Answers | Exam Prep
1. What is the first action a nurse should take when a client shows a change in
mental status after a head injury?
Plan to check his vital signs again in 30 minutes.
Administer oxygen per nasal cannula at 2 L/min.
Ask the client why he thinks there are bugs in the bed.
Notify the health care provider of the change in mental status.
2. A patient with small cell lung cancer is admitted with symptoms of confusion,
nausea and vomiting, weight gain, and severe thirst. Laboratory values
include serum sodium of 123 mEq/L, serum potassium of 3.8 mEq/L, serum
calcium of 9 mg/dL, serum creatinine of 0.4 mg/dL. The nurse prepares to
treat this patient for which of the following?
Tumor lysis syndrome
Acute renal failure
Syndrome of inappropriate antidiuretic hormone (SIADH)
Hypercalcemia of malignancy
3. In a clinical scenario, if a nurse observes that a child with rheumatoid arthritis
is experiencing significant morning stiffness, what intervention should the
nurse prioritize based on best practices?
Encourage the child to perform vigorous exercises before getting out
of bed.
Advise the parents to keep the child in bed longer to avoid pain.
Warm the child with an electric blanket prior to getting the child out
of bed.
, Immediately administer NSAIDs to the child.
4. The parents of a child with a new diagnosis of JIA asks why the child has so
much pain. What would a correct response from the nurse be?
"Adherence to anti-inflammatory medications will reduce overall pain."
"This disease destroys the joint tissues that normally lubricate the
joint and make motion smooth and pain-free."
"The pain is directly related to the child's developmental stage; the
older the child, the more pain the diagnosis will cause."
"The severe pain is related to immobility because the child will hold
the affected joint still for an extended period."
5. A nurse is caring for a client with emphysema who is experiencing acute
shortness of breath. What additional nursing intervention should be
implemented alongside positioning the client upright and forward?
Administer supplemental oxygen as prescribed.
Encourage the client to lie flat to ease discomfort.
Provide a sedative to calm the client.
Increase the room temperature to promote relaxation.
6. Why is it necessary for the nurse to remove a client's nail polish and dentures
before surgery?
It is only necessary if the client requests it.
Removing nail polish and dentures prevents complications during
surgery and ensures proper monitoring.
It helps the client feel more comfortable before surgery.
It is a routine task that can be delegated to UAP.
,7. What should a nurse do regarding a client's personal items before surgery?
Remove the client's nail polish and dentures.
Assist the client to the restroom to void.
Offer the client emotional support.
Obtain the client's height and weight.
8. If the client insists on leaving the hospital despite being advised against it,
what should the nurse do next to ensure safety?
Provide the client with a list of medications to take home.
Allow the client to leave after signing a waiver.
Call security to physically prevent the client from leaving.
Notify the healthcare provider and document the client's decision.
9. Discuss why opioids are contraindicated in patients with increased intracranial
pressure, focusing on their sedative effects.
Opioids enhance cerebral blood flow, making them safe for patients
with ICP.
Opioids do not affect the central nervous system and are safe for all
patients.
Opioids are used to decrease intracranial pressure effectively.
Opioids can cause sedation, which may lead to respiratory
depression and further increase intracranial pressure.
10. What does a visual acuity of 20/100 indicate about a client's vision?
This line should be seen clearly when the client wears corrective
lenses.
, This visual acuity result is five times worse than that of a normal
finding.
A client with normal vision can read at 100 feet what this client
reads at 20 feet.
This client can see at 20 feet what a client with normal vision can see
at 100 feet.
11. Why is it appropriate for the charge nurse to assign the multiparous client to
the new nurse?
The multiparous client is in active labor and needs constant
monitoring.
The multiparous client is experiencing complications that require
expert care.
The multiparous client is in a stable condition that is manageable for
a new nurse.
The multiparous client requires advanced interventions that the new
nurse cannot perform.
12. Why is it critical for the nurse to notify the health care provider when a client
exhibits confusion after a head injury?
It is a routine procedure that does not require urgency.
It allows the nurse to avoid taking immediate action.
Notifying the health care provider is essential to ensure timely
assessment and intervention for potential complications.
It helps the nurse to gather more information about the client's
condition.