midterm Flashcards
(164 cards)
1
Q
Which should a nurse who is caring for a hospitalized older client with dementia consider before planning care?
- Physical contact will increase dependency needs.
- Routines provide stability for clients with dementia.
- Regressive behavior should be interrupted immediately.
- Procedures do not have to be explained to clients with dementia.
A
- Routines provide stability for clients with dementia.
2
Q
Which of the following peripheral nerve disorders is being investigated for an association for occurrence after a vaccination, surgical procedure, or stressful event?
a. Bell’s palsy
b. Trigeminal neuralgia
c. Meniere’s disease
d. Guillain-Barre syndrome
A
d
3
Q
You are asked to infuse fluids intravenously at 50ml/hr. The administration set is calibrated at 60 drops/ml. How fast should you set the drop rate? A. 1 drop/min B. 10 drops/min C. 50 drops/min D. 60 drops/min
A
c
4
Q
Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?
A
Respiratory pattern and airway
5
Q
A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, “Why do I need rehabilitation?” How does the nurse respond?
A
“Rehabilitation will help you function at the highest level possible.”
6
Q
A patient is being evaluated for thrombolytic therapy. What are absolute contraindications for this procedure?(sata)
a. Ischemic stroke within 3 months
b. pregnancy
c. Suspected aortic aneurysm
d. major trauma in the last 12 months
e. Intracranial hemorrhage
f. Malignant intracranial neoplasm
A
ACEF
7
Q
A bone marrow biopsy reveals which characteristic finding is associated with Acute Myelogenous Leukemia(AML)?
A
More than 25% lymphoblasts is a confirmation. (ppt slides)
8
Q
The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan?
a. “Cut all calluses and corns from your feet as soon as you notice them.”
b. “Your balance will be steadier if you go barefoot while at home.”
c. “Use a thermometer to check the temperature of bath water.”
d. “Avoid using lotion on the feet and legs.”
A
C
The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet.
9
Q
Meet the client: Ryan Stapleton is a 20-year-old college student attending school term-0in Colorado away from his home in Arizona. He is playing football with some of his friends in the park. He jumps up in the air to catch the football and is tackled by another player. Ryan flips in midair and feels something pop in his neck as he lands hard on the ground. He does not have any pain, but when he tries to get up, he cannot move his legs or arms. Ryan is alert and is talking to his friends. What should Ryan’s friends do while waiting for emergency personnel to arrive? (sata)
A
- Place blanket over Ryan and make sure no one moves him
- Ensure that the scene around Jonathan is safe and that he is not in any immediate danger
10
Q
Which statement regarding deep vein thrombosis (DVT) in the patient with a spinal cord injury is true?
A
11
Q
The nurse is administering IV dexamethasone to a patient with a frontal lobe tumor who reports left upper quadrant pain, nausea and vomiting. Upon assessment, the nurse notes coffee ground emesis and tenderness on palpation. Which provider order would the nurse anticipate?
A
Insert NG tube
12
Q
Damage to upper motor neurons will result in
A
spastic paralysis
Damage to a lower motor neuron would result in flaccid paralysis. Having an accident that cuts through the nerve of the leg would result in flaccid paralysis. Damage to an upper motor neuron would result in spastic paralysis.
13
Q
The nurse is taking the initial history and vital signs on a patient with fatigue. The nurse notes a regular apical pulse of 130 beats/min. Which contributing factors does the nurse assess for? (sata)
a. Anxiety or stress
b. Fever
c. Hypovolemia
d. Anemia or hypoxemia
e. Hypothyroidism
f. Constipation
A
ABCD
14
Q
The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture. Which complication of this injury does the nurse monitor for?
a. is clear and tests negative for glucose
b. is grossly bloody in appearance and has a pH of 6
c. clumps together on the dressing and has a pH of 7
d. separates into concentric rings and tests positive for glucose
A
D
15
Q
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client:
a. A client complaining of muscle aches, a headache, and history of seizures
b. A client who twisted her ankle when rollerblading and is requesting medication for pain
c. A client with a minor laceration on the index finger sustained while cutting an eggplant
d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
A
D
16
Q
A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer?
a. tissue plasminogen activator
b. Heparin sodium
c. Gabapentin (Neurontin)
d. Warfarin (Coumadin)
A
A
17
Q
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client?
A
“You will need to talk to your PHCP before using an herbal substance.”
18
Q
The purpose of a carotid endarterectomy is to:
A
?remove a build-up of fatty deposits (plaque), which cause narrowing of a carotid artery (google)
19
Q
What does the nurse understand that clients with Myasthenia Gravis, Guillain-Barre syndrome, and Amyotrophic Lateral Sclerosis (ALS) share in common?
A
Increased risk for respiratory complications
20
Q
The nurse is planning care for a client who has a spinal cord injury. The _____therapist is the member of the interdisciplinary team that assists the patient with activities of day living.
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager
A
C
21
Q
What should the nurse monitor as an adverse reaction when a client is receiving a platelet aggregation inhibitor such as clopidogrel (Plavix)?
A
Epistaxis
22
Q
Which of the following is the best outcome for stroke management?
A
23
Q
Which are the two priority nursing diagnosis for the person undergoing chemotherapy for leukemia?
