Nursing Care & Prioritization for Exam Success!"
1. The nurse is delegation a task to the UAP. What is the best instruction by
the support systems nurse?
"I need to know if the client's blood pressure changes from the
normal baseline"
"Let me know if the client's blood pressure becomes elevated"
"Notify me right away if the client's systolic blood pressure is 170
or greater"
"If the client's blood pressure falls outside normal limits, come get
me"
2. A nurse is assessing an older client with a decrease in caloric intake and
weight loss. Which of the following findings should the nurse report to
the provider immediately?
Client experiences a drop in oxygen saturation to 91% while eating
Client reports abdominal pain at 5 out of 10
The client experiences coughing and wheezing after eating
Client reports a burning sensation in the epigastric area
3. Which client should the nurse prioritize for assessment in the emergency
department based on the provided scenarios?
A 6 year old client whose left shoulder is dislocated
A 76 year old client who was confused, febrile and has foul
smelling urine
A 26 year old client for sickle cell disease and a severe joint pain
,A 50- year old client who has slurred speech, is disoriented, and
reports a headache
,4. A nurse is assessing a patient who is 2 weeks post-gastric bypass surgery
and reports feeling faint after meals. Which nursing intervention should
the nurse prioritize based on the potential for dumping syndrome?
Encourage the patient to consume high-sugar foods.
Suggest the patient increase their fluid intake during meals.
Advise the patient to lie down immediately after eating.
Educate the patient to eat smaller, more frequent meals.
5. Describe the role of furosemide in the management of heart failure in
patients.
Furosemide is used to treat anemia in heart failure patients.
Furosemide is a diuretic that helps to reduce fluid overload in
patients with heart failure.
Furosemide increases blood pressure in patients with heart failure.
Furosemide enhances the effects of digoxin in heart failure
patients.
6. What is the recommended fluid to take with ferrous sulfate to enhance its
effectiveness?
Water
Fluids other than coffee or tea
Orange juice
Milk
7. Why is it important for a client with an AB negative blood type to receive
Rh immune globulin after delivering a B positive baby?
To treat the newborn's jaundice
To ensure proper blood clotting
, To prevent Rh sensitization in future pregnancies
To enhance the mother's immune response
8. What factors should the nurse consider when determining the priority of
clients in an emergency setting?
The nurse should see clients in the order they arrived regardless
of their condition.
The nurse should assess clients based on their previous medical
history alone.
The nurse should prioritize based on the age of the clients only.
The nurse should consider the severity of symptoms, potential
for life-threatening conditions, and the urgency of treatment
required.
9. A nurse is reviewing the laboratory findings of a client who had a MI 6 hr
ago. Which of the following is an expected finding for this client?
HDL 65 mg/dL
alanine aminotransferase 35 units/L
calcium 95 mg/dL
Troponin I 8 ng/mL
10. Why is it critical for the nurse to report an absolute neutrophil count of
75/mm3 in a client receiving chemotherapy?
An absolute neutrophil count of 75/mm3 means the client can
continue chemotherapy without concern.
An absolute neutrophil count of 75/mm3 indicates severe
neutropenia, which increases the risk of infection.
An absolute neutrophil count of 75/mm3 suggests the client is
recovering well from chemotherapy.