Cardiology
Respiratory
Hematology
Urology
Neurology
100
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which intervention should the nurse implement first?
Have client chew a 325 mg aspirin.
Place the client in a supine position.
Administer nitroglycerine subcutaneously.
Apply oxygen via nasal cannula or mask.
Apply oxygen via nasal cannula or mask.
Rationale: Using the ABCs (Airway, Breathing, Circulation), the priority is to improve oxygen delivery to the ischemic heart muscle.
100
Which client would be at an increased risk for development of a DVT (deep vein thrombosis) and potential for pulmonary emboli?
A client in chronic renal failure on hemodialysis.
A client who is on bed rest after spine surgery.
A client with a history of hypertension and current blood pressure of 180/110.
An older adult client with kyphosis from osteoporosis and respiratory difficulty.
A client who is on bed rest after spine surgery.
Rationale: Immobility increases the risk of developing DVT
100
A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?
Overhydration enlarges the red blood cells.
Bone marrow decreases the erythrocyte production causing decrease in hypoxia.
The client has a decreased tolerance of pain related to the chronic nature of the illness.
Vascular occlusion in small vessels, thus decreasing blood and oxygen to the tissues.
Vascular occlusion in small vessels, thus decreasing blood and oxygen to the tissues.
Rationale: A sickle cell crisis occurs when abnormal sickle-shaped red blood cells become rigid and block blood flow through small blood vessels (microvasculature).
100
A nurse is assisting in caring for a client after a laparoscopic prostatectomy. The nurse monitors the continuous bladder irrigation to detect which of the following signs of catheter blockage?
True urine output of 50 mL per hour.
Drainage that is bright red.
Drainage that is pale pink and frothy.
Urine leakage around the three-way catheter at the meatus.
Urine leakage around the three-way catheter at the meatus.
Rationale: If the catheter becomes blocked by a blood clot, irrigation fluid cannot drain from the bladder. As pressure builds inside the bladder, urine and irrigation fluid may leak around the catheter at the urinary meatus.
100
A patient is taking phenytoin sodium (Dilantin). What must you be sure to teach the patient about this drug?
Always take the drug on an empty stomach.
Avoid grapefruit and grapefruit juice.
Wear strong sunscreen and limit sun exposure.
Visit a dentist regularly.
Visit a dentist regularly.
Rationale: Causes gingival hyperplasia
200
The client’s telemetry reading below shows a P-wave before each QRS complex and the rate is 78 beats per min. Which action should the nurse implement?
Check the client’s cardiac enzymes.
Prepare to administer the medication digoxin P.O.
Document this as normal sinus rhythm.
Request a 12 – lead electrocardiogram.
Document this as normal sinus rhythm
Rationale: no intervention is necessary for a NSR that is regular, WNL, and asymptomatic.
200
Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurses’ immediate attention?
Client with a temperature of 101.6 F who did not receive their annual flu or pneumonia vaccine.
Client with COPD who has dyspnea on exertion.
Client with lung cancer with a strong cough.
Client with a sinus infection with fever.
Client with COPD who has dyspnea on exertion.
Rationale: Always use the ABC's of life to answer prioritization questions.
200
The nurse is taking care of a client with blood type A Negative. The nurse understands that this client can receive which of the following blood types?
O negative
A positive
AB negative
B negative
O negative
Rationale: O negative is the universal donor
200
A client with acute pyelonephritis is admitted to the medical unit. Which assessment finding is expected?
A. Suprapubic discomfort without fever
B. Flank pain with fever and chills
C. Painless hematuria
D. Urinary retention with bladder distention
B. Flank pain with fever and chills
Rationale: Pyelonephritis is an infection of the kidney
200
The nurse is collecting data for a patient diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis?
Negative Chvostek’s sign and facial tingling.
Positive Kernig’s sign and nuchal rigidity.
Negative Trousseau’s sign and nystagmus.
Positive Babinski’s sign and peripheral paresthesia.
Positive Kernig’s sign and nuchal rigidity.
Rationale: The inflammation causes the neck to become rigid and pain or resistance when the hip and knee is flexed.
300
The patient is being seen in the clinic to rule out mitral valve stenosis. Which data collected would be most significant?
The patient complains of abdominal pain after eating a large meal.
The patient has jugular vein distention and 3+ pedal edema.
The patient’s liver is enlarged and abdomen is edematous.
The patient complains of shortness of breath when walking.
The patient complains of shortness of breath when walking.
Rationale: Mitral valve will cause blood to back up in left atrium and pulmonary circulation leading to pulmonary congestion.
300
The nurse obtains an arterial blood gas (ABG) on a client. The results of the ABG are: pH of 7.28, paCO2 of 56, HCO3 of 25. How would this finding be classified?
Respiratory Acidosis
Metabolic Acidosis
Respiratory Alkalosis
Metabolic Alkalosis
Respiratory Acidosis
Rationale: look at pH first. Then PaCO2, then HCO3-
300
A client comes into the clinic and is diagnosed with pernicious anemia. The nurse is aware which of the following aspects of the patient's medical/surgical history may have contributed to the development of this disease.
History of hypertension.
History of gastric surgery.
Vegetarian lifestyle.
History of spinal surgery.
History of gastric surgery.
Rationale: Pernicious anemia occurs when the body cannot properly absorb vitamin B12 (cobalamin) due to a lack of intrinsic factor, a protein produced by the parietal cells of the stomach.
