Title RECALLS 13 - NP4 - KEY ✅

1-5. Situation. Nurse Kim cares for a 40-year-old male with electrolyte imbalance. On assessment, the nurse observes the client to be confused, restless and lethargic. 1. Nurse Kim carries out the order for the client to have a diagnostic test. Which of the following values indicate hyponatremia? A sodium level _____ A. Below 8.5 to 10.5 mg/dL B. Between 3.5 and 5.5 mEgL C. Above 145 mEg/L D. Below 135 mEg/L 2. Nurse Kim is aware that the MOST common electrolyte abnormality in hospitalized patient is ______ A. Hyperkalemia B. Hyponatremia C. Hypernatremia D. Hypokalemia 3. Nurse Kim writes a nursing diagnosis. Which of the following diagnoses is MOST appropriate for the client? A. Excess Fluid Volume B. Ineffective Breathing Pattern C. Deficient Fluid Volume D. Disturbed Thought Processes 4. The physician prescribes intravenous solutions for the client. Which of the following solutions is appropriate? A. 0.9 % Sodium Chloride B. Dextran 6 % in sterile water C. 0.3 % Sodium Chloride D. Dextrose 5 % in water 5. An appropriate nursing intervention for the client is for Nurse Kim to________ A. Maintain body alignment and assist with movement B. Monitor level of consciousness C. Administer oral hygiene D. Monitor laboratory findings 6-10. Situation. The nurse cares for a group of clients with allergies. 6. The nurse assesses the client who says he is highly allergic to many food items and medications. Which of the following hypersensitivity reactions would be responsible for this type of clinical manifestation? A. Type 4, delayed sensitivity B. Type 1, IgE mediated hypersensitivity C. Type 2, cytotoxic hypersensitivity D. Type 3, immune complex-mediated hypersensitivity 7. The nurse assesses an atopic client who had serious Type 1 hypersensitivity reactions. The nurse is aware that the most severe form of a Type 1 hypersensitivity reaction is which of the following conditions? A. Cell-mediated sensitivity B. Dermatitis C. Anaphylaxis D. Bronchial asthma 8. A client is experiencing anaphylaxis. Which of the following actions by the nurse takes HIGHEST priority? A. Administer epinephrine injection B. Place the client in Trendelenburg position C. Maintain an open airway D. Administer emergency oxygen 9. The nurse develops a care plan for a client with a past history of anaphylaxis. Which drug should the nurse instruct the client to always have it readily available to treat possible allergic reaction? A. Diphenhydramine B. Acetaminophen C. Epinephrine D. Acetyl Salicylic Acid 10. A client with a history of Type 1 hypersensitivity reaction is receiving immunotherapy. The nurse administers the allergen injection and asks the client to wait for how many minutes so that the immediate reactions can be treated? A. 5 – 15 minutes B. 30 – 40 minutes C. 60 minutes D. 15 – 25 minutes 11-15. Situation. Nurse Em cares for a 30 year old male who suffered a spinal cord injury sustained in a sporting accident which resulted in paraplegia. The following questions relate to the care of a client with a paraplegia. 11.The client is fortunate that the level of his injury did not affect his respiratory function. The nurse understands that the cord segments involved in maintaining respiratory function are: A. C1-2 B. C3-4 C. C5 D. C6 12. Nurse Em understands that the LEAST effective method of preventing contractures of the joints of the lower extremities would be to: A. Passively move the extremities through range of motion exercises. B. Provide the client with active exercise instructions. C. Maintain proper alignment in bed. D. Change the client’s position every two hours. 13. Nurse Em plans care for the client which includes turning the client every two hours. This nursing measure is necessary to: 1 | Page
A. Improve circulation in the lower extremities. B. Keep the client comfortable. C. Prevent occurrence of pressure sores. D. Prevent flexion contractures in the lower extremities. 14. Nurse Em recognizes that an early major problem of the client with paraplegia is: A. Client education. B. Bladder control. C. Use of mechanical aids for ambulation. D. Quadriceps setting 15. Nurse Em is aware that a complication the client with paraplegia may experience is formation of urinary calculi. The factor that contributes to this condition is: A. High fluid intake B. Increases loss of calcium for the skeletal system. C. Inadequate kidney functioning. D. Increased calcium intake. 16-20. Situation. A 63-year-old male arrives at the Out-Patient Department complaining of numbness and tingling sensation of the lower extremities and pain in the legs upon exercising. The nurse suspects the client may have Peripheral Arterial Disease (PAD). 16. The nurse asks the client the following questions. Which of the questions would determine the risk factors of PAD? 1. “Do you smoke cigarettes?” 2. “Are you diabetic?” 3. “Are you hypertensive?” 4. “Do you exercise?” 5. “Do you drink alcohol?” A. 2, 3, & 4 B. 1, 2, 3, 4, & 5 C. 1, 4, & 5 D. 1, 2, & 3 17. The client asks the nurse what the doctor meant when he heard him say that the client has intermittent claudication. The nurses’ BEST response is, Intermittent claudication is_______ A. Pain that can occur in the body with exercise B. Pain in the leg when exercising C. Pain in the leg that occurs when at rest D. A tingling feeling of sensation in the hands 18. The nurse writes a nursing diagnosis of Ineffective Tissue Perfusion for the client. Which of the following interventions is MOST appropriate for this nursing diagnosis? A. Keep his legs in dependent position B. Elevate his legs C. Take hot bath D. Limit his daily activities. 