Final Exam Flashcards
1
Q
Informed consent
A
Nurse is not responsible for obtaining consent but is responsible for witnessing.
Ensure the provider gave the necessary information
Ensure the client understood the information and is competent to give informed consent
Document questions the client has and inform the provider
2
Q
A nurse is caring for a client who is scheduled for surgery. What is the nurse’s role in regard to informed consent?
A
Determine the clients level of understanding
3
Q
Acute appendicitis- signs of perforation
A
Fever, severe abdominal pain and tenderness, vomiting
4
Q
A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?
A. Maintain NPO status.
B. Monitor oral temperature every 4hr
C. Medicate the client for pain every
4hr as needed.
D. Administer sodium biphosphate sodium phosphate.
A
D. Administer sodium biphosphate sodium phosphate.
In a suspected case of appendicitis, administering a bowel preparation could potentially worsen the condition by increasing the risk of perforation if appendicitis is present.
5
Q
Cholecystitis
A
Is an inflammation of the gallbladder wall
Most often caused by gallstones (cholelithiasis)
Can be acute or chronic, and can obstruct the pancreatic duct, causing pancreatitis.
6
Q
When taking a health history for a new patient, which information given by the patient would indicate that screening for hepatitis C is appropriate?
a. The patient had a blood transfusion after surgery in 1998.
b. The patient reports a one-time use of IV drugs 20 years ago.
c. The patient eats frequent meals in fast-food restaurants.
d. The patient recently traveled to an undeveloped country.
A
b. The patient reports a one-time use of IV drugs 20 years ago.
Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.
7
Q
Acute pancreatitis - What would you need to report immediately
A
8
Q
A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?
A. Decreased mucus in stools.
B. Decreased black tarry stools.
C. Decreased watery stools.
D. Decreased fat in stools.
A
D. Decreased fat in stools.
D. Pancrelipase is a combination of pancreatic enzymes used to increase digestion of fats, carbohydrates and proteins. The client should expect a reduction of fat in stools.
9
Q
Nasogastric tube and how to know they were effective
A
Gastric Decompression
Medication Administration
Enteral Feeding
Aspiration Prevention
Confirmation of Placement
10
Q
A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the initial placement of the tube?
A. Obtain an x-ray.
B. Auscultate injected air.
C. Take a pH measurement of gastric aspirate.
D. Identify the color of gastric contents
A
A. Obtain an x-ray.
The nurse should identify that obtaining an x-ray is most effective method to verify initial placement of a nasogastric tube.
11
Q
A nurse is checking the client’s nasogastric tube for placement. Which of the following procedures should the nurse implement?
A. Instill 20 mL of air into the tube and listen for a whooshing sound.
B. Aspirate stomach contents and check the pH.
C. Aspirate stomach contents and check their color.
D. Auscultate lung sounds.
A
B. Aspirate stomach contents and check the pH.
Checking the pH of stomach contents is recommended method for checking tube placement. The pH measurement of gastric aspirate is 4 or less. A pH measurement of gastric aspirate can be used to monitor placement after initial placement has been verified.
12
Q
A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse’s priority?
A) Dietary recommendations
B) Incision Care
C) Coughing and deep-breathing exercises
D) Pain management
A
C) Coughing and deep-breathing exercises
Coughing and deep-breathing exercises
The greatest risk to the client is respiratory compromise.
13
Q
A nurse is assessing a client who is 12hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider?
A) Hypoactive bowel sounds
B) Indwelling catheter output 25mL/hr
C) Heart rate of 96/min
D) Serous drainage at the surgical incision site
A
B) Indwelling catheter output 25mL/hr
A lower-than-expected urine output could indicate inadequate fluid intake, decreased renal perfusion, or other factors affecting renal function. In the postoperative period, maintaining adequate urine output is essential for monitoring renal function, ensuring proper hydration, and preventing complications such as acute kidney injury.
14
Q
H2RBs - therapeutic use
A
Ex: Cimetidine
Used to treat GERD and ulcers
- works by reducing the amount of stomach acid secreted by the glands in the stomach
15
Q
A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?
- Relief of heartburn
- Cessation of diarrhea
- Passage of flatus
- Absence of constipation
A
- Relief of heartburn
H2RAs are used to treat duodenal ulcers and prevent their return. In over-the-counter strengths, these medications, such as cimetidine and famotidine, are used to relieve or prevent heartburn, acid indigestion, and sour stomach.
16
Q
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client
for which of the following alterations as indications that the client has an infection?
(Select all that apply.)