A
risk for infection, bleeding ,developing TLS, massive fluid shiting in acidosis, increase uric acid level which can lead to damage to kidney, acidotic
24
Q
After a stroke, a patient has ataxia. What intervention is most appropriate to include on the patient’s plan of care?
A
Ambulate only with a gait belt
25
The Nurse is assessing a patient with Myasthenia Gravis (MG). Which manifestations can the nurse expect to observe? (sata)
a. Ptosis
b. Diplopia
c. Delayed pupillary responses to light
d. Ocular palsies
e. Decreased pupillary accommodation
f. Fatigue
ABDF
26
A 19-year-old is brought to the emergency department with sudden onset of high fever, nuchal rigidity, and vomiting. These signs and symptoms are suggestive of ___
Neisseria meningitidis?
27
Initially after a brain attack (stroke, cerebrovascular accident), a client’s pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. The nurse concludes that these signs are suggestive of:
ICP
28
The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client’s neurologic status?
Immobilize the affected portion of the spinal column.
29
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory findings, the nurse anticipates which MD order?
1. Adding a dose of heparin sodium
2. Holding the next dose of warfarin
3. Increasing the next dose of warfarin
4. Administering the next dose of warfarin
2
30
A patient with a spinal cord injury has omeprazole 25 mg once daily per gastric tube ordered. The omeprazole elixir is supplied in a 20mg per 5 milliliter concentration. How many milliliters would the nurse administer with each dose? (round to the nearest tenth )
6 or 6.25
31
A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client’s understanding. Which statement indicates that the client understands the teaching?
“Even when my seizures stop, I will continue to take this drug."
32
.The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barre syndrome?
a. Nerve impulses are not transmitted to skeletal muscle.
b. The immune system destroys the myelin sheath.
c. The distal nerves degenerate and retract.
d. Antibodies to acetylcholine receptor sites develop.
ANS: B In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract.
33
. A patient with Non-Hodgkin’s lymphoma asks why staging is so important. Which is the accurate response to his question? Staging is completed to:
A. determine if you have favorable histology.
B. establish your short- and long-term prognoses.
C. properly code your disease for statistical purposes.
D. help identify the most effective chemotherapy protocols.
D
34
The most significant observation to be reported when monitoring a patient with increased ICP are:
1. Systolic blood pressure.
2. Urine output.
3. Breath sounds.
4. Cerebral perfusion pressure.
5. Level of pain
1,4
35
A medication that helps chemotherapeutic agents cross the blood-brain barrier is __
Nitrosoureas?- mannitol
| Naicha
36
Which of the following tests does the nurse anticipate will be ordered for a patient to confirm a suspected diagnosis of epilepsy
Electroencephalogram, EEG, and Computed tomography(CT, CAT)
37
Which nursing action is appropriate for the patient in sickle cell crisis?
(from review)
regualr tx- keep them hydrated. prevent acidotic , prevent hypoxic , narcotics(opioid-codeine, oxycodone), oxygen, possibly bicarb if acidotic
(from book)
Oxygen, pain meds, hydration with NS IV and with beverages (no caffeine), remove any constrictive clothing, encourage to keep extremities extended to promote venous return
sickle cell crisis can cause metabolic acidosis- from google
38
The nurse is assessing a client scheduled for a lumbar puncture. Which clinical manifestation assessed by the nurse complicates the lumbar puncture procedure?
Restlessness and agitation
39
The brief sensory experience that occurs prior to the onset of seizure is called __
aura
40
Which is the most common type of facial paralysis?
Bell’s palsy
41
What are the most common symptoms of stroke? (sata)
numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and sudden, severe headache.
42
The spinal cord injured patient starts to develop respiratory distress. What action should the nurse take to keep the airway open without compromising the patient’s spine further?
perform the jaw thrust technique
Avoid moving the head or neck. Provide as much first aid as possible without moving the person's head or neck. If the person shows no signs of circulation (breathing, coughing or movement), begin CPR, but do not tilt the head back to open the airway. Use your fingers to gently grasp the jaw and lift it forward. If the person has no pulse, begin chest compressions.
43
The nurse is caring for a patient who has been in a long-term care facility for several months following an spinal cord injury (SCI). The patient has had issues with urinary retention and subsequent overflow incontinence and a bladder retraining program was recently initiated. Which are expected outcomes of the training program? (sata)
a. Demonstrates a predictable pattern of voiding
b. Is able to independently catheterize himself
c. Pours warm water over perineum to stimulate voiding
d. Takes bethanechol chloride (Urecholine) 1 hour before voiding
e. Is able to empty the bladder completely
f. Does not experience a urinary tract infection
AEF
44
The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client’s score on the Glasgow Coma Scale? (sata)
degree of purposeful movement by the client
appropriateness of the clients verbal responses
stimulus necessary to cause the clients eyes to open
45
A secondary brain tumor:
Metastatic brain cancer?
46
A nurse administers carbidopa-levodopa (Sinemet) to a client with Parkinson disease. Which therapeutic effect does the nurse expect the medication to procedure?
1. The client has cogwheel motion when swinging the arms.
2. The client does not display emotions when discussing the illness.
3. The client is able to walk upright without stumbling.
4. The client eats 30%-40% of meals within 1 hour.
3. The client is able to walk upright without stumbling.
47
A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse’s first action?
Palpate the area over the bladder for distention.
