ATI Adv. Med-surg FINAL EXAM(Graded A)
ATI Adv. Med-surg FINAL EXAM
1. A nurse in a burn treatment center is caring for a client who is admitted with
severe burns to both lower extremities and is pending an escharotomy. The client’s spouse asks the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
a. “large incisions will be made in the eschar to improve circulation”
b. “ I can call the doctor back here if you want me to”
c. “a piece of skin will be removed and grafted over the burned area”
d. “dead tissue will be surgically removed”
2. A nurse is monitoring the fluid replacement of a client who has sustained burns.
Which of the following fluids is used in the first 24 hours following a burn injury?
a. 5% dextrose in water
b. 5% dextrose in normal saline
c. normal saline
d. lactated ringers
3. A nurse is caring for a client who has full-thickness burns all over 75% of his
body. Which of the following methods is appropriate to accurately monitor the
a. auscultate cuff blood pressure
b. palpate pulse pressure
c. obtain a central venous pressure
d. monitor the pulmonary artery pressure
4. A nurse is assessing the depth and extent of a client who has severe burns to the
face, neck, and upper extremities. Which of the following factors is the first
priority when assessing the severity of the burn?
a. Age of the client
b. Associated medical history
c. Location of the burn
d. Cause of the burn
5. A client arrives at the emergency dept following an explosion at the chemical
plant. He has deep partial and full-thickness chemical burns over more than 25 %
of his body surface area. What is the nurse’s priority intervention?
a. Initiate fluid resuscitation
b. Medication for pain
c. Administer antibiotics
d. Maintain a patent airway
6. A nurse is caring for a client who came the emergency dept reporting chest pain.
The provider suspects a myocardial infarction. While waiting for the laboratory to
report the client’s troponin levels, the client asks what this blood test will show.
The nurse should explain that troponin is
a. An enzyme that indicates damage to brain, heart, and skeletal muscle
b. A protein whose levels reflect the risk for coronary artery disease
c. A heart muscle protein that appears in the bloodstream when there is
damage to the heart
d. A protein that helps transport oxygen throughout the body
7. A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings?
a. Excessive thrombosis and bleeding
b. Progressive increase in platelet production
c. Immediate sodium and fluid retention
d. Increased clotting factors
8. A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the
following is an appropriate nursing response?
a. It helps convert atrial fibrillation to sinus rhythm
b. Is dissolves clots in the bloodstream
c. It slows the response of the ventricles to the fast atrial impulses
d. It prevents strokes in clients who have atrial fibrillation
9. A nurse in a cardiac care unit is caring for a client with acute heart failure. Which
of the following findings should the nurse expect?
a. Decreased brian natriuretic peptide (BNP)
b. Elevated central venous pressure (CVP)
c. Decreased pulmonary pressure
d. Increases urinary output
10. A client comes into the ED reporting nausea and vomiting that worsens when
lying down and without relief from antacids. The provider suspects acute
pancreatitis. Which of the following lab test results should the nurse expect to see
if the client has acute pancreatitis?
a. Decreased WBC
b. Increased serum amylase
c. Decreased serum lipase
d. Increased serum calcium
11. A nurse in the ICU is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The
provider plans to exubate her within the next 24 hour. Which of the following is
an important criterion for exubating the client?
a. Ability to cough effectively
b. Adequate tidal volume without manually assisted breaths
c. No indication of infection
d. No need for supplemental oxygen
12. A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority
13. A nurse is caring for a female client who came in to the ED reporting SOB and
pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood
pressure 140/80 mmHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg,
PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the
a. Prepare for mechanical ventilation
b. Administer oxygen via face mask
c. Prepare to administer a sedative
d. Monitor for pulmonary embolism
14. A nurse is monitoring a client who has just had a thoracentesis to remove pleural
fluid. Which of the following clinical manifestations indicate a complication that
requires notifying the provider immediately?
a. Serosanguineous drainage from the puncture site
b. Discomfort at the puncture site
c. Increased heart rate
d. Decreased temperature
15. A group of college students was attending a weekend football rally when one of
the students stumbled and fell into the bonfire. Although several friends quickly
intervened, the client sustained partial-thickness burns to both lower legs, chest,
and both forearms. Which of the following is priority nursing action when the
client is brought to the ED?
