PN3 Final Exam 2023 UPDATE SCORED {85%}

PN3 Final Exam 2023 UPDATE SCORED {85%} 1. The nurse, planning care for a mechanically ventilated client, would plan to administer pantoprazole. The nurse understands this medication is to prevent the onset of which of the following complications? Thrombophlebitis Hypertension Hyperglycemia Stress Ulcers 2. A client is diagnosed with cardiogenic shock. The nurse should plan immediate interventions to address which of the following complications of this disorder? Pulmonary Embolism Deep vein thrombosis Acute renal failure Disseminated intravascular coagulation 3. A patient in the emergency department is experiencing a hemorrhagic stroke. The nurse anticipates which of the following symptoms may have been present at the onset? SATA Vomiting Limited mobility worse in the morning Severe, sudden headache Increased appetite Change in mental status 4. A nurse is caring for an end-of-life terminally ill client, experiencing very shallow and rapid breathing with periods of apnea. After evaluating the client, which action by the nurse would be most appropriate? Reduce the number of people in the client's room Reorient the client as needed Place the client in supine position Elevate the clients HOB 5. A nurse is admitted to the hospital with an infected postoperative surgical wound. The practitioner orders vancomycin IV. Order: Vancomycin 1 gram in 500 ml dextrose 5% water (D5W) to infuse over 2 hours via infusion pump. Calculate the flow rate in ml/hr. 250 6. A nurse assesses a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Palpate the clients head for the presence of fractures Assess the drainage from eyes and ears Assess the drainage and test the drainage to rule out cerebral spinal fluid Ask the client to keep their head elevate 7. An emergency department nurse triages a client with diabetes mellitus who has fractured her wrist. Which action would the nurse take first? Remove the medical alert bracelet from the fractured arm Place the client in a supine position with a warm blanket Cover any open areas with a sterile dressing Immobilize the arm by splinting the fracture 8. A nurse cares for a client who has obstructive jaundice. The client asks, " Why is my skin so itchy?" How would the nurse respond? "Bile salts accumulate in the skin and cause the itching." "Toxins released from an inflamed gallbladder lead to itching." "Itching is caused by the release of calcium into the skin." "Itching is caused by a hypersensitivity reaction. 9. A nurse is caring for a client on mechanical ventilation and finds the client agitated and restless. What action by the nurse is most appropriate? Reassure the client that they are safe Restrain the clients' legs and arms Sedate the client immediately Assess the cause of the agitation 10. A nurse obtains the health history of a client with a fractured femur. Which factor identified in the client's history would the nurse recognize as an aspect that may delay healing? Osteoporosis Oral contraceptives Sedentary lifestyle Current smoking history 11. The nurse is notified that the clients monitor is showing artifact. What does the nurse do next? Troubleshoot the equipment Check the status of the client Monitor and document the artifact Notify the physician for orders 12. A nurse is monitoring a client who has an acute kidney injury. Which of the following laboratory findings should the nurse expect? Hypokalemia Metabolic acidosis Hypercalcemia Elevated BUN and creatinine 13. A client in the intensive care unit is scheduled for a lumbar puncture today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. Which of the following nursing actions is the best? Ensure that informed consent is on the chart. Document these findings in the client’s record. Give the prescribed preprocedural sedation. Call a rapid response team 14. The nurse is concerned that a client may develop neurogenic shock when which of the following is assessed? Decreased sympathetic nerve impulses cause a low mean arterial pressure (MAP) Jugular vein distension caused by an elevated mean arterial pressure (MAP) Fractured lower extremity Sluggish bowel sounds 15. The nurse is the emergency department is using triage system because this system ranks clients by Name Age Body system involved The severity of illness or injury 16. A nurse cares for a client who is recovering from hypophysectomy. What action should the nurse take first? Instruct the client to cough, turn, and deep breath Assess for clear or light-yellow drainage from the nose Keep the head of the bed flat and the client supine Apply petroleum jelly to lips to avoid dryness 17. What is the rationale for chemotherapy as a cancer treatment? Decreases the client's risk for life threatening complications To disrupt one or more steps necessary for cancer to develop Less expansive and safer than radiation Concentrates in secondary lymphoid tissues and prevents widespread metastasis. 