Quiz
Nursing Finals
This quiz has question types that open in the usual player.
Questions in this quiz (120)
1A nurse has four clients to assess. After analyzing the cues, which client should the nurse
assess first?- AA client who has just received IV morphine
- BA client with a diagnosis of lung cancer who is experiencing thrombocytopenia
- CA client who has an inflamed IV site while receiving packed red blood cells
- DA client who experiences relief of dyspnea after receiving a small volume nebulizer (SVN)
2The nurse is assigned to care for four clients. After analyzing the cues, which client should the
nurse assess first?- AA postoperative client preparing for discharge with a new medication
- BA client requiring a daily dressing change of a recent surgical site
- CA client scheduled for a chest x-ray after insertion of a nasogastric tube
- DA client with asthma who requested a breathing treatment during the previous shift
3The nurse in an emergency department (ED) is assigned to triage clients coming to the ED for
treatment. After analyzing the cues, the nurse should assign priority to which client?- AA client complaining of muscle aches, a headache, and history of seizures
- BA client who twisted their ankle while rollerblading and is requesting medication for pain
- CA client with chest pain who states they just ate pizza that was made with a very spicy sauce
- DA client with a minor laceration on the index finger
4The nurse is caring for a client with dystocia (difficult labor). Which action is the priority?
- APosition changes and providing comfort measures
- BExplanations to the family about what is happening to the client
- CMonitoring for changes in the physical condition of the mother and fetus
- DReinforcement of breathing techniques learned in childbirth classes
5A client with a right arm cast complains of pain at the wrist when the arm is passively moved.
What should the nurse do first?- AElevate the arm
- BDocument the findings
- CMedicate with an additional dose of an opioid
- DCheck for paresthesia and paralysis of the right arm
6Why is it imperative for each nurse to become familiar with the nurse practice acts (NPA) of the
state in which they practice?- AThe NPA protects the nurse from malpractice suits
- BThe NPA contains national standards and responsibilities
- C. The NPA contains job descriptions for all nurses
- DThe NPA defines nursing practice and standards of care for the nurse practicing in a specific
state
7The nurse in charge of a long-term care facility is planning the client assignments for the day.
Which client should be assigned to the unlicensed assistive personnel (UAP)?- AThe client on strict bedrest
- BThe client with dyspnea who is receiving oxygen therapy
- CThe client scheduled for transfer to the hospital for surgery
- DThe client with a gastrostomy tube who requires tube feedings every 4 hours
8The nurse checks on a client who was admitted to the hospital with pneumonia. The client has
been coughing profusely and has required nasotracheal suctioning. The client has an IV
infusion of antibiotics and is febrile. The client asks the nurse if they can have a bath because
they have been perspiring profusely. Which is most appropriate to delegate to the UAP?- AAssessing vital signs
- BChanging the IV dressing
- CNasotracheal suctioning
- DAdministering a bed bath
9The nurse is caring for a client with chronic anemia. Which action is most appropriate to
delegate to the experienced LPN?- AAssist the client with basic activities of daily living
- BTeach a client about the use of home oxygen therapy
- CInstruct a client regarding the importance of increasing activity
- DAdminister the third dose of epoetin alpha (Epogen) subcutaneously
10The charge nurse is making assignments for the next shift. Which client should be assigned to
the new nurse who has been working for 2 months and has been pulled from their surgical unit
to the medical unit?- AA client on airborne precautions for bacterial meningitis
- BA client who just returned from a bronchoscopy and biopsy
- CA client who needs teaching about the use of incentive spirometry
- DA client with COPD who is ventilator dependent
11Which is an example of an independent registered nursing (RN) action?
