Deck 1: Changes in Health

Question 1

Anderson, an 85-year-old female, was admitted to the unit with a diagnosis of pneumonia. On routine assessment, the nurse observes that the client is demonstrating signs of difficulty breathing. Mrs. Anderson is also complaining of difficulty expelling her secretions. Auscultation of the lung fields reveals bronchial sounds in the left lower lobe. Which of the following nursing interventions is provided to the client first?

A)Instruct bed rest.
B)Administer oxygen.
C)Increase fluid intake per hour.
D)Administer antibiotics.

Answer 1

Administer oxygen.

Question 2

Campbell, a 25-year-old construction worker, is admitted to a burn unit after a fire in a construction site. Initial assessment reveals burn injuries involving the anterior and posterior aspects of the upper extremities. The injured surfaces are black in color and dry in texture. Tissue with fat exposure and edema are noted. Mr. Campbell reports minimal pain. The nurse assessing Mr. Campbell classifies these integumentary injuries as:

A)Superficial-thickness burns
B)Partial-thickness superficial burns
C)Full-thickness burns
D)Deep full-thickness burns

Answer 2

Full-thickness burns

Question 3

Bryan, a 17-year-old high school senior, is rushed to the emergency department after he is found lying unconscious on the floor. Physical assessment reveals cherry-red skin, mucus membranes, and nails. Based on this finding, which of the following is the most likely cause of Bryan's medical condition?

A)Excessive aspirin ingestion
B)Hydrocarbon ingestion
C)Lead poisoning
D)Carbon monoxide poisoning

Answer 3

Carbon monoxide poisoning

Question 4

A nurse is assigned to care for Amanda, a 39-year-old lawyer who was recently diagnosed with generalized anxiety disorder. Which of the following statements from Amanda would lead the nurse to suspect that Amanda's anxiety has been a long-standing problem?

A)"My mother was also diagnosed with general anxiety disorder when she was in her early 40s."
B)"Adjusting to college life was difficult. I never thought I would even receive a degree."
C)"I have always solved my problems on my own."
D)"I've had nightmares since my husband left me a year ago."

Question 5

A 23-year-old female at 35 weeks' gestation comes to the emergency department complaining of severe abdominal pain. Moderate dark vaginal bleeding is noted. Physical assessment findings include increased uterine tone with orthostatic changes in the blood pressure. External fetal monitor reveals fetal distress. Based on these initial findings, the client is most likely diagnosed with which of the following conditions?

A)Abruptio placenta
B)Placenta previa
C)Hydatidiform mole
D)Ectopic pregnancy

Question 6

Rachel, a G1P0 female at 30 weeks' gestation, was admitted to the facility due to persistent headaches. On physical assessment, a blood pressure of 180/130 mm Hg was noted. Laboratory tests were conducted, revealing proteinuria of more than 5 grams in a 24-hour collection. History reveals that Rachel was diagnosed with pre-eclampsia. Her physician orders the administration of magnesium sulfate IV to prevent convulsions. The nurse who is tasked with preparing and administering the drug ensures that which of the following medications is readily available as an antidote for magnesium sulfate toxicity?

A)Naloxone
B)Calcium gluconate
C)Protamine sulfate
D)N-acetylcysteine

Question 7

Which of the following should alert the labour nurse that her client has begun the second stage of labour?

A)The cervix is thin and fully dilated.
B)The amniotic membranes have ruptured.
C)The presenting part is below the ischial spines
D)The woman tells you she needs to push.

Question 8

Andrea, a 23-year-old female, comes to the clinic for her second pre-natal examination. On physical assessment, bluish discoloration of the mucus membranes of the cervix, vagina, and vulva is noted. This probable sign of pregnancy is called:

A)Goodell's sign
B)Hegar's sign
C)Chadwick's sign
D)Ballotement

Question 9

Kelly, a nullipara at 34 weeks' gestation, comes to the emergency department saying, "I think I'm about to go into labor." After assessing the client, the nurse alerts the physician for a possible case of pre-term labor. The nurse then initiates nursing interventions that aim to manage pre-term labor. Which of the following findings would be most likely to lead the nurse to suspect pre-term labor?

