1

NR 464 Complex Health Care Management of the Adult and Older Adult II
Final Exam_All Units

INSTRUCTIONS: Read each question carefully and choose the best answer. Place answer on the
Scantron sheet provided. Use only a #2 pencil to record answers. After completing the exam, return
the exam and Scantron sheet to the proctor. You may write on the exam.

1. While the client's full–thickness burn wounds to the chest and abdomen are exposed, what is
the best nursing action to prevent cross contamination and a potential infection?
A. Use sterile gloves when removing old dressings.
B. Wear gowns, caps, masks, and gloves during all care of the client.
C. Administer IV antibiotics to prevent bacterial colonization of wounds.
D. Turn the room temperature up to at least 70 degrees F during dressing changes.

2. A client is in the burn center 24 hours following a 40% total body surface area (TBSA) burn injury.
To maintain adequate nutrition at this time, the nurse anticipates the health care provide to first
try which of the following methods to best meet the client's nutritional requirements?
A. Infuse total parenteral nutrition via a central catheter.
B. Encourage an oral intake of at least 1000 kcal per day.
C. Administer multiple vitamins and minerals in the client’s lactated ringer's IV solutions.
D. Insert a nasointestinal feeding tube and initiate enteral feedings.

3. A client arrives at the emergency department with a chemical burn of the left eye. The first
action of the nurse is to immediately:
A. Apply a cold compress to the injured eye.
B. Flush the eye with water.
C. Apply a topical agent to the eye to relieve pain.
D. Monitor pH of eye.

4. A client with deep partial-thickness burns over 25% of his trunk and legs is going for
debridement in the cart shower 24 hours postburn. The drug of choice to control the client's
pain during this activity is:
A. IV midazolam (Versed).
B. IM meperidine (Demerol).
C. IV morphine.
D. Long-acting oral morphine.

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5. The nurse is preparing a burn client scheduled for an escharotomy for a full thickness
circumferential arm burn. The nurse understands that the anticipated outcome of the procedure
is
A. Brisk bleeding from the site.
B. Decreased edema formation.
C. Return of distal pulses.
D. Decreased keloid formation

6. In assessing the burn client, the nurse is suspicious of possible inhalation injury when the victim:
A. Is tachycardic with a low blood pressure.
B. Has a productive cough of black colored secretions.
C. Has a pulse oximetry reading of 93%.
D. Has a respiratory rate of 20 breaths per minute.

7. The nurse is caring for a client who has sustained burns over 40% of the body. Twelve hours post-
injury, the client's hematocrit is 58% with a urine output of 20 mL/hr. Which of the following
interventions should the nurse perform?
A. Elevate the head of the bed.
B. Obtain an order to insert a Dobhoff feeding tube.
C. Obtain an order to administer a blood transfusion.
D. Obtain an order to increase the flow rate of IV fluids.

8. A client who was found unconscious in a burning house is brought to the emergency department
by ambulance. The nurse notes that the client's skin color is bright (cherry) red. Which action
should the nurse take first?
A. Insert two large-bore IV lines.
B. Check the client's orientation.
C. Place the client on 100% oxygen using a non-rebreather mask.
D. Assess for singed nasal hair and dark oral mucous membranes.

9. The nurse is caring for a client who has sustained burns to the right arm and right hand from
spilled hot grease (5% Total Body Surface Area or TBSA). The burn area appears red, wet, and
glistening with blisters present. Which of the following nursing diagnoses should receive
priority?
A. Pain related to partial-thickness burn injury.
B. Body image disturbance related to disfiguring wound.
C. Hyperthermia related to full-thickness burn injury.
D. Fluid volume deficit related to massive fluid shifts.

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10. An adult client arrives in the emergency unit with burns to areas colored in the picture below.
Note burned areas include both legs and the perineum. Using the Rule of Nines, the nurse
should determine that approximately what percentage of the client's body surface has been
burned?
A. 10%.
B. 19%.
C. 37%.
D. 54%.

11. After receiving change-of-shift report, which of these clients should the nurse assess first?
A. A client with 15% total body surface area (TBSA) burns who is receiving fluids at 150
mL/hour.
B. A client with smoke inhalation who has wheezes and altered mental status.
C. A client with full-thickness leg burns who has a dressing change scheduled.
D. A client with abdominal burns who is complaining of pain at level 4 (0-10 scale).

