clearance for a client who is to receive chemotherapy. Which interventions should a nurse implement? Select all that apply. A. Insert a foley catheter in client for 24 hours. B. Post notices on the clients door to save all urine. C. Instruct the client to discard the first voided urine. D. Check for the ordered diet and medication modifications. 2. A Client with cancer of the bladder is scheduled to have an ileal conduit. Which information specific to the procedure would the nurse include in preparing this client for procedure? A. The stoma will be closed in 4-6 weeks. B. Urine will drain into a collection bag continuously. C. Kegel’s exercises are necessary to promote continence. D. A catheter will be inserted into the stoma to drain urine. 3. A nurse understands which of the following clients is at the greatest risk for developing stress incontinence? A. 29 year old male basketball player. B. 32 year old para 1 gravida 1 C. 45 year old with diabetes mellitus D. 60 year old with spinal cord injury 4. A nurse understands which of the following clients is at the greatest risk for developing bladder cancer? A. 45 year old Hispanic female who works as a nurse educator. B. 50 year old African American male with an enlarged prostate. C. 55 year old Asian female who has recently had acute pyelonephritis. D. 60 year old Caucasian male who smokes half a pack of cigarettes per day. 5. A nurse notes that the urine of a client taking Phenzopyridine (Pyridium) for dysuria is orange. What is the nurse’s next best action? A. Force fluids B. Notify the physician C. Perform a urine dipstick D. Do nothing as this is a normal finding. 6. A client from a long term care facility is admitted with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first? A. Start an IV with a 20 gauge catheter B. Initiate antibiotic therapy IVPB C. Change the indwelling catheter D. Collect a specimen for urinalysis. 7. A nurse is discharging a client with nosocomial urinary tract infection. Which information should the nurse include in the discharge teaching? A. Avoid coffee, tea, and colas. B. Be sure to void every five to six hours. C. Tub baths can be soothing to the perineum. D. Take all the antibiotics until symptoms subside. 8. Which information regarding the care of an indiana pouch should the nurse teach? A. Tell the client the stoma should be slightly dusky in color . B. Teach the client to instill a few drops of vinegar into the pouch. C. Tell the client that it is normal for the urine to be pink or red in color. D. Inform the client that they will need to self-catheterize for every 4 hours. 9. Trimethoprim/sulfamethoxazole (Bactrim) 2 tablets by mouth for 10 days had been prescribed for a client with a urinary tract infection. Which observation best demonstrates that the client followed the prescribed regimen? A. Decreased dysuria. B. Normal red blood cell count. C. Absence of bacteria on urine culture. D. Urine output of 2,500 ml in 24 hours. 10. Which of the following instructions is most important for a nurse to provide for a client who has undergone extracorporeal shock-wave lithotripsy? A. “Change the dressing if it gets wet.” B. “Take your temperature every day.” C. Increase your fluid intake to 3,000 ml/day.” D. Hematuria is expected for the next 72 hours.” 11. A client with thyroid cancer undergoes thyroidectomy. Post operatively the client complains of peripheral numbness and tingling, and muscle twitching. Which of the following drugs should the nurse prepare to administer? A. Calcium B. Barbituate C. Thyroid Hormone D. Muscle relaxant. 12. A client with Graves disease related to has been taking Propylthiouracil as prescribed. Which of the following findings noted on cardiac assessment indicates to the nurse that the client has had a sufficient response to medication therapy? A. radial pulse of 90 B. respiratory rate of 24 C. temperature of 100.6*F D. Systolic blood pressure of 148 13. A client has undergone a hypophysectomy using a transphenoidal approach. You change the mustache dressing nothing clear exudate with a pale-yellow colored ring at the edge of the drainage of the drainage on the dressing. The nurse would take with of the following actions? A. Infuse a bolus of 500ml of D5W!cant give icp bolus B. Apply an ice pack to the bridge of the nose C. Encourage the client to blow his nose to remove secretions. D. Assess the headache and complaints of salty taste in the mouth. 14. A female client newly-diagnosed with hypothyroidism indicates that she no longer wants to participate in evening social activities stating, “There is too much walking, and I prefer to go to bed early.” The nurse formulates which of the following as a priority nursing diagnoses to this client? A. Social isolation related to sleep rest needs. B. Fatigue related to reduced metabolic rate C. Decreased cardiac output related to weak myocardium. D. Disturbed sleep pattern related to excessive work demands. 15. A nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison’s disease). When assessing the client, which clinical manifestations would the nurse expect to find? A. Bulging eyes and goiter and pulse 120. B. Hirsutism, irritability and temperature 101* F C. Moon face, buffalo hump, and blood glucose of 190 mg/dl-cushing D. Bronze pigmentation, anorexia, and blood pressure 86/56 16. A nurse is performing an assessment on a client diagnosed with Cushing’s Disease. Which of the following should be reported to the physician immediately? A. Pitting edema of the legs. B. Thirst and dry mucous membranes. C. Urinating every 2-3 hours. D. Apical pulse rate of 72 and irregular. 