Fa 1-5 Ms1 Flashcards
(142 cards)
1
Q
The circulating nurse prepares sterile field in the OR. 15 minutes later, the nurse is informed
that surgery is delayed for 20 minutes because the surgeon is working for another hospital.
What is the best action for the nurse to take?
A
Monitor the sterile field until the surgeon arrives
2
Q
While team effort is needed in the OR for efficient and quality patient care delivery, you
should limit the number of people in the room for infection control. Who comprise this team?
A
surgeon, assistant, scrub nurse, circulating nurse, anesthesiologist
3
Q
While surgery was ongoing, power failure occurred. It took 5 minutes before the hospital
generator could be started. Emergency lights were malfunctioning. Whose responsibility was it
to prepare hand flashlight in the OR?
A
Circu
4
Q
When gathering data to evaluate patient outcomes, the nurse should include the:
A
Patient’s complaint of pain during perioperative period
5
Q
As the nurse is getting the patient ready for surgery, you complete the preoperative checklist.
Which of the following is not part of the preoperative checklist?
A
Conducting the time out
6
Q
Patient is having a minor procedure performed, which type of anesthesia is most likely to be
used?
A
conscious sedation
7
Q
Which of the following is the most dangerous complication during induction of spinal
anesthesia?
A
hypotension
8
Q
Which of the following nursing actions thould be given highest priority when admitting the
patient into the operating room?
A
Patient identification and correct operative consent
9
Q
- To prevent headache after spinal anesthesia the patient should be positioned
A
flat on bed for 6-8 hrs
10
Q
The nurse will provide preoperative teaching on deep breathing, coughing, and turning
exercises. When is the best time to provide preoperative teachings?
A
the afternoon or evening prior to surgery
11
Q
In the RR, the post op client suddenly becomes cyanotic. What is the most appropriate
nursing action?
A
Reposition the head and determine patency of airway
12
Q
A client is scheduled for surgery in the morning. Preoperative orders have been written.
What is the most important to do before surgery?
A
Have all consent forms signed
13
Q
The nurse is caring for a first day postoperative surgical client. Prioritize the
patient’s desired dietary progression. Arrange in sequence the dietary progression from 1 to 4. 1
Full liquid; 2 NPO; 3 Clear liquid; 4 Soft
A
2,3,1,4
14
Q
Which of the following post op findings should the nurse report to the M.D.?
A
Urine output is 20 ml/hr for the past two hours
15
Q
If wound eviscerations occurs, the immediate nursing action is
A
Cover the wound with sterile gauze moistened with sterile NSS
16
Q
Which of the following factors ensure validity of informed written consent, except
A
If the patient is unable to write, the nurse signs the consent tor the patient
17
Q
The nurse is preparing a client for surgery. What is the most effective method for obtaining
an accurate blood pressure reading from the clent?
A
Use a cuff that is wide enough to cover the upper two thirds of the client’s arm
18
Q
Which of the following items on a client’s pre surgery laboratory results would indicate a
need to contact the surgeon?
A
hemoglobin 9.5mg/dl
19
Q
The nurse is preparing the preoperative client for surgery. The following statements that
indicate the client is knowledgeable about his impending surgery, except
A
After surgery, I will need to wear the pneumatic compression device while sitting in the
chair
20
Q
Which of the following assessment data is most important to determine when caring for a
patient who has received spinal anesthesia?
A
The time of return of motion and sensation in the patient’s legs and toes
21
Q
Which of the following drugs is given to relieve nausea and vomiting?
A
plasil
22
Q
The client gave her consent for the surgery. To ensure the legality of the consent the
following conditions must be met EXCEPT
A
Signing should be done after the administration of pre-anesthesia meds
23
Q
Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before
surgery?
A
toprevent aspiration pneumonia
24
Q
The following ensure validity of informed written consent EXCEPT:
A
The consent has been secured within 24 hours before the surgery
25
To prevent complications of immobility, which activities would the nurse plan for the first
postoperative day after a colon resection?
