Predictive exam II

A nurse working in an assisted living facility notes that an older adult client with influenza has a fever of 101.8°F (38.7°C) and a dry cough. The client reports sore muscles and a headache.

The nurse instructs the unlicensed assistive personnel to encourage the client to consume extra fluids. If the client has normal cardiovascular and renal function, what is an appropriate goal for oral intake in the next 24-hour period?

A client who has degenerative arthritis is admitted for a total hip replacement.

After the client’s total hip replacement surgery, what nursing actions are essential? Select all that apply.

A 33-year-old client gave birth to a healthy newborn vaginally 6 hours ago. During the birth, the health care provider performed a right mediolateral episiotomy. Although in stable condition, the client experiences incisional discomfort.

What assessment finding by the nurse is the best indication that a perineal hematoma is present?

The nurse caring for the client with glomerulonephritis is told during the shift handoff that a 24-hour urine collection for creatinine clearance is to begin at 0800.

The client states that urine was inadvertently discarded at 0200. Which nursing instruction is most appropriate?

The client expresses concerns about the impending stapedectomy and says to the nurse, “There are so many awful complications that can happen with this surgery.”

How should the nurse position the client for the first 24 hours after a stapedectomy?

The client’s spouse tells the nurse that medical attention for chest pain was delayed because the client thought the discomfort was due to strained muscles from doing yard work.

What laboratory results would the nurse expect to be elevated if the client had a myocardial infarction (MI)?

A client who experiences recurrent pain along the sciatic nerve is scheduled for a myelogram.

When the nurse instructs the client on the myelogram procedure, which statement is a priority?

The health care provider prescribes a lumbar puncture for a 3-year-old child suspected of having a brain tumor.

How should the nurse position a child who is about to undergo a lumbar puncture?

The client’s I.V. line has infiltrated and needs to be removed and restarted in a new site. The licensed practical/vocational nurse (LPN/LVN) collaborates with the registered nurse (RN) as part of the health care team.

What laboratory result, if elevated, is most indicative that the client with cirrhosis may develop hepatic encephalopathy?

A day after a client undergoes the near-total thyroidectomy, the nurse suspects that the client is developing clinical manifestations of thyroid crisis.

What signs and symptoms are identified during SBAR communication to a health care provider which may indicate a thyroid crisis? Select all that apply.

Postoperatively, the client reports having a great deal of discomfort in the bladder area. There are several analgesic drug prescriptions for the client in anticipation of the pain associated with transurethral resection of the prostate (TURP).

What medication is most appropriate to administer to the client who is having bladder spasms?

Because a client has daily repeated episodes of angina, the nitroglycerin tablets are discontinued and replaced with a prescription for a daily nitroglycerin transdermal patch.

What nursing action is most appropriate when applying a new transdermal patch?

Cyclobenzaprine hydrochloride 30 mg orally b.i.d. is prescribed.

While assessing the client’s progress, which identifies that the medication is attaining its therapeutic outcome?

After being suspended from the team for taking anabolic steroids, the adolescent tells his parents, “I might as well be dead. My football career is over.”

When the nurse reviews the current laboratory findings of the client with anabolic steroid use disorder, what laboratory test finding is most likely to be abnormal?

The health care provider prescribes an albuterol inhaler two puffs every 3 to 4 hours and a flutter mucus-clearing device for the child with cystic fibrosis.

The nurse determines that this type of therapy is successful if what is accomplished?

A client is seen in the health care provider’s office and is given oseltamivir, an antiviral medication for the client’s symptoms of fever, chills, muscle aches, rhinitis, and sore throat related to influenza.

When the nurse is instructing the client on the effectiveness of oseltamivir, what instruction point is essential?

In the emergency department, it is necessary to estimate the total body surface that is burned.

What is the chief disadvantage when the nurse applies mafenide acetate cream to the burn wound?

A pregnant client is considering a tubal ligation after the birth of her child.

Medroxyprogesterone acetate 150 mg I.M. is prescribed for contraception for a 28-year-old woman. What nursing action(s) is appropriate when administering this medication? Select all that apply.

The client with gestational hypertension’s condition worsens and requires admission to the hospital. The health care provider prescribes magnesium sulfate.

What medication should the nurse have on hand when the client is receiving magnesium sulfate?

Before colorectal surgery, the client will receive 1 g of neomycin sulfate orally every hour for four doses and then 1 g orally every 4 hours for the balance of the 24 hours.

When the client asks the nurse why neomycin sulfate is prescribed, what is the most accurate explanation?

A 65-year-old client with severe chest pain is evaluated in the emergency department. A tentative diagnosis of myocardial infarction (MI) is made.

What nursing assessment finding is most closely correlated with an evolving MI?

A client has just returned to the nursing unit following a total hip replacement.

The nurse is instructing the unlicensed assistive personnel on proper postoperative positioning of the client. When demonstrating correct positioning technique, why does the nurse place a pillow between the client’s legs?

After thyroidectomy surgery, the client is returned to the nursing unit in stable condition.

When the nurse cares for the client following the thyroidectomy, what assessments indicate potential complications? Select all that apply.

A fluid challenge of 500 mL of I.V. fluid infused at a rapid rate is prescribed, followed by the administration of a loop diuretic to sustain or improve renal function.

Because of the client’s impaired renal function, what potential skin problem will require additional team planning?

During a routine home visit, a client describes what the nurse believes may be symptoms related to gastroesophageal reflux disease (GERD).

The home care nurse updates the plan of care to include nursing interventions related to what main symptom that accompanies gastroesophageal reflux disease (GERD)?

A nurse stops to provide emergency assistance to injured motorists.

When the nurse assesses a victim who has been thrown from the vehicle, what assessment finding is most suggestive of a serious head injury?

An adult client who has had asthma since early childhood presents to the emergency department in respiratory distress. The nurse uses pulse oximetry to monitor the asthma client’s oxygenation status.

The nurse is completing a health history. Which question is most important?

A 32-year-old client with a diagnosis of Hodgkin lymphoma is admitted to the hospital.

The most likely finding when the nurse palpates the client’s cervical lymph nodes is that the lymph nodes are:

An 8-year-old child is hospitalized for treatment of extensive partial-thickness and full-thickness burns on the face, neck, anterior chest, and left arm as a result of a house fire.

What clinical manifestation of a full-thickness burn requires close monitoring?

The nurse reviews the hereditary implications and precipitating factors of sickle cell anemia with the client.

The nurse teaches the client that the sickle cell crisis can be triggered by which precipitating factor(s)? Select all that apply.