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MS

1.) The nurse obtaining a nursing history can enhance data collection by utilizing the
communication technique contained in which of the following questions?
A. "Did your pain begin recently?"
B. "You said the pain started yesterday?"
C. "Can you tell me more about how the pain began?"-open ended question
D. "The pain isn't bad right now, is it?"
2.) A nurse who is revising the nursing plan's goals and interventions would require which of the
following?
A. Knowledge of the hospital's standards of care
B. Medical assessment and written orders
C. Healthcare team conferences
D. Validation of the effectiveness of the interventions
Rationale: Validation of the effectiveness of the interventions to achieve the clientspecific goals encompasses input from the healthcare team members and knowledge of
hospital standards of care. Medical assessment and written orders are components of
the client care but not the focus of the nursing plan of care.

3.) The nurse assesses for hyperkalemia in a client with which of the following problems?
A. Renal failure

-hyperkalemia

B. Nausea and vomiting

C. Excessive laxative use


D. Loop diuretic use-Hypokalemia

Renal failure results in the inability of the kidneys to excrete potassium and that leads to
hyperkalemia. Nausea, vomiting, excessive laxative use, and loop diuretic use will cause
hypokalemia
4.) Baseline arterial blood gases are drawn on a healthy adult scheduled for surgery. The nurse
expects the findings to be which of the following?
A. PO2 30 mmHg and PCO2 15 mmHg

C. PO2 90 mmHg and pH 7.40-Normal

B. pH 7.32 and HCO3 21 mEq/L

D. PCO2 49 mmHg and HCO3 21 mEq/L

5.) In assessing the laboratory findings for a client the nurse should be aware that a decrease in
the serum level of which laboratory value might cause digitalis toxicity?
A. Sodium
B. Potassium

C. Chloride
D. Calcium

6.) The nurse is preparing the client for an ultrasound of the gallbladder. Which of the following
statements would be the most important to prepare the client for the test?
A. "You will have food and fluids restricted for 4 to 8 hours prior to the test." -NPO tlga
B. "Stool in the bowel may cause a reporting of inaccurate findings."

C. "There is no special preparation for this procedure. You may eat and drink as usual."
D. "You will be asked to drink a solution of radionuclide 2 hours prior to the procedure."
7.) Your client has recently returned to the unit following a bronchoscopy and is requesting a
glass of water. Your first consideration in fulfilling the request would be which of the following?
A. Is the client able to ambulate without assistance?
B. Are the side rails up on the client's bed?
C. Did the client receive a local anesthetic during the procedure?- eassess gagrelfex prone
for aspiration
D. Is the call light within reach?
Rationale: The administration of a local anesthetic is possible during the procedure to decrease
the gag reflex and increase comfort. The nurse should check for the return of the gag reflex to
prevent the potential for aspiration. The position of the side rails, availability of the call light, and
the ability to ambulate without assistance are safety concerns but are not related to the specific
client request
8.) Your client is experiencing shortness of breath after oxygen that was being delivered by
nasal cannula was decreased to 2 L/min. Pulse oximetry reveals an oxygen saturation reading
of 71 percent. Which of the following would be the most appropriate immediate nursing action?
A. Closely monitor the client's condition and increase the oxygen concentration to 15 L/min.
B. Place the client in a semi-Fowler's position and continue to monitor.
C. Do nothing; the drop in oxygen concentration is expected with the change in oxygen being
delivered.
D. Sit the client up, assess the client's status, and notify the physician immediately.
9.) Which of the following steps of the nursing process would the nurse use when determining
specific client needs based on the admission history database?
A.Clientteaching

-intervention

B. Diagnosing

C.Teamcollaboration -evaluating n
D. Developing a clinical pathway-part ng lhat na nursing process
Diagnosing is a specific step of the nursing process that utilizes the information collected during
the client-specific database collection. Client teaching is a nursing intervention. Team
collaboration is important in the intervention and evaluation phases of the nursing process. The
utilization of a previously developed clinical pathway includes components of all steps of the
nursing process

10.) The nurse is implementing a plan of care. Which of the following actions would the nurse
take in this phase of the nursing process?
A. Listen for carotid bruits-Assessment
B. Assist the client to use the incentive spirometer every 2 hours
C. Prioritize care issues- Planning