- A. Administering blood
- BStarting an IV fluid
- CTeaching a client about the effects of prescribed drugs
- DAdministering emergency drugs during a code situation
12Which client is experiencing an expected assessment finding after the administration of a
sympathomimetic drug?- AA client whose respiratory rate has changed from 18 to 8 breaths/min
- BA client whose blood pressure has changed from 118/62 to 82/37
- CA client whose heart rate has changed from 47 to 82 beats/minute
- DA client whose lung sounds have changed from clear to wheezes throughout the lung fields
13What is the priority action for a client with a history of congestive heart failure demonstrating
cues of fluid overload and respiratory distress?- AInitiate IV access
- BTitrate O2 to keep sats > 95%
- CInitiate fluid restriction of 2000 mL PO daily
- DPerform daily weight
14When starting an IV, which sites should the nurse avoid?
- AA site proximal to a healing IV infiltration
- BClient’s preferred site
- CClient’s dominant hand/arm
- DA site distal to a healing IV infiltration
15The registered nurse is planning the client assignments for the day. Which is the most
appropriate assignment for an unlicensed assistive personnel (UAP)?- AA client requiring a colostomy irrigation
- BA client receiving continuous tube feedings
- CA client with difficulty swallowing food and fluids
- DA client who requires urine specimen collections
16You place two containers next to one another, separated only by a semipermeable
membrane. The solution in one container is hypotonic relative to the other. What would the fluid
in the hypotonic container do?- AMove out of the hypotonic container and into the other container
- BPull fluid from the other container into the hypotonic container
- C. Stay unchanged within the hypotonic container
- DNo fluid movement would occur
17The client’s morning assessment includes bounding peripheral pulses, weight gain of 1 kg,
pitting ankle edema, and moist crackles bilaterally with dyspnea. Which order from the
healthcare provider takes priority?- AWeigh client every morning
- BStrict intake and output
- CFluid restriction of 1500mL/day
- DAdminister furosemide 40 mg IV push
18A client has a serum potassium level of 5.5 mEq/L. Which ECG changes does the nurse
anticipate?- ATall, tented P waves
- BTall, tented T waves
- CShortened PR intervals
- DShortened QRS complexes
19The nurse receives orders to change the client’s IV fluids from D5 ½ NS with 40 mEq/L
KCl to D5 NS with 20 mEq/L KCl. Which serum laboratory results best support the rationale for
this IV order change?- ASodium 145 mEq/L; Potassium 4.8 mEq/L
- BSodium 135 mEq/L; Potassium 3.6 mEq/L
- CSodium 136 mEq/L; Potassium 4.5 mEq/L
- DSodium 144 mEq/L; Potassium 3.7 mEq/L
20The nurse is caring for a client admitted with heart failure. The morning laboratory results
reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should the
nurse withhold until consulting with the healthcare provider?- ALoop diuretics
- BAntibiotics
- CBronchodilators
- DAntihistamines
21The nurse is caring for a client with metastatic bone cancer. Which clinical manifestation
would alert the nurse to the possibility of hypercalcemia in this client?- AWeakness
- BParesthesia
- CFacial spasms
- DMuscle tremors
22Which concurrent electrolyte imbalance should the nurse anticipate while assigned to the
care of a client with hyperphosphatemia?- APotassium 2.8 mEq/L
- BSodium 131 mEq/L
- CCalcium 6.8 mg/dL
- DMagnesium 3.4 mEq/L
23While performing client teaching regarding hypercalcemia, which statement by the nurse
would be inappropriate?- AWeight-bearing exercises can help keep calcium in the bones
- BThe client should increase daily fluid intake to 3000 to 4000mL
- CRenal calculi may occur as a complication of hypercalcemia
- DTreatment of heartburn can best be managed with Tums on a PRN basis
24A client has ABGs with the following results: pH 7.52; CO2 44; HCO3 32. What acid-base
imbalance is the client experiencing?- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
25A client has ABGs with the following results: pH 7.32; CO2 29; HCO3 20. What acid-base
imbalance is the client experiencing?- ARespiratory alkalosis with partial compensation
- BRespiratory alkalosis with full compensation
- CMetabolic acidosis with partial compensation
- DMetabolic acidosis with full compensation
26A client has ABGs with the following results: pH 7.51; CO2 26; HCO3 22. What acid-base
imbalance is the client experiencing?- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
27A client has ABGs with the following results: pH 7.36; CO2 54; HCO3 30. What acid-base
imbalance is the client experiencing?- AMetabolic alkalosis with partial compensation
- BMetabolic alkalosis with full compensation
- CRespiratory acidosis with partial compensation
- DRespiratory acidosis with full compensation
28The nurse is caring for a client with an ileostomy. The nurse understands that the client is
most at risk for developing which acid-base disorder?- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
29A client with an acid-base imbalance has an altered potassium level. What does the nurse
recognize as contributing to this alteration?- APotassium is returned to extracellular fluid when metabolic acidosis is corrected
- BHyperkalemia causes an alkalosis that results in potassium being shifted into the cells
- CAcidosis causes hydrogen ions in the blood to be exchanged for potassium from the
cells - DIn alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate
30The nurse and unlicensed assistive personnel (UAP) are caring for a group of clients.
