1. A nurse is providing teaching to a client who has a sever form of stage 2 Lyme Disease. Which of the following statements made by the client reflects an understanding of the teaching?
a. My joints ache because I have Lyme disease.
2. A nurse is caring for a client who is 4 hr postop following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?
a. Extremity cool upon palpation
3. a client is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?
a. The clients HR increases
4. a nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?
a. Scan the bladder with a portable ultrasound
5. a nurse is providing discharge instructions to a client who has active tuberculosis. Which of the following information should the nurse include in the instructions
a. sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures
6. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider?
a. Crackles heard on auscultation
7. a nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include
a. numbness can occur along the inside of the affected arm
8. a nurse is providing education to a client who has TB and their family. Which of the following information should the nurse include in the teaching.
a. Family members in the household should undergo TB testing
9. A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching?
a. I will no longer floss my teeth after brushing my teeth
10. A nurse is assessing a client who is at risk for development of
pernicious anemia resulting from peptic ulcer disease. Which of the
following images depicts a condition caused by pernicious anemia?
A.) depicts oral candidiasis/thrush
B.) depicts dry oral mucous membrane
C.) depicts glossitis
D.) depicts a healthy tongue dull in color
a. Glossitis toungue
11. A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication.
a. WBC count 2,000
12. A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip.
a. Pericardial friction rub
13. a nurse is admitting a client who has active tb. which of the following types of transmission precautions should the nurse initiate?
14. A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (select all)
a. Follow a smoking cessation program
b. Maintain an appropriate weight
c. Eat a low-fat diet
15. Family teaching, alzheimers
a. Create complete outfits
16. Post op thyroidectomy
a. Temp 102F
17. Mechanical ventilation via trach tube.
a. Stress ulcers
18. Lung cancer and receving palliative care, thoracentesis
19. New prescription of psyllium
a. Drink 240 mL water after administration
20. Gingkgo biloba
a. Can cause an increased risk for bleeding
21. Home health teaching client who has stage 1 pressure injury
a. Change position every hour
22. Medical record of an older adult who is receiving IV fluid therapy. Re-evaluation of the IV therapy prescription?
a. BUN 29
23. Scheduled for a mastectomy.
a. Refer you to a community resources that can provide support
24. Extubation of endotracheatube 10 minutes ago, report immediately?
25. Diabetes insipidus, what to expect?
a. Low urine specific gravity
26. Postop following TURP
27. Arterial line, what action should nurse take?
a. Place pressure bag around the flush solution
28. Promotional presentation for group of African americans at community center, greatest risk for?
29. Dementia and require acute care for a respiratory infection. Client agitated and attempting to remove IV catheter
a. Keep client occupied with manual activity
30. External fixation device for a fracture in lower extremity
a. Use crutches with rubber tips
31. Peripheral arterial disease, what to expect
a. Hair loss on the lower legs
32. Warfarin for chronic atrial fib
a. INR 2.5
33. Osteomyelitis, prescription for gentamicin
a. Serum creatinine
34. Anemia and new prescription for oral iron supplement
a. Eat more high-fiber foods
35. Cervical spinal cord injury 1 month ago, experiencing autonomic dysreflexia?
a. HR 52
36. Gastric hemorrhage going into shock
a. administer oxygen
initiate IV therapy
insert an NG tube
37. thoracentesis, following interventions should nurse include in the plan
a. encourage to take deep breaths
38. client receiving chemotherapy, what is propriety
a. report of sore throat
39. compound fracture 3 weeks ago, unexpected finding manifestation of osteomyelitis
