1
Q
SELECT ALL THAT APPLY: A nurse is assessing a client who has a new dx of osteoarthritis. Which of the following findings should the nurse expect?
A. Crepitus with joint movement
B. Decreased range of motion of the affected joint
C. Involvement of smaller joints of the body
D. Spongy tissue over the joints
E. Joint pain that resolves with rest
A
A. Crepitus with joint movement
B. Decreased range of motion of the affected joint
E. Joint pain that resolves with rest
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2
Q
A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include?
A. Apply pressure to the site for 12hr
B. Restrict the client’s fluid intake for 24hr
C. Ensure the client lies flat for 4-8hr
D. Administer pain eds every 3-4hr
A
C. Ensure the client lies flat for 4-8hr
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3
Q
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which intervention is a priority?
A. Provide for frequent rest periods throughout the day
B. Medicate for pain on a regular schedule
C. Monitor pulse oximetry findings
D. Administer baclofen for spasicity
A
C. Monitor pulse oximetry findings
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4
Q
A nurse is assessing a client who had a right hemispheric stroke. Which deficit is expected?A. AphasiaB. Right-sided neglectC. Impulsive behaviorD. Inability to read
A
C. Impulsive behavior
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5
Q
Client who is 72hr postop AKA reports phantom limb pain. Which action should the nurse take?
A. Remind the client that the limb has been removed
B. Change the dressing on the client’s residual limb
C. Administer an oral dose of gabapentin to the client
D. Elevated the client’s residual limb above heart level
A
C. Administer an oral dose of gabapentin (neurontin) to the client
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6
Q
A nurse is teaching a client with Parkinson’s disease about a new prescription for carbidopa-levodopa (Sinemet). Which indicates an understanding?
A. I should epect a slight increase in my BP while taking these meds
B. I should take my meds with a high-protein food
C. I should expect my urine to be darker in color
D. I wll expect it to take up to a week for this medication to work
A
C. I should expect my urine to be darker in color
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7
Q
PICTURE QUESTION: how to sit post arthroplasty?
A
Try not to sit in the same position for more than 30 to 40 minutes at a time
Keep your feet about 6 inches apart. Do not bring them all the way together.
Keep your feet and knees pointed straight ahead, not turned in or out.
Sit in a firm chair with a straight back and armrests. Avoid soft chairs, rocking chairs, stools, or sofas.
Avoid chairs that are too low. Your hips should be higher than your knees when you are sitting. Sit on a pillow if you have to.
When getting up from a chair, slide toward the edge of the chair, and use the arms of the chair or your walker or crutches for support.
Do not cross your legs.
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8
Q
Client in ED post sudden LOC fall at home. Provider determines that the client has had an embolic stroke. Which medication should the nurse give?
A. Recombinant tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine
A
A. Recombinant tissue plasminogen activator
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9
Q
Client has viral meningitis. What should the nurse do?
A. Assess the client’s neurological status every 8hr
B. Maintain the client on droplet precautions
C. Monitor capillary refill at least every 4hr
D. Place the client in a well-lit environment
A
C. Monitor capillary refill at least every 4hr
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10
Q
A nurse is teaching a client with epilepsy who is to start phenytoin. Which of the following instructions should the nurse include in the client’s medication teaching plan?
A. Rinse with antiseptic mouthwash in place of using dental floss
B. Use an OTC antihistamine if a rash develops
C. Slowly taper the medication after 6 consecutive months w/o seizure activity
D. Take medication at a consistent time each day to maintain therapeutic blood levels
A
D. Take medication at a consistent time each day to maintain therapeutic blood levels
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11
Q
A nurse is caring for a client who has MS. What is expected?A. Hypoactive deep-tendon reflexesB. Ascending paralysisC. Intention tremorsD. Increased lacrimation
A
C. Intention tremors
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12
Q
A nurse is caring for a client who has a full arm cast and reports pain of 8 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
A. Administer additional pain medications
B. Check the circulation of the affected extremity
C. Document findings
D. Reposition the affected extremity
A
B. Check the circulation of the affected extremity
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13
Q
Client with possible head injury following car crash. The nurse recognizes which of the following as in indication of increasing intracranial pressure?A. RestlessnessB. DizzinessC. HypotensionD. Fever
A
A. Restlessness
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14
Q
Client is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which action should the nurse take first?A. Reposition the clientB. Provide distractionC. Administer muscle relaxantD. Check position of weights and ropes
A
D. Check position of weights and ropes
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15
Q
Post-stroke client with right-sided hom*onymous hemianopsia. The nurse should ?
