Final exam for 275
1. A client diagnosed with AKI is experiencing hyperkalemia. Which medication
would the nurse anticipate on preparing to help improve the client's potassium
level?
a. Regular insulin
2. A client is hospitalized with cirrhosis, ascites, and mild hepatic encephalopathy,
suddenly vomits 200 mL of bright red blood. Which of the following would the
nurse do first?
Insert a nasogastric tube.
Contact the physician.
Place the client in Fowler's position.
Check the stool for occult blood.
3. A client undergoes an arthroplasty with reconstruction and replacement of the
finger joints. Postoperatively, what is most important for the nurse to do?
A. position the fingers lower than the elbow
B. perform neurovascular assessments of the fingers q2-4 hr.
C. Encourage the patient to gently flex, extend, abduct, adduct, the finger's q4 hr.
D. remind the patient that function of the hands is more important than their
cosmetic appearance
4. A client undergoing surgery and radiation for treatment of breast cancer has a
nursing diagnosis of disturbed body image R/T absence of the breast. What is an
appropriate nursing intervention at this time?
a.Provide the patient with information about surgical breast reconstruction.
b. Restrict visitors and phone calls until the patient feels better about herself.
c. Arrange for a Reach to Recovery visitor or similar resource available in
the community.
d. Encourage the patient to obtain a permanent breast prosthesis as soon as she
is discharged from the hospital
5. A client with a history of heart failure, HTN, now presents with (AKI) Acute
Kidney Injury as a result of nephrotoxic diuretics. Currently his serum K+ - 6.2
mEq/L with cardiac changes, the BUN is 108 mg/dL, his serum creatinine - 4.1
,mg/d/L and his HCO3 is 14 mEq/L. He is somnolent and disoriented. Which
treatment would the nurse expect to use for this client?
a. Loop diuretics
b. Renal replacement therapy
c. Insulin and sodium bicarbonate
d. Sodium polystyrene sulfonate (Kayexalate)
6. A client with advanced AIDS has impaired memory related to neurologic
changes. In planning care, what would the nurse set as the highest priority?
maintain a safe patient environment
7. A client with rheumatoid arthritis has been on Methotrexate, a DMARD drug for
2 weeks. Which laboratory data warrants intervention by the nurse?
1. A serum creatinine level of 0.9 mg/dL.
2. A red blood cell count of 2.5 million/mm.
3. A white blood cell count of 9000 mm.
4. A hemoglobin of 14.5 g/dL and hematocrit of 43%.
8. A nurse in a medical clinic is providing teaching to an older adult client who
has osteoarthritis that is affecting her knees. Which of the following client
statements indicates an understanding of the teaching?
A. "I can use either heat or ice to help relieve the discomfort."
B. "Ibuprofen is the first step in medication therapy for osteoarthritis."
C. "I should limit physical activity to prevent further injury."
D. "I will elevate my legs by placing two pillows under my knees when I go to
bed."
9. A nurse in a provider's office is assessing a client who has rheumatoid arthritis
(RA). Which of the following findings is a late manifestation of this condition?
A. Anorexia
B. Weight loss
C. Low grade fever
D. Knuckle deformity
10. A nurse in the emergency department is planning care for a client who has a
right hip fracture. Which of the following immobilization devices should the nurse
anticipate in the plan of care?
, A. Skeletal traction
B. Buck's traction
C. Halo traction
D. Gardner-Wells traction
11.A nurse is admitting a client to the orthopedic unit following a total knee
arthroplasty. Which of the following actions by the nurse are appropriate? (Select
all that apply.)
A. Maintain continuous passive motion device.
B. Palpate dorsopedal pulses.
C. Place pillow behind the knee.
D. Elevate heels off bed.
E. Apply heat therapy to incision.
12. A nurse is admitting an adult client who has suspected osteoporosis. Which of
following findings are risk factors for osteoporosis? (Select all that apply.)
A) History of consuming one glass of wine daily
B) Loss in height of 2 in (5.1 cm)
C) BMI of 18
D) Kyphotic curve at upper thoracic spine
E) History of lactose intolerance
13. A nurse is assessing a client who had an external fixation device applied 2 hr
ago for a fracture of the left tibia and fibula. Which of the following findings is a
manifestation of compartment syndrome? (Select all that apply.)
A. Intense pain when the left foot is passively moved
B. Capillary refill of 3 sec on the client's left toes
C. Hard, swollen muscle in the left leg
D. Burning and tingling of the client's left foot
E. Client report of minimal pain relief following a second dose of opioid
medication
14. A nurse is assessing a client who has a casted compound fracture of the
femur. Which of the following findings is a manifestation of a fat embolus?
a. Altered mental status
b. Reduced bowel sounds
c. Swelling of the toes distal to the injury
1. A client diagnosed with AKI is experiencing hyperkalemia. Which medication
would the nurse anticipate on preparing to help improve the client's potassium
level?
a. Regular insulin
2. A client is hospitalized with cirrhosis, ascites, and mild hepatic encephalopathy,
suddenly vomits 200 mL of bright red blood. Which of the following would the
nurse do first?
