Miami Dade College, Miami; NUR 3805/ NUR3805 Final Exam
NUR 3805 The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority. 1. The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually. 2. The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday. 3. The 29-year-client diagnosed with septicemia who called to request more blankets because of being cold. 4. The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today. 5. The 37-year-old client who has a Stage 4 pressure sore and the dressing needs to be changed this morningSelect one: a. 1,2,4,3,5 b. 2,3,1,2,5 c. 3,4,5,1,2 d. 3,4,1,2,5 . 37-Which nursing problem is the highest priority for the client diagnosed with gastroenteritis from staphylococcal food poisoning? Select one: a. Oral mucous membrane, altered. b. Alteration in bowel elimination. c. Nutrition, altered: less than body requirements. d. Fluid and electrolyte imbalance. Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? Select all that apply. Select one or more: a. Apply oxygen via nasal cannula to the client. b. Empty the trashcans in the clients' rooms. c. Teach the client how to ambulate on the walker. d. Perform mouth care on the client with pneumonia. e. Take the empty blood bag back to the laboratory. Erythromycin (E-Mycin) has been prescribed for a client with a respiratory infection . The nurse tells the client that which frequent side effect can occur from this medication? Select one: a. Severe diarrhea. b. Yellow discoloration on the black part of the eyes. c. Abdominal cramping. d. Yellow-colored skin. A woman with type 1 Diabetes M is returned to the recovery room one hour after an uneventful delivery of a 9 lb. 8 oz, baby boy. The nurse would expect the woman's blood sugar to do which of the following? Select one: a. Change from 220 to 180 mg/dl b. Change from 110 to 80 mg/dl c. Change from 100 to 140 mg/dl. d. Change from 90 to 120 mg/hg When the community health nurse visits a patient at home, the patient states, "I haven't slept the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this patient. Select one: a. "Sometimes, I have trouble sleeping too." b. "Really?" c. "You're having difficulty sleeping?" d. "I see." A cast is applied to a 9 -month-old girl for the treatment of talipes equinovarus.Which of the following instructions is most essential for the nurse to give to the child's mother regarding her care? Select one: a. Make frequent clinic visits for cast adjustment b. Provide an analgesic as needed c. Do circulatory checks of the casted extremity d. Offer appropriate toys for her age A client taking amitriptiline hydrocloride (Elavil) calls the nurse at the physician office and reports that he has an upset stomach whenever he takes the medication. The nurse most appropriately tell the client to: Select one: a. Take the medication on an empty stomach. b. Stop the medication for 2 days and then resume the prescribed medication schedule. c. Take the medication with food. d. Take the medication with an antacid. Ciclosporine (Sandinmune) oral solution is prescribed for a client who had a kidney transplant. The nurse provide information to the client about the medication and tells that which of the following is most important to monitor? Select one: a. Apical heart rate. b. Peripheral pulses. c. Temperature. d. Platelet count. The nurse is preparing to administer atenolol to a client. The nurse should check which item before administering the medication? Select one: a. Potassium level b. Temperature c. Blood pressure d. Blood glucose level The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate to assign/delegate? Select one: a. Instruct the UAP to discontinue the client's total parenteral nutrition. b. Request the LPN to assess the abdomen of a client who has had complaints of pain. c. Ask the UAP to give the client 30 mL of Maalox for heartburn. d. Tell the LPN to administer a bulk laxative to a client diagnosed with constipation. The nurse is working in an outpatient clinic along with a licensed practical nurse(LPN). Which client should the nurse assign to the LPN? Select one: a. The client with reactive airway disease who has bilateral wheezing. b. The client with acute bronchitis who has a chronic clear mucous cough and low fever. c. The client whose purified protein derivative (PPD) induration of the left arm is 14 mm. d. The client diagnosed with pneumonia whose pulse oximeter reading is 90%. The physician orders tobramycin sulfate (Nebcin) 3 mg/kg IV every 8 hours for a 3 year-old boy. The nurse enters the client's room to administer the medication and discovers that the boy does not have and identification bracelet. Which the following should the nurse do? Select one: a. Ask the parents at the child's bedside to state their child's name b. Ask the child to say his first name and last name c. Hold the medication until an identification bracelet can be obtained d. Have a coworker identify the child before giving the medication The hospice nurse is working with a LPN. Which task could the nurse delegate to the LPN? Select one: a. Check the MAR to see that all necessary medication is available. b. Provide spiritual support for the client and family members. c. Give the client a sponge bath and rub lotion on the bony prominences. d. Sit with the client while he or she reminisces about life experiences. The nurse is admitting a client with a diagnosis of post-traumatic stress disorder to the mental health unit. The client is confused and disoriented. During the assessment, what is the nurse's primary goal for this client? Select one: a. Accept the client and make the client feel safe b. Orient the client to the unit c. Explain the unit rules d. Stabilize the client's psychiatric needs The client is diagnosed with gastroenteritis. Which laboratory data