Question 1

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?

Accepted Answer

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

Question 2

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?

Accepted Answer

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

Question 3

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?

Accepted Answer

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. A

Question 4

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?

Accepted Answer

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

Question 5

A nurse is closely monitoring a female client who is admitted due for depression. The nurse determines which behavior as an indicator that the client is suicidal?

Accepted Answer

A)  The client tells the nurse that she wants to be alone and she's too tired to interact with other clients.
B)  The client gets angry at her roommate who woreher shirt without asking.
C)  The client swears at the nurse who was facilitating a group therapy session.
D)  The client gives away her favorite book signed by the book's author.

Question 6

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?

Accepted Answer

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

Question 7

The fifteen-year-old daughter of a client diagnosed with schizophrenia asks the nurse about her chances of having the same disorder. Which of the following statements, if made by the client, would be an indication that the girl should be evaluated further?

Accepted Answer

A)  "My mood swings have been unpredictable for the past week."
B)  "I look and feel fat. I'm so ashamed to go out looking like this."
C)  "I'd rather spend most hours of the day at my friend's house."
D)  "I've been having a difficult time falling and staying asleep."

Question 8

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?

Accepted Answer

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

Question 9

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?

Accepted Answer

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

Question 10

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?

Accepted Answer

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

Question 11

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

Accepted Answer

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 12

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?

Accepted Answer

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 13

Which of the following infants should the nurse see first?

Accepted Answer

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 14

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?

Accepted Answer

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 15

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?

Accepted Answer

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

Question 16

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:

Accepted Answer

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

Question 17

A female teenaged client comes to the emergency room following an assault. The client is extremely anxious and is hyperventilating. Which of the following interventions is the most appropriate nursing action?

Accepted Answer

A)  Teach the patient how to do deep breathing exercises.
B)  Stay with the client until the level of anxiety decreases.
C)  Place the patient in a quiet room alone to decrease stimulation.
D)  Encourage the client to verbalize her feelings and fears.

Question 18

A nurse is teaching a client who has just been prescribed aluminum hydroxide. The nurse would instruct the client to do which of the following?

Accepted Answer

A)  Swallow the tablet with a glass of water.
B)  Chew the tablet thoroughly and drink ½ cup of water.
C)  Crush the tablet and add it to a glass of water.
D)  Take aluminum hydroxide with a laxative.

Question 19

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?

Accepted Answer

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 20

A client in her third trimester is admitted due to painless, bright red vaginal bleeding. The vital signs were obtained and the external monitor has been applied. What is the next action of the nurse?

Accepted Answer

A)  Develop a nursing care plan for an emergency caesarean delivery.
B)  Place the client on her left side.
C)  Perform vaginal examination.
D)  Insert a urinary catheter.

Exam 1: Changes in Health