18. A client diagnosed with cholecystitis asks the nurse what happened. The nurse correctly identifies which one of the following risk factors? A client with low body weight A client on a vegetarian diet An obese fertile client over the age of 40 A client on testosterone supplements 19. When educating clients on liver disease, the nurse correctly identifies the most common cause of cirrhosis in the United States as being which of the following? SATA Nonalcoholic steatohepatitis (NASH) Chronic viral hepatitis Bacterial hepatitis High protein diets Chronic alcoholism 20. The client with atrial fibrillation suddenly develops dyspnea, chest pain, hemoptysis, and a feeling of impending doom. The nurse recognizes these symptoms as which complication? Pulmonary embolism Absence of atrial kick Increased cardiac output Embolic stroke 21. A nurse cares for a client that was prescribed lactulose. The client states I do not want to take this medication because it causes diarrhea. How would the nurse respond? Diarrhea is expected; that’s how your body gets rid of ammonia Do not take any more of the medication until your stool firms up We will need to send a stool specimen to the laboratory You may take an antidiarrheal medication for loose stools 22. A 40-year-old obese client arrived with complaints of right upper quadrant pain radiating to the right scapula. The nurse expects which of the following conditions? Cholelithiasis Pancreatitis Gastritis Appendicitis 23. A client has a brain tumor and is receiving fosphenytoin. The spouse questions the drug use saying that the client does not have a seizure disorder. Which of the following is the best response by the nurse? Increased pressure from the brain tumor can cause seizures Seizures frequently occur in clients with brain tumors This drug is used to sedate the client with a brain tumor Preventing febrile seizures with a brain tumor is important 24. The nurse is assessing a client for the adequacy of ventilation. What assessment findings would indicate the client has good ventilation? Nail beds are pink with good capillary refill There are quiet and effortless breaths sounds at the lung base bilaterally The oxygen sat level is 98% Respiratory rate is 24 breaths/minute The trachea is just left to the sternal notch The right side of the thorax expands slightly more than the left 25. When diagnosed with Cushing syndrome. The manifestations are most likely related to an excess production of which hormone? Cortisol Antidiuretic hormone (ADH) Insulin Prolactin 26. A nurse is assessing the arteriovenous (AV) fistula of end in end-stage failure. The nurse documents the following “ bruit auscultated, and thrill palpated at left arm AV fistula” the nurse next step is to complete which of the following? Maintain the extremity in an elevated position Contact the nephrologist and notify them the fistula is not working Document the AV fistula is patent Assess the site using a 20-guage IV catheter for administration of fluids 27. A client with septic shock is breathing at a rate of 32 breaths per minute with accessory muscle use. Which of the following is the nurse’s priority? Determine the cause of sepsis Assess and provide interventions to maintain the clients’ airways Start an IV and give vancomycin after obtaining blood cultures Assess capillary refill 28. Which client is at risk for developing secondary adrenal insufficiency? Client who suddenly stops taking high-dose steroid therapy Client deficient in ADH Client with an adrenal tumor causing excessive secretion of ACTH Client who tapers the dosages of steroid therapy 29. A nurse is developing a teaching plan for client who just been diagnosed with breast cancer, which medication is used as a hormone-based therapy? SATA Tamoxifen Letrozole Cyclophosphamide Denosumab Alendronate 30. A client complains of having an irregular heartbeat in his chest. The nurse applies the cardiac monitor and correctly identifies the following rhythm as which of the following? Normal sinus rhythm Atrial fibrillation Sinus tachycardia Atrial flutter 31. A nurse plans care for a client with acute pancreatitis. Which priority intervention will the nurse include in this client plan of care? Place the client in semi-fowlers position with the head of bed elevated Provide small, frequent feedings with no concentrated sweets Administer morphine sulfate intravenously every 4 hours Maintain nasogastric suctioning at a low-intermittent level except for during administration of oral meds 32. A nurse is caring for four clients in the neurologic intensive care unit. Which client would the nurse assess first? Client who has been diagnosed with meningitis with a fever of 101°F (38.3° C) Client who had a transient ischemic attack and is in warfarin waiting for INR above 2.0 Client receiving tissue plasminogen activator (t-PA) who has a change nosebleed Client who is waiting for subarachnoid bolt insertion with the consent form already signed 33. A client has 50% burns following a car fire. In the initial resuscitation phase of care, which of the following are considered essential? Educating the client on skin care Prevention of contractures Airway management Fluid resuscitation Pain management 34. The nurse is preparing to administer IV heparin to the client. Order: 1500 units/hour. Available: 25000 units in 250 ml of normal saline. IV pump set to 15 ml/hour 35. A nurse supervises the application of electrocardiographic monitoring performed by unlicensed assistive personnel. Which statement would the nurse provide to the UAP related to this procedure? Turn off the wall oxygen before monitoring the client Add gel to the electrodes before applying them Clean the skin and clip her before applying the electrodes Place the electrodes on the posterior chest 36. After teaching a client about advanced directives, a nurse assessed the clients understanding. Which statement indicates that the client correctly understands the teaching? An advance directive will allow me to keep my money out of the reach of my family An advance directive will keep my children from selling my home when I'm old An advanced directive will specify what I want we done when I can no