NSG 4800 EXAM STUDY GUIDE
The nurse is monitoring a client in the immediate postpartum period for signs of
hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
A .temperature of 100.4°F (38°C)
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute - Answer B, During
the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be
checked every 15 minutes during the first hour. An increasing pulse is an early sign of
excessive blood loss because the heart pumps faster to compensate for reduced blood
volume. A slight increase in temperature is normal. The blood pressure decreases as
the blood volume diminishes, but a decreased blood pressure would not be the earliest
sign of hemorrhage. The respiratory rate is slightly increased from normal.
The nurse in the ambulatory care unit is providing home care instructions to a client
after cryotherapy for the treatment of malignant skin lesions. Which statement would be
most appropriate for the nurse to include in the home care instructions for this client?
"Apply ice to the site to prevent swelling."
"Clean the site with alcohol 3 times daily."
"Apply a warm, damp washcloth if discomfort occurs."
"Avoid showering or taking baths until seen by the health care provider in 1 week." -
Answer 3, Cryotherapy involves the local application of liquid nitrogen to the lesion; this
causes cell death and tissue destruction. Tissue freezing is followed in 1 to 2 days by
hemorrhagic blister formation; therefore, ice is not applied to the site. The application of
a warm, damp washcloth intermittently to the site will provide relief of any discomfort.
The nurse instructs the client to clean the site with the prescribed solution to prevent
secondary infection. A topical antibiotic also may be prescribed. Alcohol would cause
irritation to the skin. There is no reason for the client to avoid showering or bathing.
The registered nurse is caring for the following clients. It would be a priority for the
nurse to initiate a multidisciplinary conference for the client who is
A.12 years old with Autism who is starting a new school and recently had a URI (upper
respiratory tract infection)
B.39 years old, has type 2 Diabetes Mellitus, is homeless and had a recent Hemoglobin
A1c of 13%
C.52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine)
,and is employed as a mail carrier
D.79 years old, has bipolar and schizophrenia, lives alone and reports hearing non
threatening voices. - Answer B
A client with uncontrolled Diabetes Mellitus would require the greatest number of
disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work,
Nutritionist; the other choices do not require as many providers of care to meet their
needs.
A client is scheduled to begin therapy with carbamazepine. The nurse should assess the
results of which test(s) before administering the first dose of this medication to the
client?
Liver function tests
Renal function tests
Pancreatic enzyme studies
Complete blood cell count - Answer D. Carbamazepine may be used to treat a seizure
disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal
aplastic anemia. To reduce the risk of serious hematological effects, a complete blood
cell count should be done before treatment and periodically thereafter. This medication
should be avoided in clients with preexisting hematological abnormalities. The client
also is told to report the occurrence of fever, sore throat, pallor, weakness, infection,
easy bruising, and petechiae. The results of the remaining tests listed in the options are
not associated with the use of this medication.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The
initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV)
infusion of short-acting insulin is initiated, along with IV rehydration with normal saline.
The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would
next prepare to administer which medication?
An ampule of 50% dextrose
NPH insulin subcutaneously
IV fluids containing dextrose
Phenytoin for the prevention of seizures - Answer C. Emergency management of DKA
focuses on correcting fluid and electrolyte imbalances and normalizing the serum
glucose level. If the corrections occur too quickly, serious consequences, including
hypoglycemia and cerebral edema, can occur. During management of DKA, when the
blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is
reduced and a dextrose solution is added to maintain a blood glucose level of about 250
mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is
used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a
, usual treatment measure for DKA.
A client is being discharged from the emergency department after an evaluation for a
concussion. The nurse reinforces teaching regarding follow-up should the client
develop complications. Which of the following complications, if listed by the client,
would require further instruction?
1.Vomiting
2.Minor headache
3.Difficulty speaking
4.Difficulty awakening - Answer 2; all others responses would indicate IICP and needs to
go to the ER
The patient sustained an open fracture of the femur from an automobile accident. The
nurse should assess the client for which type of shock?
A. cardiogenic
B. hypovolemic
C. neurogenic
D. anaphylactic - Answer B. A fractured femur, especially an open fracture, can cause
much soft tissue damage and lead to significant blood loss. Hypovolemic shock can
develop. Cardiogenic shock occurs when cardiac output is decreased as a result of
ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic
nervous system function. Anaphylactic shock is the result of an allergic reaction.
The registered nurse has received a report on four clients. The nurse should first assess
the client who has:
A.Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 89%
B.Parkinson's Disease and is demanding to leave the hospital against medical advice
(AMA)
C.been admitted with suspected Guillian Barre Syndrome and has begun
plasmapheresis therapy
D.Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) - Answer
C.
The client admitted with Guillain-Barre' Syndrome should be assessed first because of
the possibility of rapid progression of this illness and neuromuscular respiratory failure;
clients with COPD are likely to have pulse oximetry readings of 90% related to chronic
hypoxia; this client along with the other two choices are important, but not the priority.
