COMPLETE QUESTIONS WITH ANSWERS
◉ 2. 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 bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the
past hour 75 ml of bright red blood is measured in the collection
chamber. Which intervention should the nurse implement? Answer:
a. Add sterile water to the suction control chamber.
◉ 3. A client who received hemodialysis yesterday is experiencing a
blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and
respiratory rate 36 breaths/minute. The client is manifesting
shortness of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should the nurse take
first? Answer: c. Begin supplemental oxygen.
◉ 4. A client with Addison's crisis is admitted for treatment with
adrenal cortical supplementation. Based on the client's admitting
diagnosis, which findings require immediate action by the nurse?
(Select all that apply) Answer: Headache and tremors
Irregular heart rate
,pallor and diaphoresis
◉ 5. An older client is admitted with fluid volume deficit and
dehydration. Which assessment finding is the best indicator of
hydration that the nurse should report to the healthcare provider?
Answer: d. Skin tenting occurs when the client's forearm is pinched.
◉ 6. 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? Answer: a. File a
detailed incident report with the specific hiring facility.
◉ 7. The nurse is evaluating a tertiary prevention program for
clients with cardiovascular disease implemented in a rural health
clinic. Which outcome indicate the program is effective? Answer: c.
Clients who incurred disease complications promptly received
rehabilitation.
◉ 8. 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 nurse observes that the client is having
increased shortness of breath with respirations at 23
breaths/minute. Which action should the nurse implement first?
Answer: d. Assess the delivery mechanism of the oxygen tank,
tubing, and cannula.
,◉ 9. Which statement by a client who is 24 hours post-subtotal
thyroidectomy requires an immediate investigation by the nurse?
Answer: When I get out of bed quickly, I feel a little dizzy."
◉ 10. An older adult male who is in his early 70's is admitted to the
emergency department because of a COPD exacerbation. 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 procedure and provide the
nurse a copy of the client's living will. Which action should the nurse
take? Answer: b. Notify the healthcare provider of the client's
wishes.
◉ 11. An unlicensed assistive personnel (UAP) is assigned to provide
personal care for a client whose prescribed activity is bedrest with
bedside commode use. The UAP reports to the nurse that the client
is so obese that the UAP feels unable to safely assist the client in
transferring from the bed to the bedside commode. How should the
nurse respond? Answer: c. Advice the client to maintain bedrest so
that safety can be ensured.
◉ 12. A nurse determines that more than 25% of the students at a
middle school are overweight. The nurse presents the information at
the parent-teacher meeting. What action is most important for the
nurse to include in the meeting? Answer: c. Distribute a shopping list
of suggested healthy snack items.
, ◉ 13. After several months of chronic fatigue, morning stiffness, and
join pain, a young adult is diagnosed with rheumatoid arthritis, and
the healthcare provider prescribes prednisone. Which education
should the nurse provide the client with regard to taking
prednisone? Answer: c. If sequential doses are missed, notify the
healthcare provider.
◉ 14. The psychiatric nurse is caring for clients on an adolescent
unit. Which client requires the nurse's immediate attention?
Answer: c. An 18-year-old client with antisocial behavior who is
being yelled at by other clients
◉ 15. The nurse caring for a child with mononucleosis can expect
the child to exhibit which symptoms? Answer: b. Ear pain and fever.
◉ 16. A client arrives for an annual physical exam and complains of
having calf pain. The client's health history reveals peripheral atrial
disease. Which question should the nurse ask the client about
expected finding related to chronic arterial symptoms? Answer: b.
Does the calf pain occur when walking short distances?
◉ 17. The nurse is preparing to send a client to the cardiac
catheterization lab for an angioplasty. Which client report is most
important for them to explore further prior to the start of the
procedure? Answer: d. Experience facial swelling after eating crab.