12. A client is admitted to the ED with a burn (see image). This type of burn is best classified as:
A. Full thickness burn
B. Deep partial thickness burn
C. Third degree burn
D. First degree burn

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13. You are working with a nurse in the ICU and caring for a client with heart failure who is severely
fluid overloaded. The client is receiving 1400 units of heparin per hour. Pharmacy sends 25,000
units of heparin in 250 mL of Dextrose 5%. The nurse sets the infusion pump to run at _____
mL/hr. Write answer as a whole number without decimals. Do not include the unit of
measurement in your answer. Answer__________________________

14. A client has developed a sinus bradycardia at 40 beats per minute with a BP of 80/50 mmHg. He
states feeling short of breath, lightheaded, and about to pass out. The initial action the nurse
should take is to:
A. Begin CPR and call a COR.
B. Notify MD and anticipate an atropine order.
C. Monitor client closely with frequent reassessments.
D. Prepare to give the client a dose of IV epinephrine.

15. The nurse is admitting a client with a cardiac dysrhythmia who complains of palpitations. Which
of the following nursing diagnoses should receive priority?
A. Decreased cardiac output related to altered electrical conduction.
B. Anxiety related to the presence of a potentially life-threatening dysrhythmia.
C. Knowledge deficit related to treatment regimen.
D. Activity intolerance related to imbalance between oxygen supply and demand.

16. The nurse is caring for a client who becomes asystolic on the cardiac monitor. The client is
pulseless and nonbreathing. Which of the following should the nurse do first?
A. Administer epinephrine 1.0 mg intravenous push.
B. Administer atropine 0.5 mg to 1.0 mg intravenous push.
C. Start cardiopulmonary resuscitation (CPR).
D. Perform immediate defibrillation.

17. The nurse determines that a client has ventricular bigeminy when the rhythm strip indicates that
A. There are three or more premature ventricular contractions (PVC's) in a row.
B. There are pairs of wide and distorted QRS complexes.
C. There are premature QRS complexes with two different shapes.
D. Every other QRS complex is wide and starts prematurely.

18. Identify the following rhythm (This is a six second strip.):

A. Normal sinus rhythm.
B. Sinus bradycardia.
C. Sinus tachycardia
D. Atrial flutter.

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19. Identify the following rhythm:

A. Supraventricular tachycardia.
B. Atrial paced rhythm.
C. Ventricular fibrillation.
D. Ventricular paced rhythm.

20. A client with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive
to drug therapy for over 7 days. The priority teaching needed for this client would include
information about:
A. Anticoagulant therapy
B. Permanent pacemakers
C. Electrical cardioversion
D. IV adenosine (Adenocard)

21. When an elective cardioversion is planned for a client in rapid atrial fibrillation, the nurse must
ensure that:
A. no one is touching the client or bed during the delivery of the shock.
B. the client is awake throughout the procedure.
C. the health care provider writes an order for fluid boluses pre and post procedure.
D. the routine dose of a proton pump inhibitor be given prior to the cardioversion.

22. When analyzing the rhythm of a client's electrocardiogram (ECG), the nurse will need to
investigate further upon finding a(n)
A. isoelectric ST segment.
B. P-R interval of 0.18 second.
C. P wave before each QRS.
D. QRS interval of 0.16 second.

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23. You are the nurse in charge on the telemetry floor. Standing at the nurse's station you hear Ms.
Smith's monitor alarm go off. You identify the following rhythm as (This is a six second strip.):
A. atrial fibrillation
B. normal sinus rhythm
C. atrial premature contractions
D. ventricular fibrillation

24. A client is to receive digoxin (Lanoxin) 125 mcg IVP slowly over 5 minutes for atrial fibrillation
with a ventricular rate of 136 beats per minute. Pharmacy sends the medication with the label as
shown in the image below. How many mL will the nurse draw up for the client's dose? Do not
include units of measurement in your answer. Answer___________________________

25. A client is hospitalized with possible SIADH (Syndrome of Inappropriate ADH). The client is
confused and reports a headache, muscle cramps, and twitching. The serum sodium is 125
mEq/L. The nurse would expect the initial treatment to include:
A. Administration of IV Dextrose solution to provide energy source.
B. Administration of Desmopressin.
C. Fluid restriction, especially water.
D. Aggressive physical therapy to manage muscle cramps.