Which nursing intervention should the nurse perform?- AMeasure the client’s input and output from the indwelling catheter
- BRecord the client’s intake and output on the I & O
- CInstruct the client on appropriate fluid restrictions
- DProvide water for a client diagnosed with diabetes insipidus
31The client is admitted with the following laboratory results: Hematocrit (HCT) 56%, Sodium
(Na+) 152 mEq/L, Potassium (K+) 5.5 mEq/L. Which condition is a cause for these findings?- AOverhydration
- BAnemia
- CDehydration
- DAcute kidney injury
32The auscultatory area at the left midclavicular line at the fifth intercostal space is the
location to hear sounds from which heart valve?- AAortic
- BMitral
- CTricuspid
- DPulmonic
33A client with severe aortic valve stenosis is scheduled for valve replacement. Which valve
should the client indicate as needing replacement?- APulmonic valve
- BAortic valve
- Cright circumflex artery
- Dleft circumflex artery
34A client wearing a continuous cardiac monitor triggers an alarm. The nurse sees ECG
complexes on the screen. What should the nurse do first?- ACall code blue
- BCall the healthcare provider
- CCheck the client status and lead placement
- DPress the recorder button on the ECG monitor
35A client has atrial fibrillation with a ventricular rate of 185 bpm. The nurse should assess for
which clinical manifestations?- AFlat neck veins
- BNausea and vomiting
- CHypotension and dizziness
- DHypertension and headache
36The nurse is providing education to a client with hypertension. Which statement indicates
understanding?- A“I will always require medication.”
- B“I must achieve a normal weight to lower my blood pressure.”
- C“If I am on a diuretic, I don’t have to watch my salt intake.”
- D“I will try modifying my lifestyle to lower my blood pressure.”
37The nurse is discussing hypertension. Which topics should be included? (Select all that
apply)- ALow-cholesterol, low-fat, low-salt diet
- BPhysical activity 30 minutes most days
- CDiabetes management to reduce BP
- DStress-reduction techniques
38: A client with Stage 1 hypertension frequently eats fast food. Which topic will the nurse plan
to include in teaching?- ABeta-blockers benefits and side effects
- BAlcohol effects on blood pressure
- CDecreasing caloric intake
- DLow-sodium food choices when eating out
39Which laboratory result would warrant notifying the healthcare provider for a hypertensive
client?- AABG: pH 7.35, PaCO2 34, HCO3 18
- BSerum potassium level of 3.5 mEq/L
- CSerum sodium level of 134 mEq/L
- DINR of 4.2
40A client experiences orthostatic hypotension while on captopril. What should the nurse do
first?- AAdminister IV fluids
- BAdminister adrenergic agonist
- CHold the next captopril dose
- DInstruct the client to sit for several minutes before standing
41A client is on captopril and spironolactone. Which lab value is most important to monitor?
- ASodium
- BBlood urea nitrogen
- CPotassium
- DAlkaline phosphatase
42The nurse questions administering nifedipine for which finding?