48
When teaching about the pain associated with sickle cell crisis, it is correct to explain that the pain comes from:
A. Occlusion of arteries by sickled cells
B. Decreased oxygen-carrying ability of sickled cells
C. Spasm of the blood vessels from thickened blood
D. Excessive accumulation of sickled cells in the bone marrow
A
49
To interrupt seizure activity in the patient with status epilepticus the patient must receive:
Lorazepam and Diazepam?
50
A patient experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week
C
51
The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications?
Monitor neurologic and vital signs closely to identify early changes in status.
52
When Romberg’s test is used as a diagnostic tool. The nurse is:
53
The nurse has a prescription to administer Dopamine 2mg/kg/hr. The patient weighs 70kg. and the syringe available is 800mg in 50mL. What rate do you run the syringe at (mL/hr)? (round to the nearest hundredth)
54
The doctor’s order says: Vancomycin 2,000mcg IV. The instructions on the vial of Vancomycin says to reconstitute with 15mL of sterile water for a concentration of 2mg/ml and then to dilute each 2 mg in 75 ml of sterile normal saline for administration. How many milliliters should you use to administer the ordered dose?
75 ML
55
The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that client correctly understands the teaching?
I will use my incentive spirometer every 2 hours while I'm awake
56
What should a nurse who is caring for a hospitalized older client with dementia consider before planning care?
1. Physical contact will increase dependency needs.
2. Routines provide stability for clients with dementia.
3. Regressive behavior should be interrupted immediately.
4. Procedures do not have to be explained to clients with dementia.
2
57
The nurse is assessing a patient with Parkinson’s disease. Which cardinal findings does the nurse expect to observe? (sata)
1. Tremors
2. Rigidity
3. Postural Instability
4. Slow movements
1,2,3,4
58
The staff development trainer is preparing orientation materials for new staff hired to care for patients with seizure disorders. Which data are included in this presentation? (sata)
1) Absence
2) Myoclonic
3) Tonic-clonic
4) Simple partial
5) Complex partial
2,3,4
59
A nurse is monitoring the patient’s blood pressure and ECG during a stress test. Which parameter indicates the patient should stop exercising?
a. Increase in heart rate
b. Increase in blood pressure
c. ECG showing the PQRS complex
d. ECG showing ST-segment depression
D
60
The doctor orders 1.5 liters of Lactated Ringers solution to be administered intravenously to your patient over the next 12 hours. Calculate the rate of flow if the IV tubing delivers 20 gtt/mL. (Answer in gtt/min rounded to the nearest whole number).
42 gtt/min (1.5 L x 1000 = 1500 mL; (1500 mL x 20 gtt/mL) ÷ (12 hrs. x 60 min) = 41.66 --> 42 gtt/min)
61
A patient is being treated for heart failure. Fifteen minutes after the oxygen is given via nasal cannula and he has rested the patient denies being short of breath. You obtain an oxygen saturation which is 96%. Based on the results, what do you do next?
Continue the assessment, as 96% is considered acceptable.
62
Doctor's Order: Cleocin Oral Susp 600 mg po qid; Directions for mixing: Add 100 mL of water and shake vigorously. Each 2.5 mL will contain 100 mg of Cleocin. How many tsp of Cleocin will you administer?
3 TSP
63
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
a. 1530 (3:30 PM)
b. 1600 (4:00 PM)
c. 1630 (4:30 PM)
d. 1700 (5:00 PM)
c
64
Discharge teaching for the patient with atrial fibrillation includes:
use a soft bristled toothbrush
65
The home health nurse is making the initial visit to an older adult patient with hypertension. The nurse recommends that the patient obtain which item for home use?
a. Ambulatory blood pressure monitoring device
b. Exercise bicycle
c. Blood glucose monitor scale
d. Food scale
a
66
Patient with hypovolemia is restless and anxious. The skin is cool and pale, pulse is thready at a rate of 135 beats/min. Blood pressure is 92/50 mm Hg. Respirations are 32 respirations/min. What actions does the nurse take? (sata)
a. Obtain a stat order for an IV normal saline bolus.
b. Administer supplemental oxygen.
c. Notify the Rapid Response Team.
d. Place the patient in a semi-Fowler's position.
e. Call a "code blue."
a,b,c
67
he nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe?
a. Excruciating pain
b. Decreased mobility
c. Controllable facial twitching
d. Increased talkativeness
a
68
Following the ED Provider’s assessment of an acute stroke patient, The ED nurse continues to assess the patient every 15 minutes. The patient’s son is sitting by the bedside while the nurse assesses the patient. Which assessment findings warrant immediate intervention by the nurse? (sata)
GCS changes from 12 to 9
positive Babinski's reflex bilaterally
unable to verbalize response to questions
69
The nurse assesses a client who has Guillain-Barre syndrome. Which clinical manifestation does the nurse expect to find in this client?
a. Ophthalmoplegia and diplopia
b. Progressive weakness without sensory involvement
c. Progressive, ascending weakness and paresthesia
d. Weakness of the face, jaw, and sternocleidomastoid muscles
c
70
Packed red blood cells have been prescribed to a female patient with a hemoglobin level of 7.6g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the patient’s temperature before hanging the blood transfusion and records 100.6F (38.1C) orally. Which action should the nurse take?
Delay hanging the blood and notify the primary health care provider (PHCP).
Rationale: If the client has a temperature higher than 100 °F (37.8 °C), the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.