A. Bradycardia
B. An increase in neutrophils
C. An increase in RBCs
D. An increase in platelets
E. Localized edema
A
B. An increase in neutrophils
E. Localized edema
An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms.
Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.
17
Q
A client is diagnosed with peptic ulcer disease and asks the nurse about the common risk factors for this condition. Which of the following responses should the nurse provide?
A. “Risk factors for peptic ulcer disease include a diet high in fiber and low in fat.”
B. “Smoking and alcohol consumption are not associated with an increased risk of peptic ulcer disease.”
C. “The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are common risk factors for peptic ulcer disease.”
D. “Peptic ulcer disease is primarily caused by stress and emotional factors.”
A
C. “The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are common risk factors for peptic ulcer disease.”
This statement is correct. The use of NSAIDs, such as aspirin and ibuprofen, and Helicobacter pylori infection are well-established risk factors for peptic ulcer disease.
18
Q
Risk factors for PUD
A
H. pylori NSAID & corticosteroid use
Severe stress
Familial tendency
Hypersecretory states
Gastrin-secreting benign or malignant tumors of the pancreas
Type O blood
Excess alcohol consumption
Chronic pulmonary or kidney disease
Zollinger-Ellison syndrome, pernicious anemia
19
Q
What are the risk factors associated with peptic ulcer disease?
(Select All that Apply.)
A. Family history
B. Blood type A
C. Acetaminophen (Tylenol) intake for pain
D. Smoking tobacco
E. Drinking caffeine
A
A. Family history
D. Smoking tobacco
E. Drinking caffeine
20
Q
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?
a. “Sleep on your left side.”
b. “Drink milk to soothe your stomach.”
c. “Eat four small meals each day.”
d. “Wait to go to bed for 1 hour after eating.”
A
c. “Eat four small meals each day.”
21
Q
Diabetes type 1 what is your priority if there is a mix up with insulin dose
A
Assessment
- Immediately check the patient’s blood glucose level using a glucometer.
- Assess the patient for signs and symptoms of hypo- or hyperglycemia, such as sweating, tremors, confusion, weakness, dizziness, or rapid heartbeat.
22
Q
a nurse is teaching a child who has type 1 DM about self care. which of the following statements by the child indicates understanding of the teaching?
A. I should skip breakfast when I am not hungry
B. I should increase my insulin with exercise
C. I should drink a glass of milk when I am feeling irritable
D. I should draw up the NPH insulin into the syringe before the regular insulin
A
C. I should drink a glass of milk when I am feeling irritable.
An early manifestation of hypoglycemia is irritability. Drinking a glass of milk, which is approximately 15g of carbohydrates, indicates understanding of the teaching.
23
Q
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus.
Which statement made by the client indicates an understanding of the teaching?
A. “A weight reduction program will make me hypoglycemic.”.
B. “Insulin allows me to eat ice cream at bedtime.”.
C. “I give the insulin injections in my abdominal area.”.
D. “I am to take my blood sugar reading after meals.”.
A
C. “I give the insulin injections in my abdominal area.”.
Insulin injections are often given in the abdominal area due to its high vascularity, promoting faster absorption.
24
Q
A nurse is teaching about self-monitoring to a client who has Type 1 DM. Which of the following statement by the client indicates an understanding of the teaching?
A. “ I will check my urine once a day for ketones”
B. “ I will notify my provider if per-meal glucose is 120 mg/dL”
C. “ I will check my blood glucose every 4 hours when I am sick”
D. “ I will check blood glucose every 5 minutes when lightheaded”
A
C. “ I will check my blood glucose every 4 hours when I am sick”
25
Self- monitoring for type 1 diabetes
26
COPD with asthma- assessment findings
27
Angina pectoris– propranolol and hydrochlorothiazede
28
History of comorbidities – which one is important to notify physician
29
A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?
a. take the med on an empty stomach to decrease gastrointestinal irritation
b. take the med with orange juice to enhance absorption
c. take the med with milk
d. rinse the mouth before taking the iron
b. take the med with orange juice to enhance absorption
vitamin C and other fruit juices (except grape juice) enhance the absorption of oral iron supplements in the gastrointestinal tract. Therefore, the clients are encouraged to take the supplements along with such fruit juices.
30
A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.)
