Ct Drills Baguio.docx

Safe and Effective Care Environment I. Management of Care 1. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? 1. Assess the client’s level of pain and administer prescribed analgesics. 2. Assess the client’s level of anxiety and provide emotional support. 3. Prepare the client for pulmonary artery catheterization. 4. Ensure that the client’s family is kept informed of his status. RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client’s pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at every step of the recovery process, this action isn’t the priority when treating a client with a suspected MI. 2. Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task? 1. Scheduling staff assignments for the next month 2. Terminating a nursing assistant for insubordination 3. Deciding on salary increases for nurses after they complete orientation 4. Telling a staff nurse to initiate disciplinary action against one of her peers RATIONALE: Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn’t be delegated to staff, who don’t have the power and authority to take such actions. 3. A client is admitted with inflammatory bowel syndrome (Crohn’s disease). Which therapies should the nurse expect to be part of the care plan? Select all that apply. 1. Lactulose therapy 2. High-fiber diet 3. High-protein milkshakes 4. Corticosteroid therapy 5. Antidiarrheal medications 4. Hyperbaric oxygen therapy increases the blood’s capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client With: 1. a compromised skin graft. 2. a malignant tumor.

3. pneumonia. 4. hyperthermia. 5. During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? 1. An 84-year-old client with heart failure who’s on telemetry and 2 L/minute of oxygen. 2. A 42-year-old client who has left lower lobe pneumonia and an I.V. line. 3. A 48-year-old client with chronic obstructive pulmonary disease with occasional atrial fibrillation. 4. A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 [/minute of oxygen, and has an I.V. line. 6. A client with stage IV heart failure has a living will indicating that he doesn’t want to be placed on a ventilator. A nurse is caring for this client when he begins experiencing severe dyspnea. The nurse should: 1. call for respiratory therapy to intubate the client. 2. administer oxygen, morphine, and a bronchodilator for client comfort. 3. ask the client’s family to consent to ventilator placement. 4. administer oxygen and hope the client will change his mind. RATIONALE: A living will is a statement of a client’s wishes in the event that a life-threatening illness or injury occurs. The client’s comfort should be paramount and the nurse should respect his wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will enable him to breathe more easily. The nurse shouldn’t arrange for intubation without the client’s consent or ask his family for permission to initiate mechanical ventilation. 7. A charge nurse completing a deceased client’s chart audit notes that the chart contains a copy of the client’s advance directive and the do- not-resuscitate (DNR) order. While reviewing the nurses’ notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to “Discontinue code blue due to existing advanced directives and DNR from client.” What does the charge nurse conclude? Select all that apply. 1. The nurse was correct to call a code blue. 2. The physician was correct to stop resuscitation efforts. 3. By calling a code blue, the nurse disregarded the client’s advance directives and DNR order. 4. She must have read the chart incorrectly. 5. The code should have continued. 8. Two nurses are discussing a client’s condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which accusation? 1.Assaut 2.Battery 3.Neglect 4.Breath of confidentiality

9. A nurse is making assignments for the infant unit. The shift’s team members include a licensed practical nurse (LPN) with 10 years of experience, a registered nurse (RN) with 3 months of experience, and a client care assistant. Which assignment is most appropriate for the LPN? 1. An infant being discharged to home following placement of a gastrostomy tube 2. An infant just returned from the post anesthesia care unit who requires hourly assessment of vital signs 3. An infant requiring abdominal dressing changes for a wound infection 4. An infant with agonal respirations who ¡s receiving palliative care RATIONALE: The infant requiring dressing changes ¡s within an LPN’s scope of practice. This care has a predictable outcome. Client and family teaching — such as how to care for a gastrostomy tube — is an RN’s responsibility. A client care assistant can be assigned to obtain vital signs and report the findings to the supervising RN. Because the outcome of the infant with agonal respirations is unpredictable, the RN shouldn’t delegate his care to the LPN. 10. A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? 1. Ask the client if he has trouble breathing. 2. Take the client’s blood pressure. 3. Ask the client if he has a headache. 4. Place antiembolism stockings on the client. RATIONALE: The nurse should first assess the client’s breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren’t the nurse’s top priority. 11. A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained? 1. “This implanted defibrillator will protect me against some of those bad rhythms my heart goes into.” 2. “I wonder if there is any other way to prevent these bad rhythms.” 3. “The physician will make a small incision in my chest wall and place the generator there.” 4. “A wire from the generator will be attached to my heart.” RATIONALE: The client wondering if there is another way to prevent the abnormal rhythms indicates that other treatment options weren’t discussed with the client. Before participating in a clinical trial, the client must be informed of all other available treatment options.