warrants immediate intervention by the nurse? Select one: a. A serum sodium level of 152 mEq/L. b. A serum potassium level of 4.8 mEq/L. c. An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. d. A stool sample that is positive for fecal leukocytes. Which task is most appropriate for the nurse to assign to the LPN? Select one: a. Assess the client who will be transferred to the medical unit in the morning. b. Administer a unit of blood to the client who is 1 day postoperative. c. Hang the bag of heparin for a client diagnosed with a pulmonary embolus. d. Assist the HCP with the insertion of a client's Swan-Ganz line. A man had a permanent pacemaker implanted one year ago. He returns to the outpatient clinic because he thinks the pacemaker battery is malfunctioning. It is MOST important for the nurse to assess which of the following? Select one: a. Abdominal pain, nauseas and vomiting b. Peripheral edema, shortness of breath and dizziness c. Chest pain radiating to the right arm, headache and diaphoresis d. Wheezing on exertion, cyanosis and orthopnea The nurse is caring for a hospitalized client with angina pectoris (coronary artery disease) who begins to experience chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed, but the pain is unrelieved. The nurse checks the client's blood pressure and notes that it is stable. Which action should the nurse take next? Select one: a. Contact the primary health care provider b. Administer another nitroglycerin tablet c. Call the client's family d. Reposition the client A 7-year old girl with type 1 insulin-dependent DM (IDDM) has been home sick for several days and is brought to the ED by her parents.If the child is experiencing ketoacidosis, the nurse would expect to see which of the following results? Select one: a. Hematocrit 38% b. Blood Ph 7.28 c. Serum creatine 5.2 mg/dl d. Serum glucose 140 mg/dl The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a LPN? Select one: a. The 50-year-old client complaining of chest pain. b. The 65-year-old client admitted with unstable angina. c. The 75-year-old client scheduled for a cardiac catheterization and request take Vital Signs. d. The 44-year-old client diagnosed with a myocardial infarction. The nurse review the results of a therapeutic blood level that was drawn from a client taking theophylline (Theo-Dur) and notes that the level is 22 ug/ml. The nurse would most appropriately?. Select one: a. Place the results of the blood test in medical record. b. Report the result to the health care provider. c. Administer the next scheduled dose. d. Ask the laboratory to draw another blood specimen to verify the result The doctor order Terbutaline 30 mg (Brethine), which less important assessment before administering the medication to the client?. Select one: a. Acute asthma attack. b. Normal pattern of respirations. c. Severe status epileptic. d. Assessment of apical pulse. The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Select one: a. The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today. b. The 29-year-client diagnosed with septicemia who called to request more blankets because of being cold. c. The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday. d. The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually. The nurse is caring for a client with a diagnosis of heart failure who suddenly experiences severe dyspnea and suspects that pulmonary edema has developed. What is the immediate nursing action? Select one: a. Insert a Foley catheter b. Place the client in high-Fowler's position c. Obtain a vial of furosemide and a syringe d. Obtain a dose of morphine sulfate from the opioid medication drawer Which of the following assignments by the RN would be appropriate for an LPN/LVN? Select one: a. A 41 year-old woman in traction with a fractured femur b. A 56 year old man with emphysema scheduled to be discharged later today c. A 34 year-old woman with low back pain scheduled for a myelogram in the afternoon d. A 43 year-old woman newly diagnosed with type 1 DM The nurse is admitting an infant to the pediatric unit with a diagnosis of respiratory syncytial virus (RSV).The nurse anticipates that the primary health care provider will prescribe which measure? Select one: a. Strict handwashing procedures b. Contact precautions c. A private room d. Ribavirin The nurse is preparing to change an abdominal dressing using sterile technique. What is the order of priority that the nurse should take? Arrange in order. All options must be use: 1-Wash hands. 2-Set up a sterile field. 3-Explain the procedure to the client. 4-Document the characteristics of the wound. 5-Don sterile gloves, clean the site as prescribed, and apply a new dressing. 6-Don clean gloves and remove the old dressing. Select one: a. b. c. d. The nurse enters a client room and finds the client slumped over in bed. The nurse quickly assesses the client and discovers that the client is not breathing and there is no pulse.The nurse should take which immediate action? Select one: a. Call the Primary Health care provider b. Place oxygen via a nasal cannula on the client c. Begin cardiopulmonary resuscitation (CPR) d. Sit the client upright in bed The nurse is creating a plan for delegating unit activities for the day. Which activities should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Select one or more: a. Empty urine out of Foley bags b. Take temperatures, pulses, respirations, and blood pressures c. Check all intravenous (IV) solution bags on clients receiving IV therapy for the remaining amounts of solution in the bags d. Count the substance control medications in the opioid medication supply e. Deliver fresh water to clients f. Check the crash cart for necessary supplies using a checklist A client is receiving furosemide. The