Saunders Module 10 Practice Exam

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• A client with deep vein thrombosis is monitored for pulmonary embolism. Which sign is most commonly associated with a PE?
• For a patient with skeletal traction using a boot or belt traction, which assessment is essential to monitor?
• Which finding is NOT typically associated with intussusception?
• What is the primary defect in diabetic ketoacidosis?
• For a client with Indiana pouch reservoir catheterization, what volume of normal saline is typically used for irrigation to prevent excessive mucus buildup?
• Hypoglycemia in a conscious patient with diabetes: initial management?
• Which of the following is a diagnostic criterion for diabetes mellitus?
• In a patient with an arteriovenous fistula for hemodialysis, how should the nurse assess patency?
• In Basic Life Support, where should you palpate the pulse in an infant?
• A client's serum potassium level is 5.8 mEq/L. What does the nurse interpret this finding to be related to?
• The primary health care provider prescribes intravenous potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication?
• Why is weight-based dosing important in pediatrics for acetaminophen?
• Why is a sterile dressing placed over the gibbus (the spinal defect) in a newborn with meningomyelocele before surgical closure?
• What is the primary function of the renin-angiotensin system?
• In hypovolemic shock, what are typical changes in preload and cardiac output?
• The nurse provides dietary instructions to the mother of a child with celiac disease. Which food should be included in the child's diet?
• A client with Parkinson disease is being taught strategies to overcome bradykinesia. Which instruction should the nurse give?
• For a newborn with spina bifida (meningomyelocele), which item should be placed at the bedside as a priority?
• Which signs indicate disequilibrium syndrome during initial hemodialysis treatment?
• A random plasma glucose level of ≥200 mg/dL with symptoms is diagnostic of diabetes.
• After cataract surgery, which analgesic is recommended to avoid increasing intraocular pressure and to lessen discomfort?
• Which descriptor best characterizes ventricular tachycardia on the ECG?
• What equipment should be kept in the room for a patient receiving an internal radiation therapy?
• Which parameter is used to guide resuscitation goals in initial sepsis management?
• The wife of a client with angina calls to report chest pain; the husband has taken two sublingual nitroglycerin tablets 5 minutes apart with no relief. What should the nurse tell the wife to do?
• In pregnancy, which antibody causes hemolytic disease of the newborn?
• Which of the following is a systemic corticosteroid option in the management of asthma?
• Infants born to mothers with diabetes mellitus are at risk for which neonatal complication?
• Which condition is a contraindication to CPAP/BiPAP?
• The low exhaled volume alarm on a ventilator sounds and the patient is in respiratory distress. What should the nurse do first?
• Which statement about BUN in pregnancy is true?
• What radiographic finding is characteristic of pneumonia?
• When applying a plaster cast to a fractured arm, which step best describes the procedure?
• In mastitis management, which statement is true?
• Definition of anuric kidney failure?
• A client with COPD asks which statement indicates a need for further instruction about positions that alleviate dyspnea.
• Which nutrient supplementation may be needed in the early period after starting a gluten-free diet for celiac disease?
• Which environmental condition should be provided for a client with Graves disease to mitigate symptoms?
• Nitroglycerin is considered in suspected ACS if which condition is met?
• A client with viral hepatitis is being instructed for home care. Which guidance is appropriate?
• APGAR score is calculated based on which five categories?
• What is the normal range for adult white blood cell count?
• Which of the following signs is commonly present in acute decompensated heart failure?
• After stapedectomy, which action should be avoided for 3 weeks to protect the surgical site?
• In initial sepsis resuscitation, how many mL/kg of crystalloids are recommended?
• In an unconscious adult who is not breathing, what action should the nurse perform first?
• In suspected uterine rupture during labor, which manifestation is most concerning and warrants immediate assessment?
• A client with Crohn's disease has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding is expected?
• The nurse is caring for a newborn with hyperbilirubinemia who is being breastfed. Which instruction demonstrates understanding?
• After initiation of an ACE inhibitor, which adverse effect is a key concern and should be monitored?
• Which positioning improves oxygenation in acute respiratory distress?
• For a patient experiencing cardiac arrest, what is the correct initial compression rate for CPR when a pulse check is negative?
• Which signs are typical of pediatric septic shock in early stages?
• The nurse notes ST-segment depression on the ECG monitor. With which serum potassium reading does this correlate?
• If outflow remains inadequate after confirming there are no kinks in a peritoneal dialysis setup, what action should the nurse take next?
• Which parameter is NOT part of the SIRS criteria?
