Acute B NUR2204

Question 1

A patient reports he hasn’t had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the DR. What non-invasive nursing interventions can you perform without a DR’s order?
a.
Insert a nasogastric attached to intermittent suction

b.
Administer IV fluids

c.
Encourage ambulation, maintain NPO status, and monitor intake & output

d.
Encourage at least 3000 ml of fluids per day

Answer 1

c.

Encourage ambulation, maintain NPO status, and monitor intake & output

Question 2

What is a potential postoperative concern regarding a patient who has already resumed a solid diet?

Select one:

a.
Failure to pass stool within 12 hours of eating solid foods

b.
Failure to pass stool within 48 hours of eating solid foods

c.
Passage of excessive flatus

d.
Patient reports a decreased appetite

Answer 2

b.

Failure to pass stool within 48 hours of eating solid foods

Question 3

A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?

Select one:

a.
Continue to monitor the patient

b.
Notify the Doctor (DR)

c.
Obtain an Electrocardiogram (ECG)

d.
Check the patient’s blood glucose level (BGL)

Answer 3

b.

Notify the Doctor (DR)

Question 4

A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery?

Select one:

a.
Bowel sounds

b.
Dysrhythmia

c.
Homan’s Sign

d.
Haemoglobin Level

Answer 4

c.

Homan’s Sign

Question 5

After surgery your patient is semi-comatose with vital signs within normal limits. As the nurse, what position would be best for this patient?

Select one:

a.
Semi-Fowlers

b.
Prone

c.
Low-Fowlers

d.
Side positioning preferably on the left side

Answer 5

d.

Side positioning preferably on the left side

Question 6

The nurse is monitoring the patient who is 24 hours post-op from surgery. Which finding requires intervention?

Select one:

a.
BP 100/80

b.
24-hour urine output of 300 ml

c.
Pain rating of 4 on 1-10 scale

d.
Temperature of 37.3⁰C

Answer 6

b.

24-hour urine output of 300 ml

Question 7

A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do?

Select one:

a.
Put the patient in prone position with knees extended to put pressure on the site

b.
Cover the wound with sterile normal saline dressing

c.
Monitor for signs of shock

d.
Notify the DR and administer as prescribed antiemetic to prevent vomiting

Answer 7

Put the patient in prone position with knees extended to put pressure on the site

Question 8

When assessing your patient who is post-op, you notice that the patient’s right calf vein feels hard, cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be an appropriate nursing intervention for this patient?

Select one:

a.
Allow the patient to dangle the legs to help increase circulation and alleviate pain

b.
Instruct the patient to not sit in one position for a long period of time

c.
Elevate the extremity 30 degrees without allowing any pressure on affected area

d.
Administer anticoagulants as ordered by DR

Answer 8

Allow the patient to dangle the legs to help increase circulation and alleviate pain

Question 9

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST?

Select one:

a.
Apply warm blankets & continue oxygen as prescribed

b.
Take the patient’s rectal temperature

c.
Page the doctor for further orders

d.
Adjust the thermostat in the room

Answer 9

a.

Apply warm blankets & continue oxygen as prescribed

Question 10

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is NOT an appropriate nursing intervention?

NOT an appropriate nursing intervention?

Select one:

a.
Encourage patient intake of 3000 ml/day of fluids if not contraindicated

b.
Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake

c.
Encourage early ambulation and patient to eat meals in beside chair

d.
Repositioning every 3-4 hours

Answer 10

d.

Repositioning every 3-4 hours

Question 11

The nurse must be alert for complications with Sengstaken-Blakemore intubation including:

Select one:

a.
Pulmonary obstruction

b.
Pericardiectomy syndrome

c.
Pulmonary embolization

d.
Cor pulmonale

Answer 11

a.

Pulmonary obstruction

Question 12

Peritonitis can occur as a complication of:

Select one:

a.
Septicaemia

b.
Multiple organ failure

c.
Hypovolemic shock

d.
Peptic ulcer disease

Answer 12

d.

Peptic ulcer disease

Question 13

During initial assessment of a patient post-endoscopy, the nurse notes absent bowel sounds, tachycardia, and abdominal distention. The nurse would anticipate:

Select one:

a.
Ischemic bowel

b.
Peritonitis

c.
Hypovolemic shock

d.
Perforated bowel

Answer 13

Answer: D. perforated bowel

Invasive diagnostic testing can cause perforated bowel. Ischemic bowel (Choice A) is usually not related. Peritonitis (Choice B) can be a complication after initial perforation. Hypovolemic shock (Choice C) can occur if peritonitis is allowed to continue.

Question 14

Patients with oesophageal varices would have the following assessment:

Select one:

a.
Increased blood pressure

b.
Increased heart rate

c.
Decreased respiratory rate

d.
Increased urinary output

Answer 14

b.

Increased heart rate

Question 15

A patient is admitted with lacerated liver as a result of blunt abdominal trauma. Which of the following nursing interventions would NOT be appropriate for this patient?