longer make decisions about health care An advance directive will be completed as soon as I'm incapacitated and can't think for myself 37. An intensive care unit nurse is caring for a client on a ventilator. The client develops a mucus plug and requires suctioning. Which of the following will cause a low-pressure alarm? Excessive coughing Mucus plug Disconnected tubing Extensive condensation of humidified water 38. What type of stroke is caused by occlusion of a cerebral or carotid artery and treated with fibrinolytic therapy? Hemorrhagic stroke Ischemic stroke Transient ischemic attack Arteriovenous malformation 39. The Hospice nurse is caring for a dying client and her family members what intervention does the nurse implement? SATA Teach family members about physical signs of impending death Avoid spirituality because the clients and the nurses' beliefs may not be congruent Encourage reminiscence by both client and family members Encouraged the management of adverse symptoms Request that the family limits visits with the client 40. A client presents complaining of abdominal pain and bloody stools. His skin is ashen conjunctiva pale and delayed capillary refill. Pulse is weak and thready. The nurse correctly categorizes this client as? Nonurgent (green) Terminal (black) Urgent (yellow) Emergent (red) 41. A client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in his shoulder blades. how would the nurse respond? You should cough and deep breathe every hour Ambulating in the hallway twice a day will help I will apply a cold compress to the painful area on your back Drinking a warm beverage can relieve this referred pain 42. A nurse is caring for a client diagnosed with an ST-elevation myocardial infarction (STEMI). The nurse anticipates which of the following interventions would the nurse give first? Morphine Nitrates Oxygen Aspirin 43. Client scenario describes the best example of professional collaboration? The nurse physical therapist and physician have all developed separate plan cares for client The nurse mentions to the physical therapist that the client may benefit from a muscle-strengthening evaluation The nurse and physician discussed the clients muscle weakness and initiate a referral for physical therapy The nurse physician and physical therapist have all visited separately with the client 44. Which of the following should be implemented to ensure the safe use of a defibrillator? SATA Continue manual chest compressions after the shock is delivered The person pression is "shock" button should state "I am clear, you're clear, we're all clear Place pads on top of the implanted pacemaker Do not place over metal monitoring electrodes Apply transdermal medication to the chest before using the paddles on top of the patch 45. A nurse gave medications to a client with hepatic encephalopathy for elevated ammonia levels. A family member asks what medication was given. The nurse correctly responds with which answer? This medication will decrease the blood ammonia levels by excretion through the gastrointestinal tract I'm giving this medication to increase clotting. This will help prevent excess bleeding This medication will increase intracranial pressure by decreasing ammonia This medication decreases ammonia but may also cause diarrhea 46. What blood test is the most accurate and verifying a diagnosis of acute pancreatitis? Alkaline phosphate Lactate Alanine aminotransferase Tyrosine 47. A client is experiencing sinus Brady cardia with hypotension and dizziness what medication does the nurse administer? Adenosine Lidocaine Atropine Amiodarone 48. An elderly client arrives in the emergency department after a fall resulting in a hip fracture. She reports that the fall occurred yesterday, and she was unable to get up. Her son found her this morning. Based on this scenario the nurse anticipates acute kidney injury resulting from which of the following causes? Prerenal Oliguria Intrarenal Postrenal 49. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads the clients chart that the cancer classification is T3N5M1. What does the nurse conclude about the client cancer? The primary tumor has metastasized to 5 areas, the measurement is 1 inch in diameter The primary tumor has cells that have 3 different characteristics, the tumor has metastasized to one area, and the tumor is 5 cm in diameter The primary tumor is large, there are 5 lymph nodes involved, and there are metastasis to other parts of the body There are 3 metastatic tumors that have 5 different nuclei, affecting 1 major organ 50. A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? SATA Providing vaccinations against certain cancers Demonstrate breast self-examination methods to women Teaching teams the danger of tanning booths Screening teenage girls for cervical cancer Instructing people on the use of chemoprevention 51. A new graduate nurse has started working on a medical surgical unit. What actions would the nurse take to be prepared for a disaster? SATA Know the institutions emergency response plan Participate in the institution's disaster drill Understand the nurse plays a role in every phase Develop a personal preparedness plan Be prepared to report immediately to the emergency department 52. The nurse is caring for a client on the medical surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: Perform defibrillation Administer adenosine 6 mg rapid IV push followed by 20mL saline flush Ask the family about code status Perform a synchronized cardioversion 53. The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94 