1. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA).

Which medication would the nurse anticipate being ordered for the client on discharge? a. An oral anticoagulant medication b. A beta-blocker medication c. An anti-hyperuricemic miedication d. A thrombolytic medication

2. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? a. A blood glucose level of 480 mg/dL b. A right-sided carotid bruit c. A blood pressure of 220/120 mmHg d. The presence of bronchogenic carcinoma

3. The nurse and the unlicensed nursing assistant are caring for clients on a medical-surgical unit. Which task should NOT be assigned to the CNA? a. Feed the 69-year-old client diagnosed with Parkinsons disease who is having difficulty swallowing. b. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinsons disease. c. Assist the 54-year-old client diagnosed with Parkinsons disease with toilet-training activities d. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinsons disease

4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement FIRST? a. Sponge the clients forehead b. Obtain a pulse oximetry reading c. Take the clients vital signs d. Assist the client to a sitting position

5. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement FIRST? a. Administer sublingual nitroglycerin

b. Obtain a STAT ECG c. Have the client sit down immediately d. Assess the clients vital signs

6. The health care provider prescribes an ACE inhibitor for the client diagnosed with hypertension. Which statement is the most appropriate rationale for administering this medication? a. ACE inhibitors prevent the beta-receptor stimulation in the heart b. This medication blocks the alpha receptors in the vascular smooth muscle c. ACE inhibitors prevent vasoconstriction and sodium and water retention d. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle

7. The client diagnosed with a exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement FIRST? a. Assist the client into a sitting position b. Given oxygen via nasal cannula as ordered c. Monitor vital signs with client sitting upright d. Notify the health care provider about the clients status

8. The client diagnosed with asthma has been prescribed a corticosteroid inhaled medication. Which information should the nurse teach regarding this medciation? a. Do not abruptly stop taking this medication; it must be tapered off b. Immediately rinse the mouth following administration of the drug c. Hold the medication in the mouth for fifteen seconds before swallowing d. Take the medication immediately when an attack starts

9.

The client diagnosed with Crohns disease is crying and tells the nurse, I cant take it anymore, I never know when I will get sick and end up here in the hospital. Which statement would be the nurses best response? a. I understand how frustrating this must be for you. b. You must keep thinking about the good things in your life. c. I can see you are very upset. Ill sit down and we can talk. d. Are you thinking about doing anything like committing suicide?

10. The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement FIRST?

a. b. c. d.

Weight the client daily and document it in the clients chart Teach coping strategies such as dietary modifications Record the frequency, amount, and color of stools Monitor the clients oral fluid intake every shift

11. The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention would the nurse anticipate the health care provider ordering? a. Administer total parenteral nutrition b. Maintain NPO and nasogastric tube c. Maintain on a high-fiber diet and increase fluids d. Obtain consent for abdominal surgery

12. The client is four (4) hours postoperative open cholecystectomy. Which data would warrant immediate intervention by the nurse? a. Absent bowel sounds in all four quadrants b. The T-tube with 60 mL of green drainage c. Urine output of 100 mL in the past three hours d. Refusal to turn, deep breathe, and cough

13. The client diagnosed with gastroenteritis. Which laboratory data would warrant immediate intervention by the nurse? a. A serum sodium level of 137 mEq/L b. An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO 24 c. A serum potassium level of 3.3 mEq/L d. A stool sample that is positive for fecal leukocytes

14. The client diagnosed with Type 1 diabetes has a hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? a. This result is below normal levels b. This result is within acceptable levels c. This result is above recommended levels d. This result is dangerously high

15. The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the CAN tells the nurse the client has a headache and is really acting funny. Which action should the nurse implement FIRST? a. Instruct the CAN to obtain blood glucose level b. Have the client drink eight ounces of orange juice c. Go to the clients room and assess the client for hypoglycemia d. Prepare to administer one vial of 50% Dextrose IV

16. The male client in ESRD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client would indicate the need to notify the health care provider? a. The client complains of flulike symptoms b. The client complains of being tired all the time. c. The client reports an elevation in his blood pressure d. The client reports discomfort in his legs and back.

17. The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers? a. Constant perineal moisture b. Ability of the client to reposition themselves c. Decreased elasticity of the skin d. Impaired cardiovascular perfusion of the periphery

18. The nurse writes the problem impaired skin integrity for a client with stage IV pressure ulcers. Which intervention should be included in the plan of care. Select all that apply. a. Turn the client every three to four hours b. Ask the dietician to consult c. Have the client sign a consent for pictures of the wounds d. Obtain an order for low air loss bed e. Elevate the head of the bed at all times.

19. The 65-year-old male client who is complaining of blurred vision reports that he thinks his glasses need to be cleaned all the time. He denies any type of pain in his eyes. Based on these signs/symptoms, which eye disorder would the nurse suspect the client has? a. Corneal dystrophy b. Conjunctivitis

c. Diabetic retinopathy d. Cataracts

20. The nurse is planning the care of a client diagnosed with pelvic inflammatory disease secondary to an STD. Which collaborative diagnosis is appropriate for this client? a. Risk for infertility b. Knowledge deficit c. Fluid volume deficit d. Noncompliance