rule out cerebral spinal fluid
Ask the client to keep their head elevate
7. An emergency department nurse triages a client with diabetes mellitus who has fractured her wrist. Which action
would the nurse take first?
Remove the medical alert bracelet from the fractured arm
Place the client in a supine position with a warm blanket
Cover any open areas with a sterile dressing
Immobilize the arm by splinting the fracture
8. A nurse cares for a client who has obstructive jaundice. The client asks, " Why is my skin so itchy?" How would the
nurse respond?
"Bile salts accumulate in the skin and cause itching."
"Toxins released from an inflamed gallbladder led to itching."
"Itching is caused by the release of calcium into the skin."
"Itching is caused by a hypersensitivity reaction.
9. A nurse is caring for a client on mechanical ventilation and finds the client agitated and restless. What action by the
nurse is most appropriate?
Reassure the client that they are safe
Restrain the clients' legs and arms
Sedate the client immediately
Assess the cause of the agitation
, 10. A nurse obtains the health history of a client with a fractured femur. Which factor identified in the client's history
would the nurse recognize as an aspect that may delay healing?
Osteoporosis
Oral contraceptives
Sedentary lifestyle
Current smoking history
11. The nurse is notified that the client's monitor is showing artifacts. What does the nurse do next?
Troubleshoot the equipment
Check the status of the client
Monitor and document the artifact
Notify the physician of orders
12. A nurse is monitoring a client who has an acute kidney injury. Which of the following laboratory findings should the
nurse expect?
Hypokalemia
Metabolic acidosis
Hypercalcemia
Elevated BUN and creatinine
13. A client in the intensive care unit is scheduled for a lumbar puncture today. On assessment, the nurse finds the client
breathing irregularly with one pupil fixed and dilated. Which of the following nursing actions is the best?
Ensure that informed consent is on the chart.
Document these findings in the client’s record.
Give the prescribed preprocedural sedation.
Call a rapid response team
14. The nurse is concerned that a client may develop neurogenic shock when which of the following is assessed?
Decreased sympathetic nerve impulses cause a low mean arterial pressure (MAP)
Jugular vein distension caused by an elevated mean arterial pressure (MAP)
Fractured lower extremity
Sluggish bowel sounds
15. The nurse in the emergency department is using a triage system because this system ranks clients by
Name
Age
Body system involved
The severity of illness or injury
16. A nurse cares for a client who is recovering from a hypophysectomy. What action should the nurse take first?
Instruct the client to cough, turn, and deep breath
Assess for clear or light-yellow drainage from the nose
Keep the head of the bed flat and the client supine
Apply petroleum jelly to lips to avoid dryness
17. What is the rationale for chemotherapy as a cancer treatment?
Decreases the client's risk for life-threatening complications
To disrupt one or more steps necessary for cancer to develop
Less expensive and safer than radiation
Concentrates on secondary lymphoid tissues and prevents widespread metastasis.
18. A client diagnosed with cholecystitis asks the nurse what happened. The nurse correctly identifies which one of the
following risk factors?
A client with low body weight
A client on a vegetarian diet
An obese fertile client over the age of 40
A client on testosterone supplements
19. When educating clients on liver disease, the nurse correctly identifies the most common cause of cirrhosis in the
United States as being which of the following? SATA
Nonalcoholic steatohepatitis (NASH)
Chronic viral hepatitis