71
The nurse would use which statement to describe to the patient with coronary artery disease (CAD) how fatty streaks are formed?
A. "Damaged arteries allow platelets to form a thrombus."
B. "Damaged arteries allow lipids to be deposited in the intima."
C. "Infections cause bacteria to move inside the artery wall."
D. "Increased cholesterol intake directly causes plaque formation."
b
72
A patient is undergoing a Tensilon test. If the patient has Myasthenia Gravis, the nurse expects the patient to:
Cardiac dysrhythmias
73
A patient is admitted to the hospital following a motor vehicle accident. The patient has an oval-shaped bruise behind the right ear in the mastoid region, a very runny nose, and is unable to move the muscles in the right side of his face. Which skull fracture do these clinical manifestations correspond to?
Basilar skull fracture
Basilar skull fracture is characterized by Battle's sign, rhinorrhea and facial paralysis, in addition to cerebrospinal fluid (CSF) or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, tinnitus or hearing difficulty, conjugate deviation of gaze and/or vertigo.
(HEAD INJURY SHERPATH)
74
A 50-year-old male patient with a family history of coronary artery disease (CAD) presents with mild dyspnea on exertion and occasional chest pain. The patient eats primarily red meat and vegetables, smokes cigars, and is physically inactive. What recommendations from the nurse are appropriate in the management of this high-risk patient?
a. Eat less red meat.
b. Have genetic testing done.
c. Start estrogen therapy.
d. Begin an exercise regimen.
e. Switch to chewing tobacco.
A,D
75
The nurse is caring for a patient with thrombocytopenia. Which order does the nurse question?
a. Test all urine and stool for occult blood.
b. Avoid IM injections.
c. Administer enemas.
d. Apply ice to areas of trauma.
C
76
A new patient with a spinal cord injury at C4 experiences a decrease in blood pressure to 60/44 mm Hg and a drop in heart rate to 48. Which condition would the nurse suspect?
NEUROGENIC SHOCK
77
A patient is diagnosed with anemia related to an iron deficiency. Which patient statement indicates that the appropriate nursing goals are being met?
a. "I will need cobalamin shots for the rest of my life."
b. "I will work hard to eat more foods like spinach and lentils."
c. "My primary health care provider said my folic acid levels are perfect!"
d. "I am able to rest quietly on the couch without experiencing fatigue or a racing heart."
b. "I will work hard to eat more foods like spinach and lentils."
78
A patient with a spinal cord injury has omeprazole 25 mg once daily per gastric tube ordered. The omeprazole elixir is supplied in a 20mg per 5 ml concentration. How many ml would the nurse administer with each dose?
79
patient comes to the emergency department with complaints of chest pain. The initial ECG shows ST-segment elevation in more than three leads. Which intervention should the nurse perform first?
a. Obtain a chest x-ray and complete blood count (CBC).
b. Administer oxygen and nitrates.
c. Establish a peripheral intravenous (IV) line.
d. Ask patient to rate the severity of the pain.
B
A patient with an ST-segment-elevation myocardial infarction (STEMI) requires oxygen to decrease the amount of damage to the myocardium and nitrates to increase coronary blood flow.
80
```
Excessive vagal stimulation can result from which activities? select all that apply
a jogging
b carotid sinus massage
c suctioning
d voiding
e valsalva maneuver
```
B,C,E
81
The student nurse is caring for a patient with encephalitis. Which action by the student nurse warrants intervention by the supervision nurse?
B. Elevates the head of bed to 30 degrees after a lumbar puncture
82
Unstable angina is considered an emergency because of which pathophysiological occurrence?
a. Platelet aggregation blocks the artery.
b. Fatty streaks form a plaque on the arterial wall.
c. Platelet destruction causes myocardial ischemia.
d. Plaques narrow the arterial wall causing infarction.
A
Unstable angina results from a ruptured plaque that causes platelet aggregation, which forms a thrombus. The thrombus can partially block blood flow to the heart resulting in myocardial injury, making this a medical emergency.
83
Which complication may occur if the brain tumor obstructs the ventricles?
Hydrocephalus
| sherpath brain tumors
84
With what will a patient with a cerebellar dysfunction most likely need assistance?
a. Orientation to place and time
b. Buttoning the shirt
c. Verbal communication
d. Mood and pain control
B
85
The nurse is teaching a community group how to use an AED. place the steps of using an AED in sequential order.
1. turn on the AED and follow voice prompts
2. wipe the bare chest dry
3. attach pads
4. plug in the connector if necessary
5. stand clear
6. push the analyze button
7. if it says shock advised, push shock button
8. after the shock, or if no shock is advised, preform about 2 minutes or 5 cycles of cpr
86
A nurse and patient are developing a comprehensive care plan for treating the patient's heart failure. The patient asks why he needs to monitor his sodium intake. Which response by the nurse is best?
Sodium allows the body to retain more fluid.
Sodium holds on to fluid, causing edema associated with heart failure. It is often treated by dietary restriction of sodium.
87
a 19-year-old is brought to the emergency department with sudden onset of high fever, nuchal rigidity and vomiting which are worsening over the course of the day. These signs and symptoms are consistent with:
Neisseria meningitidis?
