NURS 10005 CARE 4 FINAL EXAMS GUIDE QUESTIONS AND ANSWERS

NURS 10005 CARE 4 FINAL EXAMS GUIDE QUESTIONS AND ANSWERS 1.) A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? a. Ensure that the family receives appropriate crisis intervention services 2.) A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patient’s cardiopulmonary status, the nurse should prepare to perform what intervention? a. Administer naloxone hydrochloride - (Narcan) 3.) The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient? a. Have you ever thought about taking your own life? 4.) An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what another variable? a. The resources that the patient is likely to require 5.) A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? a. Assessment of respiratory status 6.) While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place? a) Conducting a critique and debriefing for all involved in the incident 7.) Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patients clothing and then perform what action? a. Rinse the patient with water. 8.) An industrial site has experienced a radiation leak and workers who have been potentially affected are en-route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? a. Establish a triage outside the hospital. 9.) A hospitals emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? a. Perform life-saving measures. 10.) A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? a. Doing the greatest good for the greatest number of people 11.)A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 62-year-old with a simple fracture of the left arm 12.)The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration 13.)A nurse assesses a client recently bitten by a coral snake. Which assessment is the priority? a. Respiratory rate and depth 14.)Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately 15.) The nurse in the emergency department is performing an assessment on a client who sustained a right finger laceration from a fishhook while fishing. The nurse asks the client which priority question? a. “When did you receive your last tetanus immunization?” 16.) A client is brought to the emergency department by the police after having seriously lacerated both wrists. The initial action that the nurse should take is which step? a. Assess and treat the wound sites 17.) ***With a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid strength? (Question got blurred out) 18.) A nurse is assisting with disaster triage following a bomb explosion in a bus station. Which of the following clients should the nurse identify as being the highest priority? a. A conscious adult with second degree burns on both lower legs 19.) A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming patient? a. Ensuring continuous ECG monitoring 20.) A nurse enters a client’s room and sees that ashes from a cigarette are beginning to ignite trash in a waste basket. Which of the following actions should the nurse take first? a. Rescue the client from immediate danger 21.) A client is admitted to the emergency department with complaints of severe radiating chest pain, and a myocardial infarction is suspected the nurse immediately applies oxygen to the client and plans to take which action first? a. Call the laboratory to prescribe stat blood work b. Notify the coronary care unit to inform them that the client will need admission c. Obtain a 12-lead ECG d. Call radiology to prescribe a chest radiograph 22.) A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Wash the area of the puncture thoroughly with soap and water. 23.) A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? a. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site 24.) An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Clearly communicate client data to the unit nurse 25.) A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention? a. Count the Respiratory rate 26.) An emergency department nurse is caring for a patient who had been taking in the mountains for the past 2 days. What are the most important indicators that a patient is experiencing high- altitude pulmonary edema (HAPE)? (NOT SURE IF I GOT THIS RIGHT) a. Confusion b. Ataxia c. Decreased level of consciousness d. Crackles in both lung fields e. Persistent dry cough 27.) A nursing is caring for a client who develops and airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? a. Administer the abdominal thrust maneuver 28.) The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? a. Evaluate chest expansion 29.) A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first? a. A client who has severe respiratory stridor and a deviated trachea 30.) A patient is admitted with a thermal injury, the mechanism of injury that this patient would most likely experience would be which of the following? a. Fire 31.) An ER assesses a patient who has been raped, with which health care team would the nurse collaborate with while planning this patient care a. Forensic nurse 32.)A spouse of a patient admitted with a gunshot wound ask the nurse when her husband will be discharged so that they could resume their life together. With which should the nurse respond to the spouse? a. "Right now, there is no way of knowing how soon your husband can return to his previous life." 33.)The patient is admitted with possible head and spinal injuries after falling from a ladder, the diagnostic test that will identify the extent of injuries a. MRI 34.)How can a nurse assist disaster victim to cope with their experiences? a. Active listening 35.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has slurred speech and is slow to respond to questions, what treatment would the nurse provide for this client? a. Administer warmed intravenous fluids to the client. 36.)An Elderly patient fell and hit their head was transported by ambulance, was unconscious at the scene but is conscious on arrival, triage is urgent, what is the priority assessment the nurse includes during the primary survey of the patient? a. Neurological status? 37.)A nurse is at the scene of a lightning strike during a thunderstorm, what is the priority action of the nurse? a. Move victims and first responders to a sheltered area 38.