Exit 1 Flashcards
(40 cards)
- Which individual is at greatest risk for developing hypertension?
A. 45-year-old African American attorney
B. 60-year-old Asian American shop owner
C. 40-year-old Caucasian nurse
D. 55-year-old Hispanic teacher
A: 45-year-old African American attorney
The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.
- A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?
A. Gastric lavage PRN
B. Acetylcysteine (Mucomyst) for age per pharmacy
C. Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
D. Activated charcoal per pharmacy
A: Gastric lavage PRN
Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.
- Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
A. angina at rest
B. thrombus formation
C. dizziness
D. falling blood pressure
B: thrombus formation
Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.
- A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:
A. Maintain fluid and electrolyte balance
B. Control nausea
C. Manage pain
D. Prevent urinary tract infection
C: Manage pain
The immediate goal of therapy is to alleviate the client’s pain.
- What would the nurse expect to see while assessing the growth of children during their school age years?
A. Decreasing amounts of body fat and muscle mass
B. Little change in body appearance from year to year
C. Progressive height increase of 4 inches each year
D. Yearly weight gain of about 5.5 pounds per year
D: Yearly weight gain of about 5.5 pounds per year
School age children gain about 5.5 pounds each year and increase about 2 inches in height.
- At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to
A. go get a blood pressure check within the next 48 to 72 hours
B. check blood pressure again in two (2) months
C. see the healthcare provider immediately
D. visit the health care provider within one (1) week for a BP check
A: go get a blood pressure check within the next 48 to 72 hours
The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However, immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
- The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.
A: A middle-aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago
The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.
- A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
A. Should be taken in the morning
B. May decrease the client’s energy level
C. Must be stored in a dark container
D. Will decrease the client’s heart rate
A: Should be taken in the morning
Thyroid supplement should be taken in the morning to minimize the side effects of insomnia.
- A 3-year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
A. Prepare the child for X-ray of upper airways
B. Examine the child’s throat
C. Collect a sputum specimen
D. Notify the healthcare provider of the child’s status
D: Notify the health care provider of the child’s status
These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.
- In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation?
A. Polyphagia
B. Dehydration
C. Bedwetting
D. Weight loss
C: Bedwetting
In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bedwetting in a school-age child is readily detected by the parents.
- A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
A. Trichomoniasis
B. Chlamydia
C. Staphylococcus
D. Streptococcus
B: Chlamydia
Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
- An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A. A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”
B. A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?”
C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pinpoint pupils and a relaxed respiratory rate of 10.
D. An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room.
C: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.
- When teaching a client with coronary artery disease about nutrition, the nurse should emphasize
A. Eating three (3) balanced meals a day
B. Adding complex carbohydrates
C. Avoiding very heavy meals
D. Limiting sodium to 7 gms per day
C: Avoiding very heavy meals
Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.
- Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working?
A. The client complains of discomfort at the IV insertion site
B. The client states “I just can’t get relief from my pain.”
C. The level of drug is 100 ml at 8 AM and is 80 ml at noon
D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
C: The level of drug is 100 mL at 8 AM and is 80 mL at noon
The minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container.
- The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?
A. Electrical energy fields
B. Spinal column manipulation
C. Mind-body balance
D. Exercise of joints
B: Spinal column manipulation
The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.
- The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?
A. Decrease in level of consciousness
B. Loss of bladder control
C. Altered sensation to stimuli
D. Emotional ability
A: Decrease in level of consciousness
A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
- A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?
A. Positive sweat test
B. Bulky greasy stools
C. Moist, productive cough
D. Meconium ileus
C: Moist, productive cough Option c is a later sign.
Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts, and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
- The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should
A. Place a call to the client’s health care provider for instructions
B. Send him to the emergency room for evaluation
C. Reassure the client’s wife that the symptoms are transient
D. Instruct the client’s wife to call the doctor if his symptoms become worse
B: Send him to the emergency room for evaluation
This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.
- Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?
A. Client must be NPO before the examination
B. Enema to be administered prior to the examination
C. Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
D. No special orders are necessary for this examination
D: No special orders are necessary for this examination
No special preparation is necessary for this examination.
- The nurse is giving discharge teaching to a client trseven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?
A. “You need to regain your strength before attempting such exertion.”
B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
C. “Have a glass of wine to relax you, then you can try to have sex.”
D. “If you can maintain an active walking program, you will have less risk.”
B: “When you can climb 2 flights of stairs without problems, it is generally safe.”
There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by healthcare providers.
- A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanels with crying
B. A teenager who got a singed beard while camping
C. An elderly client with complaints of frequent liquid brown colored stools
D. A middle-aged client with intermittent pain behind the right scapula
B: A teenager who got signed beard while camping
This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs have no nerve fibers so the client will not be aware of swelling.
- While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?
A. “I want to protect my child from any falls.”
B. “I will set limits on exploring the house.”
C. “I understand the need to use those new skills.”
D. “I intend to keep control over our child.”
C: “I understand the need to use those new skills.”
Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.
- The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is
A. Verify correct placement of the tube
B. Check that the feeding solution matches the dietary order
C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
D. Ensure that feeding solution is at room temperature
A: Verify correct placement of the tube
Proper placement of the tube prevents aspiration.
- The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
A. Narrowed QRS complex
B. Shortened “PR” interval
C. Tall peaked “T” waves
D. Prominent “U” waves
C: Tall peaked T waves
A tall peaked T wave is a sign of hyperkalemia. The healthcare provider should be notified regarding discontinuing the medication.