A. Assessing the peripheral pulses in the affected extremity
B. Checking the insertion site for hematoma formation
C. Evaluating temperature and color in the affected extremity
D. Assisting the patient to the bathroom after the procedure
E. Assessing vital signs every 8 hours
A. Assessing the peripheral pulses in the affected extremity
B. Checking the insertion site for hematoma formation
C. Evaluating temperature and color in the affected extremity
31
Clinical manifestations for DVT
Limb Pain
- feeling of fullness or heaviness in the legs after standing
Edema, redness, and warmth
Calf tenderness or pain
-May be asymptomatic
32
A nurse is performing a home safety assessment for a client who had a stroke. The nurse notes that the stairs in the client's home are in disrepair and pose a safety risk. The client states, "I cannot afford to have the stairs repaired." Which of the following actions should the nurse take?
A. Refer the client to a social worker.
B. Provide the client with information about the American Red Cross.
C. Ask the client's provider to postpone discharge until the stairs are repaired.
D. Recommend a long-term care facility for the client.
A. Refer the client to a social worker.
Referring the client to a social worker is the best course of action because social workers can help the client explore financial assistance options or community resources to address the issue of the disrepair of the stairs. Social workers are trained to assist clients in accessing various support services, including financial aid programs, grants, or community organizations that may provide assistance for home modifications or repairs.
33
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?
A. A reddened area over the sacrum
B. Stiffness in the lower extremities
C. Difficulty moving the upper extremities
D. Difficulty hearing some types of sounds
A. A reddened area over the sacrum
Complications of immobility, particularly in older adult clients who are unable to move independently, often include pressure ulcers or bedsores, which commonly occur over bony prominences such as the sacrum, heels, and elbows.
34
Hypoglycemia- adverse effects
35
A nurse is reviewing discharge instructions w/ a client who has RA & a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should take my flu vaccine within one week of starting this medication."
B. "I should eat more bananas while taking this medication."
C. "I should take aspirin for minor aches and pains while taking this medication."
D. "I can expect a sore throat for the first week after starting this medication."
I should eat more bananas when taking this medication
36
A nurse is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication?
a-Reduces risk of infection
b-Decreases inflammation
c-Improves peripheral blood flow
d-Increases bone density
b-Decreases inflammation
37
A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?
-Place sandbags to maintain right plantar flexion.
-Position soft pillows against the bottom of the feet.
-Apply a protective boot to the right ankle.
-Splint the right lower extremity to maintain proper alignment.
-Apply a protective boot to the right ankle.
38
A nurse is reviewing the laboratory result of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?
LDL 172 mg/dL
39
A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?
The client will walk for 30 min 5 days a week
40
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. which of the following actions is the nurse's priority?
Position the child side-lying.
This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.
41
1. A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.)
A. Provide privacy.
B. Ease the client to the floor if standing.
C. Move furniture away from the client.
D. Loosen the client's clothing.
E. Protect the client's head with padding.
F. Restrain the client.
A. Provide privacy.
B. Ease the client to the floor if standing.
C. Move furniture away from the client.
D. Loosen the client's clothing.
E. Protect the client's head with padding.
42
A nurse is caring for a client who is experiencing a seizure which of the following action should the nurse take? (Select all that apply)
A. Loosen restrictive clothing.
B. Insert a bike stick into the client's mouth.
C. Place the client into a supine position.
D. Place a pillow under the client's head.
E. Apply restraints.
A. Loosen restrictive clothing.
D. Place a pillow under the client's head.
43
You are assessing a PT with Left sided heart failure. What manifestation should you expect to find?
1. Increased abdominal girth
2. Weak peripheral pulses
3. Jugular venous neck distention
4. Dependent edema
2. Weak peripheral pulses
44
A nurse is assessing a client who is restricted to bedrest for manifestations of right-sided heart failure. Which of the following findings should the nurse expect?
Weak peripheral pulses
Angina
Sacrum edema
Crackles in the lungs
Sacrum edema
45
A nurse is assessing a client who has left-sided heart failure with decreased cardiac output. Which of the following manifestations should the nurse expect?
A. Flushing of the skin on exertion
B. Nocturia at night
C. Warm lower extremities
D. Respiratory rate of 16/min
B. Nocturia at night
This is likely to occur due to the redistribution of fluid when the patient lies down, causing increased urine output at night.
46
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?
A. Evaluating the client for nausea, vomiting, and anorexia
B. Withholding the medication if the heart rate is above 100/min
C. Instructing the client to eat foods that are low in potassium
D. Measuring apical pulse rate for 30
seconds before administration
A. Evaluating the client for nausea, vomiting, and anorexia
(Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity.)
47
A nurse is preparing to administer digoxin to a client who has heart failure.
Before administering this medication, which of the following actions should the nurse take?
A.Check the client's blood pressure.