- ABlood pressure: 110/30 mmHg
- BClient complains of dizziness
- CCalcium level: 10.5 mg/dL
- DDry mouth complaint
43A client on propranolol should report which symptom immediately?
- ALoss of energy
- BDecreased sexual function
- CDifficulty breathing
- DIncreased sweating
44Which coronary artery disease (CAD) risk factor cannot be modified?
- AHypertension
- BCigarette smoking
- CHereditary
- DDiabetes mellitus
45A client taking atorvastatin needs further teaching with which statement?
- A“I’m increasing exercise to reach my ideal weight.”
- B“I didn’t have symptoms with high lipid levels.”
- C“I take my pill after dinner.”
- D“I take my pill with grapefruit juice.”
46What is the desired effect of low-dose aspirin in CAD?
- AAnti-inflammatory effects
- BReduce cardiovascular clot risks
- CClot-dissolving effects
- DPrevent clots from becoming emboli
47A client experiences angina while walking. What is the nurse's first action?
- AAdminister nitroglycerine
- BObtain ECG
- CHave client sit down
- DAssess vital signs
48Which cue after cardiac catheterization requires immediate action?
- APedal pulses 2+ bilaterally
- BApical pulse 60 bpm
- CMean arterial pressure: 72 mmHg
- DST-segment depression on ECG
49Which cue suggests atherosclerosis?
- ALeg swelling after standing
- BJitteriness and hunger headaches
- CBilateral leg pain when walking
- DMid-epigastric pain after spicy food
50For a client with a venous stasis ulcer, what is the best nursing action?
- AEducate about vascular surgery
- BKeep the leg dependent to improve blood flow
- CMonitor for bruising/bleeding from anticoagulants
- DClean wound with saline and apply hydrocolloid dressing
51The registered nurse (RN) is working with a licensed practical nurse (LPN) and an
unlicensed personnel (UAP). Which tasks can the RN delegate or assign? (Select All That
Apply)- AThe routine oral medications for the clients
- BThe bed baths and oral care
- CEvaluating the client’s progress
- DTransporting a client to dialysis
- EAdministering scheduled vaccinations
52The nurse is administering medications on a cardiac unit. Which medication should the
nurse question?- AWarfarin to a client with an INR of 2.1 mg/dL
- BDigoxin to a client with a potassium level of 3.3 mEq/L
- CAtenolol to a client with an apical heart rate of 62 beats/min
- DLisinopril for a client with a serum creatinine level of 0.8 mg/dL
53Your post-operative client with a smoking history refuses the incentive spirometer. How
should you respond?
True
Use therapeutic communication to explore refusal reasons, educate on benefits, and
assess for pain or other barriers.- ATrue
- BFalse
54A nurse detects bilateral crackles in a client’s lungs. What is true about crackles?
- AThey’re usually heard on expiration and may clear with a cough.
- BThey’re usually heard on inspiration and may clear with a cough.
- CThey’re hissing or musical sounds heard on inspiration and expiration.
- DThey’re cracking and grating sounds heard over the problem area.
55Your client has new fine crackles. What should you do?
Encourage deep breathing and coughing,
reassess,
check for fluid overload,
and consider notifying the provider if warranted.- ATrue
- BFalse
56 A client on oxygen at 4L/min via nasal cannula complains of nasal dryness. What should
the RN suggest?- AHumidify the oxygen
- BUse a simple face mask
- CProvide an extra pillow
- DSuggest sitting up in a chair
57A client with lower lobe pneumonia is prescribed postural drainage. What position is
appropriate?- ALithotomy
- BDorsal recumbent
- CRight side with foot of the bed elevated
- DSupine with head of the bed at 90 degrees
58Your client shows yellow-green sputum. What will you do?
Assess for infection signs (vital signs, temperature) and collect a sputum culture as
needed.- ATrue
- BFalse
59Which action helps obtain a sputum specimen?
- ALimiting fluids
- BHaving the client take three deep breaths
- CAsking the client to spit into the collection container
- DObtaining the specimen after eating
60After a bronchoscopy and biopsy, which manifestation should be reported immediately?
