and n
H H
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client
n n n n n n n n n n n n n n n n n n H H n
has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority?
n n n n n n n n n n n n n n n n
A. Assess for signs of fluid volume deficit n n n n n n
B. Observe wound drainage characteristics n n n
C. Measure the level of acute pain n n n n n
D. Determine when the client last ate - ✅✅A. Assess for signs of fluid volume deficit n n n n n n n n n n n n n n
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he isexperiencing
n n n n n n n n n n n n n n n n n n n H n
heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the nurse?
n n n n n n n n n n n n n n n n n H H n
A. Encourage the client to obtain a complete physicalexam, since these symptoms are consistent with an ul
n n n n n n n n n n n n n n n H n
cer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food
n n n n n n n n n n n n n n n n n
C. Instruct the client that these mild symptoms cangenerally be controlled withchanges in his diet
n n n n n n n n n n n n n n n
D. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms -
n n n n n n n n n n n n n n n n
H ✅✅A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with
H n n n n n n n n n n n n n n n n H n
an ulcer n
A male client with stomachcancer returns to the unit following a total gastrectomy. He has a nasogastric tube
n n n n n n n n n n n n n n n n n n H n
to suction and is receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the
n n n n n n n n n n n n n n n n H H n n
nurse notes 300mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood
n n n n n n n n n n n n n n n n H H n n n n
pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse i
n n n n n n n n n n n n n n H H n n n n
mplement first? n
A. Measure and document the client's urinary output n n n n n n
B. Request the client's reserved unit of packed red blood cells n n n n n n n n n
C. Prepare for placement of a centralvenous catheter n n n n n n n
D. Increase the infusion rate of Lactated Ringer's solution - n n n n n n n n
✅✅D. Increase the infusion rate of Lactated Ringer's solution
n n n n n n n
H n n
,Page 1|44
H H H H H H
,and n
H H
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 uni
n n n n n n n n n n n n n n n n n n H H n
ts/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available soluti
n n n n n n n n n n n n n n H H n
on is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion
n n n n n n n n n n n n n n H H n n n n
pump to deliver how many mL/hour? - ✅✅-1st: calculate the weight = 220/2.2= 100kg
n n n n n n n n n n n n H n
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
n n n n n n n n n n n n
- 25000 units -
n n n
in 250 1800 units ---
n n n
H n n
in X ml n n
x = 1800 x 250/25000 =18 mL/hr
n n n n n n
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax.
n n n n n n n n n n n n n n n n n n H n
Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). Th
n n n n n n n n n n n n n H n n n n
e nurse notes that the suction control chamber is bubbling at the -
n n n n n n n n n n n n
10cm H2O mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is meas
n H H n n n n n n n n n n n n n n n n n n n n
ured in the collection chamber. Which intervention should the nurse implement?
n H H n n n n n n n n n
A. Add sterile water to the suction control chamber n n n n n n n
B. Give blood from the collection chamber as autotransfusion n n n n n n n
C. Manipulate blood intubing to drain into chamber n n n n n n n
D. Increase wall suction to eliminate fluctuation in water seal - n n n n n n n n n
✅✅A. Add sterile water to the suction control chamber
n n n n n n n H H n n
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and
n n n n n n n n n n n n n n n n n n H H n
asks how she will know that her husband's death is imminent because their two adult children want to be ther
n n n n n n n n n n n n n n n n n n H H n
e when he dies. Which is the best response by the nurse?
n n n n n n n n n n n
A. Gather information regarding how long it will take for the childrento arrive n n n n n n n n n n n n
B. Explain that the client will start to lose consciousness and the body systems will slow down
n n n n n n n n n n n n n n n
C. Reassure the spouse that the healthcare provider will notify when to call the children n n n n n n n n n n n n n
D. Offer to discuss the client's health status with each of the adult children -
n n n n n n n n n n n n n
✅✅B. Explain that the client will start to lose consciousness and the body systems will slow down
n n n n H n n n n n n n n n n n n n
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal numb
n n n n n n n n n n n n n n n n n n n n H H n
er of registered nurses will be working that shift. In planning assignments, which client should receive the mo
n n n n n n n n n n n n n n H H n n
st care hours by a registered nurse (RN)?