19. The nurse writes another nursing diagnosis of Risk for Impaired Skin Integrity related to decreased peripheral circulation. Which of the following interventions is MOST appropriate for the nurse to instruct the client? A. Monitor the extremities for color, motion and sensation, and pulses. B. Maintain an appropriate level of activity to promote circulation. C. Avoid risk factors that may increase problems with Peripheral Arterial Disease. D. Protect the legs from injury because the tissues are fragile. 20. Which of the following outcomes indicate that there is increased arterial blood supply to the extremity of the client with peripheral arterial disease? A. Reduced sensation to touch B. Reduced muscle pain C. Increased rubor D. Decreased hair on the extremity 21-25. Situation. Nurse Rose is a newly registered nurse. She is assigned to the surgical unit of X hospital. She is aware of the legal responsibilities when performing patient care. The following are situations she encountered in the surgical unit with legal significance. 21. A patient is scheduled for abdominal surgery. Which of the following statements is a responsibility of Nurse Rose in obtaining a consent form? 1. Ensure that the consent form has been signed and is attached to the chart of the patient before the operation. 2. Witness the signing of the consent before the operation is performed. 3. Provide a detailed description of the operation before asking the patient to sign the consent form 4. Answer questions that the patient may ask before the patient signs the consent form. A. 3 & 4 B. 1, 2 & 3 C. 1, 2 & 4 D. 1 & 3 22. Which of the following health care professionals is legally responsible for obtaining informed consent for an invasive procedure? The ____ A. Surgeon B. Nurse Supervisor of the unit C. Medical director D. Registered nurse on duty 23. Nurse Rose documents her observation on a patient for abdominal surgery. Which of the following statements is legally appropriate notation? A. “The charge nurse spoke with the patient about the surgery” B. “The surgeon committed an error in the medication dose to be given” 2 | Page

C. Loose teeth or dentures. D. Condition of the tonsils. 35. The correct sequence of the primary assessment of trauma clients is ____. 1)Open and inspect the client's airway while initiating or maintaining cervical spine protection. 2)Palpate a central pulse for strength and rate. 3)Conduct a brief neurologic assessment to determine the degree of disability as measured by the client’s level of consciousness. 4)Remove clothing so that all injuries can be quickly identified. 5)Assess for spontaneous breathing. A. 2, 5, 1, 3 & 4 B. 1, 2, 3, 4 & 5 C. 1, 3, 2 & 5 D. 1, 5, 2, 3 & 4 36-40. Situation. A 38 year old female trauma victim is brought to the emergency department of X hospital. 36. The trauma client has a blood type of AB+. Which type of blood will the client need? A. AB- B. AB+ C. Any type D. O+ only 37. Nurse Pau continues to monitor the condition of the trauma client. The client is in hypovolemic shock. Which of the following types of blood products should Nurse Pau prepare? A. Platelets B. Packed red blood cells C. Plasma D. Whole blood 38. Nurse Pau admits the client. What factors will assist the nurse in determining the classification of a trauma client? 1) Site the injury 2) Speed of the vehicle 3) Height of fall 4) Mechanism of injury A. 2 & 4 B. 1, 2, 3, & 4 C. 1 & 3 D. 1, 2 & 4 39. The trauma client manifests a deviated trachea, jugular vein distention, and cyanosis. Nurse Pau realizes that the trauma client is MOST likely demonstrating? A. Tension pneumothorax B. Cervical spine injury C. Blunt trauma to the chest D. Acceleration-deceleration injury 40. The physician assesses the trauma client using the Champion Revised Scoring System. Nurse Pau understands that the elements of this scoring system are which of the following: 1) Diastolic Blood Pressure 2) Systolic Blood Pressure 3) Heart Rate 4) Glasgow Coma Scale 5) Respiratory Rate A. 2, 4 & 5 B. 2, 3, 4 & 5 C. 1, 3 & 5 D. 1, 2, 3, 4 & 5 41-50. Situation. The nurse assists in the care of a 20-year old male client needing blood transfusion. The attending physician writes an order of blood transfusion of 250 cc of packed red cells after blood cross matching. 41. Before infusing the blood, the nurse assesses the client’s ________. A. Vital signs B. Mental state C. Skin color D. Hemoglobin and hematocrit levels 42. The nurse takes the temperature of the client. The temperature registers 390C. Based on this finding, the nurse should: A. Administer an antihistamine and transfuse the blood. B. Start the blood transfusion as ordered. C. Withhold the blood transfusion and notify the physician. D. Give tepid sponge bath and wait for the temperature to go down then transfuse the blood. 43. Which of the following nursing interventions should have the HIGHEST priority when caring for a client receiving blood transfusion? A. Regulate the drops accurately. B. Instruct the client to notify the nurse if the client experiences itchiness, headache or difficulty of breathing. C. Document the blood type, time transfusion started, and vital signs taken. D. Inform the client that the transfusion may last for one and a half to two hours. 44. The nurse administers the blood and starts the transfusion at 20 – 25 drops per minute. The nurse observes for a transfusion reaction which usually occurs during the _____ minutes after transfusion. A. 15 minutes B. 45 minutes C. 5 minutes D. 30 minutes 45. The client receiving blood transfusion begins to wheeze on respiration, itch and observes that his skin becomes flushed with hives. The nurse recognizes these signs as characteristic of what type of reaction? 4 | Page