The other statements about implantable cardioverter-defibrillators are all true. 12. Which situation demonstrates correct principles of confidentiality? 1. An emergency department nurse reports suspected child abuse. 2. Two nurses in an elevator are discussing a client’s status. 3. A nurse copies and e-mails client information to a friend. 4. During change-of-shift report, a nurse talks about a client’s personal problems. RATIONALE: Any health care provider must report suspected child abuse. Sharing this information doesn’t violate the client’s right to confidentiality. A discussion of confidential information in a public place may be overheard and is a breach of confidentiality. Any client information, whether written or electronic, is considered confidential; e-mailing it to a friend would be considered a breach of confidentiality. Nurses must discuss client’s problems during change-ofshift report, but these discussions should be limited to information needed to provide safe care. 13. A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: 1. “I need to keep my inhaler at the bedside.” 2. “I should eat a high-protein diet.” 3. “I should become involved in a weight loss program.” 4. “I should sleep on my side all night long.” RATIONALE: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won’t alleviate sleep apnea, and the physician probably wouldn’t order an inhaler unless the client had other respiratory complications. A highprotein diet and sleeping on the side aren’t treatment factors associated with sleep apnea. 14. A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin(Coumadin). Which response by the charge nurse is best? 1. “It’s just a coincidence; most clients with atrial fibrillation don’t receive warfarin.” 2. “Warfarin controls heart rate in the client with atrial fibrillation.” 3. “Warfarin prevents atrial fibrillation from progressing to a lethal arrhythmia.” 4. “Warfarin prevents clot formation in the atria of clients with atrial fibrillation.” 15. A registered nurse should assign a nursing assistant to care for a client with inflammatory bowel disease who:

1. requires assistance with ambulation. 2. requires nasogastric suctioning. 3. requires continuous pulse oximetry monitoring. 4. is receiving patient-controlled analgesia.

II. Safety and Infection Control 16. A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? 1. Mumps 2. Impetigo 3. Measles 4. Cholera 17. A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside? 1. Indwelling urinary catheter kit 2. Tracheostomy set 3. Cardiac monitor 4. Humidifier 18. Which nursing intervention is most appropriate if a client develops orthostatic hypotension while taking amitriptyline (Elavil)? 1. Consulting the physician about substituting a different type of antidepressant 2. Advising the client to sit up for 1 minute before getting out of bed. 3. Instructing the client to halve the dosage until the problem resolves 4. Informing the client that this adverse reaction should disappear within 1 week 19. A nurse preceptor is observing a new graduate during care of a client in contact isolation. Which action by the new graduate indicates a need for further teaching about handling infectious materials? 1. The nurse wears gloves during each client contact. 2. The nurse washes her hands when entering and exiting the room. 3. The nurse disposes of articles contaminated with blood in the room’s biohazard container. 4. The nurse uses alcohol gel to clean her hands after changing linen soiled with urine and feces. RATIONALE: Using alcohol gel isn’t acceptable after the nurse has been in contact with soiled material. The nurse should wash her hands with soap and water. The nurse demonstrates appropriate handling of infectious materials by wearing gloves with each client contact, washing her hands with soap and water when she enters and exits the room, and disposing contaminated articles in the room’s biohazard container. 20. A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is