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26. A 72-year-old client is diagnosed with hypothyroidism and levothyroxine (Synthroid) is

prescribed. During initiation of thyroid replacement for the client, the nurse is aware of potential
adverse effects of Synthroid and it is most important for the nurse to assess
A. mental status.
B. cardiac rate and rhythm.
C. nutritional level.
D. fluid balance.

27. A nursing assessment of a client with Cushing syndrome reveals that the client has truncal
obesity and thin arms and legs. An additional manifestation of Cushing syndrome that the nurse
would expect to find is
A. chronically low blood pressure.
B. moon face and buffalo hump.
C. hypoglycemia.
D. bronzed appearance of the skin.

28. A client in the emergency department who reports lethargy, muscle weakness, nausea, vomiting,
and weight loss over the past weeks is diagnosed with Addison crisis (acute adrenal
insufficiency). Which drugs does the nurse expect to administer to this client?
A. Cortisol replacement in the form of Solu-Cortef (methylprednisolone) IV
B. IV fluid of D5NS with KCl added for dehydration
C. Spironolactone (Aldactone) to promote diuresis
D. Beta blocker to control the hypertension and dysrhythmias

29. A client had surgery to remove a pituitary tumor 3 days ago, leaving her with partial left
hemiparesis and diabetes insipidus. Which of the following nursing diagnoses is of the greatest
priority postoperatively?
A. Risk for fluid volume deficit related to excessive loss via the urinary system
B. Hopelessness related to development of chronic illness (hemiparesis and diabetes
insipidus)
C. Risk for oral mucous membrane alteration related to dehydration
D. Risk for coping ineffective family: compromised related to chronic illness

30. When caring for a client following the traditional incisional cholecystectomy for cholelithiasis,
the nurse places the highest priority on assisting the client to
A. perform leg exercises hourly while awake.
B. choose low-fat foods from the menu.
C. ambulate the second day of the operative day.
D. turn, cough, and deep breathe every 2 hours.

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31. Which assessment information will be most important for the nurse to report to the health care
provider about a client with acute cholecystitis?
A. The client's urine is a light yellow color.
B. The client's stools are clay-colored (pale).
C. The client declines the morning meal.
D. The client complains of chronic heartburn.

32. A homeless client with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with
viral hepatitis and has just been admitted to the hospital. In planning care for the client, the
nurse assigns the highest priority to the client outcome of
A. maintaining adequate nutrition.
B. establishing a stable home environment.
C. increasing activity level.
D. identifying the source of exposure to hepatitis.

33. The nurse is caring for a client with cirrhosis who has developed ascites. Which of the following
is a priority treatment goal?
A. Provide good skin care to decrease pruritis.
B. Restrict fats and sodium in the diet.
C. Shift fluid to the vascular space.
D. Maintain a normal body weight.

34. A male client is admitted to a medical-surgical unit with an esophageal variceal bleed. It is most
important that the nurse ensures that the client has:
A. a stat electrolyte panel sent to the lab.
B. a family member stay with him in his room.
C. at least two large bore IV's in place.
D. an order for lactulose (Cephulac).

35. A client has been admitted with acute liver failure. Which assessment data are most important
for the nurse to communicate to the health care provider?
A. Tenderness in RUQ
B. Elevated total bilirubin level
C. Jaundiced sclera and skin
D. Asterixis and lethargy

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36. When taking the BP of a client with severe acute pancreatitis, the nurse notes carpal spasm of
the client’s hand. The client also complains of numbness and tingling in both hands and
twitching around the mouth. Which action should the nurse take next? (Select all that apply).
A. Ask the client about any arm pain.
B. Retake the client’s blood pressure.
C. Check the most recent serum calcium level.
D. Check the client’s am serum potassium level.
E. Be prepared to administer calcium IV if ordered.

37. A client with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which
information obtained by the nurse indicates that these therapies have been effective?
A. Bowel sounds are present
B. Abdominal pain is decreased
C. Electrolyte levels are normal
D. Lung sounds are clear

38. In reviewing the medical record shown in the accompanying figure for a client admitted with
acute pancreatitis, the nurse sees that the client has a positive Cullen’s sign. Indicate the area
whether the nurse will assess for this change.
A. 1
B. 2
C. 3
D. 4

39. The hemodialysis unit has requested that a client be transferred to the hemodialysis unit for
their treatment. Which information is most important for the client's primary nurse to
communicate to the hemodialysis nurse during the hand-off report?
A. The client's blood pressure.
B. Client's adherence to fluid restrictions.
C. Client's most recent serum BUN & Cr.
D. Client's intake at breakfast.