17. A client diagnosed with Addison’s Disease is admitted to the emergency department after a day at the beach. The client is lethargic, confused, and has a blood pressure of 70/50, pulse of 116, and respirations of 30. Which information should the nurse’s first action? A. Perform a head to toe assessment. B. Administer 30G of glucose tablet sublingually. C. Collect urinalysis and blood samples to calcium levels. D. Start an IV with an 18 gauge needle and infuse hydrocortisone. 18. A Nurse is admitting a client to the post anesthesia care unit following a transphenoidal hypophysectomy. Which data would warrant immediate intervention? A. The client is alert to person and place but is unable to tell the nurse the data. B. The client has an urinary output of 2500 ml since surgery and an intake of 1000ml. C. The client’s vital signs are T 99.2, P 88, BPM 120/70 R 14. D. The client has a 3cm amount of dark-red drainage on the turban dressing. 19. A client diagnosed with hypothyroidism is prescribed 50 mcg of thyroid hormone levothyroxine (Synthroid) by mouth daily. Which assessment data indicates an adverse drug effect? A. dysuria B. tachycardia C. blurred vision D. weight gain of 2 pounds 20. A client with hypothyroidism is admitted to the intensive care department diagnosed with myxedema coma. Which assessment date would warrant immediate intervention by the nurse? A. Serum glucose level of 74 B. pulse OX of 90% C. Serum cholesterol of 290 D. Telemetry reading shows sinus bradycardia 21. An intervention to prevent hypothermia in a burn client during the acute phase includes: (Select all that apply) A. Decrease the room temperature B. Cover wounds with moist sterile dressing C. Work quickly when wounds must be exposed D. Limit hydrotherapy sessions to 30 minutes or less 22. After establishing a patient airway, which collaborative intervention is priority for the burn client? A. Insert a foley catheter B. Initiate an IV with Ringers lactate solution C. Prevent contractures of extremities D. Prepare to assist with an (eschamotomy)? (couldn’t really see that word) 23. A nurse writes the nursing diagnosis “impaired skin integrity related to open burn wounds” which intervention would be most appropriate for this nursing diagnosis? A. screen visitors for respiratory infections B. provide analgesia before pain becomes severe C. encourage a low car high protein diet D. clean the clients wounds using sterile technique 24. A client is admitted with burns to more than 30% of the body. The nurse is concerned with client’s nutritional status. Which intervention should the nurse implement? A. Weigh the client weekly in the same clothes B. Monitor the client’s serum protein and albumin C. Provide a low-fat, low cholesterol diet for the client D. Encourage the client’s family to bring in favorite foods 25. A child was admitted to the emergency department with a thermal burn to the head and neck area. Which of the following assessments requires immediate action? A. Thirst B. Singed hair C. Coughing and wheezing D. Bright read skin with small blisters on the burn sites 26. The initial nursing intervention for a client in the emergency department who suffered a chemical burn to the eyes is to? A. Administer 2 mg of morphine sulfate IVP as prescribed B. Apply gentamycin to ophthalmic ionment as prescribed C. Irrigate the eyes with 0.9% saline solution or water D. Evaluate vision with and without prescription eyeglasses 27. As part of the ongoing nursing assessment of a client who has an electrical burn, a CBC, electrolyte panel, and renal panel were ordered. During the emergent phase, the nurse would expect to find which of the following results? A. Hematocrit of 30 B. Potassium level of 5.9 C. Creatine kinase of 22 to 198 D. WBC of 8,000 28. A nurse is caring for a client who is recovering from partial thickness burns. Which of the following breakfast options indicates the client understand the recommended diet? A. Two poached eggs, hash brown potatoes, whole milk. B. Corn flake cereal with skim milk, orange juice C. Three pancakes with syrup, two slices of bacon, apple juice D. One cup of oatmeal with skim milk, ½ grapefruit, coffee 29. Using the formula by the American Burn life Support course, the nurse estimates that a client with 40% TBSA who weighs 100 kg should receive how much IV fluid in the first 8 hours. A. 1,400-2,800 B. 1,500-3,500 C. 4,000-8,000 D. 8,500-16,000 30. A nurse is caring for a client and hears a physician state that the patient’s lung compliance has decreased. The nurse understands that decreased lung compliance indicates: A. Air will move more easily into the alveoli B. The work of breathing will be reduced in this client C. A greater expiratory effort will be needed for this patient to exhale D. A greater inspiratory effort will be needed to get air into the alveoli 31. An experienced nurse is explaining positive end expiratory pressure (PEEP) to a new critical care nurse. The best explanation of this therapy is: A. It will decrease the functional residual capacity (FRC) B. It will help decrease cellular oxygenation C. It is used to increase alveolar surface area D. It can be used to prevent the intubation of a client 32. To improve client outcomes and standardize nursing during mechanical ventilation, bundles of ventilator care are recommended by the institute of health care improvement. Which of the following is included in this bundle? A. wear gown, gloves and mask before providing nursing