started on the insulin infusion protocol. The nurse must monitor the client’s blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? 1. Sweating, tremors, and tachycardia 2. Dry skin, bradycardia, and somnolence 3. Bradycardia, thirst, and anxiety 4. Polyuria, polydipsia, and polyphagia 21. A nurse is caring for a cardiac client who requires various cardiac medications. When the nurse helps the client out of bed for breakfast, the client becomes dizzy and asks to lie down. The nurse helps the client lie down, puts up the side rails, and obtains the client’s blood pressure, which is 84/50 mm Hg. It’s time for the nurse to administer the client’s medications: nitroglycerin, metoprolol (Lopressor), and furosemide (Lasix). Which action by the nurse is best? 1. Withhold the medications and notify the physician. 2. Administer the medications immediately. 3. Encourage the client to sit up and eat breakfast. 4. Administer the nitroglycerin and metoprolol and withhold the furosemide. 22. A physician orders digoxin (Lanoxin) elixir for a toddler with heart failure. Immediately before administering this drug, the nurse must check the toddler’s: 1. serum sodium level. 2. urine output. 3. weight. 4. apical pulse. 23. A client with myasthenia gravis is receiving continuous mechanical ventilation. When the highpressure alarm on the ventilator sounds, what should the nurse do? 1. Check for an apical pulse. 2. Suction the client’s artificial airway. 3. Increase the oxygen percentage. 4. Ventilate the client with a handheld mechanical ventilator. 24. A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should: 1. consider the client’s urine, feces, and vomitus to be highly radioactive. 2. consider the client to be radioactive for 10 days after implant removal. 3. allow soiled linens to remain in the room until after the client is discharged. 4. maintain the client on complete bed rest with bathroom privileges only. 25. Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? 1. Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding. 2. Put on a mask, gown, and gloves when entering the client’s room.

3. Provide a clear liquid, low-sodium diet. 4. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. 26. Which infection control equipment is necessary for the client diagnosed with Clostridium difficile diarrhea? 1. Gloves 2. Mask 3. Face shield 4. N-95 respirator 27. A nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites? 1. To prevent bruising 2. To prevent medication leakage from tissue or muscle 3. To prevent erratic drug distribution 4. To prevent formation of hard nodules 28. A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? 1. Assessing the client’s temperature every 8 hours 2. Placing the client in respiratory isolation 3. Monitoring the client’s fluid intake and output 4. Wearing gloves during all client contact RATIONALE: Because the client’s signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn’t frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output maybe required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes,broken skin, blood, and other body fluids and substances. 29. A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client’s care plan? 1. Disturbed sensory percept/on (visual) 2. Dressing or grooming self-care deficit 3. Impaired verbal communication 4. Risk for injury RATIONALE: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they’re secondary because they don’t immediately affect the client’s health or safety. 30. Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? 1. Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding. 2. Put on a mask, gown, and gloves when entering the client’s room.

3. Provide a clear liquid, low-sodium diet. 4. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.

Health Promotion and Maintainance 31. A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that coincide with the client’s contractions. What term does the nurse use to document this finding? 1. Prolonged decelerations 2. Early decelerations 3. Late decelerations 4. Accelerations RATIONALE: A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they’re called early decelerations. Early decelerations result from head compression during normal labor and don’t indicate fetal distress. Prolonged decelerations, also known as reflex bradycardia, are decreases in fetal heart rate that last 60 to 90 seconds. These decelerations occur in response to sudden vagal stimulation. Prolonged decelerations may indicate fetal distress. Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends. Accelerations are transient rises in the fetal heart rate that are normally caused by fetal movements and uterine contractions. 32. A nurse is providing teaching to a client who’s being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? 1. “Client will state that she may attempt another pregnancy after 3 months of follow-up care.” 2. “Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge.” 3. “Client will state that she won’t attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises.” 4. “Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.” RATIONALE: After a molar pregnancy, the client should receive follow-up care, including regular HCG testing, for 1 year because of the risk of developing chorionic carcinoma. After removal of a hydatidiform mole, the hCG level gradually falls to a negative reading unless chorionic carcinoma is developing, in which case the hCG level rises. A Pap test isn’t an effective indicator of a hydatidiform mole. A follow up examination wouki be scheduled within weeks of the client’s discharge. The

