CTN: (Doc BJ)

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CTN: (DOC BJ) 7.

A client is having frequent premature ventricular


contractions. The nurse should place priority on
1. The nurse is assisting to defibrillate a client in assessment of which item?
ventricular fibrillation. After placing the pads on the -Blood pressure and oxygen saturation
client’s chest and before discharging the device, which
intervention is a priority? 8. The nurse is caring for a client who has just had
- Confirm that the rhythm is ventricular fibrillation implantation of an automatic internal cardioverter
defibrillator. The nurse should assess which item based
2. A client with a history of type 2 diabetes is admitted on priority?
to the hospital with chest pain. Which medication -Activation status and settings of the device
would need to be withheld for 24 hours before the
procedure and for 48 hours after the procedure? 9. The nurse is evaluating the condition of a client after
- Metformin pericardiocentesis performed to treat cardiac
tamponade. Which observation would indicate that the
3. A client with myocardial infarction suddenly becomes procedure was effective?
tachycardic , shows signs of air hunger, and begins -A rise in blood pressure
coughing frothy, pink-tinged sputum. Which finding
would the nurse anticipate when auscultating the 10. A client with variant angina is scheduled to receive
client’s breath sounds? an oral calcium channel blocker twice daily. Which
-Crackles statement by the client indicates the need for further
teaching?
4. The nurse is watching the cardiac monitor and -“My spouse told me that since I have developed this
notices that a client’s rhythm suddenly changes. There problem, we are going to stop walking in the mall
are no P waves, the QRS complex are wide, and the every morning.”
ventricular rate is regular but more than 140 beats per
minute. The nurse determines that the client is 12. A client who is receiving digoxin daily has a serum
experiencing which dysrhythmia? potassium level of 3mEq/L (3mmol/L) and reports
- Ventricular tachycardia anorexia. The health care provider prescribed a serum
digoxin level to be done. The nurse checks the results
5. A client with myocardial infarction is developing and should recognize which level that is outside of the
cardiogenic shock. What condition should the nurse therapeutic range?
carefully assess the client for? -2.2 ng/mL (2.8 nmol/L)
- Ventricular dysrhythmias
13. A client is being treated with procainamide for a
6. A client who had cardiac surgery 24 hours ago had a cardiac dysrhythmia. Following intravenous
urine output averaging 20mL/hour for 2 hours. The administration of the medication, the client complains
client received a single bolus of 500 mL of intravenous of dizziness. What intervention should the nurse take
fluid. Urine output for subsequent hour was 25 mL. first?
Daily laboratory results indicate that the blood urea -Auscultate the client’s apical pulse and blood
nitrogen level is 45mg/dL (16mmol/L) and the serum pressure.
creatinine level is 2.2mg/dL (194mmol/L). On the basis
of these findings, the nurse would anticipate that the 14. The nurse is monitoring a client with hypertension
client is a risk for? who is taking propranolol. Which assessment finding
-Acute kidney injury indicates a potential adverse complication associated
with this medication?
-Development of expiratory wheezes
15. A client is diagnosed with an ST segment elevation -Azathioprine minimizes rejection of the transplant.
myocardial infarction (STEMI) and is receiving a tissue
plasminogen activator, alteplase. Which action is a 21. A patient with a history rheumatic heart disease
priority nursing intervention? knows that she is at risk for bacterial endocarditis when
-Monitor for sign of bleeding undergoing invasive procedures. Prior to a scheduled
cystoscopy, the nurse should ensure that the patient
16. The nurse administered intravenous bumetanide to knows the importance of taking which of the following
a client being treated for heart failure. Which outcome drugs?
indicated that the medication has achieved the -Amoxicillin (Amoxil)
expected effect?
-Urine output increases from 10mL/hr to greater than 22. A patient with pericarditis has just admitted to the
50mL hourly. CCU. The nurse planning the patient’s care should
prioritize what nursing diagnosis?
17. Intravenous heparin therapy is prescribed for a -Acute pain related to pericarditis
client with atrial fibrillation. While implementing this
prescription, the nurse ensures that which medication is 23. A patient newly admitted to the telemetry unit is
available on the nursing unit? experiencing progressive fatigue, hemoptysis, and
-Protamine sulfate dyspnea. Diagnostic testing has revealed that these
signs and symptoms are attributable to pulmonary
17. The nurse provides instructions to the client about venous hypertension. What valvular disorder should the
nicotinic acid prescribed for hyperlipidemia. Which nurse anticipate being diagnosed in this patient?
statement by the client indicates understanding of the -Mitral stenosis
instructions?
-“Ibuprofen taken 30 minutes before the nicotinic acid 24. The nurse on the hospitals infection control
may decrease the flushing.” committee is looking into two cases of hospital-
acquired infective endocarditis among a specific
18. A patient with hypertophic cardiomyopathy (HCM) classification of patients. What classification of patients
has been admitted to the medical unit. During the would be at greatest risk for hospital-acquired
nurse’s admission interview, the patient states that she endocarditis?
takes over-the-counter water pills on a regular basis. -Hemodialysis patients
How should the nurse best respond to the fact that the
patient has been taking diuretics? 25. The nurse is caring for an 84-year old man who has
-Inform the care provider because diuretics are just returned from the OR after inguinal hernia repair.
contraindicated. The OR report indicates that the patient received large
volumes of IV fluids during surgery and the nurse
19. A patient who has undergone a valve replacement recognizes that the patient is at risk for left-sided heart
with a mechanical valve prosthesis is due to be failure. What signs and symptoms would indicate left-
discharged home. During discharge teaching, the nurse sided heart failure?
should discuss the importance of antibiotic prophylaxis -Bibasilar fine crackles
to which of the following?
-Dental procedures

