NSG 321 V4 EXAM QUESTIONS AND ANSWERS

NSG 321 V4 EXAM QUESTIONS AND ANSWERS 1. A client diagnosed with a deep vein thrombus (DVT), followed by a diagnosis of pulmonary embolism (PE), is receiving heparin via an infusion pump at a rate of 1400 U/hr. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home.” What response is best for the nurse to provide? A. “Heparin prevents future blood clot formation, but your risk of bleeding needs to be monitored closely.” 2. A male translator is working with the nurse who is giving discharge instructions to a non-English speaking client. When the translator restates what he nurse is saying, it appears that he is saying much more than what the nurse said. What action should the nurse take? A. Ask the translator if there is a reason for the lengthiness of the translation. 3. A nurse is named as a defendant in a malpractice case. What action should the nurse take? A. Contact the nurse’s professional liability insurance company. 4. A female client admitted to a long-term care facility appears to be confused and frightened. She offers her belongings, including valuable jewelry, to members of the nursing staff if they promise to stay with her and not leave her alone. What action should the nurse implement? A. Make and inventory of the belongings and send the valuables home with a family member. 5. The nurse is teaching a childbirth education class to prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? A. Leaking of fluid from the vagina. 6. The nurse performs a series of heel sticks to obtain glucose levels on a large-for-gestational age (LGA) newborn. Because the glucose was 48 mg/dl on admission and 39 mg/dl one hour later, a venous specimen for laboratory analysis of serum glucose concentration is obtained. What action is most important for the nurse to implement? A. Take the newborn to the mother to breastfeed. 7. A home health care agency set the goal: “Use informatics as a method for improving health care delivery.” What nursing action is directed toward achieving this goal? A. Enter accurate client data into clients’ computerized medical records. 8. A 15-year-old client with a spinal cord injury develops spastic leg tremors, sweating, and a headache. Which action should the nurse implement ? Palpate the bladder for distention 9. The DASH (Dietary Approaches to Stop Hypertension) diet is prescribed for a client with uncontrolled hypertension. Which dietary choices should the nurse instruct the client to eat? Shredded wheat 10. An adult female client is admitted to the psychiatric unit because of a complex hand washing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client’s hand washing is an example of which clinical behavior? Compulsion 11. The nurse should instruct the parents of an 11-year-old with Type I diabetes mellitus to carefully watch their child for the symptoms of diabetic ketoacidosis. In which situation is the child most at risk for becoming ketoacidotic ? During the course of an acute illness 12. A man who has a known problem with alcohol is accused of stealing from his employer. When he returns home that evening, he accuses his son of stealing from school, and physically abuses the child for what the father describes as the child’s dishonest behavior. Which two defense mechanisms are being used by the father Projection and displacement 13. ACE inhibitor is prescribed for male with diabetes whose BP is 120/60. He asks the nurse why he is getting the med when his BP is normal. Response? It slows the progression of kidney damage often associated with diabetes 14. When irrigating an occluded NG tube, what action should the nurse include? Measure the amount of fluid instilled and returned 15. Nursing diagnosis, “high risk for infection” is most relevant for client with which hematologic problem? Agranulocystosis 16. 36hrs after delivery, nurse assesses client’s fundus just above the umbilicus and displaces to the right of midline. What action? Palpate bladder for distention 17. In assessing client diagnosed with left- sided HF, nurse observes new findings of Jugular venousdistension (JVD) and pedal edema. What action? Notify HCP of the onset of R-sided failure 18.Identify location of tragus on the outer auricle. Little bump inside 19. Pt with AV graft for hemodialysis in left forearm and an infiltrated IV in right arm. After disconnecting the IV, where to start the next IV? R arm proximal to the former IV 20. 10 yr old boy reports words on teacher powerpoint presentations are blurry even though sits in front row of classroom. Based on this, which problem? Myopia 21. After phenobarbitol to infant with ICP, which response should nurse expect? Infant is sleepy and less irritable 22. A grant is awarded to provide primary preventative health care to a community-based healthcare system. When designing the program to meet the grant objective, which services should the nurse consider for inclusion? Breast screening for older women Blood pressure assessments 23. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. Action? Counsel the client about the importance of notifying his sexual partner(s) 24. Two hours after delivering a 9 lb infant, a client saturates a perineal pad every 15 minutes. Although an IV containing Pitocin is infusing, her uterus remains boggy, even with massage. The HCP prescribes methylergonovine (Methergine) 0.2 mg IM STAT. which complication should the nurse be alert to client developing? HTN 25. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in the bed. The client is diaphoretic, has a radial pulse of 110 and a respiratory rate of 35. What assessment should the nurse perform first? Pain scale 26. A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. Response? “ I cannot acknowledge if a client is here or not” 27.Which situation is a violation of the client confidentiality, as described in the Health Insurance Portability Accountability Act (HIPPA)? A nurse’s handwritten notes from a telephone report discarded in the office wastebasket 28. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway? Bilateral breath sounds can be auscultated 29. The HCP prescribes lidocaine (Lidoject-1) 100mg IV push for ventricular tachycardia (VT) for an unconscious client. Intervention? Infuse lidocaine (Lidoject-1) at 20-50 mg/minute 30. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates intervention? The client repeatedly falls asleep while talking with the nurse 31. A male client with Addison’s disease tells the nurse that he is taking hydrocortisone in a divided daily dose. He reports increasing fatigue and weakness. What action should the nurse take? Interview the client about any sources of increased stress in his life 32. The charge nurse in the Labor and Delivery Unit makes assignments for a nurse and unlicensed assistive personnel (UAP). A client in labor is admitted with contractions occurring every 3 to 5 minutes. Which task should be assigned to the UAP? Collect a urine specimen 33. With the client’s eyes closed, the nurse places a common object in the client’s hand and asks the client to describe the object. The client accurately names the object. How should the nurse document the assessment finding ? Positive for stereognosis 34. After a 92-year-old client fractured a hip trying to get out of bed, a nurse is accused of failing to notify the healthcare provider that the client was disoriented. In determining whether the nurse is guilty, a jury would consider which standard What a reasonable and prudent nurse would have done in the same situation 35. While reporting BG results to nurse, LPN states the glucometer was not calibrated prior to use because the report given by the night shift staff ran late. What action? Advise the LPN of the implications involved by not calibrating the glucometer 36. Female client instructed to do kegel exercises. What statement indicates the client understands how to perform? “When I urinate I should tighten those muscles and stop the flow of urine for 10 sec and repeat this 5-10 times” 37. Charge nurse should intervene when what behavior is observed? Hospital transporter is reading a Pts H&P while waiting for an elevator 38.Client who has L AKA 2 days ago has a soft stump dressing. To prevent the development of contracture on the left leg, which intervention? Position client prone 3-4 times a day 39. 40 yr old with type 1 developed CKD 6 mos ago from secondary complications associated with this illness. Nurse carefully assesses for? Anemia 40. Nurse developing plan of care for Pt returning from surgery after total cholectomy and ileostomy. Which diagnosis has the highest priority for the client in immediate post-op period? Risk for electrolyte imbalance R/T ileostomy 41. Which approach is best for the nurse to use when communicate with a client with ALS? Demonstrate a positive, caring demeanor 42. Client diagnosed with schizophrenia looks frightened and tells nurse “keeps hearing voices telling me to hurt somebody” Don’t you hear them?” Nurse response? 43. “I don’t hear the voices, but you seem very frightened” Newly diagnosed type 1 D receives 28 units of Humulin N at 0700. Nurse is making rounds at 1330. Which client statement requires immediate follow-up intervention? “I let my wife eat my lunch since I wasn’t hungry” 44. During breath sound auscultation of Pt being mechanically ventilated, nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. What implement? Suction the client’s ET tube 45. At community health fair, 50 yr old tells nurse she has an annual physical exam that includes a clinical breast exam and annual mammogram. How to respond? Ask woman if she also performs monthly breast self-exams 46. Adult woman and live-in boyfriend are seen in the ED following MVA. Based on which finding should further assess for domestic violence? Several old bruises appear in the woman’s chest and neck 47. Nurse knows the pt with a mechanical valve replacement understands the DC teaching. When states? “I will need to take antibiotics before any type of invasive dental work” 48. Parent s who have one male child with sickle cell anemia are concerned about having more children with the disease. What client teaching should the nurse provide? There is a chance that each future child will have the disease 49. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first? Assess the client for pallor 50. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever? Positive ASO titer 51. A client who is scheduled to have surgery in two hours tells the nurse, “My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.” Action? Call the surgeon back to clarify the information with the client 52. When the nurse is designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic? Preoperative and postoperative teaching for adrenalectomy 53.A two-year old boy begins to cry when his mother starts to leave. Best response? “let me read this book to you” 54. Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client’s signature on the consent form? The obstetrician explained a procedure that a neurologist will perform 55. An 8 year old child who weighs 60 lbs receives an order for polycillin (Ampicillin) suspension 25mg/kg/day divided in a dose every 8 hours. The medication is labeled “125mg/5ml.” How many ml should the nurse administer? 9 56. A 3-year old comes to the clinic for a well-child check up. Which respiratory assessment finding should the nurse expect this child to exhibit? Bronchovesicular breath sounds in the peripheral lung fields 57. The charge nurse is making assignment for clients on an endocrine unit. Which client is best to assign to a new graduate nurse? A perimenopausal woman with Grave’s disease who is nervous and has exophthalmos 58. A client is admitted with a medical diagnosis of acute pancreatitis. When taking the health history, which client complaint should be expected? Severe mid-epigastric pain after ingesting a heavy meal 59. An adult make who returned from a vacation in Mexico three weeks ago calls the clinic complaining of abdominal pain, weight loss, and diarrhea. What action should the nurse take? Instruct the client to bring in a stool sample 60. A newly graduated and licensed registered nurse (RN) is in the second day of orientation to the hospital unit. The education director tells the charge nurse that the new graduate should be assigned to care for one client. Which client is best for the nurse to assign to this new graduate? A client who is 4-days post myocardial infarction 61. A female who was admitted for alcohol detoxification is nauseated and describes feeling like roaches are crawling all over her. She is tremulous, and her blood pressure is 146/92; her pulse rate is 94 beats/minute; and her temperature is 100.8oF. Which PRN medication should the nurse administer first? Lorazepam (Ativan) 62. A male client with bipolar disorder has difficulty concentrating and plans to attend group for the first time. He tells the nurse that he will try to stay for the music relaxation group. After 20 minutes in the group, he becomes restless and begins to leave. What should the nurse do Allow the client to leave the group 63. Identify the placement of the stapes footplate into the bony labyrinth. (on the pic) A 60 yr old male with type 2 DM tells the nurse that he is going to join a gym and start working out. Which information is most important for the nurse to obtain? Exercise tolerance test with EKG results 64. A client is receiving an IV infusion of regular insulin, 75 units in 100 ml of normal saline at 9 units per hr. The nurse should program the pump to deliver how many ml/hr? 12 65. A new mother asks the nurse if her newborn infant has an infection because the HCP prescribed a blood test called TORCH screen test. Response? Exposure to infections that can cross the placenta cause a positive antibody titer 66. Which technique(s) should the nurse use to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Ensure that the needle is inserted into the skin with the bevel up Use a 25 gauge ½ inch needle on a 1 ml calibrated syringe Assess skin for a bleb when injecting the tuberculin antigen (ID) 67. Following rectal surgery, a female client seems very anxious about the pain that she may experience during defecation. The nurse should collaborate with HCP to administer which type of medication? Stool softener 68. Which nursing entry to the client record best reflects significant data on a male client who admitted with complaints of chest pain? Client states he will notify the nurse if chest pain returns 69. A 37 year old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client’s plan of care? High risk for injury related to ambulation 69.To assess for the presence of diaphragmatic breathing, what action should the nurse take Observe the movement of the abdomen 70. The nurse and a social worker are talking when a male client with psychosis angrily shouts at the nurse, “Stop talking about me.” The nurse should document the client is exhibiting which symptom Ideas of reference 71. Before administering a parenteral nutrition solution through a central vein, the nurse should confirm information from which sources Client’s identification band Healthcare provider’s prescription Solution label Medication