client must not become pregnant during follow-up care because pregnancy causes the hCG level to rise, making it indistinguishable from this early sign of chorionic carcinoma. 33. A client comes to the clinic because she has experienced a weight loss of 20 lb (9.1 kg) over the last month, even though her appetite has been “ravenous” and she hasn’t changed her activity level. She’s diagnosed with Graves’ disease. Which other signs and symptoms support the diagnosis of Graves’ disease? Select all that apply. 1. Rapid, bounding pulse 2. Bradycardia 3. Heat intolerance 4. Mild tremors 5. Nervousness 6. Constipation 34. An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care? 1. “I use a soft toothbrush to clean my teeth.” 2. “I remove white patches from my tongue and cheeks with my toothbrush.” 3. “I rinse my mouth every 2 to 4 hours with a solution of baking soda and water.” 4. “I don’t use commercial mouthwashes.” 35. A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process? 1. “It will get better and worse again.” 2. “When it clears up, it will never come back.” 4. “I’ll definitely need surgery for this.” 5. “It will never get any better than it is right now.” 36. A child who was hospitalized for sickie cell crisis is being discharged. Which parent outcome demonstrates effective teaching regarding prevention of future crises? 1. The parent verbalizes the need to stay away from persons with known infections. 2. The parent verbalizes appropriate dietary restrictions. 3. The parent verbalizes the need to restrict fluid intake. 4. The parent participates in an aerobic exercise program. 37. A child is receiving chemotherapy for treatment of acute lymphocytic leukemia. During discharge preparation, which topic is most important for the nurse to discuss with the child and parents? 1. How to help the child adjust to an altered body image 2. How to increase the child’s interactions with peers 3. The need to decrease the child’s activity level 4. Ways to prevent infection 38. Which client would qualify for hospice care? 1. A client with late-stage acquired immunodeficiency syndrome (AIDS) 2. A client with left-skied paralysis resulting from a stroke 3. A client who’s undergoing treatment for heroin addiction

4. A client who had coronary artery bypass surgery 2 weeks earlier RATIONALE: Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS, as well as their families. Hospice services wouldn’t be appropriate for a client with leftsided paralysis resulting from a stroke, a client who’s undergoing treatment for heroin addiction, or one who recently had coronary artery bypass surgery because these health problems aren’t necessarily terminal. 39. A child is being discharged with proventil (Albuterol) nebulizer treatments. The nurse should instruct the parents to watch for: 1. tachycardia. 2. bradypnea. 3. urine retention. 4. constipation. 40. A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? 1. “OA is a non-inflammatory joint disease. RA is characterized by inflamed, swollen joints.” 2. “OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints.” 3. “OA affects joints on both sides of the body. RA is usually unilateral.” 4. “OA is more common in women. RA is more common in men. 41. A nurse records a client’s history and discovers several risk factors for coronary artery disease (CAD). Which cardiac risk factors can the client control? 1. Diabetes, hypercholesterolemia, and heredity 2. Diabetes, age, and gender 3. Age, gender, and heredity 4. Diabetes, hypercholesterolemia, and hypertension 42. In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring (EFM) in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion? 1. Persistent fetal bradycardia 2. Variable decelerations 3. Fetal heart rate accelerations 4. Late decelerations 43. A nurse should expect to administer which vaccine to the client after a splenectomy? 1. Recombivax HR 2. Attenuvax 3. Pneumovax 23 4. Tetanus toxoid RATIONALE: Pneumovax 23, a polyvalent pneumococcal vaccine, is administered prophylactically to prevent the pneumococcal sepsis that sometimes occurs after splenectomy. Recombivax HB is a vaccine for hepatitis B. Attenuvax is a live, attenuated virus vaccine for immunization against measles (rubeola). Tetanus toxoid is administered to prevent tetanus

