NUR 2790 PN 2 FINALS (82%):Actual Questions and Answers with complete solution|Latest Update 100% Revised Correctly

NUR 2790 PN 2 FINALS (82%):Actual Questions and Answers with complete solution|Latest Update 100% Revised Correctly 2. The nurse is assessing a client with a diagnosis of left sided heart failure. Which assessment component would elicit specific information regarding the clients left sided heart function? A. Listening to lung sounds B. Palpating for organomegaly C. Assessing for jugular vein distention D. Assessing for peripheral and sacral edema 3. A client with COPD is admitted to the hospital. How can the nurse best position the client to improve gas exchange? A. Resting in bed with the head elevated 45 to 60 degrees. B. Sitting up at the bedside or in a chair and leaning slightly forward. C. Resting in bed in semi fowlers position with the knee flexed. D. In the Trendelenburg position with several pillows behind the head. 4. A client presented to the emergency department with a decreased level of consciousness, polydipsia, hyperthermia, dry mucous membranes, and a positive Babinski sign, blood glucose result was 600mg/dl and sodium (Na) = 155 mEq/L, Potassium (K+) = 6 mmol/L, and no serum ketones. The nurse determines the physician will likely diagnose the client with which of the following conditions? A. Hyperglycemic hyperosmolar nonketotic syndrome B. Hyperglycemic hyperosmolar Ketotic syndrome C. Diabetic non ketoacidosis D. Diabetic Ketoacidosis 5. The nurse is caring for a client with Parkinson’s disease. Which intervention does the nurse implement to prevent aspiration-related respiratory complications in the client? A. Keep an oral airway at the bedside B. Maintain the head of the bed at least 30 degrees or greater C. Ensure fluid intake of at least 3 L/ Day. D. Teach the client pursed lip breathing techniques. 6. A nurse is calculating the client’s intake for the 7 am- 3 pm shift. At breakfast, the client drank 1/2 cup of coffee and a 6 oz. glass of orange juice. At lunch, the client drank 2 oz. of chicken broth and 8 oz. of diet soda. What is the total oral intake of the 8-hour shift in mL? (Record answer as a whole number. Do not use a trailing zero.) 600 7. A client has the following arterial blood gases (ABGs): pH 7.30, HCO3 22 mEq/L, PCO2 55 mm Hg, PO2 86 mm Hg. Which intervention by the nurse takes priority? a. Assessing the airway b. Administering bronchodilators c. Administering mucolytics d. Providing oxygen 8. A nurse assessed a client who had Guillain-Barré syndrome. Which clinical manifestation does the nurse not expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness, and paresthesia d. Increased deep tendon reflexes 9. A nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days ago? The client report increased thirst, dry mouth and voiding frequently, what do the nurses assess? a. Weigh the client. b. Assess the client's vital signs. c. Slow down the TPN infusion. d. Assess the client's blood sugar. 10. The nurse suspects a client is experiencing an exacerbation of chronic obstructive disease (COPD) when Which of the following is assessed?(select all that apply) A. High blood pressure B. Cough C. Peripheral edema D. Dyspnea on exertion E. Jugular vein distention F. Sputum production 11. The client receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider? a. Potassium 3.5 mEq/L b. Calcuim 7.8 mg/dL c Soduim 154 mEq/L d. Magnesuim 1.8 mg/dL 12. Which arterial blood gas (ABG) values are expected with hyperventilation? a. pH, 7.32; PaCO2 55 mm Hg; HCO3 22 mEq/L b. PH 7.55; PaCO2 32mm Hg; HCO3 25 mEq/L c. pH, 7.48; PaCO2 38 mm Hg; HCO3 24 mEq/L d. pH, 7.45; PaCO2 42 mm Hg; HCO3 26 Me q/L 13. Which of the following assessment techniques can the nurse use to determine if a client is experiencing hypocalcemia? (Select all that apply) a. Allen test b. Chvostek's sign c. Trousseau's sign d. Palpation of the neck e. Auscultation of the lungs f. percussion of the abdomen 14. A nurse is reviewing the labs for a newly admitted heart failure client and notes a serum potassium (k+) of 5.8 mmol/L. Upon reviewing the client's medications, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance? a. Furosemide b. Hydrochlorothiazide c. Spironolactone d. Bumetanide 15. A client is having a sudden and severe anaphylactic reaction to the medication. The nurse immediately stops the medication and calls a rapid response. The client's blood pressure is 80/52 mm Hg heart rate 120 beats per minute and oxygen saturation 87%. Audible wheezing is noted, along with facial redness, and