B. Measure the client's apical pulse.
C. Offer the client a light snack.
D. Weigh the client.
B. Measure the client's apical pulse.
48
A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?
A oral mucosa
B. conjunctivae
C. earlobes
D soles of the feet
Oral Mucosa
49
A nurse is collecting data about the fluid status of four clients.
Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
A. A client who has NPO status since midnight for an endoscopy.
B. A client who has heart failure and is receiving diuretic therapy.
C. A client who has gastroenteritis and is receiving oral fluids.
D. A client who has end-stage kidney disease who will undergo dialysis.
B. A client who has heart failure and is receiving diuretic therapy.
A client who has heart failure and is receiving diuretic therapy is at a high risk for fluid volume deficit. Diuretics are used in heart failure to remove excess fluid from the body, but they can also lead to fluid volume deficit if not properly managed. This is because diuretics increase urine output, which can lead to a loss of fluid and electrolytes.
50
A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?
A. It requires lying quietly on one side."
B. It might cause slight discomfort in the chest area."
C. "It is best to have no food or beverages the day of the test."
D. "It takes about 5 or 10 minutes."
A. It requires lying quietly on one side."
During an echocardiogram, the client is typically asked to lie on their left side to obtain clear images of the heart. The test is non-invasive and involves using ultrasound waves to create images of the heart's structures.
51
Echocardiogram instruction
Inform the patient about the approximate duration of the test, typically between 30 to 60 minutes.
Explain that the patient will need to lie on their back on an examination table. They may also be asked to lie on their side at certain points during the procedure to obtain different views of the heart.
Emphasize the importance of remaining still during the test to obtain clear images of the heart.
52
A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first?
a. how to eliminate environmental triggers that precipitate attacks
b. the client's perception of the disease process and what might have triggered past attacks
c. the client's med regimen
d. manifestations of respiratory infections
b. the client's perception of the disease process and what might have triggered past attacks
53
A nurse is teaching the parents of a school-age child who has asthma about a rescue medication to use during an acute asthma attack. Which of the following medications should the nurse include in the teaching?
Albuterol
54
A nurse is teaching the parents of a child who has asthma about methods to decrease the child's exposure to allergens. Which of the following statements should the nurse include?
"Wet-dust your child's room once per week."
55
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care?
a. Titrate oxygen to keep saturation at least 90%.
b. Discuss a high-protein, high-calorie diet with the patient.
c. Suggest the use of over-the-counter sedative medications.
d. Teach the patient how to effectively use pursed lip breathing.
d. Teach the patient how to effectively use pursed lip breathing.
For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.
56
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?
breathe in through her nose and out through pursed lips
57
COPD- pulmonary spirometers- what questions would you ask
58
The nurse is developing a teaching plan to help increase activity tolerance at home for a 70-year-old client with severe chronic obstructive pulmonary disease (COPD). Which of the following exercise goals should the nurse teach the client?
a. Walk until pulse rate exceeds 130.
b. Walk for a total of 20 minutes daily.
c. Exercise until shortness of breath occurs.
d. Limit exercise to activities of daily living (ADLs).
b. Walk for a total of 20 minutes daily.
The goal for exercise programs for clients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the client should stop. Limiting exercise to ADLs will not improve the client's exercise tolerance. A 70-year-old client should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150).
59
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about exercise. Which of the following information should the nurse include?
a. “Stop exercising if you start to feel short of breath.”
b. “Use the bronchodilator before you start to exercise.”
c. “Breathe in and out through the mouth while you exercise.”
d. “Upper body exercise should be avoided to prevent dyspnea.”
b. “Use the bronchodilator before you start to exercise.”
Use of a bronchodilator before exercise improves airflow for some clients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Clients should be taught to breathe in through the nose and out through the mouth (using a pursed lip technique). Upper-body exercise can improve the mechanics of breathing in clients with COPD.
60
The nurse is admitting a client with chronic obstructive pulmonary disease (COPD) to the hospital. Which of the following positions should the nurse place the client in to improve gas exchange?
a. Resting in bed with the head elevated to 45–60 degrees
b. Sitting up at the bedside in a chair and leaning slightly forward
c. Resting in bed in a high Fowler’s position with the knees flexed
d. In the Trendelenburg position with several pillows behind the head
b. Sitting up at the bedside in a chair and leaning slightly forward
Clients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated would be an alternative position if the client was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the client's ability to ventilate well.
61
A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?