Get the client out of bed and ambulate to a bedside chair
26
The patient had undergone thyroidectomy. Which of the following are the earliest signs of
poor tissue perfusion and poor respiratory function
apprehension and restlessness
27
A post op client receives a dinner tray with gelatin pudding and vanilla ice cream. Based on
the foods on the client’s tray, what would the nurse anticipate the client’s current diet order to be
full liquid diet
28
The best position for kidney, chest, or hip surgery is
lateral
29
A 40 y/o female client has arrived in the post anes room following a cholecystectomy and a
common bile duct exploration. She is semi conscious. Her vs are within normal which of the
following nursing actions would be inappropriate
place her in semi fowler
30
30. A lifeguard drowned during a rescue attempt to a distressed swimmer in the sea. He was
found in a lifeless state and head down floating on water. He was brought to shore and after he
was immediately given resuscitative measures, he was brought to life. What is the ideal IV fluids
that should be administered to this patient once brought to ER?
Normal saline solution
31
Which of the following drugs is administered to minimize respiratory secretions
preoperatively?
atropine sulfate
32
A female client, 23 y/o was admitted for the first time at the Vines Hospital with the chief
complaint of Right liver Pain, accompanied by nausea and vomiting. chills and fever. She was
diagnosed to have acute appendicitis. She was scheduled to have an emergency
appendectomy under spinal anesthesia. Pre-op instructions to the client would include the
following EXCEPT:
reassuring her that narcotics will be given every 4 hours round the clock until she is
discharged
33
Which of the following is most dangerous complication during induction of spinal
anesthesia?
hypotension
34
Which of the following characterizes excitement stage of anesthesia
Extends from the loss of consciousness to the loss of lid reflex, characterized by
struggling and talking
35
Mr. Rivera has a recent history of rectal bleeding. He is being prepared for a colonoscopy.
How should nurse Patricia position the client for this test initially?
Lying on the left side with knees bent
36
Lucinda is a 37-year-old with a history of asthma who is scheduled for an appendectomy
later today. Because of her asthma, you would include as part of her preoperative teaching her
need to perform postoperatively:
coughing and deep breathing exrcises
37
65-year-old Dominic is being transferred into the PACU from the OR. Once there, initial
assessment will focus on:
airway, breathing, circulation, and wound site.
38
Denise is recovering from an open cholecystectomy. You know that because of the location
of the surgery, she has an increased risk of postoperative
respiratory complication
39
Three days after surgery, Mark notices that the wound site is more painful now than it was
the day before. When you inspect the surgical site you are looking for redness or inflanmation.
Other indicators of infection would include:
elevated WBC and temp
40
Which of the following nursing actions would help the patient decrease anxiety during the
preoperative period?
Spending time listening to the patient and answering question
41
Which of the following would be the best indication that the fluid replacement for this patient is
adequate?
a. urine output less than 50 ml/hr
b. systolic bp about 110 mmhg
c. diastolic bp about 90 mmhg
d. urine output more than 30-50 ml/hr
d
42
Nurse is caring for a patient who has massive blood loss after a vehicular accident, upon
assessment patient urine output was approximately 550 ml for 24 hrs. Which of the following
electrolyte imbalance would most likely occur in this patient?
a. hypernatremia
b. hyperkalemia
c. hypercalcemia
d. hypermagnesemia
c
43
Pt has history of COPD and was admitted with the following ABG:pH - 7.32; HCO3 - 28;
PaCO2 - 75. Which ofthe following is the correct interpretation?
partially compensated respiratory acidosis
44
Post op patient who has severe bleeding in the right shoulder due to gun shot was having the
following vital signs: BP: 89/50 PR:136, RR: 30, Temp: 36. The patient has cold clammy skin.
Which position?
flat with legs elevated
45
Ms. D, a 38 year-old sales agent was admitted afler taking excessive laxatives. On initial
assessment her vital signs were: BP85/SO, PR 50/min, RR 9cpm. She had a cardiac arrest,
intubated and was resuscitated. She was placed on cardiac monitor and given fluid
resuscitation. The nurse caring for Ms. D understands that the cause of this condition was due
to which of the following electrolyte imbalance?
hypermagnesemia
46
Nurse Kelly is caring for a patient who is diagnosed with Chronic Renal Failure. What food to
prepare?
low potassium, low protein, low sodium
47
Post op patient with significant amount of blood loss and risk for developing metabolic
acidosis because of possible hypovolemia, what to assess?
hyperventilation
48
Chemotherapy with colon cancer with several days of vomiting, regular pulse, BP 58/48, RR:
14, ABG: 7.46 O2: 95% What intervention?
