1. The client with atrial fibrillation suddenly develops dyspnea, chest pain, hemoptysis, and a f

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 1. The client with atrial fibrillation suddenly develops dyspnea, chest pain, hemoptysis, and a feeling of impending doom. The nurse recognizes these symptoms as which complication

b.       Increased cardiac output

c.       Embolic stroke

d.       Absence of atrial kick

a.     Pulmonary embolism

2.       A nurse is caring for a client diagnosed with an ST- elevation myocardial (STEMI). The nurse anticipates which of the following interventions would nurse give first?

a.       Morphine,

b.       Nitrates

c       Aspirin

d.    oxygen

3.       A nurse is assessing the arteriovenous (AV) fistula of end in end-stage failure. The nurse documents the following ” bruit auscultated and thrill palpated at left arm AV fistula” the nurse next step is to complete which of the following

a.       Wait 30 mins, then assess the AV fistula for any changes

b.       Contact the nephrologist and notify them the fistula is not working

c.       Document the AV fistula is patent

d.       Appy cool compress to the AV fv Fistula

4.       The nurse is caring for the client who was recently extubated. What is an expected assessment finding for this client?

a.       Stridor

c.       Restlessness

d.       Dyspnea

d.    Hoarseness

5.       A 40 – year old obese client arrieved with complaints of right upper quadrant pain radiating to the right scapula. The nurse expects which of the following conditions.

                                      a. pancreatitis

b.       Cholelithiasis

c.       Appendicitis

d.       Gastritis

6.       A nurse teaches a client with septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

a.       An elevated platelet count characterizes DIC

b. DIC is caused by abnormal coagulation involving fibrinogen

c.       Dic is a genetic disorder involving a vitamin k deficiency

d.       Dic is controllable with lifelong heparin usage

7.       A nurse cares for a client who is recovering from hypophysectomy. What action would the nurse take first?

a.     Access for clear or light-yellow drainage from the nose

b.       Keep the head of the flat and the client supine

c.       Instruct the client to cough, turn and deep breathe

d.       Apply petroleum jelly to lips avoid dryness

8.       An elderly client arrives in the emergency department after a fall resulting in a hip fracture. She reports that the fall occurred yesterday, and she was unable to get up. Her son found her this AM. Based on this scenario, the nurse anticipates acute kidney injury resulting from which of the following causes?

a.       Intrarenal

b.       Postrenal

c.       Prerenal

d.     Oliguria

9.       A nurse is developing a teaching plan for client who just been diagnosed with breast cancer, which medication is used for hormone receptor-positive breast cancer

a.       Progesterone

b. Tamoxifen

c.       Acetaminophen

d.       Dopamine

10.   A nurse gave medications to a client with hepatic encephalopathy for elevated amnonia levels. A family member asks what medication was given. The nurse correctly responds with which answer

a.       Im giving this medication to increase clotting. This will help prevent excess bleeding

b.       This medication decreases ammonia but may also cause diarrhea

c.       This medication will increase intracranial pressure by decreasing ammonia

d. This medication will decrease the blood ammonia levels by excretion through the GI tract. 

11.   A nurse supervises the application of electrocardiographic monitoring perform by unclicensed assistive personnel. Which statement would the nurse provide to the UAP related to this procedure

a.       Turn off the wall oxygen before monitoring the client

b.       Place the electrodes on the posterior chest

c. Clean the skin and clip hair before applying the electrodes

d.       Add get to the electrodes before applying them

12.   The client has had a transient ischemic attack. What does the nurse expect

a.       This TIA is not a warning sign for stroke

b.       The client will have a permanent disability

c.       The TIA symptoms will resolve in one week

d. The TIA symptoms will resolve within 24 hours 

13.   An emergency department nurse triages a client with diabtes mellitus who has fractured her wrist, which action would the nurse take first?

a.       Place the client in a supine position with warm blanket

b.       Cover any open areas with a sterile dressing

c. Immobilize the arm by splinting the fracture site

d.       Remove the medical alert bracelet from the fractured arm

14.   The nurse is caring for a client with a pelvic fracture, which is the nurse priority action to prevent complications

a.       Turn the client every 2 hours

b. Monitor blood pressure frequently

c.       Monitor temperature daily

d.       Insert a urethral catheter

15.   A client with septic shock is breathing at a rate of 32 breaths per minute with accessory muscle use. Which of the following is the nurse’s priority?