88
A patient has just undergone a spinal fusion and laminectomy and has returned from the operating room. Which assessments are done in the first 24 hours? (SATA)
a. take vital signs every 4 hours and assess for fever and hypotension
b. perform a neurologic assessment every 4 hours with attention to movement and sensation
c. monitor intake and output and assess for urinary retention
d. assess for ability and independence in ambulating and moving in bed
e. observe for clear fluid on or around the dressing
ABCE
89
A patient is being discharged with prescriptions for aspirin and clopidogrel after percutaneous coronary intervention (PCI) to treat acute coronary syndrome. The patient wants to know why these medications need to be taken if the artery is open after the stent was placed. Which is the best response?
a. These medications are to help relieve any post procedure pain.
b. Aspirin and clopidogrel can prevent another clot from forming.
c. Aspirin and clopidogrel help relax the artery so the stent can stay in place.
d. These medications should not be used because of an increased risk of bleeding.
B
Aspirin and clopidogrel can prevent another clot from forming. ---
After PCI, the patient is treated with dual antiplatelet agents until the intimal lining can grow over the stent and provide a smooth vascular surface that will inhibit thrombus formation.
90
While assessing a patient's gait and equilibrium, the nurse observes that the patient has the Romberg sign. What is the priority patient problem associated with this objective data?
A. Potential for falls related to dysfunction in awareness of body positions
B. Inability to do activities of daily living due to decreased muscle strength
C. Functional incontinence related to inability to ambulate to bathroom
D. Potential for falls related inability to make good judgements
A
91
fill in ____ meningitis manifestations vary according to the state of the immune system
fungal
92
```
You are asked to infuse fluids intravenously at 50ml/hr. The administration set is calibrated at 60 drops/ml. How fast should you set the drop rate?
A. 1 drop/min
B. 10 drops/min
C. 50 drops/min
D. 60 drops/min
```
C
| 50 mL/hr ÷ 1 hr/60 min x 60 drops/mL = 50 drops/min
93
the nurse notes that the patient's platelet count is 400,000/mm3. what action is the nurse most likely to take?
document the because it is within the normal range and continue to monitor patient
94
where would you place the tips of your fingers in order to assess right popliteal pulse
Place the fingertips of both hands so that they just meet in the midline behind the knee and press them deeply into the popliteal fossa.- im guessing
Move down to the level of the knee allowing it to remain slightly bent.
Place your hands around the knee and push the tips of your fingers into the popliteal fossa in an effort to feel the popliteal pulse. Note whether it feels simply pulsatile (normal) or enlarged and aneurysmal (uncommon). - google
95
fillin ____ meningitis has CSF cerebrospinal fluid that is cloudy or hazy
BACTERIAL
96
the nurse has a prescription to administer dopamine 2 mg/kg/hr. the patients weighs 70 kg. and the syringe available in 800 mg in 50 ml. what rate do you run the syringe at ml/hr?
97
A patient has received a double dose of heparin during surgery and is bleeding through the incision site. While the surgeons are working to stop the bleeding at the incision site, the nurse will prepare to take what action at this time?
a. Give IV vitamin K as an antidote.
b. Give IV protamine sulfate as an antidote.
c. Call the blood bank for an immediate platelet transfusion.
d. Obtain an order for packed red blood cell
B
98
The nurse is assessing several patients using the Glasgow coma scale (GCS). Which factors indicate the most serious neurologic presentation based on the GCS information?
a. Eye opening to sound, localizes pain, confused conversation
b. Eye opening to sound, obeys commands, inappropriate words
c. Eye opening to spontaneous, obeys commands, confused conversation
d. Eye opening to pain, abnormal flexion, incomprehensible sounds
D
99
client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?
1. 3.2 mEq/L
2. 3.8 mEq/L
3. 4.2 mEq/L
4. 4.8 mEq/L
1
The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L. The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.
100
A health care provider tells the patient that she has anemia because her red blood cells are being destroyed faster than they can be made. The patient asks the nurse for more information on the cause of her condition. The nurse provides information to the patient on which type of anemia?
a. Thalassemia
b. Acute anemia
c. Hemolytic anemia
d. B12 deficiency anemia
C
- Hemolytic anemias are due to an increase in the destruction of red blood cells resulting in a lower red blood cell count.
101
Which nursing assessment can indicate the presence of increased intracranial pressure?
Pupillary assessment
Pressure on the cranial nerves causes fixed pupils in patients with increased ICP. Brisk pupil constriction is a normal finding and is not expected with increased ICP.
102
A patient at high risk for development of coronary artery disease (CAD) indicates that the necessary lifestyle changes to decrease the risk for disease are too difficult. How should the nurse respond to help the patient understand the importance of making necessary changes?
"Are you aware of the major risk factors for CAD that you have?"
"What aspect of your current lifestyle is most important for you to maintain?"
103
Emergency personnel discovered a patient lying outside in the cool evening air for an unknown length of time. The patient is in a hypothermic state. What other assessment finding does the nurse expect to see?
a. Blood pressure and heart rate lower than normal
104
Spinal shock has which of the following clinical manifestations?
decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury.- couldn’t find actual Q&A
Bradycardia, hypotension, paralytic ileus.
105
fill in____ can be used to confirm a diagnosis of acquired myasthenia gravis.
BLOOD TEST?
106
the doctor's order says: Vancomycin 2,000 mcg IV. The instructions on the vial of Vancomycin says to reconstitute with sterile water for a concentration of 2mg/ml then to dilute each 2 mg in 75 ml of sterile Normal Sale. How many milliliters should you use to administer the ordered dose?