administration record 72. A male client with chronic asthma tells the nurse that he is having more episodes of bronchoconstiction and increased mucous production. Which action should the nurse implement? Determine if rescue inhaler is being used first during an acute episode 73. The nurse plans to administer 5,000 units of heparin, an anticoagulant. Which procedure should the nurse implement when administering this drug? Assess all needle insertion sites daily for hematoma and signs of inflammation 74. A new mother tells the nurse that she does not want her newborn to receive any immunizations. It is the hospital’s policy to routinely administer immunizations to all newborns. What intervention should the nurse implement ? Document that the mother has refused immunization permission for her newborn 75. A client in the third trimester of pregnancy reports that she feels some “lumpy places” in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? Explain that this normal secretion can be assessed at the next visit 76. A frail, elderly female with rheumatoid arthritis (RA) complains to the nurse that the weight of the sheets on her legs hurts all the time. Which action should the nurse implement ? Use a bed cradle to keep linens off her legs 77. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? Ask the client about gastrointestinal pain 78. The nurse on a busy surgical unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client is best to assign to the PN? A preoperative client who has developed urinary retention and needs a urinary catheter inserted 79. The nurse manager of a pediatric unit needs to assign a room for a 6- month-old diagnosed with respiratory syncytial virus (RSV). Which room assignment? 80. Nurse overhears 2 employees discussing confidential pt info in cafeteria. Breach of which ethical principle? Fidelity 81. Preparing to administer liter of IV solution to toddler with gastroenteritis who is dehydrated. Which action to prevent overload? Attached a volume-control device below the primary infusion 82. Assessing a 6 yr old, notices several elevated 1-3 mm white spots in the buccal mucosa. What other signs to look for? Red, blotchy macular rash on face and neck 83. Teaching using a Holter monitor, which statement indicates understanding the procedure? “I must record any symptoms occurring with my activity” 84. Female diagnosed with major depression admitted to psych unit. Refuses to take a bath, dress, eat, and wants to sleep during day. Which intervention? Provide and maintain a safe, structured daily routine 85. Pt with chronic controlled A-fib develops symptoms of PE. What intervention? Monitor O2 saturation via pulse Ox 86. School-aged child with OM receives Rx for Azithromycin 300mg once, then 150 mg daily for 4 days. Med is avail in solution containing 200mg/5ml. How many mls should nurse administer on the 1st day of Tx? 7.5ml 87. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical? Metabolic alkalosis 88. A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Intervention? Inquire about possible use of anabolic steroids 89. Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope? Blood pressure 89. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents? Worming movements of tongue 90. What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS? Recent history of recurrent pneumonia 91. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client’s right leg Right calf is 3 cm larger in circumference than the left 92. The nurse is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client? Bilirubin 93. The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse? A 78 year old female on a fixed income who lives with her relatives 94. Before administering an intramuscular injection, the nurse’s finger is stuck with the needle. Action? Prepare the medication using a new syringe 95. The nurse notices that a client with DM type 1 has a fruity breath odor. Priority action? Measure the client’s capillary blood glucose 96.A client receives a prescription for acetylcysteine (Mucomyst) 1.4 grams per nasogastric tube q4 hours. Acetylcysteine is available in a 10% solution (10 grams/100ml). How many ml of the 10% solution should the nurse administer per dose? 14 97. A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Intervention? Sit upright and flex chin forward while swallowing 98. When preparing the client for a thoracentesis, it is An older male client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) is on strict bed rest, and asks the nurse, “Why can’t I get out of bed?” what response for the nurse to provide? Bed rest decreases your body’s need for oxygen 99. At 1000 the healthcare provider prescribes an increased in the dosage of a client’s loop diuretic from 40 mg to 80 mg a day. The nurse has already administered today’s 40 mg dose of the loop diuretic at 0600. Which action should the nurse implement ? Clarify the start date of the new dose with the healthcare provider 100. Which client situation requires the most immediate intervention by the nurse ? A bedfast client