- ABlood-streaked sputum
- BHematuria
- CDry cough
- DBronchospasm
61A client’s ABGs are pH 7.5, PaCO2 26 mmHg, O2 Sat 96%, HCO3 24 mEq/L, PaO2 94
mmHg. What is the most appropriate intervention?- AAdminister a decongestant
- BInstruct to breathe into a paper bag
- COffer fluid frequently
- DAdminister supplemental oxygen
62Your client with asthma has a respiratory rate of 10 breaths/min and O2 saturation of 88%.
What will you do?
Apply 100% oxygen, administer a bronchodilator (e.g., albuterol), and call respiratory
therapy- ATrue
- BFalse
63A client with asthma has a bluish tint around the mouth and difficulty breathing. What is
your first action?- ATake vital signs
- BRequest ABGs
- CApply oxygen via nasal cannula
- DDraw blood for CBC
64During an acute asthma attack, breath sounds become inaudible. What does this indicate?
- AThe attack is over
- BSwelling has decreased
- CCrackles replaced wheezing
- DAirways are so swollen no air is passing
65For a client with COPD, which nursing intervention helps maintain a patent airway?
- ARestricting fluid intake to 1000mL/day
- BEnforcing absolute bed rest
- CTeaching controlled coughing
- DAdministering prescribed sedatives in large amounts
66A client with end-stage COPD has a pulse oximeter reading of 91%. What is the most
appropriate action?- ARequest STAT ABG readings
- BDocument the finding in the client’s chart
- CNotify the respiratory therapist immediately
- DApply oxygen via nasal cannula at 1.5L/min
67A client with COPD is admitted with pneumonia and receiving 2L/min oxygen. What should
the nurse monitor closely?- AApnea
- BAnginal pain
- CRespiratory alkalosis
- DMetabolic acidosis
68A late-stage COPD client is admitted. What might their ABGs look like?
: Likely respiratory acidosis with full compensation: pH 7.35, CO2 >45, HCO3 >26
The body compensates for chronic CO2 retention by increasing bicarbonate levels.- ATrue
- BFalse
69A client with acute exacerbation of end-stage COPD has a dusky color, dyspnea, and RR
36. What should the nurse do first?- AApply O2 at 10L/min via nasal cannula
- BAssist the client into high Fowler’s position
- CMonitor the client’s ECG
- DNotify the healthcare provider
70: A client with COPD complains of increased dyspnea at home. Their RR is 26 breaths per
minute, and they are on 2L/min oxygen. What should the nurse do?- AReassure the client
- BIncrease oxygen flow rate
- CFurther assess respiratory status
- DCall emergency services
71A client presents to the ED in status asthmaticus. What should the nurse implement first?
- AMethylprednisolone IV push 80 mg
- BAuscultate breath sounds per policy
- CAlbuterol 2.5 mg via nebulizer
- DTheophylline IV 4.6 mg/kg over 30 minutes
72Your client with asthma is confused about using their inhalers. How will you educate them? 1. [blank_start]Albuterol[blank_end] (short-acting beta agonist to open airways) 2. [blank_start]Ipratropium[blank_end] (maintenance medication to keep airways open), [blank_start]Beclomethasone[blank_end] (steroid to reduce inflammation).
- Abeclomethasone
- BBeclomethosane
- CIpratropium
- Dalbuterol
- Esteroids
- FBeclomethasone
- Gamlodipine
- HMometasone
- IAlbuterol
73Emphasize waiting ---------- minute between puffs, using a spacer for steroids, and rinsing the
mouth after steroid use to prevent thrush for Beclomethasone- A5
- B3
- C1
- D4
74A client with asthma has a blood theophylline level of 4.8 mcg/mL. What dosage change
should the nurse recommend?- AIncrease the dose
- BDecrease the dose
- CMaintain the dose
- DOmit a dose
75The nurse is caring for a client with heart failure who is dyspneic with audible crackles.
