ArcherReview Self Assessment - Adevia

Health
A self assessment form for Adevia Health

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The nurse is caring for assigned patients. The nurse should recognize that the patient at
greatest risk for postpartum hemorrhage (PPH) is the patient who has which of the
following?
A. Uterine atony and delivered with the assistance of forceps
B. Postpartum urinary incontinence and diuresis
C. An active outbreak of genital herpes and had a cesarean section
D. Gestational diabetes and has postpartum hyperglycemia

The nurse is caring for a client with a chest tube for the treatment of a pneumothorax.
Which item is essential to have at the bedside?
A. Nasal cannula oxygen
B. Tracheostomy set
C. Bottle of sterile water
D. An ampule of Dextrose 50%

The nurse is administering Pitocin intravenously to a client having an induction of labor.

The nurse notes that the client's fundus has been contracting non-stop for the past 5
minutes. Assessment of fetal heart reveals 95 beats per minute. What should be the
nurse’s initial action?
A. Place the client in Trendelenburg position
B. Stop the infusion
C. Administer oxygen via facemask
D. Administer IV fluids at a high rate

The nurse is caring for a client who has a factitious disorder. The client reports chest
pain. Which of the following actions should the nurse take? Select all that apply.
A. Provide reassurance that this is part of the disorder
B. Notify the primary healthcare physician (PHCP)
C. Obtain a 12-lead Electrocardiogram
D. Disregard the symptom as it may be unreliable
E. Assess vital signs

The nurse is working with a patient who is receiving a new prescription of prednisone.
The nurse would be most correct in instructing the client to take this medication at which
time every day?
A. In the morning
B. Around noon
C. Before bed
D. Anytime, but at the same time every day

The nurse is reinforcing discharge instructions to the parents of a 6-year-old child with

chickenpox. The nurse knows that the parents understand the discharge instructions
when they make which of the following statements?
A. “Once she has been without a fever for a day, she can go back to school.”
B. “She will still be infectious for 14 days, so we should let the school know she will be out for 2
weeks.”
C. “After antibiotics have been started, she can go back to school in 48 hours.”
D. “Once all of her sores are crusted over, it will be safe for her to go back to school.”

Which of the following are symptoms of true labor?

Select all that apply.

A. Contractions that dissipate with walking
B. Contractions that come in regular intervals
C. Lower back pain
D. Contractions of consistent intensity

You have just received a doctor’s order for amoxicillin and lidocaine. You should:
A. Call the ordering doctor because these medications, in combination, cause severe adverse
side effects.
B. Call the ordering doctor because these medications have an inhibiting effect on each other.
C. Refer to a reliable drug compatibility chart or resource to determine their compatibility with
each other.
D. Ask a more experienced nurse whether or not these two drugs are compatible with each
other.

The nurse is caring for a client who has been prescribed sertraline for major
depressive disorder. It would be a priority for the nurse to assess for which of the
following?
A. Insomnia
B. Sexual side-effects
C. Weight gain
D. Suicidal ideation

The nurse is caring for a client with venous thromboembolism who has developed

heparin-induced thrombocytopenia. After discontinuing the heparin infusion, the nurse
anticipates which prescription from the primary healthcare provider (PHCP)?
A. Enoxaparin
B. Dabigatran
C. Ketorolac
D. Epoetin alfa

While working in a pediatric cardiac unit, you are assigned to take care of an infant with
tetralogy of Fallot. During report, you are told that the infant is having frequent ‘tet
spells’. To prepare for your shift, which medication do you ensure is readily available in
case of a tet spell?
A. Morphine sulfate
B. Dexmedetomidine
C. Fentanyl
D. Atropine sulfate

The nurse is caring for a client with schizophrenia, who is speaking words
and phrases that are unrelated to one another. The nurse should document this
communication pattern as
A. pressure speech.
B. word salad
C. neologism.
D. clang association.