Select one:

a.
Monitor for respiratory distress

b.
Monitor for coagulation studies

c.
Administer pain medications as ordered

d.
Administer normal saline, crystalloids as ordered

Answer 15

Answer: C. Administer pain medications as ordered

Pain medication may mask signs and symptoms of haemorrhage, further decrease blood pressure, and interfere with assessment of neurologic status and additional abdominal injury.

Question 16

Which of the following laboratory values would be the most important to monitor for a patient with pancreatic cancer?

Select one:

a.
Serum glucose

b.
Radioimmunoassay (RIA)

c.
Creatine phosphokinase (CPK)

d.
Carcinoembryonic antigen (CEA)

Answer 16

a.
Serum glucose

In pancreatitis, hypersecretion of the insulin from a tumour may affect the islets of Langerhans, resulting in hyperinsulinemia, a complication of pancreatic cancer. Options B and D, should also be monitored to measure the effects of therapy, but hypoglycaemia may be life-threatening. Creatine phosphokinase is an enzyme that reflects normal tissue catabolism. Elevated serum levels indicate trauma to cells with high CPK content. CPK and CPK-isoenzymes are used to detect a myocardial infarction.

Question 17

You are caring for Rona, a 35-year-old female in a hepatic coma. Which evaluation criteria would be the most appropriate?

Select one:

a.
The patient demonstrates an increase in level of consciousness

b.
The patient exhibits improved skin integrity

c.
The patient experiences no evident signs of bleeding

d.
The patient verbalize decreased episodes of pain

Answer 17

Answer: A. The patient demonstrates an increase in level of consciousness

Increased level of consciousness indicates resolving of a comatose state. Other options are important evaluation but do not evaluate a patient in a hepatic coma who is responding to external stimuli

Question 18

The correct sequence for abdominal assessment is:

Select one:

a.
Inspection, percussion, palpation, auscultation

b.
Inspection, auscultation, palpation, percussion

c.
Inspection, palpation, auscultation, percussion

d.
Inspection, percussion, auscultation, palpation

Answer 18

Answer: B. inspection, auscultation, palpation, percussion

Auscultation is done before palpation to avoid stimulating peristaltic movements and distorting auscultatory sounds

Question 19

You observe changes in mentation, irritability, restlessness, and decreased concentration in a patient with cancer of the liver. Hepatic encephalopathy is suspected and the patient is ordered neomycin enemas. Which of the following information in the patient’s history would be a contraindication of this order?

Select one:

a.
Left nephrectomy

b.
Glaucoma in both eyes

c.
Myocardial infarction

d.
Peripheral neuropathy

Answer 19

Answer: A. left nephrectomy

Neomycin prevents the release of ammonia from the intestinal bacteria flora and from the breakdown of red blood cells. Common side-effects of this drug are nephrotoxicity and ototoxicity. Patients with renal disease or renal impairment should not take this drug. Peripheral neuropathy (Option D) is a chronic complication of diabetes mellitus. Options B and C are not affected by neomycin.

Question 20

Which of the following tests can be useful as a diagnostic and therapeutic tool in the biliary system?

Select one:

a.
Ultrasonography

b.
Magnetic Resonance Imaging (MRI)

c.
Endoscopic retrograde cholangiopancreatography (ERCP)

d.
Computed tomography scan (CT scan)

Answer 20

Answer: C. Endoscopic retrograde cholangiopancreatography (ERCP)

ERCP permits direct visualization of the pancreatic and common bile ducts. Its therapeutic value is in retrieving gallstones from the distal and common bile ducts and dilating strictures. Ultrasonography (Option A) aids in the diagnosis of cholecystitis, gallstones, pancreatitis, and metastatic disease. It also identifies oedema, inflammation, and fatty or fibrotic infiltrates or calcifications. MRI (Option B) detects hepatic neoplasms, cysts, abscesses, and hematomas. A CT Scan (Option D) can be done with our without a contrast medium. It can detect tumours, cysts, pseudocysts, abscesses, hematomas, and obstructions of the liver, biliary tract and pancreas.

Question 21

Which of the following would you NOT inspect while observing gait?

Select one:

a.
Base of support

b.
Posture

c.
Arm position

d.
Weight bearing stability

Answer 21

c.

Arm position

Question 22

Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first?

Select one:

a.
Assess the drainage in the dressing

b.
Slowly remove the soiled dressing

c.
Wash hands thoroughly

d.
Put on latex gloves

Answer 22

c.
Wash hands thoroughly

When caring for a patient, the nurse must first wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed

Question 23

Which nursing intervention can help a patient maintain healthy skin?

Select one:

a.
Keep the client well hydrated

b.
Avoid bathing the client with mild soap

c.
Remove adhesive tape quickly from the skin

d.
Recommend wearing tight-fitting clothes in hot weather

Answer 23

a.
Keep the client well hydrated

Keeping the patient well hydrated helps prevent skin cracking and infection because intact healthy skin is the body’s first line of defence. To help a patient maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn’t remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation

Question 24

Falling backward is an abnormal finding that is easily seen with?