A)Irregular uterine contractions; cervical dilatation is absent.
B)Painful uterine contractions occurring every 10 minutes with cervical dilatation.
C)Painful uterine contractions occurring every 10 minutes without cervical dilatation.
D)Irregular contractions every 10 minutes with cervical dilation; effacement has not started.

Question 10

A nurse auscultates the heart of Anne, a 21-year-old female. Anne seeks a consultation for dizziness and easy fatigability. During assessment, the nurse identifies a mid-to-late systolic click followed with mid-to-late systolic murmur at the cardiac apex. The murmur gets louder when Anne stands up. Based on these findings, Anne is most likely considered for which of the following cardiac problems?

A)Aortic stenosis
B)Mitral valve prolapse
C)Pulmonic stenosis
D)Mitral regurgitation

Question 11

A client who complains of moderate to severe joint pain and stiffness is diagnosed with rheumatoid arthritis. The nurse caring for the client reviews the client's record and notes which of the following as the most consistent diagnostic finding of rheumatoid arthritis?

A)Low sedimentation rate
B)Synovial tissue biopsy showing absence of inflammation
C)Greater than 80 IU/mL rheumatoid factor
D)Normal C-reactive protein levels

Question 12

A client is rushed to the emergency department after demonstrating signs of acute myocardial infarction. History reveals that the chest pain has not been resolved by sublingual nitroglycerin. The client is started on tissue plasminogen activator by infusion. The nurse caring for the client frequently assesses which of the following parameters?

A)Serum potassium levels
B)Oxygen saturation
C)Pulse rate
D)Visual acuity

Question 13

A client complaining of joint pain is diagnosed with osteoarthritis, a progressive degeneration of a joint as a result of wear-and-tear. The nurse expects to note which of the following findings in the client's record?

A)Joint symptoms in symmetrical pattern
B)Hand deformities
C)Joint pain that intensifies after inactivity
D)Joint pain that diminishes after rest

Question 14

Wanda comes to the emergency department complaining of substernal chest pain that radiates to the neck and left arm. A 12-lead electrocardiogram is attached to Wanda to evaluate the function of the heart. A nurse examines the tracing, which suggests myocardial ischemia. Which of the following electrocardiogram changes is most likely noted by the nurse?

A)Formation of Q wave
B)Depression of ST segment
C)Widened QRS complex
D)Tall T wave

Question 15

Evelyn, a 72-year-old female, was admitted to the facility due to myocardial infarction. On routine assessment, the nurse caring for Evelyn notes bilateral pitting edema in the lower extremities. Indention is 4 millimeters. Which of the following is the most appropriate action of the nurse?

A)Inform the clientthat she should limit her intake of sodium to 1 gram a day.
B)Recommend diuretic administration at bedtime.
C)Review the client's fluid intake and output for the last 48 hours.
D)Inform the clientthat she should limit her fluid intake to 1,500 mL per day.

Question 16

Jane is a 54-year-old female who was recently diagnosed with pulmonary edema. Furosemide, given through intravenous route, is ordered to the client. The nurse caring for the client reviews Jane's chart and finds out that she is also ordered to take digoxin. Which of the following is the priority action of the nurse?

A)Check the client's most recent potassium level.
B)Check the client's pulse rate.
C)Contact the physician and verify the order.
D)Check the client's creatinine levels.

Question 17

A client who has a history of diabetes mellitus type 2, angina, and myocardial infarction is diagnosed with left-sided heart failure. The nurse assessing the client identifies all of the following as symptoms of left-sided heart failure EXCEPT:

A)Orthopnea
B)Presence of crackles on auscultation
C)Enlargement of the liver
D)Cough with frothy sputum

Question 18

A client is admitted to the facility due to right-sided heart failure. The nurse notes that the client demonstrates distention of the jugular vein. The nurse places the head of the bed in which of the following positions to obtain the most accurate jugular venous pressure reading?

