Final exam for 275

1. A client diagnosed with AKI is experiencing hyperkalemia. Which medication

would the nurse anticipate on preparing to help improve the client's potassium
level?
a. Regular insulin

2. A client is hospitalized with cirrhosis, ascites, and mild hepatic

encephalopathy, suddenly vomits 200 mL of bright red blood. Which of the
following would the nurse do first?

Place the client in Fowler's position.

3. A client undergoes an arthroplasty with reconstruction and replacement of the

finger joints. Postoperatively, what is most important for the nurse to do?

B. perform neurovascular assessments of the fingers q2-4 hr.

4. A client undergoing surgery and radiation for treatment of breast cancer has a
nursing diagnosis of disturbed body image R/T absence of the breast. What is an
appropriate nursing intervention at this time?
c. Arrange for a Reach to Recovery visitor or similar resource available in
the community.

5. A client with a history of heart failure, HTN, now presents with (AKI) Acute
Kidney Injury as a result of nephrotoxic diuretics. Currently his serum K+ - 6.2
mEq/L with cardiac changes, the BUN is 108 mg/dL, his serum creatinine - 4.1
mg/d/L and his HCO3 is 14 mEq/L. He is somnolent and disoriented. Which
treatment would the nurse expect to use for this client?

a. Renal replacement therapy

6. A client with advanced AIDS has impaired memory related to neurologic

changes. In planning care, what would the nurse set as the highest priority?
maintain a safe patient environment
7. A client with rheumatoid arthritis has been on Methotrexate, a DMARD drug for
2 weeks. Which laboratory data warrants intervention by the nurse?

2. A red blood cell count of 2.5 million/mm.

8. A nurse in a medical clinic is providing teaching to an older adult client who

has osteoarthritis that is affecting her knees. Which of the following client
statements indicates an understanding of the teaching?
A. "I can use either heat or ice to help relieve the discomfort."

9. A nurse in a provider's office is assessing a client who has rheumatoid arthritis

(RA). Which of the following findings is a late manifestation of this condition?

D. Knuckle deformity

10. A nurse in the emergency department is planning care for a client who has a
right hip fracture. Which of the following immobilization devices should the nurse
anticipate in the plan of care?

B. Buck's traction

11.A nurse is admitting a client to the orthopedic unit following a total knee
arthroplasty. Which of the following actions by the nurse are appropriate? (Select
all that apply.)
A. Maintain continuous passive motion device.
B. Palpate dorsopedal pulses.

D. Elevate heels off bed.

12. A nurse is admitting an adult client who has suspected osteoporosis. Which of
following findings are risk factors for osteoporosis? (Select all that apply.)
B) Loss in height of 2 in (5.1 cm)
C) BMI of 18
D) Kyphotic curve at upper thoracic spine
E) History of lactose intolerance

13. A nurse is assessing a client who had an external fixation device applied 2 hr
ago for a fracture of the left tibia and fibula. Which of the following findings is a
manifestation of compartment syndrome? (Select all that apply.)
A. Intense pain when the left foot is passively moved

C. Hard, swollen muscle in the left leg

D. Burning and tingling of the client's left foot
E. Client report of minimal pain relief following a second dose of opioid
medication

14. A nurse is assessing a client who has a casted compound fracture of the
femur. Which of the following findings is a manifestation of a fat embolus?
a. Altered mental status

15. A nurse is assessing a client who has a puncture wound on his foot. Which of
the following findings is a manifestation of acute osteomyelitis?

C. Localized erythema

16. A nurse is assessing a client who has arteriosclerosis and is scheduled for a
possible right lower extremity amputation. Which of the following are expected
findings in the affected extremity? (Select all that apply.)
A. Skin cool to touch from mid-calf to the toes
B. Lower leg appears dusky when client is sitting

D. Lack of hair on lower leg

E. Blackened areas on several toes

17. A nurse is assessing a client who has osteoarthritis of the knees and fingers.
Which of the following manifestations should the nurse expect to find? (Select all
that apply.)
a. Heberden's nodes

d. Enlarged joint size

e. Limp when walking

18. A nurse is assessing a client who has systemic lupus erythematosus (SLE).
Which of the following findings should the nurse expect?

a. Decreased urine output

b. Butterfly rash
c. Joint inflammation

19. A nurse is assessing a client who is scheduled to undergo a right knee

arthroplasty. The nurse should expect which of the following findings? (Select all
that apply.)