20. The critical care nurse is caring for a patient who is


receiving cyclosporine postoperative heart transplant.
The patient asks the nurse to remind him what this
medication is for. How should the nurse best respond?
26. The emergency department nurse is assessing a
client who has sustained a blunt injury to the 31. The nurse has conducted discharge teaching
chest wall. Which finding indicates the presence with a client diagnosed with tuberculosis who
of a pneumothorax in this client? has been receiving medication for 2 weeks. The
A. A low respiratory rate nurse determines that the client has understood
B. Diminished breath sounds the information if the client makes which
C. The presence of a barrel chest statement?
D. A sucking sound at the site of injury A. “I need to continue medication therapy for 1
month”
27. The nurse is explaining the safe and effective B. “I can’t stop at the mall for the next 6 months”
administration of nasal spray to a patient with C. “I can return to work if a sputum culture comes
seasonal allergies. What information is most back negative”
important to include in this teaching? D. “I should not be contagious after 2 to 3 weeks of
A. Finish the bottle of nasal spray to clear the medication therapy”
infection effectively
B. Nasal spray can only be shared between 32. The nurse is preparing to give a bed bath to an
immediate family members immobilized client with tuberculosis. The nurse
C. Nasal spray should be administered in a prone should wear which items when performing this
position care?
D. Overuse of nasal spray may cause rebound A. Surgical mask and gloves
congestion. B. Particulate respirator, gown, gloves
C. Particulate respirator and protective eyewear
28. The nurse is caring for a client after a D. Surgical mask, gown, and protective eyewear
bronchoscopy and biopsy. Which finding, if
noted in the client, should be reported 33. A client has experience pulmonary embolism.
immediately to the primary health care The nurse should assess for which symptom,
provider? which is most commonly reported?
A. Dry cough A. Hot, flushed feeling
B. Hematuria B. Sudden chills and fever
C. Bronchospasm C. Chest pain that occurs suddenly
D. Blood-streaked sputum D. Dyspnea when deep breaths are taken

