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Question: 13
Which of the following is not considered one of the five rights of medication administration?
Answer: D
tion: 14
giving an intramuscular injection to an infant. Which of the following sites is preferred?
er: C
lateralis is the ideal choice for infants.
tion: 15
choosing a needle gauge for an intramuscular injection in a 12 year old boy. Which of the following ga you choose?
er: C
uge is recommended for school age children, toddlers, and adolescents while 23-25 gauge is recommen fants.
tion: 16
Dose, client, drug, route and time are considered the five rights of medication.
Ques
When
Answ
When uges
would
Answ
22 ga ded
for in
Ques
Which of the following is not considered one of the main mechanisms of Type II Diabetes treatment?
Answer: D
Insulin is not required in continuous treatment for every Type II diabetic.
Question: 17
A nurse is caring for a retired MD. The MD asks the question, "What type of cells create exocrine secretions?" The correct answer is:
Answer: C
Acinar cells create exocrine secretions.
Question: 18
se is caring for a patient who has experienced burns to the right lower extremity. According to the Rule
which of the following percents most accurately describes the severity of the injury?
er: C
ower extremity is scored as 18% according to the Rule of Nines.
tion: 19
ient has experienced a severe third degree burn to the trunk in the last 36 hours. Which phase of burn gement is the patient in?
er: A
hock phase is considered the first 24-48 hours in wound management.
tion: 20
ient has fallen off a bicycle and fractured the head of the proximal fibula. A cast was placed on the patie
A nur of
Nines
Answ
A pat mana
Answ
A pat nt’s
lower extremity. Which of the following is the most probable result of the fall?
Answer: A
The head of the proximal fibula is in close proximity to the peroneal nerve.
Question: 21
A nurse has been ordered to set-up Buck’s traction on a patient’s lower extremity due to a femur fracture. Which
of the following applies to Buck’s traction?
Answer: C
A straight line of pull is indicated with Buck’s traction.
Question: 22
er: B
ation- "Holding a bowl of soup in your hand."
tion: 23
se is caring for a retired MD. The MD asks the question, "What type of cells secrete insulin?" The corre answer is:
er: B
ells secrete insulin.
tion: 24
se is reviewing a patient’s current Lithium levels. Which of the following values is outside the therapeut
Which of the following motions is identified with the corresponding action? (Action- Turning palm of hand over to face in the anterior direction, dorsum of the hand is pointed downward toward the floor.)
Answ
A nur ct
Answ
A nur ic
range?
Answer: D
1.0-1.2 mEq/L is considered standard therapeutic range for patient care.
Question: 25
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
Nurse's Note:
0900: 70-year-old male client with a history of hypertension and diabetes presents to the emergency department with severe chest pain radiating to the left arm. The client reports associated shortness of breath and diaphoresis.
98.6°F (37°C)
80/110
94% on room air
urse suspects the client may be experiencing a myocardial infarction. Which finding supports ion? (Select all that apply.)
phoresis.
est pain radiating to the left arm. vated heart rate.
reased blood pressure. ygen saturation of 94%. tory of diabetes.
er: A, B, C, D
nation: Diaphoresis, chest pain radiating to the left arm, elevated heart rate, and increased blo re are all classic signs of myocardial infarction, indicating the need for immediate interventi
Vital Signs: Temp:
P: 115
RR: 22
BP: 1
O2: sat
The n this
suspic
Dia
Ch
Ele
Inc
Ox
His Answ
Expla od
pressu on.
Client History:
70-year-old male client with a history of heart failure presents with increased shortness of breath and a productive cough. The client reports feeling more fatigued than usual.
Vital Signs: BP: 130/80 HR: 98
Temp: 99°F (37.2°C) RR: 30
SpO2: 89% on 2L O2/NC
Identify the priority nursing interventions for this client. (Select All That Apply)
Administer diuretics as prescribed
Assess lung sounds frequently
Educate the client on daily weight monitoring
Initiate oxygen therapy
Monitor for signs of fluid overload Answer: A, B, D, E
nation: Administering diuretics helps relieve fluid overload. Assessing lung sounds frequentl to evaluate respiratory status. Initiating oxygen therapy addresses hypoxia, and monitoring f fluid overload ensures timely intervention.
nt with heart failure is prescribed furosemide. What laboratory value should the nurse monit y? (Select All That Apply)
assium levels dium levels
N and creatinine cium levels
er: A, B, C
nation: Furosemide can cause electrolyte imbalances, particularly hypokalemia and hyponatre ay affect renal function, necessitating monitoring of BUN and creatinine levels.