B. Pain when bearing weight

C. Joint crepitus
D. Swelling of the affected joint
E. Limited joint motion

20. A nurse is caring for a client following a below the elbow amputation. Which
of the following actions should the nurse take? (Select all that apply.)
A. Encourage dependent position of the residual limb
B. Inspect for presence and amount of drainage
C. Implement shrinkage intervention of the residual limb
D. Wrap the residua limb in a circular manner using gauze
E. Asses for feelings of body image changes

21. A nurse is caring for a client who had an abovetheknee amputation. The
client reports a sharp, stabbing type of phantom pain. Which of the following
actions should the nurse take?

D. Administer an anti-epileptic medication

22. A nurse is caring for a client who is in Buck's traction. Which of the following
actions should the nurse take? (Select all that apply.)
A. Monitor peripheral pulses in the affected extremity.

D. Examine the skin under the traction splint.

E. Assess the temperature of the affected extremity.

23. A nurse is caring for a client who is postoperative and in skeletal traction.
When assessing the client, the nurse should expect which of the following
findings? (Select all that apply.)

A. Slight pain at the insertion site

B. Serous drainage on the dressing

E. Minimal edema around the pin

24. A nurse is caring for a client who is postoperative following a right-sided

mastectomy and has a drain connected to a portable drainage evacuator. Which
of the following actions should the nurse?
take blood pressures on the clients non affected arm

25. A nurse is caring for a client who is postoperative following an open reduction
internal fixation (ORIF) of a femur fracture. Which of the following parameters
should the nurse include in the evaluation of the neurovascular status of the
client's affected extremity? (Select all that apply.)
a. Color
b. Temperature
 c. Sensation

26. A nurse is caring for a client who is scheduled for an arthroplasty. The nurse
asks client to state if he understands the procedure that is being performed.
Which of the following statements by the client indicates an understanding of the
procedure?
a. This procedure will replace my joint to improve function

27. A nurse is caring for a client who is taking aspirin for arthritis. The nurse
should identify which of the following findings as an adverse effect of this
medication?
a. tinnitus

28. A nurse is caring for a client who received a lower back injury during a fall
and describes sharp pain in the back and down the left leg. In which of the
following positions should the nurse plan to place the client to attempt to
decrease the pain?

a. Semi-fowler’s with a pillow under the knees

29. A nurse is completing a preoperative teaching plan for a client who is

scheduled to have a total hip arthroplasty. Which of the following should the
nurse include in the teaching plan? (Select all that apply.)
A. Encouraging complete autologous blood donation

D. Using an abductor pillow when turning

E. Performing isometric exercises

30. A nurse is completing discharge teaching to a client who had a wound

debridement for osteomyelitis. Which of the following information should the
nurse include?
A. Antibiotic therapy should continue for 3 months.
31. A nurse is completing discharge teaching with a client following arthroscopic
knee surgery. Which of the following instructions should the nurse include in the
teaching?

a. Apply ice to the affected area

32. A nurse is performing health screenings at a health fair. Which of the

following clients have a risk factor for osteoporosis? (Select all that apply.)
A) A 40-year-old client who has been taking prednisone for 4 months.

C) A 45-year-old client who takes phenytoin for seizures.

D) A 65-year-old client who has a sedentary lifestyle.
E) A 70-year-old client who has smoked for 50 years.

33. A nurse is planning a presentation about HIV for a church-based group.

Which of the following information about HIV transmission should the nurse
include?
a. It is primarily transmitted through direct contact with infected body
fluids

34.A nurse is planning discharge teaching for a client who had a total hip
arthroplasty. Which of the following should the nurse include in the teaching?
(Select all that apply.)
A. Clean the incision daily with soap and water.

C. Sit in a straight-backed armchair.

E. Use a raised toilet seat.

35. A nurse is planning discharge teaching on home safety for an adult client who
has osteoporosis. Which of the following information should the nurse include in
the teaching? (Select all that apply.)
A) Remove throw rugs in walkways.
B) Use prescribed assistive devices.
C) Remove clutter from the environment.
E) Maintain lighting of doorway areas.