• A neonate born to a mother with diabetes mellitus is monitored most closely for which finding?
• A child with pertussis is being admitted to the pediatric unit. As soon as the child arrives to the unit, what should the nurse do first?
• CPAP or BiPAP is indicated for which conditions?
• Why is local anesthesia generally not used during plaster cast application?
• After plaster cast application, which statement indicates the patient needs additional instruction?
• In a child with new-onset glomerulonephritis, which finding would the nurse expect to note?
• SIRS criteria?
• Which electrolyte imbalance is associated with decreased deep tendon reflexes, polyuria, and muscle weakness?
• In the emergency department, which patient should be assessed first?
• Which client should the nurse see first on the shift assessment?
• Which infection control measure is essential to prevent the spread of influenza and should be performed by healthcare workers?
• Which of the following would NOT be an adequate treatment for hypoglycemia in a child with type 1 diabetes?
• Which action is the nurse's highest priority when caring for a client diagnosed with AIDS?
• During a hypercyanotic episode in an infant with tetralogy of Fallot, what action should be taken immediately?
• An HbA1c of 6.5% or higher is diagnostic for diabetes.
• In a second-trimester case of abruptio placentae, which clinical manifestation would the nurse expect to be documented?
• Which statement indicates a gap in understanding gout management?
• A client with a spinal cord injury is experiencing autonomic dysreflexia. After elevating the head of the bed, which action should the nurse take first?
• Which lab finding suggests dehydration?
• What is the first step in infection control when a patient is suspected of influenza?
• For a patient on warfarin, what is the antidote for warfarin overdose?
• What is a key reason infants of mothers with diabetes mellitus are at risk for respiratory distress syndrome?
• Which ECG change is associated with hypokalemia?
• After stapedectomy, which activity should be avoided to prevent disruption of the surgical site for 2-3 weeks?
• In an unconscious patient with suspected airway obstruction, what is the initial airway management step?
• During CPR with an AED available, what should the responder do next after recognizing cardiac arrest?
• A mother reports that her newborn's umbilical cord site looks red and swollen. What is the appropriate nursing instruction?
• After resection of an abdominal aortic aneurysm, which action helps prevent graft occlusion?
• Which statement best defines mild preeclampsia?
• A vaginal assessment shows the umbilical cord protruding from the vagina. What does the nurse immediately do?
• APGAR score ranges from 0 to what maximum?
• What is the mechanism of action of loop diuretics?
• Hyperkalemia can be caused by which condition?
• A cardiac monitor alarm sounds and a straight line is seen. What is the nurse's immediate action?
• Decerebrate posturing is best described as which pattern?
• In a patient with pH 7.30, PaCO2 48 mmHg, and HCO3- 22 mEq/L, what disturbance is present?
• The nurse is monitoring a client in active labor with contractions that are coordinated but weak. Which assessment finding indicates hypotonic contractions?
• How long should a rescuer check for a pulse before starting chest compressions if a pulse is not easily felt?
• In dehydration, which assessment finding is not typically observed?
• Which statement is true about intravenous potassium chloride administration?
• Which signs best indicate acute decompensated heart failure on clinical assessment?
• In a child with a blunt eye trauma, what is the immediate first aid step?
• A nurse caring for a hospitalized client on peritoneal dialysis notes that outflow is less than inflow on the first exchange. What action should be taken first?
• Which dietary modification is recommended for a stroke patient with dysphagia to reduce aspiration risk?
• During illness, which guidance helps prevent dehydration and ketoacidosis for a client with diabetes?
• What should the nurse advise to control vertigo in Ménière disease?
• After starting an ACE inhibitor, which parameters should be monitored?
• In asthma management, which statement correctly identifies a systemic corticosteroid?
• During initial assessment for rheumatic fever, which question helps determine the development of the disease?
• In a client with mild preeclampsia, which sign indicates improvement in the condition?
• Which practice reflects current CPR guidelines regarding the priority of actions?
• A client with AIDS is assessing for Pneumocystis jiroveci infection. Which sign is the earliest manifestation?
• Distinguish colonization from infection.
• Mechanism of aspirin?
• A client with homonymous hemianopsia after a brain attack is learning compensatory strategies. Which action should the nurse tell the client to do?
• A BUN/Cr ratio greater than 20:1 is most consistent with dehydration.
• During CPR, what should be done after each chest compression to maximize effectiveness?
• In pediatric pneumonia imaging, which pattern is typical?
• What is the typical initial management of sepsis in ED?
• Which PPE is required for contact precautions with MRSA?
