EXAM RESTORATION QUESTIONS WITH
COMPLETE SOLUTION
m A patient with bacterial pneumonia has coarse lung crackles and thick sputum. Which action should
the nurse plan to promote airway clearance - - Assist the patient to splint the chest when coughing
A client has the risk of impaired skin integrity due to fluid volume deficit. What objective data would the
nurse evaluate that demonstrate an improvement in fluid volume status? Select all that apply. - -
Decrease in blood urea nitrogen (BUN) from 24 to18 mg/dl
The nurse is evaluating the client's outcome. The client's current nursing diagnosis fluid volume deficit
related to (HHS) Hyperosmolar Hyperglycemic syndrome. The nurse understands that the client has a
positive outcome when which laboratory value has returned to a normal range? - Serum osmolarity
Because the nurse is unsure about an end-stage COPD patient's wishes concerning intubation and
mechanical ventilation in an emergency situation, the nurse should take what action? - Clarify what the
patient's wishes are
Upon assessment of a client with heart failure, the nurse notes that the client is dyspneic. Which actions
should the nurse take initially? Select all that apply. -
Which assessment of a client that has just returned from having a modified neck dissection with skin flap
would require a nurse to take immediate action? Select one: - - The skin flap appears white
The nurse finds a client of a long term care facility, after the evening meal, to be unresponsive with cold,
clammy skin to touch. A finger stick reveals 21 mg/dL. What are the nurse's immediate priority actions?
Select all that apply? - Notify the health care provider of the hypoglycemic event, Administer as needed
glucagon 1 mg intramuscularly now
Which nursing action for a patient with COPD could the nurse delegate to an experienced unlicensed
assistive personnel (UP)? - - Measure oxygen saturation using pulse oximetry
The physician orders PH insulin 35 units and regular insulin 4 units to both be given now. What should
the nurse do? - - Mix both medications in the same syringe, drawing up regular insulin first and then NPH
insulin.
A nurse is caring for a postoperative patient who just had major abdominal surgery. The patient has
shallow respirations and is very reluctant to cough or be assisted out of bed to a chair. The nurse should
address the patient's increased risk for what post-operative complication? - Partial collapse of small
airways
Which of the following statements regarding auscultation of the chest is incorrect? - - Decreased breath
sounds in the pneumothorax rarely occur
, A client has been newly diagnosed with peripheral vascular disease (PVD) and has a history of congestive
heart failure. The client asks the nurse why they are having increased fatigue with their daily activities of
living and exercise. The nurse contributes this to? - - A decrease in blood flow
A patient who has gastric bypass surgery 5 weeks ago calls the office to report feelings of nausea,
sweating, and diarrhea shortly after eating meals. What response by the nurse is most appropriate? - -
"avoid large meals, limit sweets, and drink small amounts of liquids between meals."
The nurse is caring for a patient with uncomplicated rib fractures. Which nursing diagnosis should
receive priority? - - High risk for ineffective breathing pattern related to pain
A client comes to the clinic with small circular deep ulcers on the tips of the toes. Which of the following
assessment findings would the nurse also expect to find with this type of ulcer. - - Feet that are cool to
the touch
A diabetic educator is discussing "sick day rules" with a newly diagnosed type one diabetic. The educator
is aware that the patient will require further teaching when the patient states what. - - I will not take my
insulin on the days when I am sick, but I will check my blood sugar every 2 hours
A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of
benefit to the client? - - One low in protein
The nurse confirms the placement of a client's nasogastric (NG) tube using pH paper for the stomach
contents. The nurse determines the NG remains in place when the pH of the aspirate is? - Acidic
The nurse is caring for a client with a central venous catheter being used for intermittent medication
administration. When flushing the catheter prior to administering the next dose of medication, which
initial action by the nurse is most appropriate? - - Flush the injection port with a 3ml syringe full of
normal saline
A nasogastric tube has been place in a patient and is on low intermittent suction. Upon review of the
morning's blood work, the nurse observes that the client's potassium level is below reference range. The
nurse should recognize that the client may be at risk for what imbalance? - Metabolic alkalosis
A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect
related specifically to the site of irradiation does the nurse tell the client to expect? - Dysphagia
A nurse is caring for a client admitted with fluid volume access (FVE). What nursing assessment would
indicate to the nurse that the IV furosemide (Lasix)is effective in this patient plan of care. - Patient saw a
weight loss of 3 pounds after 2 days
A 1 year old is brought to the emergency department with symptoms of hyperglycemia and is diagnosed
with diabetes. Based on the fact that the child's pancreatic beta cells are being destroyed, the patient
will be diagnosed with what type of diabetes. - Type 1 diabetes
Which finding would indicate bowel functioning is returning after anesthesia and surgery? - Auscultation
indicates bowel sounds in all four quadrants
COMPLETE SOLUTION
m A patient with bacterial pneumonia has coarse lung crackles and thick sputum. Which action should
the nurse plan to promote airway clearance - - Assist the patient to splint the chest when coughing
A client has the risk of impaired skin integrity due to fluid volume deficit. What objective data would the
nurse evaluate that demonstrate an improvement in fluid volume status? Select all that apply. - -
Decrease in blood urea nitrogen (BUN) from 24 to18 mg/dl
The nurse is evaluating the client's outcome. The client's current nursing diagnosis fluid volume deficit
related to (HHS) Hyperosmolar Hyperglycemic syndrome. The nurse understands that the client has a
positive outcome when which laboratory value has returned to a normal range? - Serum osmolarity
Because the nurse is unsure about an end-stage COPD patient's wishes concerning intubation and
mechanical ventilation in an emergency situation, the nurse should take what action? - Clarify what the
patient's wishes are
Upon assessment of a client with heart failure, the nurse notes that the client is dyspneic. Which actions
should the nurse take initially? Select all that apply. -
Which assessment of a client that has just returned from having a modified neck dissection with skin flap
would require a nurse to take immediate action? Select one: - - The skin flap appears white
The nurse finds a client of a long term care facility, after the evening meal, to be unresponsive with cold,
clammy skin to touch. A finger stick reveals 21 mg/dL. What are the nurse's immediate priority actions?