75 ML/DOSE
107
The nurse would use which statement to describe to the patient with coronary artery disease (CAD) how fatty streaks are formed?
A. "Damaged arteries allow platelets to form a thrombus."
B. "Damaged arteries allow lipids to be deposited in the intima."
C. "Infections cause bacteria to move inside the artery wall."
D. "Increased cholesterol intake directly causes plaque formation.
B
108
A patient is found pulseless and the cardiac monitor shows a rhythm that has no recognizable deflections, but instead has a coarse "waves" of varying amplitudes. What is the priority ACLS intervention for this rhythm?
IMMEDIATE DEFIBRILLATION
109
signs and symptoms of chronic venous insufficiency include all of the following
Cool and cyanotic skin
Sharp pain that may be relieved by the elevation of the extremity
Full superficial veins
110
A patient is scheduled to undergo diagnostic testing for sickle cell anemia. which educational brochure is the nurse most likely to provide to the patient
how is hemoglobin S used to confirm my diagnosis
111
parkinson's disease can be identified by the following clinical manifestations
1. Increased muscle tone
2. Tremor at rest
3. Impaired postural reflexes
112
A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)
a. Long-term memory loss
b. Slower processing time
c. Increased sensory perception
d. Decreased risk for infection
e. Change in sleep patterns
ANS: B, E
Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.
113
The nurse is teaching a patient with heart failure about signs and symptoms that suggest a return or worsening of heart failure. What does the nurse include in the teaching? (Select all that apply.)
a. Rapid weight loss of 3 lbs. in a week
b. Increase in exercise tolerance lasting 2 to 3 days
c. Cold symptoms (cough) lasting more than 3 to 5 days
d. Excessive awakening at night to urinate
e. Development of dyspnea or angina at rest or worsening angina
f. Increased swelling in the feet, ankles, or hands
CDEF
114
The nurse is taking the initial history and vital signs on a patient with fatigue. The nurse notes a regular apical pulse of 130 beats/min. Which contributing factors does the nurse assess for? (select all that apply)
Anxiety or stress
Fever
Hypovolemia
Anemia or hypoxemia
other Tachycardia factors
caffeine, stimulants, exercise, pain, dehydration,
115
The student nurse asks the instructor, "Why are nurses at such great risk for developing low back pain?" Which response by the instructor is correct?
"Nurses often perform a lot of heavy lifting and bending."
The physical activities involved in patient care include lifting, turning, and bending. All of these activities can increase the risk for low back pain.
116
A patient questions a new diagnosis of chronic myelogenous leukemia (CML) because he has no symptoms. Which response by the nurse is appropriate?
a. "Some patients may not ever have symptoms with CLL."
b. "It's very common for patients with CLL to have no symptoms initially."
c. "You did have symptoms; you probably just thought it was weakness or fatigue."
d. "Your symptoms were disguised because you were battling the flu at that time, too."
B
117
The nurse is evaluating the lower extremities of several patients. Which description represents the least serious physical presentation?
a. Pain in calf; lower leg is swollen and red.
b. Progressively increasing pain; distal portion is cool and bluish.
c. Decreased sensation; lower leg has widespread brownish discoloration.
d. Tight sensation in ankle; skin appears tight, skin, and edematous.
c. Decreased sensation; lower leg has widespread brownish discoloration.
118
The patient with a history of venous thromboembolism (VTE) has been taking warfarin long-term and presents to the clinic with frequent nosebleeds. Which laboratory value should cause the nurse to contact the ordering health care provider?
a. Platelet count 275,000/mm3
b. Prothrombin time (PT) 18.2 seconds
c. International normalized ratio (INR) 6.3
d. Activate Partial Thromboplastin Time (aPTT) 34 seconds
C
This finding would indicate the warfarin dosing needs adjustment. An INR level of 4.3 is above the therapeutic range, putting the patient at risk for hemorrhage. The nurse should communicate this finding to the ordering health care provider
In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for disorders such as atrial fibrillation or a blood clot in the leg or lung.
119
Which technique would be most appropriate to use when the nurse is teaching a patient with a language barrier?
a. Obtain an interpreter who can speak in the patient's native tongue for teaching session.
b. Use detailed explanations, speaking slowly and clearly.
c. Assume that the patient understands the information presented if the patient has no questions.
d. Provide only written instructions.
A
120
```
The nurse is performing neurologic checks every 4 hours for a patient who sustained a head injury. Which early sign indicates a decline in neurologic status?
A) Nonreactive, dilated pupils
B) Change in level of consciousness
C) Decorticate posturing
D) Loss of remote memory
```
B
121
The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply.
1. Avoid magnetic resonance imaging (MRI) scans
2. Do not place cell phones directly over the pacemaker
3. Notify airline security when traveling
4. Perform shoulder range-of-motion exercises
5. Refrain from using microwave ovens
1,2,3
122
The ____ system slows the heart rate, whereas the ___ stimulation increases the heart rate
-Parasympathetic ; sympathetic
123
T/F a characteristic feature of third-degree heart blocks is that none of the sinus impulses reaches the ventricles
true?
124
Which statements about spinal shock are accurate?
flaccidity, loss of reflex activity below the level of the lesion. Bradycardia, hypotension, paralytic ileus.