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has slurred speech and is slow to respond to questions, what treatment would the nurse provide for this client? a. d. Administer warmed intravenous fluids to the client 39.)The nurse is working ER on hot humid day when a hiker is brought in after collapsing. The hiker is confused and tachycardic temp 105.6. Which IV solution and medication would the nurse administer? a. d. Normal saline and lorazepam 40.)A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man’s current mental health problem? a. a. Common response following a disaster 41.). On a hot humid day several client present to the ER with symptoms of heat exposure which client will be treated first? a. a. Client who is anxious and confused 42.)A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? a. d. Immobilize the extremity with a splint 43.). A nurse has been assigned the role triage nurse after a weather-related disaster. What is the priority action of the nurse? a. a. Perform rapid assessments and determine priority of care 44.)4. On admission to the emergency department a client states that he feels like killing himself. When planning this client care is it most important for the nurse to coordinate care with which member of the health care team? a. Psychiatric crisis nurse 45.)A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first? a. b. Prevent the client from aspirating 46.)A community nurse assesses a client who has an allergy to bees. The client lips are swollen, and wheezes are audible. Priority action of the nurse? a. b. Administer EPI pen 47.). A trauma patient with multiple open wounds is brought the ER in cardiac arrest. Which action would the nurse do prior to providing advanced cardiac life support? a. d. Don on PPE 48.). A back-country skier has been airlifted after becoming lost developing hypothermia and frostbite how should the nurse handle the patient’s frostbites? a. Immerse affected extremities in water slightly above normal body temperature 49.)Patient was brought to the ER with injuries from a wall that collapsed on his home. A nurse realized that this patients’ injuries are most likely caused by which of the following. a. b. Crushing 50.)A nurse is dining at a restaurant when a woman begins to scream the her partner is choking Which of the following actions should the nurse take? a. b. Ask the patient if he can speak 51.)The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed? a. c. If I get too cold, I can have some brandy CM Exam #2 Ch 26, 37, 51 52.) The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? d. Wash your hands on entering the client’s room. 53.)The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? c. Sometimes I wake up at night and smoke. 54.) A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? c. I will bathe and dress before breakfast. 55.) The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. c. Auscultate breath sounds over the trachea and bronchi. 56.) A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? c. Serum potassium: 6.5 mEq/L 57.) A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? c. I will demonstrate how to change your wound dressing for you and your family. 58.) A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? b. Lower blood volume lowers MAP. 59.)A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? b. Assess the clients tissue perfusion further. 60.) The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg 61.) A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? b. Drink fluids on a regular schedule. 62.) A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? b. Ensure the client has a patent airway. 63.) A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? b. Traction weights are resting on the floor 64.) A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? d. A 74-year-old man who smokes and has a fractured pelvis 65.) A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? d. Ensure that the weights remain freely hanging at all times. 66.)A nurse caring for a client notes the following assessments: white blood cell counts 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? c. Notify the health care provider immediately. 67.) A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client’s vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. 68.)A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient’s health problem? A. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. 69. In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. 70. When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. 71. A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply. B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema 72. The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? D) To maintain adequate mean arterial pressure 73. An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient’s infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient’s risk of septic shock? D) Remove invasive devices as soon as they are no longer needed 74. A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? C) Fat embolism syndrome 29. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? Confusion – Answer 31. An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? A) Bone fracture 32. A nurse is caring for a client who is postoperative following a below-the-knee-amputation and will soon undergo fitting for a leg prosthesis. which of the following is an appropriate intervention for this client at this time? a) wrap the stump with an elastic bandage in a figure-eight configuration 33. A nurse is caring for a client who is sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? b. The client develops a life-threatening situation 34. A client returns to the surgical unit from the post anesthesia care unit in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup? B. The weights rest against the foot of the bed 35. A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? D. Packed Red blood cells 36. A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? B- DIC is caused by abnormal coagulation involving fibrinogen 37. The nurse knows that a patient with crush injuries to the lower extremities is a high risk for what complication? C. Acute kidney injury 38. A middle-aged patient has a tight cast on the left lower leg. Which assessment finding would prompt the nurse to assess further for compartment syndrome? D. Pain more intense than expected based on initial injury 40. A nurse is caring for an adolescent who has a newly applied fiberglass cast for a fractured tibia. Immediately following application of a fiberglass cast, the nurse should recognize that the nursing priority is to Perform neurovascular assessment 41. A 29-year-old male is admitted to the orthopedic unit with a fractured femur after running his motorcycle into a bridge abutment. The patient has been placed in traction until his femur can be rodded in surgery. What early complications would the nurse have to monitor this patient for? (Mark all that apply.) (question was similar to this one) C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism 42. Assessment findings for hypovolemic shock? (not sure on this) -Declining lactate and potassium 43. Fluid overload: (also not sure. check me) -Increased HR -Increased BP -Increased Respirations 44. Which assessment finding does the nurse interpret as demonstrating a client’s fluid resuscitation adequacy? D. Decreased urine specific gravity 45. Which nursing interventions decreases the risk for cross-contamination in the client with a severe burn injury? Select all that apply. A. Place a client in isolation C. Ensure that no plants or flowers are in the client’s room D. Teach family members not to bring fresh fruit and vegetables 46. Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? D. Serum lactate and serum potassium levels are declining 47. With which client should the nurse remain alert for the possibility of sepsis and septic shock? C. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago 48. A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse’s best initial action? B. Perform a neurovascular assessment 49. A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was that was amputated last week. What is the nurse’s most appropriate response to the client’s pain? D. “On a scale of 0 to 10, how would you rate your pain?” 50. What is the nurse’s priority when doing an admission for a client who has returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry Which clinical manifestation does the nurse recognize that indicates worsening in the condition of a patient in the refectory face of shock? Increase respiratory rate A nurse is caring for a client who is 1 day post op following hip open reduction with internal fixation the client is scheduled to begin physical therapy in 30 minutes we should be following action should the nurse take? Offer to administer analgesia A nurse is caring for a client who has ulna fracture and a new prescription of cyclobenzaprine before administrating which of the following explanations should the nurse provide to explain the purpose of this medication? This medication will relieve muscles spasm that may occur from the fracture Med Surg Exam 3 Ch 11, 12, 13; Brunner Ch 13; Lamone Ch 10 1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? c. A 76-year-old who is cognitively impaired 2. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? b. Anxious client who has tachypnea 3. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a. Assess client’s rate, rhythm, and depth of respiration. 4. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in these clients teaching? c. Read food labels to determine sodium content. 5. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning 6. You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? D) Hypovolemia 7. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance? Brunner B) Respiratory alkalosis 8. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? Brunner B) Osmosis and osmolality 9. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability? Brunner C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. 10. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand, and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? Brunner B) Hypocalcemia 11. You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? Brunner C) Metabolic alkalosis 12. A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Brunner A) Respiratory acidosis 13. You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? Brunner A) Increased serum sodium 14. You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? Brunner D) Shallow respirations 15. The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvostek’s sign indicate? Brunner C) Hypocalcemia 16. A nurse is caring for a female client in the ED who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? Found: 10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a. Depth of respirations 11. A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the client’s respiratory rate, rhythm, and depth. 12. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? b. Connect the client to a cardiac monitor. 13. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? d. Dangle the client on the bedside before ambulating. 14. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? Brunner C) Infiltration 15. A medical nurse educator is reviewing a patient’s recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. **16. You are called to your patients’ room by a family member who voices concern about the patients status. On assessment, you find the patient tachypneic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients’ signs and symptoms? C) Hyperchloremia 17. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a. Increased rate and depth of respirations 18. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm 19. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a. Assess clients rate, rhythm, and depth of respiration. 20. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values? b. Bronchial obstruction related to aspiration of a hot dog 21. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. 22. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results? b. Anxiety-induced hyperventilation 23. A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first? a. Assess the airway. 24. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing these clients plan of care? b. You appear anxious. What is causing your distress? **25. A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? b. Ensure an x-ray is completed to confirm placement. 26. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? d. The clients left lower extremity is cool to the touch. 27. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? d. Upper extremity swelling is noted. 28. A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter. When assessing the client, the nurse notes swelling of the clients arm above the picc insertion site. Which of the following actions should the nurse take first? Measure the circumference of both upper arms 29. The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? Stop the transfusion immediately. 30. A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? Slow the infusion rate and monitor the patient closely. 31. A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? Discontinue the transfusion. 32. Renal failure can have prerenal, renal, or postrenal causes. A patient presents with acute renal failure and is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it? Heart failure 33. A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? d. Stop the infusion of intravenous fluids. 34. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client’s chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? b. Administer the prescribed medication. 35. A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Remind the provider to perform hand hygiene prior to starting the procedure. c. Ask everyone in the room to wear a surgical mask during the procedure. 36. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient’s health? D) Fluid volume status 37. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patient’s magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes 38. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response? B) Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids. 39. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? D) Hypercalcemia 40. A patient has questioned the nurse’s administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. 41. A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium? D) Bananas 42. A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need precautions implemented for what event? a. seizure Book questions: 43. When evaluating the hydration status of a new 84-year-old nursing home client, the nurse observes tenting of the skin on the back of the client’s hand. What is the nurse’s best action? Pg. 169 A. Assess the skin turgor on the client’s forehead (chest/sternum). 44. A client is receiving 250 mL of a 3% sodium chloride solution intravenously for severe hyponatremia. Which signs or symptoms indicate to the nurse that this therapy is effective? Pg. 174 D. Blood pressure has increased from 100/50 mmHg to 112/70 mmHg 45. A client asks why the provider has recommended that he breathe into a paper bag for several minutes when his anxiety disorder causes him to hyperventilate. What is the nurse’s best response? Pg. 197 D. “Breathing into the bag for several minutes helps you become distracted from whatever is making you anxious and allows you to calm down.” 46. A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What action will the nurse take first? Pg. 202 D. Stop the infusion of the drug immediately. 47. Dehydration? Urine specific gravity 48. Client in a long-term care facility, confused, dizziness when standing? Monitor for orthostatic hypotension 49. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? A. Twitching 51. Providing education to a client with severe hypomagnesemia due to alcohol disorder. IV something 52. Blood transfusion? Select all that apply Options I remember: Make sure its complete in 6 hours Check within the first 15 to 30 minutes (correct) Check with another nurse (correct) 53. Client is receiving magnesium sulfate. Which of the following information should the nurse include? You should receive a prescription for a thiazide diuretic to take with the magnesium You will have your deep tendon reflexes monitored while you are receiving magnesium* 55. Furosemide. Client is at risk for? Dehydration. 56. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing educator determines the student is unprepared for the procedure when the student states which of the following is part of the plan for preparation and administration of the potassium? C. Preparing the medication for bolus administration Exam # 5 1. A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease. a. Asterixis 2. The nurse is caring for a client with liver failure and is performing assessment and the knowledge of the clients increase risk of bleeding. The nurse recognizes that this risk is related to the client inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? d. Inability of the liver to use vitamin K 3. A nurse is assessing a client who has cirrhosis which of the following is an expected finding for this client? b. Spider angiomas 4. A nurse dis c. Daily weight 5. A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, what can I do to help prevent these infections? How should the nurse respond? c. Drink more water and empty your bladder more frequently during the day. 6. A nurse is caring for a client with hepatitis A the client as the nurse how might I have contracted the virus. Which of the following is a question the nurse might ask the client? c. Have you eaten any fresh fish lately 7. A nurse is assessing a client who has obstruction of the common bile duct resulting from chronic cholecystitis which of the following findings should the nurse expect? a. Fatty stools 8. A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. 9. A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. 10. The nurse is assessing a client suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? c. Hematuria 11. The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? c. Administering intravenous fluids through the AV fistula 12. A nurse is amending a patient plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient care plan? A) Mobilization with assistance at least 4 times daily D) Administration of diuretics as ordered 13. A nurse is preparing to administer blood transfusion to an older adult. Understanding age-related changes what alteration in the usual protocol are necessary for the nurse to implement b. Hold other IV fluids running e. Access vital signs more often 14. A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? d. Those WBCs are abnormal and don’t provide protection. 15. A client newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patient health problem d. The enzymes that your pancreas produces have damaged the pancreas itself. 16. The nurse is caring for a patient with polycystic kidney disease. Which assessment finding requires immediate nursing intervention? A. Temperature of 99° F B. Blood pressure of 170/90 C. Heart rate of 100 beats/min D. Urine output less than 30 cc/hr 17. A patient’s assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A) How many alcoholic drinks do you typically consume in a week? C) Have you ever been diagnosed with gallstones? 18. A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client plan of care to reduce discomfort? b. Maintain nothing by mouth (NPO) and administer intravenous fluids. 19. A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath 20. A community health nurse is caring for a patient whose multiple health problem include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What are the nurses most appropriate action? C) Arrange for the patient to be transported to the hospital. 21. A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? a. Gallstones 22. A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching? b. Rest frequently throughout the day 23. A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? c. Maintaining a balanced intake and output 24. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) b. Bloody drainage at site d. Foul-smelling drainage e. Urine draining from site 25. A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient’s liver? C) Place hand under right lower rib cage and press down lightly with the other hand. 26. A nurse in a clinic is caring for a client who has a history of alcohol abuse and reports bruising and frequent nosebleeds. For which of the following is the client at risk? a) Cirrhosis 27. A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient’s treatment, the nurse should anticipate what intervention? B) A regimen of antiviral medications 28. Which assessment finding requires immediate nursing intervention in a patient with severe ascites? D. Shallow respirations, rate 32 breaths/min 29. The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority? b. Assess the client for infection. 30. A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours c. Large amount of sediment in the urine e. Blood pressure of 90/60 mm Hg 31. A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action? B. Encourage ambulation once fully awake. 32. A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason. A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. 33. A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly patient may include what? D) Signs and symptoms of septic shock 34. A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? A) Inform the physician and assess the patient for signs of infection. 35. A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? C) Daily weights and abdominal girth measurement 36. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse’s priority action? d. Slow down the normal saline infusion. 37. A nurse is assessing a client receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client BP is 80/64. Which of the following action should nurse take first? c. Stop the infusion of blood 38. A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy 39. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following lab values? b. Amylase 40. A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What are the nurse’s best response to the clients statement? d. Tell me more about your feelings regarding hemodialysis treatment. 41. A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? C. Avoid foods high in fat. 42. A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. 43. 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A) Destruction of the patient’s liver tumor 44. A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? c. Determine whether the client feels like talking about his or her feelings. 45. A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics? C) Signs and symptoms of intra-abdominal complications 46. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram which of the following statements by the client should the nurse report to the provider d. I don’t eat shellfish because it gives me hives 47. a nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram a. They are going to examine my gallbladder and ducts 48. A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? a. Drink 3 L of fluid every day 49. In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? D) Respiratory rate of 28 breaths/min 50. A 23-year-old African American male with a history of sickle cell disease had an emergent open reduction and internal fixation of his right femur after a car crash. What is the initial postoperative nursing priority? B. Ensuring adequate IV hydration Exam 6 Care 1. A nurse assesses a patient who is recovering from anterior cervical discectomy and fusion. infusion. Which complication would alert the nurse to urgently communicate with the healthcare provider? a. Auscultated stridor 2. A patient with a documented history of seizure disorder experience is a generalized seizure. What nursing action is most appropriate? a. Loosen the patients restrictive clothing 3. A nurse a nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) three weeks ago. Which of the following goals should the nurse include in the client’s rehabilitation program? a. Establish the ability to communicate effectively 4. The nurse working in the emergency department assesses a patient who has symptoms of stroke. For what modifiable risk factors would the nurse assess? (Select all that apply) a. High-fat diet b. Smoking c. Alcohol intake d. Obesity 5. A nurse is presenting discharge instructions to a client who has MS. The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? a. Implement a schedule to include periods of rest 6. The student learning about neurological disorders remembers that key features of increased intracranial pressure include which of the following: (unsure of this one) a. Projectile vomiting b. Decerebrate posturing 7. A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client a. Makes up stories when he is unable to remember actual events 8. A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of the diagnosis? a. The patient needs to be assessed for MS 9. A patient in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the patient breathing irregularly with one pupil fixed and dilated, what action by the nurse is best? a. Notify the provider of the findings immediately 10. To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment? a. Blood levels of the drug must be monitored 11. The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What changes in status most clearly suggest a therapeutic benefit of this medication? a. Increased muscle strength 12. The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient safety, what nursing action should be performed? a. Ensure that suction apparatus is set up at the bedside 13. A patient with a stroke is being evaluated for fibrinolytic therapy. What information from the patient or family is most important for the nurse to obtain? a. Time of symptom onset 14. A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take? a. Assess the client for bladder distention 15. A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? a. Neck flexion produces flexion of knees and hips 16. a patient is receiving plasmapheresis. What action by the nurse best prevents infection in this patient? a. Performing appropriate hand hygiene 17. A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Decreased level of consciousness 18. The nurse is providing patient teaching to a patient with early stage Alzheimer's disease in her family. The patient has been prescribed donepezil hydrochloride (Aricept). What should the nurse explain to the patient and family about this drug? a. It slows the progression of Alzheimer's disease 19. A middle-aged woman Has sought