a. sedimentation rate
40. nephrostomy tube 12 hours ago
a. client reports back pain
41. constipation-predominant irritable bowel syndrome
a. 30 g fiber daily
42. Dementia, interventions to include in plan of care
a. Place personal items at bedside
43. Postop parathyroidectomy
a. Tracheostomy tray at the bedside
44. Completion of hemodialysis
45. Administering packed RBC, what indications hemolytic transfusions reaction
a. Low back pain and apprehension
46. Modified radical mastectomy of right breast
a. Drain removed when 25ml or less over 24 hours
47. AIDS, statements by client indicates understanding of teaching
a. Take temperature once a day
48. Lab findings client who developed chest pain 6 hours ago, indication of MI
a. Troponin 8ng
49. Osteoporosis prevention, medication increases risk
50. Phenytoin 600 mg PO daily
51. Urgent care clinic experiencing anaphylactic reaction
a. Applying oxygen via face mask
52. Administer a blood transfusion to client who has anemia
a. Check for the type and number of units of blood
53. Sealed radiation implant for cervical cancer
a. Lead-lined container in room
54. Breast cancer tells nurse they would like to have acupuncture
a. Speak to the provider about incorporating acupuncture
55. TPN and is NPO, capillary blood glucose AC and HS
a. Contact PCP
56. Positive culture for MRSA
a. Bathe client using chlorhexidine solution
57. Pneumothorax and closed-chest drainage system
a. Bubbling in water seal chamber has ceased
58. Asthma about use of metered-dose inhaler.
a. Hold breath for 10 seconds after inhaling
a. Regular insulin 20 u IV bolus
60. At risk for osteoporosis
a. Walk for 30 min four times per week
61. Hypertension and new presecription for verapamil
a. Increase fiber intake to avoid constipation
62. Undergo cataract surgery, medication is contraindicatied
63. Assessing client’s hydration status, indicated FVO
a. Distended neck veins
64. Postoperative teaching for total knee arthroplasty
a. Flex the foot every hour when awake
65. Zenker’s diverticulum
a. Pharyngeal pouch
66. ECG Rhythm strip who has temporary pacemaker
a. Document that depolarization has occurred
67. AIDS and taking amphotericin B for fungal infunction
a. BUN 34
68. Client who has end-stage kidney disease waiting for kidney transplant
a. Hemodialysis is sometimes required following surgery
69. Perimenopausal and has a prescription for hormone replacement therapy
a. Calf pain
b. Intense headaches
c. Numbness in the arm
70. Terminal cancer, “stop these treaments, I’m ready to die.”
a. “Discontinuing with the treatments is your choise if it is your wish to do so.:
71. Tonic-clonic seizure while in bed and has become cyanotic
a. Prepare to suction
b. Loosen restrictive clothing
72. Caring for a client who is receiving a blood transfusion. Client becomes restless, dyspneic and has crackles
a. Slow the infusion rate
73. Performing a preoperative assessment for a client. Allergery to food indicate latex allergy
74. Evaluating the plan of care for four clients after 2 days of hospitalization. Revise which plan
a. Reports something “popped” when they coughed
75. ABG with advanced COPD
a. PaCO2 of 56 mmHg
76. Transcutaneous electrical nerve stimulation for management of bone cancer pain
a. A tingling sensation replacing the pain
77. Teaching a group of newly licensed nurses about pain management for older adult clients
a. Ibuprofen can cause gastrointestinal bleeding in older adult clients
78. ED assessing older adult client who has fractured wrist following a fall. “last week I crashed my car because my vision suddenly became blurry.”
a. Check neuro status
79. Cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring
a. Identifies if the pacemaker cells of my heart are working properly
80. Stage 2 cervical cancer scheduled for brachytherapy
a. You will need to stay still in the bed during each treatment session
81. DKA, condition is improving
a. Glucose 272 mg/dL
82. Laryngeal cancer and is receiving radiation therapy
a. I will avoid direct exposure to the sun
83. Self-administer heparin subcutaneously
a. Electric razor to shave
84. PACU assessing postop following right nephrectomy
a. HR 110
85. Hypothyroidism, which manifestation should nurse expect
86. Assessing for compartment syndrome
a. Pain that increases with passive movement
87. Homonymous hemianopsia as a result of a stroke, to reduce risk of falls when ambulating
a. Scan environment by turning hour head from side to side
88. Nurse planning care for a client who is postop following a laparotomy, closedsuction drain
a. Compress the drain reservoir after emptying
89. Medical record of client who has SLE
a. Facial butterfly rash
90. Diagnosis of rheumatoid arthritis, nonpharmacological intervention should nurse suggest to the client to reduce pain
a. Alternate application of heat and cold to the affected joints
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