PN2 EXAM 111 STUDY GUIDE

PN2 EXAM 111 1. The nurse has just received change of shift report for four clients. Based on this report, the nurse should assess which client first?  52 years old with pneumonia and chronic pain who is requestion medication for severe pain  84 years old with left sided weakness who is slightly confused and has been awake all night  The nurse has just received change-of-shift report on four clients. Based on the following, the nurse should assess which of the following clients first? a) 35-year-old admitted after a motor vehicle accident whose urine output has totaled 30 ml over the last 2 hours. b) 84-year-old with resolving left-side weakness who is slightly confused and has been awake most of the night. c) 52-year-old with pneumonia and chronic back pain who is requesting pain medication. d) 38-year-old who is 2 days post-mastectomy due to breast cancer, having difficulty coping with the diagnosis.  a) physiological needs come first, normal is 20 ml/hr (500 ml/a day) 2.The community nurse is talking with a group of individuals about colorectal cancer (CRC) risk factors. Which community participant is at the highest risk for development of CRC?  23-year-old vegetarian  B. 30-year-old with Crohn's disease  C. 39-year-old with no family history of cancer  D. 46-year-old with genetic predisposition to cancer 3.Which respiratory value does the nurse need to evaluate to determine whether the client is acidosis has respiratory origin or metabolic origin?  PaCO2  Potassium  Lactic acid  PH 4. 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 clients bowel sounds. ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds 5. when teaching a client with urinary tract infection …. Antibiotic the nurse should tell the client to report which symptoms to the health care provider (select all that apply) Cloudy urine during first few days of treatment New onset of blood in the urine Urinating every 3 hours Mild nausea Rash Fever above 100F 6. The new nurse is working with preceptor on an inpatient medical -surgical unit the preceptor advice the student that which is the priority when working as professional nurse? Ensuring the client safety 7. The nurse is teaching a client who has fluid overload about recognizing symptoms associated with his condition. which of the following client statement indicated the teaching has been understood? (Select all that apply) If my resting heat rate is elevated, that means the condition is worsening If I gained one pound in a week, I need to call my doctor Increased blood pressure may indicate a worsening problem If my leg had edema, this could mean I am retaining fluid c If my respiration falls below18 per minute, I need to call my doctor 8. Immediately after having surgery to create an ostomy. Which goal has the highest priority? Provide relief from constipation Assisting the client with self-care activities Maintaining fluid & electrolyte balance Minimizing odor formation 9. A client has the following arterial blood gas (ABG) results; PH:7.30, HCO3:17, PaCo2: 25mmHg, P02: 98mmHg. Which intervention by the nurse is most appropriate? Assess the client and notify the physician using SBAR communication These are normal findings; document and continue to assess Place the client on 2L oxygen via nasal cannula Prepare to administer the ordered albuterol nebulizer treatment