Study online at https://quizlet.com/_7vp33l X. X. X.
1. A Nurse is caring for a clients on the med-surg D- Full thickness
X. X. X. X. X. X. X. X. X. X. X.
unit. Which client is most at risk to develop a burn, NG tube
X. X
. X. X. X. X. X. X. X. X. X. X. X.
nosocomialinfection?
X. andFoley X
. X. X
.
*Think immunosu- X.
A- clinet with alcohol abuse admitted for detox
X. pression and av-
X. X. X. X. X. X. X
. X. X.
B- Client withType I diabetes and peripheral neuropa-thy enues forinfection
X. X. X
. X. X. X. X. X. X
. X. X. X.
C- Client recovering from a choleystectomy
X. X. X. X. X.
D- Client with full thickness burns, an NG tube and
X. X. X. X. X. X. X. X. X.
aFoley
X. X
.
2. A nurse is caring for clients in the ICU. Which
X. X. X. X. X. X. X. X. X
.
client may be transferred to the step-down neuro
X. X
. B- client with an X. X. X. X. X. X. X. X. X.
unit?
X. ischemic stroke 4 X. X. X.
daysagowithcon- X. X. X. X.
A- Client with head injury and seizure
X. fusion. X. X. X. X. X. X
.
B- Client with an ischemic stroke 4 days ago
X. *Thinkwhatisnor- X. X. X. X. X. X. X. X
. X
. X
.
withconfusion
X. X
. mal and what is X
. X. X. X.
C- Client whois 1-daypost op after a
X. abnormal- who is
X. X. X. X. X. X. X. X. X. X.
transshpenoidalcraniotomy with a cerebrospinal fluid most stable
X. X
. X. X. X. X. X. X.
leak
X.
D-Client with bacterial meningitis and a Glasgowcoma X. X. X. X. X. X. X
.
sale of 7
X. X. X.
D-50 year old X. X. X.
3. After a change of shift, you are assinged to care for the withasthma who
X. X. X. X. X. X. X. X. X. X. X. X. X
. X.
following clients,Which client should you
X. com- plainsof X. X
. X. X. X. X. X. X
.
assessfirst?
X. shortnessof breath
X
. X
. X
. X.
after us- ing a X. X. X. X.
A- 60 year old client on a ventilator for whom a
X. X. brochodilator X. X. X. X. X. X. X. X. X.
sterilesputum specimen must be sent to the lab
X. X
. *Think ABCs, also X. X. X. X. X. X. X. X. X.
B-55yearoldwithCOPDandapulseoximetryreading not the desired ef-
X
. X
. X
. X
. X
. X
. X
. X
. X
. X
. X. X. X. X.
from the previous shift of 90% X. fect of the bro-
X. X. X. X. X. X. X.
C- 70 year old with pneumonia who needs to be start-ed chodilator treat-
X. X. X. X. X. X. X. X. X. X. X
. X. X.
on IV antibiotics
X. X. X. ment;should X
. X
.
D- 50 year old with asthma who complains of short-
X. X. beimproved. X. X. X. X. X. X. X. X. X
.
ness of breath after using a bronchodilator
X
. X. X. X. X. X. X.
4. The nurse just received report on the surgical
X. X. X. X. X. X. X. B- multiple
X.
ward.Which client should be assessed first?
X. X
. X. X. X. X. X. injuriesfollowing a
X. X
. X.
motor vehicle
X. X.
A- Peptic ulcer disease scheduled for a laparosopic
X. X. X. X. X. X. X. crash
X.
X. X.
, Capstone Exam 1 X. X.
Study online at https://quizlet.com/_7vp33lX. X. X.
choleycystectomy in 4 hours X. X. X. *think who is X. X.
B- Multiple injuries after a motor vehicle crash
X. X. X. X. X. X. X. mostunstable
X. X
.
C- Graves disease scheduled for a thyroidectomy
X. X. X. X. X. X.
D- Post-appendectomy waiting for discharge
X. X. X. X.
5. A hospital will receive a large number of clients be-
X. B- 66 year old X. X. X. X. X. X. X. X. X. X. X.
cause of a magor disaster in the city.Which client canbe male 5 days
X. X. X. X. X. X. X. X. X
. X. X. X
. X. X. X.
discharged first?
X. postop after total X. X. X
. X. X.
hip replacement X. X.
A- 49 year old female 24 hours postop after hysterec-
X. X. *think who is X. X. X. X. X. X. X. X. X.
tomy
X
. moststable and X. X
. X.
B- 66 year old male 5 days post op after total
X. X. would be safest to X. X. X. X. X. X. X. X. X. X. X. X.
hipreplacement
X. X
. go home X. X.
C- 79 year old female admitted 12 hours ago
X. X. X. X. X. X. X. X.
withpyrlonephritis
X. X
.
D-82 yearoldfemaleadmitted5daysagowithastage3
X
. X
. X
. X
. X
. X
. X
. X
. X
. X
. X
. X
.
pressure ulcer
X. X.
X. C- 25 year old
6. A nurse just received report on her client's at the firstofX. X. X. X. X. X. X. X. X. X
. X. X. X.
the shift.Which client should be assessed first?
X. X. woman with fruity
X
. X. X. X. X. X. X. X. X.
breath, excessive X. X.