resulting from impaired skin integrity caused by traumatic injury. 44. A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The nurse understands that this score indicates: 1. a neonate who’s in good condition. 2. a neonate who’s mildly depressed. 4. a neonate who’s moderately depressed. 4. a neonate who needs additional oxygen to improve the Apgar score. RATIONALE: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of O to 3 would indicate severe distress. 45. A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (lCD) placed. Which client statement indicates effective teaching? 1. “I’ll keep a log of each time my lCD discharges.” C 2. “I can’t wait to get back to my football league.” 0 3. “I have an appointment for magnetic resonance imaging of my knee scheduled for next week.” 4. “I need to stay at least 10’ away from the microwave.” RATIONALE: The client stating that he should keep a log of all ICD discharges indicates effective teaching. This log helps the client and physician identifý activities that may cause the arrhythmias that make the ¡CD discharge. He should also record the events right before the discharge. Clients with ICDs should avoid contact sports such as football. They must also avoid magnetic fields, which could permanently damage the lCD. Household appliances don’t interfere with the ICD. 46. A nursing assistant is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, “How can I keep from catching this from the client?” The nurse reminds the nursing assistant to wash her hands and to ensure that the client is placed: 1. on protective isolation. 2. on neutropenic precautions. 3. in a negative-pressure room. 4. on contact isolation. 47. A nurse assesses a client in the physician’s office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? 1. Facial erythema, pericarditis, pleuritis, fever, and weight loss 2. Photosensitivity, polyarthralgia, and painful mucous membrane ulcers 3. Weight gain, hypervigilance, hypothermia, and edema of the legs 4. Hypothermia, weight gain, lethargy, and edema of the arms 48. Which complication does a third heart sound (53) indicate?

1. Ventricular dilation 2. Systemic hypertension 3. Aortic valve malfunction 4. Increased atrial contractions 49. A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? 1. “I floss my teeth every morning.” 2. “I use an electric razor to shave.” 3. “I take a stool softener every morning.” 4. “I removed all the throw rugs from the house.” 50. A diet plan is developed for a client with gouty arthritis. The nurse should advice the client to limit his intake of: 1. organ meats. 2. fresh fruits. 3. green vegetables. 4. freshfish. 51. A client with chronic renal failure plans to receive a kidney transplant. Recently, the physician told the client that he is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, “I want to go off dialysis. I’d rather not live than be on this treatment for the rest of my life.” Which responses are appropriate? Select all that apply. 1. Take a seat next to the client and sit quietly. 2. Say to the client, “We all have days when we don’t feel Ike going on.” 3. Leave the room to allow the client to collect his thoughts. 4. Say to the client, “You’re feeling upset about the news you got about the transplant.” 5. Say to the client, “The treatments are only 3 days a week. You can live with that.” 52. Which signs and symptoms might a nurse observe in a client having an adverse reaction to a loop diuretic? Select all that apply. 1. Weakness 2. Irregular pulse 3. Hyperactive bowel sounds 4. Decreased muscle tone 5. Potassium level of 3.1 mEq/L 6. Ventricular arrhythmias 53. A nurse is caring for a client with advanced cancer. Based on the nursing progress notes below, what should be the nurse’s next intervention?

1. Reread the Patient’s Bill of Rights to the client. 2. Call the client’s spouse to discuss the client’s statements. 3. Tell the client that he can receive adequate pain relief only in the hospital.

4. Explain that an advance directive can express the client’s wishes. RATIONALE: The nurse should explain how an advance directive can be used to express the client’s wishes. An advance directive is a legal document that’s used as a guideline for life-sustaining medical care of the client with an advanced disease or disability who can no longer indicate his own wishes. This document can include a living will, which instructs the physician not to administer life-sustaining treatment, and a health care power of attorney, which names another person to act on the client’s behalf for medical decisions in the event that the client can’t act for himself. The Patient’s Bill of Rights doesn’t specifically address the client’s wishes regarding future care. Calling the spouse is a breach of the client’s right to confidentiality. Stating that only a hospital can provide adequate pain relief in a terminal situation demonstrates inadequate knowledge on the nurse’s part of the resources available through collaboration with hospice

58. A nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. Which interventions should the nurse perform? Select all that apply. 1. Place the client in a prone position. 2. Approach the client from the left side. 3. Encourage deep breathing and coughing. 4. Discourage bending down. 5. Orient the client to his environment. 6. Administer a stool softener. 59. A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation below, which laboratory result is the priority for the nurse to report to the physician?

54. While assessing a client’s spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.

1. Rheumatoid factor 2. Blood culture 3. Alkaline Phosphatase 4. ESR 60. A nurse is caring for dlent5 with diabetes insipidus and must be aware of the disorder’s pathophysiology. Place the following events in chronological sequence to show the pathophysiologic process. Use all of the options.

