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Question 1

A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation?
Select all that apply.

Partial thromboplastin time.

Prothrombin time.

Platelet count.

Hemoglobin

Complete Blood Count

White Blood Cell Count

Question 1 Explanation:
Question 2

A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the
diagnosis? Select all that apply.

Weight loss.

Increased clotting time.

Hypertension.

Headaches.

Question 2 Explanation:
Question 3

The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following
client actions indicates that he is using the MDI correctly? Select all that apply.

The inhaler is held upright.

Head is tilted down while inhaling the medication

Client waits 5 minutes between puffs.

Mouth is rinsed with water following administration

Client lies supine for 15 minutes following administration.

Question 4

The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would
the nurse include in the clients teaching plan? Select all that apply.

Hearing loss

Visual disturbance

Headache

Orthopnea

Gout

Weight loss

Question 4 Explanation:
Question 5

Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select
all that apply.

Auscultation of breath sounds

Auscultation of bowel sounds

Presence of chest pain.

Presence of peripheral edema

Color of nail beds

Question 5 Explanation:
Question 6

The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which
statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply.

I will need to dispose of my old clothing when I return home.

I should always cover my mouth and nose when sneezing.

It is important that I isolate myself from family when possible.

I should use paper tissues to cough in and dispose of them properly.

I can use regular plate and utensils whenever I eat.

Question 7

The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply.

Thirst

Palpitations

Diaphoresis

Slurred speech

Hyperventilation

Question 7 Explanation:
Question 8

Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to exhibit? Select all that apply:

Sweating

Low PCO2

Retinopathy

Acetone breath

Elevated serum bicarbonate

Question 8 Explanation:
Question 9

When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse
appropriately delegate to a unlicensed assistant? Select all that apply.

Assessing the clients bowel sounds

Providing skin care following bowel movements

Evaluating the clients response to antidiarrheal medications

Maintaining intake and output records

Obtaining the clients weight.

Question 9 Explanation:
Question 10

Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.

Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.

Activity intolerance related to increased cardiac output.

Decreased cardiac output related to structural and functional changes.

Impaired gas exchange related to decreased sympathetic nervous system activity.

Question 10 Explanation:
Question 11

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care
for chemotherapy administration? Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

Inspect the insertion site for swelling, erythema, or drainage.

Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.

If unable to aspirate blood, reposition the client and encourage the client to cough.

Contact the health care provider about verifying placement if the status is questionable.

Question 11 Explanation:
Question 12

A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline
personality disorder. When talking with the parents, which information would the nurse expect to be included in the clients history?
Select all that apply.

Impulsiveness

Lability of mood

Ritualistic behavior

psychomotor retardation

Self-destructive behavior

Question 13

When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior.
Which of the following assessment data is the nurse also likely to find? Select all that apply.

The client functions well in other areas of his life.

The degree of aggressiveness is out of proportion to the stressor.

The violent behavior is most often justified by the stressor.

The client has a history of parental alcoholism and chaotic, abusive family life.

The client has no remorse about the inability to control his anger.

Question 13 Explanation:
Question 14

Which of the following nursing interventions are written correctly? (Select all that apply.)

Apply continuous passive motion machine during day.

Perform neurovascular checks.

Elevate head of bed 30 degrees before meals.

Change dressing once a shift.

Question 14 Explanation:
Question 15

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a clients outflow is less than the inflow. Select
actions that the nurse should take.

Place the client in good body alignment

Check the level of the drainage bag

Contact the physician

Check the peritoneal dialysis system for kinks

Reposition the client to his or her side.

Question 15 Explanation:
Question 16

The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most
appropriate for this client? Select all that apply.

Excess Fluid Volume

Imbalanced Nutrition; Less than Body Requirements

Activity Intolerance

Impaired Gas Exchange

Pain

Question 16 Explanation:
Question 17

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the
child to demonstrate? Select all that apply.

Head tilt

Vomiting

Polydipsia

Lethargy

Increased appetite

Increased pulse

Question 17 Explanation:
Question 18

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis
above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing
interventions would be appropriate for this client? Select all that apply.

Elevate the HOB to 90 degrees

Loosen constrictive clothing

Use a fan to reduce diaphoresis

Assess for bladder distention and bowel impaction

Administer antihypertensive medication

Place the client in a supine position with legs elevated

Question 18 Explanation:
Question 19

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that
the client has correctly understood the teaching? Select all that apply.

If I limit my fluid intake I will not have to empty my ostomy pouch as often.

I can place an aspirin tablet in my pouch to decrease odor.

I can usually keep my ostomy pouch on for 3 to 7 days before changing it.

I must use a skin barrier to protect my skin from urine.

I should empty my ostomy pouch of urine when it is full.

Question 19 Explanation:
Question 20

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for
probable signs of pregnancy. Select all probable signs of pregnancy.

Uterine enlargement

Fetal heart rate detected by nonelectric device

Outline of the fetus via radiography or ultrasound

Chadwicks sign

Braxton Hicks contractions

Ballottement

Question 20 Explanation:
Question 21

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the
client for which specific signs of Preeclampsia (select all that apply)?

Elevated blood pressure

Negative urinary protein

Facial edema

Increased respirations

Question 21 Explanation:
Question 22

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing
interventions that apply in the care for the client.

Monitor maternal vital signs every 2 hours

Notify the physician if respirations are less than 18 per minute.

Monitor renal function and cardiac function closely

Keep calcium gluconate on hand in case of a magnesium sulfate overdose

Monitor deep tendon reflexes hourly

Monitor I and Os hourly

Notify the physician if urinary output is less than 30 ml per hour.

Question 22 Explanation:
Question 23

When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.

Reflects electrical impulse beginning at the SA node

Indicated electrical impulse beginning at the AV node

Reflects atrial muscle depolarization

Identifies ventricular muscle depolarization

Has duration of normally 0.11 seconds or less

Question 23 Explanation:
Question 24

When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care
for chemotherapy administration? Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals.

Inspect the insertion site for swelling, erythema, or drainage.

Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.

If unable to aspirate blood, reposition the client and encourage the client to cough.

Contact the health care provider about verifying placement if the status is questionable.

Question 24 Explanation:
Question 25

To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.)

Drinking a glass of wine just before retiring to bed

Eating a large meal 1 hour before bedtime

Consuming a small glass of warm milk at bedtime

Performing mild exercises 30 minutes before going to bed

Question 25 Explanation:
Question 26

The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply):

Extended time to fall asleep

Falling asleep at inappropriate times

Difficulty staying asleep

Feeling tired after a nights sleep

Question 26 Explanation:
Question 27

The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to
place the baby after nursing is (select all that apply):

Prone

Side-lying

Supine

Fowlers

Question 27 Explanation:
Question 28

A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder.
Select all that apply:

Chronic stress

Severe anxiety

Generalized pain

Excessive caffeine

Chronic depression

Environmental noise

Question 28 Explanation:
Question 29

Select all that apply to the use of barbiturates in treating insomnia:

Barbiturates deprive people of NREM sleep

Barbiturates deprive people of REM sleep

When the barbiturates are discontinued, the NREM sleep increases

When the barbiturates are discontinued, the REM sleep increases

Nightmares are often an adverse effect when discontinuing barbiturates

Question 29 Explanation:
Question 30

Select all that apply that is appropriate when there is a benzodiazepine overdose:

Administration of syrup of ipecac

Gastric lavage

Activated charcoal and a saline cathartic

Hemodialysis

Administration of Flumazenil

Question 30 Explanation:
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