36. A nurse is preparing a plan of care to prevent a client from developing flexion
contractions following a belowtheknee amputation 24 hr ago. Which of the
following actions should the nurse include?

a. Position the client prone several times each day

37. A nurse is presenting a community-based program about HIV and AIDS. A

client asks the nurse to describe the initial symptoms experienced with HIV
infection. Which of the following manifestations would the nurse include in her
explanation?

B) Flu-like symptoms and night sweats

38. A nurse is presenting information to a group of clients at a health fair about

measures to reduce the risk of amputation. Which of the follow information
should the nurse provide? (Select all that apply.)

a. Encourage clients who smoke to consider smoking cessation

programs

b. Encourage clients who have diabetes mellitus to maintain blood

glucose within the expected reference range
c. Instruct clients to unplug electrical equipment when performing
repairs
d. Encourage clients who have vascular disease to maintain good foot
care

39. A nurse is providing care for a client who had a vertebroplasty of the thoracic
spine. Which of the following actions should the nurse take?
Place the client in a supine position

40. A nurse is providing dietary teaching about calcium rich foods to a client who
has osteoporosis. Which of the following foods should the nurse include in the
instructions?

a. White beans or Kale

41. A nurse is providing discharge teaching to a client who has a fracture of the
right tibia and a fiberglass cast. Which of the following instructions should the
nurse include in the teaching?
a. Report any worsening to unrelieved pain.

42. A nurse is providing information about capsaicin cream to a client who

reports continuous knee pain from osteoarthritis. Which of the following
information should the nurse include in the discussion?

a. Put on gloves before applying the cream to other parts of the body

43. A nurse is providing information to a client who has osteoarthritis of the hip
and knee. Which of the following information should the nurse include in the
information? (Select all that apply.)
a. Apply heat to joints to alleviate pain

b. Reduce the amount of exercise done on days with increased pain

c. Active range of motion is more effective than passive

44. A nurse is providing nutritional teaching to a client who has osteoporosis.
Which of the following foods should the nurse recommend as being the highest in
calcium?

a. 3 oz canned salmon

45. A nurse is providing teaching for a client who has a history of low back injury.
Which of the following instructions should the nurse give the client to prevent
future problems with low back pain? (Select all that apply.)
a. Engage in regular exercise including walking

b. Create a smoking cessation plan

c. Wear low-heeled shoes

46. A nurse is reviewing the health record of a client who is to undergo total joint
arthroplasty. The nurse should recognize which of the following findings as a
contraindication to this procedure?

a. Bronchitis 2 weeks ago

47. A nurse is teaching a client about risk factors for osteoporosis. Which of the
following factors should the nurse include in the teaching? (Select all that apply.)
a. sedentary lifestyle,
b. aging,
c. caffeine intake,
d. secondhand smoke

48. A nurse is teaching a client how to manage an external fixation device upon
discharge. Which of the following statements by the client indicates
understanding? (Select all that apply.)
A. "I will clean the pins twice a day"
B. "I will use a separate cotton swab for each pin"
C. "I will report loosening of the pins to my doctor"
49. A nurse is teaching a client who is starting to take methotrexate to treat
rheumatoid arthritis. Which of the following instructions should the nurse include
in the teaching?

A: Drink at least 2 liters of water daily

50. A nurse is teaching a female client who has a new diagnosis of systemic
lupus erythematosus (SLE). The nurse should recognize the need for further
teaching when the client identifies which of the following as a factor that can
exacerbate SLE?
a. Exercise

51. A nurse is teaching with a client about taking high doses of oral
glucocorticoids for an extended period of time to treat rheumatoid arthritis. Which
of the following instructions should the nurse include in the teaching?
a. Monitor for compression fractures of the back and neck

52. A patient with circumferential burns of both legs develops a decrease in

dorsalis pedis pulse strength and numbness in the toes. Which action should the
nurse take first?
a. Notify the health care provider.