29. The nurse is assessing the respiratory status of a 34. The perioperative nurse has admitted a patient
client who has suffered a fractured rib. The who has just underwent a tonsillectomy. The
nurses should expect to note which finding? nurses postoperative assessment should
A. Slow, deep respirations prioritize which of the following potential
B. Rapid, deep respirations complications of this surgery?
C. Paradoxical respirations A. difficulty ambulating
D. Pain, especially with inspiration B. hemorrhage
C. infrequent swallowing
30. The nurse is assessing a client with multiple D. bradycardia
trauma who is at risk for developing acute
respiratory distress syndrome. The nurse should 35. a client who is human immunodeficiency virus
assess for which earliest sign of acute (HIV)- positive has had a tuberculin skin test
respiratory distress syndrome? (TST). The nurse notes a 7-mm area of
A. Bilateral wheezing induration at the site of the skin test and
B. Inspiratory crackles interprets the results as which finding?
C. Intercostal retractions A. Positive
D. Increased respiratory rate B. Negative
C. Inconclusive secretions. What should the nurse encourage
D. Need for repeat testing the patient to do?
A. Increase oral fluids unless contraindicated
36. The nurse is instructing a hospitalized client B. Call the nurse for oral suctioning, as needed
with a diagnosis of emphysema about measures C. Lie in a low fowlers or supine position
that will enhance the effectiveness of breathing D. Increase activity
during dyspneic periods. Which position should
the nurse instruct the client to assume? 41. The nurse is caring for a patient who is
A. Sitting up in bed scheduled for a lobectomy for a diagnosis of
B. Side-lying in bed lung cancer. While assisting with a subclavian
C. Sitting ina recliner chair vein central line insertion, the nurse notes the
D. Sitting up and leaning on an overbed table clients oxygen saturation rapidly dropping. The
patient complains of shortness of breath and
37. The nurse performs an admission assessment becomes tachypneic. The nurse suspects a
on a client with diagnosis of tuberculosis. The pneumothorax has developed. Further
nurse should check the results of which assessment findings supporting the presence of
diagnostic test that will confirm this diagnosis? a pneumothorax include what?
A. Chest x-ray A. Diminished or absent breath sounds on the
B. Bronchoscopy affected side
C. Sputum culture B. Paradoxical chest wall movement with
D. Tuberculin skin test respirations
C. Sudden loss of consciousness
38. The nurse is planning the care of a patient who D. Muffled heart sounds
is scheduled for a laryngectomy. The nurse
should assign the highest priority to which 42. The nurse is caring for a patient at risk for
postoperative nursing diagnosis? atelectasis. The nurse implements a first-line
A. Anxiety related to diagnosis of cancer measure to prevent atelectasis development in
B. Altered nutrition related to swallowing the patient. What is an example of a first-line
difficulties measure to minimize atelectasis?
C. Ineffective airway clearance related to airway A. Incentive spirometry
alterations B. Intermittent positive-pressure breathing (IPPB)
D. Impaired verbal communication related to C. Positive end-expiratory pressure (PEEP)
removal of the larynx D. Bronchoscopy

39. A 45-year-old obese man arrives in a clinic with 43. The perioperative nurse is writing a care plan for
complaints of daytime sleepiness, difficultu a patient who has returned from surgery 2
going to sleep at night, and snoring. The nurse hours prior. Which measure should the nurse
should recognize the manifestations of what implement to most decrease the patients risk of
health problem? developing pulmonary emboli?
A. Adenoiditis A. Early ambulation
B. Chronic tonsillitis B. Increased dietary intake of protein
C. Obstructive sleep apnea C. Maintaining the patient in a supine position
D. Laryngeal cancer D. Administering aspirin with warfarin

40. A critical care nurse is caring for a patient 44. The school nurse is presenting a class on
diagnosed with pneumonia as a surgical smoking cessation at the local high school. A
complication. The nurses assessment reveals participant in the class asks the nurse about the
that the patient has an increased work of risk of lung cancer in those who smoke. What
breathing due to copious tracheobronchial
response related to risk for lung cancer in assessment finding would the nurse expect to
smokers is most accurate? note specifically in the client?
A. The younger you are when you start smoking, A. Fatigue
the higher your risk for lung cancer B. Weakness
B. The risk for lung cancer never decreases once C. Weight gain
you have smoked, which is why smokers need D. Enlarged lymph nodes
annual chest x-rays
C. The risk for lung cancer is determined mostly by 49. A gastrectomy is performed on a client with
what type of cigarettes you smoke gastric cancer. In the immediate postoperative
D. The risk for lung cancer depends primarily on period, the nurse notes bloody drainage from
the other risk factors for cancer that you have the nasogastric tube. The nurse should take
which most appropriate action?
45. The nurse is caring for a patient in the ICU A. Measure abdominal girth
admitted with ARDS after exposure to toxic B. Irrigate the nasogastric tube
fumes from a hazardous spill at work. The C. Continue to monitor the drainage
patient has become hypotensive. What is the D. Notify the primary health care provider (PHCP)
cause of this complication to the ARDS
treatment? 50. The nurse is teaching a client about the risk
A. Pulmonary hypotension due to decreased factors associated with colorectal cancer. The
cardiac output nurse determines that further teaching is
B. Severe and progressive pulmonary hypertension necessary related to colorectal cancer if the
C. Hypovolemia secondary to leakage of fluid into client identifies which item as an associated risk
the interstitial spaces factor?
D. Increased cardiac output from high levels of A. Age younger than 50 years
PEEP therapy B. History of colorectal polyps
C. Family history of colorectal cancer
46. The nurse is reviewing the laboratory results of D. Chronic inflammatory bowel disease.
a client diagnosed with multiple myeloma.
Which would the nurse expect to note
specifically in this disorder?
A. Increased calcium level
B. Increased white blood cell
C. Decreased blood urea nitrogen level
D. Decreased number of plasma cells in the bone
marrow