to 86. What is the priority action by the nurse? Stabilize the chest wall with rib binders Notify the health care provider and prepare for advanced airway placement Encourage the client to take deep, controlled breaths Document findings and continue to monitor the client 54. In the event of a mass casualty situation, which is the best triage nurse? The lead registered nurse with the most experience The newly graduated registered nurse The recently graduated licensed vocational nurse The licensed vocational nurse with ten years' experience 55. A nurse teaches a client with septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? DIC is caused by abnormal coagulation involving fibrinogen DIC is a genetic disorder involving vitamin K deficiency An elevated platelet count characterizes DIC DIC is controllable with lifelong heparin usage 56. A nurse assesses a client with atrial fibrillation. Which manifestations would alter the nurse to the possibility of a severe complication from this condition? Sinus tachycardia Speech alterations Fatigue Dyspnea with activity 57. A nurse is caring for a client prescribed tissue plasminogen activator for a stroke. which of the following actions by the nurse are most appropriate? SATA Double-check the dose and pump rate with another nurse Administer heparin subcutaneously every shift to prevent thromboembolism Keep the client NPO until swallowing can be assessed Perform neurological assessments every 10 to 15 mins after starting the infusion Delegate the hourly vital signs to the nursing assistant 58. A nursing student learns about modifiable risk factors for coronary artery disease. Which of the following are modifiable risk factors? SATA Age Hypertension Smoking Stress Obesity 59. The emergency department nurse instructs a student to assess a client with a mild traumatic brain injury for signs and symptoms consistent with this injury. What clinical manifestation does the student recognize as consistent with a TBI? SATA Reports felling foggy when recalling the injury Sensitivity to light and sound Elevated temperature Unconscious for 1 hour after injury Widened pulse pressure 60. Which of the following is a component of the Glasgow coma scale that the nurse would assess in a client after a head injury? Blood pressure Pupillary response Verbal responsiveness Head circumference 61. An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations would alert the nurse to internal bleeding and hypovolemic shock? SATA Change in level of consciousness Right upper quadrant ecchymosis Tachycardia and hypotension Shallow respirations Flushed warm skin 62. A client that was diagnosed with stage III breast cancer seems to be overly anxious. What is the nurse's best action? Validate the clients' feelings and explore the idea of a referral to a breast cancer support group Ask the client if sexuality has been a problem with her partner Encourage the client to search internet for information tonight Evaluate if there has been any mental illness in the past 63. The nurse is concerned that a client is demonstrating signs of compartment syndrome. Which of the following is considered a classic sign of this disorder? SATA Paresthesia Pressure Pain Pallor Paraplegia Pink color 64. A client with an acute myocardial infraction is receiving tissue plasminogen activator. Which of the following is a priority nursing intervention? Monitor for signs of bleeding Monitor psychosocial status Have heparin sodium available Monitor for renal function 65. The client has had a transient ischemic attack. What does the nurse expect? The TIA symptoms will resolve within 24 hours The client will have a permanent disability The TIA symptoms will resolve in a week The TIA is not a warning sign for a stroke 66. The nurse is caring for a client with a pelvic fracture, which is the nurse priority action to prevent complications Monitor blood pressure frequently Monitor temperature daily Turn the client every 2 hours Insert a urethral catheter 67. The nurse is caring for a client with aphasia. The nurse knows this means the client has which of the following b. Inability to speak, comprehend, and write language Weakness in the extremities Difficulty swallowing liquids Disorientation to time, place, and person 68. A client in the cardiac step-down unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action is the nurse's priority? Assess and maintain airway patency Administer four chewable 81 mg acetylsalicylic acid Notify the provider Call for an ECG 69. A nurse cares for a client with 45% total burns. The client weighs 65 kg. using the parkland formula of 4ml. the nurse should calculate and set the IV pump to deliver how many ml/hr. in the first 8 hours 4mL x BSA(% ) x KG 1st 8 hours patient get half of volume total Then over the remaining 16 hours patient will get remaining fluids 4mL x 45% x 65= 731.25 ml/hour 70. A client is in the hospital after suffering a myocardial infraction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client 02 sat to be 95 on room air, pulse 88 beats/min, and respiratory rate of 16 after returning to bed, what action by the nurse is best? Allow continued bathroom privileges Administer oxygen at 2L/min Obtain a bedside commode Suggest the client uses a bed pan 71. Which of the following would the nurse identify as common physical signs and symptoms of approaching death in a terminally ill client? Irregular breathing patterns with gurgling and congestion Genitourinary function changes, such as incontinence Disorientation and restlessness Slowing of