A)Raised to 45degrees
B)Raised to 90degrees
C)Raised between 15 and 30degrees
D)Raised between 45 and 90degrees

Question 19

A female client complains of vaginal burning and itching. Vaginal discharge with a cottage-cheese-like appearance is reported. History reveals that the client is on antibiotic therapy. The nurse suspects that the client is experiencing which of the following vaginal infections?

A)Gonorrhea
B)Bacterial vaginosis
C)Trichomoniasis
D)Candidiasis

Question 20

A nurse is assigned to care for a client who was recently admitted due to dyspnea. The chart notes that the client has an endotracheal tube in place. Suctioning is ordered every four hours. The nurse keeps in mind that prior to suctioning, which of the following is performed first?

A)Hyperoxygenate the client with 100% oxygen.
B)Place saline solution down the endotracheal tube.
C)Encourage the client to perform deep breathing and coughing exercises.
D)Deflate the cuff on the endotracheal tube.

Question 21

A physician ordered Anthony, a male client who was admitted due to aspiration of gastric contents, to undergo decompression of the stomach. A nurse is tasked withinserting a nasogastric tube. As the nurse inserts the tube, resistance is met. Which of the following is the next action of the nurse?

A)Ask the client to drink swallow by sipping on small amounts of water.
B)Remove the tube and insert it into the other nostril.
C)Pull back the tube a little and then try to continue pushing the tube into the nostril.
D)Check patency by placing the open end of the tube in a cup of water.

Question 22

A nurse is caring for Mrs. Thomas, an adult female who sustained second-to-third-degree burn injuries in the anterior and posterior thorax. A physician orders silver sulfadiazine during wound dressing. The nurse recognizes the client's susceptibility to infection. Which of the following is the best action to prevent wound infection during cleaning and dressing?

A)Clean the burned areas using an irrigation system.
B)Clean the burned areas with povidine iodine before applying silver sulfadiazine.
C)Initiate contact precautions, and inform the other health care professionals about it.
D)Wear sterile gloves, mask, and gown during wound care.

Question 23

A nurse is monitoring an 82-year-old male who had a transurethral resection of the prostate 12 hours ago. A three-way urinary catheter is inserted through the client's urethra and into the bladder for continuous irrigation. A total of 3,000 mL of bladder irrigant has been infused for the past 8 hours. After assessing the client, the nurse immediately contacts the physician for a possible complication of the procedure. Which of the following is most likely noted by the nurse during the assessment?

A)Urinary output of 3,500 mL for the past 8 hours
B)Pain and sense of urgency to urinate are reported by the client
C)Blood pressure of 110/50 mm Hg; 120 bpm
D)Blood in urine with small clots

Question 24

A nurse is caring for Elaine, a 5-year-old child who was admitted due to a suspected case of brain tumor. Diagnostic tests reveal that the child has a brain tumor involving the cerebellum. A surgery is ordered. During the pre-operative period, which of the following is the most important nursing intervention for the client?

A)Initiate seizure precautions.
B)Monitor the child's temperature every 2 hours.
C)Measure the child's circumference every morning.
D)Initiate fall precautions

Question 25

A nurse is assigned to the in-hospital triage area, which utilizes a three-tier system: emergent, urgent, and non-urgent. Which of the following clients has an emergent condition and needs to receive treatment immediately or within 15 to 30 minutes of admission?

A)An 11-year-old boy with wheezing and difficulty breathing.
B)A 12-year-old boy with a complex long bone fracture.
C)A 5-year-old girl with a high fever with stable vital signs.
D)A 3-year-old girl with minor laceration in the abdominal region.

Question 26

Briana, a newlyhired nurse, is tasked with caring for female client who has an endotracheal tube in place. Suctioning is ordered, when needed. The nurse manager should intervene when Briana performs which of the following actions during suctioning?

A)The client is hyperoxygenated with 100% oxygen before suctioning.
B)The nurse applies suction only when withdrawing the catheter.
C)The nurse suctions for 20 seconds before withdrawing.
D)The nurse uses a catheter with a diameter less than 50% of the endotracheal tube diameter.

Question 27

A female client was admitted to the gastrointestinal unit two days ago. The client has been demonstrating signs of decline in gastrointestinal function for the past day and is now ordered to be transferred to the intensive care unit. Before the transfer, which of the following should the nurse do first?