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40. When administering sodium polystyrene sulfonate (Kayexalate) to a client with acute kidney
injury (AKI), the nurse will determine that this drug has been most effective if the client has
which serum lab value?
A. Creatinine = 3.8 mg/dL
B. Potassium = 4.5 mEq/L
C. Hematorcrit = 32%
D. Sodium = 146 mEq/L

41. Which of the following laboratory results would be unexpected in a client with chronic kidney
disease?
A. Serum hematocrit of 28%
B. BUN 55 mg/dL
C. Serum potassium 6.0 mEq/dL
D. Serum creatinine 1.0 mg/dL

42. A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous fistula.
The nurse expects to note which finding if the fistula is patent:
A. White fibrin specks noted in the fistula.
B. Lack of a bruit at the site of the fistula.
C. Palpation of a thrill over the site of the fistula.
D. Warmth and redness at the site of the fistula.

43. A nurse has provided information to a female client who has recently been diagnosed with a
urinary tract infection (UTI) on measures that will prevent a recurrence of the UTI. Which
statement by the client indicates a need for further information?
A. 'I will try drinking unsweetened cranberry juice every day.'
B. 'I should try to hold my urine as long as I can.'
C. 'I will drink plenty of fluids during the day.'
D. 'I will avoid bubble baths and using powder in my perineal area.'

44. Nursing staff on a hospital unit are reviewing rates of hospital-acquired infection (HAI) of the
urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in clients
admitted to the hospital?
A. Encouraging adequate oral fluid intake
B. Testing urine with a dipstick daily for nitrites
C. Avoiding unnecessary urinary catheterizations
D. Providing frequent perineal hygiene to clients

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45. After receiving change-of-shift report, which client should the nurse assess first?
A. Client who is in the drain phase of a peritoneal dialysis exchange
B. Client who has just returned from having hemodialysis and has a heart rate of 128/min
C. Client with chronic kidney disease who has an elevated phosphate level
D. Client with chronic kidney disease who has a potassium level of 3.6 mEq/L

46. Which of the following are expected findings in a client who has acute rejection of their
transplanted kidney? (Select all that apply).
A. Fever
B. Tenderness over graft site
C. Hypotension
D. Oliguria
E. Weight loss

47. Which finding by the nurse will most helpful in determining whether a client with benign
prostatic hyperplasia has an upper urinary tract infection (UTI), i.e. pyelonephritis?
A. Bladder distention
B. Foul-smelling urine
C. Suprapubic discomfort
D. Costovertebral tenderness

48. What can clients at risk for renal stones do to prevent the stones in many cases?
A. Drink enough fluids to produce dilute urine.
B. Take prophylactic antibiotics to control UTIs.
C. Limit protein and acidic foods in the diet.
D. Lead an active lifestyle.

49. The wife of a client who has undergone a TURP and has continuous bladder irrigation asks the
nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is
most appropriate?
A. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder."
B. "The irrigation is needed to keep the catheter from being occluded by blood clots."
C. "Normal production of urine is maintained with the irrigations until healing occurs."
D. "Antibiotics are being administered into the bladder with the irrigation solution."

50. A client who has bladder cancer had a cystectomy and an ileal conduit created for urinary
diversion. Which topic will be included in client teaching? (Select all that apply).
A. Presence of continuous urine flow with mucus
B. Application of ostomy (drainage) appliances
C. Education on fluid restriction
D. Barrier products for skin protection
E. Analgesic use before emptying the drainage pouch

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51. A client with a family history of prostate cancer visits the local health fair. The nurse counsels
him about the importance of obtaining the following annual screening test:
A. Digital rectal exam
B. Serum CEA (Carcinoembryonic Antigen)
C. CT scan
D. MRI

52. A client is to receive levothroyoxine (Synthroid) 50 mcg per day. How many tablets will tell the
client to take for their daily dose from the prescription bottle in the image below? Do not include
unit of measurement in your answer. Write a whole number without decimals.
_________________

53. Which action will the nurse include in the plan of care for a client with a new diagnosis of
rheumatoid arthritis?
A. Instruct the client to purchase a soft mattress.
B. Suggest that the client take a nap in the afternoon.
C. Teach the client to use cool water when bathing in the morning.
D. Advise to take Ibuprofen on an empty stomach to increase absorption.