swelling. Which initial treatment should be administered first? A. IM epinephrine B. IV Diphenhydramine C. IV Normal saline bolus D. Nebulized albuterol 16. Which client is at greatest risk for atherosclerosis? a. A 32-year-old female with mitral valve prolapse who quit smoking 10 years b. A 43-year-old male with a family history of CAD and cholesterol level of 158 mg /dL c. A 56-year-old male with an HDL of 60 mg /dL who takes atorvastatin d. A 65-year-old female who is obese with a low-density lipoprotein (LDL) of 188 mg /dL 17. The provider ordered normal saline with 4mg of magnesium sulfate to infuse at 25mL/hr. A 125 mL bag has been hung at 1100. What time does the nurse anticipate needing to hang the second bag of IV fluids? (Record the answer in military time) 1hr 125ml 125 X = = 1600 25ml 1 1 18. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds. 19. A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? a. As close to the client's face as possible b. As far away as possible, with low lights c. Directly in front of the client d. In the client’s peripheral view 20. Which of the following conditions should the nurse recognize as a type 1 hypersensitivity reaction? a. Allergic rhinitis b. Positive purified protein derivative (PPD) test c. Transfusion with the improper blood type d. Serum sickness after receiving immunoglobulin 21. A nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a correct statement following the nurse education they received concerning the medication regimen? a. I will not drink one glass of wine a night. b. I will wear a medical alert bracelet. c. I do not need to notify my provider about herbal supplements. d. I can skip a couple of pills if they make me ill. 22. A client is admitted to the Emergency Room with a respiratory rate of 6 breath per minute, Arterial blood gasses (ABGS) have been drawn and revealed the following values: ph7.22 paCO2 68, HCO3 26, PaO2 74. Which of the following is an appropriate analysis of the ABGs? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis 23. The client is worried about contacting the influenza. What is the nurse's best response to the client? A. "Flu is no longer a prevalent problem." b. "Did you receive a flu vaccine this year?" c. "Current flu strains are generally mild." d. "If you develop symptoms, antibiotics will cure you." 24. A client comes into the emergency department (ED) with acute shortness of breath and a cough that produces pink, frothy sputum. Admission statement reveals crackles and wheezes, a blood pressure of 85/46 mm Hg, and heart rate of 122 beats per minute, and respiratory rate of 38 breaths per minute. The client’s medical history included diabetes mellitus (DM), hypertension (HTN), and heart failure. Which of the following disorders should the nurse suspect? A. Pulmonary embolism B. Pulmonary hypertension C. Pneumothorax D. Pulmonary edema 25. A nurse is caring for a client and observes that the client’s urine is cloudy and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? A. Urinary tract infection B. Renal calculi C. Urinary incontinence D. Urinary retention 26. The nurse is caring for a client who is about to have immunotherapy initiated due to severe allergies. Knowing that this client is being exposed to a known allergen. What intervention does the nurse implement to provide for client safety with this allergy treatment? a. Stay with the client and ensure that emergency equipment is in the room. b. Pretreat the skin area to be tested with a cortisone-based cream. c. Apply oxygen by mask or nasal cannula before injecting the test agent. d. Cover the examination table and pillow with plastic or an ultrafine mesh. 27. A 75-year-old diabetic client presents to the emergency department after collapsing in a local department store. The client has been fasting for days, and testing has found ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client? A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis 28. Which teaching intervention is most appropriate for the client with Parkinson’s disease? A. Seizures precautions B. Universal precautions C. Fall precautions D. Isometric exercises 29. A nurse is documenting the plan of care for a client who has type 1 diabetes mellitus that has remained unstable despite conventional insulin therapy. The provider has explained to the client that the new plan will incorporate a long-acting insulin preparation. The nurse anticipates seeing a prescription for the addition of which of the following insulin preparations? A. Lispro B. Glargine C. Aspart D. Glulisine 30. A nurse is caring for a client who is admitted for an acute exacerbation of ulcerative colitis. Which of the following actions is the priority for the nurse to take? A. Review the client's electrolyte values. B. Check the client's perianal skin integrity. C. Investigate the client's emotional concerns. D. Obtain a dietary history from the client. 