AMS FINAL QUESTIONS AND VERIFIED ANSWERS
A family member is instructed by a nurse on the interventions for safe swallowing for a
client who has residual effects from a stroke. Which of the following concepts is most
important for the family members to understand? - answers - place the client in the
upright position to facilitate swallowing
A nurse is assessing a client who has an 8 score using the glasgow coma scale to
evaluate levels of consciousness. Which of the following nursing statements most
accurately describes the score? - answers - indicates the need for total nursing care
The nurse is helping a client who was recently placed on a low sodium diet to reduce
fluid retention to choose foods for lunch recommends which lunch menu that would be
most beneficial for this client? - answers - grilled chicken sandwich on white bread,
apple, salad, and iced tea
A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid.
Which of the following clinical manifestations indicates a complication that requires
notifying the provider immediately? - answers - increased hr
The nurse in the neurointensive care unit is caring for a client with a new c6 sci who is
breathing independently. Which nursing interventions should be implemented? -
answers - monitor the pulse oximetry reading
A nurse assesses a comatose, head injured client and finds flexion of the arms, wrists,
and fingers and adduction of the upper extremities. Which of the following describes
these findings? - answers - decorticate posturing
A client comes into the er with complaints of midsternal chest pain radiation to the neck
and left arm which is unrelieved by sublingual nitroglycerin. An electrocardiogram is
obtained. What observationon the ecg or on the cardiac monitor would indicate to the
nurse the need to immediately notify the physician? - answers - an st segment elevation
from the isoelectric baseline
A client comes to the emergency department via ambulance to report severe radiating
chest pain and shortness of breath. The client appears restless, frightened and slightly
cyanotic. The provider prescribes oxygen by nasal cannula at 4 l/min stat, cardiac
enzyme levels, iv fluids, and a 12-lead ecg. Which of the following actions should the
nurse take first? - answers - initiate oxygen therapy
The nurse is obtaining a health history from a client who is visiting the clinic with
complaints of a severe headache. The client provides the following data to the nurse
based on a review systems. The nurse identifies the following as modifiable risk factors
for stroke. Sata - answers - smoking
Obesity
, Decreased physical activity
Alcohol consumption
A nurse is preparing to administer insulin lispro (humalog) to a client who has type 1
diabetes mellitus. Which of the following nursing actions is appropriate? - answers -
inject the insulin 15 minutes before a meal
A nurse is caring for a client who has a new arteriovenous (av) graft in his left forearm.
Which of the following techniques should the nurse use to assess the potency of this
graft? - answers - auscultate the antecubital area using a doppler stethoscope
The client is admitted to the icu diagnosed with dka. Which interventions should the
nurse implement? Sata - answers - 1. Maintain adequate ventilation.2. Assess fluid
volume status.3. Administer intravenous potassium.4. Check for urinary ketones.5.
Monitor intake and output.
A patient's cardiac rhythm is sinus tachycardia with a heart rate of 124 beats/min. The
nurse would expect the patient to exhibit which of the following clinical associations? -
answers - hypervolemia
A nurse is assessing a client who is admitted for elective surgery and has a history of
addison's disease. Which of the following findings should the nurse expect? - answers -
hyperpigmentation
A triage nurse in an emergency department is caring for a client who has a gunshot
wound to the right side of her chest. The nurse notes a thick dressing on the chest and
sucking noise coming from the wound. The client has a blood pressure of 100/60
mmhg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the
following actions should the nurse take initially? - answers - administer oxygen via nasal
cannula
While reading a client's ecg tracing, the nurse should understand that the p wave
reflects which of the following cardiac electrical activities? - answers - atrial
depolarization
Which assessment is most important for the nurse to make in order to evaluate whether
treatment of a patient with anaphylactic shock has been effective? - answers - oxygen
saturation
The nurse is developing a care plan for a client with hypocalcemia. Which nursing
diagnosis is appropriate for this client? - answers - risk for injury related to tetany and
seizures
The client is admitted to the ed with chest trauma. Which signs and symptoms would
the nurse expect to assess that supports the diagnosis of pneumothorax? - answers -
absent breath sounds and tachypnea
A family member is instructed by a nurse on the interventions for safe swallowing for a
client who has residual effects from a stroke. Which of the following concepts is most
important for the family members to understand? - answers - place the client in the
upright position to facilitate swallowing
A nurse is assessing a client who has an 8 score using the glasgow coma scale to
evaluate levels of consciousness. Which of the following nursing statements most
accurately describes the score? - answers - indicates the need for total nursing care
The nurse is helping a client who was recently placed on a low sodium diet to reduce
fluid retention to choose foods for lunch recommends which lunch menu that would be
most beneficial for this client? - answers - grilled chicken sandwich on white bread,
apple, salad, and iced tea
A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid.
