A
B
C
D
100
4. What is the best way to assess fluid status? Txtbk pg. 994
a. Monitor I&Os manually
b. Insert an indwelling catheter
c. Weigh the patient daily
d. Ask the patient about input and output
c. Weigh the patient daily
100
6. As you walk into a patient’s room, the patient sneezes and their abdominal wound eviscerates. What is the priority nursing intervention? ATI pg.343
a. Place sterile cloths over the wound
b. Try to reinsert it
c. Call the provider
d. Leave the patient to go get help
c. Call the provider
100
8. Which of the following are appropriate nursing interventions to prevent pressure injuries? ATI pg. 346
a. Frequent turning and repositioning
b. Ensuring adequate nutrition and fluid intake
c. Using an air/foam mattress
d. Providing a bath every 3 to 4 days
a. Frequent turning and repositioning
b. Ensuring adequate nutrition and fluid intake
c. Using an air/foam mattress
100
18. A client enters the emergency department hyperventilating. The nurse should note this client is at most risk for.. Txtbk pg. 989
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis
c. Respiratory alkalosis
200
7. Which of the following nursing interventions are appropriate when caring for a patient after they underwent surgery? (SATA) ATI pg. 344
a. Provide cluster care
b. Perform aseptic technique when changing wound dressings
c. Encourage proper nutrition
d. Withhold pain medication when patient reports zero pain
a. Provide cluster care
b. Perform aseptic technique when changing wound dressings
c. Encourage proper nutrition
200
10. Which of the following might indicate that a wound is getting worse? Txtbk pg. 1242
a. Pain: 3/10
b. WBC: 12,000 mcL
c. Temp: 99.9* F
d. BP: 130/90
b. WBC: 12,000 mcL
c. Temp: 99.9* F
200
3. A patient with a BMI of 16 is diagnosed with anorexia. Which of the following is the priority nursing diagnosis? Txtbk pg. 1115-1118
a. Imbalanced nutrition
b. Disturbed body image
c. Risk for infection
d. Decreased activity tolerance
a. Imbalanced nutrition
200
1. A patient is admitted to the Emergency Department after a car accident. The doctor orders the placement of a nasogastric tube. Which of the following is the priority nursing intervention?
Engage Fundamentals: Nutrition
a. Have the patient swallow as you insert the tube
b. Check the placement of the tube by testing the pH
c. Maintain the head of bed at 90 degrees
d. Check the tube placement via x-ray
d. Check the tube placement via x-ray
300
5. A patient is admitted to the ICU with a tertiary intention wound. Which of the following is the priority nursing diagnosis? Txtbk pg. 1240
a. Impaired tissue integrity
b. Risk for infection
c. Risk for delayed surgical recovery
d. Risk for imbalanced nutrition
b. Risk for infection
300
19. For a client with ineffective airway clearance, which interventions may be appropriate?
Txtbk pg. 930
a. Administer low flow oxygen via nasal cannula
b. Help client ambulate
c. Elevate their head of the bed above 30*
d. Teach client deep breathing and cough techniques
b. Help client ambulate
c. Elevate their head of the bed above 30*
d. Teach client deep breathing and cough techniques
300
2. A patient on enteral feedings requires two medications. Which of the following actions is appropriate?
Engage Fundamentals: Nutrition
a. Grind the medication together and inject them into the nasogastric tube
b. Flush the tube, then administer one medication at a time, followed by another flush
c. Inject an IV form of the medication into the enteral feeding bag
d. Have the patient swallow the pills whole
b. Flush the tube, then administer one medication at a time, followed by another flush
300
20. A nurse just finished getting an end-of- shift report and is deciding which patient to see first. Which client should be the nurse's priority? Txtbk pg. 918-920
a. A client who smokes 2 packs a day and reports coughing
b. A client who exercises everyday and has a heart rate of 50
c. A client with asthma reporting shortness of breath
d. A client that entered with a DVT reporting shortness of breath
d. A client that entered with a DVT reporting shortness of breath
400
9. A client is placed on a reduced-sodium diet. They are only allowed 1,500mg of sodium a day. If the client eats 1 serving size of this food, how many mg of sodium does the client have left for the day? Engage fundamentals: Nutrition
a. 600 mg
b. 650 mg
c. 700 mg
d. 750 mg
b. 650 mg
400
13. Which of the following interventions should be a priority for the hypokalemic client? ATI pg. 361
a. Monitor vital signs every 4 hours
b. Place client on an ECG
c. Put client on a high potassium diet
d. Hold off on giving client their diuretic medication
b. Place client on an ECG
400
16. A nurse is reviewing a client's ABG results. The results are as follows:
pH: 7.55 pCO2: 32 HCO3: 24
Which should the nurse be concerned about? Txtbk pg. 988
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
b. Respiratory alkalosis
400
11. Which of the following should be the nurse's priority? ATI pg. 359
a. Sodium: 141 mEq/L
b. Calcium: 8.5 mEq/L
c. Potassium: 4 mEq/L
d. Magnesium: 1.6 mEq/L
b. Calcium: 8.5 mEq/L
500
15. Which of the following nursing diagnoses is priority for hypernatremia? Txtbk pg. 984
a. Risk for deficient fluid volume
b. Risk for decreased cardiac tissue perfusion
c. Risk for impaired breathing pattern
d. Risk for impaired physical mobility
a. Risk for deficient fluid volume
500
17. A client is put on an ECG to monitor heart. The nurse notices this waveform
The nurse should begin to suspect which electrolyte imbalance? txtbk pg. 986
a. Hypocalcemia
b. Hypercalcemia
c. Hypokalemia
d. Hyperkalemia
d. Hyperkalemia
500
14. For which two electrolyte imbalances are we most worried about bleeding?
ATI pg. 362 and in-class powerpoint
a. Hypocalcemia
b. Hypophosphatemia
c. Hypomagnesemia
d. Hypokalemia
a. Hypocalcemia
b. Hypophosphatemia
500
12. Which of these clients should the nurse see first? ATI pg. 359
a. A 36 year old client with Congestive Heart failure and has 3+ pitting edema
b. A 18 year old malnourished client on IV fluids
c. A 27 year old client that reports vomiting and diarrhea for the past 4 hours
d. A 56 year old client who experienced a stroke 2 days ago
c. A 27 year old client that reports vomiting and diarrhea for the past 4 hours