A. Adjust the position of the oxygen tubing.
B. Assess for signs and symptoms of hypoventilation.
C. Change the O2 flow rate to keep SpO2 as prescribed.
D. Choose which O2 delivery device should be used for the client.
A. Adjust the position of the oxygen tubing.
This task primarily involves ensuring the proper placement and comfort of the oxygen tubing, which can be safely delegated to a nursing assistant under the supervision of an RN. It does not involve altering the oxygen flow rate or making clinical judgments about oxygen therapy.
62
Multi drug therapy for TB
Streptomycin sulfate
- high level of toxicity, this med should only be used in clients who have multi drug-resistant TB
- can cause ototoxicity, so monitor hearing function and tolerance
- Report changes in urine output and renal function
**notify the provider if hearing declines**
**drink at least 2L of water**
63
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for chest x-ray?
Have client wear a mask
64
Manifestations of hypokalemia due to hydrochlorothiazide
Muscle weakness and cramps
Tachycardia
Fatigue
Constipation
Polyuria
65
A nurse is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?
a. "Take this med before bedtime"
b. "Monitor for leg cramps"
c. "Avoid grapefruit juice"
d. "Reduce intake of potassium-rich foods"
b. "Monitor for leg cramps"
66
A nurse is teaching to a client who has hypertension and a new prescription for verapamil. which of the following beverages should the nurse tell the client to avoid while taking this medication?
A. Milk.
B. Orange juice.
C. Coffee.
D. Grapefruit juice.
D. Grapefruit juice.
67
*18*. A nurse is reviewing the health history for a client who has angina pectoris and a prescription for Propranolol hydrochloride PO 40mg twice daily. Which of the following findings in the history should the nurse report to the provider?
A. The client has a history of hypothyroidism.
B. The client has a history of bronchial asthma.
C. The client has a history of hypertension.
D. The client has a history of migraine headaches.
B. The client has a history of bronchial asthma.
Propranolol hydrochloride is a beta-blocker medication commonly used to treat conditions like angina pectoris, hypertension, and certain cardiac arrhythmias. However, it's contraindicated in individuals with bronchial asthma due to its potential to exacerbate bronchospasm and respiratory distress.
68
*17* A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for the client?
Increase anteroposterior diameter of the chest
69
A nurse in a provider's office is reviewing the lab results of a client who take furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/dL. The nurse should monitor the client for which of the following?
A. cardiac dysrhythmias
B. hypoglycemia
C. seizures
D. neurogenic shock
A. cardiac dysrhythmias
Potassium is crucial for maintaining the normal rhythm of the heart, and low levels can predispose individuals to cardiac dysrhythmias, including potentially life-threatening arrhythmias.
70
*36* A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make?
1. you might feel a slight tingling while the test is being done.
2. the test will be complete in 30 to 60 minutes.
3. I will need to apply electrodes to your chest and extremities
4. the radioactivity from the dye lasts only a few hours
3. I will need to apply electrodes to your chest and extremities
71
A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?
A. To convert atrial fibrillation to sinus rhythm
B. To dissolve clots in the bloodstream
C. To slow the response of the ventricles to the fast atrial impulses
D. To reduce the risk of stroke in clients who have atrial fibrillation
D. To reduce the risk of stroke in clients who have atrial fibrillation
Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as dabigatran, help prevent thrombus formation. This reduces risk for clots.
72
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
A. Gradual onset of several hours
B. Manifestations preceded by a severe headache
C. Maintains consciousness
D. History of neurologic deficits lasting less than 1 hr
B. Manifestations preceded by a severe headache
A ruptured cerebral aneurysm often presents with a sudden, severe headache, sometimes described as the worst headache of the person's life, which can be followed by other manifestations such as neurological deficits.
73
A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the nurse include in the teaching?
A. Use Echinacea to manage joint pain.
B. Maintain a recommended body weight.
C. Apply ice to the joint before exercising.
D. Reduce the amount of purine in the diet.
Maintain a recommended body weight
74
A nurse is teaching a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?
a. Apply a heat pack at a temperature below your body temperature
b. Elevate the affected joint on large pillows
c. Take acetaminophen as the primary medication to treat the pain
c. Decrease foods high in purines
c. "Take acetaminophen as the primary medication to treat the pain."
75
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
a. Bacteria
b. Diuretics
c. Aging
d. Obesity
e. Smoking
c. Aging
d. Obesity
e. Smoking
76
A nurse is reinforcing dietary teaching about calcium‑rich foods to a client who has osteoporosis. Which of the following foods
should the nurse include in the instructions?
A.White bread
B. White beans
C. White meat of chicken
D. White rice
B. White beans
77
A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions?