A)Inform the nurse supervisor about the transfer.
B)Obtain a signed consent.
C)Search for an accepting physician.
D)Call the admitting nurse in the ICU.

Question 28

Enid is a 25-year-old female client who comes to the emergency department due to tachycardia and palpitations. The client is excessively sweating and is demonstrating signs of weakness. The client informs the nurse that the symptoms started 1 ½ hours after administering her daily insulin. Which of the following is the most appropriate intervention for the client?

A)Administer insulin.
B)Offer half a glass orange juice.
C)Administer oxygen.
D)Administer sublingual nitroglycerin.

Question 29

Adams, a 63-year-old retired bookkeeper, comes to the emergency unit with complaints of nausea and vomiting, muscle weakness, and fatigue. Nursing assessment includes a blood pressure of 180/100 mmHg and a slow irregular pulse rate. ECG results show shortened QT intervals. Which of the following electrolytes is most likely elevated?

A)Serum potassium
B)Serum calcium
C)Serum sodium
D)Serum magnesium

Question 30

A nurse is assisting Kenneth, an alcoholic for more than 20 years, who is scheduled for a liver biopsy. The nurse is correct to place the client in which of the following positions after the procedure?

A)Supine, with the right side of the right upper abdomen exposed
B)High-Fowler's position
C)Right lateral side-lying position
D)Sitting on the edge of bed and leaning over the bedside table, with the feet supported on a stool

Question 31

Bandes is a 34 year-old sales agent who has chronic low back pain. He has been taking ibuprofen intermittently for the past two years. Two days ago he experienced shooting pain from the lower back and into the buttocks and left leg. He was admitted to the facility for medical management. During the afternoon shift, he complains of mild but persistent headache. The client appears to be irritable. To ease Mr. Bandes's headache and discomfort, nursing care should include:

A)Relaying the client's complaints to his attending physician.
B)Administering the next dose of pain medication.
C)Decreasing sensory stimulation.
D)Teaching the client non-pharmacological management of pain.

Question 32

Joe Engel, a 15-year-old high school student, had a skating accident. A cast is applied to his left arm due to an ulnar fracture. The nurse teaches the client exercises that maintain the muscle strength of the affected arm. The most recommended group of exercises to regain or maintain muscle strength is:

A)Isotonic exercise
B)Isokinetic exercise
C)Isometric exercise
D)Aerobic exercise

Question 33

Flynn, a 38-year-old businessman, is admitted for severe chest pain unrelieved by sublingual nitroglycerin. Mr. Flynn is diagnosed with acute myocardial infarction and kept in complete bed rest to prevent myocardial stress. After six days, the nurse is preparing the client for ambulation, as ordered by the physician. The client is at risk of orthostatic hypotension. Which of the following activities prevents orthostatic hypotension related to hypovolemia?

A)The client independently transfers from the bed to commode.
B)The client sits on the bed three times daily.
C)Performing leg and foot exercises.
D)Performing incentive spirometry every 2 hours.

Question 34

Simon, a client with a history of congestive heart failure, complains of shortness of breath. He cannot tolerate lying flat on the bed. Physical examination reveals accumulation of fluid in the left lung. Thoracentesis is ordered. The client must be placed in which of the following positions during the procedure?

A)Semi-Fowler's position.
B)Position of comfort.
C)Lying on the unaffected side; head of bed elevated to 45-degrees.
D)Supine, with the right side of the upper abdomen exposed.

Question 35

Melissa is a 46-year-old office clerk with multiple sclerosis. Her symptoms have been progressing over the years. Melissa is complaining of difficulty of swallowing with occasional episodes of choking every time food particles get caught up in her throat. Which of the following would not be an appropriate strategy to prevent discomfort in swallowing for Melissa?

A)Allowing ample time eating.
B)Offering water during meals.
C)Encouraging her to avoid speaking while eating.
D)Encouraging her to maintain an upright position during meals.