Insert a nasogastric tube.
Contact the physician.
Place the client in Fowler's position.
Check the stool for occult blood.
3. A client undergoes an arthroplasty with reconstruction and replacement of the
finger joints. Postoperatively, what is most important for the nurse to do?
A. position the fingers lower than the elbow
B. perform neurovascular assessments of the fingers q2-4 hr.
C. Encourage the patient to gently flex, extend, abduct, adduct, the finger's q4 hr.
D. remind the patient that function of the hands is more important than their
cosmetic appearance
4. A client undergoing surgery and radiation for treatment of breast cancer has a
nursing diagnosis of disturbed body image R/T absence of the breast. What is an
appropriate nursing intervention at this time?
a.Provide the patient with information about surgical breast reconstruction.
b. Restrict visitors and phone calls until the patient feels better about herself.
c. Arrange for a Reach to Recovery visitor or similar resource available in
the community.
d. Encourage the patient to obtain a permanent breast prosthesis as soon as she
is discharged from the hospital
5. A client with a history of heart failure, HTN, now presents with (AKI) Acute
Kidney Injury as a result of nephrotoxic diuretics. Currently his serum K+ - 6.2
mEq/L with cardiac changes, the BUN is 108 mg/dL, his serum creatinine - 4.1
,mg/d/L and his HCO3 is 14 mEq/L. He is somnolent and disoriented. Which
treatment would the nurse expect to use for this client?
a. Loop diuretics
b. Renal replacement therapy
c. Insulin and sodium bicarbonate
d. Sodium polystyrene sulfonate (Kayexalate)
6. A client with advanced AIDS has impaired memory related to neurologic
changes. In planning care, what would the nurse set as the highest priority?
maintain a safe patient environment
7. A client with rheumatoid arthritis has been on Methotrexate, a DMARD drug for
2 weeks. Which laboratory data warrants intervention by the nurse?
1. A serum creatinine level of 0.9 mg/dL.
2. A red blood cell count of 2.5 million/mm.
3. A white blood cell count of 9000 mm.
4. A hemoglobin of 14.5 g/dL and hematocrit of 43%.
8. A nurse in a medical clinic is providing teaching to an older adult client who
has osteoarthritis that is affecting her knees. Which of the following client
statements indicates an understanding of the teaching?
A. "I can use either heat or ice to help relieve the discomfort."
B. "Ibuprofen is the first step in medication therapy for osteoarthritis."
C. "I should limit physical activity to prevent further injury."
D. "I will elevate my legs by placing two pillows under my knees when I go to
bed."
9. A nurse in a provider's office is assessing a client who has rheumatoid arthritis
(RA). Which of the following findings is a late manifestation of this condition?
A. Anorexia
B. Weight loss
C. Low grade fever
D. Knuckle deformity
10. A nurse in the emergency department is planning care for a client who has a
right hip fracture. Which of the following immobilization devices should the nurse
anticipate in the plan of care?
, A. Skeletal traction
B. Buck's traction
C. Halo traction
D. Gardner-Wells traction
11.A nurse is admitting a client to the orthopedic unit following a total knee
arthroplasty. Which of the following actions by the nurse are appropriate? (Select
all that apply.)
A. Maintain continuous passive motion device.
B. Palpate dorsopedal pulses.
C. Place pillow behind the knee.
D. Elevate heels off bed.
E. Apply heat therapy to incision.
12. A nurse is admitting an adult client who has suspected osteoporosis. Which of
following findings are risk factors for osteoporosis? (Select all that apply.)
A) History of consuming one glass of wine daily
B) Loss in height of 2 in (5.1 cm)
C) BMI of 18
D) Kyphotic curve at upper thoracic spine
E) History of lactose intolerance
13. A nurse is assessing a client who had an external fixation device applied 2 hr
ago for a fracture of the left tibia and fibula. Which of the following findings is a
manifestation of compartment syndrome? (Select all that apply.)
A. Intense pain when the left foot is passively moved
B. Capillary refill of 3 sec on the client's left toes
C. Hard, swollen muscle in the left leg
D. Burning and tingling of the client's left foot
E. Client report of minimal pain relief following a second dose of opioid
medication
14. A nurse is assessing a client who has a casted compound fracture of the
femur. Which of the following findings is a manifestation of a fat embolus?
a. Altered mental status
b. Reduced bowel sounds
c. Swelling of the toes distal to the injury