the circulation with coolness of extremities Alert and orientated X4 72. The nurse is caring for the client who was recently extubated. What is an expected assessment finding for this client? Hoarseness Restlessness Stridor Dyspnea 73. A nurse assesses an older adult client admitted three days ago with a fractured left hip. The nurse notes that the client is confused and restless. The clients' vital signs are 98 beats/min, respiratory rate 36 breaths/min, blood pressure 142/78, and 02 86%. Which action would the nurse take first? Assess responses to pain medication Increase the intravenous flow rate per protocol Assess the airway administer oxygen via nasal cannula Reposition to a semi fowlers position 74. The nurse assesses the client with clinical manifestation of increased intracranial pressure. Which of the following nursing intervention is appropriate to decrease intracranial pressure? SATA Preventing hyperthermia Elevate the head of the bed 90 degrees Place the client in reverse Trendelenburg Turn off the lights and provide a quiet atmosphere Enter an order for a loop diuretic and a CT with contrast when the ICP is above 20 mmHg 75. A client is being treated for a hemorrhagic stroke. Which of the following is the client at risk for 72 hours after the onset of the hemorrhagic stroke? Increased intracranial pressure due to edema Stress ulcers Rebound transient ischemic attack A hypoglycemic event 76. The nurse is instructing a client diagnosed with a brain tumor on symptoms to immediately report to her physician. Which of the following should be included in these instructions? SATA New onset of seizures One-sided weakness Loss of balance Problems with vision Inability to talk Loss of appetite 77. A nurse is caring for an unconscious client with breathing patterns characterized by alternating hyperventilation and apnea periods. The nurse should document that the client has which of the following respiratory alterations Stridor Apneustic respirations Kussmual Respirations Cheyne-stokes respirations 78. A nurse is caring for a client with Cushing's syndrome. Which of these signs and symptoms does the nurse expect to find? SATA Hypotension Hypoglycemia Moon face Purple Striae Truncal obesity 79. A client present to the emergency room with a fracture of the distal fibula. The nurse assesses that the pulse is present with the skin intact. The nurse documents this type of fracture as which of the following? Stress fracture Pathogenic fracture Closed fracture Compound fracture 80. A client is diagnosed with a fat embolism in the pulmonary circulation. The most likely origin of this fat embolism is from which condition? Pelvis fracture Arterial thrombosis Osteoporosis DVT 81. A nurse is teaching a client who has an acute kidney injury about the oliguric phase. What information should the nurse include in the teaching? Urine output is less than 400 ml in 24 hours BUN & creatinine have decreased Renal function is reestablished The GFR recovers 82. Which of the following symptoms would suggest to the nurse that a client is experiencing symptoms of pheochromocytoma? SATA Profuse sweating Severe headache Palpitations Decreased urine output Diarrhea 83. Clients with major musculoskeletal trauma are at high risk of developing DVT and PE. The nurse understands that these clients are at risk due to which factors? SATA Acid-base and electrolyte imbalance Hypoglycemia Immobility Hyperosmolarity Hyper-coagulopathy 84. In addition to treating the underlying causes, the nurse understands that management of a client ith acute respiratory distress syndrome (ARDS) will include which of the following interventions? Positive end-expiratory pressure Administration of a beta blocker Aggressive diuretic therapy Chest tube insertion 85. The nurse is caring for a critically ill client whose living will is being honored and no life-saving measures will be instituted. The nurse assess the following vitals: BP=72/30, HR=45, RR=10, Glasgow coma scale is 3. What other symptoms should the nurse anticipate? Responds only to painful stimuli Mottling of the hands and feet Increased urinary output Hyperreflexia in the arms and legs 86. A nurse is cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades rated 3/10. How should the nurse respond? You should cough and deep breathe every hour I can administer the pain medication, morphine that your provider has ordered I will apply a cold compress to the painful area on your back Ambulating in the hallway twice a day will help 87. Which of the following complications of acute liver failure will the nurse focus on assessing? SATA Renal injury related to hypovolemia Respiratory failure related to increased vascular permeability Hypoglycemia related to decreased glucose synthesis Acid-base and electrolyte imbalances The exact amount of alcohol consumed daily 88. The nurse is caring for a client with aphasia who can not comprehend what is spoken to her. The nurse knows the client has which of the following? Difficulty swallowing thin liquids Disorientation to time and place Damage to Wernicke's area of the temporal lobe Damage to Broca area of the brain in the parietal lobe 89. A client in the ICU had a lumbar puncture performed. The new graduate nurse recognizes which of the following nursing interventions is contraindicated after this bedside procedure? Encourage an increase of oral fluids Notify the provider if there is moderate drainage on the dressing with evidence of a halo sign Apply pressure to the site after the procedure Place the client with the HOB elevate to 30