55. A client is ordered heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/ml. How many milliliters of heparin should the nurse administer? Record your answer using one decimal place. Answer: 0.6ml 56. A nurse is caring for a client with a hiatal hernia. The client complains of abdominal pain and sternal pain after eating. The pain makes it difficult for him to sleep. Which instructions should the nurse recommend when teaching this client? Select all that apply. 1. Avoid constrictive clothing. 2. Lie down for 30 minutes after eating. 3. Decrease intake of caffeine and spicy foods. 4. Eat three meals per day. 5. Sleep in semi-Fowler’s position. 6. Maintain a normal body weight.

61. The nurse is admitting a client with newly diagnosed diabetes mellitus and left-sided heart failure. Assessment reveals low blood pressure, increased respiratory rate and depth, drowsiness, and confusion. The client complains of headache and nausea. Based on the serum laboratory results below, how would the nurse interpret the client’s acid—base balance?

57. A nurse is performing cardiac assessment. Identify where the nurse places the stethoscope to best auscultate the pulmonic valve.

1. Metabolic Alkalosis 2. Metabolic Acidosis 3. Respiratory Alkalosis 4. Respiratory Acidosis

62. An elderly client has a history of aortic stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur.

66. The nurse is evaluating an electrocardiogram (ECG) tracing. Which graphic shows the QT interval?

63. A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of ineffective tissue perfusion (peripheral)? Select all that apply. 1. Edema 2. Skin pink in color 3. Strong, bounding pulses 4. Normal sensation 5. Skin discoloration 6. Skin temperature changes 64. While examining the hands of a client with osteoarthritis, a nurse notes heberden’s node on the second (pointer) finger. Identify the area on the finger where the nurse observed the node.

65. 1. A client with sepsis and hypotension is being treated with dopamine hydrochloride. A nurse asks a colleague to double-check the dosage that the client is receiving. The 250-ml bag contains 400 mg of dopamine, the infusion pump ¡s running at 23 mI/hour, and the clent weighs 80 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using one decimal point. Answer: 7.7 mg/kg/min

67. A client with a bicuspid aortic valve has severe stenosis and is scheduled for valve replacement. While teaching the client about the condition and upcoming surgery, the nurse shows a heart illustration. Which valve should the nurse indicate as needing replacement?

68. A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member, the monitor exhibits the following. Which interventions should the nurse do first?

1. Place the client on oxygen 2. Confirm the rhythm with a 12-lead ECG 3. Administer amiodarone I.V. as prescribed 4. Assess the client’s airway, breathing, and circulation.

69. Following coronary artery bypass graft surgery, a client is admitted to the surgical intensive care unit and connected to a cardiac monitor. The nurse can’t detect a pulse or blood pressure and observes the following pattern on the electrocardiogram (ECG) monitor. What does this pattern show?

1. Morphine LV. 2 mg every 2 hours P.R.N. for shortness of breath 2. Furosemide I.V. 40 mg every 6 hours 3. 0.9% normal saline solution I.V. at 150 ml/hour 4. Dobutamine 5 mcg/kg/minute I.V 73. A client who is receiving procainamide has the following electrocardiogram (ECG) tracing. The nurse anticipates that the physician will order which drug?

1. Artifact 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Pulseless electrical activity 70. A nurse determines that a hockey player hospitalized with bilateral leg fractures is hemodynamically stable, She observes the following pattern on the electrocardiogram (ECG) monitor. Which nursing intervention is most appropriate at this time?

1. None; this arrhythmia is benign 2. Administering atropine sulfate, 0.5 mg, as ordered to increase heart rate. 3. Continuing to monitor if lengthening PR intervals 4. Evaluating the client’s serum electrolyte studies 71. A nurse observes the following pattern when monitoring the electrocardiogram (ECG) of a stable client. What should the nurse do?

1. Continue to observe for deterioration of the heart rhythm. 2. Administer 0.5 mg of atropine sulfate by I.V. push as ordered. 3. Prepare for transvenous pacemaker insertion as ordered. 4. Administer amiodarone (Cordarone) 150 mg I.V. as ordered. 72. A nurse is caring for a client with pulmonary edema. The physician writes the following orders. Which order should the nurse clarify?