The nurse is monitoring a client in the immediate postpartum period for signs of
hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
A .temperature of 100.4°F (38°C)
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute - Answer B, During
the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be
checked every 15 minutes during the first hour. An increasing pulse is an early sign of
excessive blood loss because the heart pumps faster to compensate for reduced blood
volume. A slight increase in temperature is normal. The blood pressure decreases as
the blood volume diminishes, but a decreased blood pressure would not be the earliest
sign of hemorrhage. The respiratory rate is slightly increased from normal.
The nurse in the ambulatory care unit is providing home care instructions to a client
after cryotherapy for the treatment of malignant skin lesions. Which statement would be
most appropriate for the nurse to include in the home care instructions for this client?
"Apply ice to the site to prevent swelling."
"Clean the site with alcohol 3 times daily."
"Apply a warm, damp washcloth if discomfort occurs."
"Avoid showering or taking baths until seen by the health care provider in 1 week." -
Answer 3, Cryotherapy involves the local application of liquid nitrogen to the lesion; this
causes cell death and tissue destruction. Tissue freezing is followed in 1 to 2 days by
hemorrhagic blister formation; therefore, ice is not applied to the site. The application of
a warm, damp washcloth intermittently to the site will provide relief of any discomfort.
The nurse instructs the client to clean the site with the prescribed solution to prevent
secondary infection. A topical antibiotic also may be prescribed. Alcohol would cause
irritation to the skin. There is no reason for the client to avoid showering or bathing.
The registered nurse is caring for the following clients. It would be a priority for the
nurse to initiate a multidisciplinary conference for the client who is
A.12 years old with Autism who is starting a new school and recently had a URI (upper
respiratory tract infection)
B.39 years old, has type 2 Diabetes Mellitus, is homeless and had a recent Hemoglobin
A1c of 13%
C.52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine)
,and is employed as a mail carrier
D.79 years old, has bipolar and schizophrenia, lives alone and reports hearing non
threatening voices. - Answer B
A client with uncontrolled Diabetes Mellitus would require the greatest number of
disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work,
Nutritionist; the other choices do not require as many providers of care to meet their
needs.
A client is scheduled to begin therapy with carbamazepine. The nurse should assess the
results of which test(s) before administering the first dose of this medication to the
client?
Liver function tests
Renal function tests
Pancreatic enzyme studies
Complete blood cell count - Answer D. Carbamazepine may be used to treat a seizure
disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal
aplastic anemia. To reduce the risk of serious hematological effects, a complete blood
cell count should be done before treatment and periodically thereafter. This medication
should be avoided in clients with preexisting hematological abnormalities. The client
also is told to report the occurrence of fever, sore throat, pallor, weakness, infection,
easy bruising, and petechiae. The results of the remaining tests listed in the options are
not associated with the use of this medication.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The
initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV)
infusion of short-acting insulin is initiated, along with IV rehydration with normal saline.
The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would
next prepare to administer which medication?
An ampule of 50% dextrose
NPH insulin subcutaneously
IV fluids containing dextrose
Phenytoin for the prevention of seizures - Answer C. Emergency management of DKA
focuses on correcting fluid and electrolyte imbalances and normalizing the serum
glucose level. If the corrections occur too quickly, serious consequences, including
hypoglycemia and cerebral edema, can occur. During management of DKA, when the
blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is
reduced and a dextrose solution is added to maintain a blood glucose level of about 250
mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is
used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a
, usual treatment measure for DKA.
A client is being discharged from the emergency department after an evaluation for a
concussion. The nurse reinforces teaching regarding follow-up should the client
develop complications. Which of the following complications, if listed by the client,
would require further instruction?
1.Vomiting
2.Minor headache
3.Difficulty speaking
4.Difficulty awakening - Answer 2; all others responses would indicate IICP and needs to
go to the ER
The patient sustained an open fracture of the femur from an automobile accident. The
nurse should assess the client for which type of shock?
A. cardiogenic
B. hypovolemic
C. neurogenic
D. anaphylactic - Answer B. A fractured femur, especially an open fracture, can cause
much soft tissue damage and lead to significant blood loss. Hypovolemic shock can
develop. Cardiogenic shock occurs when cardiac output is decreased as a result of
ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic
nervous system function. Anaphylactic shock is the result of an allergic reaction.
The registered nurse has received a report on four clients. The nurse should first assess
the client who has:
A.Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 89%
B.Parkinson's Disease and is demanding to leave the hospital against medical advice
(AMA)
C.been admitted with suspected Guillian Barre Syndrome and has begun
plasmapheresis therapy
D.Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) - Answer
C.
The client admitted with Guillain-Barre' Syndrome should be assessed first because of
the possibility of rapid progression of this illness and neuromuscular respiratory failure;
clients with COPD are likely to have pulse oximetry readings of 90% related to chronic
hypoxia; this client along with the other two choices are important, but not the priority.
