1. A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse
prioritize?
a. The client will successfully mobilize pulmonary secretions.
b. The client will maintain an oxygen saturation level of greater 98%.
c. The client will resume pre-diagnosis level of function within 72 hours.
d. The client’s pulmonary blood pressure will decrease to within reference ranges.
2. A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To
prevent further injury and pain, the nurse caring for this client is aware of what principle of care?
a. The client shoulder be fitted with a cast because use of a sling should be avoided due to
adduction of the affected shoulder.
b. Passively exercising the affected extremity is avoided in order to minimize pain.
c. Elevation of the arm and hand can lead to further complications associated with edema.
d. The client should be taught to interlace fingers, place palms together, and slowly bring
scapulae forward to avoid excessive force to shoulder.
3. A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the
client’s admission orders include specific aneurysm precautions. What nursing action will the
nurse incorporate into the client’s plan of care?
a. Maintain the client on complete bedrest.
b. Administer enemas when the client is constipated
c. Elevate the head of the bed to 75 degrees
d. Leg exercises to prevent DVT (deep vein thrombosis)
4. The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A
nasogastric tube placed upon admission has been on low intermittent suction every since. Upon
review of the morning’s blood work, the nurse notices that the client’s potassium is below
reference range. The nurse should assess for signs and symptoms of what imbalance?
a. Respiratory acidosis
b. Hypercalcemia
c. Metabolic alkalosis
d. Metabolic acidosis
5. A client arrives in the emergency department after being burned in a house fire. The client’s
burns cover the face and the left forearm. What extent of the burns does the client most likely
have, measured as a percentage?
a. The answer: 18% of the body burned
This study source was downloaded by 100000869267694 from CourseHero.com on 08-14-2023 02:31:52 GMT -05:00
, 6. A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When
providing relevant health education for this client, the nurse should ensure the client is aware of
what potential adverse effect?
a. Bowel incontinence
b. Heat intolerance
c. Drug-drug interactions
d. Abdominal pain
7. The nurse is caring for a client whose acute kidney injury has pre-renal cause. What most likely
caused the client’s health problem?
a. Heart failure
b. Ureterolithiasis
c. Aminoglycoside toxicity
d. Glomerulonephritis
By causing inadequate renal perfusion, heart failure can lead to pre-renal failure.
Glomerulonephritis and aminoglycoside toxicity are renal causes, and ureterolithiasis is a
post-renal cause.
8. A client is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output
recorded for this client was 10 mL. The tubing of the Foley is confirmed to be patent. What
should the nurse do?
a. Irrigate the Foley with 30 mL normal saline.
b. Notify the physician and continue to monitor the hourly urine output closely.
c. Decrease the IV fluid rate and message the client’s abdomen.
d. Have the client sit in high-Fowler’s position.
9. A client in the cardiac step-down unit has begun bleeding from the percutaneous coronary
intervention (PCI) access site in the femoral region. What is the nurse’s most appropriate action?
a. Call for assistance and initiate cardiopulmonary resuscitation.
b. Call for help and apply pressure to the access site.
c. Reposition the client’s leg in a nondependent position.
d. Promptly remove the femoral sheath.
This study source was downloaded by 100000869267694 from CourseHero.com on 08-14-2023 02:31:52 GMT -05:00
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