a. cover the burned area with sterile gauze
b. inspect mouth for signs of inhalation
c. administer intravenous pain medication
d. draw blood for a CBC
16. A triage nurse in an emergency dept is caring for a client who has gunshot wound to the right side of chest. The nurse notices thick dressing on the chest and
sucking noise coming from the wound. The client has a blood pressure of 100/60
mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of
the following actions should the nurse take initially?
a. Raise the foot of the bed to a 90 degree angle
b. Remove the dressing to inspect the wound
c. Prepare to insert a central line
d. Administer oxygen via nasal cannula
17. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The
client’s heart rate increases from 86/min to 110/min and becomes irregular. The
nurse should know that the client requires which of the following?
a. A cardiology consult
b. Less frequent suctioning
c. An antidysrhythmic medication
d. Pre-oxygenation prior to suctioning
18. The nurse is caring for a client who is receiving a blood transfusion. The
transfusion started 30 minutes ago at a rate of 100 mL/hr. The client begins to
complain of low back pain and headache and is increasingly restless. What is the
first nursing action?
a. Stop the transfusion, disconnect the blood tubing, and begin a
primary infusion of normal saline solution
b. Slow the infusion and evaluate the vital signs and the client’s history of
c. Slow the infusion of blood and begin infusion of normal saline solution
from the Y connector.
d. Recheck the unit of blood for correct identification numbers and
19. A client with a diagnosis of disseminated intravascular coagulation (DIC) has the
following assessment findings: blood pressure of 76/56, temperature 102.6
degrees, resp. 24 breath/min., with complaints of severe neck and back pain.
Which nursing action should the nurse implement first?
a. Administer acetaminophen (Tylenol) PO.
b. Administer ibuprofen (Motrin) PO.
c. Draw coagulation study blood work in the AM
d. Give morphine sulfate IV
20. The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client who has a history of coronary artery disease is now in congestive heart
failure. What side effects will be particularly important to observe for when the
client takes the medication?
a. Tremors and central nervous system stimulation
b. Tachycardia and chest discomfort
c. Development of oral candidiasis
d. An increase in blood pressure
21. The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea?
a. Decreased breath sounds are heard over the left side of the chest
b. Increased rhonchi are present at the lung bases bilaterally
c. Ventilator pressure alarm continues to sound
d. Client is able to speak and coughs excessively
22. What is the desired action of dopamine (Intropin) when administered in the
treatment of shock?
a. It increases myocardial contractility
b. It is associated with fewer severe allergic reactions
c. It causes rapid vasodilation of the vascular bed
d. It supports renal perfusion by dilation of the renal arteries
23. The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes after the infusion is started, the client’s BP goes from 190/120 mm Hg to 120/90 mm Hg. What is the priority nursing action?
a. Recheck the BP and call the doctor
b. Decrease the infusion rate and recheck the blood pressure in 5
c. Stop the medication and keep the IV open with D5W.
d. Assess the client’s tolerance of the current level of BP
24. Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock.
Before administering the drug, the nurse should make sure that the client has:
a. A heart rate of less than 120 beats/min
b. Urine output of at least 30 mL/hr.
c. Received adequate anticoagulation
d. Been receiving adequate IV fluid replacement
25. The client returns to his room after a thoracotomy. What will the nursing
assessment reveal if hypovolemia from excessive blood loss is present?
a. CVP of 3 cm H20 and urine output of 20 mL/hr
b. Jugular vein distention with the head elevated 45 degrees
c. Chest tube drainage of 50 mL/hr in the first 2 hours
d. Persistent increased BP and increased pulse pressure
26. The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary of 20 mL for the past hour. The nurse would interpret these findings as suggestive of which pathophysiology?
a. Reduction of circulation to the coronary arteries, this increasing the
b. Decreased glomeruli filtration rate, resulting in volume overload
c. Stimulation of the sympathetic nervous system, causing severe
d. Decrease in the cardiac output and inadequate tissue perfusion
27. The nurse applies a Nitro-Dur patch on a client who has undergone cardiac
surgery. What nursing observation indicates that a Nitro-Dur patch is achieving
the desired effect?
a. Chest pain is completely relieved
b. Client performs activities of daily living without chest pain
c. Pain is controlled with frequent changes of patch
d. Client tolerates increased activity without pain
28) The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse 52, RR 16. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication?
A. Pulse rate has increased to 70 beats/min
B. systolic BP has increased by 20
C. pupils are dilated
D. oral secretions have decreased
29) An older adult client comes into ER stating that he has no appetite, is nauseated, his heart feels funny and has noticed a haziness in his vision. The client states that he has been taking an antihypertensive drug and digitalis for more than a year. Based on the presenting symptoms, what would be the priority nursing action?
