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A male client with stomach cancer re-
turns to the unit following a total gastrec-
tomy. He has a nasogastric tube to suc-
tion and is receiving Lactated Ringer's
solution at 75 mL/hour IV. One hour
after admission to the unit, the nurse
notes 300 mL 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 d. Increase the infusion rate of Lactated
the finding to the surgeon. Which action Ringer's solution.
should the nurse implement first?
a. Measure and document the client's
urinary output.
b. Request the client's reserved unit if
packed red blood cells.
c. Prepare the placement of a central
venous catheter.
d. Increase the infusion rate of Lactated
Ringer's solution.
An adult male who fell 20 feet from the
roof of this 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 bub-
bling at the - 10 cm H2O mark, with
fluctuation in the water seal, and over
a. Add sterile water to the suction control
the past hour 75 ml of bright red blood
chamber.
is measured in the collection chamber.
Which intervention should the nurse im-
plement?
a. Add sterile water to the suction control
chamber.
b. Give blood from the collection cham-
ber as auto-transfusion
c. Manipulate blood in tubing to drain into
chamber.
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d. Increase wall suction to eliminate fluc-
tuation in water seal.
A client who received hemodialysis yes-
terday is experiencing a blood pres-
sure of 200/100 mmHg, heart rate 110
beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting
shortness of breath, bilateral 2+ ped-
al edema, and an oxygen saturation on c. Begin supplemental oxygen.
room air of 89%. Which action should the
nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
A client with Addison's crisis is admitted
for treatment with adrenal cortical sup-
plementation. Based on the client's ad-
mitting diagnosis, which findings require
immediate action by the nurse? (Select a. Headache and tremors
all that apply) b. Irregular heart rate
a. Headache and tremors e. Pallor and diaphoresis
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
An older client is admitted with fluid vol-
ume deficit and dehydration. Which as-
sessment finding
is the best indicator of hydration that the
nurse should report to the healthcare
provider? d. Skin tenting occurs when the client's
a. Urine specific gravity is 1.040b. forearm is pinched
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.
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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
a. File a detailed incident report with the
specific hiring facility.
specific hiring facility.
b. Warn the colleague that their actions
are unprofessional.
c. Comment anonymously about the ac-
tion of a staff discussion board.
d. Communicate the colleague's actions
to the unit charge nurse.
The nurse is evaluating a tertiary pre-
vention program for clients with cardio-
vascular disease implemented in a rural
health clinic. Which outcome indicate the
program is effective?
a. At-risk clients received an increased
number of routine health screenings. c. Clients who incurred disease compli-
b. Clients reported having new confi- cations promptly received rehabilitation.
dence in making healthy food choices.
c. Clients who incurred disease compli-
cations promptly received rehabilitation.
d. Client relapse rate of 30% in
a 5-year community-wide anti-smoking
campaign.
The nurse is caring for a client with
chronic obstructive pulmonary disease
(COPD) who uses oxygen at 2 L/minute
per nasal cannula continuously. The
d. Assess the delivery mechanism of the
nurse observes that the client is hav-
oxygen tank, tubing, and cannula.
ing increased shortness of breath with
respirations at 23 breaths/minute. Which
action should the nurse implement first?
a. Determine if the client is experiencing
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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.
Which statement by a client who is
24 hours post-subtotal thyroidectomy re-
quires an immediate investigation by the
nurse?
a. "When I get out of bed quickly, I feel a
little dizzy." a. "When I get out of bed quickly, I feel a
b. "The dressing over my incision feels little dizzy."
like it is too tight."
c. "I'm most comfortable when the head
of the bed is raised."
d. "This IV infusion makes me urinate
more often than usual."
An older adult male who is in his early
70's is admitted to the emergency de-
partment because of a COPD exacerba-
tion. This client is struggling to breathe
and the healthcare team is preparing for
endotracheal intubation. The spouse's
wife, who is 30 years younger than the
client, asks the nurse to stop the proce-
dure and provide the nurse a copy of the
b. Notify the healthcare provider of the
client's living will. Which actionshould the
client's wishes.
nurse take?
a. Facilitate a family meeting with the
palliative care team.
b. Notify the healthcare provider of the
client's wishes.
c. Place a certified copy of the living will
in the client's record.
d. Alert the nursing staff of the client's
don't resuscitate status.