The nurse is assessing a client who is suspected of having myasthenia gravis. Which of
the following would be an expected finding? Select all that apply.
A. Diplopia
B. Butterfly rash
C. Facial muscle weakness
D. Shuffling gait
E. Ptosis

The nurse in the surgical ward is taking care of a patient that had just undergone an
elbow arthroplasty. All of the following should be included in the patient’s care
plan, except?
A. Elevate the arms of the patient to above his shoulders for 4-5 days.
B. Check the client’s operative hand strength frequently.
C. Check the client’s radial and ulnar pulses as well as capillary refill.
D. Tell the client that he can do exercises after 2 weeks.

The nurse is caring for a client experiencing digitalis toxicity. The nurse anticipates a

prescription for which medication?
A. Digoxin immune fab
B. Milrinone
C. Amrinone
D. Flecainide

You are walking through the cafeteria in your medical center. As you enter you see a
female patient on the floor in a puddle of soda. Which of the following should you
document on the accident/incident report? The client:
A. Was found on the floor.
B. Slipped on soda and fell.
C. Slipped and hit their head.
D. Was very careless.

The patient with testicular cancer is receiving IV cisplatin. Which of the following should
the nurse assess for?
A. Irreversible heart failure
B. Bone marrow suppression
C. Cardiac toxicity
D. Peripheral neuropathy

Which medical gas is in the canister on the right?

A. Oxygen
B. Carbon dioxide
C. Air
D. Nitrous oxide

You are teaching a class to new graduate nurses about responding to medical

emergencies. Which content about anaphylactic shock should you include in this class?
A. Anaphylaxis is characterized by hypotension and respiratory stridor.
B. Anaphylaxis is characterized by severe hypertension and bradycardia.
C. Anaphylaxis is also referred to as a type of septic shock.
D. Anaphylaxis is also referred to as a type of hypovolemic shock.

The nurse is caring for a client who has developed Malignant Hyperthermia. Which of
the following actions should the nurse take?
Select all that apply.
A. Apply a cooling blanket
B. Insert indwelling urinary catheter
C. Monitor hourly blood glucose
D. Obtain blood cultures
E. Administer prescribed Dantrolene

There are several hormonal changes in patients immediately after a burn. Which of the
following hormones are secreted in burn patients?

Select all that apply.

A. Epinephrine
B. Antidiuretic Hormone
C. Aldosterone
D. Thyroid Stimulating Hormone

You are caring for a patient with blood clots in his lungs. He is receiving urokinase for
the treatment of pulmonary embolism. The urokinase has been infusing for the last 10
hours. As you assess the patient, you note that his blood pressure is 102/64, heart rate
is 108, and his respiratory rate is 16 breaths per minute. The patient asks to use the
bedpan. When he is finished, you notice that he has passed a medium-sized bloody
stool. Your best intervention is to:
A. Closely monitor the patient
B. Stop the urokinase and call the physician
C. Administer Vitamin K intramuscularly
D. Slow the administration of urokinase

Which of the following symptoms are indicative of autonomic dysreflexia in a client who
has experienced spinal cord injury?

Select all that apply.

A. Hypotension
B. Sudden headache
C. Flushed face
D. Nasal congestion

Which of the following complaints should be first evaluated in a client with respiratory

symptoms who has a history of asthma?
A. An oxygen saturation of 94%
B. Increased wheezing
C. Sustained rhonchi
D. Decreased respiratory rate

The nurse is caring for a client with an acute migraine headache. The nurse would
anticipate a prescription for which medication? 

Select all that apply.

A. Ketorolac
B. Nitroglycerin
C. Topiramate
D. Dexamethasone
E. Hydromorphone
F. Acetaminophen-caffeine

The RN is preparing to review teaching handouts about developmental milestones with

parents who have a 6-month-old child. The child was born at 28 weeks gestation. Which
of the following handouts are most appropriate when discussing the child's
development?
A. Developmental milestones for 6-month-olds
B. Developmental milestones for 3-month-olds
C. Developmental milestones for 4-month-olds
D. Developmental milestones for 1-month-olds

You are administering IV magnesium to a patient with a magnesium level of 1.5 mEq/L.
You check on them halfway through the infusion, and they report that their face feels
flushed. What is the priority nursing intervention?
A. Slow down the infusion rate.
B. Notify the healthcare provider.
C. Reassess the patient when the infusion finishes.
D. Stop the infusion.

Which of the following falls under the right dose of the 8 rights of medication
administration?

Select all that apply.

A. Using a drug reference to verify that the dose ordered is appropriate.
B. Identify the patient using 2 separate identifiers.
C. Have a second nurse independently calculate the medication dosage.
D. Double-check the last time that the medication was administered.

When assessing a patient with nausea, vomiting, and diarrhea, which of the following
focused assessment techniques should the nurse use?
A. Evaluate for dehydration, assess skin turgor, auscultate lungs
B. Auscultate lungs, auscultate heart, auscultate abdomen
C. Auscultate abdomen, palpate the abdomen, evaluate for dehydration
D. Palpate the abdomen, percuss the abdomen, auscultate heart

A nurse is caring for an 8-month-old infant. The physician notes a low potassium level
and prescribes intravenous KCl. Which of the following nursing actions should be
performed when administering the medication?
A. Administer the medication immediately
B. Administer the medication within the first hour of the order
C. Assess for adequate urine output
D. Wait until the client’s blood count results are in

The charge nurse is assigning tasks to a unlicensed assistive personnel (UAP). Which

task would be appropriate to delegate?
A. Collecting a urine specimen from an indwelling urinary catheter.
B. Increase nasal cannula oxygen for a client by one liter a minute.
C. Record how much drainage is in the suction cannister.
D. Remove a nitroglycerin patch before giving a bath.

The nurse is assigned the case manager role. She understands that case management
uses which of the following methods of patient care delivery and documentation?
A. A problem-oriented documentation system.
B. A critical pathway documentation system.
C. A source-oriented documentation system.
D. A variance-oriented documentation system.

The nurse is planning a staff development conference on the prevention of

contractures. Which of the following information should the nurse include?

Select all that apply.

A. Range-of-motion exercises of the extremities help prevent contractures.
B. Splinting the extremities may increase the risk of contractures.
C. Too many pillows under the head may cause a neck flexion contracture.
D. Using multiple staff members to reposition a client may prevent a contracture.
E. Contractures after a hip arthroplasty can be prevented with an abduction pillow.

The nurse is assessing a child with glomerulonephritis. Which assessment finding

requires follow-up by the nurse?
A. Periorbital edema
B. Decreased urine output
C. Headache
D. Hematuria

The nurse is performing community health screenings. A client tells the nurse that they
smoke two packs a day of cigarettes and have smoked for six years. The nurse should
document this finding as how many pack years?
A. 3.5 pack years
B. 3 pack years
C. 12 pack years
D. 6 pack years

Which technique is effective for determining and evaluating the effectiveness of the
nurse’s therapeutic communication and therapeutic communication techniques?
A. Performance improvement studies
B. ISBAR
C. Critical thinking
D. Process recording

You are a nurse in the emergency department of a local hospital. You are caring for a
60-year-old man with a sudden-onset headache that he describes as, “The worst
headache of my life.” You know that red flags for this problem include:

Select all that apply

A. Confusion
B. Nuchal rigidity
C. Hypotension
D. Age greater than 50 years

You are assigned to administer hydromorphone to a patient with post-operative pain.

You should be aware of which of the following legal mandates in terms of controlled
substances? 

Select all that apply.

A. The signatures of 2 registered nurses but not from practical nurses when a narcotic is
wasted.
B. Prohibitions against the use of a placebo for pain management.
C. The signatures of 3 registered nurses or practical nurses when a narcotic is wasted.
D. The verification of the narcotic count at the beginning and the end of the shift.
E. Check the controlled substance at least 3 times prior to its administration.
F. The secure locking of controlled substances to prevent diversion and theft.

The nurse is caring for a client in the emergency department. The client is short of
breath upon arrival to the ED and is coughing up purulent sputum. Oxygen is being
administered at 2 liters per minute via nasal cannula. The client's blood pressure is
100/58 mmHg, pulse is 88, and respiratory rate is 24. The client is afebrile with an
oxygen saturation of 92%. The results of arterial blood gas testing are: pH = 7.25, PaO2
= 93, PaCO2 = 69, and HCO3 = 25. The nurse understands that this ABG shows:
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

A client is brought to the emergency department after a severe car accident. They need
immediate surgery if their life is to be preserved. However, they are unconscious and
unable to consent to the operation. Which of the following is the best action?
A. Ask a friend who was with the client to sign the consent form.
B. Attempt calling a family member to obtain consent.
C. Call the on-staff nursing supervisor and request a court order for the surgery.
D. Immediately transport the client to the operating department without obtaining consent.

The mother of a toddler with Celiac disease is being instructed by the nurse regarding
dietary modifications for her child. Which food choice by the mother would indicate a
need for further discussion?
A. Rice cakes
B. Restaurant french fries
C. Milk shake
D. Grilled Chicken

The nurse manager is working on a unit where his nursing staff is not comfortable taking
care of patients from other cultural backgrounds. What is the most appropriate action for
the manager?
A. Let the staff research different articles regarding various cultures so they become more
familiar with them.
B. Transfer the nurses to another unit where they can’t be assigned to patients from other
cultures.
C. Rotate the nurses’ assignments so they can all have the opportunity to take care of patients
from other cultures.
D. Organize an activity that offers opportunities for the staff to learn about the cultures they
might encounter at work.

The nurse is caring for a client who sustained an ischemic cerebrovascular accident

(CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg.
The nurse should take which action?
A. Place the client supine
B. Continue to monitor
C. Obtain orthostatic blood pressure
D. Request a prescription for an antihypertensive

The psychiatric nurse is providing care for a patient who has just calmed down after
exhibiting inappropriate behaviors related to bipolar disorder. The nurse knows that
which of the following is the best way to help prevent another unseemly episode?

A. Identify the consequences of the behavior.

B. Assist the client in understanding triggering events or feelings that may have lead to the
outburst.
C. Ensure that the patient’s safety is upheld.
D. Offer the patient clear options to deal with their current behavior.

The nurse in the ICU is taking a client’s central venous pressure ( CVP). All of the
following are appropriate actions of the nurse when taking a CVP reading, except:
A. Placing the client supine with the head of the bed elevated to no more than 45°.
B. Placing the transducer at the fifth intercostal space, mid-axillary line.
C. Placing the transducer at the fourth intercostal space, mid-axillary line.
D. Instruct the client to relax, not strain or cough during the reading.

Which ergonomically designed work tool can prevent repetitive stress syndrome?

A. A back support belt
B. A special computer mouse
C. A special chair for sitting
D. Weighted pens and pencils

The nurse is caring for a client interested in pre-exposure prophylaxis for human
immunodeficiency virus (HIV). Which prescription would the nurse anticipate?
Voriconazole
B. Tenofovir-emtricitabine
C. Raloxifene
D. Lurasidone

The emergency department nurse is caring for a patient who presents with sudden
onset of edema of the lips and acute shortness of breath following a bee sting. The
provider’s diagnosis is anaphylaxis. The nurse knows that the first-line medication for
this diagnosis is:
A. Oral diphenhydramine
B. Nebulized albuterol
C. Oral prednisone
D. Parenteral epinephrine

Which form of therapy would most likely be used to treat a group of clients affected by
phobias?
A. Behavioral psychotherapy
B. Cognitive behavioral psychotherapy
C. Psychoanalysis
D. Cognitive psychotherapy

Calculate the total number of calories that a client will consume with a snack that
contains the following:

Carbohydrates: 16 grams

Protein: 12 grams
Fats: 5 grams
A. 47 calories
B. 57 calories
C. 107 calories
D. 157 calories

After talking to her family, an elderly client says that she wants to change the living will
she wrote two weeks ago. The nurse’s most appropriate reply would be:
A. “You can only change your living will a year after it is formulated.”
B. “Let me see if I can find someone to help you.”
C. “You can only make changes to your will after 3 weeks.”
D. “Let’s call your lawyer first and see what he thinks.”

