Situation 1: A 36 year old, female client is admitted to an acute care facility with a diagnosisofcerebrovascularaccident(CVA).Herhistoryrevealsbronchialasthma, exogenousobesity,andirondeficiencyanemia. 1.Fromtheaboveassessment,whichhistoryfindingisariskfactorforCVA? a.irondeficiencyanemia b.

encyanemia b.femalesex c.Brochialasthma d.obesity

2.Whatisaprioritynursingassessmentinthefirst24hoursafteradmissionoftheclient withathromboticstroke? a.Cholesterollevel b.Bowelsounds c.Pupilsizeandpapillaryresponse d.Echocardiogram

3.Aftercompletingtheassessmentoftheclient,nursingdiagnoseswillbedetermined. Whichofthefollowingnursingdiagnosesshouldhavethehighestpriorityforthisclient? a.Alteredthoughtprocesses b.Alteredcerebralperfusion c.Pain d.Impairedbloodflow

4. Thenurseiscreatingaplanofcareforaclientwithastroke.Inordertoreducethe complicationofaDVT,whichofthefollowingshouldbeincludedinthisplanofcare? a.Monitorintakeandoutput b.Applyelasticsupporthoes c.Applywristrestraints d.Measurelegcircumferencedaily

5. The client is experiencing an expressive aphasia, which nursing intervention is most helpfulinpromotingcommunication? a.Usegestureswithoutspeaking b.Writinggesturessotheclient canreadthem c.Speakloudly d.Usingapictureboard

Situation2:Mrs.Smith,44yearsoldisadmittedtothehospitalcomplainingofsevere abdominalpainandextremenauseaandhasvomitedseveraltimes.Adiagnosisof cholecystitisfromcholelithiasiswasmade. 6.Basedonthedata,whichnursingdiagnosiswouldhavethehighestpriorityintervention atthistime? a.Anxietyr/tsevereabdominaldiscomfort b.FluidVolumeDeficitr/tvomiting c.Painr/tgallbladderinflammation d.ImbalancedNutrition:Lessthanbodyrequirementr/tvomiting 7.PhysicalexamfindingsrevealedaseverepainintheRUQwithinspiratoryarrest.Nurse Kayeknows,thatherclientispositiveforwhichofthefollowingsigns?

a.GreyTurnerssign b.McBurneyssign `

c.Cullen'ssign d.Murphyssign

8. Mrs.Smith complained of severe right upper quadrant pain.Which of the following medicationwouldNurseKayeanticipatesadministeringtorelievetheclientspain? a.Meperidine(Demerol) b.Acetaminophenwithcodeine c.Promethazine(Phernergan) d.Morphinesulfate

9.FrequentvomitingputsMrs.Smithatriskofwhichofthefollowingacidbaseimbalance? a.metabolicacidosisandhyperkalemia b.metabolicalkalosisandhyperkalemia c.metabololicacidosisandhypokalemia d.metabolicalkalosisandhypokalemia 10.Followingacholecystectomy,drainagefromtheTtubeforthefirst24hours postoperativewas350cc.Propernursingactioninresponsetothisshouldbeto: a.notifythephysician b.raisethelevelofthedrainagebagtodecreaserateofflow c.increasetheIVflowratetocompensatefortheloss d.continuetoobserveandmeasuredrainage Situation3:A26yearoldfemaleclientwasadmittedtoemergencyunit.Hersymptoms includeburningonurinationandfrequent,urgentvoidingofsmallamountsofurine accompaniedbyfeverandvomitingandmanifestssignsofdehydration.Shewas diagnosedtohavearecurrenceurinary tractinfection(UTI). 11.Whatisthemostcommonbacteriainvolvedincommunityacquiredurinarytract infections(UTIs)? a.E.coli b.S.saprophyticus c.P .mirabilis d.K.pneumonia

12.Afterassessingtheclient,NurseJohnnotifiesthephysicianoftheclientsconditionand thefindingsfromtheassessment.Thephysiciangivesthenursetelephoneorderswhich includesaurineculture.Whichstatementbythenurseiscorrectinregardstoteachinga clienthowtoobtainaurineculture. a.YouwillneedtonotifymeassoonasyoucollectthespecimensothatIcan transportitinatimelymannertothelabfortesting. b.Assoonasyoururinestartstoflow,itshouldbecollectedinthissterilespecimen cup. c.Youwillneedtokeepyourlabiaseparatedwhilevoidingintothespecimencup. d.Youdonotneedtoretractyourforeskinforthisspecimen.Justcleansethetip withthiscleansingsolution.

13.TheclientasksNurseCocohowshecanpreventthereoccurrence.NurseCocoshould teachtheclientto: a.Doucheafterintercourse b.Voidevery3hours c.Obtainaurinalysismonthly d.Wipefrombacktofrontafter voiding

14.Dr.Zunigaprescribesnorfloxacin(Noroxin),400mgP .O.twicedaily,fortheclientwith aurinarytractinfection(UTI).Theclientasksthenursehowlongtocontinuetakingthe drug.ForanuncomplicatedUTI,theusualdurationofnorfloxacintherapyis: a.3to5days b.7to10days c.12to14days d.10to21days

15.NurseGeraldnotedtheclientwithurinarytractinfectionforsignsofdehydration.The nursedeterminesthattheclienthasreceivedadequatevolumereplacementiftheblood ureanitrogenleveldropsto: a.3mg/dL b.15mg/dL c.29mg/dL d.35mg/dL