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WorksheetsNR341 Exam 2 Review
Total questions: 90
Worksheet time: 55mins
A 52-year-old client with newly diagnosed type 2 diabetes mellitus is being discharged with metformin and a plan for lifestyle modifications. Which points should the nurse emphasize to promote effective glycemic control and overall health? Select all that apply.
Take metformin with meals to reduce gastrointestinal side effects
Avoid vigorous exercise to reduce the risk of hypoglycemia
Notify the provider if experiencing unexplained muscle pain
Limit carbohydrate intake by avoiding all fruits and vegetables
Monitor blood glucose regularly, including before & after exercise & maintain a consistent meal schedule &portion sizes
A 74-year-old client with a history of type 2 diabetes is brought to the emergency department by family members. The family reports the client has been increasingly confused, very weak, and has not been eating or drinking well for several days. Upon assessment, the client is lethargic, severely dehydrated, and has dry mucous membranes. Vital signs:
[BP: 90/54 mmHg], [HR: 122 bpm], [RR: 26/min], [Blood glucose: 880 mg/dL], [Serum ketones: Negative], [Arterial pH: 7.38], [Serum osmolality: 350 mOsm/kg]
Which condition does the nurse most likely suspect based on the client’s presentation?
Diabetic Ketoacidosis (DKA)
Hyperosmolar Hyperglycemic Syndrome (HHS)
Hypoglycemia
Septic shock
A client with diabetic ketoacidosis (DKA) is receiving IV insulin and normal saline infusions. When the client’s blood glucose approaches 250 mg/dL, which IV fluid should the nurse expect to administer?
Lactated Ringer’s solution
Total Parenteral Nutrition (TPN)
Dextrose 5% in 0.45% saline solution (D5½NS)
3% Saline solution
A client with hypothyroidism is starting levothyroxine. Which points should the nurse emphasize to ensure safe and effective therapy? SATA
Take levothyroxine with food to reduce stomach upset
Have thyroid function rechecked in about 6-8 weeks & expect to take this medication for life
Report palpitations or chest pain promptly
Store the medication in the refrigerator
Take levothyroxine first thing in the morning on an empty stomach
The nurse is assessing a patient with hypothyroidism. Which of the following are risk factors for developing myxedema coma? Select all that apply.
Discontinuation of thyroid hormone therapy
Exposure to cold temperatures
Use of sedatives or narcotics
Hyperthyroidism
Acute infection or illness
The nurse is reviewing assessment findings for clients with thyroid disorders. Which of the following are clinical manifestations associated with hyperthyroidism? Select all that apply.
Heat intolerance
Bradycardia and cold, dry skin
Weight loss despite increased appetite
Diarrhea, insomnia and restlessnessI
Exophthalmos
The nurse is caring for two clients: one with diabetes insipidus (DI) and one with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which statements reflect correct clinical reasoning for each condition? SATA
“The SIADH client is likely to have higher urine output.”
“The DI client is at risk for hypovolemia due to excessive fluid loss and may have very low urine specific gravity..”
“The SIADH client often shows hyponatremia due to dilution.”
“Desmopressin (DDAVP) is commonly used to treat SIADH.”
“Hypertonic saline could be used in severe cases of SIADH with critical hyponatremia.”
A client with type 1 diabetes asks about managing blood glucose when ill. Which instructions should the nurse include? Select all that apply.
Continue taking insulin or antidiabetic medications normally
Monitor blood glucose every 6-8 hours
Stay hydrated and take mild analgesic for fever or malaise.
Notify the provider if blood glucose is consistently elevated
If blood sugar < 60, take 30 grams of carbohydrate and recheck blood sugar in 30 minutes
A client has just returned from surgery after a total thyroidectomy. Which interventions should the nurse implement to prevent complications and ensure safety? Select all that apply.
