GRADE WITH 100% QUESTIONS AND ANSWERS.
AKnurseKisKcaringKforKaKclientKwithKsevereKperipheralKarterialKdiseaseKofKtheKrightKlowerKextrem
ity.KWhichKinterventionKisKappropriate?
A.) ApplyKcoldKcompressesKtoKtheKaffectedKextremity
B.) ApplyKwarmKcompressesKtoKtheKaffectedKextremity
C.) KeepKtheKaffectedKextremityKaboveKtheKlevelKofKtheKheart
D.) KeepKtheKaffectedKextremityKbelowKtheKlevelKofKtheKheartK-KANSWER---
>D.)KKeepKtheKaffectedKextremityKbelowKtheKlevelKofKtheKheart
RATIONALE:KTheKnurseKshouldKNEVERKapplyKdirectKheatKtoKtheKlimb.KSensitivityKisKdecreas
edKinKtheKaffectedKlimbK&KburnsKmayKresult
AKnurseKisKprovidingKcareKforKaKclientKwithKaKJackson-
PrattKdrain.KWhichKofKtheKfollowingKnursingKinterventionsKhasKtheKhighestKpriority?
A.) SecuringKtheKtubeKandKdrainageKbulbKtoKtheKpt
B.) KeepingKtheKdrainageKbulbKdepressedKtoKmanualKsuction
C.) "Milking"KtheKtubingKbeforeKemptyingKtheKdrain
D.) CleansingKtheKinsertionKsiteKofKtheKtubeKw/betadineK-KANSWER--
>B.)KKeepingKtheKdrainageKbulbKdepressedKtoKmanualKsuction
RATIONALE:KSecuringKtheKtubingKhelpsKtoKkeepKtensionKfromKbeingKplacedKonKtheKtubingK&K
bulb.KWhileKthisKisKhelpful,KmaintainingKtheKbulbKtoKsuctionKisKtheKhighestKpriorityKnursingKint
ervention
AKclientKisKscheduledKforKsurgery.KWhichKofKtheKfollowingKfindingsKshouldKtheKnurseKreportKto
KtheKproviderKpriorKtoKsurgery?
A.) SerumKpotassiumKofK3.8KmEq/L
B.) AKmissingKidentificationKband
C.) IncreasedKanxietyKlevel
D.) AKdecreaseKinKBPK-KANSWER-->D.)KAKdecreaseKinKBP
RATIONALE:KIfKaKmissingKIDKbandKisKnotedKtheKnurseKcanKrecreateKtheKbandKpriorKtoKproceed
ingKtoKtheKoperatingKroom.KTheKIDKbandKisKaKmethodKofKproperlyKidentifyingKaKptK&KnecessaryK
forKcare
AKclientKisKundergoingKcystoscopy.KWhichKofKtheKfollowingKinterventionsKshouldKtheKnurseKincl
udeKinKtheKclient'sKplanKofKcare?
A.) ProvideKeducationKonKhomeKurinaryKcatheterKcare
B.) MonitorKforKinfectionKforK48-72KhoursKfollowingKprocedure
C.) IncreaseKoralKfluidKintakeKtoKflushKcontrastKdyeKfromKsystem
D)KEducateKptKonKtheKneedKforKanticoagulantKtherapyK-KANSWER---
,>B)KMonitorKforKinfectionKforK48-72KhoursKfollowingKprocedure
,RATIONALE:KCystoscopyKdoesKnotKrequireKadministrationKofKcontrastKdye
AKnurseKisKcaringKforKaKpost-
operativeKclientKwhoKunderwentKthoracicKsurgeryK7KhoursKprior,KandKnowKhasKinKplaceKaKches
tKtubeKforKdrainage.KWhatKfindingKwouldKrequireKtheKnurseKtoKcontactKtheKproviderKimmediat
ely?
A.)KChestKtubeK&KtubingKbecomeKdisconnectedKduringKptKtransfer
B) PtKcomplainsKofKleft-
sidedKchestKpainKofK7KonKpainKscaleKwhenKperformingKincentiveKspirometry
C) ChestKtubeKdrainageKmeasuresK80KmLs/hrKofKredKblood
D) DiminishedKbreathKsoundsKauscultatedKinKleftKlowerKlobeK-KANSWER--
>C)KChestKtubeKdrainageKmeasuresK80mL/hrKofKredKblood
RATIONALE:KIfKtheKtubingKseparatesKtheKRNKwillKaskKtheKptKtoKexhaleKasKmuchKairKasKtheyKc
anKtoKremoveKairKfromKtheKpleuralKspaceK&KtheKnurseKwouldKcleanseKtheKtipsK&KreconnectKthe
Ktubing
AKnurseKisKreinforcingKteachingKwithKaKclientKwhoKhasKbeenKrecentlyKdiagnosedKwithKosteopor
osis.KWhichKofKtheKfollowingKshouldKbeKincluded?