What additional manifestations would indicate excess fluid volume?- AWeight loss and dry skin
- BFlat neck and hand veins and decreased urinary output
- CAn increase in blood pressure and increased respirations
- DWeakness and decreased central venous pressure (CVP)
76An elderly woman with a fractured hip is being stabilized before surgery. How is this surgery
classified?- AUrgent
- BElective
- CEmergency
- DPalliative
77A client expresses concern about managing care at home after a hernia repair. What is the
nurse’s best response?- A“Who is available to help you at home after the surgery?”
- B“I’m sure you will manage at home after surgery. It’s a simple procedure.”
- C“We will teach you everything you need to know to care for yourself.”
- D“Your insurance will cover in-patient care only if complications develop.”
78 During preoperative assessment, which finding indicates the greatest risk for postoperative
complications?- AClient is 60 years old
- BBlood pressure is 130/88
- CClient does not understand the surgery
- DEarly-stage Alzheimer’s disease
79What is the priority nursing intervention to help a preoperative client cope with fear of pain?
- AInform the client that pain medication will be available
- BTeach guided imagery for pain management
- C. Describe the type of pain expected after surgery
- DExplain the pain management plan, including a pain scale
80A client is to receive cimetidine preoperatively but has already taken esomeprazole. What
does the nurse explain as the purpose of cimetidine?- ACalm the client and relieve anxiety
- BProvide sedation and amnesia
- C. Prevent aspiration of stomach contents into the lungs
- DDecrease stomach acids to avoid nausea
81 During admission to the operating room, what is the perioperative nurse’s top priority?
- AVerify the client understands surgery risks
- BEnsure client identity with formal identification
- CPrepare the surgical site with antimicrobial scrubbing
- DPerform a preoperative assessment and history review
82Which concurrent health problem poses the greatest risk for postoperative complications in
clients receiving general anesthesia?- AGERD
- BReduced reflexes
- CHypothyroidism
- DEmphysema
83A client becomes restless and agitated in PACU as they regain consciousness. What
should the nurse do first?- ATurn the client to a lateral position
- BOrient the client and inform them surgery is over
- CAdminister postoperative pain medication
- DCheck oxygen saturation with pulse oximetry
84In PACU, a client’s BP drops from 126/82 to 106/78, and pulse increases from 70 to 94.
After administering oxygen, what is the next action?- AIncrease IV fluid rate per orders
- BNotify the anesthesia care provider
- CPerform neurovascular checks
- DUse a cardiac monitor to assess heart rhythm
85The nurse prepares to discharge a client after inguinal hernia repair. What would delay the
release?- AIV morphine was given 45 minutes ago
- BOxygen saturation is 92%
- COne episode of vomiting 30 minutes ago
- DClient has not voided since before surgery
86 What is the most important reason for controlling postoperative nausea and vomiting?
- ATo prevent dehydration
- BTo prevent airway issues
- CTo prevent soiling surgical dressing
- DTo prevent upsetting the client
87The charge nurse is making shift assignments. Which postoperative client should be
assigned to the most experienced nurse?- A4-year-old after tonsillectomy and able to swallow fluids
- B74-year-old after left hip repair and unable to ambulate
- C24-year-old after uncomplicated appendectomy
- D80-year-old with small bowel obstruction and congestive heart failure
88The UAP reports the vital signs for a first-day postop client. Which action is most
appropriate?- ARecommend a new antibiotic to the HCP
- BChange the dressing over the wound
- CHave the client turn, cough, and deep breath every 2 hours
- DObtain a urine sample for laboratory testing
89If the parasympathetic nervous system is stimulated, which physiological cues will occur?
