NURS 455 Final Exam | Questions and Answers (Complete Solutions)

NURS 455 Final Exam | Questions and Answers (Complete Solutions) A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system? A. Auscultate cuff blood pressure. B. Palpate pulse pressure. C. Obtain a central venous pressure. D. Monitor the pulmonary artery pressure A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. BP B. Heart rate C. Urine output D. Weight A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? A. Dextrose 5% in water B. Dextrose 5% in 0.9% sodium chloride C. 0.9% sodium chloride D. Lactated Ringer's A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling urinary catheter. B. Inspect the mouth for signs of inhalation injuries. C. Administer intravenous pain medication. D. Draw blood for a complete blood cell (CBC) count. A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse NOT expect? A. Decreased leukocyte count B. Decreased platelet count C. Decreased erythrocyte count D.Increased hemoglobin count A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? A. Sweat test B. Haptoglobin C. Antinuclear antibodies D. Schilling test A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching? A. Aplastic anemia is associated with a decreased intake of iron. B. Aplastic anemia results in an increased rate of RBC destruction. C. Aplastic anemia results in an inability to absorb vitamin B12. D. Aplastic anemia results from decreased bone marrow production of RBCs. A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia? A. Dietary iron restrictions B. Intestinal malabsorption syndrome C. Chronic blood loss D. Intestinal parasites A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? A. To convert atrial fibrillation to sinus rhythm B. To dissolve clots in the bloodstream C. To slow the response of the ventricles to the fast atrial impulses D. To reduce the risk of stroke in clients who have atrial fibrillation A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? A. Pacemaker spikes after each QRS complex B. Pacemaker spikes before each P wave C. Pacemaker spikes before each QRS complex D. Pacemaker spikes with each T wave A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? A. Airway management B. Amiodarone administration C. Defibrillation D. Epinephrine administration A client who experienced a myocardial infarction (MI) 48 hours ago is most at risk for developing: A. cardiogenic shock B. heart failure C. arrhythmias D. pericarditis A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Different blood pressures in the upper limbs. B. Differences between oral and axillary temperatures. C. Differences in upper and lower lung sounds. D. Different apical and radial pulses. A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the client's ability to sleep. D. It reduces the client's blood pressure. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure? A. "They are going to examine my gallbladder and ducts." B. "Soon those shock waves will get rid of my gallstones." C. "I'll have a camera put down my throat so they can see my gallbladder." D. "They'll put medication into my gallbladder to dissolve the stones." A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain? A. Measure the drainage every hour for the first 8 hr postoperative. B. Secure the drain to the client's bed sheet. C. Expel the air from the JP bulb after emptying to re-establish suction. D. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze. A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? A. Fatty stools B. Straw-colored urine C. Tenderness in the left upper abdomen D. Ecchymosis of the extremities A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention? A. Auscultate the client's lungs. B. Assist the client to a side-lying position. C. Provide oral hygiene. D. Withhold oral fluids and food. A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? A. Decreased WBC B. Increased serum amylase C. Decreased serum lipase D. Increased serum calcium A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? A. Gallstones B. Hypolipidemia C. COPD D. Diabetes mellitus A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? A. Glucose B. Ammonia C. Potassium D. Bicarbonate A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer? A. Vitamin K B. Vitamin B C. Heparin D. Warfarin A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an early indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness A nurse is caring for a client following surgical treatment for a brain tumor. Which of the following interventions should the nurse take? A. Elevate the head of the bed to 30°. B. Notify the provider for drainage greater than 80 mL/8hr. C. Place the client in a flat, lateral position. D. Provide passive range-of-motion exercises to the neck. A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? A. Apply restraints. B. Administer opioids. C. Darken the room. D. Reduce stimuli. A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A. A change in the Glasgow Coma Scale score from 13 to 11 B. Diplopia C. A drop in heart rate from 76 to 70/min D. Ataxia A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Administer a nitrate antihypertensive. B. Assess the client for bladder distention. C. Place the client in a high-Fowler's position. D. Obtain the client's heart rate. A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include? A. "Take this medication daily to prevent headaches." B. "Activate the patch 30 minutes after application." C. "Use contraception while taking this medication." D. "You can bathe with the patch in place." A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Keep the client's skin dry with powder. D. Use pillows to keep heels off the bed surface. A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25% An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? A. Flexion of the arms B. Pronation of the hands C. Dorsiflexion of the legs D. External rotation of the lower extremities A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client. A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection? A. Temperature 36.1° C (97.0° F) B. Insomnia C. Oliguria D. Weight loss A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? A. Renal function is reestablished. B. BUN and creatinine levels decrease. C. Urine output is less than 400 mL per 24 hr. D. The glomerular filtration rate (GFR) recovers. A nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test? A. Elevated creatinine level B. Flank pain C. Urinary retention D. Bleeding tendencies A nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following findings should the nurse expect? A. Flank pain B. Hypotension C. Confusion D. Urinary retention A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. Sodium level C. Tissue turgor D. Intake and output A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? A. Diphenhydramine B. Ondansetron C. Vancomycin D. Mannitol A nurse is teaching a client who has chronic kidney disease and a new prescription for epoetin alfa. The nurse should instruct the client to increase dietary intake of which of the following substances? A. Iron B. Protein C. Potassium D. Sodium A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Collect a urine specimen for culture and sensitivity. B. Continue routine care because the results are within the expected reference range. C. Decrease the IV fluid infusion rate and limit oral fluid intake. D. Evaluate urine for amount and for specific gravity. A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? A. Hyperactive bowel sounds B. Nausea and vomiting C. Bradycardia D. Increased urinary output A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider? A. Report of discomfort during dialysate inflow B. Blood-tinged dialysate outflow C. Dialysate leakage during inflow D. Purulent dialysate outflow A nurse is caring for a 54 y/o male patient with DKA. His arterial blood gas shows: pH: 7.28, PaCO2: 30, and HCO3: 18. How would the nurse interpret this ABG result? A. Partially compensated respiratory acidosis B. Partially compensated metabolic acidosis C. Uncompensated respiratory acidosis D. Uncompensated metabolic acidosis A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin B. Insulin glargine C. Insulin detemir D. Regular insulin A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect? A. Malignant hypertension B. Acetone odor to breath C. Cheyne-Stokes breathing D. Blood glucose level below 40 mg/dL A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? A. Glucocorticoid medications B. Dextrose 5% in 0.45% sodium chloride C. Oral hypoglycemic medications D. 0.9% sodium chloride IV bolus A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following? A. Graham crackers B. 1 tsp sugar C. 4 oz diet soda D. 4 oz skim milk A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? A. Give the client 15 to 20 g of carbohydrate. B. Monitor the client for hypoglycemia. C. Complete an incident report. D. Notify the nurse manager. A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?