53. A patient with extensive electrical burn injuries is admitted to the emergency
department. Which prescribed intervention should the nurse implement first?

a. Place on cardiac monitor

54. After teaching a client with HIV infection about using antiretroviral drugs, the
nurse recognizes that further teaching is needed when the client says
b. "If my viral load becomes undetectable, I will no longer be able to
transmit HIV to others."
55. After undergoing a modified radical mastectomy, which action is best to
delegate to an experienced LPN?
a. Monitoring the client’ dressing for any signs of bleeding

56. During the immediate postoperative period following a mastectomy, the nurse
initially institutes which exercise for the affected arm?

c. asking the patient to flex and extend fingers and wrist of the operative
side

57. Following a modified radical mastectomy, a client develops lymphedema of

the affected arm. What does the nurse teach the client to do?

b. protect the arm from any type of trauma

58. Following the change-of-shift handoff, which client would the nurse assess
first?

a. Client with alcoholic cirrhosis who has coffee-ground emesis, blood

pressure of 80/50, and pulse of 115 bpm

59. The "rapid" HIV antibody testing is performed on a client at high risk for HIV
infection. What would the nurse explain about this test?

c. If the results are positive, another blood test and a return appointment
for results will be necessary.
60. The client in end-stage liver failure with cirrhosis, is being admitted to the
medical floor. Which health-care provider order would the nurse question?

3. Administer morphine 2 mg IVP for pain.

61. The nurse is assessing a client diagnosed with peptic ulcer disease and
notes a painful hard rigid abdomen. Which intervention would the nurse
implement first?

a. Notify the HCP immediately

62. The nurse is caring for a client who is receiving antibiotics to eliminate
osteomyelitis. Which of the following is most important for the nurse to instruct
the client to do regarding his daily care?

d) A diet high in protein and nutrients

63. The nurse is caring for a client with a right total knee repair. Which
intervention would the nurse implement?
1. Monitor the continuous passive motion machine.

64. The nurse is evaluating the effectiveness of fluid resuscitation provided to a

patient with a major burn. Which evaluation criterion indicates that fluid
resuscitation has been effective during the first 24 hours of care?

D. urine output 30 to 50 mL/h

65. The patient is receiving treatment during the emergent phase of burn
management. Which laboratory result would the nurse expect for the patient at
this time?
a. ↑ Hct, ↓ serum albumin, ↓ serum Na, ↑ serum K.
66. To treat a cirrhotic client with hepatic encephalopathy, lactulose, rifaximin,
and a proton pump inhibitor are ordered. What is your best explanation to the
family on why the laxative is ordered.?

a. It traps ammonia and eliminates it in the feces.

67. What is an appropriate food for a client with a stroke who has mild
dysphagia?

c. Scrambled eggs

68. What is the percentage of total body surface area for a patient with deep
partial-thickness burns to the anterior trunk, perineum, and anterior and posterior
left arm. Using the "rule of nines", which is the percent of TBSA that was burned?

a. 28%

69. Which client goal is most appropriate for a client diagnosed with OA?

2. Maintain optimal functional ability.

.

70. Which of the following would the nurse include in the plan of care for a client
undergoing hemodialysis? Select all that apply.

3."Heparin sodium is administered during dialysis."

4."Dialysis cleanses the blood of accumulated waste products."
5."Warming the dialysate increases the efficiency of diffusion."

71. Which statements would the nurse include when teaching the client who is
newly diagnosed with osteoporosis? Select all that apply.
a.) Osteoporosis is common in females after menopause.
b.) Osteoporosis is a degenerative disease characterized by a decrease in
bone density.

d.) Osteoporosis can cause pain and injury.

72. The physician ordered Pronestyl (procainamide) 2 g in 500 mL of D5W. It is

to infuse at 0.24 g/hour per infusion pump. How many hours will the IV run?
Round to the nearest hour. 8

73. The physician ordered Lasix (furosemide) 20 mg q 8 hours as a single dose

for a child who weighs 22 lb. The safe dosage range is 2 mg/kg. a) Is this dose
safe? yes

74. The physician ordered 80 units of regular insulin in 250 mL of NS. It is to

infuse at 10 units/hour per infusion pump. What is the correct IV rate in milliliters
per hour? Round to the nearest whole number. 31

75. A nurse is assessing a client who has a urine output of 250 mL in a 24-hr
period. Which of the following descriptive terms should the nurse place in the
client's electronic record?

d) oliguria

76. A nurse is assessing a client who has chronic kidney disease for fluid volume
increase. Which of the following provides a reliable measure of fluid retention?

b) daily weight

77. A nurse is assessing a client who has pancreatitis. Which of the following
actions should the nurse take to assess the presence of Cullen's sign.

C. Inspect the skin around

the umbilicus.

78. A nurse is caring for a client who has a new arteriovenous (AV) graft in his left
forearm. Which of the following techniques should the nurse use to assess the
patency of this graft?

