Ati Advanced Med Surg Proctored 2023 With Glasgow Coma Scale Real Exam

Downloaded by Bob Michael ([email protected])lOMoARcPSD|975457 AT IADVANCEDMEDSURGPROCTORED2023WITHGLASGOWCOMASCALEREALEXAM1.Anurseinaburntreatmentcenteriscaringforaclientwhoisadmittedwithsevereburnstobothlowerextremitiesandispendinganescharotomy.Theclientsspouseasksthenursewhattheprocedureentails.Whichofthefollowingnursingstatementsisappropriate?a.largeincisionswillbemadeintheeschartoimprovecirculationb.Icancallthedoctorbackhereifyouwantmetoc.apieceofskinwillberemovedandgraftedovertheburnedaread.deadtissuewillbesurgicallyremoved2.AnurseismonitoringtheDluidreplacementofaclientwhohassustainedburns.WhichofthefollowingDluidsisusedintheDirst24hoursfollowingaburninjury?a.5%dextroseinwaterb.5%dextroseinnormalsalinec.normalsalined.lactatedringers3.Anurseiscaringforaclientwhohasfull-thicknessburnsallover75%ofhisbody.Whichofthefollowingmethodsisappropriatetoaccuratelymonitorthecardiovascularsystem?a.auscultatecuffbloodpressureb.palpatepulsepressurec.obtainacentralvenouspressured.monitorthepulmonaryarterypressure4.Anurseisassessingthedepthandextentofaclientwhohassevereburnstotheface,neck,andupperextremities.WhichofthefollowingfactorsistheDirstprioritywhenassessingtheseverityoftheburn?a.Ageoftheclientb.Associatedmedicalhistoryc.Locationoftheburnd.Causeoftheburn5.Aclientarrivesattheemergencydeptfollowinganexplosionatthechemicalplant.Hehasdeeppartialandfull-thicknesschemicalburnsovermorethan25%ofhisbodysurfacearea.Whatisthenursespriorityintervention?a.InitiateDluidresuscitationb.Medicationforpainc.AdministerantibioticslOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])d.Maintainapatentairway6.Anurseiscaringforaclientwhocametheemergencydeptreportingchestpain.Theprovidersuspectsamyocardialinfarction.Whilewaitingforthelaboratorytoreporttheclientstroponinlevels,theclientaskswhatthisbloodtestwillshow.Thenurseshouldexplainthattroponinisa.Anenzymethatindicatesdamagetobrain,heart,andskeletalmuscletissuesb.AproteinwhoselevelsreDlecttheriskforcoronaryarterydiseasec.Aheartmuscleproteinthatappearsinthebloodstreamwhenthereisdamagetotheheartd.Aproteinthathelpstransportoxygenthroughoutthebody7.Anurseisassessingaclientwhohasdisseminatedintravascularcoagulation(DIC).WhichofthefollowingshouldthenurseexpectintheDindings?a.Excessivethrombosisandbleedingb.Progressiveincreaseinplateletproductionc.ImmediatesodiumandDluidretentiond.Increasedclottingfactors8.Anurseisabouttoadministerwarfarin(Coumadin)toaclientwhohasatrialDibrillation.Whentheclientaskswhathismedicationwilldo,whichofthefollowingisanappropriatenursingresponse?a.IthelpsconvertatrialDibrillationtosinusrhythmb.Isdissolvesclotsinthebloodstreamc.Itslowstheresponseoftheventriclestothefastatrialimpulsesd.ItpreventsstrokesinclientswhohaveatrialOibrillation9.Anurseinacardiaccareunitiscaringforaclientwithacuteheartfailure.WhichofthefollowingDindingsshouldthenurseexpect?a.Decreasedbrainnatriureticpeptide(BNP)b.Elevatedcentralvenouspressure(CVP)c.Decreasedpulmonarypressured.Increasesurinaryoutput10.AclientcomesintotheEDreportingnauseaandvomitingthatworsenswhenlyingdownandwithoutrelieffromantacids.Theprovidersuspectsacutepancreatitis.Whichofthefollowinglabtestresultsshouldthenurseexpecttoseeiftheclienthasacutepancreatitis?a.DecreasedWBClOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])b.Increasedserumamylasec.Decreasedserumlipased.Increasedserumcalcium11.AnurseintheICUiscaringforaclientwhohasacuterespiratorydistresssyndrome(ARDS)andisreceivingmechanicalviaanendotrachealtube.Theproviderplanstoextubateherwithinthenext24hour.Whichofthefollowingisanimportantcriterionforextubatingtheclient?a.Abilitytocougheffectivelyb.Adequatetidalvolumewithoutmanuallyassistedbreathsc.Noindicationofinfectiond.Noneedforsupplementaloxygen12.AnurseiscaringforaclientfollowingaCTscanwithdyewhosufferedfromananaphylacticreaction.Whichofthefollowingconditionsrequiresaprioritynursingresponse?a.urticariab.stridorc.tachypnead.angioedema13.AnurseiscaringforafemaleclientwhocameintotheEDreportingSOBandpaininthelungarea.Herheartrateis110/min,resp.rate40/min,andbloodpressure140/80m8juiimHg.Herarterialbloodgasesare:pH7.5,PaCO229mmHg,PaO260mmHg,HCO320mEq/L,andSaO286%.Whichofthefollowingisthepriorityintervention?a.Prepareformechanicalventilationb.Administeroxygenviafacemaskc.Preparetoadministerasedatived.Monitorforpulmonaryembolism14.AnurseismonitoringaclientwhohasjusthadathoracentesistoremovepleuralDluid.Whichofthefollowingclinicalmanifestationsindicateacomplicationthatrequiresnotifyingtheproviderimmediately?a.Serosanguineousdrainagefromthepuncturesiteb.Discomfortatthepuncturesitec.Increasedheartrated.Decreasedtemperature15.AgroupofcollegestudentswasattendingaweekendfootballrallywhenoneofthestudentsstumbledandfellintothebonDire.AlthoughseveralfriendsquicklylOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])intervened,theclientsustainedpartial-thicknessburnstobothlowerlegs,chest,andbothforearms.WhichofthefollowingisprioritynursingactionwhentheclientisbroughttotheED?a.covertheburnedareawithsterilegauzeb.inspectmouthforsignsofinhalationc.administerintravenouspainmedicationd.drawbloodforaCBC16.Atriagenurseinanemergencydeptiscaringforaclientwhohasgunshotwoundtotherightsideofchest.Thenursenoticesthickdressingonthechestandsuckingnoisecomingfromthewound.Theclienthasabloodpressureof100/60mmHg,aweakpulserateof118/min,andarespiratoryrateof40/min.Whichofthefollowingactionsshouldthenursetakeinitially?a.Raisethefootofthebedtoa90degreeangleb.Removethedressingtoinspectthewoundc.Preparetoinsertacentrallined.Administeroxygenvianasalcannula17.Anurseissuctioningtheendotrachealtubeofaclientwhoisonaventilator.Theclientsheartrateincreasesfrom86/minto110/minandbecomesirregular.Thenurseshouldknowthattheclientrequireswhichofthefollowing?a.Acardiologyconsultb.Lessfrequentsuctioningc.Anantidysrhythmicmedicationd.Pre-oxygenationpriortosuctioning18.Thenurseiscaringforaclientwhoisreceivingabloodtransfusion.Thetransfusionstarted30minutesagoatarateof100mL/hr.Theclientbeginstocomplainoflowbackpainandheadacheandisincreasinglyrestless.WhatistheDirstnursingaction?a.Stopthetransfusion,disconnectthebloodtubing,andbeginaprimaryinfusionofnormalsalinesolutionb.Slowtheinfusionandevaluatethevitalsignsandtheclientshistoryoftranfusionreactionsc.SlowtheinfusionofbloodandbegininfusionofnormalsalinesolutionfromtheYconnector.d.RechecktheunitofbloodforcorrectidentiDicationnumbersandcrossmatchinformation19.Aclientwithadiagnosisofdisseminatedintravascularcoagulation(DIC)hasthefollowingassessmentDindings:bloodpressureof76/56,temperature102.6lOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])degrees,resp.24breath/min.,withcomplaintsofsevereneckandbackpain.WhichnursingactionshouldthenurseimplementDirst?a.Administeracetaminophen(Tylenol)PO.b.Administeribuprofen(Motrin)PO.c.DrawcoagulationstudybloodworkintheAMd.GivemorphinesulfateIV20.Thenurseadministeringalbuterol(Proventil)viaametered-doseinhaler(MDI)toaclientwhohasahistoryofcoronaryarterydiseaseisnowincongestiveheartfailure.Whatsideeffectswillbeparticularlyimportanttoobserveforwhentheclienttakesthemedication?a.Tremorsandcentralnervoussystemstimulationb.Ta c h y c a r d i aandchestdiscomfortc.Developmentoforalcandidiasisd.Anincreaseinbloodpressure21.Thenurseisassessingaclientwhoisonaventilatorandhasanendotrachealtubeinplace.WhatdataconDirmsthatthetubehasmigratedtoofarintothetrachea?a.Decreasedbreathsoundsareheardovertheleftsideofthechestb.Increasedrhonchiarepresentatthelungbasesbilaterallyc.Ve