54. Which information will the nurse include when preparing teaching materials for clients with
exacerbations of rheumatoid arthritis?
A. Application of cold packs to the affected joints may decrease joint pain.
B. Continue to exercise inflamed joints until pain becomes unbearable.
C. Limit fluid intake to decrease joint swelling.
D. Avoid taking NSAIDS during an exacerbation since will mask a fever.

55. A client with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the
nurse, "I never leave my house because I hate the way I look." An appropriate nursing diagnosis
for the client is
A. activity intolerance related to fatigue and inactivity.
B. impaired social interaction related to lack of social skills.
C. impaired skin integrity related to itching and skin sloughing.
D. social isolation related to embarrassment about the effects of SLE.

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56. Which finding for a client with systemic lupus erythematosus (SLE) is most important for the
nurse to communicate to the health care provider?
A. Serum potassium of 4.2 mEq (mmol/L).
B. Presence of malar (butterfly) rash.
C. Blood creatinine (Cr) of 3.2 mg/dL.
D. Hematocrit of 38%

57. The nurse cares for a client who is human immunodeficiency virus (HIV) positive and taking
antiretroviral therapy (ART). Which information is most important for the nurse to address when
planning care?
A. The client's blood glucose level is 124 mg/dL.
B. The client complains of feeling "constantly tired."
C. The client is unable to state the side effects of the medications.
D. The client states, "Sometimes I miss a dose of my antiretroviral medication, zidovudine
(AZT)."

58. The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV)
infection in the adolescent and young adult populations. Which information should the nurse
assign as the highest priority?
A. Methods to prevent perinatal HIV transmission
B. Ways to sterilize needles used by injectable drug users
C. Prevention of HIV transmission between sexual partners
D. Means to prevent transmission through blood transfusions

59. Which nursing action will the home health nurse include in the plan of care for a client with a
spinal cord injury at the T4 level in order to prevent autonomic dysreflexia?
A. Support selection of a high-protein diet.
B. Discuss options for sexuality and fertility.
C. Assist in planning a prescribed bowel program.
D. Use assisted coughing to strengthen cough efforts.

60. The nurse is assessing a client following craniotomy surgery for signs of increased intracranial
pressure (IICP). It is most important for the nurse to notify the health care provider for which
finding?
A. Scant amount of blood on head dressing.
B. Blood pressure of 122/82 mmHg.
C. Ipsilateral dilation of pupil.
D. Pulse oximetry reading of 92% on room air.

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61. The nurse is caring for a client with a closed head injury resulting in brain stem dysfunction.
Priority nursing assessment should focus on:
A. Motor movement.
B. Respiratory depth and rate.
C. Self-concept.
D. Pupillary reaction to light.

62. The nurse is assessing a client status post subdural bleed who does not respond to verbal stimuli.
In order to determine motor assessment in a client with a decreased level of consciousness,
which of the following actions should the nurse take?
A. Lightly pinch the skin of the hand.
B. Check deep tendon reflexes.
C. Ask the client to squeeze the nurse's fingers.
D. Apply pressure across the client's fingernail bed.

63. Which is the correct point on the accompanying figure where the nurse will assess for post-
auricular ecchymosis (Battle's sign) when admitting a client with a basilar skull fracture?
A. A
B. B
C. C
D. D

64. A client with a T2 spinal cord injury is beginning intensive rehabilitation. One morning as the
nurse prepares to assist her to transfer to the wheelchair, the client tells the nurse that she does
not feel like getting up, that she has a throbbing headache, and that she is slightly nauseated. It
is most important that the nurse first:
A. Check the client's blood pressure.
B. Notify the physician.
C. Tell her she will feel better if she sits upright in her wheelchair.
D. Do a digital rectal examination for the presence of an impaction.

65. You are caring for a client following a closed head injury. Which of the following clinical
manifestations if assessed by the nurse are indicative of the Cushing's triad? (Select all that
apply).
A. Client's cardiac monitor shows a sinus bradycardia of 40 beats per minute.
B. Client complains of a severe headache.
C. Client’s blood pressure has increased to 180/90 mmHg.
D. Client's respiratory pattern is irregular at 10 breaths per minute.
E. Client's temperature has spiked to 39 degrees Celsius.