Keep a tracheostomy tray at the bedside and monitor for signs of hypocalcemia
Maintain the client in a supine position with no pillows
Monitor VS for symptoms of thyroid storm
Encourage vigorous coughing exercises every hour
Assess for hoarseness or difficulty speaking
A client with known Addison’s disease arrives in the emergency department with severe hypotension, confusion, and hypoglycemia. Which interventions are priority? Select all that apply.
Rapid infusion of IV normal saline & high-dose IV corticosteroids
Restrict fluids to stabilize electrolyte levels
Frequent blood pressure monitoring
Obtain serum electrolyte and cortisol levels
Place the client in Trendelenburg position
A school-age child is diagnosed with growth hormone deficiency and has started recombinant growth hormone injections. Which nursing or caregiver instructions should be provided? Select all that apply.
Administer injections subcutaneously in rotating sites
Expect to see immediate growth within the first week
Teach parents to monitor height and weight regularly at home
Limit physical activity to prevent fractures and stop therapy if growth is not observed by 3 months
Adhere strictly to recommended injection schedule for best results
A 28-year-old client with hypothyroidism takes levothyroxine and recently started oral contraceptives. Which of the following statements by the patient indicates further teaching is needed? Select all that apply.
“My thyroid medication will be discontinued while I’m on oral contraceptives.”
“I will need to have frequent TSH monitoring.”
“Oral contraceptives have no effect on my thyroid hormone dose and I will likely require a lower dose of levothyroxine while on birth control.”
“If I stop taking oral contraceptives, my levothyroxine dose may change again.”
A client with acromegaly has undergone transsphenoidal hypophysectomy. Which postoperative measures should the nurse include to promote healing and prevent complications? Select all that apply.
Instruct the client to avoid coughing, sneezing, or straining
Encourage deep nasal suctioning every 2 hours
Monitor for signs of cerebrospinal fluid (CSF) leak
Position the client flat in bed to reduce strain on the surgical site
Report persistent headache or clear nasal drainage immediately
A client with cirrhosis is scheduled for a paracentesis. Which finding is most concerning?
Elevated INR
Hypoalbuminemia
Abdominal distention
Poor appetite
The nurse is caring for a client with liver cirrhosis. Which nursing assessments or interventions are appropriate for this client? Select all that apply.
Monitor for asterixis and changes in mental status
Increase protein intake for clients with hepatic encephalopathy
Elevate the head of the bed to reduce dyspnea from ascites and measure abdominal girth daily
Administer lactulose as prescribed and monitor for bruising and petechiae
Use NSAIDs (narcotics or acetaminophen) for pain management
The nurse is reviewing the list of clients scheduled for a clinic visit the next day. For which clients should the nurse plan to complete a focused assessment for end-stage liver disease (ESLD)? Select all that apply.
63-year-old smoker with chronic obstructive pulmonary disease (COPD) who drinks 6 beers a week
16-year-old girl with a history of cystic fibrosis (CF) in her first well-woman check-up
70-year-old with hypertension and recent exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
57-year-old with nonalcoholic fatty liver disease (NAFLD) and unexplained weight loss
34-year-old with acute hepatitis A infection nearing the end of treatment
The nurse is teaching a client newly diagnosed with celiac disease. Which instructions should the nurse include in the teaching plan? Select all that apply.
Avoid foods containing wheat, barley, and rye
Look for gluten-free labels on food products and expect lifelong adherence to a gluten-free diet
Include whole wheat bread for dietary fiber
Monitor for signs of iron-deficiency anemia and report persistent diarrhea or weight loss to the provider
Use oat products freely, as they are safe for all individuals with celiac disease
Which teaching point is most appropriate for a client with GERD?
Lie flat after meals
Increase intake of spicy foods
Take antacids before meals
Avoid carbonated beverages
A client with Barrett’s esophagus is prescribed omeprazole. What is the expected therapeutic effect?
Promote gastric motility
Increase stomach acid
Suppress acid production
Neutralize acid in the stomach
When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient‘s right hand. Which action would the nurse take next?
Ask the patient about any arm pain.
Retake the patient‘s blood pressure.
Check the calcium level in the health record.
