Question 1

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?

Accepted Answer

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

Question 2

A client at 32 weeks gestation chokes on her food and becomes unconscious. The nurse's immediate action is to:

Accepted Answer

A) Perform backward chest thrusts 
B) Place the client on her back with a pillow under the right abdominal flank and hip 
C) Place the client on her left side 
D) Place the paddles one rib interspace lower than usual during defibrillation

Question 3

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?

Accepted Answer

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

Question 4

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:

Accepted Answer

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

Question 5

At 9:00 a.m. a nurse finds a client, being infused with 5% dextrose in 0.9% sodium chloride, is having difficulty breathing. On assessment, the nurse notes increased blood pressure, distended jugular veins, and crackles on auscultation. A 1,000-ml infusion bag of solution was hung at 8:00 a.m. The remaining solution is measured at 600 ml. The nurse's most immediate action is to:

Accepted Answer

A) Notify the physician 
B) Place the client on semi-Fowler's 
C) Slow down the rate of infusion 
D) Stop the infusion and remove the IV catheter

Question 6

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

Accepted Answer

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 7

A client with pregnancy-induced hypertension is given magnesium sulfate. Which finding, during assessment, should alert the nurse?

Accepted Answer

A) Fetal heart rate of 155 beats per minute 
B) Urinary output of 30 ml per hour 
C) A grading of 2+ deep tendon reflexes 
D) Respiratory rate of 10 breaths/ minute

Question 8

A physician orders regular insulin at 10 units per hour to be administered by IV infusion pump. An IV infusion bag is labeled 100 units of regular insulin in 500 ml of 5% dextrose in water. The nurse prepares to set the infusion pump at how many millimeters per hour?

Accepted Answer

A) 10 ml 
B) 20 ml 
C) 50 ml 
D) 100 ml

Question 9

A client who had open heart surgery 24 hours ago has had a urine output of about 20 ml/hr for the past 12 hours. The laboratory findings reveal a BUN level of 38 mg/dl and a serum creatinine level of 2.0 mg/dl. A nurse reviewing these results determines that the client is at risk for which of the following?

Accepted Answer

A) Acute renal failure 
B) Glomerulonephritis 
C) Pyelonephritis 
D) Uremic syndrome

Question 10

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?

Accepted Answer

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 11

A nurse in the emergency room is caring for an eighteen-year-old girl who is a victim of sexual assault. The client is withdrawn and at times, becomes physically immobile. The nurse determines that:

Accepted Answer

A) The client is at risk for suicide. 
B) The client is demonstrating normal reactions. 
C) The client is showing signs of traumatic disorder. 
D) An admission to the facility is necessary.

Question 12

A nurse is giving discharge instructions to a client with myasthenia gravis about reducing the risk for aspiration when eating. Which of the following is not included in the teachings?

Accepted Answer

A) Encourage the client to sit up when eating. 
B) Instruct the client to cut his food into small pieces. 
C) Instruct the client to tip the chin down to swallow. 
D) Advise the client to lift his head upward when drinking.

Question 13

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:

Accepted Answer

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

Question 14

A client with persistent cough is complaining of severe pain when coughing. The nurse would instruct the client to do which of the following comfort measures?

Accepted Answer

A) Elevate the head of bed to 15 to 30-degrees 
B) Restrict fluid consumption 
C) Hold in coughing 
D) Splint the chest wall with a pillow

Question 15

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?

Accepted Answer

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

Question 16

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?

Accepted Answer

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 17

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?

Accepted Answer

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 18

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:

Accepted Answer

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 19

An eighty-year-old male client diagnosed with benign prostatic hypertrophy complains of pain as the nurse inflates the balloon of the indwelling urethral catheter that has been inserted. What is the best action of the nurse?

Accepted Answer

A) Aspirate the fluid, withdraw the catheter, and reinflate the balloon. 
B) Aspirate the fluid, advance the catheter, and reinflate the balloon. 
C) Remove the syringe and begin aftercare. Pain is an expected response. 
D) Aspirate the fluid, remove the catheter, and replace it with a smaller catheter.

Question 20

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?

Accepted Answer

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

Exam 1: Changes in Health