2024/2025 RASMUSSEN UNIVERSITY MDC IV (NUR2755) MDC4 FINAL EXAM 100 QUESTIONS AND ANSWERS VERIFIED 100%;(GUARANTEED SUCCESS )

  lOMoARcPSD|5967629 2024/2025 RASMUSSEN UNIVERSITY MDC IV (NUR2755) MDC4 FINAL EXAM 100 QUESTIONS AND ANSWERS VERIFIED 100%;(GUARANTEED SUCCESS ) MDC4 Final Exam 1. Which of the following describes the process of initial surveillance of victims injury severity when administering first aid in an emergency situation? A. The Good Samaritan law B. an emergency interview C. Triage D. taking vital signs 2. The nurse reminds a group of certified nursing assistants (CNA) that for a client with an elevated temperature, the quickest and simplest technique to reduce a temperature is Which of the following? A. Apply cool wash cloth to forehead B. bathe in tepid water C. remove clothing and bed linen D. give chilled drinks- don't want to give them drinks cuz they could aspirate 3. Which time of the day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? A. early in the morning when the clients energy level is high B. to coincide with the peak action of drug therapy C. immediately after a rest period D. When family members will be available 4. A client with multiple sclerosis(MS) is receiving baclofen. The nurse determines that the drug is effective with which of the following outcomes A. Induces sleep B. stimulates the client's appetite C. relieve muscular spasticity D. reduces the urine bacterial count 5. The nurse is caring for several clients on the Burn Unit who have sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typical associated with the initial third spacing fluid shift? A. Hypercalcemia B. Hypernatremia C. Hyperkalemia D. Hypokalemia 6. When taking a client's vital signs on the first postoperative day, the unlicensed assistive Personnel reports to the nurse that the oral temperature is 100 degrees. After encouraging the clients use the incentive spirometer, the nurse should delegate which activity to the UAP? A. Apply a ice caps the clients forehead B. bathe the client with cool water C. place a hyperthermia blanket on the client's bed D. continue to monitor the client's temperature 7. The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome(ARDS). the nurse assesses for which earliest sign of acute respiratory distress syndrome? A. Bilateral wheezing B. inspiratory crackles C. intercostal retractions D. increased respiratory rate 8. What drain is removed through gravity? wound vac, jp drain, penrose Penrose- I put penrose. 9. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action would the nurse take? A. Organize a pizza party for each shift B. Remind the staff of the facilities sick leave policy C. Arrange for critical incident stress debriefing D. Talk individually with staff members 10. The nurse is assessing a client for decorticate posturing. What should the nurse assess the client for? A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers B. Back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet C. Supination of arms and dorsiflexion of the feet D. Back arched and rigid extension of all four extremities 11. A client with a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehab would be appropriate for the client? The client will: A. Exhibit no further episodes of short-term memory loss B. Be able to return to his construction job in 3 weeks C. Actively participate in the rehabilitation process as appropriate D. Be emotionally stable and display preinjury personality traits 12. Which findings will the nurse observe in the client in the ictal phase of generalized tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abruptly ceasing all activity C. Facial grimaces, patting motions, and lip-smacking D. Loss of consciousness, body stiffening, and violent muscle contractions 13. The nurse is aware that the treatment for frostbite includes the following: (SATA) A.Vigorously rubbing the hands in fingers to reestablish circulation B. Immersion of hands and feet in warm water C. Tightly wrapping hands in mitten-like dressings to retain warmth D. Administering opioids to reduce pain E. Elevating the affected limbs 14. A nurse is caring for several clients at risk for shock. Which laboratory values requires the nurse to communicate with the healthcare provider? A. Creatinine: 0.9 mg/dL B. Lactate: 54 mg/dL C. Sodium: 145 mEq/L D. White Blood cell count: 11,000/mm3 15. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2f. What action by the nurse take priority? A. Document the findings in the client's chart B. Give the client warmed blankets for comfort C. Notify the health care provider immediately D. Prepare to administer insulin per sliding scale 16. During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control which of the following in the client? A. Pulse B. Respirations C. Blood pressure D. Temperature 17. A medication order for a client that weights 80 kg states, infuses dobutamine 250 mg mL D5W at 4 mcg/kg/min. The infusion pump must be set to mL/hr? (whole number) 19 18. A client has undergone preadmission laboratory studies, including a CBC, coagulation studies, and electrolytes and creatinine levels. Which of the following laboratory results should be reported to the surgeon's office by the nurse knowing that it could cause the surgery to be postponed? A. Sodium 141 B. Hemoglobin 8.0 C. Platelets, 210,000 D. Serum creatinine 0.8 19. When preparing to teach a client about phenytoin sodium therapy, the nurse should urge the client not to stop the drug suddenly due to which of the following concerns? A. Physical dependence on the drug develops over time B. Status epilepticus may develop C. A hypoglycemic reaction develops D. Heart block is likely to develop 20. A nurse wants to become part of a disaster medical assistance team (DMAT) but is concerned about maintaining licensure in several states. Which statement best addresses these concerns? A. Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. B. The government has a program for quick licensure activation wherever you are deployed C. During a time of crisis, licensure issues would not be the government's priority cause D. If you are deployed, you will be issued a temporary license in the state in which you are working. 21. The client has returned to the surgery unit from the post anesthesia unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the BP is 88/52. The client's level of consciousness is declining. What should the nurse do first? A. Call the PACU B. Call the healthcare provider (HCP) C. Call the respiratory therapists D. Call the rapid response team (RRT)/medical emergency team 22. A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged? (SATA) A. The client voids 500 mL of urine B. The client has active bowel sounds C. The client's pain is not controlled D. The client walks in the hallway unassisted E. The client 02 saturation is 90% on room air 23. The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has which of the following assessment findings? A. Drowsiness B. Inability to move C. Paresthesia D. Hypotension 24. A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag? A. Dislocated right hip and open fracture B. Large contusion to the forehead and bloody nose C. Closed fracture of the right clavicle and arm numbness D. Multiple fractured ribs and shortness of breath 25. The client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid has which of the following characteristics? A. Is clear and test negative for glucose B. Is grossly bloody in appearance and has a pH of 6 C. Clumps together on the dressing an has a pH of 7 D. Separates into concentric rings and tests positive for glucose 26. The nurse develops a care plan for a client in the acute phase of a burn injury. Which of the following would be the priority nursing diagnosis for the client? A. Risk for falls r/t contracture of burned extremities B. Risk for infection r.t slow healing graft donor site C. Risk for denial r/t inability to participate in dressing changes D. Risk for ineffective coping r/t inability to look at burn wounds 27. What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person, and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably 28. The nurse is helping to prepare a client for non-emergency surgery. The nurse should perform which of the following? A. Obtain informed consent from the client B. Explain the surgical procedure in detail C. Verify that the client understands the informed consent form D. Inform the client about the risks of the surgery to be performed 29. A client has been positioned in the lithotomy position under general anesthesia for a pelvic procedure. In which anatomic area may the client expect to experience Postoperative discomfort? A. Shoulders B. Thighs C. Legs D. Feet 30. What does the nurse consider preoperative with the client's position? A. client's pain when conscious, B. administration site of anesthetics, C. site of surgery, D. client's preference E. size, weight, and age of client. 31. A 30-year-old female client sustained deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk at 2000 while starting a bonfire. The client weighs 63kg. Use the parkland burn formula (4mL) to calculate the flow rate during the first 8 hours (mL/hr) after the burn if the client arrived to the ER at 2300? 1474 mL/hr 32. A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag valve mask by paramedics. The client has sustained obvious injuries to the head and face and an open right femur fracture that is bleeding profusely. What will the nurse do first? A. Splint the right lower extremity B. Apply direct pressure to the leg: to stop the blood lose, good for circulation/perfusion, prevents hypovolemic shock C. Assess for a patent airway D. Start two large bore IVs 33. A client is receiving warfarin after pulmonary embolism (PE). The nurse evaluates the lab results and notifies the physician that the client's warfarin level is therapeutic when which for the following number is reported? A. International normalized ratio (INR) 2.8 B. Partial thromboplastin time (PTT) 24 seconds C. International normalized ratio (INR) 1.1 D. Prothrombin time (PT) 14 seconds 34. The