1. Quinidine sulfate 2. Lidocaine (Xylocaine) 3. A higher dose of procainamide (Pronestyl) 4. Magnesium sulfate RATIONALE: This ECG shows torsades de pointes. In this variant form of ventricular tachycardia, QRS complexes rotate about the baseline, their amplitude decreasing and increasing gradually as the rhythm progresses. To shorten the QT interval and prevent this arrhythmia from recurring, the physician is likely to order magnesium sulfate. Because torsades de pointes is precipitated by a long QT interval, drugs that prolong the QT interval, such as quinidine and procainamide, are contraindicated. The most effective treatment is overdrive pacing with an electronic pacemaker until the offending drug is excreted. Typically, such drugs as lidocaine — normally effective in suppressing ventricular activity — fail to convert torsades de pointes to a normal sinus rhythm. 74. A client is admitted with acute coronary syndrome. The nurse measures the client’s blood pressure at 97/66 mm Hg, obtains a palpable femoral pulse, notes that the client is awake and coherent, and observes the following pattern on the electrocardiogram (ECG) monitor. Based on these findings, the nurse should take which action?

1. Defibrillate at 200 jouIes as ordered. 2. Administer a precordial thump as ordered. 3. Administer amiodarone (Cordarone) 150 mg I.V. 4. Continue to defibrillate at increasing joules, as ordered, until a stable heart rhythm is restored. 75. The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as:

1. Atrial fibrillation. 2. Ventricular tachycardia. 3. Premature ventricular contractions. 4. Sinus tachycardia.

76. The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram strip below). The nurse should:

1. Urine output. 2. Heart rate. 3. Blood pressure. 4. Respiratory rate. 80. An 85-year-old client is admitted to the emergency department (ED) at 8 PM with syncope, shortness of breath, and reported palpitations (See nurse's notes below). At 8:15 PM, the nurse places the client on the ECG monitor and identifies the following rhythm (see below). The nurse should do which of the following? Select all that apply.

1. Notify the physician. 2. Call the rapid response team. 3. Assess the client for changes in the rhythm. 4. Administer lidocaine as prescribed. 77. Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 AM, the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?

1. Administer the medications. 2. Call the physician. 3. Withhold the captopril. 4. Question the metoprolol dose. 78. The nurse observes the cardiac rhythm (see below) for a client who is being admitted with a myocardial infarction. What should the nurse do first?

1. Prepare for immediate cardioversion. 2. Begin cardiopulmonary resuscitation (CPR). 3. Check for a pulse. 4. Prepare for immediate defibrillation. 79. The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which of the following changes on the client's chart to the physician?

1. Apply oxygen. 2. Prepare to defibrillate the client. 3. Monitor vital signs. 4. Have the client sign consent for cardioversion as prescribed. 5. Teach the client about warfarin (Coumadin) treatment and the need for frequent blood testing. 6. Draw blood for a CBC count and thyroid function study. 81. Twenty-four hours after a client undergoes aortic valve replacement surgery, the following pattern appears on the electrocardiogram (ECG) monitor. How should the nurse interpret this pattern?

1. Atrial fibrillation 2. Normal Sinus tachycardia 3. Atrial Flutter 4. Multifocal atrial tachycardia

82. A client is admitted to the surgical intensive care unit following small-bowel resection. The ECG monitor shows the pattern below. What does this pattern indicate?

85. A nurse is evaluating an external fetal monitoring strip. Identify the are on this strip that causes her to be concerned about uteroplacental insufficiency.

1. Ventricular tachycardia 2. Atrial Flutter 3. Atrial fibrillation 4. Normal sinus rhythm 83. On the waveform below, identify the area that indicates possible umbilical cord compression.

84. While waiting to receive report at shift change, a nurse reads the entry below in a client’s chart. After reading this note, the nurse knows her client is in which stage of labor?

1. Stage 1, latent phase 2. Stage 2 3. Stage 1, active phase 4. Stage 1, transition phase RATIONALE: During the active phase of stage 1 labor, membranes may rupture spontaneously. Contractions last about 40 to 60 seconds and recur every 3 to 5 minutes, and the cervix dilates from about 3 cm to 7 cm. During the latent phase of stage 1, contractions last 20 to 40 seconds and occur every 5 to 30 minutes and the cervix dilates from O to 3 cm. During stage 2 labor, the cervix is fully dilated and effaced and the neonate is born. During the transition phase of stage 1, contractions last 60 to 90 seconds and occur every 2 to 3 minutes and the cervix dilates from 7 cm to 10 cm.