D. Consult the physical therapist about the client's progress- evaluation


Rationale: Assisting the client to use the incentive spirometer actively
operationalizes the client's plan of care to maintain optimal oxygenation status.
Auscultation of carotid bruits would be a part of the assessment process from which
a care need may be identified. Prioritization of care issues is part of the planning
stage of the nursing process from which nursing interventions are determined.
Consultation with other care providers is used in evaluating the effectiveness of the
planning of care and gathering information for possible revision

1. client has been admitted to your unit this afternoon for treatment of dehydration. The
discharge planning for this client should begin:
When the client is ready to discuss discharge.
The morning prior to discharge.
After the physician writes the discharge order.
During the initial contact between the client and nurse.
Ratio:: Discharge planning should begin on admission to the unit and should be an
ongoing process. As a rule, clients are not ready to discuss discharge plans on the
day of admission; however, planning for appropriate follow-up and coordination of
care cannot frequently be achieved on the morning of discharge.

2. The evaluation process of your nursing plan of care would include which of the following?

Ambulating your client 20 feet down the hallway


Questioning your client about his family medical history
Assessing your client's progress toward a desired outcome
Assigning a nursing diagnosis to an identified need
Ratio:: The evaluation step of the client's plan of care includes the assessment of
their progress toward a previously identified desired outcome. The desired outcome
would have been the result of gathering the client's health history, identifying a
nursing diagnosis, goal formulation, and implementing the assigned plan of care
such as ambulation.

3. You would anticipate that a client with liver failure would have an elevated serum blood level
of which of the following?
Glucose-decrease
Ammonia
Albumin-decrease
Platelet count-decrease

Ratio: : In liver failure, an excess of serum ammonia results from the liver's inability to convert
ammonia to urea for excretion. Because of the liver's inability to perform its normal functions,
glucose, albumin, and the client's platelet count may decreased rather than increased

4. Which of the following should be removed from the client in preparation for an MRI
procedure?
Urinary catheter
Plastic name band
Partial dental plate-bawal tlga to
Foam slippers

5. Which of the following isoenzymes of lactic dehydrogenase (LDH) would you expect to be elevated in
a client with a diagnosis of acute myocardial infarction (MI)?
LDH1
LDH3
LDH5
LDH4
Ratio:LDH1 and LDH2 are the primary isoenzymes for cardiac muscle and are
utilized to diagnose an acute MI. LDH3 is the primary pulmonary isoenzyme, and
LDH4 and LDH5 are indicators of hepatic dysfunction.
6. Which of the following would indicate that your client is in metabolic acidosis?
High pH, high HCO3
Low pH, low pCO2
Low pH, low HCO3
High pH, low pCO2
Ratio: Normal ABG pH is 7.35 to 7.45 and a normal bicarbonate level is 22 to 26
mEq/L. A low pH would indicate a client is in an acidotic state and the low
bicarbonate would indicate a metabolic cause for the acidosis. The pCO2 level is an
indicator of the respiratory component of the client's acid-base balance
7. Your client has been diagnosed with renal failure. What serum laboratory value would be the best
indicator of renal function?
Potassium level
Blood urea nitrogen (BUN)
Creatinine level
Specific gravity

Ratio:: Creatinine levels are more sensitive and specific for renal disease. Although the BUN level is used
to assess renal function, it can also be affected by diet and fluid status. The potassium level can be
affected by many factors as well. Specific gravity is not a blood test, but rather is performed on the urine
itself.

8. A client is scheduled for a colonoscopy and asks you what will be determined from the test. Your
response is that a colonoscopy would:
Evaluate whether there is a tumor or other problem in the large intestine.
Determine the presence of blood in the abdominal cavity.
Evaluate the presence of and possibly sclerose esophageal varices.
Assess the effectiveness of treatment of a peptic ulcer.

9. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). The nurse expects the ABGs to
reflect which of the following?
Metabolic alkalosis
Respiratory acidosis
Normal findings
Metabolic acidosis
Ratio: DKA produces an excess release of hydrogen ions into the serum that cannot
be buffered by the already depleted bicarbonate level due to an osmotic diuresis
that occurs. Therefore the client is in metabolic acidosis. There is no essential
respiratory cause for this metabolic condition and the results will not be within
normal limits due to the pathophysiology of the disease proce
10. A client presents to the Emergency Department with a complaint of left arm pain following a fall. The
first physical examination technique the nurse utilizes would be:
Palpation for any deformities or areas of tenderness.
Inspection for any deformities, discoloration, or obvious bone protrusion.
Palpation of distal pulses.
Information gathering about the circumstances of the injury.