client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving client full control over care decisions and restricting visitors B. Providing positive feedback and encouraging active range of motion- pg 916 C. Providing information, giving positive feedback, and encouraging relaxation D. Providing intravenously administered sedatives, reducing distractions, and limiting visitors 35.A nurse is triaging clients in the emergency department. Which client would the nurse classify as "non-urgent"? A. A 44 year old with chest pain and diaphoresis B. A 50 year old with chest trauma and absent breath sounds C. A 62 year old with a simple fracture of the left arm D. A 79 year old with a temperature of 104 36. On a hot, humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 degrees, pulse 132 bpm, RR 26 bpm, and BP 106/66 mm Hg. What actions would the nurse take? A. Encourage the client to drink cool water or sports drinks B. Start an intravenous line and infuse 0.9% saline solution C. Administer acetaminophen 650 mg orally D. Encourage rest and reassess in 15 minutes 37. A spectator at the little league playoffs in the month of August faints in the sun drenched stands. His face is flushed, and his skin is hot to the touch. Which would be an appropriate intervention for this client? A. Have him lie down on the bleacher seat B. Have him drink a large iced drink C. Have him remain seated in the stands, shielded from the sun with an umbrella D. Move him to a shady area, and wet his clothes with water 38. Assessment findings of the client with trauma injuries reveal cool, pale skin; reported thirst, urine output 100 mL/6hr, blood pressure 106/78 mm Hg, pulse 110 beats/min, RR 24 bpm with decreased breath sounds. This client is in what phase of shock? A. Initial B. Progressive C. Nonprogressive D. Refractory 39. The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which foods/fluids for breakfast? A. No food or fluids B. Only coffee or tea if needed C. A full breakfast as desired without coffee, tea, or energy drinks D. A liquid breakfast of fruit juice, oatmeal, or smoothie 40. The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do it within 3 hours of the client being identified as being at risk? (SATA) A. Administer antibiotics B. Measure central venous pressure- done within 6 hrs pg 765 C. Draw serum lactate levels D. Obtain blood cultures E. Infuse vasopressors 41. A client who is receiving fluid resuscitation per the parkland formula after a serious burn continues to have urine output ranging from 20-25 mL/hr. After the health care provider checks the client, which order does the nurse question? A. Increase IV fluids by 100ml/hr B. Administer furosemide 40 mg IV push C. Continue to monitor urine output hourly D. Draw blood for serum electrolytes stat 42. The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would include which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program B. Provide many layers of linen under the incontinent client C. Encourage the client to wear tight clothing D. Limit bladder catheterization to once every 12 hours 43. The nurse assesses the frostbit on a client's hands and feet to be second-degree frostbite because the skin has which of the following assessment findings? A. Reddened and has hard white plaques B. Waxy and has sensory deficits C. Reddened and has blisters filled with milky fluid D. Waxy and has blisters filled with blood 44. A client scheduled for surgery is confused and shows signs of dementia. The nurse should ask which person to sign the consent for the client? A. Minister or pastor B. nursing supervisor C. Attorney D. spouse 45. Which client has the greatest risk for latex allergies? A. A women who is admitted for her seventh surgery B. A man who works as a sales clerk C. A man with well-controlled type 2 diabetes D. A women who is having laser surgery 46. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle 47. Which manifestation is a typical reaction to long-term phenytoin sodium therapy? A. Weight gain B. Insomnia C. Excessive growth of gum tissue D. Deteriorating eyesight 48. Which of the following would be classified as an external disaster? A. A fire started in the emergency department B. A city-wide power outage C.Massive flooring D.bomb threat to administration 49. An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. What action would the nurse take first? A. Apply oxygen and continuous pulse oximetry B. Provide small quantities of ice chips and sips of water C. Request a prescription of an antitussive medication D. Ask the respiratory therapist to provide humidified air 50. The nurse is concerned about developing post traumatic stress disorder after working for several years in the emergency department. Which of the following should the nurse do to ensure this disorder does not manifest? (SATA) A. Eat well-balanced meals B. Drink water C. Take breaks when needed D. Do not work more than 12 hours per day E. Ingest at least one alcoholic drink every evening F. Do not debrief after an incident 51. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? A. Administers oxygen B. Checks the client's vital signs C. Ventilates the client manually D. Starts cardiopulmonary resuscitation 52. An emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury 53. The nurse is orienting a new nurse to the pediatric intensive care unit and discussing the care of a client recovering from drowning. Which statement by the new nurse accurately demonstrates an understanding of this condition? A. Drowning results in the collapse of alveoli and pulmonary edema B. Drowning causes an increased amount of surfactant in the lungs, which decreases airway pressure C. Since the client has recovered, we should not need to monitor for any complications D. It is okay to leave children unattended in a bathtub as long as it's only for a minute of two 54. When the nurse is assessing victims in an emergency situation, what is the priority to assess? A. Hemorrhage B. Fractures C. Mobility D. Abnormal breathing 55. The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the clients states that he or she will: A. Sit in soft, deep chairs B. Exercise in the evening to combat fatigue C. Rock back and forth to start movement with bradykinesia D. Buy clothes with many buttons to maintain finger dexterity 56. An elderly man was found unresponsive in his home and unable to give a history of any contributing events. The nurse recognizes the man's skin color of "cherry red" as a sign that he has suffered from? A. Cardiac arrest B. HEmorrhagic stroke C. Carbon monoxide poisoning D. Cyanide poisoning 57. A nurse is assessing a client's surgical incision for signs of infection. Which finding by the nurse is interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, tender skin 58. The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities? A. Blowing the nose B. Isometric exercises C. Coughing vigorously D. Exhaling during repositioning 59. A client has experienced a pulmonary embolism. A nurse assesses for which most commonly reported symptoms? A. Hot, flushed feeling B. Sudden chills and fever C. Chest pain that occurs suddenly D. Dyspnea when deep breaths are taken 60. A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness, with an oxygen saturation of 88% on room air. What is the priority action? A. Place the client on continuous electrocardiographic monitoring B. Notify the ED physician C. Administer oxygen via nasal cannula D. Establish intravenous (IV) access 61. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? A. Decrease the heparin rate B. Increase the heparin rate C. No change to the heparin site D. Stop heparin, start warfarin 62. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (SATA) A. Client who had a reaction to contrast dye yesterday B. Older client who is 1-day post hip replacement surgery C. Client with a new spinal cord injury on a rotating bed D. Young obese client with a fractured femur E. Middle aged man with an exacerbation of asthma F. Older adult with chronic atrial fibrillation 63. The nurse is assessing a client for the adequacy of ventilation. What assessment findings would indicate the client has good ventilation? (SATA) A. RR 24 bpm B. The oxygen saturation level is 98% C. The right side of the thorax expands slightly more than the left D. The trachea is just to the left of the sternal notch E. Nail bed are pink with good capillary refill F. There is a presence of quiet, effortless breath sounds at lung bases bilaterally 64. A client with a head injury regains consciousness after several days. When the client first awakes, What should the nurse say to the client? A. I will get your family B. Can you tell me what you remember C. I will bet you are a little confused right now D. You are in the hospital. You were in an accident and unconscious 65. The nurse cautions that when cooling down a victim of heatstroke, one must be careful to prevent shivering because shivering can cause which of the following? A. Paralytic ileus B. Cardiac arrhythmias C. An increase in temperature D. A seizure 66. For which event would the hospital's disaster plan typically be activated? A. Fight between to local street gangs B. School bus involved in an accident C. Explosion at a chemical factory D. Three-car collision on the highway 67. A nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits which of the following? A. A negative Kernig sign B. Absence of nuchal rigidity C. A positive brudzinski sign D. A glasgow coma scale score of 15 68. The nurse comes upon a car accident while driving home from work. Which of the following may be included in the nurse's primary survey of injury? (SATA) a. Assess LOC pg 130 for all answers b. Remove clothing soaked with gasoline c. Remove the unconscious driver from the driver's seat- ya, no we wouldn't pull them out as a nurse d. Apply tourniquet proximal to an actively bleeding open tibia fracture e. Prepare for intubation if glasgow coma scale (GCS) is 12 or higher 69. The nurse is caring for an elderly client who has suffered from a myocardial infarction. The nurse identifies the need for vigilant monitoring against which form of shock in this client? A. Septic shock