47. The nurse should plan to implement which


intervention in the care of a client experiencing
neutropenia as a result of chemotherapy?
A. Restrict all visitors
B. Restrict fluid intake
C. Teach the client and family about the need for
hand hygiene
D. Insert an indwelling urinary catheter to prevent
skin breakdown

48. A client is admitted to the hospital with a


suspected diagnosis of Hodgkin’s disease. Which
51. The nurse is assessing the colostomy of a client C. Avoidance of complications in patients with
who has an abdominal perineal resection for a alloantibodies
bowel tumor. Which assessment finding D. Prevention of alloimmunization
indicates that the colostomy is beginning to
function? 56. A patient is being treated for the effects of a
A. The passage of flatus longstanding vitamin B12 deficiency. What
B. Absent bowel sounds aspect of the patients health history would
C. The client’s ability to tolerate food most likely predispose her to this deficiency?
D. Bloody drainage from the colostomy A. The patient has irregular menstrual periods
B. The patient is vegan
52. The nurse is monitoring a client for signs and C. The patient donated blood 60 days ago
symptoms related to superior vena cava D. The patient frequently smokes marijuana
syndrome. Which is an early sign of this
oncological emergency? 57. The nurse is assessing a new patient with
A. Cyanosis complaints of overwhelming fatigue and a sore
B. Arm edema tongue that is visibly smooth and beefy red. This
C. Periorbital edema patient Is demonstrating signs and symptoms
D. Mental status changes associated with what form of what hematologic
53. The nurse is instructing a client with iron disorder?
deficiency anemia regarding the administration A. Sickle cell anemia
of a liquid oral iron supplement. Which B. Hemophilia
instruction should the nurse tell the client? C. Megaloblastic anemia
A. Administer the iron at mealtimes D. Thrombocytopenia
B. Administer the iron through a straw
C. Mix the iron with cereal to administer 58. A nurse is planning the care of a patient with a
D. Add the iron to apple juice for easy diagnosis of sickle cell disease who has been
administration admitted for the treatment of an acute vaso-
occlusive crisis. What nursing diagnosis should
54. The nurse is caring for a patient receiving a the nurse prioritize in the patients plan of care?
transfusion notes that 15 minutes after the A. Risk for disuse syndrome related to ineffective
infusion of packed red blood cells (PRBCs) has peripheral circulation
begun, the patient is having difficulty breathing B. Functional urinary incontinence related to
and complains of severe chest tightness. What urethral occlusion
is the most appropriate initial action for the C. Ineffective tissue perfusion related to
nurse to take? thrombosis
A. Notify the patients physician D. Ineffective thermoregulation related to
B. Stop the transfusion immediately hypothalamic dysfunction
C. Remove the patients IV access
D. Assess the patients chest sounds and vital signs 59. A woman aged 48 years comes to the clinic
because she has discovered a lump in her
55. A patient undergoing a hip replacement has breast. After diagnostic testing, the woman
autologous blood on standby if a transfusion is receives a diagnosis of breast cancer. The
needed. What is the primary advantage of woman asks the nurse when her teenage
autologous transfusions? daughters should begin mammography. What is
A. Safe transfusion for patients with a history of the nurses best advice.
transfusion reactions A. Age 28
B. Prevention of viral infections from another B. Age 35
person’s blood C. Age 38
D. Age 48
64. The nurse has instructed the family of a client
60. A 42-year-old patient tells the nurse that she with stroke (brain attack) who has homonymous
has found a painless lump in her right breast hemianopsia about measures to help the client
during her monthly self-examination. She says overcome the deficit. Which statement suggests
that she is afraid that she has cancer. Which that the family understands the measures to
assessment finding would most strongly suggest use when caring for the client?
that this patients lump is cancerous? A. “We need to discourage him from wearing
A. Eversion of the right nipple and mobile mass eyeglasses.”
B. A nonmobile mass with irregular edges B. “We need to place objects in his impaired field
C. A mobile mass that is soft and easily delineated of vision.”
D. Nonpalpable right axillary lymph nodes C. “We need to approach him from the impaired
field of vision”
61. The nurse is assessing the motor and sensory D. “We need to remind him to turn his head to
function of an unconscious client who sustained scan the lost visual field”
a head injury. The nurse should use which
technique to test the client’s peripheral 65. The nurse is teaching a client with myasthenia