n n n n n n n
P a g e 2 | 44
n n n H nH n n
, and n
H H
A. A 48-year- n
oldmarathon runner with a central venous catheter who is experiencing nausea and vomiting due to
n n n n n n n n n n n n n
H n n
electrolyte disturbance following a race
n n n n n
B. A 34-year- n
old admitted today afteranemergency appendectomy who has a peripheral intravenous catheter and a F
n n n n n n n n n n n n
H n n n
oley catheter n
C. A 63-year- n
old chainsmoker admitted with chronic bronchitis who is receivingoxygen via nasal cannula and has a saline-
n n n n n n n n n n n n n n H n n n
locked peripheral intravenous catheter n n n
D. An 82-year-old client with Alzheimer's disease and a newly-
n n n n n n n n
fractured femur who has a Foley catheter and soft wrist restraints applied - ✅✅D. An 82-year-
n n n n n n n H n n n n n n n n
old client with Alzheimer's disease and a newly-
n n n n n n n
H fractured femur who has a Foley catheter and soft wrist restraints applied
H n n n n n n n n n n n n
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4mL". How m
n n n n n n n n n n n n n n n n n H H n
any mL should the nurse administer? Round to nearest tenth. - ✅✅0.2 mL
n n n n n n n n n n n n
In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse t
n n n n n n n n n n n n n n n n n H H n
o monitor?
n
A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin - ✅✅C. Glucose n n n
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rat
n n n n n n n n n n n n n n H H n
e 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath,
n n n n n n n n n n n n n H H n n
bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take fir
n n n n n n n n n n n n n n n n H H n n n
st?
A. Elevate the foot of the bed n n n n n
B. Restrict the client's fluids n n n
C. Begin supplementaloxygen n n
D. Prepare client forhemodialysis - ✅✅C. Begin supplemental oxygen n n n n n n n n
When caring for a client with full thickness burns to both lower extremities, which assessment findings warra
n n n n n n n n n n n n n n n H H n
nt immediate intervention? Select all that apply
n n n n n n
A. Sloughing tissue around wound edges n n n n
H H
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client
n n n n n n n n n n n n n n n n n n H H n
has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority?
n n n n n n n n n n n n n n n n
A. Assess for signs of fluid volume deficit n n n n n n
B. Observe wound drainage characteristics n n n
C. Measure the level of acute pain n n n n n
D. Determine when the client last ate - ✅✅A. Assess for signs of fluid volume deficit n n n n n n n n n n n n n n
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he isexperiencing
n n n n n n n n n n n n n n n n n n n H n
heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the nurse?
n n n n n n n n n n n n n n n n n H H n
A. Encourage the client to obtain a complete physicalexam, since these symptoms are consistent with an ul
n n n n n n n n n n n n n n n H n
cer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food
n n n n n n n n n n n n n n n n n
C. Instruct the client that these mild symptoms cangenerally be controlled withchanges in his diet
n n n n n n n n n n n n n n n
D. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms -
n n n n n n n n n n n n n n n n
H ✅✅A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with
H n n n n n n n n n n n n n n n n H n
an ulcer n
A male client with stomachcancer returns to the unit following a total gastrectomy. He has a nasogastric tube
n n n n n n n n n n n n n n n n n n H n
to suction and is receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the
n n n n n n n n n n n n n n n n H H n n
nurse notes 300mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood
n n n n n n n n n n n n n n n n H H n n n n
pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse i
n n n n n n n n n n n n n n H H n n n n
mplement first? n
A. Measure and document the client's urinary output n n n n n n
B. Request the client's reserved unit of packed red blood cells n n n n n n n n n
C. Prepare for placement of a centralvenous catheter n n n n n n n
D. Increase the infusion rate of Lactated Ringer's solution - n n n n n n n n
✅✅D. Increase the infusion rate of Lactated Ringer's solution
n n n n n n n
H n n
,Page 1|44
H H H H H H
,and n
H H
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 uni
n n n n n n n n n n n n n n n n n n H H n
ts/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available soluti
n n n n n n n n n n n n n n H H n
on is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion
n n n n n n n n n n n n n n H H n n n n
pump to deliver how many mL/hour? - ✅✅-1st: calculate the weight = 220/2.2= 100kg
n n n n n n n n n n n n H n
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
n n n n n n n n n n n n
- 25000 units -
n n n
in 250 1800 units ---
n n n
H n n
in X ml n n
x = 1800 x 250/25000 =18 mL/hr
n n n n n n
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax.
