1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of
the following findings indicates that the client is experiencing increased ICP?
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening, motor,
and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for electve cardioversion. Which of the
following prescribed medicatons should the nurse instruct the clients to withhold for 48hr prior to
cardioversion?
a. Enoxaparin
b. Metormin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent
blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac catheterization or
other procedures involving contrast dye in order to prevent damage to the kidneys.
However, metformin should not be withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients prior to cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This medication
should not be withheld.
j. Digoxin: ANSWER
k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for
ventricular fibrillation after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystts. which of the following findings is the nurse’s priority?
, a. Anorexia
b. Abdominal pain radiatng to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client who has
acute cholecystitis. Therefore, there is another finding that is the nurse's
priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore, there is
another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should
position the head of the client's bed flat and report this finding immediately
to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an expected
finding for a client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following
items at the client’s bedside?
a. Sucton machine
b. Wire cuters
c. Padded clamp
d. Communicaton board
e. Suction machine: ANSWERThe nurse should ensure that a suction machine is at the
bedside of a client who has dysphagia to clear the client's airway as needed and
reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client
who has an inner maxillary fixation to cut the wires in case the client vomits. This
enables the client to clear their airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a
client who has a chest tube to clamp the tube and prevent air from entering the
client's chest if there is an interruption in the sealed drainage system.
, h. Communication board: The nurse should ensure a communication board is at the
bedside of a client who has aphasia to assist the client with communicating.
5. A nurse is caring for a client who is having a seizure. Which of the following interventon is the nurse’s priority?
a. Loosen the clothing around the client’s neck
b. Check the client’s pupillary response
c. Turn the client to the side.
d. Move furniture away from the client
i. Loosen the clothing around the client's neck: The nurse should loosen any
restrictive clothing the client is wearing to prevent injury to the client.
However, another action is the priority.
ii. Check the client's pupillary response: The nurse should perform neurologic
checks after the seizure to monitor the client's recovery. However, another
action is the priority.
iii. Turn the client to the side.: The greatest risk to this client is hypoxia from an
impaired airway. Therefore, the priority intervention the nurse should take is
to place the client in a side-lying position to prevent aspiration.
iv. Move furniture away from the client.: AThe nurse should move furniture away
from the client to prevent self-injury. However, another action is the priority.
6. A nurse is providing teaching to aclient who has hypothyroidism and is receiving levothyroxine. The nurse should
instruct the client that which of the following supplements can interfere with the effectveness of the
medicaton?
a. Ginkgo biloba
b. Glucosamine
c. Calcium
d. Vitamin C
i.
Ginkgo biloba
ii. Ginkgo biloba reduces the pain associated with peripheral vascular disease
by promoting vasodilation. It can interact with medications that have
anticoagulant properties, but it is not known to interfere with the absorption
of levothyroxine.
iii. Glucosamine: Glucosamine treats osteoarthritis by decreasing inflammation
and stimulating the body's production of synovial fluid and cartilage. It can
interact with medications that have antiplatelet or anticoagulant properties,
but it is not known to interfere with the absorption of levothyroxine.
iv. Calcium:NSWER
v. Calcium limits the development of osteoporosis in clients who are
postmenopausal and works as an antacid. Calcium supplements can interfere
, with the metabolism of a number of medications, including levothyroxine. The
nurse should instruct the client to avoid taking calcium within 4 hr of
levothyroxine administration.
vi. Vitamin C: Vitamin C promotes wound healing. It can cause a false negative
in fecal occult blood tests, but it is not known to interfere with the absorption
of levothyroxine.
7. A nurse is planning to irrigate and dress a clean, granulaton wound for a client who has a pressure injury. Which
of the following actons should the nurse take?
a. Apply a wet-to-dry gauze dressing
b. Irrigate with hydrogen peroxide soluton
c. Use a 30-ml syringe
d. Atach a 24-gauge angiocatheter to the syringe.
8.
a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-to-dry dressings
to clean, granulating wounds as they interrupt viable, healing tissues when they are
removed. Appropriate dressings for a wound that is developing granulation tissue
include a hydrocolloid dressing and a transparent film dressing.
b. Irrigate with hydrogen peroxide solution: the nurse should use hydrogen peroxide to
clean contaminated surfaces. Hydrogen peroxide should not be used on a pressure
injury wound because it destroys newly granulated tissue. Instead, the nurse should
use solutions specifically designed as wound cleansers or 0.9% sodium chloride
irrigation to irrigate the wound.
c. Use a 30-mL syringe: NSWERThe nurse should use a 30-mL to 60-mL syringe with
an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square
inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the
wound irrigation should be delivered at between 4 and 15 psi.
d. Attach a 24-gauge angiocatheter to the syringe:the nurse should use an 18- or 19-
gauge catheter that will apply the appropriate irrigation pressure. A 24-gauge
angiocatheter delivers solutions at a higher pressure than necessary for irrigation
and a can potentially damage the developing granulation tissues.
1. a nurse Is assessing a client who has Graves’ disease. Thich of the collowing images should undicate to the
nurse that the client has exophthalmos:
the following findings indicates that the client is experiencing increased ICP?