(Select all that apply)- AConstriction of the bronchi
- BDilation of skin blood vessels
- C. Increased secretion of insulin
- DIncreased blood glucose levels
- ERelaxation of the urinary sphincters
90A client has an obstruction of the anterior cerebral artery. Which function does the nurse
hypothesize will be impaired?- AVisual imaging
- BBalance and coordination
- C. Judgment, insight, and reasoning
- DLanguage comprehension
91The nurse is planning to test the function of cranial nerve V. Which items should the nurse
gather?- AFlashlight, pupil size chart, millimeter ruler
- BTuning fork and audiometer
- CSafety pin, hot and cold water in test tubes, cotton wisp
- DSnellen’s chart, ophthalmoscope
92A client with intracranial pressure monitoring has a pressure of 12 mmHg. How should the
nurse interpret this?- ASevere decrease in cerebral perfusion pressure
- BAlteration in cerebrospinal fluid production
- CLoss of autoregulatory control of intracranial pressure
- DNormal balance between brain tissue, blood, and cerebrospinal fluid
93How should a nurse position a client with increased intracranial pressure?
- AKeep the head of the bed flat
- BElevate the head of the bed to 30 degrees
- CMaintain client on left side with head supported by a pillow
- DUse a rotation bed to continuously change position
94A client with generalized seizures is admitted. What seizure precautions should the nurse
implement? (Select all that apply)- APadded side rails
- BFunctional suction equipment
- COxygen administration equipment
- DPadded tongue blade at the head of the bed
- EItems for insertion of an IV catheter
95A client is experiencing a generalized seizure. What is the nurse's first action?
- ATurn the client on their side
- BStart oxygen by mask at 6L/min
- CRestrain arms and legs to prevent injury
- DRecord the time sequence of movements and responses
96A client starts to experience a generalized seizure. What is the priority nursing action?
- AHyperextend the neck to open the airway
- BPlace a padded tongue depressor between the teeth
- CRecord all events during seizure activity
- DRemain with the client and prevent injury
97A client is admitted with status epilepticus. What is the nurse's first action?
- AAssess the client’s neurological status
- BMonitor heart rhythm via telemetry
- CAdminister IV diazepam
- DAdminister PO phenytoin
98A client on phenytoin for focal seizures has a WBC of 2300/mcL. Why is this a concern?
- AEnlarged and inflamed gums
- BLow WBC count (neutropenia)
- COccasionally forgets to take medication
- DWants to renew driver’s license
99For a client suspected of having a stroke, what is the most critical piece of information?
- ATime of the client’s last meal
- BTime stroke symptoms first appeared
- CClient’s hypertension history
- DFamily history of cardiovascular disease
100Which information helps differentiate a hemorrhagic stroke from a thrombotic stroke?
- ASensory disturbance
- BHypertension history
- CMotor weakness
- DSudden severe headache
101After a craniotomy, which cue should be reported immediately to the HCP?
- AConfusion upon awakening
- BPupillary changes to unequal and reactive on one side
- CUrine output increased to 150 mL/hour
- DDecreased breath sounds bilaterally
102A postop craniotomy client becomes lethargic and confused. What should the nurse
report?- APulse rate decrease from 90 to 70 bpm
- BBP decrease from 140/90 to 120/80 mmHg
- COrientation changes to lethargic and confused
- DDecreased bilateral breath sounds
103What finding in a craniotomy client suggests meningitis?
- APositive Brudzinski’s sign
- BNegative Kernig’s sign
- CAbsence of nuchal rigidity
- DGlasgow Coma Scale score of 15
104Why should a client lie flat for 3-6 hours after a lumbar puncture?
- ADecrease effects of hypertension
- BIncrease spinal fluid replacement rate
- CImprove lung expansion
- DPrevent headache from spinal fluid loss
105A bacterial meningitis client has a headache, photophobia, and fever of 102.6°F. What
should the nurse do first?- AAdminister codeine for the headache
- BInfuse ceftriaxone IV for infection
- CGive acetaminophen to reduce fever
- DAdminister furosemide to reduce ICP
106A client with type 1 diabetes plans to enroll in a tennis class. Which statement shows
understanding of exercise’s effect on insulin demand?- A“I will carry a high-fat, high-calorie food, such as a cookie.”
- B“I will administer 1 unit of lispro insulin prior to playing tennis.”