B. Obstructive shock C. Cardiogenic shock D. Hypoboemic shock 70. The nurse in the emergency department is using a triage system because this system ranks clients by what? A. The severity of illness or injury B. Body systems involved C. Name in alphabetical order D. Age to prioritize youngest first 71. The experienced nurse is teaching a new nurse about hospital emergency plans and personal emergency preparedness. Which statement by the new nurse indicates a need for further teaching? A. I need to assemble a personal readiness go bag B. I need to have plans for child and elder care C. I need to know where I am expected to report D. I need to know exactly how long this is expected to last 72. A nurse wants to become involved in community disaster preparedness, and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? A. The medical reserve corps B. The national guard C. The health department D. A disaster medical assistance team 73. The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing B. Restraining the clients limbs C. Removing the pillow and raising padded side rails D. Positioning the client to the side, if possible, with the head flexed forward 74. What is the priority assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram 75. A nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which of the following signs that could indicate an evolving compilation? A. Increase restlessness B. a pulse of 86 BPM C. blood pressure of 110 / 70 D. hypoactive bowel sounds in all four quadrants 76. A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery. 1 formulating a response, the nurse and incorporating the understanding that retained pulmonary secretions in a postoperative client can lead to which of the following? A. Pneumonia B. Fluid imbalance C. pulmonary embolism D. Carbon dioxide retention 77. A student nurse is caring for a client who suffered massive blood loss after trauma. How does a student nurse correlate the blood loss with the client mean arterial pressure(MAP)? A. it causes vasoconstriction and increase map B. lower blood volume lower the map C. there is no direct correlation to map D. it raises cardiac output and map 78. A nurse prepares to administer intravenous cimetidine to a client who has a new brain injury. The client asks, why am I taking this medication? How would the nurse respond? A. Cimetidine stimulates intestinal movement so you can eat more B. it improves fluid retention, which helps prevent hypovolemic shock C. it helps prevent stomach ulcers, which are common after Burns D. cimetidine protects the kidney from damage caused by dehydration 79. The nurse is working in the triage area of an emergency department, and the following for a client to approach the triage desk at the same time. What is the order in which the does the nurse assess these clients? a. Client 1: An ambulatory, dazed 25 year old man with a bandaged head wound b. Client 2: an irritable infant with the fever, petechiae, and nuchal rigidity c. client 3: a 35 year old jogger with a twisted ankle who has a pedal pulse and no deformity d. client 4: a 50 year old woman with moderate abdominal pain and occasional vomiting Client 2: an irritable infant with the fever, petechiae, and nuchal rigidity Client 1: An ambulatory, dazed 25 year old man with a bandaged head wound Client 4: a 50 year old woman with moderate abdominal pain and occasional Vomiting Client 3: a 35 year old jogger with a twisted ankle who has a pedal pulse and no deformity 80. A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? A. Slow deep respirations B. rapid deep respirations C. paradoxical respirations D. pain, especially with inspiration 81. A client presents to the emergency room with Burns to the front of both legs and the front torso (chest and abdomen) after a firework went off when he was nearby. Estimate the percentage of body surface area burned using the rule of nines A. 54% B. 45% C. 36 % D. 27% 82. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by which of the following? A. Eating large, well-balanced meals B. doing muscle strengthening exercises C. doing all chores early in the day while less fatigued D. taking medication on time to maintain therapeutic blood levels 83. A nurse Is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths per minute. And the pulse rate increased from 86 to 98 beats per minute since the client was last with us 4 hours ago. What is the priority assessment for this client? A. Asked if the client needs pain medication B. assess the client's tissue perfusion further C. document the findings in the client chart D. increase the rate of the clients IV infusion 84. A nurse works at a community center for older adults. What self-management measures can the nurse teach the clients to prevent shock? A. Do not get dehydrated in warm weather B. drink fluids on a regular schedule C. seek attention for every scrape or cut D. take medications as prescribed 85. The nurse has completed discharge instructions for the client with application of a Halo device. The nurse determines that the client needs further