Which of the following are features characteristic of fetal alcohol spectrum disorder?

Select all that apply.

A. Macrocephaly
B. Attention deficit disorder
C. Encephalopathy
D. Enlarged philtrum

Many documents fall under the category of an advanced directive. One of the most
common legal papers is called 'Durable Power of Attorney for Health Care' and works
to:
A. Review a person’s personal preferences for medical care in the future.
B. Authorize another person to make medical decisions for a person if they become unable to
on their own.
C. Assign a legal authority in making medical decisions while honoring the spoken word of the
family.
D. Define what care should be administered or withheld by health care professionals, no matter
which medical facility the patient finds themselves in.

The nurse is caring for a patient exhibiting signs of poor muscle

coordination, stooped posture, and slow movements. The medication most likely to
cause these symptoms would be which of the following?
A. Haloperidol
B. Nifedipine
C. Venlafaxine
D. Prazosin

Which of the following client needs would be the highest priority and the one that is also
supported by an appropriate rationale?
A. The need to develop trust versus mistrust because this is the most basic of all needs.
B. The need to be free of fear and anxiety because these feelings impede coping.
C. The need for adequate cardiovascular functioning because, without this, life cannot be
sustained.
D. The need for a patent airway because, without this, life cannot be sustained.

What action does the nurse perform to follow safe technique when using a portable
oxygen cylinder?
A. Check the amount of oxygen in the cylinder before using it.
B. Use a cylinder for a patient transfer that indicates available oxygen is at 500 psi.
C. Place the oxygen cylinder on the stretcher next to the patient.
D. Discontinue oxygen flow by turning the cylinder key counter-clockwise until it is tight.

A 16-year old patient injures her ankle on the soccer field. She is taken to the
emergency department by ambulance. In the ambulance, she starts hyperventilating.
Upon arrival to the waiting room, an arterial blood gas is drawn. What values will most
likely appear on the results?
A. pH: 7.55, CO2: 22, HCO3: 24
B. pH: 7.35, CO2: 39, HCO3: 26
C. pH: 7.32, CO2: 47, HCO3: 25
D. pH: 7.55, CO2: 42, HCO3: 34

When instructing a post-surgical patient with an abdominal incision on deep breathing

and coughing, the nurse explains that the patient should be sitting up for these activities
because:
A. It is physically more comfortable for the patient
B. Helps the patient to support their incision with a pillow
C. Loosens respiratory secretions
D. Allows the patient to observe their area and relax

The nurse receives a call from a post-abdominal surgery client. He reports some

numbness in his right leg and a funny feeling in his toes. What should the nurse
do next?
A. Elevate the client’s legs by placing a pillow underneath and tell him to drink more water.
B. Tell the client to stay in bed and call the physician.
C. Instruct the client to rub or massage his legs to stimulate the blood flow.
D. Encourage the client to ambulate and educate him on the dangers of prolonged bed rest.

A school-aged child has developed a phobia for school. The nurse is talking to the
child’s parents regarding ways that could help with the child’s phobia. Which statement
by the parents is accurate?
A. “We will just wait until his fears wear off; until then, we will just keep him home.”
B. “Teachers and counselors at school cannot possibly help him.”
C. “We’ll try not to talk to him about it too much.”
D. “We will discuss some solutions with him together with a counselor.”

When observing a patient on antivirals. The nurse notices the patient has developed
bruising. This could indicate which of the following?
A. The patient is being abused by a family member.
B. The patient is experiencing minor adverse reactions
C. The patient is not taking the medications as ordered.
D. The patient may be experiencing bone marrow suppression.