Question 36

An emergency nurse is admitting a 32-year-old female office clerk who was rushed to the emergency department for abdominal pain. Client history reveals occasional episodes of mild abdominal pain that occur especially after eating fatty foods. A significant nursing assessment that indicates inflammation and infection of the gall bladder is:

A)Temperature of 37.9°C.
B)Sudden and rapidly increasing right upper abdominal pain.
C)Pain radiating to the back and left shoulder.
D)Palpable abdominal mass.

Question 37

A registered nurse reviews the charts of the clients who are admitted to a nursing unit. The RN determines that one of the clients is incorrectly positioned. Which of the following clients shouldbe placed in another position and evaluated for complications caused by the wrong positioning?

A)A post-hypophysectomy client with the head of bed elevated
B)A client who had myelogram with a water-based dye; the head of bed elevated 30to 60degrees
C)A client who had a cataract surgery in the left eye; right-side lying position
D)A post-lumbar puncture client; lateral side-lying position with the knees flexed up to the abdomen and the head bent

Question 38

John Isles, a 10-year-old client with sickle cell disease, is admitted for sickle cell crisis. Initials assessment shows a temperature of 38.2°Cand swelling in the left leg. The client complains of severe pain in the affected extremity. The nurse recognizes this as what type of sickle cell crisis?

A)Vaso-occlusive
B)Hypovolemic
C)Aplastic
D)Sequestration

Question 39

LaShonda, a 29-year-old female, is admitted to the unit due to a possible case of hypothyroidism. The client's history and physical assessment findings are indicative of hyposecretion of the thyroid hormones. The nurse expects to note which of the following findings in the client's chart?

A)Heat intolerance
B)Edema around the eyes
C)Diarrhea
D)Smooth and soft skin

Question 40

The nurse is caring for a one-month-old baby girl who has myelomeningocele. Assessment findings reveal that the infant has a temperature of 37.9°C. The initial action of the nurse is to:

A)Report the finding to the physician.
B)Assess the sac for feces or urine contamination.
C)Decrease the infant's temperature by sponge bath.
D)Record the infant's temperature.

Question 41

Karin, a 42-year-old female, demonstrates an enlarged thyroid gland, exophthalmos, and hypertension. The client also complains of diarrhea, nervousness, and heat intolerance. The laboratory tests reveal that the client has hyperthyroidism. Which of the following medications is most likely prescribed to the client to manage her condition?

A)Levothyroxine sodium
B)Propylthiouracil
C)Liothyronine
D)Alendronate

Question 42

A low-residue diet consists of foods high in carbohydrates that are low in residue. A physician is most likely to order this therapeutic diet to which of the following clients in the unit?

A)A client ordered for an initial feeding after a complete bowel rest
B)A client with dysphasia
C)A client with an inflammatory bowel disease
D)A client with reflux esophagitis

Question 43

Nikki, a female client who had an abdominal surgery a week ago, demonstrates separation of the wound edges at the suture line. Increased drainage and appearance of underlying tissues through the wound are noted. Which of the following is the most appropriate initial nursing intervention for the client?

A)Cover the wound with a sterile normal saline solution.
B)Place the client in low Fowler's position with the knees bent.
C)Instruct the client to splint the incision.
D)Notify the physician.

Question 44

A physician orders corticosteroid therapy to a female client with Addison's disease. The nurse informs the client that steroid administration can lead to a number of side effects. The nurse lists all of the following as common side effects of corticosteroids EXCEPT:

A)Water retention
B)Hypokalemia
C)Osteoporosis
D)Hypoglycemia

Question 45

The nurse assessing Fran, a 39-year-old female with a history of asthma, notes increase in respiratory rate, rapid and irregular pulse, and mental status changes. Laboratory results reveal that the client has respiratory acidosis. Which of the following nursing interventions is the most appropriate for the client?

A)Assist the client in voluntary holding of breath.
B)Administer oxygen.
C)Administer tranquilizers, as prescribed.
D)Encourage use of rebreathing mask.

Question 46

The nurse attending Inna, a female client who had a recent surgery with spinal anesthesia, notes restlessness, cool clammy skin, and hypotension. Hypovolemic shock is suspected. Which of the following is NOT a safe nursing intervention for the client?