• Which predialysis and postdialysis measurements are used to determine dialysis effectiveness?
• Which ABG finding indicates acute respiratory acidosis?
• Which assessment finding indicates improvement in a client with congestive heart failure related to fluid volume overload?
• Why is Homans sign not used to diagnose DVT?
• Which client will the nurse monitor most closely for excessive fluid volume?
• A female client with a sealed radiation implant asks whether she can take a walk around the nursing unit. How should the nurse respond?
• What is the normal platelet range?
• In anaphylaxis, what is the most critical initial action?
• Which of the following are early signs of hypoglycemia?
• Which sequence correctly reflects the recommended order in adult CPR?
• After scleral buckling, which postoperative finding is expected?
• Which statement indicates a need for further instruction regarding skin care during external radiation therapy?
• Which statement demonstrates correct understanding of plaster cast drying after application?
• Which examination is contraindicated when placenta previa is suspected?
• The nurse is reviewing a rhythm strip from a cardiac monitor. Which type of abnormal beat does the nurse recognize?
• Which finding confirms the diagnosis of tuberculosis?
• An alarm on a client's cardiac monitor goes off, and the nurse rushes to the bedside and finds the client unconscious. After noting the following rhythm on the monitor, what should the nurse immediately do?
• A father caring for a child with croup indicates a need for further instruction if he says...
• A client with a leg fracture has skeletal traction; which finding would require contacting the orthopedic specialist?
• Classic signs of bacterial meningitis include which of the following combinations?
• Severe hyperkalemia with ECG changes: common urgent treatments?
• In a child with increased intracranial pressure, decorticate posturing indicates what about neurological status?
• In sepsis, what is the MAP target used in resuscitation?
• Which imaging study is commonly used to evaluate acute decompensated heart failure?
• Which manifestation is most consistent with hypercalcemia due to hyperparathyroidism?
• Which statement best describes the policy on chemical restraints in acute agitation?
• A client with diabetes asks how to prevent diabetic ketoacidosis during illness. What should the nurse tell the client to do?
• A child with new-onset type 1 diabetes mellitus is experiencing a hypoglycemic reaction. What should the nurse immediately give the child?
• In the fourth stage of labor, the uterine fundus is firmly contracted and midline at the level of the umbilicus. The nurse should primarily
• Which electrocardiographic finding is typically seen with hyperkalemia?
• A 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note?
• A nurse is obtaining subjective data from the mother of a child admitted with intussusception. Which finding would the nurse expect the mother to report?
• What is the therapeutic INR range for most patients on warfarin?
• After a stapedectomy, which home care instruction is appropriate?
• In interpreting tuberculin skin test results for a low-risk individual, an induration of 10 mm or more indicates exposure to TB. Which option reflects this interpretation?
• Which statement about vision after scleral buckling is true?
• How does renal impairment affect pharmacokinetics, and what does this require?
• What should be assessed before starting heparin therapy?
• In glomerulonephritis, which electrolyte abnormality is most likely due to reduced filtration?
• For a client with a sealed radiation implant, which restriction is appropriate for visitors?
• Rheumatic fever typically develops after a streptococcal infection lasting how long before onset?
• A patient arrives with a surface eye injury from a foreign body. What should the nurse assess first?
• In a patient with poor oxygenation and respiratory distress, what is the most appropriate nursing action?
• Which electrolyte abnormality is associated with tall peaked T waves on ECG?
• A client has had a transurethral resection of the prostate (TURP). Initially the urine is light cherry colored, but later it becomes bright red with clots and the patient develops a drop in blood pressure. What is the appropriate nursing action?
• Which position is NOT recommended for relieving dyspnea in a client with COPD?
• Which infection-control measure is most appropriate for an immunocompromised patient, such as someone with AIDS?
• Which pain assessment methods are appropriate for critically ill patients?
• In which position should a patient be placed after cataract surgery to prevent edema at the surgical site?
• A client with a below-the-knee amputation is learning about residual limb and prosthesis care. Which statement indicates a need for further instruction?
• The arterial blood gas assessment in respiratory distress is used to evaluate what?
• During a yearly eye examination, the intraocular pressures are Right 12 mm Hg and Left 19 mm Hg. What should the nurse tell the patient?
• A client who has undergone internal cervical radiation implant reports that the implant has fallen out and is lying in the bed. What should the nurse do first?
• In evaluating acute decompensated heart failure, which biomarker is commonly elevated and used in assessment?
• Mastitis is diagnosed in a client who recently gave birth. Which teaching is correct regarding management?