A. White Bread
B. Kale
C. Apples
D. Brown rice
B. Kale
78
Calcium rich foods
- Dairy products have the highest calcium content.
- Dark green, leafy vegetables contain high amounts of calcium. ...
- A serving of canned salmon or sardines has about 200 mg of calcium. ...
- Cereal, pasta, breads and other food made with grains may add calcium to the diet.
79
A nurse is caring for a client who is 24 hours postop following a total hip arthroplasty. Which of the following action should the nurse take?
Maintain abduction of the affected extremity
80
A nurse is caring for a client who is 24 hours postop following a total hip arthroplasty. Which of the following action should the nurse take?
Maintain abduction of the affected extremity
81
A nurse is caring for a client who is postoperative following total hip arthroplasty.
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
A.Keep an abduction pillow between the client's legs.
B. Elevate the client's affected leg on a pillow when in bed.
C. Position the client's knees slightly higher than the hips when up in a chair.
D. Raise the head of the client's bed to a high-Fowler's position.
Keep an abduction pillow between the client's legs.
82
A nurse is caring for a client who is postoperative following total hip arthroplasty.
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
A.Keep an abduction pillow between the client's legs.
B. Elevate the client's affected leg on a pillow when in bed.
C. Position the client's knees slightly higher than the hips when up in a chair.
D. Raise the head of the client's bed to a high-Fowler's position.
Keep an abduction pillow between the client's legs.
83
A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation?
A. Encourage the client to lean forward when attempting to stand.
B. Elevate the knees higher than the hips when sitting.
C. Remove the wedge device when turning.
D. Place two bed pillows between the legs when in bed.
D. Place two bed pillows between the legs when in bed.
84
A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation?
A. Encourage the client to lean forward when attempting to stand.
B. Elevate the knees higher than the hips when sitting.
C. Remove the wedge device when turning.
D. Place two bed pillows between the legs when in bed.
D. Place two bed pillows between the legs when in bed.
85
A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which
of the following medications should the nurse plan to administer for DVT prophylaxis?
A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which
of the following medications should the nurse plan to administer for DVT prophylaxis?
A. Enoxaparin subcutaneous
B. Heparin infusion
C. Aspirin PO
D. Warfarin PO
A. Enoxaparin subcutaneous (lovenox)
Enoxaparin is a low molecular heparin that inhibits thrombus and clot formation. Preventive doses of enoxaparin are low and the client does not require monitoring of prothrombin time or activated partial thromboplastin time, making it the preferred treatment for VT prophylaxis following orthopedic
surgery.
86
A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?
Flexing her knees and feet frequently
Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting.
87
A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)
A. BMI of 20
B. Oral contraceptive use
C. Hypertension
D. Smoking
E. Immobility
B. Oral contraceptive use
E. Immobility
Obesity and trauma are other risk factors for DVT
88
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?
A. Stopping the transfusion
B. Covering the client with a blanket
C. Assessing the client's skin for a rash
D. Notifying the provider
A. Stopping the transfusion
89
A nurse is assessing a client who is receiving one unit of packed red blood cells to treat intraoperative blood loss. The client reports chills and back pain and the clients blood pressure is 80/64 mmHg. Which of the following actions should the nurse take first?
A. Inform the provider
B. Stop the infusion of blood
C. Notify the laboratory
D. Obtain a urine specimen
B. Stop the infusion of blood
The client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take it to stop the infusion of blood.
90
A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?
A. Dyspnea
B. Fever
C. Pruritus
D. Bradycardia
A. Dyspnea
Fluid accumulation in the lungs can lead to difficulty breathing or shortness of breath, especially when lying flat or with exertion.
Other indications of fluid overload include: bounding pulse, edema, weight gain, hypertension, coughing or wheezing, and confusion
91
A nurse is preparing to infuse a 250 ml unit of packed RBC's over 2 hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should adjust the flow rate to deliver how many drops per minute? (Round to whole number)
31 gtt/min
92
Oral medication dosage question
93
A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 unit/hr. Available is heparin 25,000 units in 500 ml D5W. The nurse should set the IV pump to deliver how many ml/hr? (round to nearest 10th/whole number)
24 ml/hr
94
Normal RBC levels
Females: 4.2-5.4 x 106 cells/uL
Males: 4.7-6.1 x 106 cells/uL
95
Preparing oral medication
96
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A. A room with air exhaust directly to the outdoor environment
B. A room with another nonsurgical client
C. A room in the ICU
D. A room that is within view of the nurses' station
A. A room with air exhaust directly to the outdoor environment
A room with air exhaust directly to the outdoor environment: This is the correct answer. The preferred room assignment for a client with active tuberculosis is one with proper ventilation that allows air to be exhausted directly to the outdoor environment. Negative pressure rooms with high-efficiency particulate air (HEPA) filtration are often used to minimize the risk of airborne transmission.