experiences an episode of urinary incontinence 101. A terminally ill client on a palliative care unit has an advanced directive stipulating comfort measures only. The client has not taken oral fluids in the last 36 hours and is not receiving intravenous fluids. The client’s blood pressure is 64/38 and urinary output is 50 ml for the last 12 hours. What is the priority nursing intervention? Determine the client’s level of discomfort 102. A sign of cough in a pregnant woman may indicate a sign of cardiac disease 103. Breast engorgement wear support bra 104. New born crying and shaking check blood sugar 105. Halo traction always leave pliars at the bedside 106. Question about skin cancer answer is basal cell carcinoma 107.Accutane (acne medication) instruct the client to stop taking vitamins(vitamin A) 108. Patient receiving internal radiation and the source becomes dislodged 109. use long handled forceps to place the source in the lead container in the clients room 110. Paracentesis have the client void before the procedure 111. Give Carafate 2 hours apart from other meds 112. Question about nasal decongestants medication Alternate the nostrils when giving the medication 113. Abdominal aneurysm Lower back pain is a sign of an emergency 114. Bell’s Palsy inability to raise the eyebrows, frown, smile, close the eyes (question was something about how to tell if the client is having a stroke or if its something else) 115. ALS Disease the nurse should monitor the can while feeding the patient 116. Kyphosis check the spine (sorry I don’t remember the question) 117. Lumber Puncture lie flat and monitor for headaches 118. Pheochromocytoma monitor blood pressure 119. Recommended foods to help prevent rickets fortified milk 120. Client who is on a clear liquid diet have a cup of coffee remind the client not to put any milk or cream in the coffee 121. One of the math questions answer was 0.75 122. Video with student demonstration of feeding tube multiple choice- (the instructor was watching her and she needs to identify what the student needs to do) it’s more than one answer suppose to put one in at a time 123. A person on a camping trip splint the leg with branches 124. Abo incompatibility-know when to administer rh immune globulin rh negativie mom, and rh positive baby 125. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a BP of 90/50, and Pulse of 112. Which triage tag color should the nurse place on this client? Red 126. Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)? Monitor serum creatinine levels 127. A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data? Breath sounds 128. A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with the client, which information is most important? The nurses’ feelings about this client 129. Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia? A middle-aged male client in renal failure following an unsuccessful kidney transplant 130. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. Action? Measure the length of the apneic periods 131. A client in the oliguric phase of acute renal failure (ARF) has a 24 hour urine output of 400ml. nurse should allow this client to have how much oral intake during the next 24 hours? Limit oral intake to 900 to 1000 ml 132. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks her what happened. She doesn’t respond. Next? Take the client to a room for supervision by staff 133. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)? Inspection of the mouth 134. The nurse is preparing to administer an IM dose of Vitamin B1 (thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “what do you think you’re doing?” Response? “this shot will help relieve the pain in your feet” 135. When administering an intramuscular injection containing 3 ml of a painful medication, Intervention? Select a large, deep muscle mass 136. Nurses working in L & D are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to L & D is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. Action? Propose a method for self-staffing labor and delivery 137. Locate the optic disk It is the really light area on the right 138. The nurse who is performing blood sugar and cholesterol screenings at a community health fair determines that a female client’s blood sugar is 59 mg/dl at 10:00 a.m. Which nursing intervention is most important for the nurse to implement ? Ask the client how she is feeling 139. The nurse is responding to telephone messages at a psychiatric day clinic. Which client situation requires immediate intervention by the nurse ? The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her 140. A mother reports to the nurse that the thick-honey-colored crusts on her child’s legs began as flat red spots. This is highly indicative of what condition? Impetigo 141. A young woman is preparing to leave for a 7-day boat trip. She requests a prescription for motion sickness so the healthcare provider prescribes meclizine (Antivert). Which instruction should the nurse include in this client’s teaching ? Suck on hard candy for a dry mouth while taking this drug