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66. A client who is unconscious following a subdural hematoma has a nursing diagnosis of ineffective
cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be
included in the plan of care?
A. Keep the head of the bed elevated to 30 degrees.
B. Consult health care provider for order to administer hypotonic IV fluids.
C. Cluster nursing interventions to provide rest periods.
D. Encourage family members to converse with client frequently.

67. A client is to receive Humulin NPH insulin 15 units every AM at 0800. When checking the
capillary blood glucose (CBG) at 0745 prior to the client's breakfast, the nurse obtained a reading
of 213 mg/dL. The client could receive additional insulin based on the sliding scale below. How
many total units of insulin (NPH + Regular) should the nurse give? Do not add units of
measurement to your answer. Write answer as a whole number.
Answer_____________________

Sliding Scale Humulin Regular Insulin

CBG Value (mg/dL) Humulin Regular Insulin Dose

<180 0 units

180-200 2 units

201-220 4 units

221-240 6 units

>240 Call health care provider

68. After change-of-shift report on the oncology unit, which client should the nurse assess first?
A. Client who has a platelet count of 82,000/µL after chemotherapy
B. Client who has dry desquamation after receiving head and neck radiation
C. Client who is neutropenic and has a temperature of 100.5° F (38.1° C)
D. Client who is worried about getting the prescribed long-acting opioid on time

69. A client with metastatic cancer of the colon experiences severe vomiting following each
administration of chemotherapy. A priority nursing intervention for the client is to
A. teach about the importance of nutrition during treatment.
B. administer prescribed antiemetic one hour before the treatments.
C. have the client eat large meals when nausea is not present.
D. obtain counseling to help the client to deal with the psychologic reactions to the disease.

70. A client is to receive a combination of chemotherapeutic medications. The nurse administering

these drugs should

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A. Administer intravenous medications only in the intensive care unit.

B. Apply ice to the area after an intramuscular injection of chemotherapy.
C. Put the client in respiratory isolation during administration of the agent.
D. Wear gloves and a gown during preparation and administration of the drugs.

71. The nurse is conducting a cancer-screening program. The nurse would recognize that which of
the following people present a high-risk symptom for cancer and should be referred for further
testing?
A. A 70-year-old female with hypertension.
B. A 45-year-old who reports increased urinary output.
C. A 65-year-old who complains of activity intolerance.
D. A 50-year-old male with hemoptysis and a persistent cough.

72. A chemotherapeutic agent known to cause alopecia is prescribed for a female client. Which
action is best for the nurse to take to help the client maintain self-esteem while experiencing loss
of her hair?
A. Tell the client to limit social contacts until regrowth of the hair occurs.
B. Encourage the client to purchase a wig or hat and wear it once hair loss begins.
C. Teach the client to gently wash hair with a mild shampoo to minimize hair loss.
D. Tell the client not to worry so much about her hair loss since it will eventually grow back.

73. A client undergoing external radiation has developed a dry desquamation of the skin in the
treatment area. Which client statement indicates that the nurse's teaching about management
of the skin reaction has been effective?
A. "I will only use lotion on this area if approved by my doctor."
B. "I will expose the treatment area to a sun lamp daily."
C. "I can use ice packs to relieve itching in the treatment area."
D. "I will scrub the area with warm water to remove the scales."

74. When caring for a client who is pancytopenic, which action by nursing assistive personnel (NAP)
indicates a need for the RN to intervene?
A. The NAP holds oral care to avoid the risk of bleeding.
B. The NAP adds baking soda to the client's saline oral rinses.
C. The NAP puts fluoride toothpaste on the client's oral swabs.
D. The NAP has the client rinse after meals with a saline solution.

75. A client who has terminal cancer of the liver and is cared for by family members at home tells
the nurse, "I have intense pain most of the time now." The nurse recognizes that teaching
regarding pain management has been effective when the client
A. agrees to take the medications by the IV route to improve effectiveness.

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B. uses the ordered opioid pain medication whenever the pain is greater than 5 on a 10-
point scale.
C. takes opioids around the clock on a regular schedule and uses additional doses when
breakthrough pain occurs.
D. states that nonopioid analgesics may be used when the maximal dose of the opioid is
reached without adequate pain relief.