A.)KIncreaseKintakeKofKdietaryKcalcium
b. WalkingKforKoneKtoKtwoKhoursKdailyKisKrecommended.
c. EliminateKsafetyKhazardsKinKtheKhome
d. Long-termKestrogenKreplacementKtherapyKwillKbeKrequired.K-KANSWER--
>C.)KEliminateKsafetyKhazardsKinKtheKhome
RATIONALE:KIntakeKofKcalciumKaloneKisKnotKaKtreatmentKforKosteoporosis,KbutKcalciumKisKan
KimportantKpartKofKaKpreventionKprogramKtoKpromoteKboneKhealth.KMostKpeopleKdoKnotKgetKeno
ughKcalciumKinKtheirKdiet,KandKthereforeKcalciumKsupplementsKareKneeded.
AKnurseKisKevaluatingKplacementKofKaKnasogastricK(NG)Ktube.KWhichKofKtheKfollowingKisKtheKlea
stKreliableKmethodKtoKdetermineKcorrectKNGKtubeKplacement?
a. AspirateKtoKcollectKgastricKcontent.
b. TestKpHKofKgastricKcontents
c. AskKtheKclientKtoKtalk.
d. InjectKairKintoKtubeKandKlistenKoverKabdomen.K-KANSWER--
>D.)KInjectKairKintoKtubeKandKlistenKoverKabdomen
RATIONALE:KOtherKthanKX-
ray,KaspirationKofKgastricKcontentsKwithKpHKtestingKisKtheKmostKreliableKmethodKtoKdetermineKc
orrectKNGKtubeKplacement.KAKpHKofK4KorKlessKisKexpected.
AKnurseKisKcaringKforKaKclientKwithKheartKfailure.KWhichKofKtheKfollowingKinterventionsKshould
KtheKnurseKtakeKifKtheKclientKisKexperiencingKdyspnea?
a. PlaceKclientKinKhighKFowler'sKposition.
b. PlaceKclientKinKtheKreverseKtrendelenbergKposition
, c. PerformKcoughingKandKdeepKbreathingKexercisesKeveryK8Khours.
d. ObtainKserialKABGsKeveryK8Khours.K-KANSWER-->A)KPlaceKptKinKhighKfowler'sKposition
RATIONALE:KPlacingKtheKclientKinKreverseKtrendelenbergKwouldKnotKpromoteKlungKexpansionK
andKimproveKoxygenationKasKwellKasKhighKFowler'sKposition.
AKnurseKisKprovidingKeducationKtoKaKclientKwithKcoronaryKarteryKdisease.KWhichKofKtheKfollowi
ngKcholesterolKvaluesKshouldKtheKnurseKidentifyKasKaKgoalKforKthisKclient?
a. HDL-CKlevelK60Kmg/dL
b. HDL-CKlevelK20Kmg/dL
c. LDL-CKlevelK98Kmg/dL
d. LDL-CKlevelK120Kmg/dLK-KANSWER-->A)KHDL-CKlevelK60Kmg/dL
RATIONALE:KWhileKaKvalueKofK<130Kmg/dLKisKanKacceptedKnormalKvalue,KthisKclientKhasKcor
onaryKarteryKdiseaseKandKaKvalueKbelowK70Kmg/dLKisKdesirableKforKclientsKdiagnosedKwithKCV
DKorKwhoKareKdiabetic.
AKclientKisKrecoveringKfromKacuteKrespiratoryKdistressKsyndromeK(ARDS).KWhichKclinicalKmani
festationKrequiresKimmediateKattentionKbyKtheKnurse?
a. IncreaseKinKpulseKrate
b. AKdecreaseKinKtemperature
c. AKdecreaseKinKbloodKpressure
d. IncreasedKoxygenKsaturationK-KANSWER-->C)KAKdecreaseKinKBP
RATIONALE:AnKincreaseKinKaKclient'sKpulseKrateKisKaKfindingKthatKneedsKadditionalKdataKcoll
ectionKbecauseKitKmayKbeKindicativeKofKanKautonomicKresponseKtoKpain,Kanxiety,KandKother
AKnurseKisKcaringKforKaKclientKwithKaKnewKonsetKbowelKobstruction.KWhatKassessmentKfinding
KwouldKbeKanticipatedKwhenKcompletingKanKabdominalKassessment?
Ka.KHyperactiveKbowelKsounds.
b. HypoactiveKbowelKsounds.
c. NormalKbowelKsounds.
d. AbsentKbowelKsounds.K-KANSWER-->A)KHyperactiveKbowelKsounds
RATIONALE:KHypoactiveKbowelKsoundsKmayKbeKfoundKinKlaterKstagesKofKobstruction,KbutKhy
peractiveKbowelKsoundsKareKtypicalKinKearlyKstagesKofKobstruction.
AKclientKisKadmittedKtoKtheKhospitalKwithKaKdiagnosisKofKGrave'sKdisease.KWhichKofKtheKfollowi
ngKfindingsKshouldKbeKreportedKtoKtheKproviderKimmediately?
a. HyperactiveKdeepKtendonKreflexes
b. IncreaseKinKwhiteKbloodKcellKcountKfromK6,000Kmm3KtoK8,000Kmm3
c. IncreaseKinKtemperatureKfromK99.5KFKtoK100.5KF