care from her primary care provider an undergone diagnostic testing that has resulted in the diagnosis of MS. What sign or symptom is most likely to have promoted the woman to seek care? a. Difficulty in coordination 20. An emergency room nurse initiates care for a patient with a cervical spinal cord injury who arrives via emergency medical service. What action would the nurse take first? a. Evaluate respiratory status 21. A nurse is teaching a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects? a. Difficulty voiding 22. A patient with Guillain-Barre syndrome is admitted to the hospital. The nurse plans care giving priority to the interventions that address which priority patient problem? a. Inadequate airway 23. The nurse understands which symptom is the earliest indicator of increased intracranial pressure when caring for a patient with a head injury? a. Agitation and confusion 24. A nurse cares for a client who is experiencing status epilepticus. which prescribed medication with the nurse prepare to administer? a. Lorazepam (Ativan) 25. A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following intervention should the nurse include? (Select all that apply) a. Provide a suction setup at the bedside b. Elevate the side rails near the head when the client is in bed c. Keep in oxygen set up at the bedside 26. A nurse is caring for four patients in the neurologic/neurosurgical intensive care unit. Which patient would the nurse assess first? a. A patient receiving tissue plasminogen activator (tPA) who has a change in respiratory pattern and rate 27. A nurse is teaching the family of a client who has Alzheimer’s disease about donepezil. Which of the following information should the nurse include in the teaching? a. Syncope episodes may occur when taking this medication 28. A nurse assesses a client who has a history of migraines. Which clinical manifestation would the nurse identify as an early sign of a migraine with aura? a. Visual disturbances 29. A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate? a. Brain stem herniation 30. A patient scheduled for a magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepared the patient for the MRI should prioritize which of the following action? a. Removing all metal-containing objects 31. The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? a. Maintaining a patent airway 32. A nurse promotes the prevention of lower back pain by teaching patients at a community center. Which instruction would the nurse include in this education? a. Participate in an exercise program to strengthen muscles 33. A nurse is caring for a client who has expressive aphasia following a cerebral vascular accident (CVA). which of the following parameters should the nurses assess the clients pain level? a. A self-report pain rating scale 34. A patient with MS has developed dysphasia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? a. Position the patient upright during feeding 35. the nurse learns that the pathophysiology of Gillian-Barre syndrome includes segmental demyelination. The nurse understands that this causes what? a. Slowed nerve impulse transmission 36. A nurse is assessing a client who has Parkinson's disease. Which of the following manifestation should the nurse expect? a. Bradykinesia 37. A patient with myasthenia gravis asked the nurse to explain the disease. What response by the nurse is best? a. MG is an autoimmune problem in which nerves do not cause muscles to contract 38. A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? a. Move objects away from the client 39. The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments a. Assessment of gag reflex 40. A patient with MS has been admitted to the hospital following an acute exacerbation. When planning their patients care, the nurse should address they need to enhance bladder control period what aspect of nursing care is most likely to meet this goal? a. Establish a timed voiding schedule 41. a nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? a. Decrease tremors 42. My nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? a. Suction saliva from the client's mouth 43. the critical care nurses caring for 25-year-old man admitted to the ICU with a brain Abscess. What is a priority nursing responsibility in the care of this patient? a. Monitoring neurologic status closely 44. A nurse is in a client’s room when the client begins having a tonic clonic seizure. Which of the following action should the nurse take first? a. Turn the clients head to the side 45. You are providing care for an 82-year-old man whose signs and symptoms of Parkinson's disease have become more severe over the past several months. The man tells you that he can no longer do as many things for himself as he used to be able to do. What factor should you recognize as impacting your patient’s life most significantly? a. Loss of independence 46. The critical care nurses is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? a. Providing ventilatory assistance 47. A nurse in the emergency Department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (select all that apply) a. Absence of bowel sounds b. Weakened gag reflex c. Hypotension 48. A 69-year-old client is brought to the ED by ambulance because a family member found them lying on the floor disoriented and lethargic. The HCP suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. b. Administer antipyretics as prescribed c. Monitor pain levels and administer analgesics d. Perform frequent neurological assessments 49. A nurse is caring for a patient with paraplegia who is scheduled to participate in a rehabilitation program. The patient states, “I do not understand the need for rehabilitation; the paralysis will not go away, and it will not get better.” How should the nurse respond? a. “The rehabilitation program will teach you how to maintain the functional ability you have and prevent disability.” 50. A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement would the nurse include in this client’s teaching? a. “Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches.” Exam 7: Chapters 28, 31, 32 1. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply) B. Pleural friction rub D. Petechiae E. Tachycardia 2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: HR 117/min, RR 38/min, temp 38.4 (101.2), BP 100/54. Which of the following actions is the priority action at this time? C. Administer oxygen therapy 3. A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply) A. A client who has a BMI of 30 C. A client who has a fractured femur E. A client who has chronic atrial fibrillation 4. A nurse is suctioning the endotr