Which of the nursing interventions by the nurse is appropriate?
a. Teach controlled coughing and deep breathing
b. Provide a brightly lit environment
c. Elevate the head of the bed 30 degrees
d. Encourage minimum intake of 2000 mL/day of clear fluids
2. A client is brought to the emergency roo...
1. The nurse is caring for a client who has increased intracranial
pressure. Which of the nursing interventions by the nurse is
appropriate?
a. Teach controlled coughing and deep breathing
b. Provide a brightly lit environment
c. Elevate the head of the bed 30 degrees
d. Encourage minimum intake of 2000 mL/day of clear fluids
2. A client is brought to the emergency room with a 30 percent burn over
her lower extremities. Which of the following interventions should the
nurse perform first?
a. Clean and dress the wound
b. Remove the clients clothing
c. Administer a tetanus
booster d. Initiate a peripheral
IV
3. A nurse is caring for a client admitted to the nursing unit from the
PACU following a craniotomy. The initial nursing assessment should
focus on
a. Intracranial pressure
b. Pupillary reflexes
c. Level of
consciousness d. Airway
patency
4. A nurse is caring for a client who has just returned from the surgical suite
following a thoracotomy. Which of the following postoperative
interventions should the nurse give highest priority to?
a. Administer oxygen by mask via cannula at 6 L/min
b. Monitor urinary output via foley catheter every 2hr
c. Assess chest tube drainage hourly
d. Maintain intravenous of D 5 ½ normal saline at 125 mL/hour
5. A nurse is caring for a client who has acute pancreatitis. After the client’s
pain has been addressed, which of the following is next intervention to
include in the plan of care?
a. Monitor respiratory status every 8 hr
b. Encourage a side-lying position with knees flexed
c. Provide frequent oral
hygiene d. Maintain NPO status
6. A nurse in the emergency department is caring for a client who has
a myasthenia gravis and is in crisis. The nurse knows that which of
the following factors can cause myasthenic crisis?
a. Developing a respiratory infection
b. Taking too much prescribed medication
c. Not getting enough sleep
d. Not exercising enough
7. A nurse is monitoring cardiac output on a client who has left-sided
heart failure. The nurse should expect which of the following findings to
compromise the readings?
a. The client who has premature atrial contractions
b. The client who has decreased oxygen saturations
c. The client who has bilateral wheezes
, d. The client who has lower leg edema
8. An acute care nurse receives shift report for a client with increased
intracranial pressure and is told the client demonstrates decorticate
posturing. Which of the following should the nurse expect to observe
upon assessment of this client?
a. Extension of the extremities
b. Pronation of the hands
c. Plantar flexion of the legs
d. External rotation of the lower extremities
9. A client who has angina pectoris comes to the emergency department
reporting chest pain. When assessing the client, which of the
following findings should the nurse expect? (select all that apply)
a. Weakness in the arms
b. Abdominal
cramps c. Diaphoresis
d. Severe apprehension
e. Dizziness
10. A nurse is preparing to start an intravenous infusion of lactated ringers for
a client who sustained a burn injury. The client is prescribed to receive
5,200 mL of fluid over the first 24 hrs/ How many mL/hr will the nurse set
the pump to infuse for the first 8 hr?
a. 325 mL/hr
11. A nurse is monitoring a client who is receiving a blood transfusion. Which
of the following findings indicates an allergic reaction?
a. Generalized urticarial
b. Blood pressure 184/92 mmHg
c. Distended jugular veins
d. Bilateral flank pain
12. A nurse is caring for a client admitted to the emergency department with
extensive partial and full-thickness burns of the head, neck and chest. While
planning the clients care, the nurse should be aware that initially the client
is at greatest risk for
a. Airway obstruction
b. Infection
c. Fluid imbalance
d. Paralytic ileus
13. A nurse is caring for a client who has a blood pressure of 156/98. Which
of the following finds would the client manifest with Stage 1 hypertension?
a. Vertigo
b. Uremia
c. Blurred vision
d. Dyspnea
14. A nurse is preparing to administer drotecogin alfa (Xigirs) to a client who
has severe sepsis from receiving whole blood. The nurse should be aware
of which of the following when giving the medication?
a. Compatibility with heparin
, b. Parietal thromboplastin
time c. Signs of hemorrhage
d. Administration with NSAIDS
15. A nurse is caring for a client who is receiving a transfusion with one unit of
packed cells because of blood loss during surgery. Thirty minutes after the
unit of blood is hung, the client reports chills and back pain. The client’s
blood pressure is 80/64 mmHg. Which of the following is the first action
the nurse should take?
a. Stop the infusion of blood
b. Inform the provider
c. Obtain a urine specimen
d. Notify the Laboratory
16. A nurse is caring for a client who is receiving a unit of packed red blood
cells. Fifteen minutes following the start of the transfusion, the nurse notes
that the client is flushed, febrile, and having chills. To establish a diagnosis
of hemolytic transfusion reaction, the nurse should assess the client for
which of the following?
a. Headache
b. Anxiety
c. Urticaria
d. Flank pain
17. A nurse is receiving a transfer report for a client who has a head injury.
The client has a Glasgow coma scale score of 3 for eye opening, 5 for best
verbal response, and 5 for the best motor response. Which of the following
is an appropriate conclusion based on this data?
a. The client can follow simple motor commands
b. The client is unstable to make vocal sound
c. The client is unconscious
d. The client opens his eyes when spoken to
18. A nurse is reading a clients ECG tracing. There are nine QRS complexes in a
6 second interval. What is the client’s heart rate?
a. 90/min
19. A nurse is caring for a client who has a spinal fracture and complete spinal
cord transection at the level of C5. Which of the following rehabilitation
goals should the nurse add to the client’s plan of care?
a. Ability to achieve independent transfer from bed to wheelchair
b. Independent control of bowel and bladder function
c. Use of a wheelchair with a chin or mouth stick
d. Ability to self-feed with the use of adaptive equipment
20. A nurse is monitoring a client who has an anterior septal myocardial
infarction. The client is on a dobutamine hydrochloride (Dobutrex) drip.
The nurse understands the rationale for the clients dobutamine drip is to
a. Dilate veins and
arteries b. Improve cardiac
output
c. Reduce hypertension
d. Reduce heart rate
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