Question: The client is a 68-year-old female with a history of diabetes mellitus, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end stage renal disease (ERSD). She has been on hemodialysis three times a week for the last month. She presented to the emergency department with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reported she had bouts of nausea and had a poor appetite and was not able to go for her scheduled dialysis. The client also reports that her doctor had recently started her on lisinopril for blood pressure control, but it doesn’t seem to help. She was diagnosed with hyperkalemia with potassium level of 5.9 mEq/L (5.9 mmol/L) and transferred to the intermediate medicine unit (IMU) for treatment and monitoring.
Answer Choices:
A) Draw potassium level STAT, B) Call the healthcare provider to notify changes in vital signs, C) Check blood glucose level STAT, D) Perform a focus cardiovascular assessment, E) Clarify order of lisinopril with the healthcare provider, F) Perform a 12 lead electrocardiogram (ECG) STAT, G) Teach client to take slow and deep breaths, H) Administer calcium gluconate STAT, I) Administer nausea medication, J) Request for more frequent blood glucose checks.
Answer: B) Call the healthcare provider to notify changes in vital signs, D) Perform a focus cardiovascular assessment, E) Clarify order of lisinopril with the healthcare provider, F) Perform a 12 lead electrocardiogram (ECG) STAT, H) Administer calcium gluconate STAT.
Question: In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
Answer Choices:
A) Hairless lower extremities and cool feet, B) Absent pedal pulses and shiny skin, C) Irregular ulcer shapes and severe edema, D) Black ulcers and dependent rubor.
Answer: C) Irregular ulcer shapes and severe edema.
Question: A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?
Answer Choices:
A) Administer analgesics on a fixed and continuous schedule. B) Frequently evaluate the client’s pain. C) Replace transdermal analgesic patches every 72 hours. D) Monitor client for breakthrough pain.
Answer: B) Frequently evaluate the client’s pain.
Question: A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?
Answer Choices:
A) Dark yellow urine, B) Excessive perspiration, C) Myalgia in wrists and hands, D) Cold hands and feet.
Answer: B) Excessive perspiration.
Question: Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH3) level of 220 µg/dL (157.1 µmol/dL). Which action should the nurse take?
Answer Choices:
A) Hold the next dose of lactulose, B) Replace total volume voided with oral or IV fluids, C) Continue the prescribed dose of lactulose, D) Report the number of diarrhea stools to the healthcare provider (HCP).
Answer: C) Continue the prescribed dose of lactulose.
Question: Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Answer Choices:
A) Continue to monitor the drainage system. B) Inspect the tube insertion site for leaking. C) Lift and clear drainage from the chest tube. D) Auscultate lungs for unequal breath sounds.
Answer: A) Continue to monitor the drainage system.
Question: The nurse practitioner prescribes diazepam 8 mg IM every 4 hours PRN muscle spasms for a client with a fractured femur. The available vial is labeled, “Diazepam Injection, USP 10 mg/2 mL.” How many mL should the nurse administer to the client?
Answer Choices:
(Requires numerical input)
Answer: 1.6 mL.
Question: The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?
Answer Choices:
A) Sputum culture positive for Mycobacterium tuberculosis, B) Hemoccult test on sputum collected from hemoptysis, C) Positive purified protein derivative (PPD) skin test, D) Chest x-ray or computed tomography (CT).
Answer: A) Sputum culture positive for Mycobacterium tuberculosis.
Question: A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?
Answer Choices:
A) Compare the client’s pain scale rating with the prescribed dosing, B) Document the client’s report of pain in the electronic medical record, C) Ask the client to choose which medication is needed for the pain, D) Determine which prescription will have the quickest onset of action.
Answer: D) Determine which prescription will have the quickest onset of action.
Question: An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?
Answer Choices:
A) Lower extremity edema. B) Jugular vein distension. C) Hepatomegaly. D) Fatigue.
Answer: A) Lower extremity edema.
Question: A 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. The client has a history of peripheral vascular disease, high blood pressure, and has a pacemaker for 2nd degree heart block.
Answer Choices:
Various patient activities and whether they indicate positive or negative health promotion post-amputation.
Answer: Activities like “Executes pull-ups on trapeze bar” indicate positive health promotion, whereas “Avoids looking at residual limb” could be seen as negative.
Question: A client with draining skin lesions of the lower extremity is admitted with possible methicillin resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care?
Answer Choices:
A) Monitor the client’s white blood cell count. B) Institute contact precautions for staff and visitors. C) Send wound drainage for culture and sensitivity. D) Explain the purpose of a low bacteria diet. E) Use standard precautions and wear a mask.
Answer: B) Institute contact precautions for staff and visitors and C) Send wound drainage for culture and sensitivity.
Question: A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?
Answer Choices:
A) Administer a PRN analgesic. B) Measure the blood pressure. C) Implement distraction techniques. D) Assess right radial pulse volume.
Answer: D) Assess right radial pulse volume.
Question: A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?
Answer Choices:
A) Outflow obstruction. B) Peritonitis. C) Atelectasis. D) Exit site infection.
Answer: B) Peritonitis.
Question: An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?
Answer Choices:
A) Jogging or running are excellent aerobic exercises, B) Tennis or racquetball will increase your muscle strength, C) Limit your exercise to just your daily activities, D) Swimming is an excellent exercise for you.
Answer: D) Swimming is an excellent exercise for you.
Question: The healthcare provider prescribes regular insulin 6 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% sodium chloride. How many mL/hr should the nurse program the infusion pump?
Answer Choices:
Enter numerical value only.
Answer: 6 mL/hr.
Question: A 19-year-old female college student has had type 1 diabetes mellitus for 14 years. She is concerned about her feet, reporting that they itch so much that she gets distracted in school. Upon assessment, scaliness and cracking skin between the toes on the left foot are noted. Hemoglobin A1C (today) is 8.2% and Hemoglobin A1C (3 months ago) was 7.5%. Which condition is she most likely experiencing and what actions should the nurse take?
Answer Choices:
Tinea pedis, Plan for cryotherapy, Request an order for griseofulvin, Instruct the client to change to clean, dry socks, etc.
Answer: Condition: Tinea pedis. Actions: Request an order for griseofulvin and instruct the client to change to clean, dry socks. Parameters to monitor: Spread to other areas of the body and nail growth and color.
Question: A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
Answer Choices:
A) An acutely distended bladder, B) A severe pounding headache, C) Profuse forehead diaphoresis, D) Skeletal traction misalignment.
Answer: A) An acutely distended bladder.
Question: While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Answer Choices:
A) Evaluate for evidence of incontinence. B) Observe for prolonged periods of apnea. C) Observe for lacerations to the tongue. D) Document details of the seizure activity.
Answer: D) Document details of the seizure activity.
Question: The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
Answer Choices:
A) Apical heart rate of 100 to 110 beats/minute, B) High-pitched sound heard upon inspiration, C) Redness and edema noted at the incision site, D) Pain rating of 8 on a scale of 0 to 10.
Answer: D) Pain rating of 8 on a scale of 0 to 10.
Question: A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
Answer Choices:
A) Indication of the onset of joint degeneration. B) Evidence of spread of the disease to the kidneys. C) Confirmation of the autoimmune disease process. D) Representative of a decline in the client’s condition.
Answer: C) Confirmation of the autoimmune disease process.
Question: A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
Answer Choices:
A) Consume a high protein diet, B) Increase physical activity, C) Take vitamin supplements, D) Obtain a prostate-specific antigen blood level test.
Answer: B) Increase physical activity.
Question: The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?
Answer Choices:
A) Marked loss of weight and appetite over the last 3 or 4 months. B) Frequent use of chewable and liquid antacids for indigestion. C) Upper mid abdominal pain described as gnawing and burning. D) Severe abdominal cramps and diarrhea after eating spicy foods.
Answer: C) Upper mid abdominal pain described as gnawing and burning.
Question: The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?
Answer Choices:
A) Risk for injury related to effects of thrombolysis, B) Activity intolerance related to ischemia, C) Ineffective breathing pattern related to adverse drug effects, D) Deficient knowledge related to a new medication regimen.
Answer: A) Risk for injury related to effects of thrombolysis.
Question: The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
Answer Choices:
A) Calcium level and skin condition. B) Hematocrit and blood pressure. C) White blood cell count and pulse rate. D) Serum amylase and level of consciousness.
Answer: B) Hematocrit and blood pressure.
Question: The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump?
Answer Choices:
(Requires numerical input)
Answer: 10 mL/hr.
Question: In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?
Answer Choices:
A) Avoid going outdoors whenever the pollen count is high, B) Keep a food diary for one week and bring to next appointment, C) Notify the healthcare provider of any change in sputum color, D) Stay in the house if the outdoor temperature is hot and humid.
Answer: D) Stay in the house if the outdoor temperature is hot and humid.