31. A client diagnosed with type 1 diabetes mellitus administers a dose of regular insulin at 7.00 a.m. At which of the following times would this client most likely exhibit hypoglycemia? A. 1300 B. 1400 C. 1000 D. 0800 32. The nurse is notifying the health care provider via telephone of a change in the condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. 1. Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatment twice daily. Oxygen is prescribed at 2 L nasal cannula. 2. I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon 3. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. 4. Hello, My name is Nurse Jones from Unit D. 5. Respirations are now 32 breaths/ minute. The pulse oximeter is 89% on 2L nasal cannula. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. A. 4,5,2,1,3 B. 4,2,1,5,3 C. 4,1,2,5,3 D. 4,5,1,2,3 33. A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the client's family history of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection 34. The nurse reviews the arterial blood gas (ABG) result of a client and notes the following pH 7.45, PaCO2 30 mm Hg, and HCO3 20 mEq/L. The nurse analyzes these results as indicating which conditions? A. Metabolic acidosis, fully compensated B. Respiratory alkalosis, fully compensated C. Metabolic alkalosis, uncompensated D. Respiratory acidosis, uncompensated 35. A client is to receive 1 unit of packed red blood cells over 3 hours. There is 425 mL in the infusion bag. The IV administration infusion bag. The IV administration infusion set delivers 20 gtts/mL. At what flow rate (in drops per minute) should the nurse run the infusion? (Record your answer using a whole number. Do not use a trailing zero) 20gtt 425ml 1hr 8500 X X = = 47 1ml 3hrs 60mins 180 36. A client ask the nurse why it is important to be weighed everyday if he has right sided-heart failure. What is the nurse’s best response? a. "Weight is one of the best indicators that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure." 37. The nurse is discussing a bedbound elderly client’s risk factors.The nurse knows this client is most at risk for which complication? A. Deep vein thrombosis B. isolation C. Depression D. Malnutrition 38. The nurse is caring for four clients with asthma. Which client does the nurse assess first? a. Client with a barrel chest and clubbed fingernails b. Client with an SaO2 level of 92% at rest c. Client whose expiratory phase is longer than the inspiratory phase d. Client whose heart rate is 120 beats/min 39. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? (Select all that apply) A. Subcutaneous nodules B. Elevated creatinine C. Renal Calculi D. Butterfly rash E. Joint inflammation 40. The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath." 41. A client is prescribed Lidocaine to infuse at 10 mcg/kg/min. The drug concentration is 500 mg in 250mL dextrose 5% water (D5W), the client’s weight is 150 kg. what is the flow rate in mL/hr.? (Round the answer to the nearest whole number. Do not use a trailing zero) 250mL 1mg 10mcg 150kg 60mins X X X X = = 45 500mg 1000mcg 1kg 1 1hr 500000 42. The nurse is instructing a client diagnosed with type 2 diabetes mellitus on diagnostic tests used to evaluate how well the control of the disorder has been managed. The nurse should instruct the client on which of the following diagnostic tests that will provide this information? a. Fasting plasma glucose b. Glycosylated hemoglobin c. Random plasma glucose d. Two-hour oral glucose tolerance test 43. The client with heart failure has been prescribed intravenous nitroglycerin and furosemide for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client’s blood pressure. c. Place the nitroglycerin under the client’s tongue. d. Monitor the client’s serum glucose level. 44. A client with diabetes mellitus is prescribed to take insulin glargine once daily and regular insulin four times daily. How will the nurse teach the client to take these two medications when the first dose of regular insulin should be given at the same time of day as the insulin glargine dose? a. “Draw up and inject the insulin glargine first, then draw up and inject the dose of regular insulin in a separate syringe.” b. “Draw up and inject the insulin glargine first, wait 1 hour, then draw up and inject the dose of regular insulin.” c. “First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together.” d. “First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.” 