A. Obtain an order for an EKG and serum potassium and digitalis levels
B. Perform a neurological assessment to determine whether he has one side weakness.
C. Assess lungs for decreased breath sounds and/or adventitious breath sounds.
d. Obtain an order for an EKG
30) the nurse is administering alteplase to a client who has been diagnosed with acute coronary syndrome. What are important nursing implications for this medication?
A. Monitor the ECG for dysrthymias
B. Place the client on bleeding precautions
C. monitor urine output hourly
D. Monitor for activity tolerance
31) The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an important nursing measure at this time?
A. Measure urinary output hourly and maintain continuous cardiac monitoring
B. Encourage client to perform slow pressure exercise of the affected side to promote circulation.
C. Maintain pressure over catheter insertion site and determine distal circulation status.
D. Evaluate apical pulse and determine presence of pulse deficit.
32. The nurse in a cardiac stepdown unit has received a hand-off shift report for these clients. Which client should be assess first?
A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent.
B. A client who is in heart failure and has gained 2 pnds in the last 24 hours.
C. a client with endocarditis who has temperature elevation of 100F and P 100 beats/min
D. A client who was cardioverted from atrial fib 24 hours ago and has had 3 atrial premature
33) What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain?
A. Prolonged PR interval
B. Wide QRS complex
C. ST- Segment elevation or depression
D. Tall, peak T-waves
34) A new employee at a facility needs a hepatitis vaccine. Which statement reflects accurate understanding of the immunization?
A. I need to get 6 shots of hep C
B. Once I receive the Hep vaccine I will always been immune
C. I will receive 3 injections over a period of months, which should protect me from hep B
D. Hep vaccine is an oral vaccine with live attenuated Virus
35) While talking with a client with a diagnosis of end stage liver disease. The nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition?
B. Increased Bile production
C. Increased blood ammonia levels
36) The nurse is caring for a client with chronic hep B. What will the teaching plan for this client include?
A. use a condom for sexual intercourse
B. Report any clay- colored stools.
C. Eat a high protein diet
D. Perform daily urine bilirubin checks
37. A patient with massive trauma and possible spinal cord injury is admitted to the
emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. cool clammy skin
b. inspiratory crackles
c. apical heart rate of 48 beats/min
d. temperature 101.2* F
38. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous and pulmonary artery wedge pressure are 4. Which of these orders by the health care provider will the nurse question?
a. Give furosemide (Lasix) 40 mg IV
b. increase normal saline infusion to 150 mL/hr
c. Administer hydrocortisone (SoluCortef) 100 mg IV
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
39. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of which of the following?
a. Nitroglycerin (Tridil)
b. Sodium nitroprusside (Nipride)
c. Drotrecogin alpha (Xigris)
d. Norepinephrine (Levophed)
40. Which of these findings is the best indicators that the fluid resuscitation for a patient with hypovolemic shock has been successful?
a. hemoglobin is within normal limits
b. Urine output is 60 mL over the last hour
c. Pulmonary artery wedge pressure (PAWP) is 10 mmHg
d. Mean arterial pressure (MAP) is 55 mm Hg
41. Which interventions will the nurse include in the plan of the care for a patient who has cardiogenic shock?
a. Avoid elevating head of bed
b. Check temperature every 2 hours
c. Monitor breath sounds frequently
d. Assess skin for flushing and itching
42. Which assessment is most important for the nurse to make in order to evaluate
whether treatment of a patient with anaphylactic shock has been effective?
a. Pulse rate
c. Blood pressure
d. Oxygen saturation
43. When caring for the patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? (TB ch.67 Q.17)
a. BP 92/56 mm Hg
b. Skin cool and clammy
c. apical pulse 118 beats/min
d. Arterial oxygen saturation 91%
44. During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which findings is most important for the nurse to report to the HCP?
a. Decreased bowel sounds
b. Apical pulse 110 beats/min
c. Pale, cool, and dry extremities
d. New onset of confusion and agitation
45. A patient is admitted to the burn unit with burns the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased ad no wheezes are audible. What is the best action for the nurse to take?
