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- 1. Open Ended0The nurse notes that a clioent is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client. Select all that apply: 1: Use active listening skills to seek information from the client. 2: Encourage the client to describe the problem as she sees it. 3. Ask the client to tell you exactly what she thinks is happenning. 4. Tell the client that she is delusional and you can help her. 5. Explain to the client that most people are not investigated by the CIA. 6. Reassure the client that you are not with the CIA.
- 2. Open EndedWhich nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply: 1. Position the client directly on the trochanter when side lying. 2. Avoid use of donut type devices. 3. Massage bony prominences. 4. Elevate the HOB no more than 30 degrees when possible. 5. When the client is side lying, use the 30 degree lateral inclined position. 6. Avoid uninterrupted sitting in an chair or wheelchair.
- 3. Open EndedThe nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply: 1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. 2. Determine whether the client has any sudden loss of vision accompanied by pain. 3. Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision. 4. Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes.
- 4. Open EndedA nurse knows the clinical manifestations of a client with Addison's disease include which of the following? Select all that apply: 1. Nausea 2. Hypothermia 3. Hypertension 4. Hyperpigmentation 5. Hypotension 6. Hypernatremia
- 5. Open EndedThe nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. What should be included in the nurse's instructions? Select all that apply: 1. Dressings do not need to be changed frequently because there is minimal drainage. 2. Healing will be facilitated by wearing leg compression devices. 3. When the client is in sitting position, he should keep his legs elevated. 4. Avoid standing for long periods of time. 5. Cool packs can be applied to the ulcers to decrease inflammation. 6. Soak the affected extremity in warm water every evening.
- 6. Open EndedThe nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply: 1. Presence of cardiac pain. 2. Medications taken before hospitalizations. 3. Presence of jugular vein distention. 4. Heart sounds and apical rate. 5. Presence of diaphoresis. 6. History of difficulty breathing.
- 7. Open EndedThe nurse is preparing a client for cardiac catheretization. Which nursing interventions are neccesary in preparing the client for this procedure. Select all that apply: 1. Verify consetn has been signed. 2. Explain procedure to client. 3. Provide clear liquid, no caffiene diet. 4. Evaluate peripheral pulses. 5. Obtain a 12 lead ECG 6. Obtain history of shellfish allergy.
- 8. Open EndedThe nurse is preparing discharge for a patient with GERD. What would be important for the nruse to include in this teaching plan? Select all that apply: 1. Elevate the HOB. 2. Decrease intake of caffiene. 3. Discuss strategies for eight loss if overweight. 4. Increase fluid intake with meals. 5. Take ranitidine (Zantac) at hs. 6. Eat a bedtime snack of milk and protein.
- 9. Open EndedThe nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern ragarding the development of compartment syndrome? Select all that apply: 1. Decrease in pulse rate in affected leg. 2. Paresthesia distal to area of injury. 3. Toes on affected leg cool to touch and edematous. 4. Complaints that pins are hurting. 5. Complaints of leg pain unrelieved by analgesics or repositioning. 6. Client angry and calling loudly to the nurse every ten minutes.
- 10. Open EndedThe nurse understands that the following clinical findings are indications for dialysis. Select all that apply: 1. Volume overload 2. BUN 18 mg/dL 3. K 5.2 mEq/L 4. Decreased creatinine clearance. 5. Metabolic acidosis 6. Cr 5.0 mg/dL
- 11. Open EndedThe nurse is evaluating a client's response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply: 1. Serum potassium level decreases from 5.4 to 4.6 mEq/L 2. Cr decreases from 1.6 to 0.8 mg/dL 3.Hgb increases from 10-12 g/dL 4. WBC increase from 5000 to 8000/mm^3 5. BUN decreases from 110 to 90 mg/dL
- 12. Open EndedA nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply: 1. Warming the dialysate 2. Too rapid instillation 3. Infiltration of the solution into the bloodstream 4. Accumulation of dialysate solution under the diaphragm 5. Too rapid outflow of the dialysate.
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