A)Elevate the legs above the level of the heart.
B)Administer oxygen.
C)Administer colloid solutions, as prescribed.
D)Monitor level of consciousness.

Question 47

Benny, a male client who has been on steroid therapy, has been recently diagnosed with a duodenal ulcer. Which of the following assessment findings is most likely noted in the client's chart?

A)Gnawing pain in the midepigastric area one hour after eating
B)Vomiting
C)Pain in the abdomen, relieved by eating
D)Sour taste in the mouth

Question 48

Janna, a 52-year-old female, had a surgical procedure with permanent ileostomy. A nurse gives an enema through the stoma to stimulate emptying. Which of the following actions by the nurse demonstrates proper technique of irrigating the colostomy?

A)The nurse uses warm tap water for irrigation.
B)The bottom of the bag is at the level of the client's shoulder.
C)The nurse performs irrigation two hours after meals.
D)The irrigation tube is quickly inserted to the stoma.

Question 49

After the arterial blood gas test results are reviewed, a client with signs of diabetic ketoacidosis is diagnosed with metabolic acidosis. The nurse caring for the client expects to note which of the following laboratory results in the client's chart?

A)Low pH; low bicarbonate concentration
B)High pH; high bicarbonate concentration
C)Low pH; high PCO2
D)High pH; low PCO2

Question 50

A female client can take some oral nutrition, but her food intake is not enough to meet the needs of her body. A total parenteral nutrition is ordered for a week. Only small amounts of carbohydrates, fats, and proteins are required. The nurse expects the physician to deliver the nutrients in which of the following veins?

A)Subclavian
B)External jugular
C)Internal jugular
D)Basilic

Question 51

A client with total parenteral nutrition complains of chest pain and difficulty breathing. The nurse suspects air embolism. Which of the following is the initial action of the nurse?

A)Notify the physician.
B)Clamp the intravenous catheter.
C)Place the client in left-side lying position.
D)Administer oxygen.

Question 52

Lipids are ordered to be administered to Gertrude, a client with fatty acid deficiency, through a peripheral vein. Which of the following is the correct way of preparing or administering lipids through a peripheral vein?

A)The nurse adds additives into the fat emulsion solution.
B)The nurse uses an intravenous filter.
C)Lipids are given in a hypotonic solution administered through a peripheral vein.
D)The nurse refrains from using a bottle of lipids observed to have separation of emulsion into layers.

Question 53

Olson, an alcoholic for almost 30 years, was diagnosed with liver cirrhosis. The client is noted with jaundice, ascites, hepatomegaly, fetor hepaticus, and asterexis. Laboratory tests revealed the client's ammonia content is significantly higher than the recommended values. Which of the following interventions specifically aims to excrete ammonia?

A)Fluid restriction.
B)Administration of lactulose, as ordered.
C)Administration of diuretics, as ordered.
D)Prepare the client for parenthesis.

Question 54

A physician orders a hypotonic solution to a client with a fluid volume deficit. The physician is most likely to order which of the following solutions to the client?

A)5% dextrose in water
B)5% dextrose in 0.9% saline
C)5% dextrose in lactated Ringer's solution
D)0.45% saline

Question 55

A client comes to the emergency department complaining of abrupt onset of midepigastric pain with radiation to the back. Cullen's sign, Turner's sign, abdominal guarding, decreased bowel sounds, and nausea and vomiting are documented. The client is diagnosed with acute pancreatitis. Which of the following medications is a physician most likely to prescibe to this client in order to relieve pain?

A)Morphine sulfate
B)Meperidine hydrochloride
C)Codeine sulfate
D)Neomycin

Question 56

A physician orders a medication to a client with fluid volume deficit. The medication is ordered to be administered through the intravenous route. Which of the following actions by the nurse is the least appropriate when inserting an intravenous line?

A)Using sterile technique when inserting an intravenous line.
B)Cleaning the skin using an inner to outer circular motion.
C)Priming the tubing.
D)Starting the intravenous infusion proximally.