97
A nurse is teaching a client who has angina about nitroglycerin sublingual tablets. Which of the following statements should the nurse include in the teaching?
-nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart
98
A is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?
-place the tablet under your tongue, and then take a small sip of water
99
A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching?
-I will dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more
tablets 5 minutes apart while waiting
100
A nurse teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?
-take one tablet at the first indication of chest pain
101
A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min the states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
-administer another nitroglycerin tablet
102
Expected findings of PAD- Peripheral Arterial Disease
Burning
Cramping
Pain in legs during exercise
Numbness or burning pain primarily in the feet when in bed
Pain that is relieved by placing legs at rest in a dependent position
103
A nurse is performing a physical assessment of a client who has Chronic Peripheral arterial disease (PAD). Which of the following is an expected finding?
A.Edema around the client's ankles and feet
B. Ulceration around the client's medial malleoli
C. Scaling eczema of the client's lower legs with stasis dermatitis
D. Pallor on elevation of the client's limbs are dependent
D. Pallor on elevation of the client's limbs are dependent
104
A nurse is performing a physical assessment of a client who has Chronic Peripheral arterial disease (PAD). Which of the following is an expected finding?
A.Edema around the client's ankles and feet
B. Ulceration around the client's medial malleoli
C. Scaling eczema of the client's lower legs with stasis dermatitis
D. Pallor on elevation of the client's limbs are dependent
D. Pallor on elevation of the client's limbs are dependent
Edema around the ankles and feet is an expected finding in venous stasis, not arterial disease. Ulceration around the malleolus is also an expected finding of venous stasis. Scaling eczema is also a finding of venous stasis. In PAD, there is pallor with elevation and rubor when dependent.
105
Which finding is expected in a client with Peripheral arterial disease (PAD)?
Pallor on elevation of the limbs, and rubor when the limbs are dependent
106
Which finding is expected in a client with Peripheral arterial disease (PAD)?
Pallor on elevation of the limbs, and rubor when the limbs are dependent
107
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?
- Thin, pliable toe nails
- Leg pain at rest
- Hairy legs
- Flushed, warm legs
- Leg pain at rest
108
A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?
A. Cabbage
B. Cantaloupe
C. Green beans
D. White beans
A. Cabbage
Cabbage should be limited in the diet when taking warfarin, because it is rich in vitamin K. This is because vitamin K role is blood clotting which contradicts the use of warfarin.
109
A nurse is teaching a client who has a new prescription for allopurinol. Which of the following instructions should the nurse include?
A. Avoid driving or activities that require mental alertness.
B. Avoid crushing the tablets.
C. Limit fluid intake during therapy.
D. Limit potassium while taking allopurinol.
A. Avoid driving or activities that require mental alertness.
Allopurinol can cause drowsiness. The nurse should instruct the client to avoid driving or activities that require mental alertness until they know the effect the drug will have on them.
110
A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the nurse include in the teaching?
Maintain a recommended body weight
111
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
a. "Take the medication between meals."
b. "Take the medication with orange juice.
c. "Take the medication with milk."
d. "Take the medication on an empty stomach."
c. "Take the medication with milk."
This option may be particularly helpful for individuals who experience gastrointestinal irritation when taking medication on an empty stomach. However, it's important to note that this recommendation may vary depending on the individual's specific needs and their healthcare provider's instructions.
112
A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
A. Speak to the client about one idea at a time
B. Ask the client to multi-task.
C. Limit questions to yes and no answers
D. Focus on a single form of communication.
A. Speak to the client about one idea at a time
113
A nurse is caring for a client who has global aphasia following a cerebrovascular accident (CVA). Which of the following actions should the nurse incorporate into the client's care?
A. Provide the client with two-step tasks
B. Request a consult with the speech-language pathologist.
C. Ask questions the client can answer with a simple "yes" or "no."
D. Use a raised voice when speaking to the client.
B. Request a consult with the speech-language pathologist.
The speech-language pathologist can recommend specific communication strategies for a client who has global aphasia. By identifying this need, the nurse is advocating for the client.
114
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
a. Urinary retention
b. Low back pain
c. Incontinence
d. Confusion
d. Confusion
Confusion is a clinical finding of UTis specifically associated with older adult clients.