Select one:

a.
Cervical Spondylosis

b.
Parkinson’s Disease

c.
Arthritis

d.
Scoliosis

Answer 24

b.

Parkinson’s Disease

Question 25

The evening nurse reviews the nursing documentation in the patient’s chart and notes that the day nurse has documented that the patient has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the patient’s sacral area? Select one: a. Intact skin b. Full-thickness skin loss c. Exposed bone, tendon, or muscle d. Partial-thickness skin loss of the dermis

Answer 25

d. Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

Question 26

Nurse Harry documents the presence of a scab on a patient’s deep wound. The Nurse identifies this as which phase of wound healing? Select one: a. Inflammatory b. Migratory c. Proliferative d. Maturation

Answer 26

b. Migratory The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound. In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound. In the maturation phase, cells and vessels return to normal and the scab sloughs off.

Question 27

A female patient with cellulitus of the lower leg has had cultures done on the affected area. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin? Select one: a. Staphylococcus epidermidis b. Staphylococcus aureus ``` c. Escherichia coli (E. coli) ``` d. Candida albicans

Answer 27

Answer: C. Escherichia coli (E. coli) E. coli normally is found in the intestines and constitutes a common source of infection of wounds and the urinary system. The other microbes listed are part of the normal flora of the skin. The correct answer is: Escherichia coli (E. coli)

Question 28

Which of these movements DOES NOT test range of motion: Select one: a. Protrude and retract jaw b. Move jaw side to side c. Open mouth as wide as possible d. Clench the teeth

Answer 28

ANSWER: D: Clench the teeth

Question 29

A patient with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the patient for which adverse reaction to this drug? Select one: a. Aplastic anaemia b. Ototoxicity c. Cardiac arrhythmia d. Seizures

Answer 29

Answer: B. Ototoxicity The most significant adverse reactions to gentamicin and other aminoglycosides are ototoxicity (indicated by vertigo, tinnitus, and hearing loss) and nephrotoxicity (indicated by urinary cells or casts, oliguria, proteinuria, and reduced creatinine clearance). These adverse reactions are most common in elderly and dehydrated clients, those with renal impairment, and those receiving concomitant therapy with another potentially ototoxic or nephrotoxic drug. Gentamicin isn’t associated with aplastic anaemia, cardiac arrhythmias, or seizures.

Question 30

Which test do you perform when assessing for the risk of falling? Select one: a. Nudge Test b. Fall Test c. Risk Test d. Sternum Test

Answer 30

a. | Nudge Test

Question 31

A diabetic patient has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. Which of the following actions by the nurse is the priority? Select one: a. Send blood to the laboratory for analysis b. Administer the prescribed insulin c. Administer oxygen per nasal cannula d. Administer 50% dextrose IV per protocol

Answer 31

ANSWER: D The body responds to hypoglycaemia by mounting a sympathetic response, causing tachycardia, diaphoresis, and pallor. The patient may become unresponsive as the glucose supply to the brain decreases. The correct answer is: Administer 50% dextrose IV per protocol

Question 32

The nurse is assessing the glucose level of a patient with a diagnosis of diabetes. Which of these is most helpful in evaluating this patient’s long-term glucose management? Select one: a. Fasting blood glucose level b. Haemoglobin A1c c. Urine specific gravity d. The patient’s food diary

Answer 32

ANSWER: B Haemoglobin A1c Glucose in the blood adheres to haemoglobin, a process called glycosylation. The amount of glycosylation is directly correlated to the amount of glucose in the blood, so the haemoglobin A1c can assess the patient’s glucose control over the past 3 months. The correct answer is: Haemoglobin A1c

Question 33

The nurse is teaching a group of students about the characteristics of type 1 diabetes mellitus. Which of the following describe the underlying cause of the disease? Select one: a. Increased hepatic glycogenesis b. Cellular resistance to insulin c. Destruction of pancreatic beta cells d. Atrophy of pancreatic alpha cells

Answer 33

ANSWER: C The beta cells in a patient with type 1 diabetes mellitus are destroyed, so the patient has no endogenous insulin. The correct answer is: Destruction of pancreatic beta cells

Question 34

An unresponsive patient who has diabetes is brought to the emergency department with slow, deep respirations. Additional findings include: blood glucose 24.9 mmol/L, arterial pH 7.2, and urinalysis showing presence of ketones and glucose. Which of the following statements best describes the underlying cause of this patient’s presentation? Select one: a. Hyperglycaemia causes oxidative stress, renal dysfunction, and acidosis b. Hypoglycaemia causes release of glucagon resulting in glycogenolysis and hyperglycaemia c. Nocturnal elevation of growth hormone results in hyperglycaemia in the morning d. Lack of insulin causes increased counter regulatory hormones and fatty acid releas

Answer 34

ANSWER: D This patient is suffering from diabetic ketoacidosis, caused by insulin deficiency. The body responds by releasing an counter regulatory hormones and undergoing lipolysis to increase glucose, resulting in hyperglycaemia, ketogenesis, and acidosis. The correct answer is: Lack of insulin causes increased counter regulatory hormones and fatty acid release

Question 35

A diabetic patient has been prescribed an alpha-1 glucosidase inhibitor. When teaching the patient about the medication, which of the following information will the nurse include? Select one: a. “Call us immediately if you experience tremors or palpitations.” b. “Take one tablet daily first thing in the morning.” c. “Take this medication with the first bite of each meal.” d. “You should select foods low in protein when taking this medication".