76. A client with tumor lysis syndrome (TLS) is taking allopurinol (Xyloprim). Which laboratory value
should the nurse monitor to determine the effectiveness of the medication?
A. Uric acid level
B. Serum potassium
C. Serum phosphate
D. Blood urea nitrogen

77. Which information noted by the nurse reviewing the laboratory results of a client who is
receiving chemotherapy is most important to report to the health care provider?
A. Hematocrit of 30%
B. Platelets of 95,000/µL
C. Hemoglobin of 10 g/L
D. WBC count of 1,200/µL

78. When caring for a client with a temporary radioactive cervical implant, which action by nursing
assistive personnel (NAP) indicates that the RN should intervene? The NAP
A. flushes the toilet twice after emptying the client's bedpan.
B. stands by the client's bed for 30 minutes talking with the client.
C. places the client's bedding in the designated laundry container in the client's room.
D. gives the client an antiseptic mouthwash (CREST) to use for oral care.

79. In assessing a client receiving chemotherapy, which of the following is top priority that would
require further evaluation?
A. Pale and moist mucous membranes.
B. Frequent nose bleeds.
C. Weight loss of 1 kg over 10 days.
D. Client states feels fatigued after walking in hallway.

80. The nurse is taking care of a client receiving chemotherapy. The client is placed on neutropenic
precautions. Which of the following interventions are appropriate for this client? (Select all that
apply).
A. Consult physician for erythropoietin order.
B. Provide fresh produce with each meal.
C. Limit visitors to healthy adults.

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D. Ensure a mask is worn by the client if taken to x-ray department.

81. A client is diagnosed with a benign tumor of the brain. The nurse understands that a benign
tumor is best described as:
A. Having early metastasis to other organs
B. Being encased in a fibrous capsule that stays localized
C. As a malignancy
D. As cancer with a very poor prognosis

82. A client has breast cancer and has developed oral ulcers following chemotherapy. Which nursing
action will be most effective in improving oral intake for this client with the nursing diagnosis of
Imbalanced nutrition: less than body requirements related to painful oral ulcers?
A. Offer the client frequent small snacks between meals.
B. Assist the client to choose favorite foods from the menu.
C. Provide education about the importance of nutritional intake.
D. Apply the ordered anesthetic gel to oral lesions before meals.

83. A client is receiving heparin 25,000 units in 500 mL of Dextrose 5% at 950 units per hour per
infusion pump. Based on the client's most recent APTT and the prescribed heparin protocol, the
nurse is to decrease the heparin dose by 200 units per hour. The nurse should set the infusion
pump at _____mL/hr for the new dose. Write answer as a whole number. Do not include units
of measurement. Answer_______________

84. A client is to receive a daily IV dose of gentamycin (Garamycin) 300 mg in 225 mL of Dextrose 5%
to run over 90 minutes. The nurse will set the infusion pump to run at ____mL/hr. Write
answer as a whole number. Do not include the unit of measurement in your answer.
Answer_________________

85. The nurse caring for the client in cardiogenic shock notifies the physician of the client's
deteriorating status when the client's ABG results include:
A. pH 7.28, PaCO2 30, HCO3 12
B. pH 7.35, PaCO2 42, HCO3 23
C. pH 7.48, PaCO2 36, HCO3 28
D. pH 7.45, PaCO2 46, HCO3 24

86. A client was admitted to the CCU with an anterior wall MI. He becomes increasingly disoriented,
diaphoretic, and restless. You take his vital signs and document: BP 80/50, HR 128, and RR 30.
You auscultate crackles in his lungs bilaterally. You suspect he is at risk for developing
A. Neurogenic shock.
B. Hypovolemic shock.
C. Septic shock.
D. Cardiogenic shock.

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87. The nurse is caring for a client in cardiogenic shock. The nurse would expect which of the
following drugs the client is receiving to exert a positive inotropic effect (i.e., directly improves
cardiac output)?
A. Morphine
B. Dobutamine (Dobutrex)
C. Atropine
D. Furosemide (Lasix)

88. The nurse is assessing a client in the late or irreversible stages of shock. Which of the following
clinical manifestations would the nurse anticipate?
A. Anuria.
B. Systolic blood pressure 120 mm Hg.
C. Hyperactive bowel sounds.
D. Metabolic alkalosis.

89. A client in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP
and cardiac output. The nurse anticipates the administration of:
A. nitroglycerin (Tridil).
B. sodium nitroprusside (Nipride).
C. norepinephrine (Levophed)
D. digoxin (Lanoxin).