response to pain? gravis about the prevention of myasthenic and
A. Sternal rub cholinergic crises. Which client activity suggests
B. Nailbed pressure that teaching is most effective?
C. Pressure on the orbital rim A. Taking medications as scheduled
D. Squeezing of the sternocleidomastoid muscle B. Eating large, well-balanced meals
C. Doing muscle-strengthening exercises
62. The nurse is caring for the client with increased D. Doing all chores early in the day while less
intracranial pressure a s a result of a head fatigued
injury? The nurse would note which trend in
vital signs if the intracranial pressure is rising? 66. The client is admitted to the hospital with a
A. Increasing temperature, increasing pulse, diagnosis of Guillain-Barre syndrome. Which
increasing respirations, decreasing blood past medical history finding makes the client
pressure most at risk for this disease?
B. Increasing temperature, decreasing pulse, A. Meningitis or encephalitis during the last 5
decreasing respirations, increasing blood years
pressure B. Seizures or trauma to the brain within the last
C. decreasing temperature, decreasing pulse, year
increasing respirations, decreasing blood C. Back injury or trauma to the spinal cord during
pressure the last 2 years
D. decreasing temperature, increasing pulse, D. Respiratory or gastrointestinal infection during
decreasing respirations, increasing blood the previous year.
pressure
67. A client has a neurological deficit involving the
63. The nurse is evaluating the neurological signs of limbic system. On assessment, which finding is
a client in spinal shock following spinal cord specific to this type of deficit?
injury. Which observation indicates that spinal A. Is disoriented to person, place, and time
shock persists? B. Affect is flat, with periods of emotional lability
A. Hyperreflexia C. Cannot recall what was eaten for breakfast
B. Positive reflexes today
C. Flaccid paralysis D. Demonstrates inability to add and subtract;
D. Reflex emptying of the bladder does not know who is the president of the
Philippines
68. A patient with metastatic cancer has developed homemade chicken strips and carrot sticks the
trigeminal neuralgia and is taking evening prior. Which bacterial infection would
carbamazepine (Tegretol) for pain relief. What the nurse suspect this little girl of contracting?
principle applies to the administration of this A. Escherichia coli
medication? B. Salmonella
A. Tegretol is not known to have serious adverse C. Shigella
effects D. Giardia lamblia
B. The patient should be monitored for bone
marrow depression 73. A long term care facility is the site of an
C. Side effects of the medication include renal outbreak of infectious diarrhea. The nurse
dysfunction educator has emphasized the importance of
D. The medication should be first taken in the hand hygiene to staff members. The use of
maximum dosage form to be effective alcohol-based cleansers may be ineffective ass
what?
69. Family members are caring for a patient with A. Shigella
HIV in the patients home. What should the B. Escherichia coli
nurse encourage family members to do to C. Clostridium difficile
reduce the risk of infection transmission? D. Norovirus
A. Use caution when shaving the patient
B. Use separate dishes for the patient and family 74. A 19-year-old man comes to clinic complaining
members of 2 days of severe dysuria and urethral
C. Use separate bed linens for the patient discharge. Urine analysis shows pyuria. He
D. Disinfect the patients bedclothes regularly reports unprotected sexual contact with a new
partner within the past week. DNA probe is
70. A nurse is preparing to administer a patients positive for N. gonorrhea. Which of the
schedule dose of subcutaneous heparin. To following is the most effective therapy?
reduce the risk of needlestick injury, the nurse A. Intravenous ceftriaxone
should perform what action? B. Intramuscular penicillin
A. Recap the needle before leaving the bedside C. Oral azithromycin
B. Recap the needle immediately before leaving D. Oral cefixime
the room E. Oral levofloxacin
C. Avoid recapping the needle before disposing of
it 75. Which of the following antibiotics inhibit cell
D. Wear gloves when administering the injection wall synthesis?
A. Ciprofloxacin, metronidazole, and
71. A 16-year-old male patient comes to the free quinupristin/dalfopristin
clinic and is subsequently diagnosed with B. Rifampin, sulfamycin, and clindamycin
primary syphilis. What health problem most C. Tetracycline, daptomycin, and azithromycin
likely prompted the patient to seek care? D. Tobramycin, chloramphenicol, and linezolid
A. The emergence of a chancre on his penis E. Vancomycin, bacitracin, and penicillin
B. Painful urination
C. Signs of a systemic infection
D. Unilateral testicular swelling

