The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?
1. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?
2. A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?
3. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?
4. The nurse takes a client’s temperature before giving a blood transfusion. The temperature is 100° F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?
5. The nurse is doing a routine assessment of a client’s peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?
6. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?
7. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?
8. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?
9. The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?
10. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?
11. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?
12. The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
13. The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client’s fears and misconceptions about surgery?
14. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?
15. The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client’s blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed?
16. A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?
17. The nurse is monitoring an adult client for postoperative complications. Which is mostindicative of a potential postoperative complication that requires further observation?
18. The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?
19. The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain?
20. The nurse checks the client’s surgical incision for signs of infection. Which is indicative of a potential infection?
21. The nurse is checking a client’s surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse?
22. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which first action?
23. The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first?
24. A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action?
25. The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item?
26. The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action?
27. The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?
28. The nurse assists in planning care for a child who sustained a burn injury. The nurse plans care based on which accurate statement?
29. The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform? Select all that apply.
30. The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?
31. The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color is becoming dusky. The nurse should interpret this data as indicating which?
32. The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?
33. A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?
34. The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?
35. The nurse witnesses a client sustain a fall and suspects that the client’s leg may be fractured. Which action is the priority?
36. A client with a hip fracture asks the nurse why Buck’s extension traction is being applied before surgery. The nurse’s response is based on the understanding that Buck’s extension traction has which primary function?
37. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?
38. The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first?
39. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity?
40. The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection?
41. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition?
42. The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention?
43. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?
44. The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply.
45. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?
46. The nurse is evaluating the client’s use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action?
47. The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action?
48. A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?
49. The client is brought to the emergency department and is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?
50. The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client’s bedside?
51. The nurse notes the appearance of skin breakdown on a client’s hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure.
52. A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, “I don’t feel any better than I did before surgery.” Which response by the nurse is most appropriate?
53. A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement?
54. A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown?
55. A client has been placed in Buck’s extension traction. Which technique provided by the nurse will provide countertraction?
56. A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?
57. The health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank. Round the answer to the nearest whole number.
58. The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?
59. The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?
60. The nurse is explaining The Joint Commission’s (TJC’s) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?
61. A client who had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.
62. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client?
63. The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful?
64. The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight “puffiness” along the edges and is non-reddened with no apparent drainage. The client’s temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings?
65. A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse?
66. A family of a spinal cord–injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which?
67. A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client’s history?
68. A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, “I think I’m going crazy. I can feel my left foot itching.” How does the nurse correctly interpret the client’s statement?
69. The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which should be done?
70. A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The nurse should take which action?
71. A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate?
72. A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor?
73. The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium?
74. The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder?
75. A client is treated in the health care provider’s office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours?
76. The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement?
77. The nurse in the health care provider’s office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?
78. A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client’s vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which?
79. A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?
80. One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.
81. The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?
82. A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.
83. The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? Select all that apply.
84. Intravenous (IV) lactated Ringer’s (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student?
85. The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date?
86. A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority?
87. The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?
88. A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication?
89. The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). Which should the nurse anticipate as the likely initial treatment?
90. The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?
91. The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen (Tylenol). How should the nurse administer the medication?
92. The nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse should document the presence of which as a normal finding?
93. The nurse is providing care for the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client?
94. A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure?
“95. A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. How should the nurse interpret this injury?
96. The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room?
97. The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting?
98. The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan?
99. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question?
100. The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?
101. A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client?
102. A client has Buck’s extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device?
103. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm?
104. The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?
105. The nurse has reinforced the client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?
106. A client has slight weakness in the right leg. Which type of mobility device would benefit the client the most?
107. A client who has experienced a stroke (brain attack) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is no longer sufficient. Which device would suit the client better if greater support and stability is needed?
108. A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane?
109. A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance?
110. The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?
111. The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse could place the client at increased risk for disturbed thought processes?
112. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client?
113. A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client?
114. The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint?
Apply a knee immobilizer before getting the client up, and elevate the client’s surgical leg while sitting.
115. A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action?
116. A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure?
117. A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client’s needs should best be addressed by referral to which service?
118. The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client?
119. A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?
120. A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem?
121. The nurse is caring for a client diagnosed with Paget’s disease. The nurse plans care, knowing that this condition usually affects which bones?
122. The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin?
123. The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?
Maintaining body weight at or above minimum recommended levels
124. The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?
120.) A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem?
121.) The nurse is caring for a client diagnosed with Paget’s disease. The nurse plans care, knowing that this condition usually affects which bones?
122.) The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin?
123.) The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?
124.) The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?
125.) The nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which is a sign/symptom associated with the disorder?
126.) The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client?
127.) The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicates to the nurse favorable resolution of the fat embolus?
128.) A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site?
129.) The nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome?
130.) A client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse should anticipate which observation on inspection of the client’s leg?
131.) A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted?
132.) A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement?