300
A nurse is caring for a client with acute kidney injury (AKI). Which laboratory value should the nurse expect?
A. Decreased serum creatinine
B. Elevated blood urea nitrogen (BUN)
C. Low serum potassium
D. Increased urine output
B. Elevated blood urea nitrogen (BUN)
Rationale: Due to the decrease infiltration, there will be an increase in filtration, which will increase the Blood Urea Nitrogen concentration in the blood
300
A nurse is assigned to assist in caring for a client who sustained a closed head injury 6 hours previously. After report, the nurse finds that the client has vomited, is confused, and complains of dizziness and headache. Which of the following is the most important first nursing action?
A. Administer prescribed acetaminophen for the headache and reassess pain level.
B. Perform a focused neurologic assessment and notify the RN/provider of changes in the client's level of consciousness.
C. Place the client in a quiet, dark room to decrease stimulation and promote rest.
D. Encourage oral fluids to prevent dehydration from vomiting.
Perform a focused neurologic assessment and notify the RN/provider of changes in the client's level of consciousness.
Rationale: These are s/s of increased intracranial pressure.
400
The nurse is taking care of a client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in heart failure?
An elevated B-type natriuretic peptide (BNP)
An elevated creatinine kinase (CK-MB)
A positive D-dimer
A positive ventilation-perfusion (V/Q) scan
An elevated B-type natriuretic peptide (BNP)
Rationale: BNP is released by the ventricles of the heart when they are stretched due to increased pressure or volume.
400
The nurse is caring for a client with chronic bronchitis in a long-term care facility. The client's oxygen saturation has dropped from 91% to 89% in the last 4 hours. Which action will the nurse complete first?
Listen to the lung sounds.
Administer ipratropium (Atrovent) as prescribed.
Administer albuterol (Proventil) prn inhaler as prescribed.
Call the on-call physician.
Listen to the lung sounds.
Rationale: Always assess first. That will guide the next interventions.
400
A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold?
200 cells/mm3 of blood
325 cells/mm3 of blood
400 cells/mm3 of blood
425 cells/mm3 of blood
200 cells/mm3 of blood
Rationale: 500-1500 is the normal range.<200 is the AIDS threshold
400
The nurse is working on a urology unit. After the afternoon report, which client should the nurse see first?
A. The client who had ileal conduit surgery this morning and has not had any drainage in the drainage bag.
B. The client who is scheduled for surgery in the morning and wants an explanation of the operation before signing the permit.
C. The client who is one day post-operative and is complaining of pain at the surgical site at a 6 out of 10.
D. The patient who has a CBI with blood tinged urine in his urine collection bag.
A. The client who had ileal conduit surgery this morning and has not had any drainage in the drainage bag.
Rationale: an ileal conduit should flow continuously through the stoma.
400
The patient admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. What information should the nurse teach the patient post-procedure?
Explain that this allows analysis of a sample of the cerebrospinal fluid
Instruct the patient that an orthopneic position will help the practitioner to obtain the sample
Discuss that lying supine with the head flat will prevent head pressure and pain.
Tell the patient to decrease fluid intake to 300 ml for the next 48 hours.
Discuss that lying supine with the head flat will prevent head pressure and pain.
Rationale: This can lead to the development of a headache as well as causing a decrease in CSF that worsens if upright.
500
The LPN in a cardiac medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and a nurse suspects pulmonary edema. The LPN immediately notifies the RN and expects which interventions to be implemented? SATA
Administer oxygen
Inserting a Foley Catheter
Administering furosemide
Administering morphine sulfate intravenously
Transporting the client to the coronary care unit
Placing the client in low-Fowler's side-lying position
Administer oxygen
Inserting a Foley Catheter
Administering furosemide
Administering morphine sulfate intravenously
Transporting the client to the coronary care unit
Placing the client in low-Fowler's side-lying position
500
The client is diagnosed with pleurisy. The nurse would expect to see which signs and symptoms? SATA
Pleural friction rub.
Sharp, knife-like pain.
Cyanosis of lips and nailbeds.
Pain that occurs on both sides of the chest.
Pain occurs most often during inspiration.
Pleural friction rub.
Sharp, knife-like pain.
Pain occurs most often during inspiration.
500
In a client with severe anemia from an active bleed, the nurse would expect to find? SATA
Dyspnea
Tachycardia
Pallor
Wheezing
Bradypnea
Dyspnea
Tachycardia
Pallor
500
The client with chronic renal failure is on chronic hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Select all that apply.
Appetite improves
Urine output increases
Weight loss
Red blood cell count is lower
Blood pressure falls
Potassium level falls
Appetite improves
Weight loss
Blood pressure falls
Potassium level falls
500
The nurse is caring for a patient with a T5 complete spinal cord injury the nurse notes flushed skin, diaphoresis above T5 and a blood pressure of 162/96 mmHg. The patient reports a severe pounding headache indicating autonomic dysreflexia. Which nursing interventions would be appropriate for this patient? Select all that apply.
Turn the temperature up to promote diaphoresis.
Place the patient in a supine position with legs elevated.
Check for bladder distention and bowel impaction.
Administer an antihypertensive medication as ordered.
Raise the head of the bed to 30-45 degrees.
Check for bladder distention and bowel impaction.
Administer an antihypertensive medication as ordered.
Raise the head of the bed to 30–45 degrees.