86. The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance. 1. Administer the medication over 5 minutes. 2. Dilute the medication with normal saline. 3. Draw up the medication in a tuberculin syringe. 4. Check the client’s identification band. 5. Clamp the primary tubing distal to the port. 11. Correct Answer: 3, 2, 4, 5, 1 3. Because this is less than 1 mL, the nurse should draw this medication up in a 1-mL tuberculin syringe to ensure accuracy of dosage. 2. The nurse should dilute the medication with normal saline to a 5- to 10-mL bolus to help decrease pain during administration and maintain the IV site longer. 3. Administering 0.25 mg of digoxin in 0.5 mL is very difficult, if not impossible, to push over 5 full minutes, which is the manufacturer’s recommended administration rate. If the medication is diluted to a 5- to 10-mL bolus, it is easier for the nurse to administer the medication over 5 minutes. 4. The nurse must check two identifiers according to the Joint Commission safety guidelines. 5. The nurse should clamp the tubing between the port and the primary IV line so that the medication will enter the vein, not ascend up the IV tubing. 1. Cardiovascular and narcotic medications are administered over 5 minutes. 87. The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first? 1. Discontinue the client’s vasoconstrictor, dopamine. 2. Notify the client’s healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client’s neurological status. 12. 1. The nurse should first discontinue the medication that is causing the increase in the client’s blood pressure prior to doing anything else. 2. The nurse should notify the HCP but not prior to taking care of the client’s elevated

blood pressure. 3. The client may need a medication to decrease the blood pressure but the nurse should first discontinue the medication causing the elevated blood pressure. 4. The nurse must first decrease the client’s blood pressure prior to assessing the client. MAKING NURSING DECISIONS: The test taker should remember that when the client is in distress, do not assess. The nurse must intervene and take care of the client. If any of the options is assessment data the HCP will need or an intervention that will help the client, then the test taker should not select the option to notify the HCP. 88. The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with acute rheumatic fever carditis who does not want to stay on bed rest. 2. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; CO3, 22. 3. The client who is showing multifocal premature ventricular contractions (PVCs). 4. The client diagnosed with angina who is scheduled for a cardiac catheterization. 13. 1. The client with rheumatic heart fever is expected to have carditis and should be on bed rest. The nurse needs to talk to the client about the importance of being on bed rest but this client is not in a life-threatening situation and does not need the most experienced nurse. 2. These ABG values are within normal limits; therefore, a less experienced nurse could care for this client. 3. Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client. 4. A cardiac catheterization is a routine procedure and would not require the most experienced nurse. 89. The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? 1. The UAP is instructed to bathe the client who is on telemetry. 2. The UAP is requested to obtain a bedside glucometer reading. 3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic. 14. 1. All clients in the ICU are on telemetry, and the UAP could bathe the client. This would not warrant intervention by the charge nurse. 2. The UAP can perform glucometer checks at the bedside, and there is nothing that indicates the client is unstable. This would not warrant intervention by the charge nurse. 3. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. 4. This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client. 90. The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice.

2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min. 3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8. 15. 1. The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice. 2. The apical heart rate should be greater than 60 beats/minute before administering the medication; therefore, the nurse would not question administering this medication. 3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be taken with foods to prevent gastric upset; therefore, the nurse would not question administering this medication. 4. The INR therapeutic level for warfarin (Coumadin), an anticoagulant, is 2 to 3; therefore, the nurse would not question administering this medication. 91. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D)55 year-old Hispanic teacher The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising. 92. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids. 93. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. 94. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain.

95. What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height. 96. At a community health fair the blood pressure of a 62 yearold client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long. 97. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with StevensJohnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home. 98. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia 99. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status The correct answer is D: Notify the health care provider of the child''s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform

intubation or a tracheostomy in the event of further or complete obstruction. 100. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents