Predictive exam XVI RN

The nurse analyzed an electrocardiogram (ECG) strip (refer to figure) for a client demonstrating left-sided heart failure and interprets the ECG strip as which rhythm?

A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?

The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which action would the nurse implement?

The nurse assesses a peripheral intravenous (IV) dressing and notes that it is damp and the tape is loose. What action would the nurse take initially?

The nurse assists the primary health care provider with the removal of a chest tube inserted to treat a client who experienced a pneumothorax. During the procedure, the nurse instructs the client to perform which action?

The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What action would the nurse implement?

The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which information would the nurse use to plan interventions for this client? Select all that apply.

The nurse plans care for a client with dehydration requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply.

A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?

The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition?

The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which assessment findings does the nurse expect to note documented in the client’s medical record? Select all that apply.

The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions would the nurse implement? Select all that apply.

A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse would ask the client about a recent history of which event?

A client has just been admitted to the emergency department with reports of chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis?

As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?

The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube after surgery for stomach cancer. The nurse would place the client in which position to administer the feeding?

The nurse monitors a patient diagnosed with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed?

After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client?

Which important parameter would the nurse assess daily for a client diagnosed with nephrotic syndrome?

A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?

The client with heart failure states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?

The nurse admits a client who is in sickle cell crisis. The nurse would prepare for which intervention as a priority in the management of the client?

The nurse suspecting that a client is developing cardiogenic shock would assess for which peripheral vascular manifestation of this complication? Select all that apply.

The nurse teaching an older client about general hygienic measures for foot and nail care would include which instructions? Select all that apply.

A client diagnosed with renal cancer is being treated preoperatively with radiation therapy. The nurse evaluates that the client has an understanding of proper care of the skin over the treatment field when the client makes which statement?

The home health nurse is performing an initial assessment on a client who has been discharged after an insertion of a permanent pacemaker for a bradydysrhythmia. Which client statement indicates that an understanding of self-care is evident?

A client experiencing a major depressive episode is unable to address activities of daily living (ADLs). Which nursing intervention best meets the client’s current needs therapeutically?

A pregnant client at 32 weeks of gestation is admitted to the obstetrical unit for observation after a motor vehicle crash. When the client begins experiencing slight vaginal bleeding and mild cramps, which action would the nurse take to determine the viability of the fetus?

The nurse is reviewing the results of a sweat test performed on a child diagnosed with cystic fibrosis (CF). Which finding would the nurse identify as supporting this diagnosis?

The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal would the nurse expect to note? Select all that apply.

The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse would determine that there is a need for close observation and a need for follow-up if which is noted?

The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?

The nurse caring for a client returning to the unit after right radical mastectomy to treat breast cancer includes which intervention in the nursing plan of care for this client?

The nurse is assisting a client diagnosed with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree item?

A client with a colostomy reports gas buildup in the colostomy bag. The nurse instructs the client that consuming which food items would help prevent this problem? Select all that apply.

A client receiving total parenteral nutrition (TPN) reports nausea, polydipsia, and polyuria. To determine the cause of the client’s report, the nurse would assess which client data?

A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication?

The nurse who practices culturally sensitive nursing care incorporates which concepts into client care when addressing issues related to pain? Select all that apply.

While gathering data, the nurse notes that the client has been prescribed tolterodine tartrate. The nurse would determine that the client is taking the medication to treat which disorder?

The nurse provides discharge instructions to a client with diabetes mellitus beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply.

The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse would document that the treatment was effective if which finding was present? Select all that apply.

The nurse instructs a preoperative client about the proper use of an incentive spirometer to minimize the risk of postoperative complications. What result would the nurse use to determine that the client is using the incentive spirometer effectively?

A client prescribed prazosin hydrochloride asks the nurse why the first dose must be taken at bedtime. Which response by the nurse is based on the understanding of the first dose use of prazosin hydrochloride?

The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method would the nurse use to cover the dressing?

A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child’s stools will have which characteristic?

A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?

A client who undergoes a gastric resection is at risk for developing dumping syndrome. Which manifestation would the nurse monitor the client for in association with eating? Select all that apply.

A client experiencing difficulty breathing and increased pulmonary congestion as a result of heart failure was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment finding indicates that the therapy has been effective?

Skin closure with heterograft will be performed on a client with a burn injury. When the client asks the nurse where the heterograft comes from, the nurse would explain it is from which source?