a. encourage the patient to cough and auscultate the lungs again
b. Notify the HCP and prepare for endotracheal intubation
c. Document the results and continue to monitor the patient’s resp. rate
d. Reposition pt in high-Fowler’s position and reassess breath sounds
46. During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor
b. Monitor daily weight
c. Assess mucous membranes
d. Measures hourly urine output
47. After receiving change-of-shift report, which of these patients should the nurse assess first?
a. A patient with smoke inhalation who has wheezes and altered mental
b. A patient with full-thickness leg burns who has a dressing change scheduled
c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale)
d. A patient with 40% total body surface area (TBSA) burns who is receiving IV
fluids at 500 mL/hr
48. The RN observes all of the following actions begin taken by a staff nurse who has
floated to the unit. Which action requires that the RN intervene?
a. The nurse uses latex gloves when applying antibacterial cream to a burn
b. The float nurse obtains burn cultures when the patient has a temp of 101* F
c. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes
before a dressing change
d. The float nurse calls the health care provider for an insulin order when a
nondiabetic pt has an elevated serum glucose
49) A client with cervical neck fracture is admitted to the intensive care unit. Which findings would the nurse recognize as indicative of spinal shock?
A. Spastically, neuromuscular irritability, hyperreflexia
B. Flaccidity and lack of sensation below the level of spinal cord lesion.
C. Automatic dysreflexia with neurogenic bladder symptoms
D. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of spinal cord lesion.
****know T2-T3: paraplegic ***************
50) A client with T6 spinal cord injury is being discharged. The PT is concerned about automatic dysreflexia. S/S include the following:
A. Dialited pupils
B. Sudden vomiting and diarrhea
C. drop in BP and pulse
D. Diaphoresis above the level of the lesion
51) A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want to get pregnant, but I don’t know how I will tolerate pregnancy because I have lupus. Which response is best?
A. Most women find that they feel better when they are pregnant
B. How long have you been in remission?
C. Women with lupus frequently have slightly longer gestation
D. Its best to become pregnant within the first 6 months of diagnosis
52. The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the fistula if which finding are noted? Select all that apply
A. presence of a thrill on palpation over the fistula
*B. Absence of a bruit on auscultation over the fistula
C. Presence of a pulse in the extremity below the fistula
*D. Complaints of tingling or discomfort in the extremity
E. Warm hand and fingers in the extremity in which the fistula is located.
53. Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following?
A. It is used to lower your blood pressure
*B. It is used to treat anemia
C. It will help to increase the potassium levels in your body
D. It is an anticonvulsant medication given to all clients after dialysis to prevent seizure activity.
54. A client with and ECG reading showing sinus bradycardia has a blood pressure of 47/28 mmhg. Which drugs does the nurse expect the physician to order for this client?
A. Lidocaine (Xylocaine)
*B. Atropine sulfate
C. Isoproterenol hydrochloride (Isuprel)
55. Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion will be needed?
B Nifedipine (Procardia)
C Lidocaine (Xylocaine)
*D. Amiodarone (Cordarone)
56. A nurse assesses a comatose, head-injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. Which of the following describes these findings?
B. Epileptic Seizure
*C. Decorticate posturing
D. Decerebrate posturing
57. The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
A Confirm that the ventilator settings are correct
B Verify that the ventilator alarms are functioning properly
*C. Assess the respiratory status and pulse oximeter reading.
D Monitor the clients arterial blood gas results.
58. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action?
A. Administer oxygen
B. Checks the client’s vital signs
*C Ventilates the client manually
D. Starts cardiopulmonary resuscitation
59. The client is admitted to the ED with chest trauma. Which signs/symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax?
A. Bronchovesicular lung sounds and friction rub
*B Absent breath sounds and tachypnea
C Nasal flaring and lung consolidation
D Symmetrical chest expansion and bradypnea.
60. A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply
A. Clamping the chest tube intermittently
*B. Changing the client’s position frequently
*C. Maintaining the collection chamber below the client’s waist
*D. Adding water to the suction control chamber as it evaporates.
*E Taping the connection between the chest tube and the drainage 	 	system.
61. A client has a total serum calcium level of 7.5 mg/dl. Which clinical manifestations would the nurse expect to note on assessment of the client? Select all
*B Muscle twitches
C Hypoactive bowel sounds
*D Hyperactive deep tendon reflexes
*E Positive Trousseau’s sign and positive Chvostek’s sign
*F. Prolong ST interval and QT interval on ECG
62. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
A. Administer sublingual nitroglycerin.
B Obtain a STAT electrocardiogram
*C Have the client sit down immediately
D Assess the clien’ts vital signs.