- CI will eat a 15-gram carbohydrate snack before playing tennis.”
- D“I will decrease the meal prior to the class by 15 grams of carbohydrate.”
107A client receives 4 units of regular insulin and 8 units of NPH insulin at 0730. Which
statement about the insulin is correct?- AThe onset of regular insulin will be at 0745 and the peak at 1300.
- BThe onset of regular insulin will be at 0800 and the peak at 1000.
- CThe onset of NPH insulin will be at 0800 and the peak at 1000.
- DThe onset of NPH insulin will be at 1230 and the peak at 2330.
108What is the scientific rationale for prescribing metformin to a client with type 2 diabetes?
- ADecreases insulin resistance to improve glucose control.
- BAllows carbohydrates to pass slowly through the large intestine.
- CStimulates beta cells to release more insulin.
- DDecreases hepatic production of glucose from stored glycogen.
109A type 1 diabetes client with diabetic ketoacidosis (DKA) is being treated. What lab result is
expected?- AHypokalemia
- BFluid overload
- CHypoglycemia
- DHyperkalemia
110A type 1 diabetes client with nausea, vomiting, and diarrhea calls the clinic. What is the
most important advice?- AWithhold the regular dose of insulin.
- BDrink cool fluids with high glucose content.
- CCheck blood glucose levels every 2-4 hours.
- DUse less strenuous exercise until the illness resolves.
111: What is the most appropriate goal for a class on managing newly diagnosed type 2
diabetes?- AMake all clients responsible for managing their disease.
- BInvolve family and significant others in care.
- CEnable clients to actively participate in managing their disease.
- DProvide as much information as possible to prevent complications.
112A client’s fasting plasma glucose level is 120 mg/dL. What should the nurse say?
- A“The test result confirms type 2 diabetes.”
- B“You will develop type 2 diabetes within 5 years.”
- C“You are at increased risk for developing diabetes.”
- D“The test result is normal; diabetes isn’t a problem.”
113A client has a serum calcium level of 13.4 mg/dL. What disorder might the nurse suspect?
- AHyperthyroidism
- BHypoparathyroidism
- CHyperparathyroidism
- DType 2 diabetes mellitus
114What is a potential adverse effect of palpating the thyroid gland?
- ACarotid artery obstruction
- BDamage to cricoid cartilage
- CRelease of excessive thyroid hormone into circulation
- DHoarseness from pressure on the recurrent laryngeal nerve
115When starting replacement therapy for longstanding hypothyroidism, what is most
important to monitor?- AInsomnia
- BWeight loss
- CNervousness
- DDysrhythmias
116Which client statement suggests hypothyroidism?
- A“I have a bowel movement once a day.”
- B“I keep putting lotion on my dry skin.”
- C“I have trouble going to sleep at night.”
- D“I wake up at night feeling hot all over.”
117A hypothyroidism client is prescribed levothyroxine. What data indicates effectiveness?
- ARadial pulse of 88 bpm
- B4-pound weight loss in 1 week
- CComplaints of being cold
- DTemperature of 97.0°F
118After thyroidectomy, what observation concerns the nurse most?
- AIncreased thirst
- BSore throat when swallowing
- CSupporting the head when moving in bed
- DHarsh, vibratory sounds when breathing
119A client with Grave’s disease received iodine 131. Which statement shows a need for
more teaching?- A“I will wear a radioactive badge during treatment.”
- B“I shouldn’t be around young children or pregnant women.”
- C“I will flush the toilet twice after I urinate.”
- D“I shouldn’t sleep in the same room as my husband for a few days.”
120What is an appropriate intervention for a client with hyperparathyroidism?
- APad side rails as a seizure precaution.
- BIncrease fluid intake to 3000-4000 mL daily
- CMaintain bedrest to prevent pathologic fractures
- DMonitor for positive Trousseau’s or Chvostek’s sign.
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- Quiz on Nursing Finals , created by Vincent Tam on 08/12/2024.
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- Vincent Tam
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