Question 57

A client's venipuncture site is swollen and cool to touch. The nurse occludes the vein proximal to the intravenous site. The intravenous fluid continues to flow. Which of the following is the next action of the nurse?

A)Remove the intravenous device.
B)Elevate the extremity.
C)Apply compress.
D)Rub the infiltrated area.

Question 58

A male client with alcohol dependence will be placed on disulfiram therapy. Before the start of the therapy, the nurse reminds the client that disulfiram is an alcohol deterrent, which will sensitize the client to alcohol. The nurse instructs the client to abstain from alcohol for at least:

A)72 hours
B)48 hours
C)24 hours
D)12 hours

Question 59

Cooper is a 7-year-old male diagnosed with bronchial asthma. The boy and his mother consult a physician after he experiences increasingly frequent episodes of Cooper's acute asthma over a period of several months. The child has a case of hypersensitivity. The physician describes a medication taken routinely to prevent acute asthma episodes. Which of the following medications is taken prophylactically?

A)Albuterol
B)Ipratropium
C)Cromolyn sodium
D)Methylprednisolone

Question 60

A client complains of gradual loss of peripheral vision. Blurred vision, eye pain, and halos around white lights are also reported by the client. The client's intraocular pressure is 30 mm Hg. The nurse caring for the client expects that the physician might prescribe any of the following medications EXCEPT:

A)Carbachol
B)Pilocarpine
C)Scopalamine
D)Demarcium

Question 61

Marc, a 30-year-old client, is rushed to the emergency department due to mental status changes. Physical examination reveals dilated pupils, tachycardia, and hypertension. The nurse prepares to administer which of the following medications to the client?

A)Naloxone
B)Methadone
C)Bromocriptine
D)Flumazenil

Question 62

Celine, a 45-year-old client, complains of sense of a curtain being drawn in her vision. Flashes of light, floaters, and blurred vision are also reported. Based on these details of information, the client is most likely diagnosed with:

A)Hyphema
B)Glaucoma
C)Retinal detachment
D)Cataract

Question 63

A female client is rushed to the emergency department after an accident. The nurse utilizes the Glasgow Coma Scale to assess the client's neurological condition. The client opens her eyes in response to sound, but she does not spontaneously open her eyes. The client is confused in conversation. Pain stimuli are localized, but the client cannot obey simple responses. The client's Glasgow Coma Scale score is:

A)10
B)12
C)11
D)9

Question 64

A client who was admitted to the neurology unit has injuries above T6. A urinary catheter is in place. After the morning care, the client begins to complain of severe headache. Physical examination reveals flushing of face and neck, bradycardia, hypertension, dilated pupils, and piloerection. Which of the following is an appropriate intervention for the client?

A)Maintain the client in supine position.
B)Monitor the client's vital signs every 30 minutes.
C)Check for kinks in the urinary tubing.
D)Administer oxygen.

Question 65

An 18-year-old male was admitted to the unit after sustaining a head trauma during a football game. The nurse caring for the client recognizes the client's greater risk for increased intracranial pressure. Which of the following findings should alert the nurse as it is the earliest indication of increasing intracranial pressure?

A)Bradycardia
B)Widened pulse pressure
C)Declining level of consciousness
D)Elevated temperature

Question 66

Michelle is a 37-year-old female experiencing severe diarrhea that contains blood and mucus. The client is admitted to the facility for treatment. After a series of tests, the client is diagnosed with ulcerative colitis. The nurse caring for the client implements which of the following as the priority intervention during the acute phase of ulcerative colitis?

A)Restrict the client's activity
B)Maintain a clear liquid diet.
C)Maintain NPO status.
D)Administer bulk-forming agents.

Question 67

Which of the following infants should the nurse see first?

A)A one-day-old infant with a bulging anterior fontanel when crying
B)A one-day-old infant born at 43 weeks with parchment-like skin
C)A 3-month-old infant with a respiratory rate of 55 breaths per minute who experiences brief pauses of breathing during sleep.
D)A one-day-old infant lying quietly and awake with an apical rate of 180

Question 68

A client diagnosed with severe anemia is receiving packed red blood cells. Around fifteenminutes after the infusion is started, the client complains of itching, lower back pain, shortness of breath, and development of hives on the chest area. The client has chills and fever. Which of the following should the nurse do first?

