Exam 2 Practice Exam

Question 1

diarrhea is likely to cause what -lyte issues

Answer 1

potassium

Question 2

older adult just started on beta blocker the nurse should teach what

Answer 2

orthostatic hypo

Question 3

elderly + diuretics = you manage what

Answer 3

volume level

Question 4

intermitten claudication

Answer 4

muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest

Question 5

what to get the patient to eat

Answer 5

Family involvement and home-cooked favorite foods may help the patient to eat

Having visitors at mealtimes may make eating more pleasant and increase the patient’s appetite

Question 6

hypertension target organ getting worse =

Answer 6

vessel damage

Question 7

Arterial insufficiency may result in

Answer 7

gangrene

Question 8

To identify complications or worsening hypertension, the patient is questioned about

Answer 8

target organ relation

Question 9

elderly s/s of gallstones

Answer 9

The elderly patient may not exhibit the typical symptoms of fever, pain, chills jaundice, and nausea and vomiting.

*Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, change in mental status, tachycardia, and tachypnea.

Question 10

fecal occult blood test
- which drug to avoid

Answer 10

NSAIDS

Question 11

how to verify NG placement

Answer 11

There are a variety of methods to check tube placement. The safest way to confirm placement is to utilize a combination of assessment methods.

“Use a combination of at least two accepted methods for confirming placement.”

Question 12

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse’s assessment should be planned in light of the possibility of what potential complications?

Answer 12

pneumonia
metabolic imbalances
atelectasis
- chronic gastritis is not a surgical complication

Question 13

When pulses cannot be reliably palpated

Answer 13

a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels

Question 14

The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient’s warfarin is at therapeutic levels?

Answer 14

International normalized ratio (INR) between 2 and 3

Question 15

Warfarin is also considered to be at therapeutic levels when the client’s PT is

Answer 15

1.5 to 2 times the control.

Question 16

Higher values (INR, PT) indicate increased risk of

Answer 16

bleeding and hemorrhage

Question 17

lower values (INR PT) indicate increased risk of

Answer 17

blood clot formation

Question 18

a falling hematocrit in a client taking warfarin may be a sign of

Answer 18

hemorrhage

Question 19

Prehypertension is defined

Answer 19

systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg.

Question 20

The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications?

Answer 20

Bleeding and perforation

Question 21

ERCP removal of gallstones peritonitis how common

Answer 21

less common

Question 22

UC stools

Answer 22

Watery with blood and mucous

Question 23

A patient’s sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patient’s discharge education?

Answer 23

The patient can resume a normal routine immediately.

Question 24

what do we asses about constipation

Answer 24

activity
food
fluid
fiber

Question 25

A healthy, viable stoma should be

Answer 25

hiny and pink to bright red.

Question 26

The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse’s assessment should include which of the following components? Select all that apply.

Answer 26

Comparison of temperature in the patient’s legs
Bilateral comparison of peripheral pulses
Location and type of pain Identification of mobility limitations

Question 27

The patient with a diagnosis of appendicitis has an acute risk of

Answer 27

infection related to the possibility of rupture

Question 28

A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?

Answer 28

insertion of a NG tube

Question 29

what are not indicated with an bowel obstruction

Answer 29

enemas, suppositories, laxatives

Question 30

Oral cancers are often associated with the use of

Answer 30

alcohol and tobacco, which when used together have a synergistic carcinogenic effect

Question 31

are Diabetes, dentures, dental caries, and GERD risk for oral cancer

Answer 31

no

Question 32

An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins?

Answer 32

Walk for several minutes every hour to promote circulation.

Question 33

varicose veins and crossing legs

Answer 33

contraindicated

Question 34

why not do elevation to help prevent varicose veins

Answer 34

only helps blood passively return to the heart and does not maintain competency of the value sin the vein

Question 35

ankle compression socks and varicose veins

Answer 35

Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.

Question 36

Signs of impending rupture include

Answer 36

severe back or abdominal pain, which may be persistent or intermittent

Question 37

A patient has a nasogastric tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse’s priority during this aspect of the patient’s care?

Answer 37

measure and record drainage

Question 38

why measure and record drainage

Answer 38

This drainage should be measured and recorded because it is a significant indicator of GI function.

Question 39

why not look for color change in NG output

Answer 39

The nurse should indeed monitor the color of the output, but fluid balance is normally the priority

Question 40

Reglan use

Answer 40

promote gastic motility

Question 41

Omeprazole and lansoprozole

Answer 41

PPI

Question 42

Famotidine

Answer 42

H2 receptor antagonists

Question 43

MRI

Answer 43

remove all metal containing objects

Question 44

A patient who had surgery for a bowel obstruction has just returned to the post surgical unit from post anesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician?

Answer 44

rigidity of the abdomen

Question 45

post op bowel surgery, why not be worries about decreased breath sounds

Answer 45

The location of the subcostal incision will likely cause the patient to take shallow breaths to prevent pain, which may result in decreased breath sounds.

Question 46

why should we not be worried about pain in a post op bowel obstruction patient

Answer 46

Acute pain is an expected assessment finding following surgery

Question 47

why should we not be worried about drainage of bile colored fluid onto the abdominal dressing for a post op bowel obstruction patient

Answer 47

Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing

Question 48

pros to a capsule endoscopy

Answer 48

noninvasive

Question 49

do we still need prep for capsule endoscopy

Answer 49

yes

Question 50

A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days. The nurse’s attempts at therapeutic dialogue have been rebuffed. What is the nurse’s most appropriate action?

Answer 50

make appropriate referrals to service that provide psychosocial support

Question 51

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?

Answer 51

small frequent meals

Question 52

laxative long or short term use

Answer 52

avoid long term

Question 53

what commonly occur with nitro

Answer 53

headache and dizziness

Question 54

Complications of PTCA may include

Answer 54

bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery

Question 55

what are important strategies for managing three major CV risk factors (hyperlipidemia, hypertension, diabetes)

Answer 55

Dietary modifications, exercise, weight loss, and careful monitoring

Question 56

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what?

Answer 56

myocardial ischemia

Question 57

what natural body process with decrease myocardial perfusion

Answer 57

increase in HR (coronary arteries are perfused during diastole)

Question 58

Cardiac catheterization is usually used

Answer 58

to assess coronary artery patency to determine if revascularization procedures are necessary.

Question 59

The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patient’s symptoms are due to an MI, what will have happened to the myocardium?

Answer 59

It may have developed an increased area of infarction during the time without treatment.