n t i l a t o rpressurealarmcontinuestosoundd.Clientisabletospeakandcoughsexcessively22.Whatisthedesiredactionofdopamine(Intropin)whenadministeredinthetreatmentofshock?a.Itincreasesmyocardialcontractilityb.Itisassociatedwithfewersevereallergicreactionsc.Itcausesrapidvasodilationofthevascularbedd.Itsupportsrenalperfusionbydilationoftherenalarteries23.ThenurseismonitoringanIVinfusionofsodiumnitroprusside(Nirpride).Fifteenminutesaftertheinfusionisstarted,theclientsBPgoesfrom190/120mmHgto120/90mmHg.Whatistheprioritynursingaction?a.RechecktheBPandcallthedoctorb.Decreasetheinfusionrateandrecheckthebloodpressurein5minutesc.StopthemedicationandkeeptheIVopenwithD5W.d.AssesstheclientstoleranceofthecurrentlevelofBPlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])24.Norepinephrine(Levophed)hasbeenorderedforaclientinhypovolemicshock.Beforeadministeringthedrug,thenurseshouldmakesurethattheclienthas:a.Aheartrateoflessthan120beats/minb.Urineoutputofatleast30mL/hr.c.Receivedadequateanticoagulationd.BeenreceivingadequateIVOluidreplacement25.Theclientreturnstohisroomafterathoracotomy.Whatwillthenursingassessmentrevealifhypovolemiafromexcessivebloodlossispresent?a.CVPof3cmH20andurineoutputof20mL/hrb.Jugularveindistentionwiththeheadelevated45degreesc.Chesttubedrainageof50mL/hrintheDirst2hoursd.PersistentincreasedBPandincreasedpulsepressure26.ThenurseisperforminganassessmentandDindstheclienthascold,clammyskin,pulseof130beats/minandweak,bloodpressureof84/56mmHg,andurinaryof20mLforthepasthour.ThenursewouldinterprettheseDindingsassuggestiveofwhichpathophysiology?a.Reductionofcirculationtothecoronaryarteries,thisincreasingthepreloadb.DecreasedglomeruliDiltrationrate,resultinginvolumeoverloadc.Stimulationofthesympatheticnervoussystem,causingseverevasoconstrictiond.Decreaseinthecardiacoutputandinadequatetissueperfusion27.ThenurseappliesaNitro-Durpatchonaclientwhohasundergonecardiacsurgery.WhatnursingobservationindicatesthataNitro-Durpatchisachievingthedesiredeffect?a.Chestpainiscompletelyrelievedb.Clientperformsactivitiesofdailylivingwithoutchestpainc.Painiscontrolledwithfrequentchangesofpatchd.Clienttoleratesincreasedactivitywithoutpain28)TheV/SofaclientwithCardiacdiseaseareasfollows:BP102/76mm/hg,Pulse52,RR16.AtropineisadministeredIVpush.Whatnursingassessmentindicatesatherapeuticresponsetothemedication?lOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])A.Pulseratehasincreasedto70beats/minB.systolicBPhasincreasedby20C.pupilsaredilatedD.oralsecretionshavedecreased29)AnolderadultclientcomesintoERstatingthathehasnoappetite,isnauseated,hisheartfeelsfunnyandhasnoticedahazinessinhisvision.Theclientstatesthathehasbeentakinganantihypertensivedruganddigitalisformorethanayear.Basedonthepresentingsymptoms,whatwouldbetheprioritynursingaction?A.ObtainanorderforanEKGandserumpotassiumanddigitalislevelsB.Performaneurologicalassessmenttodeterminewhetherhehasonesideweakness.C.Assesslungsfordecreasedbreathsoundsand/oradventitiousbreathsounds.d.ObtainanorderforanEKG30)thenurseisadministeringalteplasetoaclientwhohasbeendiagnosedwithacutecoronarysyndrome.Whatareimportantnursingimplicationsforthismedication?A.MonitortheECGfordysrthymiasB.PlacetheclientonbleedingprecautionsC.monitorurineoutputhourlyD.Monitorforactivitytolerance31)Thenurseiscaringforaclientwhounderwentcardiaccatheterization1hourago.Whatisanimportantnursingmeasureatthistime?A.MeasureurinaryoutputhourlyandmaintaincontinuouscardiacmonitoringB.Encourageclienttoperformslowpressureexerciseoftheaffectedsidetopromotecirculation.C.Maintainpressureovercatheterinsertionsiteanddeterminedistalcirculationstatus.D.EvaluateapicalpulseanddeterminepresenceofpulsedeDicit.32.Thenurseinacardiacstepdownunithasreceivedahand-offshiftreportfortheseclients.WhichclientshouldbeassessDirst?A.aclientwhohasjustreturnedfromacoronaryartierogramwithplacementofanintracoronarystent.B.Aclientwhoisinheartfailureandhasgained2pndsinthelast24hours.C.aclientwithendocarditiswhohastemperatureelevationof100FandP100beats/minlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])D.AclientwhowascardiovertedfromatrialDib24hoursagoandhashad3atrialpremature33)WhatECGchangeswouldreDlectmyocardialischemiainaclientwhohasbeenadmittedforobservationafterexperiencinganepisodeofchestpain?A.ProlongedPRintervalB.WideQRScomplexC.ST-SegmentelevationordepressionD.Ta l l ,peakT- w a v e s34)Anewemployeeatafacilityneedsahepatitisvaccine.WhichstatementreDlectsaccurateunderstandingoftheimmunization?A.Ineedtoget6shotsofhepCB.OnceIreceivetheHepvaccineIwillalwaysbeenimmuneC.Iwillreceive3injectionsoveraperiodofmonths,whichshouldprotectmefromhepBD.HepvaccineisanoralvaccinewithliveattenuatedVirus35)Whiletalkingwithaclientwithadiagnosisofendstageliverdisease.Thenursenoticestheclientisunabletostayawakeandseemstofallasleepinthemiddleofasentence.Thenurserecognizesthesesymptomstobeindicativeofwhatcondition?A.HyperglycemiaB.IncreasedBileproductionC.IncreasedbloodammonialevelsD.Hypocalcaemia36)ThenurseiscaringforaclientwithchronichepB.Whatwilltheteachingplanforthisclientinclude?A.useacondomforsexualintercourseB.Reportanyclay-coloredstools.C.EatahighproteindietD.Performdailyurinebilirubinchecks37.Apatientwithmassivetraumaandpossiblespinalcordinjuryisadmittedtotheemergencydepartment(ED).WhichDindingbythenursewillhelpconDirmadiagnosisofneurogenicshock?a.coolclammyskinb.inspiratorycracklesc.apicalheartrateof48beats/mind.temperature101.2*FlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])38.Apatientwithsepticshockhasaurineoutputof20mL/hrforthepast3hours.Thepulserateis120andthecentralvenousandpulmonaryarterywedgepressureare4.Whichoftheseordersbythehealthcareproviderwillthenursequestion?a.Givefurosemide(Lasix)40mgIVb.increasenormalsalineinfusionto150mL/hrc.Administerhydrocortisone(SoluCortef )100mgIVd.Preparetogivedrotrecoginalpha(Xigris)24mcg/kg/hr39.Afterreceiving1000mLofnormalsaline,thecentralvenouspressureforapatientwhohassepticshockis10mmHg,butthebloodpressureisstill82/40mmHg.Thenursewillanticipatetheadministrationofwhichofthefollowing?a.Nitroglycerin(Tridil)b.Sodiumnitroprusside(Nipride)c.Drotrecoginalpha(Xigris)d.Norepinephrine(Levophed)40.WhichoftheseDindingsisthebestindicatorsthattheDluidresuscitationforapatientwithhypovolemicshockhasbeensuccessful?a.hemoglobiniswithinnormallimitsb.Urineoutputis60mLoverthelasthourc.Pulmonaryarterywedgepressure(PAWP)is10mmHgd.Meanarterialpressure(MAP)is55mmHg41.Whichinterventionswillthenurseincludeintheplanofthecareforapatientwhohascardiogenicshock?a.Avoidelevatingheadofbedb.Checktemperatureevery2hoursc.Monitorbreathsoundsfrequentlyd.AssessskinforDlushinganditching42.Whichassessmentismostimportantforthenursetomakeinordertoevaluatewhethertreatmentofapatientwithanaphylacticshockhasbeeneffective?a.Pulserateb.Orientationc.Bloodpressured.OxygensaturationlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])43.Whencaringforthepatientwhohassepticshock,whichassessmentDindingismostimportantforthenursetoreporttothehealthcareprovider?