90. The nurse is caring for a newly admitted client with warm septic shock. After obtaining cultures,
the nurse should institute which of the following physician orders first?
A. Administer antipyretic medication.
B. Begin broad-spectrum antibiotics.
C. Give proton pump inhibitor.
D. Schedule for an abdominal ultrasound at bedside.

91. The nurse is admitting a client suspected to be in the early stages of septic shock (warm or
hyperdynamic) secondary to gram-negative septicemia. Which of the following assessment
criteria would support this diagnosis?
A. Cool, clammy skin.
B. Angioedema of the lips.
C. Fever.
D. Elevated troponin levels.

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92. The nurse has initiated an infusion of penicillin on a client and is assessing the client for side
effects related to the medication. Which of the following signs would indicate to the nurse that
the client is developing an anaphylactic reaction (or shock)?
A. Noticeable hives on chest, wheezing, low systolic blood pressure.
B. Temperature of 38 degrees Celsius, heart rate 110 BPM, itching on arms.
C. Heart rate 50 BPM, persistent sneezing and coughing, BP 160/90 mmHg.
D. Full bounding pulses at 4+, cyanosis, temperature of 35 degrees Celsius.

93. The nurse is caring for a postoperative client who exhibits signs and symptoms of hypovolemic
shock. Which of the following interventions would be helpful to improve venous return to the
heart to increase cardiac output?
A. Place the client in low Fowler's position.
B. Place the client in reverse Trendelenburg’s position.
C. Alternately raise and lower the legs.
D. Position the head of the bed flat and elevate the legs.

94. During treatment for hypovolemic shock secondary to dehydration, the client receives fluid
volume replacement. The nurse will notify the physician if the client's urinary output is:
A. 20 ml/hr for 2 consecutive hours
B. 60 ml/hr for 2 consecutive hours
C. 120 ml for 3 consecutive hours
D. 150 ml for 3 consecutive hours

95. A client has just arrived in the ED following a MVA with trauma to abdominal region and a
fractured left leg. The client has a palpable blood pressure of 60 and a pulse of 140. After
adequate ventilation, the nurse anticipates that the initial treatment priority is which of the
following??
A. Administration of 50 ml of sodium bicarbonate.
B. IV bolus of one liter of normal saline at 'wide open' rate.
C. Insertion of a Foley catheter.
D. Insertion of a nasogastric tube with instillation of 500 ml of water.

96. A client has developed disseminated intravascular coagulation. He is bleeding from cuts in his
mouth, from his nose, and from every IV site. His laboratory work indicates:
A. Increased partial thromboplastin time (PTT) and increased fibrin split products.
B. Increased platelet count and decreased fibrin split products.
C. Decreased bleeding time and increased platelet count.
D. Decreased prothrombin time and decreased fibrin split products.

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97. A client with septic shock has a decreased urine output of 20 mL/hr for the past 3 hours. The
pulse rate is 120 and the central venous pressure (CVP) is low. Which of these orders by the
health care provider will the nurse question?
A. Give furosemide (Lasix) 40 mg IV.
B. Increase normal saline infusion to 150 mL/hr.
C. Draw a serum lactate level.
D. Titrate oxygen to pulse oximetry reading of 90% or greater.

98. The following interventions are ordered by the health care provider for a client who has is
diagnosed with anaphylactic shock after eating strawberries. The client is experiencing acute
respiratory distress. Which will the nurse complete first?
A. Start a normal saline infusion.
B. Start continuous ECG monitoring.
C. Give epinephrine (Adrenalin).
D. Give diphenhydramine (Benadryl).

99. The emergency department nurse is assessing a client who has lost a large volume of blood.
Assessment data reveals: blood pressure, 90/70; pulse, 140/min; low central venous pressure
(CVP); respiration, 28/min; deep and regular; weak pulses, skin, cool and pale. Nursing
intervention is based on the understanding of which of the following?
A. The client has not lost enough blood to be at risk for developing shock.
B. The client should be treated for hypovolemic shock.
C. Measures to slow the heart rate and decrease the metabolic rate should be instituted.
D. Measures to reduce anxiety and decrease catecholamine release should be instituted.

100. Which intervention will the nurse include in the plan of care for a client who has
cardiogenic shock?
A. Check temperature every 2 hours.
B. Monitor breath sounds frequently.
C. Maintain client in supine position.
D. Assess skin for flushing and itching.

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