PREBOARD 5 ASSESSMENT
May 29 & 30, 2021
- A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar
hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider’s prescription?
- Endotracheal intubation
- 100 units of NPH insulin
- Intravenous infusion of normal saline
- Intravenous infusion of sodium bicarbonate
- The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and
ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply.
- Polyuria
- Shakiness
- Palpitations
- Blurred vision
- Lightheadedness
- Fruity breath odor
- A client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report recurrent
episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?
- “I should not exercise since I am taking insulin.”
- “The best time for me to exercise is after breakfast.”
- “The best time for me to exercise is mid- to late afternoon.”
- “NPH is a basal insulin, so I should exercise in the evening.”
- The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client’s nostril.
The nurse should take which initial action?
- Lower the head of the bed.
- Test the drainage for glucose.
- Obtain a culture of the drainage.
- Continue to observe the drainage.
- The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary
hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply.
- Polyuria
- Headache
- Bone pain
- Nervousness
- Weight gain
- The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone
secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions should the nurse anticipate receiving? Select all that apply.
- Initiate an infusion of 3% NaCl.
- Administer intravenous furosemide.
- Restrict fluids to 800 mL over 24 hours.
- Elevate the head of the bed to high-Fowler’s.
- Administer a vasopressin antagonist as prescribed
- A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will
the interprofessional health care team focus on? Select all that apply.
- Hypotension
- Leukocytosis
- Hyperkalemia
- Hypercalcemia
- Hypernatremia
- The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal
hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply.
- Anxiety
- Leukocytosis
- Chvostek’s sign
- Urinary output of 800 mL/hr
- Clear drainage on nasal dripper pad
- The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines
that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.
- Tremors
- Weight loss
- Feeling cold
- Loss of body hair
- Persistent lethargy
- Puffiness of the face
- The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute
pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.
- Maintain NPO (nothing by mouth) status.
- Encourage coughing and deep breathing.
- Give small, frequent high-calorie feedings.
- Maintain the client in a supine and flat position.
- Give hydromorphone intravenously as prescribed for pain.
- Maintain intravenous fluids at 10 mL/hr to keep the vein open.
- The nurse is providing discharge teaching for a client with newly diagnosed Crohn’s disease about dietary
measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?
- “I should increase the fiber in my diet.”
- “I will need to avoid caffeinated beverages.”
- “I’m going to learn some stress reduction techniques.”
- “I can have exacerbations and remissions with Crohn’s disease.”
- The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is
documentation of the presence of asterixis. How should the nurse assess for its presence?
- Dorsiflex the client’s foot.
- Measure the abdominal girth.
- Ask the client to extend the arms.
- Instruct the client to lean forward.
- The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS).
Which statement by the client indicates a need for further teaching?
- “I need to limit my intake of dietary fiber.”
- “I need to drink plenty, at least 8 to 10 cups daily.”
- “I need to eat regular meals and chew my food well.”
- “I will take the prescribed medications because they will regulate my bowel patterns.
- The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings
indicate this occurrence?
- Sweating and pallor
- Bradycardia and indigestion
- Double vision and chest pain
- Abdominal cramping and pain
- The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should
expect to note which finding?
- Slow, deep respirations
- Rapid, deep respirations
- Paradoxical respirations
- Pain, especially with inspiration
- A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive
sign of flail chest?
- Cyanosis
- Hypotension
- Paradoxical chest movement
- Dyspnea, especially on exhalation
- The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for
tuberculosis. Which instructions should the nurse include on the list? Select all that apply.
- Activities should be resumed gradually.
- Avoid contact with other individuals, except family members, for at least 6 months.
- A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
- Respiratory isolation is not necessary, because family members already have been exposed.
- Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
- When 1 sputum culture is negative, the client is no longer considered infectious and usually can
return to former employment.
- The community health nurse is conducting an educational session with community members regarding the
signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select 1608all that apply.
- Dyspnea
- Headache
- Night sweats
- A bloody, productive cough
- A cough with the expectoration of mucoid sputum
- Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and
tuberculosis. The nurse should monitor for which side and adverse effects of rifabutin? Select all that apply.
- Signs of hepatitis
- Flu-like syndrome
- Low neutrophil count
- Vitamin B6 deficiency
- Ocular pain or blurred vision
- Tingling and numbness of the fingers
- The nurse has just administered the first dose of omalizumab to a client. Which statement by the client alerts
the nurse of a life-threatening effect?
- “I have a severe headache.”
- “My feet are quite swollen.”
- “I am nauseated and may vomit.”
- “My lips and tongue are swollen.”
- The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should
assess the client for which associated signs and/or symptoms? Select all that apply.
- Syncope
- Dizziness
- Palpitations
- Hypertension
- Flat neck veins
- The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply.
- Administering oxygen
- Inserting a Foley catheter
- Administering furosemide
- Administering morphine sulfate intravenously
- Transporting the client to the coronary care unit
- Placing the client in a low-Fowler’s side-lying position
- The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client
has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client’s blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning.Which nursing action is the priority?
- Check the serum albumin level.
- Check the urine specific gravity.
- Continue monitoring urine output.
- Call the primary health care provider (PHCP)
- The nurse is monitoring a client with heart failure who is taking digoxin. Which findings are characteristic of
digoxin toxicity? Select all that apply.
- Tremors
- Diarrhea
- Irritability
- Blurred vision
- Nausea and vomiting