(from review)
125
the neurologic assessment of a client who had a craniotomy includes the glasgow coma scale,what does the nurse evaluate to assess the client score
degree of purposeful movement by the client
appropriateness of the client's verbal responses
stimulus necessary to cause the clients eyes to open
126
Which clinical manifestations of disseminated intravascular coagulation (DIC) are due to the depletion of clotting factors?
purple spots
heart rate of 120 beats/min
blood pressure 88/54 mm Hg
127
The nurse is interviewing a patient with spontaneous VT who may be a possible candidate for an ICD. The nurse senses that the patient is anxious. What is the nurse's most therapeutic response?
"You seem anxious. What are your concerns about having this treatment?"
128
Which characteristics would the nurse associate with hemophilia? (Select all that apply. One, some, or all responses may be correct.)
1) A deficiency of factor IX
2) A deficiency of factor XI
3) A deficiency of factor VIII
4) An inherited X-linked disorder
5) An inherited Y-linked disorder
134
129
Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?
Respiratory pattern and airway
130
he nurse is caring for a patient who has been in a long-term care facility for several months following an SCI. The patient has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. Which are expected outcomes of the training program? (Select all that apply)
a. Demonstrates a predictable pattern of voiding
b. Is able to independently catheterize himself
c. Pours warm water over perineum to stimulate voiding
d. Takes bethanechol chloride (Urecholine) 1 hour before voiding
e. Is able to empty the bladder completely
f. Does not experience a urinary tract infection
AEF
131
__ is the phase called that is considered the beginning symptom of a seizure
prodromal
132
A patient with heart failure (HF) is admitted to the hospital, put on bed rest, administered oxygen, and treated with an angiotensin-converting enzyme (ACE) inhibitor. Additionally, the patient is educated about healthy lifestyle choices to prevent HF symptoms. Which statements by the patient indicate that the collaborative care goals have been met?
- "It is much easier to breathe."
- "I am able to walk to and from the restroom much easier now."
- "I have been taking this medication as ordered since it was prescribed."
133
The patient on warfarin presents to the clinic with a subtherapeutic international nationalized ratio (INR) level. Which patient statement would cause the nurse to provide further teaching about the medication?
a. ) "My family helped me declutter my house so that I am less likely to trip."
b. ) "I have been drinking a lot of water so that I do not become dehydrated."
c. ) "Wearing my graduated compression stockings is still important even though I am on warfarin."
d. ) "Since my leg venous thromboembolism, I have been trying to be healthier by eating more fruits and salads."
d.) "Since my leg venous thromboembolism, I have been trying to be healthier by eating more fruits and salads."
Vitamin K, found often in green leafy vegetables, decreases the effectiveness of warfarin. If the patient has suddenly increased their Vitamin K intake, INR levels will decrease. The patient should maintain their vitamin K intake at a constant level, not increase or decrease.
134
The nurse is administering antihypertensive drugs to older adult patients. The nurse knows that which adverse effect is of most concern for these patients?
a. Dry mouth
b. Hypotension
c. Restlessness
d. Constipation
B
135
A male patient diagnosed with acute ST-segment-elevation myocardial infarction (STEMI) is receiving thrombolytic therapy. Which assessment finding by the nurse would require immediate intervention?
The skin is pale and cool with bilateral pedal pulses faintly palpable.
Bleeding is a complication associated with thrombolytic therapy. Skin that is pale and cool, in association with faint peripheral pulses, can indicate low blood pressure related to major bleeding, which requires immediate intervention.
136
A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action?
palpate the area over the bladder for distention
137
A patient who has recently had a myocardial infarction (MI) has started therapy with a beta blocker. The nurse explains that the main purpose of the beta blocker for this patient is to
a. cause vasodilation of the coronary arteries.
b. prevent hypertension.
c. increase conduction through the SA node.
d. protect the heart from circulating catecholamines.
D
Rationale: If the client has a temperature higher than 100 °F (37.8 °C), the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.
138
Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 °F (38.1 °C) orally. Which action should the nurse take?
1. Begin the transfusion as prescribed.
2. Administer an antihistamine and begin the transfusion.
3. Delay hanging the blood and notify the health care provider (HCP).
4. Administer 2 tablets of acetaminophen and begin the transfusion.
3
139
Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?
ICP
140
What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury?
a. Heatstroke
b. Paralytic ileus
c. Hypertensive stroke
d. Aspiration pneumonia
C
| Naicha: bradycardia, headache, HTN, nasal stuffiness, flushing warm skin
141
a nursing student is identifying situations that involve the psychomotor domain of learning as part of the a class project. which are examples of learning activities that involve the psychomotor domain
a. teaching a patient how to self-administer eye drops
b. have a patient list the adverse effects of an antihypertensive drug
c. discussing what foods to avoid while taking antilipemic drugs
d. teaching a patient how to measure the pulse before taking a beta blocker
e. teaching a family member how to give and injection
f. teaching a patient the rationale for checking a drug blood level
ADE
142
The nurse will monitor the patients who are taking a muscle relaxant for which adverse effect?
CNS DEPRESSION
143
fillin digitalis preparation is given to patients to ___ contractility
Increase?