115
A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?
a. "The procedure will be cancelled if the urinalysis indicates the presence of red blood cells."
b. "High frequency sound waves will be used to identify renal system structures."
c. "You will be able to resume your regular diet as soon as the test is complete."
d. "After the procedure you will be encouraged to drink plenty of fluids."
d. "After the procedure you will be encouraged to drink plenty of fluids."
The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure.
116
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?
a. "I drink at least 2 quarts of fluid every day."
b. "The last time I voided it was painful and red-tinged."
c. "My period ended 2 days ago."
d. "I don't eat shellfish because it gives me hives."
d. "I don't eat shellfish because it gives me hives."
The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.
117
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
a. Notify the provider.
b. Check the tubing for kinks.
c. Adjust the rate of the bladder irrigant.
d. Irrigate the catheter.
b. Check the tubing for kinks.
When providing client care, the nurse should first use the least restrictive intervention; nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage therefore, the nurse should check the catheter tubing for kinks. The from the catheter to prevent clotting, which could occlude the catheter lumen.
118
A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor?
a. COPD
b. Diabetes mellitus
c. anemia
d. Osteoporosis
b. Diabetes mellitus
Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.
119
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections, Which of the following actions shouid the nurse include in the client's plan of care?
a. Cleanse the perineum from back to front.
b. Obtain a prescription for an indwelling urinary catheter.
c. Encourage fluid intake at and between meals.
d. Offer the client the bedpan every 2 hr.
c. Encourage fluid intake at and between meals.
Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital- acquired) UTI is reduced, even for a client who has a spinal cord injury.
120
A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching?
a. "You should limit fluids for 12 hr following the procedure."
b. "You may have pink-tinged urine after this procedure."
c. "You can eat a full liquid meal up to 1 hour before the procedure." d. "You will be placed on your right side during the procedure."
b. "You may have pink-tinged urine after this procedure."
The client might have blood-tinged, or pink, urine after the procedure. The client should report dark red urine because it is an indication of bleeding.
121
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)
A. Report of feeling pressure
b. Tenderness over the symphysis pubis
c. Distended bladder
d. Voiding 30 ml frequently
E. Dysuria
A.
B.
C.
D.
122
The health care provider requests phenazopyridine (Pyridium) for a patient with cystitis. What does the nurse tell the patient about the drug?
a. "It will act as an antibacterial drug."
b. "You need to take the drug on an empty stomach."
c. "Your urine will turn red or orange while on the drug."
d. "This drug will treat your infection, not the symptoms of it."
c. "Your urine will turn red or orange while on the drug."
Phenazopyridine will turn the patient's urine red or orange. Patients should be warned about this effect of the drug because it will be alarming to them if they are not informed, and care should be taken because it will stain undergarments. Phenazopyridine reduces bladder pain and burning by exerting a local analgesic/anesthetic effect on the mucosa of the urinary tract. It does treat the symptoms of bladder infection; it has no antibacterial action. Phenazopyridine should be taken with a meal or immediately after eating.
123
A nurse is completing teaching for a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL). Which of the following statements made by the client indicates understanding of the teaching?
A. "I will be fully awake during the procedure."
B. "Lithotripsy will reduce my chances of having stones in the future."
C. "I will report any bruising that occurs to my doctor."
D. "Straining my urine following the procedure is important."
D. "Straining my urine following the procedure is important."
A client is instructed to strain urine following lithotripsy to verify that the stone has been passed.
124
A nurse is collecting data from a client who is postoperative following extracorporeal shockwave lithotripsy (ESWL). The nurse should identify which of the following findings is the priority?
A) Report of palpitations
B) Pink-tinged urine
C) Bruising on the flank area
D) Stone fragments in the urine
A) Report of palpitations
The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood.
125
Lithotripsy adverse effect
Bruising
126
The teaching for a patient who is taking tamsulosin to reduce urinary obstruction due to benign prostatic hyperplasia will include which of these?
A. Get up slowly from a sitting or lying position.
B. Take the medication with breakfast to promote the maximum effects of the drug.
C. Fluids need to be restricted while on this medication.
D. Blood pressure must be monitored because the medication may cause hypertension.
A. Get up slowly from a sitting or lying position.
Due to postural hypotension
127
A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?
A. Protein in the urine
B Dehydration
C. Iron Deficiency
D. Obesity
B. Dehydration
Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.
128
A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority?
a. monitor intake and output
b. strain the urine
c. administer pain meds
d. administer an antiemetic
C. Administer pain medication
