Exam 1 Flashcards

1
Q

Which urine specific gravity would be expected in a patient admitted with dehydration?

A

1.030

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2
Q

A nurse is assessing a patient who has an acute respiratory infection that puts her at risk for hypoxemia. Which findings are early indicators?

A

Restlessness
Tachypnea
Confusion
Pallor

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3
Q

A nurse is assessing a patient who is having difficulty breathing. The patient is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following intervention is the nurse’s first priority?

A

Assist the patient to high fowler’s position

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4
Q

A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Patient and family teaching by the nurse should include which of the following instruction? (Select all that apply)

A

Check the position of the cannula frequently

Report any nasal stuffiness, nausea, or fatigue

Post “no smoking” signs in a prominent location

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5
Q

A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug?

A

hypokalemia

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6
Q

Oxygen is a therapeutic gas that treats

A

hypoxemia

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7
Q

True or false: Administering and adjusting oxygen levels requires a provider’s prescription

A

True

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8
Q

Which of the following are low-flow oxygen delivery systems?

A

nasal cannula

partial rebreather

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9
Q

Which of the following are manifestations of oxygen toxicity?

A

substernal pain

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10
Q

A nurse if providing tracheostomy care for her patient. In order to prevent infection and skin breakdown the nurse should provide tracheostomy care every

A

8 hours

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11
Q

The heart contains specialized areas of nerve tissue that initiate electrical impulses. Which of the following is considered the “pacemaker”?

A

SA node

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12
Q

You are caring for a patent with heart failure. All of the following statements are true about heart failure except:

A

does not lead to systemic and pulmonary edema impairing gas exchange

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13
Q

The heart valves that are the most commonly affected by structural abnormalities are:

A

mitral and aortic

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14
Q

True or false: anemia has an abnormally low level of red blood cells, hemoglobin,or both

A

true

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15
Q

What are examples of sensible fluid loss?

A

skin and lungs

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16
Q

Potassium, sodium, and calcium are examples of

A

cations

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17
Q

First symptom of volume loss is

A

thirst

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18
Q

A ph of

A

Acidosis

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19
Q

A pH of >7.45 is considered

A

alkalosis

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20
Q

a pH of 7.4 is considered

A

normal

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21
Q

A 63 –year-old man with emphysema says, “My doctor wants me to quit smoking. It’s too late now, though; I already have lung problems.” Which of the following would be the best response to his statement?

A

“Once you stop smoking, your body will begin to repair some of the damage to your lungs.”

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22
Q

Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions?

A

pneumonia

23
Q

The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? (Select all that apply)

A

“Keep healthy snacks or gum available to chew instead of smoking a cigarette.”

“Plan a time to quit when you will not have many other demands or stressors in your life.”

“Reward yourself with an activity you enjoy when you quit smoking.”

24
Q

Which of the following factors influence normal lung volumes and capacities? (Select all that apply)

A

activity level
body size
age

25
Q

Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

A

. Catecholamines

26
Q

Which part of the ECG tracing represents ventricular depolarization?

A

t wave

27
Q

Nursing interventions to reduce the risk of clot formation in the legs include which of the following activities?

A

Apply compression devices (sequential compression devices)

Turn the patient frequently or encourage frequent position changes

promote adequate hydration by encouraging oral intake

28
Q

Your patient is a healthy, older adult who has come to the health clinic because she reports not feeling like herself. When interviewing her she tells you she is feeling more fatigue when walking upstairs and doing her normal activities. What normal physiologic changes in the cardiovascular system occur with aging? (Select all that apply)

A

Cardiac contractile strength is reduced

Heart valves become more rigid

Peripheral vessels lose elasticity

29
Q

Troponin is a serum evaluation of contractile proteins that remain elevated for up to 7 days after a myocardial infarction

A

true

30
Q

Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why?

A

Anions, because they carry a negative charge

31
Q

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

A

active transport

32
Q

Which of the following is the principal site for regulation of fluid and electrolyte balance?

A

renal system

33
Q

Where sodium goes ____ goes

A

water

34
Q

The nurse gathers the following data: BP=150/94Hg; neck veins distended; P-104 beats/min; pulse bounding; respiratory rate=20 breaths/min; T=98.6F. What disorder should the nurse suspect?

A

hypervolemia

35
Q

The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to “shut up and act you age.” How should the nurse respond?

A

Calmly approach the child and tell him what is going to happen

36
Q

The nurse assesses that her patient’s intravenous solution has infiltrated into the tissues. What action should the nurse take first?

A

Stop the infusion immediately

37
Q

In a healthy adult, which of the following regulate(s) body fluids? (Select all that apply)

A

hormone levels
fluid intake
kidney function

38
Q

Identify the mechanism(s) involved in acid-base balance. (Select all that apply)

A

buffer systems

renal mechanisms

respiratory mechanisms

39
Q

Identify the appropriate intervention(s) for a patient with hypovolemia. (Select all that apply)

A

monitor I&O for at least every 8h

encourage fluid intake

monitor electrolyte lab values

40
Q

Incentive spirometry measures the depth of

A

inspiration

41
Q

During the simulation, Rosa DeLuca was 2 days post right hip surgery. Her surgical dressing was 48 hours old and had not been changed and as the nurse you noted red drainage. What is the proper procedure in the care of her wound dressing?

A

dd and secure 4X4 dressing material and call the surgeon

42
Q

When putting electrodes on the chest for an ECG why does the gel on the electrode need to be moist versus dry?

A

A dry electrode will not conduct electrical activity

43
Q

Of the following what contraindicates the placement of ECG leads on the skin of the chest?

A

leisons

44
Q

as a lead clinical RN who can you delegate the task of doing an ECG?

A

another RN

45
Q

Pale, cool, grayish skin; absence of a pulse; apnea; and pupil dilation may be signs of a

A

cardiac arrest

46
Q

All of the following are the steps in providing CPR, which one is not?

A

When giving a breath (30 sec) making the chest rise and fall

47
Q

True/False: the parasympathetic nervous system has no significant control over blood vessels

A

False

48
Q

Cocaine has been linked to

A

endocarditis
aortic dissection
dysrhythmias

49
Q

When caring for a patient who is on a continuous mechanical ventilator the bed should be raised to a level of 30-45 degrees to promote lung expansion, reduce gastric reflux, and prevent ventilator associated pneumonia. This position is called the

A

Semirecumbent position

50
Q

When a patient is on a mechanical ventilator it is extremely important to prevent respiratory aspiration to prevent

A

pneumonia

51
Q

Which procedure of care has been associated with preventing Ventilator-associated pneumonia (VAP)?

A

mouth care

52
Q

A sac-like protrusion from a blood vessel or the heart, resulting from a weakening of the vessel wall or heart muscle is called an

A

aneurysm

53
Q

What does ABCDE stand for?

A
A = asymmetry or shape 
B = Border irregularity 
C = Color variation within on lesion
D = Diameter greater than 6 mm 
E = Evolving or changing in anyway