D5W in normal saline with potassium chloride for 3 minutes at 125 ml/hr
49
A patient suffered from respiratory acidosis disease. In renal compensation of respiratory
acidosis, the kidney will compensate by?
Hydrogen secretion increases and bicarbonate reabsorption increases
50
Lola Gloria is admitted for respiratory tract infection and dehydration. In evaluating lola
gloria, you will check for serum sodium levels as?
135
51
Nico, a student nurse, is caring for a patient with second and third degree burns. Nico knows
that in 24-48 hours, patients will develop hypovolemia. In this case, what is the cause of
hypovolemia?
third spacing or shifting fluids
52
Irritable rather than restless patient, what electrolytes to monitor?
potassium
53
A 28 year old client is admitted with severe bleeding from a fractured femur. Which IV fluid
should the nurse anticipate using to replace potential fluid loss?
normal saline
54
Serum calcium level of 7.4 mg/dL. This level could lead to:
cardiac arrest
55
Maria is caring for a patient with chronic renal failure. On her assessment, she noticed the
patient has oliguria. Which of the following would be prescribed as the treatment for oliguria.
Irrigation of the foley catheter
56
A nurse student is assigned to care for a client with a diagnosis of acute renal failure,
diuretic phase. The nursing instructor asks the student about the primary goal of treatment plan
for this client. Which of the following statements, if made by the nursing student, would indicate
an understanding of the treatment plan for this client?
prevent loss of electrolyte
57
A nurse is caring for a client who has lost a significant amount of blood after being stabbed
twice on the right upper abdomen. The nurse understands that which of the following client
measurements will provide the earliest indication of decrease in fluid volume?
blood pressure
58
A nurse is caring for a client who has lost a significant amount of blood after being stabbed
twice on the right upper abdomen. The nurse understands that which of the following client
measurements will provide the earliest indication of decrease in fluid volume?
hypokalemia
59
After surgery, a patient was brought back to his room with an indwelling catheter in place.
Your priority nursing intervention for care of the indwelling catheter would be?
Ensure that the catheter is draining freely
60
The nurse is caring for a client with chronic renal failure. Knowing that the client is a
candidate for development of hypermagnesemia, for which of the following signs and symptoms
should the nurse closely monitor the client?
lethargy
61
Nurse Kevin is giving health teachings to his dehydrated patient about the importance of
increasing fluid intake. He explains that urine tends to be darker and has higher specific gravity
when a person does not consume enough fluids. Which of the following urinalysis findings
would indicate the patient is dehydrated? Select all that apply.
- sp. gravity 1.035
- urine osmolality 195 mOsm/kg
62
Your client is complaining of muscle weakness, very tired all the time and feels dizzy.
He is always irritable and appears to be restless.
You are aware that his medication includes Furosemide (Lasix). Which of the following
electrolytes would you monitor?
Potassium
63
The nurse is caring for a client with multiple renal calculi. Which nursing interventions
Should be included in the plan of care? Select all that apply.
- Administer analgesics at regularly scheduled intervals
- Encourage fluid intake of up to 3 L/day
64
At 6:00 a.m. the nurse from the graveyard shift endorsed a patient who had an IVF of 5%
dextrose in 0.9% sodium chloride IL at the level of 900mL.