nurse should monitor the client for which adverse effect of the medication? Select one: a. Nausea b. Gastric upset c. Muscle weakness d. Increase in urinary output The nurse is preparing to administer atenolol (Tenormin) to a client.The nurse checks which of the follow before administering the medication? Select one: a. Blood Glucose level. b. Potassium level. c. Blood pressure. d. Temperature. A 21 year-old woman in active labor is admitted to the labor suite. An hour later. The membranes rupture spontaneously. The nurse observes a glistening white cord protruding from the vagina.Which of the following actions should the nurse take first? Select one: a. Place a clean towel over the cord and wet it with sterile NS b. Return to the nurse's station and place an emergency call to the physician. c. Apply manual pressure to the presenting part and have the mother assume a knee-chest position d. Administer O2 by mask at 10-12 L/min and assess the mother's vital signs The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse? Select one: a. Assign an RN to perform all sterile procedures. b. Assign an UAP to complete the a.m. care. c. Assign an LPN to write the care plans. d. Assign an LPN to give all IV medications. Ibuprofen (Motrin) is prescribed for a client with rheumatoid arthritis. On a follow-up visit to the physician office, the nurse asks the client whether the medication has provided relief from which of the following symptoms?. Select one: a. Dyspepsia. b. Flatulence. c. Joint pain. d. Diarrhea. The charge nurse has completed report. Which client should be seen first? Select one: a. The elderly client admitted from another facility who is refusing to be seen by the nurse. b. The client with hemorrhoids who had spotting of bright red blood on the toilet tissue. c. The client diagnosed with ulcerative colitis who had five loose stools the previous shift. d. The client with intractable vomiting who has tented skin turgor and dry mucous membranes. Which medication is most appropriate for the nurse to assign to the LPN to administer? Select one: a. The subcutaneous low-molecular-weight heparin to the client with a pulmonary embolus. b. The PO pentoxifylline (Trental) to the client who has intermittent claudication. c. The sublingual nitroglycerin to the client who is complaining of chest pain. d. The intravenous push antiemetic to the client who is nauseated and vomiting. A physician has prescribed Cotrimoxasole (Bactrin) for a client with a Urinary Tract Infection. With priority action will the nurse take before administering this medication?. Select one: a. Ask the pt about an allergy to sulfonamides. b. Check the medication supply room to find out if the medication needs to be ordered. c. Call the pharmacy to order medication. d. Inform the pt about the need to increase fluid intake. The nurse is reviewing the nursing care plan of a hospitalized client with sickle cell crisis. Which client problem is the least priority? Select one: a. Inability to cope with the disease b. Lack of perfusion to peripheral tissues c. Signs of dehydration d. Generalized pain The male client with chronic kidney disease has received the initial dose of erythropoietin, a biological response modifier, 1 week ago. Which data warrants the nurse to notify the healthcare provider? Select one: a. The client has a platelet count of 155,000. b. The client has a blood pressure reading of 184/102. c. The client's pulse oximeter reading of 95%. d. The client has a tympanic temperature of 99.8°F A 50 year-old male pt come the nurse's station and ask the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the pt become verbally abusive. Which of the following approaches by the nurse would be most effective? Select one: a. Ask the pt what he wants from the cafeteria and have it delivered to his room b. Calmly but firmly escort the pt back to his room c. Tell the pt to lower his voice, because he is disturbing the other pts d. Assign a NA to accompany the pt to the cafeteria After receiving a report from the night nurse, which of the following clients should the nurse see first? Select one: a. A 65 year-old man with a NG tube who had a bowel resection yesterday b. A 52 year-old woman complaining of pain, chills and fever who is scheduled for a cholecystectomy c. A 31 year-old woman refusing sucralfate (carafate) before breakfast d. A 40 year-old man with left-side weakness asking for assistance to the commode Metoprolol (Lopressor) has been prescribed for a client. The nurse performs which most important assessment before administering the medication to the client? Select one: a. Check the client for peripheral edema. b. Takes the client temperature. c. Checks the client lung sound. d. Takes the client blood pressure. The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which intervention task by the UAP is not correct ? Select one: a. The UAP is instructed to bathe the client who is on telemetry. b. The UAP is told to feed a client who is dysphagic. c. The UAP is asked to assist with a portable chest x-ray. d. The UAP is requested to obtain a bedside glucometer reading. A client with congestive heart failure is receiving furosemide (Lasix). The nurse monitors the client for which adverse effect of the medication?. Select one: a. Gastric upset. b. Increase in urinary output. c. Muscle weakness d. Nausea.
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- NUR 3805 Final Exam (NUR3805)
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nur 3805 final exam
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the nurse on a medical unit is making rounds after receiving the shift report which client should the nurse see first
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which nursing problem is the highest priority for the client
