Predictive exam III

A visitor collapses in the hospital, and a nurse goes to the victim’s aid.

Two nurses are performing cardiopulmonary resuscitation (CPR). To meet the goal of high-quality CPR, the nurses must accurately complete which sequence?

The nursing team develops a care plan for a client who has been diagnosed with cancer of the larynx. The client is scheduled for a total laryngectomy. After surgery, the client is taken to the recovery room until stabilized.

The nurse is evaluating a family member’s suction technique of the client’s tracheostomy. After the catheter is appropriately introduced, suction is applied for no longer than which amount of time?

Before discharging the client, the nurse provides plaster cast care instructions and information about signs and symptoms of complications.

When the client returns to the clinic several hours later with bloody drainage seeping through the cast, what action should the nurse take next?

A male client is expressing frustration with urination at his health care provider’s appointment. The client states, “I am coming to that age where I am having difficulty with urination. I suppose that it has to do with my enlarged prostate gland.”

What assessment finding strongly suggests that a client with an enlarged prostate gland is experiencing urinary retention?

Assessment reveals that the client has hemianopia following a cerebral vascular accident (CVA).

When the nurse prepares to assess the client with a cerebral aneurysm, what assessment is the highest priority?

A postterm male newborn in no apparent distress is admitted to the nursery after an uneventful planned cesarean birth.

What assessment finding would the nurse consider most indicative of congenital hip dysplasia in a newborn?

A 60-year-old client seeks medical attention with symptoms of vomiting blood and passing bloody stools. The tentative diagnosis is cirrhosis of the liver.

What information in the client’s health history most likely relates to the development of cirrhosis? Select all that apply.

A client is admitted for surgical treatment of a pilonidal cyst.

When obtaining the client’s health history, what characteristic finding(s) would the admitting nurse expect the client to report? Select all that apply.

A nurse participates in a community-wide screening to identify adults who may have undiagnosed diabetes mellitus.

What signs and symptoms are most appropriate for the nurse to investigate when screening adults who have come to have their blood glucose tested?

The health care provider prescribes an I.V. infusion of dextrose 2.5% in normal saline solution.

What information regarding infant I.V. therapy is correct?

A nephrectomy is performed on a client with a kidney tumor.

Postoperatively, what assessment finding is most suggestive that the client is hemorrhaging following the nephrectomy?

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

If the open method of burn wound management is used when caring for the client with both partial-thickness and full-thickness burns, what potential problem is most important for the nurse to detect?

A 63-year-old client with liver cancer is admitted to the medical-surgical unit with a diagnosis of pericarditis.

When auscultating the client’s heart and breath sounds during a routine shift assessment, what action by the nurse is most appropriate?

The toddler develops acute respiratory distress during the night and is taken to the hospital’s emergency department. The health care provider admits the toddler for further treatment.

What beverage should the nurse avoid when offering liquids to a toddler with croup?

A 28-year-old multipara client is admitted to the hospital for observation during the 10th week of pregnancy. The client has a history of habitual spontaneous abortions.

What finding(s) reported by the client at this time suggests there is a threat of aborting the fetus? Select all that apply.

A 20-year-old college student goes to the university health service after developing a sudden onset of flu-like symptoms.

When the health nurse reviews the client’s laboratory test results, what elevated level would strongly suggest a possible liver disorder?

A client with a compound fracture of the left radius will have a plaster arm cast applied.

What is the best method to assess circulation in the casted extremity?

A client with type 1 diabetes mellitus presents to the clinic with reports of persistent bouts of nausea, vomiting, and diarrhea for the past 4 days. The client has skipped insulin injections because of not being able to eat or keep anything down.

The nurse instructs a client about using a Humulin 70/30 prefilled insulin pen. What statement by the client needs further clarification?

The licensed practical/vocational nurse (LPN/LVN) assists the registered nurse (RN) in inserting a nasogastric (NG) tube in the client with a perforated ulcer.

What is the best evidence-based practice to determine if a nasogastric tube is located in the stomach?

The newborn’s total bilirubin level is 11 mg/dL (188.1 mmol/L). The health care provider prescribes conventional phototherapy using lights suspended above the newborn rather than a biliblanket that is placed directly on the skin.

When providing care for a newborn receiving phototherapy, what nursing intervention is most appropriate?

A 68-year-old client who is currently being treated for major depression is transferred to a medical unit after an episode of acute abdominal pain.

What nursing instruction(s) is appropriate to include in the teaching plan of a client who is just beginning treatment with imipramine hydrochloride? Select all that apply.

The health care provider prescribes phenytoin. After several days on the medication, the preschooler has no further seizure activity. The health care provider writes a discharge prescription, which includes 0 administering phenytoin at home.

During the discharge process, what long-term adverse effect of phenytoin should the nurse include in the instructions to the parents?

Colchicine is prescribed to be given every hour until the client’s pain is relieved during an acute attack of gout.

What client symptom indicates that the nurse should withhold the medication until checking with the prescriber even if the client’s pain is unrelieved?

After confirming the client had a myocardial infarction (MI), an infusion of streptokinase is begun.

What is the best explanation the nurse can provide for why the streptokinase is being administered?

Another participant asks the nurse to explain the difference between oral contraceptive packages that have 21 pills and those that have 28 pills.

The nurse obtains a sample package of 28 pills for instruction and states that packages containing 28 pills:

Three days after going to the clinic, the client phones the health office and explains that it is difficult to swallow the large iron capsule. A liquid iron preparation is prescribed.

When instructing the client about the administration of the liquid iron preparation, what information should the nurse provide?

The client’s electrolyte imbalance is corrected. Before the colonoscopy, the client is given moderate sedation using midazolam hydrochloride.

During the colonoscopy and in the immediate recovery period, for what potential adverse effect of midazolam hydrochloride is it essential that the nurse assess the client closely?

Drug therapy is unsuccessful for the client with trigeminal neuralgia; one of the branches of the trigeminal nerve is severed as additional treatment. Eye irrigations are prescribed postoperatively.

To correctly perform the eye irrigation, in what direction should the nurse instill the irrigant?

The health care provider prescribes two puffs of albuterol sulfate twice a day as needed using a metered-dose inhaler.

After administering the first puff of medication, what client action demonstrates proper use of the inhaler?

The newborn’s parents also want to know about the ointment that is being placed in the newborn’s eyes.

The nurse explains to the parents that erythromycin is given to protect the newborn from neonatal blindness, which can occur if the newborn develops an eye infection caused by what organisms?