a.       Determine the cause of sepsis

b. Assess and provide interventions to maintain the client’s airways

c.       Start an IV and give vancomycin after obtaining blood cultures.

d.       Assess capillary refill

16.   What is the rationale for chemotherapy as cancer treatment?

a.       Concentrates in secondary lymphoid tissues and prevents widespread metastasis

b. To disrupt one or more steps necessary for cancer development

c.       Decreases the client risk for life- threatening

d.       Less expensive and safer than radiation

17.   A client is being treated for a hemorrhagic stroke. Which of the following is the client at risk for 72 hours after the onset of the hemorrhagic stroke?

a. Increased intracranial pressure due to edema

b.       Rebound transient ischemic attack (TIA)

c.       Stress ulcers

d.       A hypoglycemic event

18.   The emergency department nurse instructs a student to assess a client with a mild traumatic brain injury for signs and symptoms consistent with this injury. What clinical manifestation does the student recognize as consistent with a TBI

a.       Elevated temp

b. Reports feeling froggy when recalling the injury

c.       Unconscious for 1 hour after injury

d. Sensitivity to light and sound

e.       Widened pulse pressure

19.   The nurse assesses the client with clinical manifestation of increased intracranial pressure. Which of the following nursing intervention is appropriate to decrease intracranial pressure?

a.       Elevate the head of the bed 90 degrees

b.       Place the client in reverse Trendelenburg

c. Elevate the head of the bed 30 degrees

d.        Place the client in a supine position

20.   A nurse cares for a client that was prescribed lactulose. The client states I do not want to take this medication because it causes diarrhea. How would the nurse respond

a.       You may take an antidiarrheal medication for loose stools

b. Diarrhea is expected; that’s how your body gets rid of ammonia

c.       Do not take any more of the medication until your stools firm up

d.       We will need to send a stool specimen to the laboratory

21.   When educating clients on liver disease, the nurse correctly identifies the most common causes of cirrhosis in the united states as being which of the following

a.       Nonalcoholic steatohepatitis

b. Chronic alcoholism

c. Bacteria hepatitis 

d. High protein diets

22.   A client has 50% burns following a car fire. In the initial resuscitation phase of care, which of the following are considered essential?

a. Pain management 

b.       Fluid resuscitation

c. Prevention of contractures 

d. airway management

e.       Educating the client on skincare

23.   A nursing student learns about modifiable risk factors for coronary artery disease. Which of the following are modifiable risk factors?

a. Hypertension

b. Smoking

c.       Age

d. stress

e. Obesity

24.   A nurse plans care for a client with acute pancreatitis. Which priority intervention will the nurse include in this clients plan of care?

a.       Place the client in semi-fowler position with the head of the bed elevated

b. Maintain nothing by mouth NPO status and administer intravenous

c.       Provide small, frequent feedings with no concentrated sweets

d.       Administer morphine sulfate intravenously every 4 hours

25.   A client has a brain tumor and is receiving fosphenytonin. The spouse questions the drug use saying that the client does not have a seizure disorder. Which of the following is the best response by the nurse?

a.       Seizures frequently occur in clients with brain tumors

b. increased pressure from the brain tumor can cause seizures

c.       Preventing febrile seizures with a brain tumor is important

d.       This drug used to sedate the client with a brain tumor

26.   Which client scenario describes the best example of professional collaboration?

a.       The nurse, physician, and physical therapist have all visited separately with the client

b.       The nurse, physical therapist, and physician have all developed separate care plans for the client

c.       The nurse mentions to the physical therapist that the client may benefit from a muscle-strengthening evaluation

d. The nurse and physician discuss the clients muscle weakness and initiate a referral for physical therapy. 

27.   A hospice nurse is caring for a dying client and her family members. Which intervention does the nurse implement?

                                       a. Teach family members about physical signs of impeding death

b. Encourage the management of adverse symptoms 

c. Encourage reminiscence by both client and family members

d.       Avoid spirituality because the clients and the nurses’ beliefs may not be congruent

e.       Request that the family limits visits with the client

28.   A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer?

a.       Digoxin

b.       Metoprolol

c.       Lidocaine

d.    Atropine

29.   Which of the following should be implemented to ensure the safe use of a defrillator?

a. The person pressing the shock button should state I am clear your clear were all clear

b.       Apply transdermal medication to the chest before using the paddles on top of the patch

c. Continue manual chest compressions after shock delivered

d.       Place pads on top of the implanted pacemaker

e. Do not place over metal monitoring electrodes

30.   The nurse is concerned that a client may develop neurogenic shock when which of the following is assessed?

a.       Jugular vein distention caused by an elevated mean arterial pressure

b.       Sluggish bowel sounds

c.       Fractured left lower extremity

d. Decreased sympathetic nerve impulses causing a low mean arterial pressure. 

