NURSING 428 Trends Exit Exam Questions with Answers

NURSING 428 Trends Exit Exam Questions with Answers 1. The nurse assesses a client one hour after starting a transfusion of packed RBC and determines that there are no indicators of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel UAP who is working with the nurse? a. Notify the nurse when the transfusion has finished, so further client assessment can be done b. Monitor the client carefully for the next three hours and report the onset of the reaction immediately c. Continue to measure the client’s vital signs every thirty minutes until transfusion is complete d. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion 2. An older client is brought to the clinic for appointment by a grandson. The client is withdrawn and allows the grandson to answer the nurse’s questions. The nurse observes the grandson makes frowning facial expressions and shakes his head sighing when speaking to the client. Which action the nurse take next? a. Ask the client if an assisted living facility has been considered b. Request social services to make a home visit c. Interview the client privately without the family member present d. Complete a neurological and musculoskeletal assessment 3. The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected? a. Skin of palms of the hand b. Current height and weight c. Condition of tooth enamel d. Length of the last menses 4. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-guage needle. Which action should the charge nurse implement? a. Prompt the nurse to apply povidone to the site b. Suggest the nurse use a 20-guage needle c. Direct the nurse to change the IV tubing d. Instruct the nurse to remove the needle 5. After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? SATA a. Location of the initial IV site b. Swollen lymph nodes in the groin c. White blood cell count (WBC) d. Core body temperature e. Red blood cell count (RBC) 6. A client has an abdominal wound dehiscence when the surgical staples are removed. What intervention should the nurse implement first. a. Place the client in protective (reverse) isolation b. Notify the surgeon immediately c. Place a saline dressing over the wound d. Assess the client’s bowel sounds 7. After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client ‘s serum creatinine is 0.3mg/dL (22.9 micro….). which action should the nurse implement? a. Assess the client for signs of hypokalemia b. Initiate the urine collection as prescribed c. Notify the healthcare provider of the results d. Evaluate the client’s serum BUN level 8. The nurse is preparing to administer histamine 2 -receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug? a. Destroys microorganisms causing stomach inflammation b. Neutralizes hydrochloric acid (HCl) in the stomach c. Inhibits action of acetylcholine by blocking parasympathetic nerve endings d. Decreases the amount of HCI secretion by the parietal cells in the stomach 9. The nurse is working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse do first? a. Assess the level of consciousness and vital signs for both clients b. Complete a head-to-toe assessment of the client with pneumonia c. Change the surgical dressing to observe the appearance of the incision d. Review the plan of care and the medications that are due to both clients 10. Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)? a. An adult client in remission after a series of chemotherapy treatments who is receiving intramuscular iron injections for anemia b. A middle-aged male client who has just undergone an excisional biopsy and has been told that his tumor appears to be benign c. A young adult client who is experiencing fatigue while undergoing a series of external beam radiation treatments for stage one cancer d. An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease Control 11. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? a. Peripheral edema b. Ketonuria c. Elevated blood pressure d. Hypokalemia 12. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic pain. A nasogastric tube and left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds on the left side, and chest movement that occurs only on the right side of the thorax. Which procedure should the nurse prepare for first? a. Insertion of a left-sided chest tube b. Set-up of patient-controlled analgesia c. Retraction of the nasogastric tube d. Placement of an endotracheal tube 13. A older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms? a. Destruction of joint cartilage b. Infectious process in the synovial fluid c. Systemic inflammatory response d. loss of bone mineral density 14. The father of a four year old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his health care provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. Reassure the client that his child will be allowed to visit b. Provide the client written information about end-of-life care c. Obtained a detailed report from the nurse transferring the client d. Mark the chart with the client’s request for no heroic measures 15. In evaluating the effectiveness of postoperative client’s intermittent pneumatic compression device, which assessment is most important for the nurse to complete? a. Evaluate the client ability to use an incentive spirometer b. Observe both lower extremities for redness and swelling c. Palpate a peripheral pulse points for volume and strength d. Monitor the amount of drainage from the client’s incision 16. The nurse implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective a. Average client scores improved on specific risk factor knowledge tests b. Healthcare providers prescribed 40% more human papillomavirus (HPV) vaccines c. Condoms were provided in all health clinics in the community colleges d. More than 50% of at-risk clients were diagnosed early in their disease process 17. The nurse is preparing discharge instruction for an older client with heart failure who will be starting a new prescription medications. Which action should the nurse take when reviewing the instructions with the client? a. Stand behind the client to avoid intimidation b. Provide handouts written at 12th grade reading level c. Turn on the overhead light when giving instructions d. Use background music to promote relaxation 18. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the healthcare provider? a. Pruritus and muscle aches b. Vomiting and diarrhea c. Decreased white blood cell count d. Elevated liver function tests 19. The nurse on the pediatric unit observes a distraught mother in the hallway scolding her 3-year- old son for wetting his pants. What initial action should the nurse take? a. Inform the mother that toilet training is slower for boys b. Refer the mother to a community parent education program c. Suggest that the mother consult a pediatric nephrologist d. Provide disposable training pants while calming the mother 20. While caring for a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s laboratory values? a. Serum blood glucose (BG) level b. Creatinine level c. Serum albumin d. Culture for sensitive organism 21. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? a. Advise the client to maintain bedrest so that safety can be ensured b. Instruct the UAP that all clients deserve equal care c. Assign another UAP to care for the client d. Determine the client’s level of mobility and need for assistance 22. What action should the nurse take first when a client is advertently given an incorrect dose of a medication? a. Notify the healthcare provider b. Assess the client for any adverse effect c. Complete an incident report documenting the facts d. Document the events leading to the error in the nurses notes 23. The nurse is assessing a client who is receiving enteral feedings. Which clinical data indicate the client may not be tolerating the tube feeding? SATA a. Absent bowel sounds b. Nausea and vomiting c. Flatulence d. Abdominal cramping e. Abdominal tympany 24. A nurse receives report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the clients perineal pad hourly, and that it is again saturated. The previous nurse also reports that the client’s urinary output has decreased. Which action should the nurse implement first? a. Assess for weakness or dizziness b. Change the perineal pad c. Evaluate skin turgor d. Measure the urinary output 25. After receiving the Braden Scale findings of residents at a long-term facility, the charge nurse should tell the unlicensed assistive personnel (UAP) to provide skin care for which client? a. A woman with osteoporosis who is unable to bear weight b. An older adult who is unable to communicate elimination needs c. A older man whose sheets are damp each time he is turned d. A poorly nourished client who requires liquid supplements 26. There are some lab values that I am not able to see clearly A female client with a history of heart failure (HF) arrives at the clinic after what she describes as a very long trip. Following the initial physical assessment and chart review, which priority action should the nurse implement? a. Administer the prescribed diuretic b. Give potassium supplement c. Reteach medication regimen d. Auscultate and heart sounds 27. A middle-aged client admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on this client’s age and recent life-threatening crisis, which intervention should the nurse implement? a. Allow long periods of uninterrupted rest in order to reduce fatigue b. Discuss the cause of the accident with the client and his family c. Provide a routine schedule of activities to facilitate trust d. Encourage the client to reflect on personal goals and priorities 28. A client with Alzheimer’s Disease (AD) is receiving trazodone, a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? a. Confirm that the desired effect of the medication has been achieved b. Explain that it may take several weeks for the medication to be effective c. Evaluate when and how the medication is being administered to the client d. Notify the healthcare provider that a change in dosage may be needed 29. A client who weighs 176 pounds receives a prescription for lorazepam 0.05mg/kg intramuscularly 2 hours before a scheduled procedure. The medication is available in 4mg/mL. how many mL should the nurse administered? (enter numeric value only) 30. The nurse is admitting a client with a history of gout. In assessing the client’s hand, how should the nurse assess for the presence of tophi? a. Palpate for hand nodules on the fingers b. Listen for grating sound with joint flexion c. Observe knuckle joints for erythema d. Note the appearance of the fingernails 31. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? a. Observe the infant latching onto the breast b. Administer vitamin k injection c. Place the ID bands on the infant and the mother d. Obtain the infants vital signs 32. A client is recovering in the critical care unit following a cardiac catherization. IV nitroglycerine and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. What action should the nurse implement? a. Stimulate the client to take deep breaths b. Assess distal lower extremity capillary refill c. Evaluate the integrity of the IV insertion site d. Check femoral site for hematoma formation 33. A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is distended, blood pressure is elevated, and 6,500 mL were infused while 5, 500 mL were drained. In response to this finding, what action should the nurse take? a. Turn the client from side to side b. Irrigate the drainage tube with normal saline c. Lower the head of the bed d. Instruct the client to cough 34. An older client with a 3 day history of abdominal distention is admitted with a small bowel obstruction. The nurse inserts a nasogastric tube and attaches it to low intermittent suction. Which ongoing client assessment takes priority when providing care? a. Auscultate bowel sounds b. Monitor fluid balance c. Observe skin integrity d. Measure abdominal girth 35. A female client with dementia who needs assistance with meals and activities of daily living often screams at the staff and threatens to hit those who come near her. Which nursing problem should be included in the treatment plan? a. Risk for acute confusion b. Risk for other-directed violence c. Impaired verbal communication d. Caregiver role strain 36. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important to the nurse to include in the discharge plan? a. Encourage self-care and independence b. Teach tracheal suctioning techniques c. Explain how to use communication tools d. Demonstrate how to clean tracheostomy site 37. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? a. Review the client’s current list of medications b. Check the client’s hemoglobin level c. Assess the client for the presence of hemorrhoids d. Administer a prescribed PRN antiemetic 38. A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to maintaining physical safety, which short-term goal should the nurse include in the plan of care? a. Engages in one client-to-client interaction daily b. Sleeps at least 6 hours per night c. Attends one group activity per day d. Consumes 3 meals and 1500 mL of fluid per day 39. Which self care measure is most important to the nurse to include in the plan of care of a client recently diagnosed with type2 diabetes mellitus? a. A realistic exercise plan b. Blood glucose monitoring c. Diabetic diet mela planning d. Self-injection techniques 40. The nurse is providing discharge instruction to a client who is receiving sertraline 50 mg by mouth daily for depression. Which symptom should the nurse tell the client to report to the healthcare provider? a. Gastric irritation b. Rapid weight gain c. Dry mucous membrane d. Photosensitivity 41. An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the emergency department in respiratory distress. The healthcare prescribed furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF? a. Decreased afterload b. Reduced preload c. Relaxed vascular tone d. Increased cardiac contractility 42. A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Witness consent for procedure b. Identify client’s pulse points c. Prepare skin for procedure d. Check telemetry monitoring 43. Which intervention should the nurse implement when beginning a physical assessment of a 6- month-old infant? a. Instruct the caretaker to place the infant on the exam table b. Suggest that the caretaker stand at the foot of the exam table c. Allow the child to remain in the caretaker’s lap d. Direct the caretaker to place the infant supine in the crib 44. After inflating a blood pressure cuff an releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next? a. Continue with the blood pressure assessment b. Reinflate the cuff to a higher number c. Note the presence of an auscultatory gap d. Reposition the stethoscope over the brachial artery 45. A client with chronic obstructive lung disease who is receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take? a. increase oxygen to three liters/minute b. ask the client to take short, rapid breaths c. have the client breathe into a paper bag d. instruct the client in pursed lip breathing 46. A young female adult wanders into the emergency department. She is disheveled and confused and states, “My date must have put something in my drink. He took my car, and I think he raped me. I don’t exactly remember, but I know he hurt me”. How should the nurse respond? a. He hurt you? What makes you think you were raped? b. Yes, I can see. Tell me more about what you remember c. Did you try to resist or fight back when you were attacked? d. It is ok to cry, but first we need to take care of your injuries 47. An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150 mL of dark brown emesis. In what order should the nurse implement these interventions? (arrange with the highest priority intervention on top, and lowest priority intervention on bottom) a. Elevate the head of the bed b. Offer PRN medication c. Complete focus assessment d. Send emesis sample to lab 48. Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm? a. Monitor capillary refill distal to the infusion site b. Explain that temporary burning at the IV site may occur c. Assess IV site frequently for signs of extravasation d. Apply a topical anesthetic at the infusion site for burning 49. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying “Kill. Kill”. What question should the nurse ask the client next?