133.) The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action?
134.) A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which?
135.) The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position?
136.) The nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding?
137.) The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement?
138.) The nurse is caring for a client with a diagnosis of osteoarthritis. Which would be least helpful for the client?
139.) The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action?
140.) The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?
141.) The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data would be included?
142.) A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which?
143.) A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?
144.) An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?
145.) The nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed?
146.) The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client’s alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next?
147.) The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate?
148.) A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment?
149.) Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client’s legs on the operating table?
150.) During a surgical procedure, the nurse prevents a client’s extremities from dangling over the sides of the table, knowing that this action may cause what?
151.) The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?
152.) The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the nurse has which?
153.) The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further teaching?
154.) The nurse is caring for a client who had a below-the-knee amputation of the right leg. A cast that was placed on the residual limb has fallen off. Which action should the nurse take immediately?
155.) The nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse should take which action?
156.) The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately?
157.) The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning?
158.) A client who sustained a severe burn injury is brought to the emergency department. The nurse prepares to implement which immediate action?
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159.) The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?
160.) The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for what data first?
161.) The nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130 beats per minute. The nurse immediately notifies the registered nurse and prepares the client for which initial intervention?
162.) A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action should the nurse take immediately?
163.) The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the initial nursing action is which?
164.) The nurse hangs a 1000-mL bag of intravenous (IV) fluid on an assigned client. Forty-five minutes later, the nurse notes that the client is complaining of a pounding headache, is dyspneic, is apprehensive, and has an increased pulse rate. The IV bag has 500 mL remaining. The nurse should take which action?
165.) A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, Which is the initial nursing assessment?
166.) The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?
167.) The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication?
168.) The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?
169.) The nurse is preparing a client for surgery. Which would be a component of the plan of care?
170.) A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions?
171.) The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?
172.) The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the health care provider’s (HCP) prescriptions and notes that the HCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure.
173.) A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, “I think I’m going crazy. I feel like I’m starving, and yet that bag is supposed to be feeding me.” Which is the best response from the nurse?
174.) A mother of a 6-year-old-child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which should the nurse tell the mother to immediately perform?
175.) A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform?
176.) A client in labor states to the nurse, “I think my water just broke.” On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. Which should the nurse do immediately?
cord.
177.) The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse should immediately place the client in which position?
178.) The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action?
179.) A client with skeletal traction applied to the right leg complains to the nurse about severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take?
180.) A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. Based on these findings, the nurse should take which action?
181.) The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client’s heartbeat. The nurse immediately performs which action?
182.) The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action should be the nurse’s immediate response?
183.) The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client’s hourly urine output is 25 mL. Based on this finding, what should be the nurse’s first action?
184.) The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?
185.) The nurse is preparing for the intershift report when a nurse’s aide pulls an emergency call light in a client’s room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first?
186.) The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication?
187.) A client arrives at the emergency department with an acetaminophen (Tylenol) overdose. Acetylcysteine is prescribed to be administered to the client immediately. The nurse prepares to administer the medication by which route?
188.) The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client?
189.) The nurse employed in the emergency department is preparing to administer syrup of ipecac to a 7-month-old child. The nurse prepares 5 mL of the syrup and administers one half glass of water following administration of the ipecac syrup. Which response should the nurse expect?
190.) The nurse employed in the emergency department receives a telephone call from the emergency alert system informing the department that a child who ingested a bottle of acetaminophen (Tylenol) is en route to the emergency department. The nurse prepares the room for the arrival of the child and checks the medication supply to determine whether which medication that is the antidote is available?
191.) Following surgical removal of a brain tumor, the health care provider writes a prescription to maintain the child in a semi-Fowler’s position. In the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has dropped significantly from the baseline value. The nurse suspects that the child is in shock. Which nursing action would be appropriate?
192.) A licensed practical nurse (LPN), employed in the emergency department, prepares to assist in treating a child with an acetaminophen (Tylenol) overdose. The LPN checks the medication supply room, anticipating that which medication will be prescribed?
193.) A 4-year-old child has been brought to the emergency department after the grandparents found him with an open bottle of chewable, orange-flavored 81-mg aspirin tablets. In order to determine whether the child is experiencing a toxic effect, which question should the nurse ask the child?
194.) The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted?
195.) The nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse should anticipate which sign in the client?
196.) A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the client?
197.) The nurse has administered a dose of salmeterol (Serevent Diskus) to a client. Following administration, the client develops a generalized rash and urticaria and the eyelids begin to swell. Which action should the nurse take?
198.) The nurse is assisting in caring for a client admitted to the emergency department with diabetic ketoacidosis. The nurse anticipates that the health care provider will prescribe which type of insulin for intravenous administration to treat this disorder?
199.) A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosus. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition?
200.) A depressed client is found unconscious on the floor in the dayroom of a psychiatric nursing unit. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. What is the immediate action of the nurse?
201.) A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care?