45. A nurse is caring for a client who has deep vein thrombosis (DVT) and has been on continuous heparin infusion for five days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and warfarin work together to dissolve the clots." D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay." 46. A client is suspected of having an abdominal aortic aneurysm (AAA). Which question is the highest priority for the nurse to ask first? A. “Do you get frequent headaches” B. “Do you have any abdominal or back pain” C. “Have you had bowel movements that looked black or tarry” D. “Have you ever had any blood in your urine?” 47. The nurse conducts a physical assessment for a client with abdominal pain. Which following leads the nurse to suspect appendicitis? a. Constant right lower quadrant (RLQ) pain b. Abdominal pain that started a day after vomiting began c. Abdominal pain that increases with knee flexion d. Marked peristalsis and hyperactive bowel sounds 48. A client who is experiencing an exacerbation of Crohn’s disease should be monitored for which complications? A. Hypercalcemia B. Dehydration C. Hyperkalemia D. Constipation 49. The nurse assesses for which clinical manifestations in a client with suspected diabetic ketoacidosis (DKA)? a. Increased rate and depth of respirations b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe hypertension 50. The home care nurse is about to administer intravenous medication to the client and reads in the chart that the peripherally inserted central catheter (PICC) line in the client’s left arm has been in place for four weeks. The PICC line is patent, with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. What is the nurse’s best action? a. Notify the physician. b. Administer the prescribed medication. c. Discontinue the PICC line. d. Switch the medication to the oral route. 51. A client is diagnosed with glaucoma and is prescribed medication to treat it. The nurse knows that which of the following best explains the purpose of the medication? a. This medication lowers blood pressure b. This medication helps dry up excess secretions. c. This medication strengthens the muscles of the eye. d. This medication lowers intraocular pressure. 52. A client with Alzheimer’s disease is admitted to the hospital. Which psychosocial assessment is most important for the nurse to complete? a. Ability to recall past events b. Ability to perform calculation c. Reaction to a change of environment d. Relationship with close family members 53. The nurse is caring for a client who is administering insulin for diabetes mellitus for the first time. The nurse is instructing the client on mixing Humulin N insulin and Humulin R insulin in one syringe. Arrange the instruction in the correct order. 1. withdraw the Humulin R. 2. wipe with alcohol and inject air (equal to units ordered) into the Humulin N insulin 3. wipe with alcohol and inject air (equal to units ordered) into the Humulin R insulin 4. gently roll both insulin between your hands 5. double-check the total number of units in the syringe 6. Withdraw Humulin N insulin A. 4,3,2,1,6,5 B. 4,2,3,6,1,5 C. 2,3,4,1,6,5 D. 4,2,3,1,6,5 54. An older adult who has a mature cataract in the right eye states, “Now I have lost the sight in my right eye because I waited too long for treatment”. How does the nurse best respond to the client? A. "Yes, this type of blindness could have been prevented by earlier treatment." B. "It is fortunate you came for treatment in time to save the sight of your other eye." C. "Nothing you could have done would have made any difference." D. "Surgery can still save the sight in your eye with removal of the cataract." 56. Which medication will the nurse prepare to administer to the client who is experiencing status epilepticus? A. Lorazepam B. Propranolol C. Theophylline D. Atropine 57. A client with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension at home for indigestion is drowsy and has decreased deep tendon reflexes. Which action should the nurse take first? a. Notify the patient's health care provider. b. Withhold the next scheduled dose of aluminuim hydroxide/magnesium hydroxide c. Review the magnesium level on the patient's chart. d. Check the chart for the most recent potassium level. 