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1. The nurse is assessing a client who is suspected of having a pulmonary embolism (PE).
Which of the following ?ndings is consistent with this diagnosis?
Cough
2. The nurse is caring for a client who is 4 days postoperaBve and suddenly develops
diCculty breathing and sharp chest pain. The nurse has called the rapid response team
(RRT), raised the head of the bed (HOB), and applied oxygen to the client. Which acBons
from the box below should the nurse take next?
o Auscultate the client’s lung sounds.
o Ini5ate con5nuous cardiac monitoring.
o Prepare to administer intravenous (IV) alteplase.
o Connect the client to a con5nuous pulse oximeter.
o Apply bilateral anBembolism stockings to the legs.
o Assess the client’s skin color.
1, 2, 4, 6
3. The nurse has provided discharge teaching to a client who developed a pulmonary
embolism (PE) following a surgical procedure. The client will be taking newly prescribed
warfarin at home. Which of the following client statements indicates a correct
understanding of the teaching?
I should avoid anything rectally, such as enemas or suppositories.
4. The nurse is caring for a client who appears to have developed a pulmonary embolism
(PE). Which of the following arterial blood gas (ABG) results would the nurse expect the
client to ini5ally have?
Ph = 7.50; PaO2 = 79mm Hg; PaCO3 = 32 mm Hg; HCO3 = 23 mEq/L; SaO2 = 88%
5. The nurse is caring for the following assigned clients. The nurse should Rrst see the
client who has?
Received a heparin infusion for the last 10 days and has a platelet count of 90,000
6. The nurse is caring for a client who has a chest tube. Which assessment ?ndings from
the box below requires the nurse to immediately noBfy the primary health care provider
(PHCP)?
a. ConBnuous bubbling in the sucBon control chamber
b. Tracheal devia5on
c. Tidling in the water seal chamber with breathing
d. 100 mL of drainage within an hour
e. Visibility of the eyelets of the chest tube
f. Low water level in the water seal chamber
2, 4, 5
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7. The nurse is assessing a client who had a chest tube placed 36 hours ago for the
treatment of a pneumothorax. The nurse observes conBnuous bubbling in the water seal
chamber. Which of the following acBons should the nurse take?
Inform the primary health care physician (PHCP) that there is a leak in the system
8. The nurse working in the emergency department (ED) is caring for a client who was in a
boaBng crash 3 hours ago and has the following data: The nurse concludes that the
client is developing?
a. Reports a headache
b. Restless and irritable
c. (ABG) pH: 7.28, PaO2 60mm Hg, PaCO2 52 mm Hg, HCO3 24 mEq/L, SaO2 84%
d. Pulse 110
e. RespiraBons 10 and dyspneic
f. Blood pressure 145/86 mm Hg
Acute respiratory failure (ARF)
9. The nurse is assessing clients for the risk of developing acute respiratory distress
syndrome (ARDS). The nurse should idenBfy at greatest risk the client who?
Has sepsis and is receiving nutri5on via con5nuous tube feeding
10. The nurse working on a medical surgical unit is caring for assigned clients. It indicates
appropriate clinical judgement if the nurse ini5ally assesses the client who has?
An arterial oxygen (PaO2) level of 59 mm Hg while receiving 100% oxygen
11. The nurse is caring for a client who developed acute respiratory distress syndrome
(ARDS) and has been placed on mechanical venBlaBon. Which of the following is a
priority acBon for the nurse to take?
Obtain a special bed that will turn the client
12. The nurse has a`ended a conBnuing educaBon program on interdisciplinary care. It
would indicate a correct understanding of the program if the nurse idenB?es that an
interdisciplinary conference would be most important for the client who is
21-year-old, is a college student, and has been receiving mechanical ven5la5on for 14
days for the treatment of acute respiratory distress syndrome (ARDS)
13. The nurse working in the emergency department (ED) is assessing a client who has a lea
pneumothorax. Which of the following assessment ?ndings should the nurse expect?
Limited chest expansion
14. The nurse is caring for a client who is receiving mechanic venBlaBon. It indicates a
correct understanding about managing a client on a venBlator if the nurse
Determines if the client needs to be suc5oned when the high-pressure alarm sounds
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15. The nurse is caring for a client who is receiving mechanical venBlaBon via an
endotracheal (ET) tube and is unable to speak. The client’s family is frightened that the
client has permanently lost their voice. Which of the following responses should the
nurse make?
