A client arrives to the emergency department
reporting an intermittent fever
and night sweats for the past 3 weeks and has developed a productive cough
containing small amounts of blood.
Which intervention should the nurse
prioritize?
a. Move into airborne isolation
b. Collect specimens for
blood cultures.
c. Arrange transport for radiographic imaging.
d. Obtain a sputum sample - Answer-a. Move into airborne isolation
/.A client arrives to the medical-surgical unit 4 hours after a transurethral resection of
the prostate. A triple-lumen catheter for the continuous bladder
irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow
with blood clots in the tubing collection bag.
Which action should the nurse take?
a. Monitoring catheter drainage (pic one says this)
b. irrigation the catheter manually.
c. Decreasing the flow rate.
d. Discounting infusing solution. - Answer-a. Monitoring catheter drainage (pic one says
this)
/.A client experiences an AOB incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
,d. arthritic joint changes and chronic pain - Answer-a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
/.A client is diagnosed with chronic kidney disease and needs to begin dialysis.
Which condition entered on the client's medical record should the nurse recognize as a
contraindication for peritoneal dialysis?
a. Nephrotic syndrome history.
b. Latent hepatitis C.
c. Crohn's disease with colectomy.
d. Type 2 diabetes mellitus - Answer-c. Crohn's disease with colectomy.
/.A client presents to the emergency department reporting chest pain that is radiation to
the left arm, shortness of breath, and diaphoresis.
Which medication should the nurse anticipate being prescribed by the healthcare
provider?
a. Fentanyl.
b. Hydromorphone.
c. Oxycodone.
d. Morphine - Answer-d. Morphine
/.A client receives a prescription for 1 liter of Ringer's intravenously to be infused over 6
hours.
How many mL/hr should the nurse program the infusion pump to deliver?
(Enter numerical value only. If rounding is required, round to the nearest whole
number.) - Answer-167 mL
1000mL/6(hours) =166.6=167mL
/.A client who had colon surgery 3 days ago is anxious and requesting
assistance to reposition. While the nurse is turning the client, the wound dehiscence's
and eviscerates. The nurse moistens an a available sterile dressing
and places over the wound.
Which intervention should the nurse implement
next?
, a. Prepare the client to return to the operating room.
b. Auscultate the abdomen for bowel sound activity.
c. Obtain a sample fo the drainage to send to the lab.
d. Bring additional sterile dressing supplies to the room - Answer-d. Bring additional
sterile dressing supplies to the room
/.A client who has a history of hypothyroidism was initially with lethargy and confusion.
Which additional finishing warrants finding warrants the most immediate action by the
nurse?
a. Facial puffiness and periorbital edema.
b. Further decline in level consciousness.
c. Hematocrit of 30% (0.30).
d. Cold and dry skin. - Answer-b. Further decline in level consciousness.
/.A client who has developed acute kidney injury (AKI) due to aminoglycoside antibiotics
has moved from the oliguric phase to the diuretic phase of AKI.
Which parameters are most important for the nurse to plan to carefully monitor?
a. Uremic irritation of mucous membranes and skin surfaces.
b. Hypovolemia and electrocardiographic (ECG) changes.
C. Side effects of total parental nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood urea nitrogen (BUN) - Answer-b. Hypovolemia and
electrocardiographic (ECG) changes.
/.A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and
shortness of breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and r
hythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume,
and pitting edema.
reporting an intermittent fever
and night sweats for the past 3 weeks and has developed a productive cough
containing small amounts of blood.
Which intervention should the nurse
prioritize?
a. Move into airborne isolation
b. Collect specimens for
blood cultures.
c. Arrange transport for radiographic imaging.
d. Obtain a sputum sample - Answer-a. Move into airborne isolation
/.A client arrives to the medical-surgical unit 4 hours after a transurethral resection of
the prostate. A triple-lumen catheter for the continuous bladder
irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow
with blood clots in the tubing collection bag.
Which action should the nurse take?
a. Monitoring catheter drainage (pic one says this)
b. irrigation the catheter manually.
c. Decreasing the flow rate.
d. Discounting infusing solution. - Answer-a. Monitoring catheter drainage (pic one says
this)
/.A client experiences an AOB incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
,d. arthritic joint changes and chronic pain - Answer-a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
/.A client is diagnosed with chronic kidney disease and needs to begin dialysis.
Which condition entered on the client's medical record should the nurse recognize as a
contraindication for peritoneal dialysis?
a. Nephrotic syndrome history.
b. Latent hepatitis C.
c. Crohn's disease with colectomy.
d. Type 2 diabetes mellitus - Answer-c. Crohn's disease with colectomy.
/.A client presents to the emergency department reporting chest pain that is radiation to
the left arm, shortness of breath, and diaphoresis.
Which medication should the nurse anticipate being prescribed by the healthcare
provider?
a. Fentanyl.
b. Hydromorphone.
c. Oxycodone.
d. Morphine - Answer-d. Morphine
/.A client receives a prescription for 1 liter of Ringer's intravenously to be infused over 6
hours.
How many mL/hr should the nurse program the infusion pump to deliver?
(Enter numerical value only. If rounding is required, round to the nearest whole
number.) - Answer-167 mL
1000mL/6(hours) =166.6=167mL
/.A client who had colon surgery 3 days ago is anxious and requesting
assistance to reposition. While the nurse is turning the client, the wound dehiscence's
and eviscerates. The nurse moistens an a available sterile dressing
and places over the wound.
Which intervention should the nurse implement
next?
, a. Prepare the client to return to the operating room.
b. Auscultate the abdomen for bowel sound activity.
c. Obtain a sample fo the drainage to send to the lab.
d. Bring additional sterile dressing supplies to the room - Answer-d. Bring additional
sterile dressing supplies to the room
/.A client who has a history of hypothyroidism was initially with lethargy and confusion.
Which additional finishing warrants finding warrants the most immediate action by the
nurse?
a. Facial puffiness and periorbital edema.
b. Further decline in level consciousness.
c. Hematocrit of 30% (0.30).
d. Cold and dry skin. - Answer-b. Further decline in level consciousness.
/.A client who has developed acute kidney injury (AKI) due to aminoglycoside antibiotics
has moved from the oliguric phase to the diuretic phase of AKI.
Which parameters are most important for the nurse to plan to carefully monitor?
a. Uremic irritation of mucous membranes and skin surfaces.
b. Hypovolemia and electrocardiographic (ECG) changes.
C. Side effects of total parental nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood urea nitrogen (BUN) - Answer-b. Hypovolemia and
electrocardiographic (ECG) changes.
/.A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and
shortness of breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and r
hythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume,
and pitting edema.
