Reduction of Risk Potential – Part 3

1. Which of the following conditions may warrant a serum creatinine level?

2. Which of the following is an advantage of working with psychiatric clients in a group setting?

3. A nurse is caring for a client who is having blood tests and who has an elevated lymphocyte level. Based on knowledge of cellular components, the nurse knows that these cells:

4. Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?

5. A client returns from surgery after having a colon resection. The nurse is performing his assessment and notes the wound edges have separated. This condition is called:

6. Mobility is an important human function. The hazards of immobility lead to many physical problems and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin and emotional changes. Which of the following is an example of a skeletal hazard of immobility?

7. Which is a physical, integumentary risk among the elderly population?

8. You are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for because of all three of these factors: the confusion, lethargy and items in the bed?

9. One of the complications of complete bed rest and immobility is which of the following?

10. Plantar flexion can be prevented with ________________.

11. Which of the following people is at highest risk of suicide?

12. Mrs. J is in the adult ICU on a ventilator. The nurse caring for her recognizes that her endotracheal tube needs suctioning. Based on the nurse’s understanding of this procedure, what level of pressure should the nurse apply while suctioning?

13. The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?

14. Which of the following conditions is a contraindication for performing a diagnostic peritoneal lavage?

15. A nurse is preparing to change a client’s dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?

16. A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:

17. A nurse is assisting Mr. L, a client who has a new colostomy after a bowel resection. The nurse is teaching this client how to care for his colostomy bag. Which of the following statements from Mr. L indicates the need for more education?

18. Which of the following clients is most appropriate for receiving telemetry?

19. Mr. B is recovering from a surgical procedure that was performed four days ago. The nurse’s assessment finds this client coughing up rust-colored sputum; his respiratory rate is 28/minute with expiratory grunting, and his lung sounds have coarse crackles on auscultation. Which of the following conditions is the most likely cause of these symptoms?

20. Your patient has been confused for years. Your patient can be best described as a patient with a chronic ___________ disorder.

21. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions are appropriate when caring for this access site?

22. A nurse is instructing a client in the use of his incentive spirometer. Which of the following statements from the nurse indicates correct teaching about using this device?

23. Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?

24. Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?

25. A nurse is assisting with a physical exam for a client who presents with possible meningitis. The nurse bends the client’s leg at the hip to a 90-degree angle. When she extends the leg at the knee, the client experiences severe pain. Which type of test is this nurse performing?

26. Which of the following types of dressing changes works as a form of wound debridement?

27. A nurse is caring for a client who was recently diagnosed with breast cancer. The oncologist uses the TNM staging system to classify this case as T2, N2, M0. The nurse understands that TNM stands for:

28. Mr. V is receiving treatment for a spinal cord injury after falling off of his deck at home. He has undergone spinal surgery, and has been placed in a halo traction device. Which of the following nursing interventions are most appropriate for a client with a spinal cord injury?