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WorksheetsFall 76-100
Total questions: 25
Worksheet time: 6hrs 15mins
A 36-year-old client is admitted to the ICU following a six-hour surgery to repair a fractured pelvis, and the estimated intraoperative blood loss (EBL) was 3,000 ml. Current client data include: BP 85/70, heart rate 140 beats/minute, urine output 10 ml/hr, PAWP 2, RAP -3, Hct 20%, Hgb 7 g/dl. What action should the nurse take at this time?
Administer propranolol (Inderal) to decrease the heart rate.
Infuse blood and IV fluids to correct the hypovolemia.
Start a dopamine (Intropin) infusion to raise the BP.
Draw serum blood cultures to check for infection.
An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take?
Notify the unit manager that an emergency court order is needed to allow the surgery.
Continue to prepare the client for the surgery without a signed informed consent.
Ask the woman's friend to sign the informed consent since the client is
unresponsive.
Maintain continuous monitoring of the client until a family member can be
located.
Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse to provide for this 3-year-old child?
Set of cloth hand puppets.
Barbie doll and clothes.
Duck that squeaks.
Hand-held video game.
While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?
Call 911 immediately then begin cardiopulmonary resuscitation.
The Heimlich maneuver using chest thrusts.
The Heimlich maneuver using subdiaphragmatic thrusts.
Cardiopulmonary resuscitation with uterine tilt.
After placing a 36-week-gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next
Open the isolette door to assess the infant's vital signs.
Place erythromycin opthalmic ointment in both eyes.
Remove the wet blankets and linens from the isolette.
Administer the vitamin K (AquaMEPHYTON) injection.
A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement?
Reschedule administration of the antibiotic until after he completes his prayers.
Instruct the client that the antibiotics must be given on time to be effective.
Notify the healthcare provider that the client has refused the scheduled antibiotic.
Ask the pharmacist to supply an oral form of the antibiotic for the client.
The nurse learns that a newly admitted adult client has a six month history of recurring somatic pain. During the admission interview, it is most important for the nurse to question the client about what problem ?
Episodes of tremors.
Feelings of depression.
Periods of restlessness.
Nausea and vomiting.
The nurse administers nalbuphine (Nubain) to a postoperative client. What etiology, secondary to the medication's effects, places the client at risk for injury?
Bleeding complications.
Adverse CNS effects.
Electrolyte imbalance.
Immune system suppression.
A client who has end-stage renal disease (ESRD) continues to be despondent after receiving the biologic response modifier (BRM) epoetin alfa (Epogen, Procrit) for 3 weeks. Which parameters should the nurse assess when evaluating the effectiveness of this BRM?
WBCs, neutrophil and T4 count.
RBCs, hemoglobin, and hematocrit.
Blood pressure, heart rate, and temperature
Serum potassium, calcium, and phosphorus.
A 25-year-old male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. What is the most important information for the nurse to include in the teaching plan?
Avoid penile contact with the rectal area.
Epididymitis is a pre-cancerous condition.
Obtain an annual prostate digital exam.
Surgical intervention is often indicated
A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?
Increase the intake of salty foods.
Administer NaCl supplements.
Restrict oral fluid intake.
Hold the client's loop diuretic.
A young adult male is brought to the emergency room with multiple gunshot wounds in the chest, abdomen, and head. After collecting the client's blood-saturated clothing as forensic evidence for the medical examiner, which action should the nurse implement?
Fold clothing in a large specimen container and send to the pathology lab.
Roll the clothing in a towel and cover it with an impermeable drape.
Place the clothes in a paper bag and transfer bag to a red biohazard bag.
Drop the clothes in a red plastic bag and maintain blood-borne
A male client asks the nurse how long his hospital stay will be following his scheduled surgery. Which resource provides the best guide for the nurse in responding to the client?
Critical pathway for the scheduled surgery.
Diagnosis-related group (DRG) for the surgery.
The client's preferred provider arrangement.
Standards of clinical nursing practice.
A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?
Disturbed thought processes.
Altered sleep pattern.
Imbalanced nutrition: less than.
Risk for injury.
The nurse-preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
Warm skin, hypertension, and constricted pupils
Bradycardia, hypotension, and respiratory acidosis.
Mottled skin, tachypnea, and hyperactive bowel sounds
Tachycardia, mental status change, and low urine output.
Prior to obtaining an axillary temperature, the nurse should perform which action?
Check the last oral temperature reading.
Ask the client when he last ate or drank.
Place a protective sheath over the thermometer.
Position the client's arm at heart level.
When is the best time for the nurse to assess a client for residual urine?
When the client's bladder is distended.
Immediately after the client voids.
Just prior to the client voiding.
After draining the urinary catheter bag.
Which finding should raise the greatest concern for a nurse who is performing an ENT examination?
A painful ulcerated mucosal area inside the cheek for 1 day.
Stippled gingival margins that adhere firmly to the teeth.
A number of small yellowish-white and raised lesions on the buccal mucosa.
An ulceration under the tongue that has been present for the last three weeks.
During a home visit, the nurse should evaluate the adequacy of a client's treatment for COPD by assessing for which primary symptom?
Dyspnea
Tachycardia.
Unilateral diminished breath sounds.
Edema of the ankles.
The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?
An Asian-American mother reports using cupping to treat infection, resulting in
a pattern of red round marks on her toddler's back.
A Hispanic pregnant client who is often late for appointments, arrives late for
today's appointment.
A Native-American who is being interviewed will not make direct eye
contact when asked about violence in the home.
An African-American infant who is spitting up milk has lost 6 ounces since last
week's clinic visit.
When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling "out of breath" but denies any other complaints. What action should the nurse take at this time?
Administer a PRN prescription for diphenhydramine (Benadryl).
Start the normal saline attached to the Y- tubing at the same rate.
Decrease the intravenous flow rate of the PRBC transfusion.
Ask the respiratory therapist to administer PRN albuterol (Ventolin.).
The nurse observes that a client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?
Discontinue the IV and apply pressure at the site.
Decrease the saline to a keep-open rate.
Increase the rate of the current IV solution.
Change the IV fluid to 0.45% normal saline at the same rate.
A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time?
Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant.
Help the client place a call to the HMO to seek information about limitations of coverage.
Encourage the client to call a lawyer so that a lawsuit can be filed against the HMO if necessary.
Have the social worker call the state board of insurance to register a complaint against the HMO.
98. The charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel
Remove the glass of water and speak to the UAP.
Discuss the incident with the UAP at the end of the day.
Write an incident report and notify the healthcare provider.
Remind the client of the potential for electrolyte imbalance.
Which assessment is most important for the nurse to complete to determine a client's tolerance for ambulation?
Respiratory rate.
Capillary refill.
Pedal pulses.
Skin turgor.