144
Which nursing intervention has the highest priority for the nurse caring for a patient experiencing a sickle cell crisis?
administer IV fluids
145
A patient undergoing radiation therapy for breast cancer reports feeling fatigued during normal daily activities. The nurse indicates that the patient may be at risk for anemia due to which physiological effect of cancer treatment?
a. Excessive blood loss
b. Destruction of red blood cells
c. Decreased synthesis of hemoglobin
d. Decreased number of red blood cell precursors
d. Decreased number of red blood cell precursors
- Radiation can decrease the production of red blood cell precursors, leading to a decrease in the production of red blood cells, resulting in anemia.
146
Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?
ICP
147
1,000mL of IV solution is running at a rate of 125mL/hr. If this started at 0100, what time would you hang the next bag?
0900?
1000/125= 8h
148
the brief sensory experiences that occur prior to the onset of seizures is called…
prodromal or aura?
149
A patient is being evaluated for thrombolytic therapy. What are absolute contraindications for the procedure? (sata)
a. Ischemic stroke within 3 months
b. pregnancy
c. Suspected aortic aneurysm
d. major trauma in the last 12 months
e. Intracranial hemorrhage
f. Malignant intracranial neoplasm
ACEF
150
The pt and family are referred to the nurse for education about amyotrophic lateral sclerosis (ALS). What information does the nurse include in the educational session? (select all)
a. it is a progressive disease involving the motor system
b. the cause of ALS is unknown
c. memory loss will occur but it will be very gradual
d. death typically will occur several decades after diagnosis
e. there is no known cure for ALS
ABE
151
What should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel?
Nausea
Epistaxis
Chest pain
Elevated temperature
EPISTAXIS
152
The nurse is caring for a patient with relatively minor head injury after a bump to the head. The nurse has the greatest concern for which symptom?
a. "I should not let her fall asleep"
b. She may have nausea or headache for the first 24 hours"
c. "She should gently blow her nose and I'll observe for bleeding"
d. "She can run and play as she usually does"
B
153
What response would be the best response to a client with a new spinal cord injury (SCI) who asks if this current paralysis will be permanent?
It's Temporary- couple of days up to 2-3 weeks, thoracically paralysis- is not permanent
Loss of reflex activity below level of injury
154
The Emergency Department (ED) nurse completes the admission assessment. Mr. Jones is alert but struggles to answer questions. When he attempts to talk, he slurs his speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Mr. Jones' symptoms have been caused by a stroke?
carotid bruit
elevated BP
hyporeflexic DTR(deep tendon reflex)
155
A patient with a spinal cord injury has omeprazole 25 mg once daily per gastric tube ordered. The omeprazole elixir is supplied in 20mg per 5 milliliter concentration. How many milliliters would the nurse administer with each dose? (round to the nearest tenth
6?
156
Which symptoms indicate that a patient with spinal cord injury is experiencing autonomic dysreflexia? (sata)
Bradycardia
Headache
Hypertension
Nasal stuffiness
also
sweating, dilated pupils, infection, constipation, nausea, they can break femur
157
Which of the following is the drug of choice for a client who just arrived ED and got diagnosed with an ischemic stroke?
TPA (tissue plasminogen activator)
also called alteplase (Activase) or tenecteplase (TNKase)
?
158
```
You are asked to infuse fluids intravenously at 50ml/hr. The administration set is calibrated at 60 drops/ml. How fast should you send the drip rate?
A. 1 drop/min
B. 10 drops/min
C. 50 drops/min
D. 60 drops/min
```
C. 50 drops/min
| 50 mL/hr ÷ 1 hr/60 min x 60 drops/mL = 50 drops/min
159
Which nursing action is appropriate for the patient in sickle cell crisis?
hydration, narcotics, oxygen, prevent from infection
160
A patient experiences imparired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week
C
161
The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? (sata)
DRIVING
also no physical activity
162
A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client
1. Is contraindicated because it will increase bleeding
2. May be necessary to prevent pulmonary thrombosis
3. Is inadvisable because it may mask signs and symptoms
4. Will be started if necessary to enhance cerebral circulatioN
1
163
The nurse has a prescription to administer dopamine 2mg/kg/hr. The patient weighs 70kg and the syringe available is 800 mg in 50mL. What rate do you run the syringe at (ml/hr)? (round to the nearest hundredth)
4?
| 800/50=16, 70kg=31.8 31.8*2=62.63, 62.63/16= 3.977
164
N. NOTES
Naicha
Sluggish pupil response to light-vomiting-Check LOC
Sickle cell- pain comes from ruptured arteries
Peripheral neuropathy- you know lower extremities are numb, they can’t feel. So you have to make sure that patients wear shoes, temp of the water is checked, etc
Chemo therapy- mannitol crosses the BBB
Bladder training- to help improve bladder control. You want them to void again, empty there bladder, no infections
Seizures- myoclonic, partial, tonic-clonic, atonic, epilepticus, generalized, absent
Halo device- no contact sports, no usage of machinery
Platelet aggregation- bleeding problems
Romberg test- screen for balance- mirror function- muscle movement , size, tone and strength
Upper and lower motor neurons, when to give Blood or steps for blood is in the blue print
ECG for Seizures
SCI- respiratory problems
CAD- clogged (plaque) arteries, need to exercise, diet
Know INR: 2 to 3 and PT:
Meningitis symptoms- Michael rigidity, fever,
Chest pain- angina- oxygen and nitrates
Spinal shock- Flaccid paralysis
• Loss of reflex activity below level of injury
• Bradycardia
• Hypotension
• Paralytic Ileus