Answer 35

ANSWER: C The patient should be instructed to take the medication with the first bite of food at each main meal. Glucosidase inhibitors do not cause hypoglycaemia on their own The correct answer is: “Take this medication with the first bite of each meal.”

Question 36

The nurse is caring for a patient who has diabetes and is also diagnosed with hypertension. Which of the following medications on the patient’s medication administration record will cause the most concern? Select one: a. Calcium channel blocker b. Beta-blocker c. Angiotensin receptor blocker d. ACE inhibitor

Answer 36

ANSWER: B Beta-blockers reduce blood pressure by blocking actions of the sympathetic nervous system, which is activated when a patient becomes hypoglycaemic. Blocking of adrenergic beta receptors will also block many of the symptoms of hypoglycaemia, hindering the patient’s ability to recognize early signs of hypoglycaemia. The correct answer is: Beta-blocker

Question 37

Which of the following laboratory results would alert the nurse that a patient who has diabetes is experiencing diabetic nephropathy? Select one: a. Haemoglobin A1c 6% b. Decreased BUN c. Ketonuria d. Microalbuminuria

Answer 37

ANSWER: D Nephropathy results in the loss of proteins in the urine The correct answer is: Microalbuminuria

Question 38

A patient diagnosed with type 2 diabetes mellitus is admitted to the medical unit with pneumonia. The patient’s oral antidiabetic medication has been discontinued and the patient is now receiving insulin for glucose control. Which of the following statements best explains the rationale for this change in medication? Select one: a. Acute illnesses like pneumonia will cause increased insulin resistance b. Infection has compromised beta cell function so the patient will need insulin from now on c. Insulin administration will help prevent hypoglycaemia during the illness d. Stress-related states such as infections increase risk of hyperglycaemia

Answer 38

ANSWER: D Glucocorticoids and epinephrine increase blood glucose levels. Type 2 diabetics may temporarily require insulin during acute illnesses and hospitalizations, but they often return to their normal medication regimen after they recover The correct answer is: Stress-related states such as infections increase risk of hyperglycaemia

Question 39

Which of the following arteries primarily feeds the anterior wall of the heart? Select one: a. Circumflex artery b. Internal mammary artery c. Left anterior descending artery d. Right coronary artery

Answer 39

Answer: C. Left anterior descending artery Option C: The left anterior descending artery is the primary source of blood for the anterior wall of the heart. Options A, B, and D: The circumflex artery supplies the lateral wall, the internal mammary artery supplies the mammary, and the right coronary artery supplies the inferior wall of the heart.

Question 40

What is the term used to describe an enlargement of the heart muscle? Select one: a. Cardiomegaly b. Cardiomyopathy c. Myocarditis d. Pericarditis

Answer 40

Answer: A. Cardiomegaly Option A: Cardiomegaly denotes an enlarged heart muscle Option B: Cardiomyopathy is a heart muscle disease of unknown origin Option C: Myocarditis refers to inflammation of heart muscle The correct answer is: Cardiomegaly

Question 41

Which of the following parameters should be checked before administering digoxin? Select one: a. Apical pulse b. Blood pressure c. Radial pulse d. Respiratory rate

Answer 41

Answer: A. Apical pulse Option A: An apical pulse is essential for accurately assessing the client’s heart rate before administering digoxin. The apical pulse is the most accurate point in the body Option B: Blood pressure is usually only affected if the heart rate is too low, in which case the nurse would withhold digoxin Option C: The radial pulse can be affected by cardiac and vascular disease and therefore, won’t always accurately depict the heart rate Option D: Digoxin has no effect on respiratory function The correct answer is: Apical pulse

Question 42

Which of the following is the MOST common symptom of myocardial infarction? Select one: a. Chest pain b. Dyspnoea c. Oedema d. Palpitations

Answer 42

Answer: A. Chest pain Option A: The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart Option B: Dyspnoea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI Option C: Oedema is a later sign of heart failure, often seen after an MI Option D: Palpitations may result from reduced cardiac output, producing arrhythmias The correct answer is: Chest pain

Question 43

Which of the following landmarks is the correct one for obtaining an apical pulse? Select one: a. Left intercostal space, mid-axillary line b. Left fifth intercostal space, midclavicular line c. Left second intercostal space, midclavicular line d. Left seventh intercostal space, midclavicular line

