1 A nurse is assessing for early signs of compartment syndrome for a client
who has a short-leg fiberglass cast. Which of the following findings should
the nurse expect?
ACapillary refill less than 2
seconds B.Bounding distal
pulses C.Intense pain with
movement
D. Erythema of the toes
2 A nurse is monitoring a client who is receiving 2 units packed RBCs.
Which of the following manifestations indicates a hemolytic transfusion
reaction?
A. Chills? (think fever, you get cold when your body is hot)
B.Hypertensi
on
C.Bradycardia
D.Back pain
3 A nurse is caring for a client who had a total hip arthroplasty. Which of
the following actions should the nurse take to prevent hip dislocation?
A. Remove the wedge device when turning
B. Place two bed pillows between the legs when in bed
C. Encourage the client to lean forward when attempting to stand
D.Elevate the knees higher than the hips when sitting
4 A nurse is assessing a client who is preoperative and reports an allergy
to bananas. The nurse should recognize that the client is at risk for an
allergic cross-reactivity to which of the following substances
A.Povidone-
iodine
B.Adhesive
tape C.Latex
D. Anesthetics
5 A nurse is teaching a client about the use of an incentive spirometer.
Which of the following instructions should the nurse include in the
teaching?
APlace hands on the upper abdomen during
inhalation. B.Position the mouthpiece 2.5 cm (1
in) from the mouth C. Exhale slowly through
pursed lips
D. Hold breaths about 3 to 5 seconds before exhaling
6 A nurse is caring for a client who arrives at the emergency department
and reports vomiting and diarrhea for the past 3 days. The client's serum
potassium level is 2.8mEqttiL. Which of the following interventions should
the nurse implement first?
Priority question remember, what can I do first, you can start a K+ drip
,without knowing how their heart is affected.
A. Check the clients hand grasps
B. Administer an IV potassium
drip C.Listen to the client's
bowel sounds
, D. Initiate cardiac monitoring for the clients This is a priority!!!
7 A nurse is preparing to administer peritoneal dialysis to a client. Which of
the following actions should the nurse take?
A. Chill the dialysate before administration
B. Hang the drainage bag below the client's abdomen
C. Place the client in high-Fowlers
position DUse clean technique to
access the catheter
8 A nurse is preforming a cranial nerve assessment on a client following a
head injury. Which of the following findings should the nurse expect if the
client has impaired function of the vestibulocochlear nerve (cranial nerve
VIII)?
A. Inability to smell
B. loss of peripheral vision
C. Disequilibrium with movement
D. Deviation of the tongue from midline
9 A nurse is planning care for a client who is one day postoperative
Following an open cholecystectomy. Which of the following interventions
should the nurse include in the plan of care?
Place pillows under the clients
knees B.Avoid use of
anticoagulants C.Discourage leg
exercises while in bed
D.apply compression stockings to the lower extremities
10A nurse is caring for a male client who has an exacerbation of heart
failure. Which of the following prescriptions should the nurse expect to
receive from the provider? (click on the "exhibit" button for additional
information about the client. There are 3 tabs that contain separate
categories of data.)
A. Atropine 1mg IV bolus every 5 min up to 3 mg ?
B. Adenosine 6mg rapid IV bolus
now C.Verapamil 80 mg PO TID
D.Furosemide 40 mg IV bolus every
6 hr.
11A nurse is providing a discharge teaching to a client following a modified
left radical mastectomy with breast expander. Which of the following
statements by the client indicates an understanding of the teaching?
"I will keep my left arm flexed at the elbow as much as possible" ?
"I should expect less than 25 mL of secretions per day in the drainage devices"
"I will perform strength building arm exercises using a 15 pound weight"
" I will have to wait 2 months before additional saltine can be added to my
breast expander"
12A nurse is teaching a client about using a metered-dose rescue inhaler.