Which of the following clinical manifestations indicates a complication that requires
notifying the provider immediately? - answers - increased hr
The nurse in the neurointensive care unit is caring for a client with a new c6 sci who is
breathing independently. Which nursing interventions should be implemented? -
answers - monitor the pulse oximetry reading
A nurse assesses a comatose, head injured client and finds flexion of the arms, wrists,
and fingers and adduction of the upper extremities. Which of the following describes
these findings? - answers - decorticate posturing
A client comes into the er with complaints of midsternal chest pain radiation to the neck
and left arm which is unrelieved by sublingual nitroglycerin. An electrocardiogram is
obtained. What observationon the ecg or on the cardiac monitor would indicate to the
nurse the need to immediately notify the physician? - answers - an st segment elevation
from the isoelectric baseline
A client comes to the emergency department via ambulance to report severe radiating
chest pain and shortness of breath. The client appears restless, frightened and slightly
cyanotic. The provider prescribes oxygen by nasal cannula at 4 l/min stat, cardiac
enzyme levels, iv fluids, and a 12-lead ecg. Which of the following actions should the
nurse take first? - answers - initiate oxygen therapy
The nurse is obtaining a health history from a client who is visiting the clinic with
complaints of a severe headache. The client provides the following data to the nurse
based on a review systems. The nurse identifies the following as modifiable risk factors
for stroke. Sata - answers - smoking
Obesity
, Decreased physical activity
Alcohol consumption
A nurse is preparing to administer insulin lispro (humalog) to a client who has type 1
diabetes mellitus. Which of the following nursing actions is appropriate? - answers -
inject the insulin 15 minutes before a meal
A nurse is caring for a client who has a new arteriovenous (av) graft in his left forearm.
Which of the following techniques should the nurse use to assess the potency of this
graft? - answers - auscultate the antecubital area using a doppler stethoscope
The client is admitted to the icu diagnosed with dka. Which interventions should the
nurse implement? Sata - answers - 1. Maintain adequate ventilation.2. Assess fluid
volume status.3. Administer intravenous potassium.4. Check for urinary ketones.5.
Monitor intake and output.
A patient's cardiac rhythm is sinus tachycardia with a heart rate of 124 beats/min. The
nurse would expect the patient to exhibit which of the following clinical associations? -
answers - hypervolemia
A nurse is assessing a client who is admitted for elective surgery and has a history of
addison's disease. Which of the following findings should the nurse expect? - answers -
hyperpigmentation
A triage nurse in an emergency department is caring for a client who has a gunshot
wound to the right side of her chest. The nurse notes a thick dressing on the chest and
sucking noise coming from the wound. The client has a blood pressure of 100/60
mmhg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the
following actions should the nurse take initially? - answers - administer oxygen via nasal
cannula
While reading a client's ecg tracing, the nurse should understand that the p wave
reflects which of the following cardiac electrical activities? - answers - atrial
depolarization
Which assessment is most important for the nurse to make in order to evaluate whether
treatment of a patient with anaphylactic shock has been effective? - answers - oxygen
saturation
The nurse is developing a care plan for a client with hypocalcemia. Which nursing
diagnosis is appropriate for this client? - answers - risk for injury related to tetany and
seizures
The client is admitted to the ed with chest trauma. Which signs and symptoms would
the nurse expect to assess that supports the diagnosis of pneumothorax? - answers -
absent breath sounds and tachypnea