(TBch.67Q.17)a.BP92/56mmHgb.Skincoolandclammyc.apicalpulse118beats/mind.Arterialoxygensaturation91%44.Duringchange-of-shiftreport,thenurselearnsthatapatienthasbeenadmittedwithdehydrationandhypotensionafterhavingvomitinganddiarrheafor3days.WhichDindingsismostimportantforthenursetoreporttotheHCP?a.Decreasedbowelsoundsb.Apicalpulse110beats/minc.Pale,cool,anddryextremitiesd.Newonsetofconfusionandagitation45.ApatientisadmittedtotheburnunitwithburnstheupperbodyandheadafteragarageDire.Initially,wheezesareheard,butanhourlater,thelungsoundsaredecreasedadnowheezesareaudible.Whatisthebestactionforthenursetotake?a.encouragethepatienttocoughandauscultatethelungsagainb.NotifytheHCPandprepareforendotrachealintubationc.Documenttheresultsandcontinuetomonitorthepatientsresp.rated.Repositionptinhigh-Fowlerspositionandreassessbreathsounds46.Duringtheemergentphaseofburncare,whichnursingactionwillbemostusefulindeterminingwhetherthepatientisreceivingadequateDluidinfusion?a.Checkskinturgorb.Monitordailyweightc.Assessmucousmembranesd.Measureshourlyurineoutput47.Afterreceivingchange-of-shiftreport,whichofthesepatientsshouldthenurseassessDirst?a.Apatientwithsmokeinhalationwhohaswheezesandalteredmentalstatusb.Apatientwithfull-thicknesslegburnswhohasadressingchangescheduledc.Apatientwithabdominalburnswhoiscomplainingoflevel8(0to10scale)pain.d.Apatientwith40%totalbodysurfacearea(TBSA)burnswhoisreceivingIVDluidsat500mL/hrlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])48.TheRNobservesallofthefollowingactionsbegintakenbyastaffnursewhohasDloatedtotheunit.WhichactionrequiresthattheRNintervene?a.Thenurseuseslatexgloveswhenapplyingantibacterialcreamtoaburnwoundb.TheDloatnurseobtainsburncultureswhenthepatienthasatempof101*Fc.TheDloatnurseadministersPRNfentanyl(Sublimaze)IVtoapt5minutesbeforeadressingchanged.TheDloatnursecallsthehealthcareproviderforaninsulinorderwhenanondiabeticpthasanelevatedserumglucose49)Aclientwithcervicalneckfractureisadmittedtotheintensivecareunit.WhichDindingswouldthenurserecognizeasindicativeofspinalshock?A.Spastically,neuromuscularirritability,hyperreflexiaB.Flaccidityandlackofsensationbelowthelevelofspinalcordlesion.C.AutomaticdysreDlexiawithneurogenicbladdersymptomsD.MuscularspasticityandlossofmotorreDlexesinallpartsofthebodybelowthelevelofspinalcordlesion.****know T2-T3: paraplegic *************** 50)AclientwithT6spinalcordinjuryisbeingdischarged.ThePTisconcernedaboutautonomicdysreDlexia.S/Sincludethefollowing:A.DialitedpupilsB.SuddenvomitinganddiarrheaC.dropinBPandpulseD.Diaphoresisabovethelevelofthelesion51)Awomanhasbeenrecentlydiagnosedwithsystemiclupusandshareswiththenurse,Iwanttogetpregnant,butIdontknowhowIwilltoleratepregnancybecauseIhavelupus.Whichresponseisbest?A.MostwomenDindthattheyfeelbetterwhentheyarepregnantB.Howlonghaveyoubeeninremission?C.WomenwithlupusfrequentlyhaveslightlylongergestationD.ItsbesttobecomepregnantwithintheDirst6monthsofdiagnosis52.ThenurseisassessingthepatencyofanarteriovenousDistulaandsuspectsclottingintheDistulaifwhichDindingarenoted?SelectallthatapplyA.presenceofathrillonpalpationovertheDistula*B.AbsenceofabruitonauscultationovertheOistulalOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])C.PresenceofapulseintheextremitybelowtheDistula*D.ComplaintsoftinglingordiscomfortintheextremityE.Wa r mhandandDingersintheextremityinwhichtheDistulaislocated.53.Epoetinalfa(Epogen)isprescribedforaclientdiagnosedwithchronicrenalfailure.Theclientasksthenurseaboutthepurposeofthemedication.Theappropriateresponsewouldbewhichofthefollowing?A.Itisusedtoloweryourbloodpressure*B.ItisusedtotreatanemiaC.ItwillhelptoincreasethepotassiumlevelsinyourbodyD.Itisananticonvulsantmedicationgiventoallclientsafterdialysistopreventseizureactivity.54.AclientwithandECGreadingshowingsinusbradycardiahasabloodpressureof47/28mmhg.Whichdrugsdoesthenurseexpectthephysiciantoorderforthisclient?A.Lidocaine(Xylocaine)*B.AtropinesulfateC.Isoproterenolhydrochloride(Isuprel)D.Epinephrine55.ChemicalcardioversionisprescribedfortheclientwithatrialDibrillation.ThenursewhoisassistinginpreparingtheclientwouldexpectthatwhichmedicationspeciDicforchemicalcardioversionwillbeneeded?A.NitroglycerinBNifedipine(Procardia)CLidocaine(Xylocaine)*D.Amiodarone(Cordarone)56.Anurseassessesacomatose,head-injuredclientandDindsDlexionofthearms,wrists,andDingersandadductionoftheupperextremities.WhichofthefollowingdescribestheseDindings?A.StrokeB.EpilepticSeizure*C.DecorticateposturingD.Decerebrateposturing57.TheclientdiagnosedwithARDSistransferredtotheintensivecaredepartmentandplacedonaventilator.WhichinterventionshouldthenurseimplementDirst?AConDirmthattheventilatorsettingsarecorrectlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])BVerifythattheventilatoralarmsarefunctioningproperly*C.Assesstherespiratorystatusandpulseoximeterreading.DMonitortheclientsarterialbloodgasresults.58.Thelow-pressurealarmsoundsonaventilator.Anurseassessestheclientandthenattemptstodeterminethecauseofthealarm.Thenurseisunsuccessfulindeterminingthecauseofthealarmandtakeswhatinitialaction?A.AdministeroxygenB.Checkstheclientsvitalsigns*CVe n t i l a t e stheclientmanuallyD.Startscardiopulmonaryresuscitation59.TheclientisadmittedtotheEDwithchesttrauma.Whichsigns/symptomswouldthenurseexpecttoassessthatsupportsthediagnosisofpneumothorax?A.Bronchovesicularlungsoundsandfrictionrub*BAbsentbreathsoundsandtachypneaCNasalDlaringandlungconsolidationDSymmetricalchestexpansionandbradypnea.60.AnurseisplanningcareforaclientwithachesttubeattachedtoaPleur-Evacdrainagesystem.Thenurseincludeswhichinterventionsintheplan?SelectallthatapplyA.Clampingthechesttubeintermittently*B.Changingtheclientspositionfrequently*C.Maintainingthecollectionchamberbelowtheclientswaist*D.Addingwatertothesuctioncontrolchamberasitevaporates.*ETa p i n gtheconnectionbetweenthechesttubeandthedrainagesystem.61.Aclienthasatotalserumcalciumlevelof7.5mg/dl.Whichclinicalmanifestationswouldthenurseexpecttonoteonassessmentoftheclient?SelectallAConstipation*BMuscletwitchesCHypoactivebowelsounds*DHyperactivedeeptendonreflexes*EPositiveTrousseaussignandpositiveChvostekssign*F.ProlongSTintervalandQTintervalonECG62.Theclientdiagnosedwithrule-outmyocardialinfarctionisexperiencingchestpainwhilewalkingtothebathroom.WhichactionshouldthenurseimplementDirst?A.Administersublingualnitroglycerin.lOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])BObtainaSTATelectrocardiogram*CHavetheclientsitdownimmediatelyDAssesstheclientsvitalsigns.63.ThenurseiscaringforaclientdiagnosedwithARDSwhoisonaventilator.Whichinterventionsshouldthenurseimplement.Selectall*AAssesstheclientslevelofconsciousness*BMonitorclientsurineoutput*CPerformpassiverangeofmotionexercise*DmaintainintravenousOluidsasorderedEPlacetheclientwiththeHOBDlat64.Thenurseisassessingaclientexperiencingmotorlossasaresultofaleftsidedcerebrovascularaccident(CVA).Whichclinicalmanifestationswouldthenursedocument?ThemostcommonmotordysfunctionofaCVAisparalysisofonesideofthebody,hemiplegia;inthiscasewithaleft-sidedCVA,paralysiswouldaffecttherightside.Ataxiaisanimpairedabilitytocoordinatemovement.65.Whenteachingaclientabouttheexpectedoutcomesafterintravenousadministrationoffurosemide,thenursewouldincludewhichoutcome?A.Increasedbloodpressure*BIncreasedurineoutputCDecreasedpainDDecreasedPVCs66.Aclientarrivesattheemergencydepartmentwithdeeppartialthicknessandburnsover15%ofhisbody.Atadmissionhisvitalsignsarebloodpressure100/50mmHg,heartrate130beats/minuteandrespiratoryrate20breaths/minute.Whichnursinginterventionareappropriateforthisclient?SelectallthatapplyA.StartinganIVinfusionoflactatedRingerssolutionB.Administering6mgofmorphineIVC.Administeringtetanusprophylaxisasordered67.Ifdietarytraysareusuallybroughttothenursingunitat8:00