RN Exit v2 test with correct answers

answerd. The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority? A. Assess for signs of fluid volume deficit B. Observe wound drainage characteristics C. Measure the level of acute pain D. Determine when the client last ate - correct answers.A. Assess for signs of fluid volume deficit A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food C. Instruct the client that these mild symptoms can generally be controlled with changes in his diet D. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms - correct answers.A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse implement first? A. Measure and document the client's urinary output B. Request the client's reserved unit of packed red blood cells C. Prepare for placement of a central venous catheter D. Increase the infusion rate of Lactated Ringer's solution - correct answers.D. Increase the infusion rate of Lactated Ringer's solution A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? - correct answers.-1st: calculate the weight = 220/2.2= 100kg -Then calculate total dose in units = 18units x 100kg = 1800 units/hr - 25000 units - in 250 1800 units ---in X ml x = 1800 x 250/25000 =18 mL/hr An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water to the suction control chamber B. Give blood from the collection chamber as autotransfusion C. Manipulate blood in tubing to drain into chamber D. Increase wall suction to eliminate fluctuation in water seal - correct answers.A. Add sterile water to the suction control chamber An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arrive B. Explain that the client will start to lose consciousness and the body systems will slow down C. Reassure the spouse that the healthcare provider will notify when to call the children D. Offer to discuss the client's health status with each of the adult children - correct answers.B. Explain that the client will start to lose consciousness and the body systems will slow down The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? A. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race B. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied - correct answers.D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest tenth. - correct answers.0.2 mL In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin - correct answers.C. Glucose A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? A. Elevate the foot of the bed B. Restrict the client's fluids C. Begin supplemental oxygen D. Prepare client for hemodialysis - correct answers.C. Begin supplemental oxygen When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention? Select all that apply A. Sloughing tissue around wound edges B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses D. Loss of sensation to the left lower extremity E. Weeping serosanguineous fluid from wounds - correct answers.B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses D. Loss of sensation to the left lower extremity An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? A. Urine specific gravity is 1.040 B. Systolic blood pressure decreases 10 points when standing C. The client denies being thirsty D. Skin tenting occurs when the client's forearm is pinched - correct answers.D. Skin tenting occurs when the client's forearm is pinched The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A. Difficulty locating the uterine fundus B. Excessive lochia C. Saturation of more than one pad per hour D. Hypertension - correct answers.D. Hypertension After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? A. File a detailed incident report with the specific hiring facility B. Warn the colleague that their actions are unprofessional C. Comment anonymously about the action on a staff discussion board D. Communicate the colleague's actions to the unit charge nurse - correct answers.A. File a detailed incident report with the specific hiring facility The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective? A. At-risk clients received an increased number of routine health screenings B. Clients reported having new confidence in making healthy food choices C. Clients who incurred disease complications promptly received rehabilitation D. Client relapse of 30% in a 5-year community-wide anti-smoking campaign - correct answers.C. Clients who incurred disease complications promptly received rehabilitation While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Culture for sensitive organisms B. Serum blood glucose (BG) level C. Creatinine level D. Serum albumin - correct answers.A. Culture for sensitive organisms A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding should the nurse report immediately to the healthcare provider? A. Anorexia and abdominal distention B. Abdominal pain and vomiting C. Confusion and tremors D. Yellowing and itching of skin - correct answers.C. Confusion and tremors A client with leukemia who is receiving a myleosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client's plan of care? A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain client's temperature q4 hours - correct answers.A. Assess urine and stool for occult blood When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this findings be most significant? A. Crying B. Sitting upright C. Vomiting D. Straining on stool - correct answers.B. Sitting upright A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A. Patch one eye B. Evaluate swallow C. Reorient often D. Range of motion - correct answers.B. Evaluate swallow The nurse is caring for a client with chronic obstructive disease (COPD) who uses oxygen at 2L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? A. Determine if the client is experiencing any anxiety B. Auscultate the client's bilateral lung sounds and oxygen saturation C. Notify the healthcare provider about the client's distress D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula - correct answers.D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Assess for symptoms of AIDS dementia B. Monitor for secondary infections C. Identify local HIV support groups D. Observe for adverse drug reactions - correct answers.B. Monitor for secondary infections An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care? A. Have the client vocalize the instructions provided B. Ensure that someone will stay with the client for 24 hours C. Speak clearly and face the client for lip reading D. Provide written instructions for eye drop administration - correct answers.A. Have the client vocalize the instructions provided An older woman with history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an international normalized ratio (INR) value of 5.0. Upon admission, which prescription should the nurse expect to implement? A. Administer Vitamin K injection B. Start continuous heparin infusion C. Continue warfarin at same dose D. Transfuse unit of packed red blood cells - correct answers.A. Administer Vitamin K injection A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50mL/h