Answer 43

Answer: B. Left fifth intercostal space, midclavicular line Option B: The correct landmark for obtaining an apical pulse is the left intercostal space in the midclavicular line. This is the point of maximum impulse and the location of the left ventricular apex Option C: The left second intercostal space in the midclavicular line is where the pulmonic sounds are auscultated Option A and D: Normally, heart sounds aren’t heard in the mid-axillary line or the seventh intercostal space in the midclavicular line

Question 44

What supplemental medication is most frequently ordered in conjunction with frusemide (Lasix)? Select one: a. Chloride b. Digoxin c. Potassium d. Sodium

Answer 44

Answer: C. Potassium Option C: Supplemental potassium is given with frusemide because of the potassium loss that occurs as a result of this diuretic Options A and D: Chloride and sodium aren’t lost during diuresis Option B: Digoxin acts to increase contractility but isn’t given routinely with frusemide

Question 45

Which of the following blood tests is most indicative of cardiac damage? Select one: a. Lactate dehydrogenase b. Complete/Full blood count c. Troponin I d. Creatine kinase

Answer 45

Answer: C. Troponin I Option C: Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren’t detectable in people without cardiac injury Option A: Lactate dehydrogenase is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. Option B: CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes Option D: Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury

Question 46

Atherosclerosis impedes coronary blood flow by which of the following mechanisms? Select one: a. Plaques obstruct the vein b. Plaques obstruct the artery c. Blood clots form outside the vessel wall d. Hardened vessels dilate to allow the blood to flow through

Answer 46

Answer: B. Plaques obstruct the artery Option B: Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Option A: Atherosclerosis is a direct result of plaque formation in the artery. Option D: Hardened vessels can’t dilate properly and, therefore, constrict blood flow.

Question 47

Stimulation of the sympathetic nervous system produces which of the following responses? Select one: a. Bradycardia b. Tachycardia c. Hypotension d. Decreased myocardial contractility

Answer 47

Answer: B. Tachycardia Option B: Stimulation of the sympathetic nervous system causes tachycardia and increased contractility. Options A, C, and D: The other symptoms listed are related to the parasympathetic nervous system, which is responsible for slowing the heart rate

Question 48

What is the primary reason for administering morphine to a patient with myocardial infarction? Select one: a. To sedate the patient b. To decrease the patient’s pain c. To decrease the patient’s anxiety d. To decrease oxygen demand on the patient’s heart

Answer 48

Answer: D. To decrease oxygen demand on the patient’s heart Option D: Morphine is administered because it decreases myocardial oxygen demand. Options A, B, and C: Morphine will also decrease pain and anxiety while causing sedation, but isn’t primarily given for those reasons

Question 49

A patient with chronic kidney disease (CKD) has a low erythropoietin (EPO) level. The patient is at risk for? Select one: a. Blood clots b. Hypercalcemia c. Hyperkalaemia d. Anaemia

Answer 49

The answer is B- Anaemia EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anaemia.

Question 50

A patient with Stage 5 Chronic Kidney Disease is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood? Select one: a. Erythropoietin b. c. Phosphate d. Calcium e. Urea

Answer 50

The answer is B - Urea This patient is experiencing uremic frost that occurs in severe chronic kidney disease. This is due to high amounts of urea in the blood being secreted via the sweat glands onto the skin, which will appear as white deposits on the skin. The patient will experience itching with this as well.

Question 51

A 55 year old male patient is diagnosed with chronic kidney disease. The patient's recent GFR was 25 mL/min. What stage of chronic kidney disease (CKD) is this known as? Select one: a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

Answer 51

The answer is D- Stage 4 This is known as Stage 4 of CKD because the GFR (glomerular filtration rate) for this stage is 15-29 mL/min (patient's GFR is 25 mL/min). The other stage's criteria are as follows: Stage 1: Kidney damage with normal renal function GFR >90 ml/min but with proteinuria (3 months or more); Stage 2: Kidney damage with mild loss of renal function GFR 60-89 ml/min with proteinuria (3 months or more); Stage 3: Mild-to-severe loss of renal function GFR 30-59 mL/min; Stage 4: Severe loss renal function GFR 15-29 mL/min; Stage 5: End stage renal disease GRF less 15 mL/min

Question 52

Your patient with chronic kidney disease is scheduled for dialysis in the morning. While examining the patient's telemetry strip, you note tall peaked T-waves. You notify the doctor who orders a STAT basic metabolic panel (BMP). What result from the BMP confirms the ECG abnormality? Select one: a. Potassium 7.1 mmol/L b. Phosphate 3.2 mg/dL c. Magnesium 2.2 mg/dL d. Calcium 9.3 mg/dL

Answer 52

The answer is D – Potassium 7.1 mEq/L The patient's potassium level is extremely elevated. A normal potassium level is 3.5-5.1 mEq/L. This patient is experiencing hyperkalaemia, which can cause tall peak T-waves. Remember in CKD (especially prior to dialysis), the patient will experience electrolyte imbalances, especially hyperkalaemia The correct answer is: Potassium 7.1 mmol/L