31.   The intensive care unit nurse is caring for a client on a ventilator. The client develops a mucus plug and requires suctioning. Which of the following ventilator alarms will sound?

a.  High-pressure

b.       Apnea alarm

c.       Ventilator inoperative alarm

d.       Low-pressure alarm

32.   A client diagnosed with cholecystitis asks the nurse why this happened. The nurse correctly identifies which of the following risk factors?

a.       A client on a vegetarian diet

b.       A client with low body weight

c.       A client on testosterone supplements

d. An obese fertile client over 40 years old. 

33.   The nurse is concerned that a client is demonstrating signs of compartment syndrome. Which of the following is considered a classic sign of this disorder?

a. Paresthesia

b. Pressure

c.       Pink

d. Pain

e. Pallor

f. Paraplegia

34.   A nurse assesses an older adult client admitted three days ago with a fractured left hip. The nurse notes that the client is confused and restless. The clients vital signs are 98 beats/min, respiratory rate 36 breaths/min, blood pressure 142/78, and 02 86%. Which action would the nurse take first?

a.       Assess responses to pain medication

b.       Increase the intravenous flow rate per protocol

c. Assess the airway, administer oxygen via nasal cannula

d.       Resposition to a semi fowlers position

35.   A client with an acute myocardial infraction is recivinf tissue plasminogen activator. Which of the following is a priority nursing intervention.

a. Monitor for signs of bleeding

b.       Monitor psychosocial status

c.       Have heparin sodium available

d.       Monitor for renal function

36.   A client in the cardiac step-down unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action id the nurse’s priority?

a.       Call for an electrocardiogram

b. Assess and maintain airway patency

c.       Notify the provider

d.       Administer four chewable 81 acetysakucykic acid

37.   A nurse cares for a client who is recovering from laparoscopiv cholecystectomy surgery. The client reports oain in the shoulder blades. How would the nurse respond?

a.       You should cough and deep breathe every hour.

b.       Drinking a warm beverage can relieve this referred pain

c.       I will apply a cold compress to the painful area on your back

d. Ambulating in the hallway twice a day will help

38.   A nurse assesses a client with atrial fibrillation. Which manifestations would alter the nurse to the possibility of a severe complication from this condition?

a.       Sinus tachycardia

b.       Speech alterations

c.       Fatigue

d. Dyspnea with activity

39.   The nurse is notified that that the clients monitor is showing artifact. What does the nurse do next?

a Check the status of the client

b.       Monitor and document the artifact

c.       Troubleshoot the equipment

d.       Notify the physician for orders

40.   A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client would the nurse assess first?

a.       A client who had a transcient ischemic attack and is waiting for reaching on clopidogrel

b.       A client who is waiting for subarachnoid bolt insertion with consent form already signed

c.       A client who has been diagnosed with meningitis with a fever of 101

d. Client receiving tissue plasminogen activator who has a change in respiratory pattern and rate.

41.   A client is in the hospital after suffering a myocardial infraction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client 02 sat to be 95 on room air, pulse 88 beats/min, and respiratory rate of 16 after returning to bed, what action by the nurse is best?

a.       Suggest the client uses a bedpan

b. Allow continued bathroom privileges

c.       Administer oxygen a 2 l/min

d.       Obtain a bedside commode

42.   The nurse in the emergency department is using a triage system because this system ranks clients by

a.       Age

b. The severity of illness or injuiry

c.       Name

d.       Body system involved

43.   The nurse is assessing a client for the adequacy of ventilation. What assessnebt finsings would indicate the client has good ventilation

a.       The right side of the thorax expands slightly more than the left

b. Nail beds are pink with good capillary refill

c.       Respiratory rate is 24 breaths

d. There are quiet and effortless breath sounds at the lung base bilaterally.

e.       The trachea is just to the left of the sternal notch

f. The oxygen Sat level is 98%

44.   Which client is at risk for developing secondary adrenal insufficiency?

a. Client with an adrenal tumor causing excessive secretion of ACTH

b.       Client who tapers the dosages of steroid therapy

c.       Client deficient in ADH

d.       Client who suddenly stops taking high-dose steroid therapy

45.   A nurse cares for a client with 45% total nburns. The client weighs 65 kg. using the parkland formula of 4ml. the nurse should calculate and set the IV pump to deliver how many ml/hr in the first 8 hours

a.       731

46.   A nurse assessed a client who substained a basal skull fracture and notes a thin stream of clear drainage coming from the clients right nostril. Which of the following actions should the nurse take first?