n n n n n n n n n n n n n n n n n n H n
Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). Th
n n n n n n n n n n n n n H n n n n
e nurse notes that the suction control chamber is bubbling at the -
n n n n n n n n n n n n
10cm H2O mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is meas
n H H n n n n n n n n n n n n n n n n n n n n
ured in the collection chamber. Which intervention should the nurse implement?
n H H n n n n n n n n n
A. Add sterile water to the suction control chamber n n n n n n n
B. Give blood from the collection chamber as autotransfusion n n n n n n n
C. Manipulate blood intubing to drain into chamber n n n n n n n
D. Increase wall suction to eliminate fluctuation in water seal - n n n n n n n n n
✅✅A. Add sterile water to the suction control chamber
n n n n n n n H H n n
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and
n n n n n n n n n n n n n n n n n n H H n
asks how she will know that her husband's death is imminent because their two adult children want to be ther
n n n n n n n n n n n n n n n n n n H H n
e when he dies. Which is the best response by the nurse?
n n n n n n n n n n n
A. Gather information regarding how long it will take for the childrento arrive n n n n n n n n n n n n
B. Explain that the client will start to lose consciousness and the body systems will slow down
n n n n n n n n n n n n n n n
C. Reassure the spouse that the healthcare provider will notify when to call the children n n n n n n n n n n n n n
D. Offer to discuss the client's health status with each of the adult children -
n n n n n n n n n n n n n
✅✅B. Explain that the client will start to lose consciousness and the body systems will slow down
n n n n H n n n n n n n n n n n n n
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal numb
n n n n n n n n n n n n n n n n n n n n H H n
er of registered nurses will be working that shift. In planning assignments, which client should receive the mo
n n n n n n n n n n n n n n H H n n
st care hours by a registered nurse (RN)?
n n n n n n n
P a g e 2 | 44
n n n H nH n n
, and n
H H
A. A 48-year- n
oldmarathon runner with a central venous catheter who is experiencing nausea and vomiting due to
n n n n n n n n n n n n n
H n n
electrolyte disturbance following a race
n n n n n
B. A 34-year- n
old admitted today afteranemergency appendectomy who has a peripheral intravenous catheter and a F
n n n n n n n n n n n n
H n n n
oley catheter n
C. A 63-year- n
old chainsmoker admitted with chronic bronchitis who is receivingoxygen via nasal cannula and has a saline-
n n n n n n n n n n n n n n H n n n
locked peripheral intravenous catheter n n n
D. An 82-year-old client with Alzheimer's disease and a newly-
n n n n n n n n
fractured femur who has a Foley catheter and soft wrist restraints applied - ✅✅D. An 82-year-
n n n n n n n H n n n n n n n n
old client with Alzheimer's disease and a newly-
n n n n n n n
H fractured femur who has a Foley catheter and soft wrist restraints applied
H n n n n n n n n n n n n
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4mL". How m
n n n n n n n n n n n n n n n n n H H n
any mL should the nurse administer? Round to nearest tenth. - ✅✅0.2 mL
n n n n n n n n n n n n
In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse t
n n n n n n n n n n n n n n n n n H H n
o monitor?
n
A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin - ✅✅C. Glucose n n n
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rat
n n n n n n n n n n n n n n H H n
e 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath,
n n n n n n n n n n n n n H H n n
bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take fir
n n n n n n n n n n n n n n n n H H n n n
st?
A. Elevate the foot of the bed n n n n n
B. Restrict the client's fluids n n n
C. Begin supplementaloxygen n n
D. Prepare client forhemodialysis - ✅✅C. Begin supplemental oxygen n n n n n n n n
When caring for a client with full thickness burns to both lower extremities, which assessment findings warra
n n n n n n n n n n n n n n n H H n
nt immediate intervention? Select all that apply
n n n n n n
A. Sloughing tissue around wound edges n n n n