The tube is causing a temporary loss of the voice
16. The nurse has been made aware of the following client situaBons. The nurse should
ini5ally follow up with the client who is receiving.
mechanical ven5la5on with PEEP and develops le^ tracheal devia5on.
17. The nurse is reviewing chest radiography (x-ray) results on an assigned client. The x-ray
reveals 3 rib fractures. Based on these ?ndings, the nurse should
Place suc5on set up at the bedside
18. The nurse is caring for a client who has been admi`ed for suspected diabetes insipidus
(DI). Which of the following assessment ?ndings is a priority for the nurse to follow-up
on?
Bounding peripheral pulses with a decrease in thirst
19. The nurse has taught a client who has diabetes insipidus (DI) about self-care at home.
Which of the following client statements indicates the need for further teaching?
I will test urine daily for posi5ve ketones and report any Rndings.
20. The nurse is providing discharge instrucBons to a client who has permanent diabetes
insipidus. Which of the following client statements would indicate a correct
understanding of discharge instrucBons?
I should report if I develop increased thirst or urina5on.
21. The nurse caring for a client who has developed diabetes insipidus (DI). Which of the
following should the nurse correlate to the development of this condiBon?
Recent craniotomy
22. The nurse is caring for a client who has syndrome of inappropriate anBdiureBc hormone
(SIADH) and a serum sodium level of 114 mEq/L. Which of the following acBons is most
important for the nurse to take?
Reduce environmental noise and ligh5ng
23. The nurse is reviewing the below data for a client who has syndrome of inappropriate
anBdiureBc hormone (SIADH): Which of the following acBons should the nurse take
Rrst?
a. Chief complaint: fell and hit head 2 days ago
b. Neurological status: reports a dull headache, drowsy
c. Temperature: 97.8 F
d. Pulse: 100
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e. RespiraBons: 18
f. Blood pressure: 140/95 mm Hg
g. Sodium level: 120 mEq/L
h. 24-hour intake: 3500 mL
i. 24-hour output: 1500 mL
Perform a complete neurological assessment
24. The nurse is performing a health history on a 45-year-old female client who is suspected
of having Cushing’s syndrome. Which of the following quesBons is a priority for the
nurse to ask the client?
What prescribed medica5ons do you take?
25. The nurse has taught a client who has Cushing’s disease about changes in dietary habits.
Which of the following meal choices indicates a need for further teaching?
Bacon, lebuce, and tomato sandwich on wheat toast and a glass of apple juice
26. The nurse is assessing clients for the risk of developing Cushing’s syndrome. The nurse
should idenBfy of greatest risk the client who is a
44-year-old female and has frequent exacerba5ons of chronic obstruc5ve pulmonary
disease (COPD).
27. The nurse working in the emergency department (ED) is caring for a client who has
Addison’s disease and was brought in by emergency medical services (EMS). The client
has the following admission date: which of the following acBons by the nurse is priority?
a. Temperature: 101.8 F
b. Pulse: 64
c. RespiraBons: 22
d. Blood pressure: 94/56 mm Hg
e. ECG: Atrial ?brillaBon (AF)
f. Potassium level: 6.2 mEq/L
g. Sodium level: 122 mEq/L
h. Reports of nausea
Ini5ate an infusion of 20 units of regular insulin with 20 mg of dextrose in normal
saline (NS).
28. The nurse is caring for a client who has adrenal insuCciency and is experiencing an
exacerbaBon. Which of the following acBons should the nurse plan to take?
Monitor the client’s sodium level
29. The nurse is caring for a client who was admi`ed with a pheochromocytoma. Which of
the following assessment ?ndings should the nurse expect in this client?
Palpita5ons
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30. The nurse preceptor is observing a newly hired nurse care for a client with suspected
pheochromocytoma. Which of the following acBons by the newly hired nurse requires
the nurse preceptor to intervene?
Avoid palpita5ng and percussion of the client’s abdomen
31. The nurse is assessing a client who has Grave’s disease and notes that the client’s
temperature has increased by 1 F. Aaer noBfying the primary health care physician
(PHCP), the nurse should Rrst
Administer prescribed oral an5-thyroid
32. The nurse has instructed a male client who has hyperthyroidism and is scheduled to
receive radioacBve iodine (RAI) therapy. Which of the following client statements
indicates a correct understanding of the instrucBons?