a.       Palpate the clients head for the presence of fractures

b. Assess the drainage and test the drainage to rule out cerebral spinal fluid.

c.       Assess for drainage from the eyes and ears

d.       Ask the client to keep their head elevated

47.   The nurse is preparing to administer IV heparin to the client. The health care provider orders to deliver an IV Heparin infusion at 1500 units/hr. the available medication is heparin 25,000 units in 250ml of normal saline solution.

a.       15

48.   A nurse is monitoring a client who has acute kidney injury, which of the following lab finds should the nurse expect?

a. Elevated blood urea nitrogen and creatinine

b.       Metabolic alkalosis

c.       Hypercalcemia

d.       Hypokalemia

49.   A client that was diagnosed with stage III breast cancer seems to be overly anxious. What is the nurses best action?

a. Validate the client’s feelings and explore the idea of a referral to a breast cancer support group

b.       Encourage the client to search the internet for information tonight

c.       Evaluate if there has been any mental illness in her past

d.       Ask the client if sexuality has been a problem with her partner

50.   The nurse is caring for a client with aphasia. The nurse knows this means the client has which of the following

a.       Weakness in the extremeites

b. Inability to speak, comprehend and write language

c.       Disorientation to time, place and person

d.       Difficulty swallowing thin liquids

51.   What blood test is the most accurate in verifying a diagnosis of acute pancreatitis

a.       Alkaline phosphatse

b.       Tyrosine

c.       Alanine aminotransferase

d. Amylase and lipase

52.   A nurse is participating in primary prevention efforts directed against cancer. In which activites is this nurse nist likely to engage.

                                      a. Providing vaccinations against certain cancers

                                     b. Demonstrate breast self -examination methods to women

                                      c. Teaching teams the danger of tanning booths

d.       Instructing people on the use of chemoprevention

e. Screening teenage girls for cervical cancer

53.   A client in the intensive unit is scheduled for a lumbar puncture today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. Which og the following nursing action is best?

a.       Give the prescribed pre-procedure sedation

b.       Document these findings on the clients record

c. Call a rapid response

d.       Ensure that informed consent is on the chart

54.   A client is in the oncology clinic for a first visist since being diagnosed with cancer. The nurse reads the clients chart that the cancer classification is TISN0M0. What does the nurse conclude about this clients cancer?

a.       The primary site of cancer determines distant metastases

b. The tumor is in-situ with no distened metastases

c.       There are multiple lymph nodes involved already

d.       Regional lymph nodes could not be assessed

55.   When diagnosed with crushing syndrome. The manifestations are most likely related to an excess production of which hormone

a.       Insulin

b.       Prolactin

c.       Antidiuretic hormone

d. Cortisol

56.   A client is diagnosed with cardiogenic shock. The nurse should plan immediate interventions to address which of the following potential complications of this disorder?

a. Myocardial infarction 

b.       Pulmonary embolism

c.       Deep vein thrombosis

d.       Chronic renal failure

57.   A client in the emergency department is experiencing a hemorrhagic stroke. The nurse anticipates which of the following symptoms may have been present at the onset

a. Sudden, severe headache

b. Vomiting

c.       Limited mobility worse in the morning

d.       Increased appetite

e. Change in mental status

58.   A nurse is caring for a client prescribed tissue plasminogen activator for a stroke.. which of the following actions by the nurse are most appropriate?

a.       Delegate the hourly vital signs to the nursing assistant

b. Double-check the dose and pump rate with another nurse

c Administer heparin subcutaneously, every shift to prevent thromboembolism

d. Keep the client NPO until swallowing can be assessed 

e. Perform neurological assessment every 10-15 mins after starting the infusion

59.   The nurse is caring for a client on the medical surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below

a. Initiate chest compressions

b.       Start an 18-guage intravenous line

c.       Ask the family about code status

d.       Perform an unsynchronized defibrillation

60.   A client presents complaining of abdominal pain and bloody stools. His skin is ashen, conjunctiva pale, delayed capillary refill. Pulse is weak and thready. The nurse correctly categorized this client as

a. Emergent (Red)

b.       Non-urgent (green

c.       Terminal (black)

d.       Urgent (yellow)