63. The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement. Select all
*A Assess the client’s level of consciousness
*B Monitor clients urine output
*C Perform passive range of motion exercise
*D maintain intravenous fluids as ordered
E Place the client with the HOB flat
64. The nurse is assessing a client experiencing motor loss as a result of a left sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?
The most common motor dysfunction of a CVA is paralysis of one side of 	the body, hemiplegia; in this case with a left-sided CVA, paralysis would 	affect the right side. Ataxia is an impaired ability to coordinate 	movement.
65. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome?
A. Increased blood pressure
*B Increased urine output
C Decreased pain
D Decreased PVCs
66. A client arrives at the emergency department with deep partial thickness and burns over 15% of his body. At admission his vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute and respiratory rate 20 breaths/minute. Which nursing intervention are appropriate for this client? Select all that apply
A. Starting an IV infusion of lactated Ringers solution
B. Administering 6mg of morphine IV
C. Administering tetanus prophylaxis as ordered
67. If dietary trays are usually brought to the nursing unit at 8:00am the nurse should plan to administer intermediate- acting insulin (Humlin N) 40 units SQ to the client between?
ANSWER- 630am and 700 am
68. What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain?
ANSWER- ST segment elevation or depression
69. The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse would plan which of the following as a priority action?
ANSWER- Place the client on a cardiac monitor
67. The nurse is caring for a client who underwent cardiac catherization 1 hour ago. What is an important nursing measures at this time?
ANSWER- MAINTAIN PRESSURE OVER CATHETER INSERTION SITE AND DETERMINE DISTAL CIRCULATION STATUS.
68. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s heart rate increases ??? to 110min and becomes irregular. The nurse should know that the client requires?
ANSWER- OXYGENATE PRIOR TO SUCTIONING
69. A client comes into the ER with complains of midsternal chest pain radiating to the neck and left arm which is unrelieved by sublingual nitroglygen. An electrocardiogram (ECG) is obtained. What observation on the ECG or on the cardiac monitor would indicate to the nurse the need to immediately notify the physician?
A. PR impulse 0.20 sec
B. Tachycardia rate of 125 beat of premature
C. premature ventricle beat
D. An ST segment elevation from the isoelectric baseline.
70. A client begins complains of chills and discomfort after about 50ml of blood has packed red blood cells. The best nursing action at this time is to
A. Discontinue the transfusion and move the IV and restart IV transfusion at another site.
B. compare the VS now and what they were before the transfusion begin
C. STOP THE TRANSFUSION AND MAINTAIN A PATENT LINE WITH NORMAL SALINE solution and new tubing
D. slow down the transfusion blood and dilute with normal saline solution
71. The vital signs of a client with cardiac disease are as follows blood pressure of 103/78 mm Hg, heart rate ??? beats/min, and respiratory rate of 16 breaths/min. Atropine (atropine???? Administered IV push. What nursing assessment indicates a therapeutic response to the medication?
ANSWER- Pulse rate has increased to 70 beats/min
72. Order rocephen 1g over 30minutes Q6H. Supply 1g/100mL. How many mL per hour will the nurse infuse? Round the nearest whole number.
ANSWER- 200 ml/hr
73. The nurse is caring for client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40 percent. The 02 saturation measured by pulse oximeter was 83 ABG results are pH 7.31, PACO2 93mmHg, HCO3 25 meq/L. Which of the following is an appropriate action by the nurse?
ANSWER- POSITION CLIENT IN HIGH- FOWLERS AND ENCOURAGE USE OF INCENTIVE SPIROMETER AND COUGHING.
74. The diabetic educator is teaching a class on Diabetes Type 1 and is discussing sick day rules. Which interventions should the diabetes counselor include in the teaching? Select all that apply
A) Take diabetic medication even if unable to eat the client’s normal diet.
B) If unable to eat, drink liquids equal to the client’s normal diet.
D) Test the blood glucose levels and test the urine ketones once a day
and keep a record.
75. The nurse is monitoring a client receiving pertional dialysis notes that the client’s outflow is less than inflow. What action should the nurse take? Select all that apply?
ANSWER- (SELECT ALL ANSWERS EXPCEPT – CONTACT THE HEALTH CARE PROVIDER & INCREASE THE FLOW- DO NOT SELECT THOSE TWO ANSWERS)
76. The nurse is obtaining a health history from a client who is visiting the clinic with complaints of a severe headache. The client provides the following data to the nurse based on a review of systems. The nurse identifies the following as a modifiable risk for stroke? Select all the apply.