• A client who experienced a brain attack (stroke) exhibits left unilateral neglect. Where should the nurse place the client's personal care items?
• The home care instruction after tonsillectomy is reviewed. The nurse would identify need for further instruction if the parent states to...
• What type of drainage is typically expected on the eye dressing after scleral buckling surgery?
• Regarding dosimeter badges for staff caring for a sealed radiation implant patient, which statement is true?
• To aid communication with a hearing-impaired client, which practice should the nurse instruct the unlicensed assistive personnel to perform?
• Which facial features are typical of fetal alcohol syndrome?
• A patient recovering from radical neck dissection has a sudden drop in blood pressure and an increased pulse. What should the nurse do first?
• During chest pain, a patient with a history of ischemia has an ECG. Which finding is most consistent with ischemia?
• In early goal-directed therapy for sepsis, which lactate-guided steps are included?
• A woman in the third trimester has painless vaginal bleeding and placenta previa is suspected. For which intervention should the nurse prepare the client?
• Which instruction should be included in teaching plan for parents of an infant with a ventricular peritoneal shunt?
• During an oral glucose tolerance test, what is the 2-hour plasma glucose threshold used to diagnose diabetes?
• A brain attack patient has residual dysphagia. Which mealtime modification is most appropriate?
• Live vaccines are contraindicated in pregnancy; name one example.
• What is first-line therapy during a COPD acute exacerbation?
• Which upright position is recommended to improve oxygenation in acute respiratory distress?
• A patient with left-sided heart failure is admitted for cardiac monitoring. Which finding would the nurse most likely observe?
• What PPE is required for airborne isolation?
• Which action should be avoided with an arteriovenous fistula used for hemodialysis?
• A client with Graves disease has a hypermetabolic state. Which intervention belongs in the plan?
• In chronic kidney disease, which electrolyte abnormality is most likely?
• A patient with unilateral neglect should have personal items placed on which side of the tray to promote safety?
• What should be collected and monitored before starting heparin therapy?
• In suspected DVT when Homans sign is unreliable, which imaging modality confirms diagnosis?
• During assessment of a pregnant client with mild preeclampsia, the client reports upset stomach and epigastric pain. What should the nurse do?
• Loop diuretics can cause which electrolyte disturbance?
• Which statement best reveals a misconception about joint exercises for rheumatoid arthritis?
• During cast care, when a wound is present under the cast, what modification is made?
• Which finding would indicate graft occlusion after an abdominal aortic aneurysm repair?
• Differentiate hypovolemic versus septic/distributive shock: key hemodynamic differences?
• The Indiana pouch is created for urine diversion after cystectomy. What should the nurse tell the client about reservoir drainage initially?
• If the umbilical cord is protruding from the vagina, which action is NOT recommended?
• Which position, besides the knee-to-chest posture, may ease pancreatitis pain?
• What is the correct compression-to-ventilation ratio for CPR in adults?
• In Buck extension traction for a leg fracture, which assessment is essential to monitor?
• An adult patient presents with signs suggesting anaphylaxis after suspected drug exposure. After securing a patent airway, what is the first nursing intervention?
• During chest pain in a client with angina, which rhythm on the monitor is most consistent with ventricular tachycardia?
• Which statement indicates a patient needs additional instruction after outpatient cataract removal?
• What immediate therapy is started for suspected acute coronary syndrome (ACS)?
• During CPR on an adult, what is the recommended depth of chest compressions?
• Which finding is not typically observed with hyponatremia?
• Which catheter size is used for Indiana pouch reservoir catheterization?
• A patient receiving external radiation therapy to the neck is most likely to experience which site-specific side effect?
• What methods confirm correct endotracheal tube placement?
• An emergency department nurse is preparing for a burn victim with facial and upper-arm burns. Which action should be performed first?
• During the subacute phase of Kawasaki disease, what requires close monitoring?
• In autonomic dysreflexia, which action should be performed first to identify the triggering stimulus?
• The client with GERD is being taught measures to prevent reflux during sleep. Which statement indicates a need for additional instruction?
• Common adverse effects of anticholinergic medications in older adults?
• Into which position will ease the abdominal pain for a client with acute pancreatitis?
• Which finding is most consistent with left-sided heart failure?
• Which of the following is the most common trigger for autonomic dysreflexia in a spinal cord injury patient?
• Which leukocyte count would meet the SIRS leukocytosis criterion?
• A patient on a ventilator suddenly pulls out the endotracheal tube. After assessing for spontaneous breathing, what should the nurse do next?