Question 53

Which patient below is NOT at risk for developing chronic kidney disease (CKD)? Select one: a. A 78 year old female with an intrarenal injury b. A 45 year old female with polycystic ovarian disease c. A 69 year old male with diabetes mellitus d. A 58 year old female with uncontrolled hypertension

Answer 53

The answer is C- A 45 year old female with polycystic ovarian disease Options A, B, and D are all at risk for developing CKD. However, option C is not at risk for CKD

Question 54

A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of uncontrolled hypertension and coronary artery disease. You're assessing the new medication orders received for this patient. Which medication ordered by the physician will help treat the patient's hypertension along with providing a protective mechanism to the kidneys? Select one: a. Verapamil b. Metoprolol c. Lisinopril d. Amlodipine

Answer 54

The answer is A- Lisinopril There are two types of drugs that can be used to treat hypertension and protect the kidneys in patients with CKD. These drugs include angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs). The only drug listed here that is correct is Lisinopril. This drug is known as an ACE inhibitor. Metoprolol is a BETA BLOCKER. Amlodipine and Verapamil are calcium channel blockers.

Question 55

In caring for patients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant? Select one: a. Assist the patient with preparation of a sitz bath b. Monitor the patient for signs of discomfort while ambulating c. Coach the patient to deep breathe during painful procedures d. Evaluate relief after applying a cold application

Answer 55

Answer: A. Assist the patient with preparation of a sitz bath. The nursing assistant is able to assist the patient with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the patient, teaching techniques, and evaluating outcomes are nursing responsibilities

Question 56

For a cognitively impaired patient who cannot accurately report pain, what is the first action that you should take? Select one: a. Closely assess for nonverbal signs such as grimacing or rocking b. Obtain baseline behavioural indicators from family members c. Look at the medication chart, to note the time of the last dose and response d. Give the maximum PRN dose within the minimum time frame for relief

Answer 56

Answer: B. Obtain baseline behavioural indicators from family members. Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behaviour and careful documentation to determine pain and relief patterns.

Question 57

In applying the principles of pain treatment, what is the first consideration? Select one: a. Treatment is based on patient goals b. A multidisciplinary approach is needed c. The patient must be believed about perceptions of own pain d. Drug side effects must be prevented and managed

Answer 57

Answer: C. The patient must be believed about perceptions of own pain. The patient must be believed and his or her experience of pain must be acknowledged as valid. The data gathered via patient reports can then be applied to other options in developing the treatment plan.

Question 58

In caring for a young child with pain, which assessment tool is the most useful? Select one: a. Simple description pain intensity scale b. 0-10 numeric pain scale c. Faces pain-rating scale d. McGill-Melzack pain questionnaire

Answer 58

Answer: C. Faces pain-rating scale The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and use of advanced vocabulary.

Question 59

The doctor has ordered a placebo for a chronic pain patient. You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? Select one: a. Prepare the medication and hand it to the physician b. Check the hospital policy regarding use of the placebo c. Follow a personal code of ethics and refuse to give it d. Contact the charge nurse for advice

Answer 59

Answer: D. Contact the charge nurse for advice. The charge nurse is a resource person who can help locate and review the policy. If the physician is insistent, he or she could give the placebo personally, but delaying the administration does not endanger the health or safety of the patient. While following one’s own ethical code is correct, you must ensure that the patient is not abandoned and that care continues.

Question 60

A patient with chronic pain reports to you, the charge nurse that the nurse have not been responding to requests for pain medication. What is your initial action? Select one: a. Check the medication chart and nurses’ notes for the past several days b. Ask the nurse educator to give an in-service about pain management c. Perform a complete pain assessment and history on the patient d. Have a conference with the nurses responsible for the care of this patient

Answer 60

Answer: D. Have a conference with the nurses responsible for the care of this patient As charge nurse, you must assess for the performance and attitude of the staff in relation to this patient. After gathering data from the nurses, additional information from the records and the patient can be obtained as necessary. The educator may be of assistance if knowledge deficit or need for performance improvement is the problem.

Question 61

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: Select one: a. Monitor fluctuations in the water-seal chamber b. Clamp the chest tube once every shift c. Encourage coughing and deep breathing d. Milk the chest tube every 2 hours

Answer 61

Answer: C. Encourage coughing and deep breathing When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

Question 62

For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? Select one: a. Restricting fluid intake to 1,000 ml per day b. Enforcing absolute bed rest c. Teaching the patient how to perform controlled coughing d. Administering prescribe sedatives regularly and in large amounts

Answer 62

Answer: C. Teaching the patient how to perform controlled coughing Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient’s ability to maintain a patent airway, causing a high risk for infection from pooled secretions.