B. ALCOHOL CONSUMPTION
C. DECREASED PHYSICAL ACTIVITY
77. The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which intervention should the nurse implement? Select all that apply
A. Assess the client’s level of consciousness.
B. Monitor the client’s urine output
C. Perform passive range of motion (ROM) exercise.
D. Maintain intravenous fluids as ordered.
78. The nurse is performing an assessment on a client who has returned from dialysis unit following hemodialysis. The client is complaining of headache, nausea, and is extremely restless. Which of the following ?? the most appropriate nursing action?
ANSWER- NOTIFY THE PHYSICANS
79. The nurse determines that a client with diabetes- mellitus is experiencing fat breakdown for conversion to glucose if the client has elevated levels of which substance in the urine?
80. The client is admitted the ED with chest trauma. Which signs and symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax?
ANSWER- ABSENT BREATHS SOUNDS TACHYPNEA
81. The nurse is caring for hospitalized clients. Which of the following clients is at greatest risk for fluid volume deficit?
ANSWER- THE CLIENT WHO HAS JUST BEEN ADMITTED HAS SEVERE DIARRHEA AND IS febrile.
82. PT & INR for Coumadin, INR 2.8: continue medication
83. Hot spot: apical pulse
84. Hot spot: T wave
85. Hot spot: P wave
86. P wave: atrial depolarization
87. Assessing response in an unconscious patient: nail bed pressure (peripheral)
88. HbA1c considerations for about 3 months of glucose monitoring
a.	less than 6% for nondiabetic
b.	diabetic controlled should be less than 7%
89. Sengstaken-Blakemore tube prevents bleeding (esophageal varices)
a.	Triple lumen
b.	Have scissors at the bedside
c.	Provide oral and nasal care every 3 hours
d.	Used to reduce bleeding
90. Planning rehabilitation for a stroke patient
a.	Assess functional status before developing plan
i.	Walking, speaking, eating, ADLs
91. Cranial nerve II: Snellen test
92. T2-T3: Paraplegia
93. ICP: no lumbar
94. A nurse observing a close chest tube drainage system is postop 1 day thoracotomy? Continue bubbling in the suction chamber?
A. check the control outlet against the wall
B. observe all the connection tubing
C. Continue to monitor client respiratory status
D. Notify MD of the oxidation
95. A client admit to hospital report recurrent flank pain, nausea, and vomiting within 24 hours. Which of the following priority nursing action?
A.	Administered pain medication
B.	Monitor intake and output
C.	Administered antiemetics
D.	Strain urine
96. A nurse is caring for client who have type 1 DM. The nurse misread client morning blood glucose level at 210 mg/dL instead of 120 mg/dL base on this error. She admitted insulin dose of 200 mg/dL before client breakfast. Which of the nursing priority?
Monitor client for hypoglycemia
97. A nurse is caring a client who is schedule of colonoscopy. The client ask the nurse if there will be a lot of pain during procedure. Which of the following is appropriate nursing response?
A.	No, you shouldn’t feel any pain because your rectum will be anesthesia
B.	You may be sedated but you will feel discomfort during the instrument insertion
C.	Don’t worry ??
98. A nurse is performing teaching for client who have recently diagnosis type 2 DM. nurse should recognize that the client understood the teaching. Identify hypoglycemia? Select all
A.	Moist, clammy skin
99. A nurse admitted morphine 2 mg IV push after client report pain and evaluate client 15 min. later injection. Which follow adverse effect?
A . pain scale level of 6 to 4
B. sleepy but arouse when name call
C. O2 sat 94%
D. RR 8 bpm
100. A nurse assess a client who 8 score using the Glasgow coma scale to elevate of consciousness. Describe the score.
A.	Reflex alert client
B.	Need of total nursing caring
C.	Client in deep coma
D.	Stable neurological status
101. client low sodium diet and reduce fluid intake to choose lunch.
A.	Tuna sandwich on wheat bread, can of cocktail fruit, salad, and soda
B.	Grill chicken sandwich on white bread, apple, salad, and ice tea
C.	Grill cheese sandwich, tomato soup,???
D.	Ham and bean???
102. client acute MI. an cardiac enzyme obtain. Cardiac enzyme identify?
A. damage to the myocardial
B. determine the size MI
C. help to determine the location MI
104. administered DDAVP to client diagnosis DI. Therapeutic effect
1.	Specific gravity (1.015)