The laboratory report lists the white blood cell (WBC) differential for your
client who is experiencing an allergic reaction. Which type of cell would you
expect to be elevated?
Neutrophils
Monocytes
Eosinophils
Lymphocytes

Ratio.:Eosinophils are responsible for responding to allergic reactions. Neutrophils


and monocytes are primary responders to infection and tissue injury and
inflammation. Lymphocytes assist in immune responses.

2.
The nurse has completed the client database and has determined the client's
needs for nursing care. The nurse will next formulate client goals based
primarily on which of the following?
Staff availability.
Medical orders.
Client's desired goals.
Nursing diagnosis statements.
Ratio:Client goals are based on the identified nursing diagnostic statements
developed from the client database. Although the goals will take into account
the client's desired goals and the physician's medical orders, the goals will
be those influenced by nursing interventions. Staff availability should not be
a consideration in identifying the desired clien

3.
The nursing diagnosis for a client admitted with a wound infection should
include which of the following?
The medical diagnosis.
Client signs and symptoms.
Interventions to alleviate the identified need.
Clients response to the nursing care.

4.
A male client has recently received a report of his cholesterol levels and asks
you which are the "good" ones. Your response would be which of the
following?
High-density lipoprotein (HDL)
Low-density lipoprotein (LDL)
Total cholesterol
Triglycerides

Rationale: HDL is felt to be a beneficial lipoprotein because of its protective function


against coronary artery disease. LDL and HDL are fractions of the total cholesterol
level. Triglycerides and LDL have proven to be major contributors to and predictors
of coronary artery disease

5.
An example of an independent nursing intervention for your client with a
recent amputation would be which of the following?
Administer morphine sulfate 1 to 2 mg q2h.
Assess effectiveness of pain management.
Order a unit of packed red blood cells for a hemoglobin of 8.2 g/dL.
Start IV hydration because the client is nauseated after surgery and has poor
intake.
Ratio: : An independent nursing order is one that the registered nurse is licensed to
prescribe, perform, or delegate based on knowledge and skill. The ordering of IV
fluids, pain medication, and blood are within the realm of medical treatment.

6.
The client complains of loss of warmth in the foot after a fall from the bed.
The assessment technique the nurse should perform following inspection of
the foot would be to:
Palpate the pedal pulses.
Palpate for sensation of touch.
Palpate for any bony deformities.
Percuss the bony prominence.

7.
Your client has recently completed chemotherapy and has developed bone
marrow suppression. Which laboratory report should you monitor?
Calcium
Phosphorus
White blood cell (WBC) count
Serum prostate-specific antigen (PSA)

8.

A male client with a left lower leg prosthesis states that he can feel his heart
"skipping beats" when he walks up the stairs. He states his doctor has
ordered an outpatient test that will take many hours, and he wants to know
what it is. Your response would be:
"Your physician has ordered an echocardiogram, which will utilize sound
waves to project a picture of your heart in motion."
"Your physician has ordered a Holter monitor test, which will record your
cardiac rhythm and rate while you go about your normal activities."
"Your physician has ordered a graded exercise treadmill test (GXT), which will
record your cardiac activity as you exercise on a treadmill."
"Your physician has ordered a 12-lead ECG, which will record your resting
heart rhythm and rate."
A Holter monitor is a 24-hour test during which the client can perform his routine
daily activities as the monitor records any cardiac arrhythmia. The 12-lead ECG and
the echocardiogram would not require an extended period of time and do not
usually capture activity-related events. A GXT would not be appropriate for this
client because of the prosthesis.

9.
The nurse has completed the health history for a new client and is ready to
begin a physical assessment. What assessment technique will the nurse
describe to the client that will be completed first?
Inspection
Percussion
Palpation
Auscultation

10.
A client presents to the clinic with a chief complaint of a swollen and painful
great toe as shown in the picture. He states that his brother has it, and he
has the same symptoms. The physician suspects gout. What specific
laboratory test would you expect to be ordered for this client?
Calcium
Hematocrit
Uric acid
Sodium