,While assessing a radial artery catheter, the client complains of numbness and pain
distal to the insertion site. What interventions should the nurse implement? - CORRECT
ANSWERS-Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding
accident. To differentiate the vascular source of the intracranial bleeding, which finding
should the nurse monitor? - CORRECT ANSWERS-Rapid onset of decreased level of
consciousness.
When preparing a client for discharge from the hospital following a cystectomy and a
urinary diversion to treat bladder cancer, which instruction is most important for the
nurse to include in the client's discharge teaching plan? - CORRECT ANSWERS-Report
any signs of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of hyperemia. To
assess for blanching, what action should the nurse take? - CORRECT ANSWERS-
Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint secured as
seen in the picture. What action should the nurse take? - CORRECT ANSWERS-
Reposition the restraint tie onto the bedframe.
A female client with acute respiratory distress syndrome (ARDS) is chemically
paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2.
Which assessment finding warrants
immediate intervention by the nurse? - CORRECT ANSWERS-Diminished left lower
lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax,
which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of sequential events. Arrange the
pathophysiological events in orders of occurrence. (Place the first event on top and the
last on the bottom) - CORRECT ANSWERS-Arterial endothelium injury causes
inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her
urine output is 25 ml/hour for the last two hours. What pathophysiological reason
supports the nurse's decision to report this finding to the healthcare provider? -
CORRECT ANSWERS-Oliguria signals tubular necrosis related to hypoperfusion
,A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? -
CORRECT ANSWERS-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive Pulmonary
Disease (COPD), which approach should the nurse use? - CORRECT ANSWERS-
Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The nurse
asks the client to perform a series of movements that require use of the facial muscles.
What symptoms suggest that the client has most likely experience a Bell's palsy rather
than a stroke? - CORRECT ANSWERS-Inability to close the affected eye, raise brow, or
smile
The nurse is teaching a client how to perform colostomy irrigations. When observing the
client's return demonstration, which action indicated that the client understood the
teaching? - CORRECT ANSWERS-Keeps the irrigating container less than 18 inches
above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? - CORRECT ANSWERS-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include the client's risk for developing increased intracranial
pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has
increased? - CORRECT ANSWERS-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
The nurse is caring for a client receiving continuous IV fluids through a single lumen
central venous catheter (CVC). Based on the CVC care bundle, which action should be
completed daily to reduce the
risk for infection? - CORRECT ANSWERS-Confirm the necessity for continued use of
the CVC.
During an annual physical examination, an older woman's fasting blood sugar (FBS) is
determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during
a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus
(DM)? - CORRECT ANSWERS-Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4
mmol/L (SI).
, A client who was admitted yesterday with severe dehydration is complaining of pain a
24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention
should the nurse implement first? - CORRECT ANSWERS-Stop the normal saline
infusion.
An elderly female is admitted because of a change in her level of sensorium. During the
evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's
skin traction is applied to the left leg while waiting for surgery. Which intervention is
most important for the nurse to include in this client's plan care? - CORRECT
ANSWERS-Ensure proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath sound
over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate
of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF)
tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what
recommendation should the nurse give the healthcare provider? - CORRECT
ANSWERS-Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.) -
CORRECT ANSWERS-Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that the
educational materials include which
characteristics? Select all that apply - CORRECT ANSWERS-Written at a twelfth grade
reading level
Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory or cognitive
changes, such as
decreased visual or hearing acuity, slower thought or reasoning processes, and shorter
attention span.
Materials for this age group should include at least of terms, such as a medical
terminology that incline
may not know and use common words that expresses information clearly and simply.
Simple, attractive
pictures help hold the learner's attention. The reading level of material should be at the
4th to 5th grade
distal to the insertion site. What interventions should the nurse implement? - CORRECT
ANSWERS-Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding
accident. To differentiate the vascular source of the intracranial bleeding, which finding
should the nurse monitor? - CORRECT ANSWERS-Rapid onset of decreased level of
consciousness.
When preparing a client for discharge from the hospital following a cystectomy and a
urinary diversion to treat bladder cancer, which instruction is most important for the
nurse to include in the client's discharge teaching plan? - CORRECT ANSWERS-Report
any signs of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of hyperemia. To
assess for blanching, what action should the nurse take? - CORRECT ANSWERS-
Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint secured as
seen in the picture. What action should the nurse take? - CORRECT ANSWERS-
Reposition the restraint tie onto the bedframe.
A female client with acute respiratory distress syndrome (ARDS) is chemically
paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2.
Which assessment finding warrants
immediate intervention by the nurse? - CORRECT ANSWERS-Diminished left lower
lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax,
which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of sequential events. Arrange the
pathophysiological events in orders of occurrence. (Place the first event on top and the
last on the bottom) - CORRECT ANSWERS-Arterial endothelium injury causes
inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her
urine output is 25 ml/hour for the last two hours. What pathophysiological reason
supports the nurse's decision to report this finding to the healthcare provider? -
CORRECT ANSWERS-Oliguria signals tubular necrosis related to hypoperfusion
,A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? -
CORRECT ANSWERS-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive Pulmonary
Disease (COPD), which approach should the nurse use? - CORRECT ANSWERS-
Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The nurse
asks the client to perform a series of movements that require use of the facial muscles.
What symptoms suggest that the client has most likely experience a Bell's palsy rather
than a stroke? - CORRECT ANSWERS-Inability to close the affected eye, raise brow, or
smile
The nurse is teaching a client how to perform colostomy irrigations. When observing the
client's return demonstration, which action indicated that the client understood the
teaching? - CORRECT ANSWERS-Keeps the irrigating container less than 18 inches
above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? - CORRECT ANSWERS-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include the client's risk for developing increased intracranial
pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has
increased? - CORRECT ANSWERS-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
The nurse is caring for a client receiving continuous IV fluids through a single lumen
central venous catheter (CVC). Based on the CVC care bundle, which action should be
completed daily to reduce the
risk for infection? - CORRECT ANSWERS-Confirm the necessity for continued use of
the CVC.
During an annual physical examination, an older woman's fasting blood sugar (FBS) is
determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during
a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus
(DM)? - CORRECT ANSWERS-Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4
mmol/L (SI).
, A client who was admitted yesterday with severe dehydration is complaining of pain a
24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention
should the nurse implement first? - CORRECT ANSWERS-Stop the normal saline
infusion.
An elderly female is admitted because of a change in her level of sensorium. During the
evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's
skin traction is applied to the left leg while waiting for surgery. Which intervention is
most important for the nurse to include in this client's plan care? - CORRECT
ANSWERS-Ensure proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath sound
over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate
of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF)
tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what
recommendation should the nurse give the healthcare provider? - CORRECT
ANSWERS-Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.) -
CORRECT ANSWERS-Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that the
educational materials include which
characteristics? Select all that apply - CORRECT ANSWERS-Written at a twelfth grade
reading level
Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory or cognitive
changes, such as
decreased visual or hearing acuity, slower thought or reasoning processes, and shorter
attention span.
Materials for this age group should include at least of terms, such as a medical
terminology that incline
may not know and use common words that expresses information clearly and simply.
Simple, attractive
pictures help hold the learner's attention. The reading level of material should be at the
4th to 5th grade