A. Check the client’s cheek for food
B. Encourage the client to sit upright with his head tilted slightly forward during meals
C. Provide the client with eating utensils that have large handles
D. Remind the client to look consciously at both sides of his meal tray
A
D. Remind the client to look consciously at both sides of his meal tray
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16
Q
PICTURE QUESTION: Which image indicates a comminuted fracture?
A
It is a fracture in which the bone is splintered, crushed, or broken into pieces
17
Q
A nurse is caring for a client admitted for status epilepticus and is on seizure precautions. Which action should the nurse plan to take?
A. Assess hourly for a spike in BP
B. Maintain the client on bed rest
C. Keep a padded tongue blade at the bedside
D. Establish IV access
A
D. Establish IV access
18
Q
Client is prescribed alendronate (Fosamax) for osteoporosis. Which should the nurse teach?
A. Take this med with 240mL (8oz) milk
B. Remain upright for 30min after taking this med
C. Expect this med to increase serum calcium levels
D. Increase Vitamin D intake to promote medication absorption
A
B. Remain upright for 30min after taking this med
19
Q
8hr postop craniotomy. Which action should the nurse take?
A. Suction the client every 2hr
B. Report wound drainage greater than 50mL/8hr
C. Position the client flat in bed
D. Assess the client’s neurologic status every 8hr
A
B. Report wound drainage greater than 50mL/8hr
20
Q
Client with rheumatoid arthritis. Which of the following assessments is expected?A. Unilateral joint involvementB. Ulnar deviationC. Fractures of the spineD. Decreased sedimentation rate
A
B. Ulnar deviation
21
Q
A nurse is giving postop cataract surgery instructions. Which statement indicates an understanding?
A. I should call my doctor if I experience a decrease in my vision
B. I may take aspirin for eye discomfort
C. I can blow my nose to clear out any drainage
D. I can lift objects up to 20lbs
A
A. I should call my doctor if I experience a decrease in my vision
22
Q
A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which intervention is a priority?
A. Maintain a PaCO2 of approximately 35mmHg
B. Provide small doses of fentanyl via IV bolus for pain mgmt
C. Monitor body temperature every 1-2hr
D. Reposition the client every 2hr.
A
A. Maintain a PaCO2 of approximately 35mmHg
23
Q
Client with Meniere’s disease. What should the nurse include in her instructions?
A. Move head slowly to decrease vertigo
B. Apply warm compress to affected ear during acute attacks
C. Increase intake of foods and fluids high in salt
D. Administer corticosteroids during acute attacks
A
A. Move head slowly to decrease vertigo
24
Q
Family informed of client’s dx of Alzheimer’s disease. Family indicates understanding by saying ?
A. There is a test for AD that can establish a reliable dx
B. The goal of med therapy is to reverse the degenerative changes
C. Early manifestations of AD include mild tremors and muscular rigidity
D. The drugs used to treat AD can help delay cognitive changes
A
D. The drugs used to treat AD can help delay cognitive changes
25
Q
Client with retinal detachment. Which of the following reports is expected?A. PhotophobiaB. Complete blindnessC. Flashes of bright lightD. Pain
A
C. Flashes of bright light
26
Q
Client in ED reports sudden, severe eye pain with blurred vision. The provider determines that the client was primary angle-closure glaucoma. Which meds should be administered?A. Osmotic diuretics via IV bolusB. Mydriatic opthalmic dropsC. Corticosteroid opthalmic dropsD. Epinephrine via IV bolus
A
A. Osmotic diuretics via IV bolus
27
Q
Client with basilar skull fracture from a fall. Which should the nurse report?
A. Glasgow Coma Scale score of 15
B. Intracranial pressure reading of 15mmHg
C. Ecchymosis at base of skull
D. Clear drainage from nose
A
D. Clear drainage from nose
28
Q
A nurse is assessing a client in the ED with myasthenis gravis. The client reports recent increasing muscle weakness and the nurse suspects that the client is experiencing myasthenic crisis. Which is a priority?A. Administer artificial tearsB. Assist with Tensilon testC. Administer immunosuppressantsD. Assist with plasmapheresis
A
B. Assist with Tensilon test
29
Q
Client has spastic bladder following spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?
A. Encourage the client to use the Valsalva maneuver
B. Administer a diuretic
C. Perform the Crede maneuver
D. Stroke the client’s inner thigh
A
D. Stroke the client’s inner thigh
30
Q
Assessing a client who is quadriplegic secondary to a cervical fracture at C5, nurse notes facial flushing a BP of 220/110. Client reports a throbbing headache and nausea. The nurse should take which action first?A. Administer hydralazine via IV bolusB. Loosen the client's clothingC. Empty the client's bladderD. Elevate the head of the bed
A
D. Elevate the head of the bed