72. A 2-year-old is brought to the clinic by he


mother who tells the nurse her daughter has
diarrhea and the child is complaining of pain in
her stomach. The mother says that the little girl
had not eaten anything unusual, consuming
Pre test 76-100

QUESTION 76
A 22-vear-old male comes to the clinic reporting severe penile itching and new skin lesions. His last
sexual encounter was unprotected sex 3 weeks prior with a new female partner in her bed. He has
not seen her since. Over the last 3 davs he noticed new lesions on his penis and scrotum. The
lesions are extremely pruritic. particularly at night and after a shower. His physical examination is
shown in the figure. Which of the rollowing is the best therapy.
A. Ceftriaxone plus azithromycin
B. Penicillin G
C. Permethrin
D. vancomycin

QUESTION 77
Which non-medical intervention is no longer recommended in the prevention of COVID-19
transmission and infection as per DOH
Workplace Guideline Version 2 (October 2021)?
A. Face mask + protective eyewear (face shield) in areas with sustained community transmission
B. Properly fitted surgical masks for workers with high risk of exposure to COVID-19
C. Snugly fitting cloth masks (at least 2 layers of cotton and non-woven nylon with aluminum nose
bridge)
D. Disinfection tents, misting chambers, sanitation booths

QUESTION 78
Patient RW, a 44YO male, working as a seafarer submitted for COVID-19 RTPCR testing as a
requirement prior to boarding the ship which turned out unfortunately positive. He claimed to have
no close contact or any potential/suspicious exposure. No comorbidities, intake of maintenance,
and medications claimed. No signs and symptoms claimed by patient. He claimed to have received
his second dose of COVID vaccine 3 days ago. What is an expected management of Patient RW's
case? (PSMID Unified COVID-19
Algorithm Version 4)
A. Complete 7 days of isolation from day 0
B. Anticipate to give Azithromycin and antihistamine as ordered
C. Complete 10 days of isolation from day 0
D. Discharge from isolation

QUESTION 79
Patient GO a 55VO female known case of diahetes and ischemic heart disease with non-compliance
to maintenance medications was admitted due to dusonea
At the ER, BP noted at 70/80 mmHg, HR 133 bpm, RR 36 cm, afebrile at 37.5 C.
Chest CT scan revealed peripheral ground-glass opacities with consolidation. sPO2 noted at 87%
with FIO2 0.6. Pa02/FiO2 ratio of 85. RTPCR revealed positive result for COVID-19. Which of the
following interventions will best management Patient GQ? SELECT ALL THAT APPLY. (Interim
Guidelines in Clinical Management of Adult Patients with Suspected or Confirmed COVID-19
Infection, Version 3.1, July 2020,
A. Perform in bag-mask ventilation in preparation for for rapid sequence intubation usine
videolarvngoscope
B. Use IV fluids instead of crystalloids in addressing hypotension.
C. Initiate prone position for 16-20 hours.
D. Anticipate the need to start y steroids and anticoagulation therapy.
E. Avoid sedation until radiographic findings have improved