A)Slow down the rate of infusion
B)Stop the infusion
C)Place the client in high Fowler's position
D)Call the physician

Question 69

Which of these clients should the nurse assess first?

A)A 10-year-old boy who is scheduled for a tonsillectomy in an hour
B)A 3-year-old boy who had an episode of tonic-clonic seizure a day ago
C)A 5-year-old child on a gluten-restricted diet initiated 48 hours ago
D)A 6-month-old child sleeping quietly with bulging and tense anterior fontanel

Question 70

The nurse receives the client assignment for the day. After making her rounds, which of the following clients would be nurse's first priority?

A)A client with a chest tube who needs assistance with ambulation
B)A client scheduled for myelogram in 4 hours
C)A client with fever and diaphoresis
D)A client who had cholecystectomy 12 hours ago and who received his pain medications 15 minutes ago

Question 71

A nurse in the emergency room receives a female client with critically lacerated wrists. The initial action of the nurse is to:

A)Notify the physician
B)Examine and treat the wound
C)Administer tetanus toxoid
D)Instruct the client to perform deep breathing techniques

Question 72

An 11-year-old girl had a brain tumor resection. After the procedure, the child starts to demonstrate difficulty with her fine motor skills and is now unable write. The nurse refers the child to which health care professional?

A)Nutritionist
B)Occupational therapist
C)Physical therapist
D)Speech therapist

Question 73

A nurse would see which of the following clients first?

A)A client scheduled for thoracentesis in an hour
B)A client in sickle crisis with an infiltrated IV
C)A client with a leg cast who is ready for discharge
D)A client with diabetes who requires a dressing change for a stasis ulcer

Question 74

A nurse received four messages while she was out of the clinic. The nurse would call which of the following clients first?

A)A male client with a cast on his left leg, reporting that his injured leg feels numb
B)A female client with osteoporosis, reporting low back pain
C)A female client prescribed with an antidepressant a week ago, reporting that she does not feel any improvement
D)A mother who gave birth a week ago, complaining of abdominal cramps during breastfeeding

Question 75

A nurse just received the report from the previous shift. Which of the following clients would the nurse see first?

A)A client who has been vomiting for the past 24 hours
B)A client who is scheduled for a cholecystectomy in an hour
C)A client who had tumor lysis syndrome 3 hours ago
D)A client who has been having recurring pain for short periods of time for the past 24 hours

Question 76

The nurse is planning care for an eighty-two-year old confused client with a nursing diagnosis of altered mental status. Which of the following interventions should the nurse include in her plan of care?

A)Keep the client's room well-lit at all times
B)Place a bedside commode device adjacent to the side of the bed
C)Reorient the client frequently
D)Leave the television on at all times

Question 77

A nurse is alerted when she finds a 10-year-old child having seizures. Which of the following nursing actions is most appropriate?

A)Insert a padded tongue blade into the child's mouth and depress the tongue.
B)Restrain the child's legs and arms.
C)Pad the side rails of the bed with soft blankets.
D)Ask assistance from the nursing assistant to hold the child still.

Question 78

A nurse is receiving a ten-year-old child from the post-anesthesia care unit who has just undergone a tonsillectomy. The nurse ensures the child's safety by placing the child in which of the following positions?

A)Supine position
B)Side-lying position
C)Prone position
D)Semi-Fowler's position

Question 79

A nurse arrives at an emergency scene. The nurse determines that which of the following clients is least in need of an emergency assessment?

A)A pregnant woman who is in labor
B)A male client with second-degree burns assessed an hour ago
C)A client bleeding from the right side of the head
D)An unresponsive client

Question 80

A three-day-old full-term infant is observed with yellowish skin and sclera. Laboratory examination reveals a total serum bilirubin level of 15 mg/dl. The nurse determines that these symptoms suggest:

A)Jaundice of prematurity
B)Physiological jaundice
C)Pathological jaundice
D)Breastfeeding jaundice