care B. using proton-pump inhibitors to decrease gastric acid secretions C. suctioning the client every two hours to prevent mucous pooling orally D. keeping the patient sedated for the first 3days of being mechanically ventilated 33. The triage nurse understands which of the following clients would be seen first by the health care team? The client: A. Bitten by the neighbor’s dog B. Who fell from a 12 foot ladder C. That has a laceration on the forehead D. with first degree burns on the entire right hand 34. The nurse is suctioning a client admitted with respiratory distress who is placed on mechanical ventilation. Which of the following best indicator that suctioning has been effective? A. Pulse rate of 72 B. Brisk capillary refill C. Decreased secretions D. Clear breath sounds on auscultation 35. A nurse is monitoring a client newly diagnosed with acute hear failure (HF) which of the following lab/ diagnostic results would indicate the presence of significant HF? A. Potassium of 5.7 B. BNP of 1000 C. Sodium of 150 D. pH of 7.30 36. A client is admitted with severe uncompensated pulmonary edema secondary to chronic heart failure. After diagnostic testing. It is found that the left coronary artery is blocked, which has led to his pulmonary edema. Which of the following manifestations is consistent with diagnosis? A. CVP level of 22 B. B/P 160/94 C. PAWP of 20 D. O2 sat of 99 37. A nurse is assessing the laboratory values for a client with chronic heart failure before administering furosemide (Lasix). Which of the following values would cause the nurse to withhold this drug and notify the primary care provider? A. Potassium Level of 3.5 mEq/L B. Digoxin level of 0.7 ng/mL C. Calcium level of 9 mg/dL D. Magnesium sulfate 38. A client is suspected of having a decreased cardiac output due to dysrhythmias. Which of the following assessments would the nurse observe? Select all that apply: A. Elevated jugular vein distention B. Polyuria C. Full and bounding pulses D. Diaphoresis E. Muffled heart sounds 39. A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client’s arterial blood has is 7.28. What should the nurse do first? A. Apply electrocardiogram leads B. Prepare to assist with ventilation C. Insert a nasogastric tube for gastric lavage. D. Obtain urine for a drug toxicology 40. After a left pneumonectomy, a client has a chest tube in place. When preparing a care plan for this client, the nurse should include which of the following interventions? A. Milk the chest tube every 2 hrs B. Clamp the chest tube as necessary. C. Assist the client in using the incentive spirometer D. Monitor for fluctuations in the water-seal chamber. 41. The client has the following electrocardiogram strip. What is the nurses next best action? A. Defibrillate B. Begin chest compression! pulseless, apneic, unresponsive C. Administer a precordial thump D. Administer 4L of oxygen 42. The client who has had a bone marrow transplant wants to attend a holiday party. Which of the following would the nurse tell the client to avoid in order to protect against germs? A. chips and dip B. fried foods C. cocktails D. nuts 43. The client receiving chemotherapy develops nausea and vomiting. Which of the following actions should be given highest priority? A. Offer small frequent meals B. Instruct the client on diversional techniques C. Force Fluids for during chemotherapy administration D. Administer granisetron (Kytril) and dexamethasone (Decadron) as ordered. 44. A nurse is providing teaching to a client with acquired immunodeficiency syndrome (AIDS). Which of the following actions is most important for the nurse to stress? A. Practice safe sex B. Avoid drugs and alcohol C. Wash all eating utensils separately D. Inform sex partners of the diagnosis as required by law. 45. A nurse understands, which of the following couples has the highest risk of having a child with sickle cell disease? A. Father has sickle cell disease and the mother has sickle cell disease. B. Father has sickle cell disease and the mother has sickle cell trait. C. Father has normal hemoglobin and the mother has sickle cell disease. D. Father has sickle cell trait and the other has sickle cell trait. 46. For a client with Hepatitis C, which of the following manifestations would alert a nurse to a decrease in liver function? A. Jaundice B. Pruritis C. Anorexia D. Drowsiness 47. A nurse recognizes that a client with azotemia understands dietary restrictions when the following lunch selection is chosen: low protein, no dairy A. Turkey sandwich with swiss cheese and skim milk B. Pasta with vegetables, canned pears, and iced tea. C. Cheeseburger, pound cake, sliced peaches and coffee. D. Chicken breast with lettuce and tomato and chocolate milk. 48. A nurse is planning for an interdisciplinary team conference. Which of the following clients would be most appropriate for referral to hospice care? A. A client who is HIV positive B. A client with metastatic cancer who has chronic pain. C. A client who is undergoing treatment for schizophrenia D. A client who had an external defibrillator placed 1 week ago. E. A client with leukemia who is undergoing a bone marrow transplant. 49. A client exposed to radiation following a radiological incident is brought to the emergency room with open wounds. Which of the following is the most immediate concern for this client? A. infection B. Tissue necrosis C. Internal contamination D. Development of local radiation injury 50. A client is declared brain dead after a motor vehicles accident. The client is an organ donor but the spouse refuses to donate his organs, after speaking with the Organ Donation nurse. The organ donation should: A. Remind the spouse that she is not following her husband’s wishes. B. Call the physician to come and speak with spouse. C. Report the problem to the nursing supervisor D. Respect the spouses wishes. 51. A nurse is caring for a client admitted with pancreatitis. What is the appropriate diet for this client during the first 24 hours after admission? A. Clear liquids B. Full liquids C. Regular diet D. Nothing by mouth 52. A nurse recognizes the client requires further teaching regarding patient controlled analgesia (PCA) from which of the following statements? A. “The PCA pump can prevent over medication” B. “I can push the button when my pain level increases” C. “My family can push the button for me if I am sleeping” D. “I’ll receive the same amount of medication as I would if given an injection” 53. A nurse manager is performing a chart audit. Which documentation statement reflects cause for concern? A. “Client requires additional teaching regarding self injection of insulin” B. “2×2 cm pressure ulcer noted on left calcaneus, without drainage or odor.” C. “Refused milk of magnesia stating she had a bowel movement this morning” D. “Incident report filled out after client slipped to the floor while getting out of bed. Denied getting hurt”. 54. A nurse is caring for a client with type 1 Diabetes Mellitus who exhibits confusion and light-headedness. The client has just lost consciousness. The nurse should first administer: A. IM or sq glucagon B. 10 unit of sq of Novolog C. 15-20 Grams of carbohydrates such as orange juice 55. A nurse is performing a neurologic assessment on a client. Which photo demonstrates the technique the nurse should use to evaluate cranial nerve XII? tongue 56. A nurse is assisting the physician to apply a fiberglass cast to a client who has a sustained a fracture left fibula. Which action should the nurse include in a care plan for this client? A. Assess capillary refill of the toes. B. Keep the casted leg warm with a light blanket. C. Avoid handling the cast for 24 hours until it dries D. Instruct the client to squeeze a soft ball with the left hand. 57. A client has left hemiparesis following a stroke. When creating a care plan for this client which intervention should take the highest priority? A. Toilet client every 2 hours. B. Perform passive range of motion exercise every shift. C. Encourage self-care during activities of daily living. D. Assist the client to a high fowler’s position before meals. 58. A client with bacterial pneumonia is receiving oxygen via nasal cannula at 2L per min. Which should the nurse consider the most reliable indicator in assessing the effectiveness of the oxygen therapy? A. Secretions are clear. B. Increase in arterial blood gas pH. C. Temperature is within normal range. D. Partial pressure of PaO2. 59. A client is experiencing an acute asthma attack is seen in the ER. While waiting to be seen by the physician, a nurse notes that wheezing has stopped and the client becomes diaphoretic. What is the next best action? A. Auscultate breath sounds B. Provide humidifies oxygen. C. Page the respiratory therapist. D. Prepare the client for discharge as the attack has spontaneously resolved. 60. Before administering medication through an NG tube, which action should the nurse perform first? A. Auscultate bowel sounds. B. Flush the tube with 30mL of water. C. Use a penlight to inspect the oral cavity. D. Aspirate gastric contents and check pH. 61. A nurse educator is conducting a lesson on restraints. Which statement made by the student nurse indicates that teaching has been successful? A. “Physical restraints should be used if the client can’t follow simple commands.” B. “The least restrictive form of restraint should be used to prevent injury to the client.” C. “Restraints should be removed once a shift and range of motion exercises performed.” D. “A nurse can apply restraints for 24 hours if a physician’s order can’t be immediately obtained.” 62. A nurse working in the CCU anticipates a client in cardiogenic shock will require an Intra-Aortic Balloon Pump (IABP). The nurse explains to the patient that this device will: A. Be needed until a permanent pacemaker can be implanted. B. Replace many of the medications the client is taking now. C. Increase preload and afterload of the heart. D. Decrease myocardial oxygen consumption. 63. A client has sustained severe burns on both the anterior right and left leg and the anterior chest and abdomen. According to the rule of nines, what percentage of the body has been burned? ______________________________________% 64. A client with hypotension is receiving renal dopamine. The 250mL bag contains 400mg of dopamine and is running at 23mL per hour. The client weighs 80 kg. Calculate how many milligrams are contained in each milliliter of fluid. _________________________ mg/mL 65. An adult with Hodgkin’s disease who weighs 143 pounds is to receive Vincristine 20mcg/kg IV. How many mcg should the client receive? _________________________ mcg Bonus: A client is pulled from a burning building at 1300 hours. He has sustained burns to his head and neck area. He arrives at the hospital at 1400 hours. Using the Parkland formula, calculate the amount of fluid resuscitation the patient will receive in the first 24 hours. ______________________________________

Question 1. A physician has ordered a 24 hour urine collection for creatineclearance for a client who is to receive chemotherapy. Which interventions should a nurse implement? Select all that apply. A. Insert a foley catheter in client for 24 hours. B. Post notices on the clients door to save all urine. C. Instruct the client to discard the first voided urine. D. Check for the ordered diet and medication modifications. 2. A Client with cancer of the bladder is scheduled to have an ileal conduit. Which information specific to the procedure would the nurse include in preparing this client for procedure? A. The stoma will be closed in 4-6 weeks. B. Urine will drain into a collection bag continuously. C. Kegel’s exercises are necessary to promote continence. D. A catheter will be inserted into the stoma to drain urine. 3. A nurse understands which of the following clients is at the greatest risk for developing stress incontinence? A. 29 year old male basketball player. B. 32 year old para 1 gravida 1 C. 45 year old with diabetes mellitus D. 60 year old with spinal cord injury 4. A nurse understands which of the following clients is at the greatest risk for developing bladder cancer? A. 45 year old Hispanic female who works as a nurse educator. B. 50 year old African American male with an enlarged prostate. C. 55 year old Asian female who has recently had acute pyelonephritis. D. 60 year old Caucasian male who smokes half a pack of cigarettes per day. 5. A nurse notes that the urine of a client taking Phenzopyridine (Pyridium) for dysuria is orange. What is the nurse’s next best action? A. Force fluids B. Notify the physician C. Perform a urine dipstick D. Do nothing as this is a normal finding. 6. A client from a long term care facility is admitted with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first? A. Start an IV with a 20 gauge catheter B. Initiate antibiotic therapy IVPB C. Change the indwelling catheter D. Collect a specimen for urinalysis. 7. A nurse is discharging a client with nosocomial urinary tract infection. Which information should the nurse include in the discharge teaching? A. Avoid coffee, tea, and colas. B. Be sure to void every five to six hours. C. Tub baths can be soothing to the perineum. D. Take all the antibiotics until symptoms subside. 8. Which information regarding the care of an indiana pouch should the nurse teach? A. Tell the client the stoma should be slightly dusky in color . B. Teach the client to instill a few drops of vinegar into the pouch. C. Tell the client that it is normal for the urine to be pink or red in color. D. Inform the client that they will need to self-catheterize for every 4 hours. 9. Trimethoprim/sulfamethoxazole (Bactrim) 2 tablets by mouth for 10 days had been prescribed for a client with a urinary tract infection. Which observation best demonstrates that the client followed the prescribed regimen? A. Decreased dysuria. B. Normal red blood cell count. C. Absence of bacteria on urine culture. D. Urine output of 2,500 ml in 24 hours. 10. Which of the following instructions is most important for a nurse to provide for a client who has undergone extracorporeal shock-wave lithotripsy? A. “Change the dressing if it gets wet.” B. “Take your temperature every day.” C. Increase your fluid intake to 3,000 ml/day.” D. Hematuria is expected for the next 72 hours.” 11. A client with thyroid cancer undergoes thyroidectomy. Post operatively the client complains of peripheral numbness and tingling, and muscle twitching. Which of the following drugs should the nurse prepare to administer? A. Calcium B. Barbituate C. Thyroid Hormone D. Muscle relaxant. 12. A client with Graves disease related to has been taking Propylthiouracil as prescribed. Which of the following findings noted on cardiac assessment indicates to the nurse that the client has had a sufficient response to medication therapy? A. radial pulse of 90 B. respiratory rate of 24 C. temperature of 100.6*F D. Systolic blood pressure of 148 13. A client has undergone a hypophysectomy using a transphenoidal approach. You change the mustache dressing nothing clear exudate with a pale-yellow colored ring at the edge of the drainage of the drainage on the dressing. The nurse would take with of the following actions? A. Infuse a bolus of 500ml of D5W!cant give icp bolus B. Apply an ice pack to the bridge of the nose C. Encourage the client to blow his nose to remove secretions. D. Assess the headache and complaints of salty taste in the mouth. 14. A female client newly-diagnosed with hypothyroidism indicates that she no longer wants to participate in evening social activities stating, “There is too much walking, and I prefer to go to bed early.” The nurse formulates which of the following as a priority nursing diagnoses to this client? A. Social isolation related to sleep rest needs. B. Fatigue related to reduced metabolic rate C. Decreased cardiac output related to weak myocardium. D. Disturbed sleep pattern related to excessive work demands. 15. A nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison’s disease). When assessing the client, which clinical manifestations would the nurse expect to find? A. Bulging eyes and goiter and pulse 120. B. Hirsutism, irritability and temperature 101* F C. Moon face, buffalo hump, and blood glucose of 190 mg/dl-cushing D. Bronze pigmentation, anorexia, and blood pressure 86/56 16. A nurse is performing an assessment on a client diagnosed with Cushing’s Disease. Which of the following should be reported to the physician immediately? A. Pitting edema of the legs. B. Thirst and dry mucous membranes. C. Urinating every 2-3 hours. D. Apical pulse rate of 72 and irregular. 17. A client diagnosed with Addison’s Disease is admitted to the emergency department after a day at the beach. The client is lethargic, confused, and has a blood pressure of 70/50, pulse of 116, and respirations of 30. Which information should the nurse’s first action? A. Perform a head to toe assessment. B. Administer 30G of glucose tablet sublingually. C. Collect urinalysis and blood samples to calcium levels. D. Start an IV with an 18 gauge needle and infuse hydrocortisone. 18. A Nurse is admitting a client to the post anesthesia care unit following a transphenoidal hypophysectomy. Which data would warrant immediate intervention? A. The client is alert to person and place but is unable to tell the nurse the data. B. The client has an urinary output of 2500 ml since surgery and an intake of 1000ml. C. The client’s vital signs are T 99.2, P 88, BPM 120/70 R 14. D. The client has a 3cm amount of dark-red drainage on the turban dressing. 19. A client diagnosed with hypothyroidism is prescribed 50 mcg of thyroid hormone levothyroxine (Synthroid) by mouth daily. Which assessment data indicates an adverse drug effect? A. dysuria B. tachycardia C. blurred vision D. weight gain of 2 pounds 20. A client with hypothyroidism is admitted to the intensive care department diagnosed with myxedema coma. Which assessment date would warrant immediate intervention by the nurse? A. Serum glucose level of 74 B. pulse OX of 90% C. Serum cholesterol of 290 D. Telemetry reading shows sinus bradycardia 21. An intervention to prevent hypothermia in a burn client during the acute phase includes: (Select all that apply) A. Decrease the room temperature B. Cover wounds with moist sterile dressing C. Work quickly when wounds must be exposed D. Limit hydrotherapy sessions to 30 minutes or less 22. After establishing a patient airway, which collaborative intervention is priority for the burn client? A. Insert a foley catheter B. Initiate an IV with Ringers lactate solution C. Prevent contractures of extremities D. Prepare to assist with an (eschamotomy)? (couldn’t really see that word) 23. A nurse writes the nursing diagnosis “impaired skin integrity related to open burn wounds” which intervention would be most appropriate for this nursing diagnosis? A. screen visitors for respiratory infections B. provide analgesia before pain becomes severe C. encourage a low car high protein diet D. clean the clients wounds using sterile technique 24. A client is admitted with burns to more than 30% of the body. The nurse is concerned with client’s nutritional status. Which intervention should the nurse implement? A. Weigh the client weekly in the same clothes B. Monitor the client’s serum protein and albumin C. Provide a low-fat, low cholesterol diet for the client D. Encourage the client’s family to bring in favorite foods 25. A child was admitted to the emergency department with a thermal burn to the head and neck area. Which of the following assessments requires immediate action? A. Thirst B. Singed hair C. Coughing and wheezing D. Bright read skin with small blisters on the burn sites 26. The initial nursing intervention for a client in the emergency department who suffered a chemical burn to the eyes is to? A. Administer 2 mg of morphine sulfate IVP as prescribed B. Apply gentamycin to ophthalmic ionment as prescribed C. Irrigate the eyes with 0.9% saline solution or water D. Evaluate vision with and without prescription eyeglasses 27. As part of the ongoing nursing assessment of a client who has an electrical burn, a CBC, electrolyte panel, and renal panel were ordered. During the emergent phase, the nurse would expect to find which of the following results? A. Hematocrit of 30 B. Potassium level of 5.9 C. Creatine kinase of 22 to 198 D. WBC of 8,000 28. A nurse is caring for a client who is recovering from partial thickness burns. Which of the following breakfast options indicates the client understand the recommended diet? A. Two poached eggs, hash brown potatoes, whole milk. B. Corn flake cereal with skim milk, orange juice C. Three pancakes with syrup, two slices of bacon, apple juice D. One cup of oatmeal with skim milk, ½ grapefruit, coffee 29. Using the formula by the American Burn life Support course, the nurse estimates that a client with 40% TBSA who weighs 100 kg should receive how much IV fluid in the first 8 hours. A. 1,400-2,800 B. 1,500-3,500 C. 4,000-8,000 D. 8,500-16,000 30. A nurse is caring for a client and hears a physician state that the patient’s lung compliance has decreased. The nurse understands that decreased lung compliance indicates: A. Air will move more easily into the alveoli B. The work of breathing will be reduced in this client C. A greater expiratory effort will be needed for this patient to exhale D. A greater inspiratory effort will be needed to get air into the alveoli 31. An experienced nurse is explaining positive end expiratory pressure (PEEP) to a new critical care nurse. The best explanation of this therapy is: A. It will decrease the functional residual capacity (FRC) B. It will help decrease cellular oxygenation C. It is used to increase alveolar surface area D. It can be used to prevent the intubation of a client 32. To improve client outcomes and standardize nursing during mechanical ventilation, bundles of ventilator care are recommended by the institute of health care improvement. Which of the following is included in this bundle? A. wear gown, gloves and mask before providing nursing care B. using proton-pump inhibitors to decrease gastric acid secretions C. suctioning the client every two hours to prevent mucous pooling orally D. keeping the patient sedated for the first 3days of being mechanically ventilated 33. The triage nurse understands which of the following clients would be seen first by the health care team? The client: A. Bitten by the neighbor’s dog B. Who fell from a 12 foot ladder C. That has a laceration on the forehead D. with first degree burns on the entire right hand 34. The nurse is suctioning a client admitted with respiratory distress who is placed on mechanical ventilation. Which of the following best indicator that suctioning has been effective? A. Pulse rate of 72 B. Brisk capillary refill C. Decreased secretions D. Clear breath sounds on auscultation 35. A nurse is monitoring a client newly diagnosed with acute hear failure (HF) which of the following lab/ diagnostic results would indicate the presence of significant HF? A. Potassium of 5.7 B. BNP of 1000 C. Sodium of 150 D. pH of 7.30 36. A client is admitted with severe uncompensated pulmonary edema secondary to chronic heart failure. After diagnostic testing. It is found that the left coronary artery is blocked, which has led to his pulmonary edema. Which of the following manifestations is consistent with diagnosis? A. CVP level of 22 B. B/P 160/94 C. PAWP of 20 D. O2 sat of 99 37. A nurse is assessing the laboratory values for a client with chronic heart failure before administering furosemide (Lasix). Which of the following values would cause the nurse to withhold this drug and notify the primary care provider? A. Potassium Level of 3.5 mEq/L B. Digoxin level of 0.7 ng/mL C. Calcium level of 9 mg/dL D. Magnesium sulfate 38. A client is suspected of having a decreased cardiac output due to dysrhythmias. Which of the following assessments would the nurse observe? Select all that apply: A. Elevated jugular vein distention B. Polyuria C. Full and bounding pulses D. Diaphoresis E. Muffled heart sounds 39. A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client’s arterial blood has is 7.28. What should the nurse do first? A. Apply electrocardiogram leads B. Prepare to assist with ventilation C. Insert a nasogastric tube for gastric lavage. D. Obtain urine for a drug toxicology 40. After a left pneumonectomy, a client has a chest tube in place. When preparing a care plan for this client, the nurse should include which of the following interventions? A. Milk the chest tube every 2 hrs B. Clamp the chest tube as necessary. C. Assist the client in using the incentive spirometer D. Monitor for fluctuations in the water-seal chamber. 41. The client has the following electrocardiogram strip. What is the nurses next best action? A. Defibrillate B. Begin chest compression! pulseless, apneic, unresponsive C. Administer a precordial thump D. Administer 4L of oxygen 42. The client who has had a bone marrow transplant wants to attend a holiday party. Which of the following would the nurse tell the client to avoid in order to protect against germs? A. chips and dip B. fried foods C. cocktails D. nuts 43. The client receiving chemotherapy develops nausea and vomiting. Which of the following actions should be given highest priority? A. Offer small frequent meals B. Instruct the client on diversional techniques C. Force Fluids for during chemotherapy administration D. Administer granisetron (Kytril) and dexamethasone (Decadron) as ordered. 44. A nurse is providing teaching to a client with acquired immunodeficiency syndrome (AIDS). Which of the following actions is most important for the nurse to stress? A. Practice safe sex B. Avoid drugs and alcohol C. Wash all eating utensils separately D. Inform sex partners of the diagnosis as required by law. 45. A nurse understands, which of the following couples has the highest risk of having a child with sickle cell disease? A. Father has sickle cell disease and the mother has sickle cell disease. B. Father has sickle cell disease and the mother has sickle cell trait. C. Father has normal hemoglobin and the mother has sickle cell disease. D. Father has sickle cell trait and the other has sickle cell trait. 46. For a client with Hepatitis C, which of the following manifestations would alert a nurse to a decrease in liver function? A. Jaundice B. Pruritis C. Anorexia D. Drowsiness 47. A nurse recognizes that a client with azotemia understands dietary restrictions when the following lunch selection is chosen: low protein, no dairy A. Turkey sandwich with swiss cheese and skim milk B. Pasta with vegetables, canned pears, and iced tea. C. Cheeseburger, pound cake, sliced peaches and coffee. D. Chicken breast with lettuce and tomato and chocolate milk. 48. A nurse is planning for an interdisciplinary team conference. Which of the following clients would be most appropriate for referral to hospice care? A. A client who is HIV positive B. A client with metastatic cancer who has chronic pain. C. A client who is undergoing treatment for schizophrenia D. A client who had an external defibrillator placed 1 week ago. E. A client with leukemia who is undergoing a bone marrow transplant. 49. A client exposed to radiation following a radiological incident is brought to the emergency room with open wounds. Which of the following is the most immediate concern for this client? A. infection B. Tissue necrosis C. Internal contamination D. Development of local radiation injury 50. A client is declared brain dead after a motor vehicles accident. The client is an organ donor but the spouse refuses to donate his organs, after speaking with the Organ Donation nurse. The organ donation should: A. Remind the spouse that she is not following her husband’s wishes. B. Call the physician to come and speak with spouse. C. Report the problem to the nursing supervisor D. Respect the spouses wishes. 51. A nurse is caring for a client admitted with pancreatitis. What is the appropriate diet for this client during the first 24 hours after admission? A. Clear liquids B. Full liquids C. Regular diet D. Nothing by mouth 52. A nurse recognizes the client requires further teaching regarding patient controlled analgesia (PCA) from which of the following statements? A. “The PCA pump can prevent over medication” B. “I can push the button when my pain level increases” C. “My family can push the button for me if I am sleeping” D. “I’ll receive the same amount of medication as I would if given an injection” 53. A nurse manager is performing a chart audit. Which documentation statement reflects cause for concern? A. “Client requires additional teaching regarding self injection of insulin” B. “2×2 cm pressure ulcer noted on left calcaneus, without drainage or odor.” C. “Refused milk of magnesia stating she had a bowel movement this morning” D. “Incident report filled out after client slipped to the floor while getting out of bed. Denied getting hurt”. 54. A nurse is caring for a client with type 1 Diabetes Mellitus who exhibits confusion and light-headedness. The client has just lost consciousness. The nurse should first administer: A. IM or sq glucagon B. 10 unit of sq of Novolog C. 15-20 Grams of carbohydrates such as orange juice 55. A nurse is performing a neurologic assessment on a client. Which photo demonstrates the technique the nurse should use to evaluate cranial nerve XII? tongue 56. A nurse is assisting the physician to apply a fiberglass cast to a client who has a sustained a fracture left fibula. Which action should the nurse include in a care plan for this client? A. Assess capillary refill of the toes. B. Keep the casted leg warm with a light blanket. C. Avoid handling the cast for 24 hours until it dries D. Instruct the client to squeeze a soft ball with the left hand. 57. A client has left hemiparesis following a stroke. When creating a care plan for this client which intervention should take the highest priority? A. Toilet client every 2 hours. B. Perform passive range of motion exercise every shift. C. Encourage self-care during activities of daily living. D. Assist the client to a high fowler’s position before meals. 58. A client with bacterial pneumonia is receiving oxygen via nasal cannula at 2L per min. Which should the nurse consider the most reliable indicator in assessing the effectiveness of the oxygen therapy? A. Secretions are clear. B. Increase in arterial blood gas pH. C. Temperature is within normal range. D. Partial pressure of PaO2. 59. A client is experiencing an acute asthma attack is seen in the ER. While waiting to be seen by the physician, a nurse notes that wheezing has stopped and the client becomes diaphoretic. What is the next best action? A. Auscultate breath sounds B. Provide humidifies oxygen. C. Page the respiratory therapist. D. Prepare the client for discharge as the attack has spontaneously resolved. 60. Before administering medication through an NG tube, which action should the nurse perform first? A. Auscultate bowel sounds. B. Flush the tube with 30mL of water. C. Use a penlight to inspect the oral cavity. D. Aspirate gastric contents and check pH. 61. A nurse educator is conducting a lesson on restraints. Which statement made by the student nurse indicates that teaching has been successful? A. “Physical restraints should be used if the client can’t follow simple commands.” B. “The least restrictive form of restraint should be used to prevent injury to the client.” C. “Restraints should be removed once a shift and range of motion exercises performed.” D. “A nurse can apply restraints for 24 hours if a physician’s order can’t be immediately obtained.” 62. A nurse working in the CCU anticipates a client in cardiogenic shock will require an Intra-Aortic Balloon Pump (IABP). The nurse explains to the patient that this device will: A. Be needed until a permanent pacemaker can be implanted. B. Replace many of the medications the client is taking now. C. Increase preload and afterload of the heart. D. Decrease myocardial oxygen consumption. 63. A client has sustained severe burns on both the anterior right and left leg and the anterior chest and abdomen. According to the rule of nines, what percentage of the body has been burned? ______________________________________% 64. A client with hypotension is receiving renal dopamine. The 250mL bag contains 400mg of dopamine and is running at 23mL per hour. The client weighs 80 kg. Calculate how many milligrams are contained in each milliliter of fluid. _________________________ mg/mL 65. An adult with Hodgkin’s disease who weighs 143 pounds is to receive Vincristine 20mcg/kg IV. How many mcg should the client receive? _________________________ mcg Bonus: A client is pulled from a burning building at 1300 hours. He has sustained burns to his head and neck area. He arrives at the hospital at 1400 hours. Using the Parkland formula, calculate the amount of fluid resuscitation the patient will receive in the first 24 hours. ______________________________________ Health Science Science Nursing NUR 450 Share QuestionEmailCopy link Comments (0)

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