Notify the health care provider immediately.
Which action would the nurse plan when admitting a patient with acute diverticulitis plan for initial care?
Administer IV fluids.
Prepare for colonoscopy.
Encourage a high-fiber diet.
Give stool softeners and enemas.
The nurse is assessing a client diagnosed with peptic ulcer disease (PUD). Which findings or interventions should the nurse include as part of the care plan? Select all that apply.
Position the client flat after meals to aid digestion
Encourage frequent use of NSAIDs for pain control
Monitor for black, tarry stools and teach the client to avoid caffeine, alcohol, and tobacco
Monitor hemoglobin and hematocrit levels regularly
Recommend small, frequent meals to reduce gastric acid secretion
The nurse is providing discharge teaching to a client diagnosed with irritable bowel syndrome (IBS). Which instructions should the nurse include in the teaching plan? Select all that apply.
Limit intake of caffeine and gas-producing foods and keep a food diary to identify trigger foods
Practice stress-reduction techniques such as yoga or meditation
Use bulk-forming laxatives or antidiarrheals as prescribed
Avoid all fiber in the diet to prevent flare-ups
Establish a regular meal and bowel routine
The nurse is caring for a client with a diagnosis of ulcerative colitis (UC). Which findings or interventions are appropriate for this client? Select all that apply.
Monitor for bloody diarrhea and abdominal cramping
Encourage high-fiber foods to reduce constipation
Assess for signs of dehydration and electrolyte imbalance and administer corticosteroids as prescribed
Prepare the client for possible colonoscopy and teach the client to avoid NSAIDs
Expect cobblestone appearance on colonoscopy
The nurse is caring for a client diagnosed with Crohn’s disease. Which findings or nursing interventions are appropriate for this condition? Select all that apply.
Monitor for weight loss and nutritional deficiencies
Expect a cobblestone appearance of the intestinal mucosa on colonoscopy
Encourage a high-residue, high-fiber diet during flare-ups
Administer anti-inflammatory and immunosuppressive medications as prescribed
Expect continuous lesions beginning at the rectum
After an unimmunized person is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take? (Select all that apply.)
Administer hepatitis B vaccine.
Test for antibodies to hepatitis B.
Teach about a-interferon therapy.
Give hepatitis B immune globulin.
Explain options for oral antiviral therapy.
The nurse is caring for a client with portal hypertension and esophageal varices. Which interventions or assessment findings are appropriate to include in the nursing care plan? Select all that apply.
Monitor for signs of gastrointestinal bleeding such as hematemesis and teach the client to avoid straining during bowel movements
Encourage vigorous coughing to clear secretions
Administer prescribed nonselective beta blockers (e.g., propranolol)
Insert a nasogastric (NG) tube immediately for all clients with varices
Encourage a high-protein diet to promote liver healing
Which information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?
Hematocrit
Liver function
Serum iron level
Mucous membrane color
A nurse is caring for a client with hemochromatosis. What teaching is appropriate?
Increase iron-rich foods
Take iron supplements
Avoid vitamin C supplements
Eat liver and red meat frequently
The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action?
Perform a complete neurologic assessment.
Assess the cranial nerve functions.
Contact the Rapid Response Team.
Reassess the client in 30 minutes.
What is the priority nursing concern for a client experiencing a migraine headache?
Pain
Anxiety
Hopelessness
Risk for brain injury
A client presents to the emergency department with a headache following a recent head injury. Which of the following medications is most appropriate for the nurse to administer to manage the client’s headache?
Ibuprofen (Advil)
Acetaminophen (Tylenol)
Aspirin (Bayer)
Ketorolac (Toradol)
The nurse is assessing a client with a closed head injury. Which of the following findings are most concerning and require immediate follow-up? Select all that apply.
Client reports a headache rated 7 out of 10
Client is oriented but intermittently drowsy
Apical heart rate of 51 bpm
Pupils are equal and reactive to light
Blood pressure of 150/60 mmHg
A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, “I cannot teach any more. It will be too upsetting if I have a seizure at work.” How would the nurse respond to specifically address the patient‘s concern? Select all that apply.
“You may need to stop working permanently to prevent stress from worsening your condition.”
“There are medications that help control seizures in most people with epilepsy.”
“It’s important to educate coworkers and students on how to respond if a seizure does occur.”
“Would you like to talk to someone who has epilepsy and continues working in a similar profession?”
“It’s normal to feel anxious, but epilepsy doesn’t necessarily mean you have to stop working.”
The nurse is reviewing the medication orders for a client admitted with an upper GI bleed due to suspected peptic ulcer disease. Which of the following medications are commonly used in the treatment or management of GI bleeding? Select all that apply.
Pantoprazole (IV)
Octreotide (IV infusion)
Ibuprofen (oral)
Vasopressin (IV infusion)
Sucralfate (oral suspension)
A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene?
Helping the client ambulate to the bathroom and back to bed
Reminding the client not to look at his feet when he is walking
Performing the client’s complete bathing and oral care
Setting up the client's tray and encouraging the client to feed himself
A nurse is assessing a patient with suspected Bell's Palsy. Which of the following symptoms would the nurse most likely observe?
Bilateral facial drooping
Inability to close the eyelid on the affected side
Severe headache and neck stiffness
Sudden vision loss in one eye
Four hours after supratentorial surgery, the client is receiving IV fluid at 80 ml/hr, and the nurse is monitoring the Glasgow Coma Scale. At 1015, the client has turned to the left side and is lying flat. At 1030, the nurse notes change in the client’s status (see table). What should the nurse do next?
Note the changes, and continue to assess the client every 15 minutes.
Notify the surgeon of these findings.
Position the client supine with the HOB elevated to 30 degrees.
Slow the rate of the IV fluid to 60 ml/hr.
The nurse is assessing a client’s motor response after brain surgery. The nurse pinches the client’s skin to elicit a response and observes the client’s arms and legs moving straight out and the feet and toes bending downward. How should the nurse document this response?
Flaccid paralysis
Flexion posturing
Chronic spastic paralysis
Extension posturing
The nurse is caring for a client with increased intracranial pressure (ICP). Which interventions and assessment findings are appropriate to include in the client’s care plan? Select all that apply.
Keep the head of the bed elevated to 30 degrees and avoid hip/neck flexion when positioning the client
Encourage frequent coughing/ suctioning and position the client in Trendelenburg for good venous outflow from the brain
Maintain a calm, quiet environment with minimal stimulation
Monitor for changes in level of consciousness and pupil size
Administer stool softeners as prescribed to prevent straining during bowel movements
Which of the following are characteristics of Cushing's Triad, a late sign of increased intracranial pressure (ICP)?
Hypertension, tachycardia, and apnea
Hypotension, tachycardia, and tachypnea
Hypertension, bradycardia, and irregular respirations
Hypertension, bradycardia, and apnea
A client is diagnosed with increased intracranial pressure (ICP) due to cerebral edema following a traumatic brain injury. Which of the following medications is most appropriate to help reduce the client’s cerebral edema and ICP?
Furosemide (Lasix)
Dexamethasone (Decadron)
Mannitol (Osmitrol)
Phenytoin (Dilantin)
A nurse is caring for a client diagnosed with a subdural hematoma. Which of the following statements regarding client positioning requires correction?
"I will keep the head of the bed elevated to 30 degrees to reduce ICP."
"The client should remain supine at all times to improve cerebral perfusion."
Head midline positioning can help promote venous drainage."
"I will avoid extreme neck flexion when positioning the client."
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What action(s) should the nurse take? SATA
Encourage the client to cough to expectorate secretions.
Elevate the HOB 30 degrees.
Contact the HCP if the ICP is higher than 28 mmHg
Monitor the neurologic status using the Glasgow Coma Scale.
Stimulate the client with active range of motion exercises.
The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens their eyes only as a response to pain, responds with sounds that are not understandable, and has an abnormal extension of their extremities. What should the nurse do?
Attempt to arouse the client
Reposition the client with the extremities in normalalignment.
Chart the client’s level of consciousness as coma.
Notify the health care provider (HCP).
A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient‘s Glasgow Coma Scale score?
9
11
13
15
A nurse is teaching a group of nursing students about the Glasgow Coma Scale. The nurse explains that the lowest possible score on the scale is 3. Which of the following is the reason for this score?
The patient is fully awake and oriented.
The patient does not open eyes, make any sounds, or move.
The patient is in a coma but responds to painful stimuli.
The patient is disoriented and confused.
A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first?
Administer the ordered acetaminophen.
Check the Foley tubing for kinks or obstruction.
Adjust the temperature in the client’s room.
Notify the health care provider about the change in status.
A client presents with signs of anaphylactic shock after a medication reaction. Which of the following interventions should the nurse implement first?
Administer diphenhydramine 25 mg IV push
Administer oxygen
Insert a large-bore IV catheter
Complete a full head-to-toe assessment
A nurse is explaining the pathophysiology of septic shock to a new graduate nurse. Which statements accurately describe the underlying mechanisms? (Select all that apply.)
Caused by systemic inflammation leading to widespread vasodilation.
Leads to increased vascular permeability
Sepsis causes microthrombi formation, leadingto impaired tissue perfusion.
Hypotension is resistant to fluid resuscitation.
Primarily results from an excessive immune response to an infection.
A nurse is preparing to administer the first-line treatment for septic shock. Which interventions should be initiated immediately? (Select all that apply.)
Obtain blood cultures
Administer a 30 ml/kg IV fluid bolus
Start norepinephrine
Broad-spectrum IV antibiotics
Measure serum lactate levels
A nurse is monitoring a patient with sepsis. Which finding requires immediate intervention?
Temperature of 100.5°F (38.1 °C)
White blood cell count of 22,000/mm3
Heart rate of 108 bpm
Lactate level of 4.5 mmol/L
A patient with sepsis is at risk for developing complications. Which conditions should the nurse monitor for? (Select all that apply.)
Acute respiratory distress syndrome (ARDS)
Disseminated intravascular coagulation (DIC)
Myocardial infarction (Ml)
Acute kidney injury (AKI)
Multi-organ dysfunction syndrome (MODS)
Which laboratory findings suggest sepsis progressing to septic shock? (Select all that apply.)
Elevated lactate and elevated procalcitonin
Leukocytosis
Increased platelet count
Metabolic acidosis
Hyperglycemia
A nurse is assessing a client with suspected cardiogenic shock. Which of the following findings is most characteristic of cardiogenic shock?
Warm, flushed skin
Hypertension with a widened pulse pressure
Weak, thready pulse with hypotension
Bradycardia with bounding pulses
A client arrives in the emergency department with acute pulmonary edema and a history myocardial infarction. The physician suspects cardiogenic shock. Which initial diagnostic test is most helpful in confirming this diagnosis?
Echocardiogram
12-lead ECG
Chest X-ray
Serum electrolytes
The nurse is caring for a client with cardiogenic shock who is receiving intravenous dobutamine. Which assessment finding indicates that the medication is effective?
Improved peripheral pulses and warm extremities
Heart rate of 120 bpm
Mean arterial pressure (MAP) of 55 mmHg
Urine output of 0.3 mL/kg/hr
A nurse is preparing to administer carvedilol to a client in mild cardiogenic shock. Which assessment finding would cause the nurse to hold the medication and notify the provider?
Blood pressure of 144/82 mmHg
Heart rate of 55 bpm
Respiratory rate of 20 breaths/min
Oxygen saturation of 92% on room air
A nurse is assessing a client with cardiogenic shock. Which of the following clinical manifestations would the nurse expect to find? (Select all that apply)
Crackles in the lungs
Bounding peripheral pulses
Oliguria & Hypotension
Jugular venous distention
Bradycardia
A nurse is preparing to administer medications to a client in cardiogenic shock. Which medications might be used to improve cardiac output? (Select all that apply)
Dobutamine
Metoprolol
Milrinone
Digitalis
Furosemide
The nurse is planning care for a client with cardiogenic shock who is at high risk for complications. Which of the following complications are most directly associated with cardiogenic shock? (Select all that apply)
Acute renal failure
COPD
Pulmonary edema
Liver cirrhosis
Disseminated intravascular coagulation (DIC)
A nurse is caring for a client with cardiogenic shock who is hemodynamically unstable. Which immediate interventions might the care team implement to stabilize this client’s
condition? (Select all that apply)
Insertion of an intra-aortic balloon pump
Administration of packed red blood cells
Administration of IV fluids at a rapid rate
Continuous infusion of inotropes (e.g., dobutamine)
Vasopressor support (e.g., norepinephrine)
Which statement best explains the pathophysiology of neurogenic shock following acute spinal cord injury?
Increased parasympathetic outflow causes systemic vasoconstriction and bradycardia.
Increased sympathetic outflow leads to severe tachycardia and elevated blood pressure.
Decreased parasympathetic outflow causes vasoconstriction and bradycardia.
Decreased sympathetic outflow leads to vasodilation and decreased heart rate.
A 25-year-old patient with an acute cervical spine injury is experiencing neurogenic shock. After stabilizing the cervical spine, what is the nurse’s priority intervention?
Begin IVfluid bolus
Administer intravenous atropine
Ensure adequate ventilation
Administer a vasopressor infusion
A patient with a C5 spinal cord injury is in neurogenic shock. What is the best nursing assessment to detect impending respiratory failure?
Continuous monitoring of end-tidal CO₂
Pulse oximetry reading every four hours
Obtaining arterial blood gases (ABGs) once per shift
Assessing for cyanosis once per shift
When monitoring a patient in neurogenic shock, which lab value is most critical to assess frequently to ensure adequate perfusion?
Hemoglobin and hematocrit
Serum potassium level
Serum lactate level
BUN and creatinine
A patient recovering from neurogenic shock asks the nurse if the shock state can improve. Which response by the nurse is most accurate?
“Neurogenic shock is typically permanent and leads to permanent bradycardia.”
“Once your spinal cord swelling decreases and your sympathetic pathways recover, the shock can resolve.”
“Neurogenic shock always resolves within 24 hours regardless of the injury level.”
“Neurogenic shock may improve only with surgical intervention.”
The nurse recognizes that the primary goal of pharmacologic therapy in neurogenic shock is to:
Reduce afterload and promote vasodilation
Increase heart rate and systemic vascular resistance
Decrease oxygen demand of the myocardium
Promote diuresis to lower intracranial pressure
Which client is at the highest risk for developing acute renal failure (ARF)?
A 25-year-old client with asthma using albuterol inhaler.
A 50-year-old client with heart failure.
A 32-year-old client recovering from an uncomplicated appendectomy.
A 70-year-old client with pneumonia.
A nurse is assessing a client with suspected acute renal failure. Which clinical manifestation should the nurse expect?
Polyuria
Decreased blood pressure
Hypercalcemia
Hyperkalemia
A client with acute renal failure has a potassium level of 6.5 mEq/L. Which action should be assigned to the first- year student nurse?
Administer sodium polystyrene sulfonate (Kayexalate)
Assess the cardiac rhythm
Administer oral potassium.
Administer calcium gluconate intravenously
Which dietary recommendation is most appropriate for a client in the oliguric phase of acute renal failure?
High-protein, low-carbohydrate diet
High-carbohydrate, low-protein diet
High-protein, high-sodium diet
Low-carbohydrate, high-fat diet
A client undergoing peritoneal dialysis develops cloudy dialysate effluent, along with abdominal pain, and cramping. After receiving orders from the HCP, which is the priority intervention?
Abdominal ultrasound
Administer prescribed antibiotics
Surgical consult for hemodialysis catheter placement.
Increase the dwell time of dialysis fluid.
The nurse knows that prerenal causes of acute renal failure include which of the following?
Glomerulonephritis
Prolonged hypotension
Kidney stones
Acute tubular necrosis
A nurse is administering fluids to a burn patient. Which indicator best determines the adequacy of fluid resuscitation?
Central venous pressure (CVP)
Blood Pressure
Skin Turgor
Adequate urine output
The nurse is preparing to measure a client’s central venous pressure (CVP). To ensure accurate measurement, where should the zero-reference point of the transducer be placed?
At the mid-axillary line at the 4th intercostal space (phlebostatic axis)
At the head of the bed above the client’s neck
In line with the CVP catheter insertion site
At the mitral valve area, left 5th intercostal space
The nurse is reviewing hemodynamic principles with a nursing student. Which of the following statements accurately describes the effects of increased afterload?
Increased afterload decreases myocardial oxygen demand and increases cardiac output
Increased afterload reduces the workload of the heart and enhances stroke volume
Increased afterload results in increased oxygen demand and decreased cardiac output
Increased afterload improves ventricular filling and reduces preload
The nurse reviews an ABG report for a client with chronic obstructive pulmonary disease (COPD). The results are as follows.
pH = 7.35; pCO2 = 62; pO2 = 70; HCO3 = 34
What should the nurse do first?
Apply a 100% non-rebreather mask
Assess the vital signs
Reposition the client
Prepare for intubation
A nurse is caring for a client admitted with pneumonia. The client’s vital signs are:
Temperature: 100.8°F (38.2°C)
Heart Rate: 112 bpm
Blood Pressure: 90/54 mmHg
Oxygen Saturation: 93% on room air
Place the nurse’s actions in the correct order of priority.
1.) Apply nasal cannula at 2L/min and titrate to maintain O₂ saturation >95%
2.) Administer Vancomycin 750 mg IV infusion
3.) Administer 1L Normal Saline over 1 hour
4.) Obtain urine and blood cultures
5.) Place the client in high Fowler’s position
5 → 4 → 2 → 3 → 1
4→ 2 → 5 → 3 → 1
5 → 1 → 4 → 3 → 2
Based on the client's condition and priority need, which orders by the physician would the nurse anticipate at this time? Select all that apply:
1) Start two IV lines with large bore catheters.
2) Administer IV esomeprazole bolus.
3) Place client on strict NPO.
4) Type and cross match 2 units of packed red blood cells.
5) Prepare client for surgery immediately.
6) Start O₂ via nasal cannula.
7) Give 500 mL normal saline over 30 minutes.
8) Monitor continuous oxygen saturation.
1, 2, 3, 4, 5, 6, 7, 8
1, 2, 3, 4, 5, _, 7, 8
1,3, 6, 7, 8
1, 2, 3, 6, 7, 8
1, 2, 3, 4, 6, 7, 8
A client who is 5 days postoperative following a right colectomy to remove a bowel tumor calls the nurse and states that they felt a popping sensation in the incision after an episode of forceful coughing. The nurse removes the abdominal dressing and notes that the incision has opened, wound layers are separated, and a portion of the bowel is protruding from the wound. Select the potential intervention listed below if it is indicated (appropriate or necessary) for the plan of care for the client at this time.
Place the client with the head and body flat & with the hips and knees bent.
Place a sterile, warm, saline-soaked dressing over the open wound.
Don sterile gloves & gently reinsert the protruding bowel into the wound & provide the client with small amounts of water to stay hydrated.
Notify the surgeon & prepare the client for surgery.
Assess VS every 10 minutes.
A 39-year-old client is being seen in the outpatient pain management clinic. The client was in a motor vehicle accident 1 year ago & sustained an injury to the cervical & lumbar spine & has been experiencing neck & back pain since the injury. The client has tried conservative measures, including ice & heat, massage, & PT. The client has also tried acetaminophen, NSAIDs, muscle relaxants, and opioid analgesics, & the pain has become intolerable again even with these measures. The pain management specialist has added amitriptyline to the treatment plan, & the nurse provides teaching to the client about the plan. The client returns to the clinic 1 month later for a follow-up evaluation. Which observations indicate that the treatment plan is effective?