202.) Several clients arrive simultaneously at the emergency department after sustaining burn injuries in a house fire. Which client will require the closest observation for signs of respiratory distress?
203.) The nurse is assisting in admitting a client to the emergency department with suspected carbon monoxide poisoning. The nurse understands that which sign/symptom is least reliable for determining the oxygenation status of this client?
204.) The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process?
205.) A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?
206.) A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis?
207.) An emergency department nurse prepares to collect data from a pregnant woman. The woman tells the nurse that she felt a large gush of fluid on the way to the hospital. The nurse checks the fetal heart rate (FHR) and notes that it is 90 beats per minute. On physical examination, the nurse notes that the umbilical cord is protruding from the vagina. Which is the initial nursing action?
208.) When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client’s name?
209.) The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?
210.) Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a need for further teaching?
211.) The nurse is working in the primary care office and is conducting an interview with the parents of a child. The parents of the child state that syrup of ipecac is kept at home in case of an accidental poisoning. The nurse provides which appropriate instruction specific to the use of this medication?
212.) The nurse caring for a client at home arrives to find the client in the bedroom, unconscious and with a pill bottle of the selective serotonin reuptake inhibitor, sertraline (Zoloft), on the bed. Which assessment has priority?
213.) During admission data collection, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area?
214.) An assessment of a woman at 32 weeks of gestation indicates moderate fetal distress. Which intervention is the nurse’s priority?
215.) When positioning for a surgical procedure, the nurse understands that the client’s respiratory system is most at risk for dysfunction when in which position?
216.) A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client’s postoperative bleeding, the nurse would implement which intervention?
217.) The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?
218.) A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of both a clear liquid and a portion of the umbilical cord. Which initial action should the nurse take?
219.) The nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. Which is the first action by the nurse?ANSWER: Check that the tubing is securely attached.
220.) The nurse assisting in caring for a client with a myocardial infarction is monitoring for cardiogenic shock. The nurse should monitor for which peripheral vascular symptoms?
221.) The nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse should document that the treatment has been successful if which result is obtained?
222.) The nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client reports chest pain. When the administration of a sublingual nitroglycerin tablet as prescribed does not relieve the chest pain, which is the next nursing action?
223.) The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking which criteria? Select all that apply.
224.) The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse’s initial action?
225.) The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client’s plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing which action?
226.) The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which findings does the nurse identify as early signs of possible fat embolism?
227.) The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action?
228.) The nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client’s casted extremity for which reason?
229.) The skin surrounding a postoperative client’s abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?
230.) A client presents to the urgent care center with a chemical burn of the right eye. The priority for the nurse is to prepare the client for which?
231.) A client has been on total parenteral nutrition for 8 weeks. The health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, “Why doesn’t the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?” The nursing response should be to explain that the health care provider is concerned about which phenomenon?
232.) A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action?
233.) A health care provider prescribes a parenteral nutrition solution to start at 50 mL/hr by infusion pump via an established subclavian central line. After 2 hours of initiating the parenteral nutrition infusion, the client suddenly complains of difficulty in breathing and chest pain. Which action would the nurse prepare to do first?
234.) The nurse is assigned to care for a client receiving total parenteral nutrition via the subclavian vein. The nurse should identify which intervention in the plan of care for the client as the priority?
235.) A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client’s problem?
236.) The nurse is caring for a client who was admitted to the maternity unit at 8:00 am with contractions occurring every 2 minutes, lasting 1½ minutes, and who is dilated 4 cm with a cervical effacement of 60%. At 10:30 am, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which complication?
237.) Which finding in the prenatal client supports the medical diagnosis of placental abruption?
238.) The nurse caring for a client diagnosed with placental abruption should plan which action?
239.) A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless, the heart rate and blood pressure increase, and the client’s pulse oximetry reading is decreasing. The nurse calls for the registered nurse and plans to take which immediate nursing action?
240.) An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client’s upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client’s clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, which percentage would characterize the burn injury? Refer to the figure. Fill in the blank.
241.) The nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by nitroglycerin given by the nurse. Which action by the nurse would be appropriate at this time?
242.) The nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform?
243.) A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed?
244.) A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm?
245.) The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement?
246.) The nurse is talking to a client who underwent a below-the-knee amputation 2 days earlier. The client says to the nurse, “I hate looking at this; I feel that I’m not even myself anymore.” The nurse understands that the client is experiencing which problem?
247.) A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. Which action should the nurse take first?
248.) A licensed practical nurse (LPN) assisting a registered nurse in the cardiac care unit (CCU) prepares to admit a client with a diagnosis of myocardial infarction (MI). The LPN should be certain to have which item(s) readily available on the unit when the client arrives by stretcher?
249.) A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse should obtain which medication from the emergency cart to have ready for use as prescribed?
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250-374
A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage?
Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?
The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching?
The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate?
An emergency department nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle crash. The nurse understands that the initial data collection should focus on which sign/symptom?
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