58. A client diagnosed with heart failure is prescribed furosemide. Which of the following should this client be monitored for because of this medication? (Select all that apply) A. dehydration B. rebound fluid volume overload C. hyponatremia D. hypokalemia E. Hypernatremia F. Hyperkalemia 59. The nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? A. Time of the last dressing change. B. Tightness of the tubing connections. C. Client's temperature. D. Expiration date on the bag. 60. A client is receiving an IV infusion of heparin sodium at 1500 units/hr. The drug concentration is 10000 units/500mL. What is the rate (in mL/hr.) the nurse must infuse the medication at? (Round the answer to the nearest whole number. Do not use a trailing zero) 1500unit 500ml 750000 X = = 75 1hr 10000 10000 61. Which assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated? a. The client has dry, scaly skin on bilateral upper and lower extremities. b. The client states that he gets up three or more times during the night to urinate. c. The client states that he feels lightheaded when he gets out of bed or stands up. d. The nurse observes nonpitting bilateral ankle edema 62. A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care? a. Placing the client in at least semi-fowlers position during meals b. Providing a straw for consumption of liquids c. Encourage larger bites d. Instructing the client to throw head back when swallowing 63. Which action by the nurse is most effective to prevent becoming exposed to the human immunodeficiency virus (HIV)? A. Convert parenteral medications to an oral form for clients who are HIV positive B. Always use standard precautions with all clients in the workplace C. Utilize sterile gloves for all procedures. D. Place clients who are HIV positive in contact precautions. 64. A nurse is teaching a group of nursing students about a dissecting abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching? a. Has a high survival rate. b. Can be treated in the outpatient setting. c. It is a medical emergency requiring immediate treatment. d. Palpating the abdomen is the best way to assess. 65. A client receiving a unit of red blood cells begins to report chest and lower back pain, which action does the nurse take first? a. Administer morphine sulfate 1 mg IV. b. Assess the level of the pain. c. Stop the transfusion. d. Reposition the client on the right side. 66. The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expert to observe in this client? a. Muscle weakness that worsens with use and improves with rest. b. Muscle rigidity c. Hyperactive deep tendon reflexes d. impaired stereognosis 67. A client is admitted with a possible deep vein thrombosis (DVT). What nursing interventions should be implemented to prevent which complication? A. Myocardial infarction. B. Renal failure C. Pulmonary embolism D. Pneumonia 68. The nurse writes the nursing problem of “fluid volume excess” (FVE). Which intervention should the nurse include in the plan of care? A. Change the IV fluid from 0.9% normal saline (NS) to dextrose 5% water (D5W). B. Restrict the client's sodium in the diet. C. Monitor blood glucose levels. D. Prepare the client for hemodialysis. 69. A client is receiving total parental nutrition (TPN). Which of the following routes is appropriate for this type of nutrition administration? A. Peripherally inserted central catheter B. Peripheral intravenous catheter C. Arteriovenous fistula D. Percutaneous endoscopic gastronomy (PEG) tube. 70. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the actions should the nurse take first? A. Check the clients’ vital signs B. Request a dietitian consult C. Suggest that the client rest before eating the meal D. request an order of antiemetic 71. The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin sodium. What instruction does the nurse provide to this client? a. "You need prothrombin time (PT)/ international normalized ratio (INR) checked every two weeks." b. "Massage the injection site after the enoxaparin is injected." c. "Notify your health care provider if your stools appear tarry." d. "You must have your activated partial thromboplastin (aPTT) checked daily" 72. A client with diabetes has hot, dry skin, rapid and deep respirations, and a fruity odor to his breath. Which of the following tasks are appropriate? (SATA) A. Checking the client's fingerstick glucose level B. Encouraging the client to drink 4-6oz orange juice C. Checking the client's order for sliding-scale insulin dosing D. Assessing the client's vital signs every 15 minutes E. Initiate IV fluids as ordered 73. A client receiving care for a spinal cord injury complains of a pounding headache, flushed skin, cardiac dysrhythmias, and has a blood pressure of 220/125 mmHg. what is the first action the nurse should take? a. Administer medication as ordered. b. Position the client on the left side. c. Turn off the lights and decrease the noise in the room. d. Check the bladder for distension. 