61.   The nurse, planning care for a mechanically ventilated client, would plan to administer pantoprazole. The nurse understands this medication is to prevent the onset of which of the following complications?

a.       Hyperglycemia

b.       Hypertension

c. Stress ulcers

d.       Thrombophlebitis

62.   An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations would alert the nurse to internal bleeding and hypovolemic shock?

a. Change in level of consciousness

b. Right upper quadrant exxhymosis

c. Tachycardia and hypotension

d.       Flushed warm skin

e. Shallow respirations

63.   A client complains of having an irregular heartbeat in his chest, the nurse applies the cardiac monitor and correctly identifies the following rhythm as which of the following

a   Atrial fibrillation

b.       Sinus tachycardia

c.       Atrial flutter

d.       Normal sinus rhythm

64.   Which of the following would the nurse identify as common physical signs and symptoms of approaching death in a terminally ill client?

a. Irregular breathing patterns with gurgling and congestion

b. Genitourinary function changes, such as incontinence

c.       Alert and oriented X 4

d. Disorientation and restlessness

e. slowing of the circulation with coolness of extremities

65.   A nurse obtains the health history of a client with a fractured demur. Which factor identified in the clients history wiykd the nurse recognize as an aspect that may delay healing?

a.       Oral contraceptives

b.       Current smoking history

c. osteoporosis

d.       Sedentary lifestyle

66.   The nurse is caring or an end of life terminally ill client, experiencing very shallow rapid breathing with periods of apnea. After evaluating the client, which action by the nurse would be the most appropriate?

a.       Place the client in a supine position

b.       Reorient the client as needed

c.       Reduce the number of people in the client’s room

d. Elevate the clients head of the bed

67.   A new graduate nurse has started working on a medical surgical unit. What actions would the nurse take to be prepared for a disaster?

a . Know the institutions emergency response plan

b. Participate in the institution disaster drills 

c.       Be prepared to report immediately to the emergency department

d. Understand the nurse plays a role in every phase

e. Develop a personal preparedness plan. 

68.   A client is admitted to the hospital with an infected postop surgical wound, the practitioner orders vancomycin IV. Order vancomycin 1 gram in 500 ml dextrose 5% water (D5W) to infuse over 2 hours via an infusion pump. Calculate the flow rate in ml/hr ?

69.   A nurse cares for a client who has obstructive jaundice. The client asks why is my skin so itchy? How would the nurse respond?

a. Bile salt accumulate in the skin and cause the itching 

b.       Itching is caused by the release of calcium into the skin

c.       Itching is caused by a hypersensitivity reaction

d.       Toxins released from an inflamed gallbladder lead to itching

70.   What type of stroke is caused by occlusion of a cerebral or carotid artery treated with fibrinolytic therapy?

a.       Arterioveneous malformation

b. ischemic stroke 

c.       Hemorrhagic stroke

d.       Transisent ischemic attack

71.   Which of the following is a component of the Glasgow coma scale that the nurse would assess in a client after a head injury?

a.       Blood pressure

b. Pupillary response 

c.       Verbal responsiveness

d.       Head circumference

72.   A nurse is caring for a client on a mechanical ventilation and finds the client agitated and restless. What action by the nurse is most appropriate?

a.       Sedate the client immediately

b. Assess the cause of the agitation

c.       Restrain the clients hands and legs

d.       Reassure the client that they are safe

73.   After teaching a client about advanced directives, a nurse assessed the clients understanding. Which statement indicates that the client correctly understands the teaching?

a.       An advanced directive will be completed as soon as im incapacitated and cant think for myself

b.       An advanced directive will allow me to keep my momeny out of reach of my familu

c.       An advaqnced directive will keep my children from selling my home when im old

d. An advance directive will specify what I want to be done when I can no longer make decisions about health care. 

74.   In the event of a mass caulaty situation, which is the best triage nurse?

a.       The recently graduated registered nurse

b. The lead registered nurse with the most experience 

c.       The licensed vocational nurse with ten years of experience

d.       The recently graduated licensed vocational nurse

75.   The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhakation and out during exhalation. The clients oxygen saturation has dropped from 94 to 86. What is the priority action by the nurse?

a.       Stabilize the chest wall with rib binders

b, Notify the health care provider and prepare for advanced airway placement 

c.       Encourage the client to take deep, controlled breaths

d.       Document findings and continue to monitor the client 


NUR 2868


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