Question 63

Nurse Maureen has assisted a doctor with the insertion of a chest tube. The nurse monitors the patient and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? Select one: a. Inform the doctor b. Continue to monitor the patient c. Reinforce the occlusive dressing d. Encourage the patient to deep breathe

Answer 63

Answer: B. Continue to monitor the patient The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re-expanded. Options A, C, and D are incorrect.

Question 64

Nurse Reynolds caring for a patient with a chest tube turns the patient to the side, and the chest tube accidentally disconnects. The initial nursing action is to: Select one: a. Call the doctor b. Place the tube in bottle of sterile water c. Immediately replace the chest tube system d. Place a sterile dressing over the disconnection site

Answer 64

Answer: B. Place the tube in bottle of sterile water If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

Question 65

For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? Select one: a. Encouraging the patient to drink three glasses of fluid daily b. Keeping the patient in semi-Fowler’s position c. Using a high-flow venture mask to deliver oxygen as prescribe d. Administering a sedative, as prescribe

Answer 65

Answer: C. Using a high-flow venture mask to deliver oxygen as prescribe The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary centre in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler’s position and should not receive sedatives or other drugs that may further depress the respiratory canter.

Question 66

On auscultation, which finding suggests a right pneumothorax? Select one: a. Bilateral inspiratory and expiratory crackles b. Absence of breaths sound in the right thorax c. Inspiratory wheezes in the right thorax d. Bilateral pleural friction rub

Answer 66

Answer: B. Absence of breaths sound in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

Question 67

Nurse Lei caring for a patient with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? Select one: a. Do nothing, because this is an expected finding b. Immediately clamp the chest tube and notify the doctor c. Check for an air leak because the bubbling should be intermittent d. Increase the suction pressure so that the bubbling becomes vigorous

Answer 67

Answer: A. Do nothing, because this is an expected finding Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

Question 68

A patient arrives at the emergency room and has experienced frostbites to the right hand. Which of the following would the nurse note on assessment of the patient’s hand? Select one: a. A pink, oedematous hand b. A fiery red skin with oedema in the nail beds c. Black fingertips surrounded by an erythematous rash d. A white colour to the skin, which is insensitive to touch

Answer 68

Answer: D. A white colour to the skin, which is insensitive to touch Assessment findings in frostbite include a white or blue colour; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue oedema appears. Options A, B, and C are incorrect.

Question 69

A female patient is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? Select one: a. 18% b. 27% c. 30% d. 36%

Answer 69

Answer: D. 36% The Rule of Nines divides body surface area into percentages that, when totalled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this patient’s burns cover 36% of the body surface area.

Question 70

In a female patient with burns on the legs, which nursing intervention helps prevent contractures? Select one: a. Applying knee splints b. Elevating the foot of the bed c. Hyperextending the patient’s palms d. Performing shoulder range-of-motion exercises

Answer 70

Answer: A. Applying knee splints Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

Question 71

When planning care for a male patient with burns on the upper torso, which nursing problem should take the highest priority? Select one: a. Ineffective airway clearance related to oedema of the respiratory passages b. Impaired physical mobility related to the disease process c. Disturbed sleep pattern related to facility environment d. Risk for infection related to breaks in the skin

Answer 71

Answer: A. Ineffective airway clearance related to oedema of the respiratory passages When caring for a patient with upper torso burns, the nurse’s primary goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. Option B isn’t appropriate because burns aren’t a disease. Option C and D may be appropriate, but don’t command a higher priority than option A because they don’t reflect immediately life-threatening problems.

Question 72

A female patient with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the patient doing arm exercises. The nurse knows that this patient should avoid exercise because it may: Select one: a. Dislodge the autografts b. Increase oedema in the arms c. Increase the amount of scarring d. Decrease circulation to the fingers

Answer 72

Answer: A. dislodge the autografts Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the patient to keep the grafted extremity in a neutral position. None of the other options results from exercise

Question 73

The nurse is assessing a male patient admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? Select one: a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg b. Urine output of 20 ml/hour c. White pulmonary secretions d. Rectal temperature of 38° C

Answer 73

Answer: B. Urine output of 20 ml/hour A urine output of less than 40 ml/hour in a patient with burns indicates a fluid volume deficit. This patient’s PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The patient’s rectal temperature isn’t significantly elevated and probably results from the fluid volume deficit.

Question 74

Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care? Select one: a. Stress-reduction techniques b. Home environment evaluation c. Skin-care measures d. Participation in activities of daily living

Answer 74

Answer: B. Home environment evaluation After discharge, the patient is responsible for his own care and health maintenance management. Discharge includes assessing the home environment for determining the patient’s ability to maintain his health at home.

Question 75

A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the patient? Select one: a. Room temperature reduction b. Fluid restriction of 2,000 ml/day c. Axillary temperature measurements every 4 hours d. Antiemetic agent administration

Answer 75

Answer: A. Room temperature reduction For patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary. Antipyretics, and not antiemetic, are indicated to reduce fever. Oral or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Fluids should be encouraged, not restricted to compensate for insensible losses.