During initial rounds at 6:45 a.m. the client complained to the incoming nurse that he's having
severe headache. Upon assessment, the patient appeared dyspneic, experiencing chills, and
apprehensive, with bounding pulse and an increased pulse rate. The intravenous (IV) bag is
now at 400 mL. remaining. Which of the following nursing actions should the nurse do first?
slow the IV infusion
65
Nurse Ely is caring for a patient diagnosed with Chronic Renal Failure. He was asked by the
patient's family about what food to prepare for the patient. Nurse Ely instructs the patient and
family that the most appropriate diet for a patient with CRF is:
Low protein, low potassium, low sodium
66
Nurse Ely is caring for a patient diagnosed with Chronic Renal Failure. He was asked by the
patient's family about what food to prepare for the patient. Nurse Ely instructs the patient and
family that the most appropriate diet for a patient with CRF is:
low protein, low potassium, low sodium
67
25 year-old Grab driver was brought to the hospital ER due to a motorcycle accident. The
Grab driver was bleeding on his upper right arm, and suffered burns on both his legs. His
admitting vital signs were: PR- 142/min, BP-90/50 & is oliguric and also appears to be lethargic.
The admitting physician ordered intravenous fluid to run at fast drip to replace his fluid loss. A
foley catheter was inserted in the ward. The unit nurse immediate Nursing Diagnosis for this
patient should be:
decreased cardiac output
68
client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmo/L) and
creatinine of 4.5 mg/dL (398 mmol/L). What is the priority prescribed intervention?
Administer IV 50% dextrose and regular insulin
69
third year nursing student was brought to the university clinic as she was complaining of
difficulty breathing due to asthma attack. Which nursing intervention is the most appropriate for
the client who is subsequently developing respiratory alkalosis?
encouraging slow, deep breaths
70
Mr. John Smith has a history of COPD and was admitted with the following arterial blood
gas results: pH = 7.32; bicarbonate 28 mEq/L;
partial carbon dioxide 60mmHg.
Respiratory Acidosis Partially Compensated
71
Your client is complaining of muscle weakness, very tired all the time and feels dizzy.
He is always irritable and appears to be restless. You are aware that his medication includes
Furosemide (Lasix). Which of the following electrolytes would you monitor?
potassium
72
The nurse has assessed 4 children. Which finding requires immediate follow up with the
health care provider?
Child who had a surgical repair of hypospadias earlier today with no urinary output in the
past two hours
73
The nurse is conducting a pain assessment on a client with dysuria, which pain description
is most likely associated with pyelonephritis?
Dull flank pain; extending toward the umbilicus
74
34. A nurse is caring for a client after a renal transplant; The client is receiving
immunosuppressant therapy, Including corticosteroids. The nurse would plan to carefully
monitor which of the following laboratory results for this client?
potassium
75
35. A newly hired nurse is reviewing the assessment findings of a patient diagnosed with
nephrotic syndrome: Aler recalling what nephrotic syndrome means, the nurse notes which of
the following manifestations the patient may possibly have? Select all that apply.
-Hypernatremia
- Decreased serum albumin levels
- Generalized edema
76
A tamaraw nurse has just been employed in a hospital working in a medical ward. The first
patient he'll be caring for is a patient with hypokalemia. He received an order to administer KCL.
The nurse whose transcribing orders should clarify.
potassium chloride, 40 mEg IV in 10 mL DSW IV push
77
A student nurse is caring for a patient with hypo-osmolar imbalance secondary to water
intoxication. The patient was an athlete who manifested the following signs and symptoms of
hypo-osmolarity imbalance EXCEPT one.
thirst
78
Nurse Kevin is giving health teachings to his dehydrated patient about importance of
increasing fluid intake. He explains that urine tends to be darker and has higher specific gravity
when a person does not consume enough fluids. Which of the following urinalysis findings
would indicate the patient is dehydrated? Select all that apply.
- Sp. Gravity 1,035
- Urine osmolarity 387 mmol/L
79
You were taking the blood pressure of a patient when you suddenly noticed that his hand
and wrist went into spasm. Which of the following clectrolyte imbalances would you associate
this symptom? Select all that apply.
-
Hypocalcemia
-
hyperphosphatemia
-
hypomagnesemia
80
You are assigned to care for a geriatrie patient named Mrs. R. D. who has stress
continence. The primary goal of nursing care for clients with stress incontinence is to:
Decrease the number of incontinence episodes
81
The client with acute renal failure is recovering and asks the nurse,
"Will my kidneys ever
function normally again?" The nurse's response is based on knowledge that the client's renal
status will most likely:
Continue to improve over a period of weeks
82
43. A 78-year-old client is admitted with fluid volume deficit & urinary tract infection. Aler a
mapid IV infusion of 750mL. NS, the client begins to cough and asks for the head of the bed e
elevated to ease breathing. The nurse assesses the jugular vein distention (JVD) and
decreased respiratory rate. What should the nurse suspect is happening to this client?