74. A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36 breaths per minute, and he appears very restless. The nurse anticipates which of the following values to be outside the expected reference range if the client is experiencing respiratory alkalosis? A. PaO2 B. PaCO2 C. Sodium D. Bicarbonate 75. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from the supply department d. Tell the client to take slow, deep breaths. 77. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when the identifies which of the following as manifestations specific to hypoglycemia? (Select all that apply) A. Polyuria B. Blurred or double vision C. Polydipsia D. Dry skin E. Cool, clammy skin 78. To delay the onset of microvascular and macrovascular complications in the diabetic client, the nurse stresses which action? a. Controlling hyperglycemia. b. Preventing hypoglycemia. c. Restricting fluid intake. d. Preventing ketosis. 79. The nurse is caring for a client experiencing a seizure that has persisted for 5 minutes. What is the nurse’s priority action? A. Establish a large-bore IV catheter and start 0.9% sodium chloride IV B. Start the patient on 2L of oxygen via nasal cannula C. Establish airway D. Guide the client to prevent injury during convulsions 80. A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A. Prepare to administer the antidote. B. Prepare to draw a sample for type and crossmatch and transfuse the client. C. Prepare to draw a sample for an activated partial thromboplastin time (aPTT) level. D. Prepare to draw a sample for prothrombin time (PT) and international normalized ratio (INR) 81. A client has returned to the nursing unit after a prostatectomy. Which activities does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. Demonstrating how to use the incentive spirometer b. Measuring and recording output from the in-dwelling catheter c. Encouraging the client to get out of bed and into the chair d. Irrigating the catheter with normal saline for blood clots e. Assessing the client for new onset of pain A client has returned to the nursing unit after an appendectomy. Which activities does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. Demonstrating how to use the incentive spirometer b. Teaching the client how to obtain a mid-stream catch for a urine analysis c. Walking with the client in the hallway d. Assisting the client with a bed bath e.Assessing the client for new onset of pain 82. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which arterial blood gas (ABG) lab value would the nurse expect to see with his client? a. pH 7.13; PaCO2 39 mm Hg; HCO3 17 mEq/L b. pH 7.47; PaCO2 45 mm Hg; HCO3 28 mEq c. pH 7.33; PaCO2 49 mm Hg; HCO3 26 mEq/L /Ld. pH 7.46; PaCO2 34 mm Hg; HCO3 23 mEq/L 83. A client with benign prostatic hyperplasia (BPH) asks why his enlarged prostrate is causing difficulty with urination. Which is the nurse’s most accurate response? a. "It compresses the urethra, blocking the flow of urine." b. "It presses on the kidneys, decreasing urine formation." c. "It secretes acids that weaken the bladder, causing dribbling." d. "It destroys nerves, decreasing awareness of a full bladder." 84. The nurse assesses a client diagnosed with a peripheral arterial occlusion. Which of the following will the nurse assess in this client? (Select all that apply) A. Pulselessness B. Paralysis C. Pain D. Pallor E. Petechiae F. Paresthesia 86. A nurse suspects anaphylaxis when caring for a client following the initial administration of an intravenous infusion of an antibiotic. Which of the following would the nurse likely assess in this client? (Select all that apply) a. Bradycardia b. Hypotension c. Hypertension d. Edema/swelling e. Tachycardia f. itchiness 87. Which of the following would the nurse most likely assess in a client diagnosed with right-sided heart failures? A. Cough with frothy blood-tinged sputum B. Oliguria C. Hepatomegaly D. Syncope 88. A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a deep vein thrombosis (DVT) (select all that apply) A. Administer ordered subcutaneous heparin B. Decrease fluid intake C. Assess legs for redness or swelling D. Massage the calves every day E. Apply sequential compression device (SCDs) 89. A client is experiencing a loss of central vision but not a loss of peripheral vision. The nurse realizes the client should be evaluated for which condition? A. Nystagmus B. Conjunctivitis C. Macular degeneration D. Detached retina syndrome 90. A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 100 units of insulin in 100 mL of normal saline solution administered via an infusion pump set at 30 mL/hr. The nurse determines that the client is receiving how many units of insulin each hour? (Record your answer using a whole number? 