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening, motor,
and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for electve cardioversion. Which of the
following prescribed medicatons should the nurse instruct the clients to withhold for 48hr prior to
cardioversion?
a. Enoxaparin
b. Metormin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent
blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac catheterization or
other procedures involving contrast dye in order to prevent damage to the kidneys.
However, metformin should not be withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients prior to cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This medication
should not be withheld.
j. Digoxin: ANSWER
k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for
ventricular fibrillation after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystts. which of the following findings is the nurse’s priority?
, a. Anorexia
b. Abdominal pain radiatng to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client who has
acute cholecystitis. Therefore, there is another finding that is the nurse's
priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore, there is
another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should
position the head of the client's bed flat and report this finding immediately
to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an expected
finding for a client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following
items at the client’s bedside?
a. Sucton machine
b. Wire cuters
c. Padded clamp
d. Communicaton board
e. Suction machine: ANSWERThe nurse should ensure that a suction machine is at the
bedside of a client who has dysphagia to clear the client's airway as needed and
reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client
who has an inner maxillary fixation to cut the wires in case the client vomits. This
enables the client to clear their airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a
client who has a chest tube to clamp the tube and prevent air from entering the
client's chest if there is an interruption in the sealed drainage system.
, h. Communication board: The nurse should ensure a communication board is at the
bedside of a client who has aphasia to assist the client with communicating.
5. A nurse is caring for a client who is having a seizure. Which of the following interventon is the nurse’s priority?
a. Loosen the clothing around the client’s neck
b. Check the client’s pupillary response
c. Turn the client to the side.
d. Move furniture away from the client
i. Loosen the clothing around the client's neck: The nurse should loosen any
restrictive clothing the client is wearing to prevent injury to the client.
However, another action is the priority.
ii. Check the client's pupillary response: The nurse should perform neurologic
checks after the seizure to monitor the client's recovery. However, another
action is the priority.
iii. Turn the client to the side.: The greatest risk to this client is hypoxia from an
impaired airway. Therefore, the priority intervention the nurse should take is
to place the client in a side-lying position to prevent aspiration.
iv. Move furniture away from the client.: AThe nurse should move furniture away
from the client to prevent self-injury. However, another action is the priority.
6. A nurse is providing teaching to aclient who has hypothyroidism and is receiving levothyroxine. The nurse should
instruct the client that which of the following supplements can interfere with the effectveness of the
medicaton?
a. Ginkgo biloba
b. Glucosamine
c. Calcium
d. Vitamin C
i.
Ginkgo biloba
ii. Ginkgo biloba reduces the pain associated with peripheral vascular disease
by promoting vasodilation. It can interact with medications that have
anticoagulant properties, but it is not known to interfere with the absorption
of levothyroxine.
iii. Glucosamine: Glucosamine treats osteoarthritis by decreasing inflammation
and stimulating the body's production of synovial fluid and cartilage. It can
interact with medications that have antiplatelet or anticoagulant properties,
but it is not known to interfere with the absorption of levothyroxine.
iv. Calcium:NSWER
v. Calcium limits the development of osteoporosis in clients who are
postmenopausal and works as an antacid. Calcium supplements can interfere
, with the metabolism of a number of medications, including levothyroxine. The
nurse should instruct the client to avoid taking calcium within 4 hr of
levothyroxine administration.
vi. Vitamin C: Vitamin C promotes wound healing. It can cause a false negative
in fecal occult blood tests, but it is not known to interfere with the absorption
of levothyroxine.
7. A nurse is planning to irrigate and dress a clean, granulaton wound for a client who has a pressure injury. Which
of the following actons should the nurse take?
a. Apply a wet-to-dry gauze dressing
b. Irrigate with hydrogen peroxide soluton
c. Use a 30-ml syringe
d. Atach a 24-gauge angiocatheter to the syringe.
8.
a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-to-dry dressings
to clean, granulating wounds as they interrupt viable, healing tissues when they are
removed. Appropriate dressings for a wound that is developing granulation tissue
include a hydrocolloid dressing and a transparent film dressing.
b. Irrigate with hydrogen peroxide solution: the nurse should use hydrogen peroxide to
clean contaminated surfaces. Hydrogen peroxide should not be used on a pressure
injury wound because it destroys newly granulated tissue. Instead, the nurse should
use solutions specifically designed as wound cleansers or 0.9% sodium chloride
irrigation to irrigate the wound.
c. Use a 30-mL syringe: NSWERThe nurse should use a 30-mL to 60-mL syringe with
an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square
inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the
wound irrigation should be delivered at between 4 and 15 psi.
d. Attach a 24-gauge angiocatheter to the syringe:the nurse should use an 18- or 19-
gauge catheter that will apply the appropriate irrigation pressure. A 24-gauge
angiocatheter delivers solutions at a higher pressure than necessary for irrigation
and a can potentially damage the developing granulation tissues.
1. a nurse Is assessing a client who has Graves’ disease. Thich of the collowing images should undicate to the
nurse that the client has exophthalmos:
