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Worksheets1111 exam 5 pt.2 oucomes
Total questions: 65
Worksheet time: 33mins
A client receiving a rapid blood transfusion reports sudden shortness of breath, has crackles in all lung fields, and a BP increase from 128/70 to 168/90. What is the nurse’s priority action?
Slow the infusion to keep vein open
Stop the transfusion and position the client upright with legs dependent
Increase oxygen to 2 L/min
Assess temperature and check for fever
A client with CHF receiving IV fluids at 150 mL/hr develops a new S3 sound and jugular venous distention. What additional finding supports circulatory overload?
Bounding peripheral pulses and increased respiratory rate
Decreased blood pressure
Dry mucous membranes
Flat neck veins
A postop client receiving IV antibiotics suddenly develops restlessness, tachypnea, and pink frothy sputum. Which lab finding is consistent with fluid overload?
Serum osmolality 285
BNP 1,200 pg/mL
Potassium 4.1
Hemoglobin 12.5
Which task should the RN delegate to an AP for a client on fall precautions with new hyponatremia?
Educate the client on fluid restriction
Perform hourly rounding and assist with ambulation using a gait belt
Evaluate response to hypertonic saline
Monitor neurological status every hour
The RN is caring for multiple clients. Which task can be delegated to an AP?
Assessing peripheral edema
Reinforcing fat-soluble vitamin teaching
Monitoring for dyspnea during IV Lasix
Obtaining daily weights using the same scale at the same time each day
The RN is delegating care on a postoperative unit. Which assignment is appropriate for an AP?
Ambulate a client 1 hour after receiving IV morphine
Assess surgical dressing integrity
Assist a stable client to the bathroom using a walker after safety checks
Teach incentive spirometry use
A client with a suspected paralytic ileus after surgery reports increasing abdominal distention and nausea. Which intervention is appropriate?
Provide clear liquids as tolerated
Maintain NPO status and anticipate NG tube decompression per provider order
Administer oral simethicone
Encourage ambulation immediately
A nurse reviews findings for a client with a paralytic ileus. Which assessment requires immediate action?
Hypoactive bowel sounds
Mild abdominal tenderness
Vomiting large amounts of green bile despite NPO status
Pulse 88/min
A client with prolonged immobility is diagnosed with a paralytic ileus. Which priority intervention supports resolution?
Providing a high-fiber diet
Administering IV fluids to correct electrolyte imbalances that worsen ileus (e.g., hypokalemia)
Encouraging oral potassium
Restricting mobility
While checking equipment, the nurse finds an IV pump with an exposed wire. Which action is appropriate?
Cover with tape until maintenance arrives
Remove pump from service and label as “Do Not Use” immediately before notifying biomedical engineering
Continue using and monitor for sparks
Turn pump off and return to storage
A nurse is educating AP staff about electrical safety. Which statement indicates understanding?
I can use extension cords if the outlet is far.
I will plug equipment only into grounded, hospital-approved outlets.
I can operate equipment with frayed cords if it still works.
I can unplug devices by pulling the cord.
A nurse plugs a portable suction machine into a non-grounded outlet and senses heat from the cord. What should the nurse do?
Continue using it but monitor
Reduce suction pressure
Disconnect immediately and report a potential electrical hazard to engineering services
Move the cord under the bed
A client with osteoporosis needs dietary teaching. Which menu choice reflects good understanding?
Oatmeal with raisins
White bread and jelly
Apple juice and toast
Greek yogurt with fortified orange juice on the side
A nurse teaches a client about calcium absorption. Which statement indicates correct understanding?
Caffeine will help my body absorb more calcium.
I need vitamin D along with dietary calcium for proper absorption.
Spinach is the best source of absorbable calcium.
Calcium supplements should be taken with soda.
A client recently started a calcium supplement. Which finding indicates inadequate dietary calcium intake?
Tachycardia
Hyperreflexia
Numbness and tingling around the mouth (positive Chvostek sign) despite supplementation
Constipation
A postop abdominal surgery client is at risk for dehiscence. Which finding increases that risk?
BMI 24
Albumin 4.0
Persistent cough with poor pain control at incision site
Controlled glucose
Which client is MOST at risk for wound dehiscence?
Client with asthma
Client with hypoalbuminemia and vomiting episodes after surgery
Client with controlled hypertension
Client with no nausea
A nurse assesses a surgical incision that suddenly begins leaking large amounts of serosanguinous fluid. What does this suggest?
Infection
Evisceration only
Potential early dehiscence requiring immediate support of incision with sterile dressings
Hematoma formation
A nurse caring for a client 6 hours postop notes decreased urine output and HR 118/min. Which action is priority?
Administer PRN opioids
Encourage incentive spirometry
Assess volume status and review IV fluid orders for possible hypovolemia correction
Increase ambulation
A client recovering from abdominal surgery suddenly becomes pale, restless, and hypertensive. What is the nurse’s FIRST action?
Assess the airway and apply oxygen as needed before further interventions.
Apply warm blankets
Change the dressing
Reposition supine
A nurse notes that a postop client has a weak cough and shallow breathing. Which complication is most likely?
Hypokalemia
Hypertension
Atelectasis due to poor lung expansion postoperatively
Urinary retention
Before giving Kayexalate, which finding must the nurse assess?
Calcium level
BUN
Bowel sounds and abdominal assessment for hypomotility risk before administering medication
Capillary refill
Which action indicates that Kayexalate has been effective?
Increased urine output
Improved appetite
Serum potassium decreases from 6.4 to 5.1 mEq/L
Regular heart rate of 100/min
A client receiving Kayexalate reports watery diarrhea. What is the nurse’s priority?
Encourage ambulation
Monitor for dehydration and electrolyte shifts due to sodium polystyrene sulfonate effect
Hold all medications
Increase dietary potassium
A client taking calcium carbonate reports nausea and muscle weakness. Which finding indicates toxicity?
Potassium 3.9
Sodium 136
Magnesium 1.9
Calcium 12.8 mg/dL with decreased reflexes and confusion
Which client finding suggests adverse effects from excessive calcium supplementation?
Hyperreflexia
Kidney stone formation and flank pain reported over 2 days
Diarrhea
Tachycardia
A client on chronic calcium supplements shows ECG changes. Which lab finding explains this?
K+ 4.0
Ca+ 13.2 mg/dL (dangerously high)
Mg 1.8
Phos 3.4
A client with long-term alcohol use presents with tremors, diaphoresis, and BP 164/102. What is the immediate nursing action?
Provide juice
Start IV fluids
Administer scheduled benzodiazepine per CIWA protocol for withdrawal symptoms
Encourage deep breathing
Which finding indicates complications from chronic alcohol use?
Normal blood pressure
Peripheral neuropathy with numbness and burning in extremities
Increased appetite
Decreased bilirubin
A nurse is preparing teaching for a client with a history of alcohol abuse. Which nutrient is MOST important?
Vitamin C
Thiamine (B1) to prevent Wernicke-Korsakoff syndrome
Vitamin K
Calcium
A client asks how gas exchange works. Which statement shows understanding of diffusion?
My lungs push oxygen into my blood.
Oxygen moves from high concentration in the lungs to lower concentration in the blood.
CO₂ requires energy to move out of my body.
The heart forces gases across membranes.
A nurse evaluating teaching recognizes correct understanding when the client states:
Diffusion moves particles from low to high concentration.
Water follows protein in diffusion.
Diffusion does not require energy and goes down a concentration gradient.
Diffusion only happens in the kidneys.
Which situation best represents diffusion?
Water moving through a membrane
Sodium moving via protein pump
Oxygen moving from alveoli to pulmonary capillaries down its gradient.
Glucose transported with insulin
A client with vomiting and diarrhea has K+ of 2.6 mEq/L. Which assessment finding is expected?
Hyperactive bowel sounds
Hypertension
Decreased respiratory rate
Flattened T waves and weak, irregular pulse on ECG monitoring
A nurse suspects hypokalemia. Which manifestation supports the finding?
Diarrhea
Muscle twitching
Shallow respirations and decreased breath sounds due to weak respiratory muscles
Tall peaked T waves
A client with hypokalemia related to NG suction will likely exhibit which finding?
Hyperreflexia
Abdominal distention and hypoactive bowel sounds due to decreased smooth muscle contraction.
Increased GI motility
Hypertensive crisis
Before initiating an IV solution, which action is PRIORITY?
Document rate
Check blood sugar
Verify provider order, solution type, and compatibility before obtaining fluid bag.
Apply warm compress
A nurse prepares to start IV D5 ½NS. Which assessment must be done first?
Pedal pulses
Respiratory rate
Inspect IV site for patency and signs of infiltration before connecting solution.
Temperature
A client receiving hypertonic saline must be monitored for which complication?
Hypovolemia
Fluid overload and pulmonary edema due to fluid shift into vascular space.
Bradycardia
Hypoglycemia
While infusing IV antibiotics, the client reports burning at the site. What is the FIRST action?
Increase rate
Flush the IV
Notify provider
Stop infusion and assess for phlebitis or infiltration.
A client receiving blood develops mild back pain and fever. What should the nurse do next?
Give acetaminophen
Stop transfusion and maintain IV line with normal saline for possible reaction.
Elevate legs
Take blood pressure only
A nurse monitoring an infusion notes cool skin, swelling at the IV site, and slowed rate. What is suspected?
Phlebitis
Infiltration requiring site removal and warm compress application.
Air embolism
Hematoma
A client with peripheral arterial disease needs DVT prevention. Which intervention is appropriate?
Massage the legs
Apply warm compresses
Teach ankle pumping exercises every hour and avoid crossing legs.
Maintain bedrest at all times
Which client action helps reduce venous thromboembolism risk?
Using sequential compression devices consistently while in bed.
Wearing tight socks
Sitting with legs dependent
Avoiding fluid intake
A nurse identifies need for further teaching when a client states:
I’ll do foot circles.
I’ll walk as tolerated.
I’ll use my SCDs every night.
I should massage my calves if they feel tight.
Which statement indicates appropriate preoperative teaching?
I should stay in bed after surgery.
I can eat breakfast before my procedure.
I need to stop herbal supplements 1–2 weeks prior to surgery.
A nurse plans pre-op teaching for total knee replacement. Which should be included?
Avoid incentive spirometry
Expect to stay on strict bedrest
Practice deep-breathing, coughing, and leg exercises before surgery.
Drink water up until surgery
Which finding indicates appropriate preop learning?
I’ll take all my meds the morning of surgery.
I won’t wear lotion or makeup on the day of surgery.
I’ll bring valuables with me.
I will avoid moving after surgery.
A postop client reports a sudden “popping” at the incision site. The nurse finds the wound partially separated. What is the FIRST action?
Remove sutures
Cover wound with sterile saline-soaked dressing and notify provider immediately.
Apply abdominal binder
Ambulate client
A nurse teaches about potassium-rich foods. Which meal shows correct understanding?
Turkey sandwich
Baked potatoes with spinach and yogurt smoothie.
White rice with carrots
Chicken noodle soup
A nurse reviews labs for a client with dehydration receiving a continuous IV infusion. Which action is priority?
Maintain infusion at ordered rate
Monitor lungs closely for fluid overload as rehydration proceeds.
Restrict fluids
Stop infusion for mild edema
During IV therapy, the client develops chest pain and dyspnea. What is the FIRST nursing action?
Check BP
Trendelenburg position
Clamp IV tubing and place client on left side to prevent air embolus travel.
Obtain ECG
Which finding after spinal anesthesia requires rapid response?
Mild itching
Headache relieved when lying flat
Severe hypotension with bradycardia and decreased sensation above expected level.
Nausea
A nurse suspects catheter-related pneumothorax after central line insertion. Which finding supports this?
Crackles
Sudden shortness of breath and tracheal deviation toward opposite side.
Fever
Hypertension
Which client is MOST at risk for surgical complications?
50-year-old nonsmoker
22-year-old athlete
74-year-old diabetic client with BMI 36 and history of COPD.
40-year-old with stable vitals
A client received 250 mL IV antibiotics and 50 mL for flushes. What should the nurse document as intake?
100 mL
300 mL total IV intake.
250 mL
50 mL
Before a colonoscopy, which instruction is appropriate?
Eat light breakfast
Avoid clear liquids
Take bowel prep and maintain NPO after midnight per orders.
Avoid walking
Which postop finding in a smoker requires IMMEDIATE intervention?
Slight cough
Diminished breath sounds with low O2 saturation unresponsive to coughing.
HR 96
Pain 4/10
A nurse reviews PO potassium orders for a client with K+ of 3.0. Which action is correct?
Crush extended-release tablets
Give on empty stomach
Administer with a full glass of water and monitor for GI upset.
Push IV K+ rapidly
Which teaching about DVT prevention is accurate?
I shouldn’t move my legs.
I’ll flex my feet and rotate my ankles while in bed.
I should massage my calves.
I won’t drink fluids.
A nurse teaches incentive spirometer use. Which instruction is correct?
Exhale quickly into the device
Inhale slowly and deeply to raise the marker, then hold breath for 3–5 seconds.
Use once per day
Lie flat while using
Which teaching about DVT prevention is accurate?
I shouldn’t move my legs.
I’ll flex my feet and rotate my ankles while in bed.
I should massage my calves.
I won’t drink fluids.
A nurse teaches incentive spirometer use. Which instruction is correct?
Exhale quickly into the device
Inhale slowly and deeply to raise the marker, then hold breath for 3–5 seconds.
Use once per day
Lie flat while using
A client recovering from magnesium sulfate therapy becomes hypotensive with decreased respirations. What is the antidote?
Vitamin K
Sodium chloride
Calcium gluconate IV push per protocol.
Potassium chloride
A client receiving magnesium sulfate develops absent reflexes. What should the nurse do first?
Increase infusion
Reassess in 30 min
Stop infusion and prepare calcium gluconate.
Administer diuretics