100units 30ml 300 X = = 30 100ml 1hr 100 91. Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures which medication is available on the nursing unit? A. vitamin K B. protamine sulfate C. potassium chloride D. aminocaproic acid 92. The nurse is concerned that a client with a gastrostomy feeding tube is developing a complication. Which of the following are considered complications associated with this type of feeding tube? (Select all that apply) a. Nausea b. Vomiting c. Leg cramps d. Abdominal distention e. Aspiration f. Muscle pain 93. The nurse student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for his procedure if the student states that which action is part of the plan for preparation and administration of the potassium? A. Obtaining an intravenous (IV) infusion pump B. Monitoring urine output during administration C. Preparing the medication for bolus administration D. Ensuring that the medication is diluted in the appropriate amount of normal saline 94. Which actions should the nurse take when caring for a newly admitted client receiving a blood transfusion?(SATA) A. Remain with the client for the first 60 minutes of the transfusion B. Warm the blood prior to transfusion C. Instructing the client to report any itching, chest pain, or dyspnea. D. Verify informed consent. E. Hang Lactated Ringers with the blood 95. The nurse is assigned to care for a group of clients. Upon reviewing the client’s medical records, the nurse determines which client is most likely at risk for a fluid volume deficit? A. A client experiencing an ulcerative colitis flare up B. A client with heart failure C. A client on long term corticosteroid therapy D. A client receiving frequent wound irrigations 96. A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause? a. Do you use sugar substitutes? b. Do you use diuretics or laxatives? c. Do you have any kidney disease? d. Have your bowel habits changed recently? 99. The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 196 mg/dL and hemoglobin A1C of 6.6%. what are the nurse’s interpretations of these findings? a. The client's glucose control for the past 24 hours has been good, but the overall control is poor. b. The client's glucose control for the past 24 hours has been poor, but the overall control is good. c. The values indicate that the client has poorly managed his or her disease. d. The values indicate that the client has managed his or her disease well. 100. A client being treated for a spinal cord injury needs immediate ventilator support. The nurse realizes that this client’s level of injury is most likely at which level. A. L5 B. C8 C. C3 D. T3 101. A nurse is assessing a client with anemia. Which clinical manifestation does the nurse not expect to see in this client? A. Fatigue B. Pallor C. Hypertension D. Dyspnea with activity 102. A client with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea.What is the nurse’s first priority? a. Obtain the client’s blood pressure the options for number 102 is not complete 103. Which clinical manifestation would be required to confirm the diagnosis of Parkinson diseases? a. Tremors at rest and bradykinesia b. Rigidity only c. Tremor at rest and flaccidity d. Bradykinesia only 104. The nurse is reviewing the record of a client with Crohn disease.Which stool characteristic should the nurse expect to note documented in the client’s record? a. Constipation alternating with diarrhea b. Diarrhea c. Chronic constipation d. Stool constantly oozing from the rectum 105. A client was admitted to the ICU with a diagnosis with hyponatremia.Which of the following assessment findings would cause the nurse to become concerned? (Select all that apply) a. Seizures b. Alert and oriented x 4 c. Increased appetite d. Coma e. Increased grip strength f. Lethargy 106. The nurse is caring for a client with a history of chronic renal failure.The nurse should assess the client’s electrocardiogram rhythm for signs of which electrolyte abnormality? a. Hypernatremia b. Hyperkalemia c. Hyponatremia d. Hypokalemia