Question 76

Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which patient statement indicates to the nurse that Tom understands the discharge teaching about cellular injury? Select one: a. “I do not have to see my doctor unless i have problems.” b. “I can stop taking my antibiotics once I am feeling better.” c. “If I have redness, drainage, or fever, I should call my doctor.” d. “I can return to my normal activities as soon as I go home.”

Answer 76

Answer: C. “If I have redness, drainage, or fever, I should call my doctor.” Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury — require reporting indicates that the patient has understood the nurse’s discharge teaching. Follow-up check-ups should be encouraged with an emphasis of antibiotic compliance even if the patient feels better. There are usually activity limitations after cellular injury.

Question 77

Joshua is receiving frusemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the patient? Select one: a. Sodium level b. Magnesium level c. Potassium level d. Calcium level

Answer 77

answer: C. Potassium level Diuretics such as furosemide may deplete serum potassium, leading to hypokalaemia. When the patient is also taking digoxin, the subsequent hypokalaemia may potentiate the action of digoxin, placing the patient at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or renal losses, not diuretic therapy.

Question 78

A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury? Select one: a. Administering anti-inflammatory agents as prescribed b. Elevating the injured area to decrease venous return to the heart c. Keeping the skin clean and dry d. Applying warm packs initially to reduce oedema

Answer 78

Answer: A. Administering anti-inflammatory agents as prescribed Anti-inflammatory agents help reduce oedema and relieve pressure on nerve endings, subsequently reducing pain. Elevating the injured area increases venous return to the heart. Maintaining clean, dry skin aids in preventing skin breakdown. Cool packs, not warm packs, should be used initially to cause vasoconstriction and reduce oedema.

Question 79

Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the patient? Select one: a. Prevention of fluid volume excess b. Maintenance of adequate oxygenation c. Education about infection prevention d. Pain reduction

Answer 79

Answer: B. Maintenance of adequate oxygenation For the patient with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this patient. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.

Question 80

Lisa, a patient with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling? Select one: a. Inserting an indwelling Foley catheter b. Having the patient perform Kegel exercises c. Keeping the skin clean and dry d. Using pads or diapers on the patient

Answer 80

Answer: B. Having the patient perform Kegel exercises Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain urinary continence. To perform these exercises, the patient tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an indwelling Foley catheter increases the risk for infection and should be avoided. The nurse should encourage the patient to develop a toileting schedule based on normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or diapers should be used only as a resort.

Question 81

A student nurse is caring for a 75-year-old patient who is very confused. The student’s communication tools should include: Select one: a. Written directions for bathing b. Speaking very loudly c. Gentle touch while guiding ADLs (activities of daily living) d. Flat facial expression

Answer 81

Answer C- Gentle touch while guiding ADLs (activities of daily living) Nonverbal, gentle touch is an important tool here. Providing appropriate forms of touch to reinforce caring feelings. Because tactile contacts vary considerably among individuals, families, and cultures, the nurse must be sensitive to the differences in attitudes and practices of clients and self

Question 82

Which of the following would BEST indicate to the nurse that a depressed patient is improving? Select one: a. Reduced levels of anxiety b. Changes in vegetative signs c. Compliance with medications d. Requests to talk to the nurse

Answer 82

Answer B - Changes in vegetative signs Reduced levels of anxiety do not indicate an improvement in depressive symptoms. Vegetative signs such as insomnia, anorexia, psychomotor retardation, constipation, diminished libido, and poor concentration are biological responses to depression. Improvement in these signs indicates a lifting of the depression. Compliance with medications does not indicate improvement in depression. Requests to talk to the nurse vary. Requests may show trust in the nurse but are not a sign that depression has diminished.

Question 83

A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience? least likely to experience? Select one: a. Diaphoresis and tremors b. Increased blood pressure and heart rate c. Illusions d. Delusions of grandeur

Answer 83

Answer D- Delusions of grandeur Diaphoresis and tremors occur in the first phase of alcohol withdrawal. The blood pressure and heart rate increase in the first phase of alcohol withdrawal. Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim artificial lighting where the environment is not perceived accurately. Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal.

Question 84

A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment? be least likely to find Select one: a. Inability to make decisions b. Feelings of hopelessness c. Family history of depression d. Increased interest in sex

Answer 84

d. | Increased interest in sex

Question 85

A nurse is teaching a stress-management program for a patient. Which of the following beliefs will the nurse advocate as a method of coping with stressful life events? Select one: a. Avoidance of stress is an important goal for living b. Control over one’s response to stress is possible c. Most people have no control over their level of stress d. Significant others are important to provide care and concern

Answer 85

Answer B- Control over one’s response to stress is possible When learning to manage stress, it is helpful to believe that one has the ability to control one’s response to stress. It is impossible to avoid stress, which is a normal experience. Stress can be positive and growth enhancing as well as harmful. The belief that one has some control can minimize the stress response