QUESTION 80
The following are TRUE about the use of corticosteroids in the management of COVID-19 infection:
(SELECT ALL THAT APPLY)
Interim Guidelines in Clinica Management of Adult Patients with Susoected or Confirmed COVID-19
Infection. Version 3.1. Julv 20201
A. They inhibit multiple inflammatory cytokines resulting in decreased edema, capillary leakage,
migration of inflammatory cells
B. Recommended regimen is Dexamethasone 6mg IV for 10 days
C. Inhaled steroids are recommended as adjunctive treatment
D. Oral, inhaled, or IV steroids are recommended for prophylaxis
E. It inhibits viral replication through premature termination of RNA transcription.
F. Blocks viral entry into cells by inhibiting glycosylation of host receptors, proteolytic processing,
endosomal acidification.

QUESTION 81
A client arrives at the emergency department with complaints of low abdominal pain and hematuria.
The client is afebrile. The nurse next assesses the client to determine a history of which condition?
A. Pyelonephritis
B. Glomerulonephritis
C. Trauma to the bladder or abdomen
D. Renal cancer in the client's family

QUESTION 82
The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating
hemodialysis. Which finding indicates that the fistula is patent? ignatavicius, Workman, Rebar
(2018), p. 1415.
A. Palpation of a thrill over the fistula.
B. Presence of a radial pulse in the left wrist.
C. Visualization of enlarged blood vessels at the fistula site.
D. Capillary refill less than 3 seconds in the nailbeds of the fingers on the left hand.

QUESTION 83
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse
would plan which actions as a priority? SELECT ALL THAT APPLY.
A. Place the client on a cardiac monitor.
B. Notify the primary health care provider (PHCP).
C. Put the client on NPO (nothing by mouth) status except for ice chips.
D. Review the client's medications to determine whether any contain or retain potassium.
E. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

QUESTION 84
A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and
complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air
embolism. What are the priority nursing actions? SELECT ALL THAT APPLY. Lewis, S., Harding, M.,
Kwong, J., Roberts, D., Hagler,
D., & Reinisch, C. (2020).

A. Administer oxygen to the client.


B. Continue dialysis at a slower rate after checking the lines for air.
C. Notify the primary health care provider (PHCP) and Rapid Response Team.
D. Stop dialysis, and turn the client on the left side with head lower than feet.
E. Bolus the client with 500 mL of normal saline to break up the air embolus.

QUESTION 85
The nurse is performing an assessment on a client who has returned from the dialysis unit following
hemodialysis. The client is complaining of head- ache and nausea and is extremely restless.
Which is the priority nursing action?
A. Monitor the client.
B. Elevate the head of the bed.
C. Assess the fistula site and dressing.
D. Notify the primary health care provider (PHCP). -
DISEQUILIBRIUM SYNDROME
QUESTION 86
A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis.
The nurse anticipates that which treatment will be done to relieve the obstruction? SELECT ALL
THAT APPLY.
A. Peritoneal dialysis
B. Analysis of the urinary stone
C. Intravenous opioid analgesics
D. Insertion of a nephrostomy tube
E. Placement of a ureteral stent with ureteroscopy

QUESTION 87
A client is brought to the emergency department in an unresponsive state, and a diagnosis of
hyperosmolar hyperglycemic syndrome (HHS) is made. The nurse would immediately prepare to
initiate which anticipated primary health
care provider's prescription
Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagier, D., & Reinisch, C (2020). pp 1133

A. Endotracheal intubation
B. 100 units of NPH insulin
C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate

QUESTION 88
The nurse is performing an assessment on a client
with pheochromocytoma. Which assessment data would indicate a potential complication
associated with this disorder?
Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). pp. 1168-1169.
A. A urinary output of 50 mL/hr
B. A coagulation time of 5 minutes
C. A heart rate that is 90 beats per minute and irregular
D. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L)

QUESTION 89
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic
hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mol/L). Which primary health
care provider prescriptions would the nurse anticipate receiving? SELECT ALL THAT APPLY.
A. Initiate an infusion of 3% NaCI.
B. Administer intravenous furosemide.
C. Restrict fluids to 800 mL over 24 hours.
D. Elevate the head of the bed to high-Fowler's.
E. Administer a vasopressin antagonist as prescribed.