A- 45 year old woman with a BP of 90/60 and hot,
X. X. thirstandpolypha- X. X. X. X. X. X. X. X. X. X. X
. X
.
dryskin
X. X
. gia X
.
B- 37 year old man with BP 130/70,sleeping quietly inhis *who is showing
X. X. X. X. X. X. X. X
. X. X. X
. X. X.
bed
X. definite signs of a X. X. X. X.
C- 25 year old woman with fruity breath, excessivethrist problem not just
X. X. X. X. X. X. X. X. X
. X. X. X.
and polyphagia
X. X. questionableones X. X.
D- 16 year old boy with irritability and tremor
X. X. X. X. X. X. X. X.
7. The staff nurse receives on her assignment for
X. X. X. X. X. X. X. B- A client with
X. X. X.
theshift.Which client should she assess first?
X. X
. X
. X. X. X. X. X. frequentwaterydi-
X. X. X.
arrhea,
X
.
A- Aclientreportingaheadachewithapainscore3/10
X
. X
. X. X
. X. X
. X. X
. X
. X. abdominalpain
X. X
.
B- A client with frequent watery diarrhea,
X. X. X. X. X. X. and nausea
X. X.
abdominalpain, nausea
X. X
. X. *think about de- X. X.
C- A client with respirations of 20 and O2 sat of 94%on
X. X. X. X. X. X. X. X. X. X. X. X
. hyration and elec-
X. X. X.
room ait
X. X. trolyte inbalance
X
. X.
D- A client with nausea after taking oral contrast
X. X. X. X. X. X. X. X.
forabdominal CT scan
X. X
. X. X.
X. X.
, Capstone Exam 1 X. X.
Study online at https://quizlet.com/_7vp33l
X. X. X.
8. The client with COPD tells the CNA that he did not get
X. X. X. X. X. X. X. X. X. X. X. D- Oral tempera-
X. X.
his annual flu shot this year and has not had a
X. X. X. X. X. X. X. X. X. X. X. ture of 38.4
X
. X. X.
pneumonia vaccination.You would be sure to
X. X. X
. X. X. X. X. *most indicitive X.
instructthe CNA to report which of these?
X. X
. X. X. X. X. X. X. ofinfection
X. X
.
A- Blood pressure of 152/84 mmHg
X. X. X. X. X.
B- Respiratory rate of 27 breaths per minute
X. X. X. X. X. X. X.
C- Heart rate of 92 beats/min
X. X. X. X. X.
D- Oral temperature of 38.4
X. X. X. X.
9. When assessing a 22-year old client who required
X. D- Switch the X. X. X. X. X. X. X. X.
emergency surgery and multiple transfusion 3 days
X. client to a non- X. X. X. X. X. X. X. X. X. X.
ago, you find that the client looks anxious and has
X. X. rebreather X. X. X. X. X. X. X. X. X.
labred respirations at the rate of 38
X. X. maskat 95- X. X. X. X. X. X. X
. X.
breaths/min.Theoxygen saturation is 90% with the
X. 100% O2 X
. X
. X. X. X. X. X. X.
oxygen delivery at 6 L/min via nasal cannula. Which
X. and call the physi-
X. X. X. X. X. X. X. X. X. X. X.
action is most apropriate?
X. X. cian to discuss X. X. X
. X. X.
theclient's status. X. X
. X.
A- Increase the flow rate on the oxygen to 10 L/minand *think Breath-
X. X. X. X. X. X. X. X. X. X. X
. X.
reassess the client after about 10 minutes
X. ing/oxygen satu- X. X. X. X. X. X. X. X.
B- Assis the client in using the incentive
X. ration (delievery)-
X. X. X. X. X. X. X. X.
spirometerand splint his chest with a pillow while he
X. make sure you X
. X. X. X. X. X. X. X. X. X. X. X.
coughs
X. don't choose any- X. X. X.
C-Administertheorderedmorpinesulfatetotheclientto thing that is bad
X
. X
. X
. X
. X
. X
. X
. X
. X
. X. X. X. X.
decrease his anxiety and reduce the hyperventila- tion practice like 10 L
X. X. X. X. X. X. X. X. X. X. X. X.
D- Switch the client to a nonrebreather mask at
X. onanasalcannula X. X. X. X. X. X. X. X. X
. X
. X
.
95-100% oxygen and call the physician to discuss X. X. X. X. X. X. X.
theclient's status.
X. X
. X.
10. An office nurse just checked her secure
X. X. X. X. X. X.
email.Whichmessage should the nurse return first?
X. X
. X
. X. X. X. X. X. A- multipara X.
at 34 weeks
X. X
. X.
A- Multipara at 34 weeks with headache and
X. X. X. X. X. X. X. with headache
X. X
.
blurredvision
X. X
. and
X. blurred X
.
B- Primipara at 22 weeks with supine dizziness
X. X. X. X. X. X. X. vision
X.
C- Primipara at 15 weeks says she has not felt
X. X. X. X. X. X. X. X. X. *thisis preeclamp- X. X.
babymove
X. X
. sia and that can be
X
. X. X. X. X.
D- Multipara at 12 weeks with white vaginal discharge
X. X. X. X. X. X. X. X. lifethreatening-
X
. X
.
think in order of
X
. X. X. X.
severity
X.
X. X.
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