Exam 1 Review
The most immediate concern to the nurse for 8am sinus surgery
would be...
At 8:00, the registered nurse is admitting a client scheduled for
sinus surgery to the outpatient surgery department. Which
information given by the patient would be the most of concern to
the nurse?
a. the client has an allergy to iodine and shellfish
b. the client was nauseated after a previous surgery
✅✅
c. the client has a glass of juice before arriving
d. the client expresses anxiety about the surgery - -If the client
had glass of juice before arriving
(Risk for aspiration!)
Client in postoperative phase of his surgical experience. In order to
avoid under medicating the client for acute pain, the nurse should...
a. observed for restlessness, aggression, and increased confusion
b. monitor blood pressure and respirations every 15 to 30 minutes
c. be prepared to administer naloxone (Narcan)
✅✅
d. note evidence of respiratory depression, hypotension, and
nausea - -a. observe for restlessness, aggression, or
increased confusion
Which of the following manifestations does not correlate with the
clinical manifestations of inflammation?
a. Warmth
b. Redness
✅✅
c. Pain
d. Ecchymosis - -d. Ecchymosis
When caring for Claire, a 65-year-old woman suffering from OA
(osteoarthritis), which nursing diagnoses and collaborative
problems would you expect not to follow?
a. Impaired walking related to joint pain
b. Ineffective Coping related to Chronic Pain and decreased
function
, ✅✅-d.
c. Activity intolerance related to pain and fatigue
d. Imbalanced Nutrition: Less than Body Requirements -
Imbalanced Nutrition: Less than Body Requirements
Laboratory tests for a client show a serum potassium level of 2.2
mEq/L. Which of the following nursing actions is the highest
priority?
a. keep the client on bedrest
b. initiate cardiac monitoring
✅✅
c. start oxygen at 2 L/min
d. initiate seizure precautions - -B. Initiate cardiac monitoring
When assessing a client with fluid volume deficit, the nurse would
expect to find:
a. increase pulse and bp
b. dyspnea and respiratory crackles
✅✅
c. headache and muscle cramp
d. orthostatic hypotension and flat neck veins - -d. orthostatic
hypotension and flat neck veins
A client is admitted with a suspected heroin overdose and a
respiratory rate of 5 to 6 per minute. Which of the following
assessment data would the nurse not anticipate?
A. pH 7.29
B. alert and oriented
✅✅
C. PaCO2 54 mmHg
D. HCO3 42 mEq/L - -B. alert and oriented
While working in the emergency department, the RN admits a client
with extensive burn injuries caused by a fire at the client's home.
Which assessment should the RN accomplish first?
a. determine the total body surface area burned
b. breath sounds
✅✅
c. pain level
d. blood pressure - -B. Breath sounds
, During the fluid shift phase of burn management, what diagnostic
test result should the nurse expect to find?
a. increased hemocrit
b. decreased potassium
✅✅
c. increased sodium
d. increased serum albumin - -a. Increased Hemocrit
A RN is planning a teaching session for a 65 year old client who is
responding well to medical management for chronic arthritic pain.
Which is the most important for the RN to consider as he plans for
a teaching session?
a. Chronic noncancer pain serves no biologic purpose.
b. Neuropathic pain is one of the most challenging types of pain
because it results from some type of nerve injury.
c. The gate control theory will help the client understand the
relationship between pain and emotion.
✅✅
d. The client's self-report is the most reliable indication of pain. -
-d. The client's self-report is the most reliable indication of
pain.
The primary role of the nurse in pain management is to advocate
for the patient by believing reports of pain. According to McCaffery,
"pain is whatever the experiencing person says it is and exists
whenever he or she says it does."
In completing the preoperative checklist on a client scheduled for
general surgery, the nurse recognizes which of the following as the
greatest risk for the planned procedure?
a. Age 59
b. Ten pounds over ideal body weight
✅✅
c. Diet-controlled diabetes mellitus
d. Brother had complications with general anesthesia - -c.
Diet-controlled diabetes mellitus
The nurse maintains the privacy of a client having a vaginal
hysterectomy by:
a. Ensuring that drapes minimize perineal exposure
The most immediate concern to the nurse for 8am sinus surgery
would be...
At 8:00, the registered nurse is admitting a client scheduled for
sinus surgery to the outpatient surgery department. Which
information given by the patient would be the most of concern to
the nurse?
a. the client has an allergy to iodine and shellfish
b. the client was nauseated after a previous surgery
✅✅
c. the client has a glass of juice before arriving
d. the client expresses anxiety about the surgery - -If the client
had glass of juice before arriving
(Risk for aspiration!)
Client in postoperative phase of his surgical experience. In order to
avoid under medicating the client for acute pain, the nurse should...
a. observed for restlessness, aggression, and increased confusion
b. monitor blood pressure and respirations every 15 to 30 minutes
c. be prepared to administer naloxone (Narcan)
✅✅
d. note evidence of respiratory depression, hypotension, and
nausea - -a. observe for restlessness, aggression, or
increased confusion
Which of the following manifestations does not correlate with the
clinical manifestations of inflammation?
a. Warmth
b. Redness
✅✅
c. Pain
d. Ecchymosis - -d. Ecchymosis
When caring for Claire, a 65-year-old woman suffering from OA
(osteoarthritis), which nursing diagnoses and collaborative
problems would you expect not to follow?
a. Impaired walking related to joint pain
b. Ineffective Coping related to Chronic Pain and decreased
function
, ✅✅-d.
c. Activity intolerance related to pain and fatigue
d. Imbalanced Nutrition: Less than Body Requirements -
Imbalanced Nutrition: Less than Body Requirements
Laboratory tests for a client show a serum potassium level of 2.2
mEq/L. Which of the following nursing actions is the highest
priority?
a. keep the client on bedrest
b. initiate cardiac monitoring
✅✅
c. start oxygen at 2 L/min
d. initiate seizure precautions - -B. Initiate cardiac monitoring
When assessing a client with fluid volume deficit, the nurse would
expect to find:
a. increase pulse and bp
b. dyspnea and respiratory crackles
✅✅
c. headache and muscle cramp
d. orthostatic hypotension and flat neck veins - -d. orthostatic
hypotension and flat neck veins
A client is admitted with a suspected heroin overdose and a
respiratory rate of 5 to 6 per minute. Which of the following
assessment data would the nurse not anticipate?
A. pH 7.29
B. alert and oriented
✅✅
C. PaCO2 54 mmHg
D. HCO3 42 mEq/L - -B. alert and oriented
While working in the emergency department, the RN admits a client
with extensive burn injuries caused by a fire at the client's home.
Which assessment should the RN accomplish first?
a. determine the total body surface area burned
b. breath sounds
✅✅
c. pain level
d. blood pressure - -B. Breath sounds
, During the fluid shift phase of burn management, what diagnostic
test result should the nurse expect to find?
a. increased hemocrit
b. decreased potassium
✅✅
c. increased sodium
d. increased serum albumin - -a. Increased Hemocrit
A RN is planning a teaching session for a 65 year old client who is
responding well to medical management for chronic arthritic pain.
Which is the most important for the RN to consider as he plans for
a teaching session?
a. Chronic noncancer pain serves no biologic purpose.
b. Neuropathic pain is one of the most challenging types of pain
because it results from some type of nerve injury.
c. The gate control theory will help the client understand the
relationship between pain and emotion.
✅✅
d. The client's self-report is the most reliable indication of pain. -
-d. The client's self-report is the most reliable indication of
pain.
The primary role of the nurse in pain management is to advocate
for the patient by believing reports of pain. According to McCaffery,
"pain is whatever the experiencing person says it is and exists
whenever he or she says it does."
In completing the preoperative checklist on a client scheduled for
general surgery, the nurse recognizes which of the following as the
greatest risk for the planned procedure?
a. Age 59
b. Ten pounds over ideal body weight
✅✅
c. Diet-controlled diabetes mellitus
d. Brother had complications with general anesthesia - -c.
Diet-controlled diabetes mellitus
The nurse maintains the privacy of a client having a vaginal
hysterectomy by:
a. Ensuring that drapes minimize perineal exposure