Client states: "My back and neck are sore after PT.”
Client states: “I have been walking a mile each day before going to work.”
Client states: “I need to wear my neck collar all the time because I need it for added support.”
Client ambulates to the examination room and is limping and leaning the hand on the wall while walking.
Client states: “I know that new medication is used for depression but it has helped my pain too.”
The nurse is reviewing hemodynamic concepts with a nursing student. Which of the following statements accurately reflect an understanding of cardiac output, stroke volume, and central venous pressure (CVP)? Select all that apply.
Stroke volume is the amount of blood ejected from the ventricle with each heartbeat
Cardiac Output (CO) is the volume of blood the heart pumps per minute.
Normal central venous pressure (CVP) ranges from 2 to 8 mmHg and measured from the right atrium/superior vena cava
Cardiac output reflects the amount of blood pumped by the heart every hour
Decreased contractility increases stroke volume
A client with a SAH (Subarachnoid Hemorrhage) has a seizure that lasts 3 minutes. Which assessment should the nurse complete first?
auscultate for bowel sounds
check the clients pulse oximetry
check for incontinence of urine or stool
place client on monitor and assess cardiac rhythm
The nurse is preparing to perform an abdominal assessment on a client. Which of the following actions reflect the correct sequence of assessment techniques for the abdomen? Select all that apply.
A. Inspect the abdomen for contour and skin changes
B. Palpate the abdomen for tenderness or masses
C. Auscultate bowel sounds in all four quadrants
D. Percuss the abdomen to identify underlying structures
A. Inspect the abdomen for contour and skin changes
B. Auscultate bowel sounds in all four quadrants
C. Percuss the abdomen to identify underlying structures
D. Palpate the abdomen for tenderness or masses
A nurse is performing the primary survey on a client who was brought to the emergency department after a motor vehicle accident. Which of the following actions should the nurse include in the primary survey? Select all that apply.
Check the client's airway for patency
Assess the client's level of consciousness
Inspect the client for external bleeding
Place the client in a side-lying position
Expose the client to check for injuries
A homeless client arrives at the trauma emergency department with a knife protruding from his thigh. According to EMTALA regulations, which of the following are appropriate actions for the trauma nurse to take? Select all that apply.
Begin an emergency medical screening examination immediately
Stabilize the client’s condition before discussing transfer options
Remove the knife to begin wound cleaning and closure
Ensure the client is not delayed or turned away based on ability to pay
Document that the client was examined and stabilized regardless of financial status
What are common drugs ordered for client(s) with symptomatic bradycardia?
Atropine, Dopamine, & Epinephrine
Atropine, Diphenhydramine, & Famotidine
Adenosine, Demerol, & Epinephrine
Adenosine, Metoprolol, & Epinephrine
The nurse is reviewing emergency cardiac interventions with a student nurse. Which of the following statements accurately describe the differences between synchronized cardioversion and defibrillation? Select all that apply.
Synchronized cardioversion delivers a shock timed with the R wave of the QRS complex
Defibrillation is used for pulseless ventricular tachycardia and ventricular fibrillation
Synchronized cardioversion is appropriate for unstable atrial fibrillation and SVT
Defibrillation can be used for asystole and pulseless electrical activity (PEA)
Synchronized cardioversion is used for clients with a pulse who are hemodynamically unstable
The nurse is reviewing emergency interventions for cardiac dysrhythmias. Which of the following cardiac rhythms are treated with synchronized cardioversion? Select all that apply.
Unstable supraventricular tachycardia (SVT)
Pulseless ventricular tachycardia (V-Tach)
Ventricular fibrillation (V-Fib)
Unstable atrial fibrillation
Unstable monomorphic ventricular tachycardia with a pulse