amthenurseshouldplantoadministerintermediate-actinginsulin(HumlinN)40unitsSQtotheclientbetween?ANSWER-630amand700am68.WhatECGchangeswouldreDlectmyocardialischemiainaclientwhohasbeenadmittedforobservationafterexperiencinganepisodeofchestpain?ANSWER-STsegmentelevationordepression69.Theclientwithacuterenalfailurehasaserumpotassiumlevelof6.0mEq/L.Thenursewouldplanwhichofthefollowingasapriorityaction?lOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])ANSWER-Placetheclientonacardiacmonitor67.Thenurseiscaringforaclientwhounderwentcardiaccatherization1hourago.Whatisanimportantnursingmeasuresatthistime?ANSWER-MAINTAINPRESSUREOVERCATHETERINSERTIONSITEANDDETERMINEDISTALCIRCULATIONSTATUS.68.Anurseissuctioningtheendotrachealtubeofaclientwhoisonaventilator.Theclientsheartrateincreases???to110minandbecomesirregular.Thenurseshouldknowthattheclientrequires?ANSWER-OXYGENATEPRIORTOSUCTIONING69.AclientcomesintotheERwithcomplainsofmidsternalchestpainradiatingtotheneckandleftarmwhichisunrelievedbysublingualnitroglygen.Anelectrocardiogram(ECG)isobtained.WhatobservationontheECGoronthecardiacmonitorwouldindicatetothenursetheneedtoimmediatelynotifythephysician?A.PRimpulse0.20secB.Tachycardiarateof125beatofprematureC.prematureventriclebeatD.AnSTsegmentelevationfromtheisoelectricbaseline.70.Aclientbeginscomplainsofchillsanddiscomfortafterabout50mlofbloodhaspackedredbloodcells.ThebestnursingactionatthistimeistoA.DiscontinuethetransfusionandmovetheIVandrestartIVtransfusionatanothersite.B.comparetheVSnowandwhattheywerebeforethetransfusionbeginC.STOPTHETRANSFUSIONANDMAINTAINAPAT E N TLINEWITHNORMALSALINEsolutionandnewtubingD.slowdownthetransfusionbloodanddilutewithnormalsalinesolution71.Thevitalsignsofaclientwithcardiacdiseaseareasfollowsbloodpressureof103/78mmHg,heartrate???beats/min,andrespiratoryrateof16breaths/min.Atropine(atropine????AdministeredIVpush.Whatnursingassessmentindicatesatherapeuticresponsetothemedication?ANSWER-Pulseratehasincreasedto70beats/min72.Orderrocephen1gover30minutesQ6H.Supply1g/100mL.HowmanymLperhourwillthenurseinfuse?Roundthenearestwholenumber.ANSWER-200ml/hr73.Thenurseiscaringforclientwhois1daypostoperativefollowinganopenthoracotomy.Theclientisreceivingoxygenmistat40percent.The02saturationlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])measuredbypulseoximeterwas83ABGresultsarepH7.31,PACO 293mmHg,HCO325meq/L.Whichofthefollowingisanappropriateactionbythenurse?ANSWER-POSITIONCLIENTINHIGH-FOWLERSANDENCOURAGEUSEOFINCENTIVESPIROMETERANDCOUGHING.74.ThediabeticeducatoristeachingaclassonDiabetesType1andisdiscussingsickdayrules.Whichinterventionsshouldthediabetescounselorincludeintheteaching?SelectallthatapplyANSWER-A)Ta k ediabeticmedicationevenifunabletoeattheclientsnormaldiet. B)Ifunabletoeat,drinkliquidsequaltotheclientsnormaldiet.D)Testthebloodglucoselevelsandtesttheurineketonesonceadayandkeeparecord.75.ThenurseismonitoringaclientreceivingpertionaldialysisnotesthattheclientsoutDlowislessthaninDlow.Whatactionshouldthenursetake?Selectallthatapply?ANSWER-(SELECTALLANSWERSEXPCEPT-CONTACTTHEHEALTHCAREPROVIDER&INCREASETHEFLOW-DONOTSELECTTHOSETWOANSWERS)76.Thenurseisobtainingahealthhistoryfromaclientwhoisvisitingtheclinicwithcomplaintsofasevereheadache.Theclientprovidesthefollowingdatatothenursebasedonareviewofsystems.ThenurseidentiDiesthefollowingasamodiDiableriskforstroke?Selectalltheapply.A.SMOKINGB.ALCOHOLCONSUMPTIONC.DECREASEDPHYSICALACTIVITYD.OBESITY77.ThenurseiscaringforaclientdiagnosedwithARDSwhoisonaventilator.Whichinterventionshouldthenurseimplement?SelectallthatapplyA.Assesstheclientslevelofconsciousness.B.MonitortheclientsurineoutputC.Performpassiverangeofmotion(ROM)exercise.D.MaintainintravenousOluidsasordered