Select all that apply? - Notify the health care provider of the hypoglycemic event, Administer as needed
glucagon 1 mg intramuscularly now
Which nursing action for a patient with COPD could the nurse delegate to an experienced unlicensed
assistive personnel (UP)? - - Measure oxygen saturation using pulse oximetry
The physician orders PH insulin 35 units and regular insulin 4 units to both be given now. What should
the nurse do? - - Mix both medications in the same syringe, drawing up regular insulin first and then NPH
insulin.
A nurse is caring for a postoperative patient who just had major abdominal surgery. The patient has
shallow respirations and is very reluctant to cough or be assisted out of bed to a chair. The nurse should
address the patient's increased risk for what post-operative complication? - Partial collapse of small
airways
Which of the following statements regarding auscultation of the chest is incorrect? - - Decreased breath
sounds in the pneumothorax rarely occur
, A client has been newly diagnosed with peripheral vascular disease (PVD) and has a history of congestive
heart failure. The client asks the nurse why they are having increased fatigue with their daily activities of
living and exercise. The nurse contributes this to? - - A decrease in blood flow
A patient who has gastric bypass surgery 5 weeks ago calls the office to report feelings of nausea,
sweating, and diarrhea shortly after eating meals. What response by the nurse is most appropriate? - -
"avoid large meals, limit sweets, and drink small amounts of liquids between meals."
The nurse is caring for a patient with uncomplicated rib fractures. Which nursing diagnosis should
receive priority? - - High risk for ineffective breathing pattern related to pain
A client comes to the clinic with small circular deep ulcers on the tips of the toes. Which of the following
assessment findings would the nurse also expect to find with this type of ulcer. - - Feet that are cool to
the touch
A diabetic educator is discussing "sick day rules" with a newly diagnosed type one diabetic. The educator
is aware that the patient will require further teaching when the patient states what. - - I will not take my
insulin on the days when I am sick, but I will check my blood sugar every 2 hours
A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of
benefit to the client? - - One low in protein
The nurse confirms the placement of a client's nasogastric (NG) tube using pH paper for the stomach
contents. The nurse determines the NG remains in place when the pH of the aspirate is? - Acidic
The nurse is caring for a client with a central venous catheter being used for intermittent medication
administration. When flushing the catheter prior to administering the next dose of medication, which
initial action by the nurse is most appropriate? - - Flush the injection port with a 3ml syringe full of
normal saline
A nasogastric tube has been place in a patient and is on low intermittent suction. Upon review of the
morning's blood work, the nurse observes that the client's potassium level is below reference range. The
nurse should recognize that the client may be at risk for what imbalance? - Metabolic alkalosis
A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect
related specifically to the site of irradiation does the nurse tell the client to expect? - Dysphagia
A nurse is caring for a client admitted with fluid volume access (FVE). What nursing assessment would
indicate to the nurse that the IV furosemide (Lasix)is effective in this patient plan of care. - Patient saw a
weight loss of 3 pounds after 2 days
A 1 year old is brought to the emergency department with symptoms of hyperglycemia and is diagnosed
with diabetes. Based on the fact that the child's pancreatic beta cells are being destroyed, the patient
will be diagnosed with what type of diabetes. - Type 1 diabetes
Which finding would indicate bowel functioning is returning after anesthesia and surgery? - Auscultation
indicates bowel sounds in all four quadrants
