Exam 1

Question 1

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

Answer 1

1.030

Question 2

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

Answer 2

Restlessness
Tachypnea
Confusion
Pallor

Question 3

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?

Answer 3

Assist the patient to high fowler’s position

Question 4

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)

Answer 4

Check the position of the cannula frequently

Report any nasal stuffiness, nausea, or fatigue

Post “no smoking” signs in a prominent location

Question 5

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?

Answer 5

hypokalemia

Question 6

Oxygen is a therapeutic gas that treats

Answer 6

hypoxemia

Question 7

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

Answer 7

True

Question 8

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

Answer 8

nasal cannula

partial rebreather

Question 9

Which of the following are manifestations of oxygen toxicity?

Answer 9

substernal pain

Question 10

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

Answer 10

8 hours

Question 11

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

Answer 11

SA node

Question 12

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

Answer 12

does not lead to systemic and pulmonary edema impairing gas exchange

Question 13

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

Answer 13

mitral and aortic

Question 14

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

Answer 14

true

Question 15

What are examples of sensible fluid loss?

Answer 15

skin and lungs

Question 16

Potassium, sodium, and calcium are examples of

Answer 16

cations

Question 17

First symptom of volume loss is

Answer 17

thirst

Question 18

A ph of

Answer 18

Acidosis

Question 19

A pH of >7.45 is considered

Answer 19

alkalosis

Question 20

a pH of 7.4 is considered

Answer 20

normal

Question 21

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?

Answer 21

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

Question 22

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

Answer 22

pneumonia

Question 23

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)

Answer 23

“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.”

Question 24

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

Answer 24

activity level
body size
age

Question 25

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

Answer 25

. Catecholamines

Question 26

Which part of the ECG tracing represents ventricular depolarization?

Answer 26

t wave

Question 27

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

Answer 27

Apply compression devices (sequential compression devices) Turn the patient frequently or encourage frequent position changes promote adequate hydration by encouraging oral intake

Question 28

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)

Answer 28

Cardiac contractile strength is reduced Heart valves become more rigid Peripheral vessels lose elasticity

Question 29

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

Answer 29

true

Question 30

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

Answer 30

Anions, because they carry a negative charge

Question 31

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

Answer 31

active transport

Question 32

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

Answer 32

renal system

Question 33

Where sodium goes ____ goes

Answer 33

water

Question 34

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?

Answer 34

hypervolemia

Question 35

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?

Answer 35

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

Question 36

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

Answer 36

Stop the infusion immediately

Question 37

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

Answer 37

hormone levels fluid intake kidney function

Question 38

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

Answer 38

buffer systems renal mechanisms respiratory mechanisms

Question 39

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

Answer 39

monitor I&O for at least every 8h encourage fluid intake monitor electrolyte lab values

Question 40

Incentive spirometry measures the depth of

Answer 40

inspiration

Question 41

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?

Answer 41

dd and secure 4X4 dressing material and call the surgeon

Question 42

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

Answer 42

A dry electrode will not conduct electrical activity

Question 43

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

Answer 43

leisons

Question 44

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

Answer 44

another RN

Question 45

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

Answer 45

cardiac arrest

Question 46

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

Answer 46

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

Question 47

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

Answer 47

False

Question 48

Cocaine has been linked to

Answer 48

endocarditis aortic dissection dysrhythmias

Question 49

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

Answer 49

Semirecumbent position

Question 50

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

Answer 50

pneumonia

Question 51

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

Answer 51

mouth care

Question 52

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

Answer 52

aneurysm

Question 53

What does ABCDE stand for?

Answer 53

``` 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 ```