QUESTION 90
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute
pancreatitis. Which interventions would the nurse expect to be prescribed for the client? SELECT
ALL THAT APPLY. Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020).
pp. 994-996.
A. Maintain NPO (nothing by mouth) status.
B. Encourage coughing and deep breathing.
C. Give small, frequent high-calorie feedings.
D. Maintain the client in a supine and flat position.
E. Give hydromorphone intravenously as prescribed for pain.
F. Maintain intravenous fluids at 10 mL/hr to keep the vein open.

QUESTION 91
The primary health care provider has determined that a client has contracted hepatitis A based on
flulike symptoms and jaundice. Which statement made by the client supports this medical
diagnosis?
A. "I have had unprotected sex with multiple partners."
B. "I ate shellfish about 2 weeks ago at a local restaurant."
C. "I was an intravenous drug abuser in the past and shared needles."
D. "I had a blood transfusion 30 years ago after major abdominal surgery."

QUESTION 92
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is
scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and
begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds
are di-minished. Which is the most appropriate nursing intervention? Lewis, s., Harding,
M. Kwong. . Roberts, D. Hagler, D. & Reinisch, c. 20201 pp. 937-938.

A. Notify the surgeon.


B. Administer the prescribed pain medication.
C. Call and ask the operating room team to perform surgery as soon as possible.
D. Reposition the client and apply a heating pad on the warm setting
to the client's abdomen.

QUESTION 93
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of
these clinical manifestations support this diagnosis? SELECT ALL THAT APPLY. Ignatavicius, D.,
Workman,
M., Rebar, C., & Heimgartner, N. (2021). pp. 1178-1179
A.Fever
B. Positive Cullen's sign
C. Complaints of indigestion
D. Palpable mass in the left upper quadrant
E. Pain in the upper right quadrant after a fatty meal
F. Vague lower right quadrant abdominal discomfort

QUESTION 94
A client with severe Crohn's disease has just had surgery to create an ileostomy. The nurse
assesses the client in the immediate postoperative period for which most frequent complication of
this type of surgery? Lewis, s. Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020).
pp. 956
A. Folate deficiency
B. Malabsorption of fat
C. Intestinal obstruction
D. Fluid and electrolyte imbalance

QUESTION 95
The nurse is providing discharge instructions to a client following gastrectomy and would instruct
the client to take which measure to assist in preventing dumping syndrome? ignatavicius, D.,
Workman, M., Rebar, C., & Heimgartner, N. (2021). pp. 1106-1108.
A. Ambulate following a meal.
B. Limit the fluids taken with meals.
C. Eat cakes and pastries only if they are homemade.
D. Eat three meals a day rather than small frequent meals.

QUESTION 96
The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The
nurse reminds the children that chemical sunscreens are most effective when applied at which
times? Lewis, s., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). PP. 410
A. Immediately before swimming
B. 5 minutes before exposure to the sun
C. Immediately before exposure to the sun
D. At least 30 minutes before exposure to the sun

QUESTION 97

QUESTION 98
Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication,
the nurse anticipates that which laboratory test will be prescribed?
A. Potassium level
B. Triglyceride level
C. Hemoglobin Alc
D. Total cholesterol level

QUESTION 99
Which cast care instructions would the nurse provide to a client who just had a plaster cast applied
to the right forearm? SELECT ALL THAT APPLY. Lewis, s., Harding, M., Kwong, J., Roberts, D.,
Hagler, D., & Reinisch, C. (2020). pp. 1453
A. Keep the cast clean and dry.
B. Allow the cast 24 to 72 hours to dry.
C. Keep the cast and extremity elevated.
D. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to
dry the cast.
E. Use a soft, padded object that will t under the cast to scratch the skin under the cast.

QUESTION 100
The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury
who has just returned from the recovery room following a thoracotomy with wedge resection. Which
are the expected assessment findings? SELECT ALL THAT APPLY.
A. Excessive bubbling in the water seal chamber
B. Vigorous bubbling in the suction control chamber
C. Drainage system maintained below the client's chest
D. 50 ml of drainage in the drainage collection chamber
E. Occlusive dressing in place over the chest tube insertion site
F. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

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