Hypervolemia is developing
83
A nurse is performing a respiratory assessment on a client with asthma. The nurse is alert to
a worsening of the dients respiratory status when which of the following occurs?
Noticeably diminished breath sounds
84
A client with bronchitis is given oxygen Inhalation via nasal cannula Which is an indication
that this therapy is effective?
O2Sat of 98%
85
nurse is Interviewing a client with COPD who has respiratory rate of 35 breaths/ minute and
is experiencing extreme dyspnea. Which nursing diagnosis would the nurse identify as a barrier
to collecting data from the client?
Impaired verbal communication related to difficulty of breathing
86
A client in the ICU has been admitted due to chest trauma. The nurse is closely monitoring
him for tension pneumothorax. Which group of manifestations below may indicate the
development of this condition?
Hypotension, tracheal deviation, and dyspnea
87
Michael, a 45-year-old man, has a history of smoking for 20 years. He complained of a
month-long persistent coughing with difficulty breathing and has unexplained weight loss. What
respiratory disease might Michael be at risk for?
emphysema
88
Maria, 60-year-old, is recently experiencing sudden difficulty of breathing, wheezing, and
tightness in her chest niter coming into contact with a known allergen. What is likely happening
to Maria?
asthma attack
89
7. John, a 50-year-old man, is a former smoker who quit smoking 10 years ago. He now
experiences a persistent cough, mucus production and difficulty of breathing especially in the
morning. What condition might John be dealing with?
COPD
90
Which of the following will alert the nurse as an early sign of hypoxia?
Client is frequently turning from side to side
91
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
Applying a dressing over the wound and taping it on three sides
92
A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions.
Which action will be best for the nurse to include in the plan of care?
Offer the patient fluids at frequent intervals.
93
An emergency room nurse is assessing a male client who has sustained a blunt injury to the
chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
diminished breath sounds
94
What distinguishes hypercapnic respiratory failure from hypoxemic respiratory failure?
Low oxygen saturation despite administration of supplemental oxygen
95
A patient was subjected for ABG analysis. Few hours later, the result was forwarded to the
nurses' station, Which of the following ABG analysis reading would alarm the nurse?
pa02 of 89 mmHg
96
A parent of a child with asthma is learning about postural drainage exercises. The nurse
should teach them to perform which action before performing exercise?
administer the child’s bronchodilators
97
Mr. X has the following arterial blood gas values: pH, 752; Pa02, 60 mmHg: PaCO2, 28
mmHg: HCO3-
, 24 Eq/L, 025at 78%. Based upon Mr. X's oxygenation, which of the following
conclusions would be accurate?
Mr. X. is severely hypoxic
98
What clinical indicators should the nurse expect to identify when assessing an individual
with a spontaneous pneumothorax?
shortness of breath
99
A patient presents with chronic abnormal distention of the air spaces beyond the terminal
bronchioles, with the destruction of the walls of the alveoli. Which of the following respiratory
disorders best describe this condition?
emphysema
100
The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD)
deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse
assess first?
Mental confusion
101
In addition to treatment of the underlying cause, which medical intervention should the nurse
anticipate will be included in the management of a client with acute respiratory distress
syndrome (ARDS)?
Positive end expiratory pressure
102
Full compensation of an acid - base imbalance is completed when you noticed which of the
following:
The pH has been normalized, both PaCO, and HCO, are abnormal (one is acidotic, the
other is alkalotic)
103
Which type of surgery is most likely to predispose a patient to postoperative atelectasis,
pneumonia, or respiratory failure?
Upper abdominal surgery on an obese patient with a long history of smoking
104
The electrical activity of the heart is initiated by the:
sinoatrial node
105
A thorough physical assessment, a diagnostic exam was scheduled for Mr. Mark
Hernandez prior to admission. Auscultation of the heart sound can reveal:
Heart rate, rhythm, and presence of murmur
106
A 50 yr old female client with atherosclerosis complains of pain in the legs and arms.