The nurse receives a prescription from the primary healthcare provider (PHCP) for
0.375 mg of digoxin intravenously (IV). The nurse has a vial that reads digoxin 0.25
mg/mL. How many mL will administer the appropriate dose? Fill in the blank.
Please enter in mL

0.3

The obstetric nurse is reading the prenatal client’s chart. The nurse notes that the
patient is suffering from preeclampsia and knows to observe for which complications in
the newborn?
A. Shaking and agitation
B. Low birth-weight
C. Abnormal kidney function
D. Blurred vision
The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor
pulmonale. Which nursing intervention would be most important to include in regards to
monitoring this patient’s peripheral edema?
A. Assess for skin tenting over the sternum
B. Weigh patient at same time daily
C. Obtain baseline BNP level
D. Record calf circumference daily

The nurse observes a patient clutching her abdomen and complaining of cramping,

which is accompanied by sharp pain. Which of the following types of pain is the client
experiencing?
A. Cutaneous or superficial somatic
B. Visceral
C. Deep somatic
D. Radiating

The nurse is assessing a patient with syndrome of inappropriate antidiuretic hormone

(SIADH). Which of the following laboratory tests require careful monitoring?
A. Potassium
B. Sodium
C. Glucose
D. Magnesium

Which of the following findings would prompt immediate investigation when performing
an assessment of a patient on a medical/surgical unit?
A. Bowel sounds of 14 per minute
B. High-pitched bowel sounds at a rate of 4 per minute
C. Bowel sounds greater than 60 per minute
D. Low-pitched bowel sounds at a rate of 30 per minute

The nurse plans care for a client experiencing a hyperglycemic-hyperosmolar state

(HHS). The nurse should anticipate which prescriptions from the primary healthcare
provider (PHCP)?
A. 0.9% saline infusion
B. Glargine insulin
C. Sodium polystyrene
D. Sodium bicarbonate

A common prerenal cause of acute kidney injury is:

A. Nephrotoxicity
B. Bladder cancer
C. Contrast media
D. Hypovolemia

Which of the following interventions should the nurse anticipate for an infant with
omphalocele awaiting surgical repair?

Select all that apply.

A. Cover the intestines with a sterile gauze soaked in saline
B. Prone positioning
C. Radiant warmer for thermoregulation
D. Trophic feedings

A mother states that she refuses to have her children immunized because she believes
vaccinations increase a child's odds of developing autism. Which of the following should
the nurse point out to her as the consequences of her decision to the community
overall?

Select all that apply

A. Reduction in herd immunity
B. Increase in teenage pregnancy
C. Increased incidence of diseases once thought to be eradicated
D. Increase in absences from school or workdays
E. Reduction in the incidence of physical or mental impairment
F. Increased costs associated with doctor and hospital visits

The nurse is caring for a client receiving total parenteral nutrition (TPN) started twelve
hours ago. The priority assessment should be the client's
A. urine output.
B. oral temperature.
C. weight.
D. capillary blood glucose.

A woman is in the labor and delivery suite at 37 weeks gestation. She has been under
her obstetrician’s care for preeclampsia. The labor nurse notices that the fetus is
experiencing heart rate decelerations. You are part of the neonatal resuscitation team
that responds to the call from the labor room nurse. The infant is born but does not
respond to tactile stimulation. The group moves the infant to the warmer. You evaluate
the infant and confirm he is still not breathing. You begin positive pressure blowing with
room air. Another team member notes that the heart rate is 72 bpm and the newborn’s
chest is not moving with PPV on room air. The next appropriate action is to:
A. Reposition the infant to open the airway
B. Begin CPR
C. Suction the infant with a bulb syringe
D. Increase the oxygen concentration

A semiconscious client in the postanesthesia care unit (PACU) is experiencing dyspnea.

Which action should the nurse perform first?
A. Place a pillow under the client’s head
B. Remove the oropharyngeal airway
C. Administer oxygen by mask
D. Reposition the client to keep the tongue forward

The nurse is working with a child who has a learning disability. The child is ten years old
and has trouble reading and interpreting words, letters, and symbols. What is the most
likely diagnosis?
A. Phonologic processing deficit
B. Dyslexia
C. Tourette’s syndrome
D. Apraxia
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