I will use disposable 5ssues rather than a cloth handkerchief
33. The nurse is caring for a client who is 12 hours postoperaBve from a total thyroidectomy
and has developed stridor. Which of the following acBons should the nurse take?
Prepare the client for an emergency tracheostomy
34. The nurse has instructed a female client who has hyperthyroidism about a newly
prescribed medicaBon, methimazole. Which of the following client statements indicates
a need for further teaching?
I might have heat intolerance or hot fashes while taking this medica5on
35. The nurse has become aware of the following client situaBons. It would be a priority for
the nurse to follow up with the client who
Had a subtotal thyroidectomy 12 hours ago and reports 5ngling of the Rngers
36. A paBent presents with these signs. Which of the following should the nurse suspect
that the client is experiencing?
a. DiCculty with memory
b. Facial edema
c. Dry skin
d. Amenorrhea
e. Pulse: 60
f. Decreased peripheral pulses
g. Blood glucose: 64 mg/dL
h. Sodium level of 135 mEq/L
i. Weight gain of 5 lbs in 1 week
Myxedema coma
37. The nurse is caring for a client who was recently diagnosed with hypothyroidism and is
receiving the iniBal doses of levothyroxine. During the iniBaBon of this medicaBon
therapy, it is a priority for the nurse to assess the client for the development of
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6
Chest pain and dyspnea
38. The nurse is teaching a client who has hypothyroidism about self-management. Which of
the following should the nurse include in the teaching plan?
Avoid the use of any Rber supplements with thyroid replacement medica5ons
39. The nurse is developing a plan of care for a client who has hyperparathyroidism and an
increased calcium level of 12.0 mg/dL. Which of the following prescripBons should the
nurse quesBon?
Hydrochlorothiazide 25 mg IV twice a day.
40. The nurse is caring for a client who has hyperparathyroidism. It requires follow-up if the
client
Develops epigastric pain
41. The nurse is providing care to a client who has hypoparathyroidism and has developed a
posiBve Trousseau’s sign. Which of the following acBons is a priority for the nurse to
take?
Implement seizure precau5ons for the client
42. The nurse is admihng a client who has hyperglycemic hyperosmolar state (HHS). Which
of the following complicaBons is the client at increased risk for developing?
Dehydra5on
43. The nurse is caring for a client who is being treated for hyperglycemic hyperosmolar
state (HHS). The client has been receiving intravenous normal saline (NS) and is now
adequately rehydrated. Which of the following intervenBons should the nurse be
prepared to implement next?
Ini5ate a prescribed insulin drip
44. The nurse is preparing to administer a regular insulin iv bolus to a client who has HHS.
The primary health care provider has prescribed an iniBal dose of bolus 0.1 units/kg. the
client weighs 120lb. how much regular insulin should the nurse administer to the client
as an IV bolus.
5 units
45. The nurse is caring for a client who is being treated for HHS. Which of the following
?ndings indicates to the nurse that treatment needs to be adjusted?
Serum osmolarity
46. The nurse is reviewing prescripBons for newly admi`ed clients. It would require
immediate follow-up by the nurse if the PHCP prescribed?
3% normal chloride at 100ml/hr. for a client receiving treatment for HHS.
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47. The nurse is caring for a client who has DKA. Which of the following should the nurse
expect to assess in the client?
ABG results of PH 7.22, PaCO2 42, HCO3 15. (metabolic acidosis)
48. The nurse is teaching a client who is newly diagnosed with diabetes mellites type 1
about sick day rules. Which of the following instrucBons from the box below should the
nurse include?
a. Check blood glucose levels q 4hrs.
b. Hold insulin injecBons if vomiBng occurs
c. Get plenty of rest and sleep
d. Drink 8-12 ounces of sugar free liquids everyday while awake
e. Abempt to eat meals at regular 5mes
f. Test urine for ketones with every void if blood glucose is greater than 200.
1,3,4,5
49. Which of the following acBons should the nurse take next, with ?ndings?
a. Blood pressure 90/60
b. Urine output 160 ml/8hrs
c. Potassium level 5.3
d. Blood glucose 350
e. Increase IV kuid rate to 10ml/kg/hr.
Increase rate of the IV fuids as prescribed
50. The nurse has provided discharge instrucBons to a client who is postoperaBve from a
transsphenoidal hypophysectomy. Which of the following client statements indicates a
need for further teaching?
I will wash the incision everyday with hydrogen peroxide and cover with a dressing.
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