She asks the nurse about which factors can cause this. What is the nurse’s best
response?
A combination of platelets and fats accumulate, narrowing arteries, and reducing the
blood flow.
107
A junior nursing student was assessing the vital signs of the patient who weighs 95 kg.
While taking the patient's BP, the BP cuff seems small for the patient. The student knows
that if the sphygmomanometer cuff is too small for the patient, the blood pressure
reading would probably be:
falsely elevated
108
A student nurse who is caring for a patient diagnosed with coronary artery disease is
auscultating the patient’s heart sounds. The student knows that the first heart sound is
generated by:
Closing of atrioventricular valve
109
The nurse understands that the client with pernicious anemia will have which
distinguished laboratory findings:
Intrinsic factor absent
110
Nurse Even is caring for a patient with symptoms of anemia. He knows that anemia will
develop if which of the following blood component is decreased:
erythrocytes
111
A 60 yr old male client comes into the ER department with complaints of severe rushing,
chest pain that radiates to shoulder and left arm. The admitting diagnosis is Acute
Myocardial Infarction. Immediate admission orders include: Oxygen via nasal cannula at
4 L/min, blood work, chest x ray, ECG, and 4 mg morphine given intravenously. The
nurse should first:
administer the morphine
112
A nurse is giving instruction to a patient taking Nitroglycerine. Which of the following is a
common side effect of Nitroglycerine:
headache
113
A nurse is going to give health teachings to a client diagnosed with atherosclerosis. The
nurse recognizes that which of the following is at great risk for developing
atherosclerosis? Select all that apply.
- Father with diabetes mellitus
- Smoking one pack of cigarettes daily
114
11. A client was admitted with iron deficiency anemia and blood-streaked emesis: Which
question is most appropriate for the nurse to ask in determining the extent of the client's
activity intolerance?
- What activities were you able to do 6 months ago compared with the present?"
115
Electrocardiography (ECG) is a diagnostic tool used to evaluate the electrical activity of
the heart. Which of the following ECG results would reveal that there is myocardial
ischemia?
ST segment elevation and inverted T wave
116
A nurse giving health instruction to a patient with coronary artery disease should inform
patient of which of the following risk factors for CAD?
high cholesterol diet
117
14. Nitroglycerin is prescribed as an initial step in treating a client with angina. As a nurse,
you are aware that this drug's principal effects are produced by:
Vasodilation of peripheral vasculature
118
A client with acute myelogenous leukemia is receiving induction phase chemotherapy.
Which assessment information is of most concern?
Serum potassium level of 7.8 mEq/L
119
16. A nurse is assigned to care for a patient with a congestive heart failure. A nurse knows
that when there is incomplete closure of the tricuspid valve, this will result in a backflow
of blood from the
right ventricle to the right atrium
120
You are a student nurse taking care of a client with a diagnosis af angina pectoris and is
prescribed to receive oxygen via nasal cannula at 21/min. The client asks why the
oxygen is necessary. Your best response is?
The pain of angina pectoris occurs because of a decreased oxygen supply to heart
cells.
121
Patient education includes telling someone who takes Nitroglycerine sublingually that he
or she should go quickly to the nearest emergency room if the person has taken
_
tablets) at 5-minutes interval, without relief.
3 or more
122
Which of the following symptoms is most commonly associated with left-sided heart
failure?
crackles
123
Mr. Smith is complaining of pain in his edematous lower extremities. Which statements if
made by Mr. Smith would require further clarification?
I may sleep with my affected leg hanging from the bed.
”
124
A nurse who is interviewing a candidate for Percutaneous Transluminal Coronary
Angioplasty (PTCA) knows that this patient with coronary artery disease has:
- at least 70% occlusion of a major coronary artery
125
Nurse Juliet is attending to a client who is complaining of severe chest pains. Nurse
Juliet knows that the pain of Angina pectoris is primarily produced by:
Narrowing of the coronary arteries
126
Myocardial cell damage can be reflected by high levels of cardiac enzymes. The most
sensitive and reliable indicator of all cardiac enzymes is:
Creatinine Kinase
127
24. The client with chronic peripheral arterial disease and claudication tells the nurse that
burning pain often awakens: him from sleep: What is the nurse's. interpretation of this
change?
The client's disease is worsening
128
A community health nurse is giving health instructions to a client with hypertension.
Which of the following statements made by the client would indicate a need for further
teaching about HPN therapy?
When my BP becomes normal, I will no longer need to take medication.
129
Nurse Evelyn is a new RN and is preparing to administer packed red blood cells
(PRBCs) to a client whose anemia was caused by blood loss after surgery. Which action
if done by nurse Evelyn willineed immediate intervention?
Primes the transfusion set using 5% dextrose in lactated Ringer's solution.
130
A 32-year-old client with a history of sickle cell anemia is admitted to the hospital during
a sickle cell crisis. The physician orders all of these interventions. Which order will you
implement first?
Administer oxygen at an F102 of 100% per non-rebreather mask
131
Which of the following interventions should be the first priority when treating a patient
experiencing chest pain while walking?
Ask patient to sit down
132
The nurse devises a teaching plan for the patient with aplastic anemia. Which of the
following is the most important concept to teach for health maintenance?
- Avoid exposure to others with acute infection
133
1. Colon cancer will undergo colonic surgery. low residue diet, why?
A. To reduce bulk of the feces
B. To prevent post infection
C. To prevent post op hemorrhage
D. To prevent intestinal obstruction
a
134
2. A client suspected with ovarian tumor is scheduled for a pelvic ultrasound. the nurse
provides which pre-procedure instruction to the client?
A. Maintain NPO status before procedure
B. Eat a light breakfast only
C. Instruct client to drink water and hold urine
D. Wear comfortable clothing and shoes for the procedure
C
135
A home healthcare nurse is caring for a client with cancer. The client is complaining
of excruciating pain. The most appropriate nursing assessment for a patient's pain
would include which of the following?
A. Client’s pain rating
B. Nurse impression of the client’s pain
C. Nonverbal cues
D. Pain relief after appropriate nursing intervention
A
136
A nurse is teaching a patient about risk factors associated with colorectal cancer. The
determines that further teaching is necessary when the client states:
A. Inflammatory bowel disease
B. Family history of colon cancer
C. High fiber diet
D. Diet high in fats and carbs
C.
137
A community health nurse of San Nicolas Health Center conducts a health promotion
regarding testicular cancer to community members. The nurse determines that further
information needs to be provided if the community members states that which of the
following is a sign of testicular cancer:
A. Painless testicular swelling
B. Hairy sensation in the scrotum
C. Alopecia
D. Back pain
C.
138
The nurse is reviewing the laboratory results of a client receiving chemotherapy. The
platelet count is 10,000 cells/mm. Based on this laboratory value, the priority nursing
assessment is which of the following?
A. Assess level of consciousness
B. Assess temperature
C. Assess bowel sounds
D. Assess skin turgor
A.
139
7. The client complains of a nodule in the breast that is fixed. Other deviations that
should be reported would include all except:
A. Inverted nipple
B. Peau D’orange
C. Dimpling
D. Evident asymmetry
A
140
8. A nurse interviews a patient diagnosed with cervical cancer. Which of the findings
would the nurse anticipate to find in health history?
A. Irregular menses
B. Dysmenorrhea
C. Weight gain
D. Post coital bleeding
D
141
Joseph who has a history of long term smoking and alcoholism is diagnosed with
Oropharyngeal Cancer. He is admitted into the chemo unit for the initiation of
chemotherapy. Which of the following tests is performed before the infusion of
chemotherapeutic agents?
A. CBC
B. Peripheral Blood Smear
C. Lumbar Puncture
D. Liver Function Test
D
142
Nausea and vomiting are common adverse effects of radiation and chemotherapy.
When should a nurse administer antiemetics?
A. Immediately after nausea begins
B. With the administration of therapy
C. 30 mins before the initiation of therapy
D. When therapy is completed
C