.78.Thenurseisperforminganassessmentonaclientwhohasreturnedfromdialysisunitfollowinghemodialysis.Theclientiscomplainingofheadache,nausea,lOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])andisextremelyrestless.Whichofthefollowing??themostappropriatenursingaction?ANSWER-NOTIFYTHEPHYSICANS79.Thenursedeterminesthataclientwithdiabetes-mellitusisexperiencingfatbreakdownforconversiontoglucoseiftheclienthaselevatedlevelsofwhichsubstanceintheurine?ANSWER-ketones80.TheclientisadmittedtheEDwithchesttrauma.Whichsignsandsymptomswouldthenurseexpecttoassessthatsupportsthediagnosisofpneumothorax?ANSWER-ABSENTBREATHSSOUNDSTA C H Y P N E A81.Thenurseiscaringforhospitalizedclients.WhichofthefollowingclientsisatgreatestriskforDluidvolumedeDicit?ANSWER-THECLIENTWHOHASJUSTBEENADMITTEDHASSEVEREDIARRHEAANDISfebrile.82.PT&INRforCoumadin,INR2.8:continuemedication83.Hotspot:apicalpulse84.Hotspot:Twave85.Hotspot:Pwave86.Pwave:atrialdepolarizationlOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])87.Assessingresponseinanunconsciouspatient:nailbedpressure(peripheral)88.HbA1cconsiderationsforabout3monthsofglucosemonitoringa.lessthan6%fornondiabeticb.diabeticcontrolledshouldbelessthan7%89.Sengstaken-Blakemoretubepreventsbleeding(esophagealvarices)a.Triplelumenb.Havescissorsatthebedsidec.Provideoralandnasalcareevery3hoursd.Usedtoreducebleeding90.Planningrehabilitationforastrokepatienta.Assessfunctionalstatusbeforedevelopingplani.Walking,speaking,eating,ADLs91.CranialnerveII:Snellentest92.T2-T3:Paraplegia93.ICP:nolumbarpuncture94.Anurseobservingaclosechesttubedrainagesystemispostop1daythoracotomy?Continuebubblinginthesuctionchamber?A.checkthecontroloutletagainstthewallB.observealltheconnectiontubingC.ContinuetomonitorclientrespiratorystatusD.NotifyMDoftheoxidation95.AclientadmittohospitalreportrecurrentDlankpain,nausea,andvomitingwithin24hours.Whichofthefollowingprioritynursingaction?A.AdministeredpainmedicationB.MonitorintakeandoutputC.AdministeredantiemeticsD.Strainurine96.Anurseiscaringforclientwhohavetype1DM.Thenursemisreadclientmorningbloodglucoselevelat210mg/dLinsteadof120mg/dLbaseonthiserror.Sheadmittedinsulindoseof200mg/dLbeforeclientbreakfast.Whichofthenursingpriority?lOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])Monitorclientforhypoglycemia97.AAnurseiscaringaclientwhoisscheduleofcolonoscopy.Theclientaskthenurseiftherewillbealotofpainduringprocedure.Whichofthefollowingisappropriatenursingresponse?A.No,youshouldntfeelanypainbecauseyourrectumwillbeanesthesiaB.Yo umaybesedatedbutyouwillfeeldiscomfortduringtheinstrumentinsertionC.Dontworry??D.???A.Anurseisperformingteachingforclientwhohaverecentlydiagnosistype2DM.nurseshouldrecognizethattheclientunderstoodtheteaching.Identifyhypoglycemia?SelectallA.Moist,clammyskinB.Ta c hyc a r d i aC.PolyuriaD.PolydipsiaE.PolyphagiaF.???99.Anurseadmittedmorphine2mgIVpushafterclientreportpainandevaluateclient15min.laterinjection.Whichfollowadverseeffect?A.painscalelevelof6to4B.sleepybutarousewhennamecallC.O2sat94%D.RR8bpmA.nurseassessaclientwho8scoreusingtheGlasgowcomascaletoelevateofconsciousness.Describethescore.A.ReDlexalertclientB.NeedoftotalnursingcaringC.ClientindeepcomaD.StableneurologicalstatuslOMoARcPSD|9754571Downloaded by Bob Michael ([email protected])101.clientlowsodiumdietandreduceDluidintaketochooselunch.A.Tunasandwichonwheatbread,canofcocktailfruit,salad,andsodaB.Grillchickensandwichonwhitebread,apple,salad,andiceteaC.Grillcheesesandwich,tomatosoupD.Hamandbean102.clientacuteMI.acardiacenzymeobtain.Cardiacenzymeidentify?A.damagetothemyocardialB.determinethesizeMIC.helptodeterminethelocationMID.????104.administeredDDAVPtoclientdiagnosisDI.Therapeuticeffect1.SpeciOicgravity(1.015)