clarification of the instructions if the client states that he or she will do which of the following? A. You with a straw for drinking B. Drink only during the daytime C. use caution because the device Alters balance D. wash your skin daily under the lambswool liner of the vest 86. The nurse has instructed the family of a client with a stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do Which of the following? A. Place objects in the client impaired field of vision B. discourage the client from wearing eyeglasses C. approach the client from the impaired field of vision D. Remind the client to turn the head to scan the last visual field 87. A client arrives in the emergency department with an in shimek stroke. Because the healthcare team is considering ministering tissue plasminogen activator )t-PA) administration, the nurse should perform which of the following first? A. Ask what medication the client is taking B. complete a history and health assessment C. identify the time of onset of the stroke D. determine if the client is scheduled for any surgical procedures 88. Following a stroke, a client has dysphagia and left sided facial paralysis. Which feeding techniques will be most helpful at this time? A. Encourage sipping diluted liquid meal supplements from a straw B. position the client with the bed at a 30 degree angle C. offer solid foods from the unaffected side of the mouth D. feed the client a soft diet from a spoon into the left side of the mouth 89. a client flail chest. A nurse assesses the client for which most distinctive sign of flail chest? A. Cyanosis B. Hypotension C. paradoxical chest movement D. dyspnea, especially on exhalation 90. A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks for the client when the high-pressure alarm on the ventilator sounds and notes that the client has an absence of breath sound in the right upper lobe of the lung. The nurse immediately assesses for other signs for Which of the following? A. Right pneumothorax B. pulmonary embolism C. displace endotracheal tube D. acute respiratory distress distress syndrome 91. After receiving a report for clients, the nurse determines the order of care for the clients. Based on the report, the nurse will prioritize the clients to see which one first? A. A newborn with mottling of extremities B. a 72 year old with dry, tenting skin C. a thirty-five-year-old athlete with a heart rate of 50 beats per minute D. a healthy 18 year old with rapid shallow respirations 92. A client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nursing choirs during the nursing admission interview if the client has a history of which of the following? A. Seizures or trauma to the brain B. meningitis during The Last 5 Years C. back injury or trauma to the spinal cord D. respiratory or gastrointestinal infection during the previous month 93. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persisted? A. Hyperreflexia B. positive reflexes C. reflex empty none of the bladder D. flaccid paralysis 94. When at a public place, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. What action would the nurse take first? A. Elevate this site and notify the person's next of kin B. remove the Stinger with tweezers and encourage rest C. administer diphenhydramine and apply ice D. administer an EpiPen from the first aid kit and call 911 95. A client with which situation would best benefit from always carrying an EpiPen A. no prior allergic reaction to bee or wasp stings B. allergy to poison ivy in grass C. no history of being stung by a bee or wasp D. previous allergic reaction to a wasp sting 96. A nurse is caring for a client suspected of having a heat stroke. Which findings are consistent with this diagnosis? (SATA) A. Bradycardia B. Tachycardia C. Dysrhythmias D. Hallucinations E.decreased urinary output 97. A medication order States, infuses 0.9% normal saline(NS) solution 1000 ml IV over 8 hours. The drop factor of the manual IV tubing available is 15 gtt / ml. The nurse should set the flow rate to deliver how many gtt/min? (round to nearest whole number) 31 98. A nurse is assessing a child at the sea Navy school bus crash. The child has several bruises and a superficial 5 centimeter laceration that has stopped bleeding on the left arm. The nurse should assign the child to which of the following triage categories? A. Emergent / red B. expectant / black C. urgent / yellow D. not urgent / green 99. A client has accidentally received twice the normal dose of medication that was administered on the previous shift. What should the nurse who discovers the arrow do first? A. Call a person who made the error and request that an incident report be completed B. Assess the client, and note any changes in condition C. call the healthcare provider to obtain a prescription for additional IV fluids to dilute the drug D. administer a drug antidote for standing prescription 100. MAP BP was 104/50 and it was what the clients were at increased risk of: decreased perfusion to organs, something about relapsing hypertension, increased cardiac output, and can't remember.