C. Palpate the site for a bruit.

79. A nurse is caring for a client who reports recurrent flank pain, nausea, and
vomiting for 24 hr. Which of the following actions is the nurse's priority?

C.) Administer the pain medication.

80. A nurse is planning care for a client who is scheduled to have a kidney
biopsy. Which of the following information should the nurse include in the plan?
(Select all that apply).
A. Obtain a urine specimen prior to the procedure
B. Obtain written, informed consent

D. Maintain NPO status prior to the procedure

E. Obtain coagulation studies

81. A nurse is reviewing a new prescription for ursodiol with a client who has
cholelithiasis. Which of the following information should the nurse include in the
teaching?

D. This medication dissolves gallstones gradually over a period of up to 2

years.
82. A nurse is teaching a client who is scheduled for extracorporeal shock wave
lithotripsy (ESWL). Which of the following statements by the client indicates
understanding of the teaching?
Straining my urine following the procedure is important

83. You are caring for a patient who was admitted with cirrhosis. For the nursing
diagnosis of Excess Fluid Volume, which indicator is the most reliable for tracking
fluid retention?
c. Performing daily weights with the same amount of clothing

84. What treatment for acute cholecystitis will prevent further stimulation of the
gallbladder?
A. NPO with NG suction

85. A client has a spinal cord injury at the level of the T2-T3 vertebrae. When
planning care, the nurse would anticipate which of the following types of
disability?

a. paraplegia

86. A client with a spinal cord injury at the cervical level is identified. What
intervention will be done to facilitate respirations?
Ventilator

87. A nurse caring for a client who had a right-sided stroke and is exhibiting
homonymous hemianopsia when eating. Which of the following actions should
the nurse take?
a. Remind the client to look for food on the left side of the tray.

88. A nurse is assessing a client who has Parkinson's disease. Which of the
following manifestations should the nurse expect? Select all that apply.
B. Pill-rolling tremor of the fingers
C. Shuffling gait
D. Drooling

F. Lack of facial expression

89. A nurse is assessing a client's cranial nerves as part of a neurological

examination. Which of the following actions would the nurse take to assess
cranial nerve III?
Checking the pupillary response to light

90. A nurse is caring for a client who has impairment of cranial nerves IX and X.
Which of the following actions would the nurse take?
a. Place suction equipment at the client's bedside.

91. A nurse is caring for a client who is prescribed seizure precautions. Which of
the following interventions should the nurse include in the client’s plan of care?
a. Obtain IV access.

92. A nurse is caring for a client who has had a stroke involving the right
hemisphere. Which of the following alterations in function should the nurse
expect?

a. Inability to recognize his family members

93. A nurse is planning care for a client who had a traumatic brain injury and is
emerging restlessly from a coma. Which of the following interventions would the
nurse include in the plan?
reduce stimuli (↓ # of visitors, remain calm, & create a quiet environment)

94. A nurse suspects that a client admitted for treatment of bacterial meningitis is
experiencing increased intracranial pressure (ICP). Which of the following
assessment findings by the nurse supports this suspicion?
 a. Diplopia

95. During an admission health assessment, the nurse elicits a positive Kernig's
sign from the patient. Which diagnostic test procedure would the nurse anticipate
the HCP ordering to confirm a diagnosis?

a. Lumbar puncture (LP)

96. The client diagnosed with an acute exacerbation of multiple sclerosis is

placed on high-dose intravenous injections of corticosteroid medication. Which
nursing intervention would be implemented?

3. Monitor the client's serum blood glucose levels frequently

97. The nurse determines that teaching about management of migraine

headaches has been effective when the patient says which of the following?

c. "I will lie down someplace dark and quiet when the headaches begin."

98. The nurse is caring for a client with a hemorrhagic stroke. Which medication
would the nurse question administering?
1.Clopidogrel (Plavix), an antiplatelet.

99. A nurse is caring for a client who is unconscious following a cerebral

hemorrhage. Which of the following nursing interventions is of highest priority?

C. Suction saliva from the client's mouth

100. A nurse is providing discharge instructions on phenytoin to a client with

tonic-clonic seizure disorder. Which instructions would the nurse include? Select
all that apply.
a. Monitor the body for any skin rash

b. Perform good oral hygiene, including daily flossing and brushing

c. Receive necessary periodic blood work
d. Report any problems with walking or coordination, slurred speech, or
nausea