Expla y is
critical for
signs o
A clie or
closel
Pot
So
BU
Cal Answ
Expla mia,
and m
Nurse's Note:
1500: 82-year-old female client with a history of dementia presents with increased agitation and refusal to eat. The family reports a sudden change in her behavior.
Vital Signs:
Temp: 98.5°F (36.9°C) P: 80
RR: 16 BP: 120/80
O2: sat 95% on room air
Which 4 findings from the nurse's notes are most important to address immediately?
Increased agitation.
Refusal to eat.
Sudden change in behavior.
Normal vital signs.
History of dementia.
nation: Increased agitation and refusal to eat are concerning as they may indicate underlying medical issues or acute changes in the client’s condition. A sudden change in behavior necessitates
evaluation to identify possible causes.
Note:
9-year-old male client with a history of asthma presents with severe wheezing and shortnes after exposure to allergens. The client reports increased use of his rescue inhaler.
igns:
98.4°F (36.9°C)
25/80
87% on 3L O2 via nasal cannula
4 findings from the nurse's notes are most critical to address immediately? vere wheezing.
ortness of breath.
reased use of rescue inhaler.
Family concerns. Answer: A, B, C, F Expla
further
Nurse's
1600: 4 s of
breath
Vital S Temp: P: 100
RR: 28
BP: 1
O2: sat Which
Se
Sh
Inc
Oxygen saturation of 87%.
Normal blood pressure.
Elevated pulse rate. Answer: A, B, D, C
Explanation: Severe wheezing and shortness of breath indicate an acute asthma exacerbation requiring immediate treatment. An oxygen saturation of 87% suggests hypoxia, necessitating urgent intervention.
Nurse's Note:
2600: 65-year-old male client with a history of chronic heart failure presents with increased edema and shortness of breath. The client reports a rapid weight gain of 5 pounds over the past week.
Vital Signs:
Temp: 98.7°F (37.1°C) P: 90
35/85
90% on 3L O2 via nasal cannula
findings from the nurse's notes require immediate attention? (Select all that apply.) reased edema.
ortness of breath. pid weight gain.
ygen saturation of 90%. vated blood pressure. tory of heart failure.
er: A, B, D, C
nation: Increased edema and shortness of breath are indicative of fluid overload that requires ention. An oxygen saturation of 90% suggests hypoxia that needs to be addressed immediatel
nurse is preparing to administer a blood transfusion. Which of the following assessments should med before starting the transfusion? (Select All That Apply)
eck the patient's vital signs
RR: 24
BP: 1
O2: sat Which
Inc
Sh
Ra
Ox
Ele
His Answ
Expla urgent
interv y.
A be
perfor
Ch
Confirm the blood type and Rh factor with another nurse
Assess for any history of allergic reactions to blood products
Obtain a signed consent form Answer: A, B, C, D
Explanation: It is essential to check vital signs to establish a baseline, confirm blood type for compatibility, assess for allergic history to prevent reactions, and ensure that informed consent is obtained before any transfusion.
Client History:
65-year-old female client with a history of hypertension presents with severe headache and visual disturbances. The client reports a sudden onset of symptoms and has a family history of stroke.
Nurse's Note:
mine the priority nursing actions for this client. (Select All That Apply) minister antihypertensive medication
iate a stroke protocol
nitor neurological status frequently pare for a CT scan
vide education on stroke prevention er: B, C, D
nation: Initiating a stroke protocol is crucial for rapid assessment and intervention. Monitorin ogical status helps detect changes in condition. Preparing for a CT scan is essential to rule o rhagic stroke.
nurse is assessing a client with pneumonia. Which of the following findings would indicate the need mediate intervention? (Select All That Apply)
spiratory rate of 28 breaths per minute ygen saturation of 90%
ductive cough with green sputum
Vital signs reveal elevated blood pressure, and the client is diaphoretic. Neurological assessment shows weakness on the right side.
Deter
Ad
Init
Mo
Pre
Pro Answ
Expla g
neurol ut
hemor
A
for im
Re
Ox
Pro
Chest pain with inspiration Answer: A, B, D
Explanation: Increased respiratory rate, low oxygen saturation, and chest pain during inspiration indicate potential respiratory distress and warrant immediate intervention.
Nurse's Note:
1500: 65-year-old male client with a history of coronary artery disease presents with chest pain described as "pressure" and shortness of breath. The client is on aspirin and a beta-blocker.
Vital Signs:
Temp: 98.6°F (37°C) P: 112
RR: 24
BP: 160/100
indings from the nurse's notes require immediate intervention? (Select all that apply.) est pain described as "pressure."
ortness of breath.
vated heart rate. vated blood pressure.
tory of coronary artery disease. ygen saturation of 94%.
er: A, B, D, C
nation: Chest pain and shortness of breath in the context of coronary artery disease are critica quire urgent assessment. Elevated heart rate and blood pressure may indicate increased myoc
demand, necessitating immediate intervention.
istory:
-old client diagnosed with type 1 diabetes presents with severe abdominal pain, nausea, an ng. The client has been experiencing increased thirst and urination. Laboratory results reveal lucose level of 450 mg/dL and metabolic acidosis.
O2: sat 94% on room air What f
Ch
Sh
Ele
Ele
His
Ox
Answ
Expla l signs
that re ardial
oxygen
Client H
45-year d
vomiti a
blood g
Nurse's Note:
The client appears lethargic and dehydrated. The respiratory rate is rapid, and breath has a fruity odor. The renal function tests indicate elevated creatinine levels.
Determine the priority nursing diagnosis for this client. (Select All That Apply)
Risk for fluid volume deficit
Ineffective airway clearance
Impaired glucose metabolism
Risk for impaired skin integrity
Acute pain related to abdominal distention Answer: A, C
Explanation: The client presents with hyperglycemia and signs of diabetic ketoacidosis (DKA), indicating impaired glucose metabolism. Risk for fluid volume deficit is significant due to dehydration from osmotic diuresis. Addressing these issues is critical for the client’s stabilization.
istory:
-old female client with a history of chronic kidney disease presents with fatigue, pruritus, a ion. The family reports increased forgetfulness.
igns: 20/70
98.9°F (37.2°C)
96% on room air
Identify the priority nursing interventions for this client. (Select All That Apply) minister phosphate binders as prescribed
ucate the client on fluid restrictions
nitor laboratory values for renal function sess skin integrity regularly
plement a low-protein diet er: A, C, E
nation: Administering phosphate binders helps manage hyperphosphatemia. Monitoring labor is essential for tracking renal function, and implementing a low-protein diet is critical to red rkload on the kidneys.
Question: 1668
Client H
67-year nd
confus
Vital S BP: 1
HR: 85
Temp: RR: 20 SpO2:
Ad
Ed
Mo
As
Im
Answ
Expla atory
values uce
the wo
A nurse is reviewing a client’s lab results. Which result would indicate a need for further investigation in a patient undergoing treatment for cancer?
Elevated white blood cell count
Low hemoglobin level
Elevated liver enzymes
Normal platelet count Answer: C
Explanation: Elevated liver enzymes could indicate liver metastasis or toxicity from chemotherapy, requiring further investigation.
Quest
Client H
istory:
-old female client with a history of heart failure presents with sudden onset of shortness of est pain. The family reports increased fatigue over the past week.
Note:
ient appears anxious, and lung auscultation reveals bilateral crackles. Vital signs indicate ardia and hypotension.
igns: 0/60
10
98.6°F (37°C)
92% on 3L O2/NC
Identify the priority nursing interventions for this client. (Select All That Apply) minister diuretics as prescribed
pare for possible intubation ess for signs of fluid overload nitor vital signs frequently
ucate the family on heart failure management
79-year breath
and ch
Nurse's The cl tachyc
Vital S BP: 9
HR: 1
Temp: RR: 30 SpO2:
Ad
Pre
Ass
Mo
Ed
Answer: A, B, C, D
Explanation: Administering diuretics helps relieve fluid overload. Preparing for intubation may be necessary if the respiratory distress worsens. Assessing for signs of fluid overload is critical, and monitoring vital signs frequently ensures timely interventions.
A patient has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing an exacerbation. What is the most critical nursing intervention?
Encourage deep breathing exercises
Administer bronchodilators as ordered
Provide supplemental oxygen
Monitor respiratory rate Answer: B
an exacerbation.
Note:
A 50-year-old client with a history of liver cirrhosis is admitted with gastrointestinal bleed ient reports vomiting bright red blood and has dark, tarry stools.
igns:
7°F (36.1°C), HR 130, BP 85/50, RR 24.
esults:
.0 g/dL, Hct 25%, Platelets 90,000/mm3, INR 2.5.
Identify the critical factors for the nurse to consider in this case. (Select all that apply.) ght red blood in vomit
k, tarry stools
hemoglobin and hematocrit levels vated INR
tory of liver cirrhosis
er: A, B, C, D, E
Explanation: Administering bronchodilators is critical for relieving bronchospasm and improving airflow during
Nurse's
Report: ing.
The cl
Vital S Temp 9
Lab R Hgb 8
Bri
Dar
Low
Ele
His Answ
Explanation: Each option presents vital information regarding the severity of the client's condition, indicating significant hemorrhage and potential liver dysfunction requiring immediate nursing action.
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