athabasca nurs 400

Question 1

the nurse is caring for a patient with a chest tube during the assessment palpates a crackling area (crepitus) around the insertion site. What to do?

Answer 1

draw a circle around the area to see if the subcutaneous emphysema is resolving

Question 2

assessing the clients understanding of medication use. A medication that may cause a complication with diabetes?

Answer 2

steroids

Question 3

pt has aortic stenosis, feeling tired, naps daily. Apical heart sounds 2cm left of mediclavicular line. Crackles lower lungs.B/P 110/90. Wt gn 5.5 lbs in 24 hours. Number one priority?

Answer 3

crackles

Question 4

care of ileostomy. Pt at risk for anemia; because?

Answer 4

iron absorption depends on simultaneous bile salt absorption in the terminal ileum

Question 5

pt with end stage pancreatic cancer decides to terminate medical intervention. what to expect when consulting palliative care?

Answer 5

referral for bereavement

Question 6

evaluating pin insertion/skeletal traction. what indicates complication?

Answer 6

loose pins

Question 7

48 hours post lower lobectomy, receiving morphine via PCA. c/o pain left thorax - worse with coughing

Answer 7

check pca

Question 8

asthma pt/ beclomethasone inhaler. To assess if client is rinsing mouth look for?

Answer 8

thrush

Question 9

pt had chemo. WBC count 2300mm. HGB 98 platelets 80,000, potassium 3.8. symptom that takes priority?

Answer 9

Fever

Question 10

ICU pt. Jugular vein distention noted

Answer 10

++poor cardiac output

Question 11

Parkinsons pt. rx levadopa makes improvement in what area?

Answer 11

muscle rigidity

Question 12

evaluation of cranial nerves on routine exam. To assess cranial nerve X11 ( hypoglossia) nurse should test?

Answer 12

protrude tongue

Question 13

which WBC is most numerous?

Answer 13

neutrophils

Question 14

nurse should teach client about what potential risk factor for the development of colon cancer?

Answer 14

history of inflammatory disease

Question 15

diabetes pt says if I avoid carbs my diet will be okay. Nurse should reply on the knowledge that diabetes affects which nutrients

Answer 15

carbs

Question 16

focused assessment of bladder cancer includes looking for what common sign?

Answer 16

hematuria

Question 17

how to explain to female elderly decreasing in height

Answer 17

related to menopause and loss of bone density

Question 18

21 days post hemicolectomy. pt having difficulty maintaining an adequate intake of metabolic needs for optimal healing. The nurse should recommend?

Answer 18

nasogastric feeding tube with protein supplement

Question 19

which combination of adverse affect should be monitored when administering IV insulin to a patient with diabetic ketoacidosis

Answer 19

hypoglycemia and hyperkalemia

Question 20

a client is scheduled to receive PHY through a nasogastric tube and has a tube feeding supplement bed is elevated to 30 degrees. prior to administering med nurse should?

Answer 20

flush with water

Question 21

medical nurse educator is reviewing a clients recent episode of metabolic acidosis with members of the nursing staff. what should the educator describe as the role of the kidneys in metabolic acidosis? (acid)

Answer 21

kidneys excrete hydrogen (acid pee) ions and conserve bicarbonate (tums) ions to help restore balance

Question 22

A client has been prescribed hydrochlorothiazide (potasium conserver) to treat heart failure. The nurse should tell the client to report…

Answer 22

muscle weakness ( pee out potasium, lack of potasium)

Question 23

a client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?

Answer 23

the severity of discomfort isnt related to the size of varicoities.

Question 24

Primary cancer prevention program an oncology nurse answers questions from the public at a health laryngeal cancer

Answer 24

laryngeal cancer is one of the most preventable types of cancer

Question 25

client with thrombocytopenia secondary to leukemia develops epistatxis, The nurse should instruct

Answer 25

sit up lean forward

Question 26

nurse is caring for a client with a chest tube inserted 12 hours ago for tx of pleural effusion. Which assessment is more determining the clients response to the treatment?

Answer 26

breathing dif

Question 27

a client with venous insufficiency

Answer 27

the severity of discomfort isnt related to the size of varicosites

Question 28

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority?

Answer 28

deficient fluid volume related to osmotic diuresis

Question 29

which registered nurse should be assigned to the patient who had a chest tube yesterday?

Answer 29

cardiovascular

Question 30

pt reports dull headache, and dizziness, increased pulse rate. The results of arterial bld gas analysis are aa follows; PH pressure of carbon dioxide 50mm, 6.7kpa, bicarbonate 24. These findings indicate which of the following imbalances?

Answer 30

respiratory acidosis

Question 31

the nurse should teach the patient with hep A

Answer 31

increase carbs and protein diet

Question 32

routine check up for aids pt; most common cancer

Answer 32

Kaposi sarcoma

Question 33

pt with choleithasis has a gallstones lodge in common bile duct. When assessing the client the nurse expects to note;

Answer 33

pale stools.. clay like

Question 34

which one of the following expected outcomes about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer?

Answer 34

learn self admin of feeds every 4

Question 35

pt with trach tube, 3 days post insertion, what should nurse do?

Answer 35

sterile catheter each time suctioning

Question 36

pt with T5 spinal injury. Pt on bed rest, foley catheter. C/o headache, diaphoresis/ nausea. What is the nursing priority?

Answer 36

removing any stimulus to skin

Question 37

which of the following assessment findings in an elderly client require intervention?

Answer 37

change in mole/ elevated irregularly shaped mole

Question 38

pt with blistering wounds cause NYD chemical agent. Intervention?

Answer 38

irrigate with water

Question 39

assessment of pt with tracheotomy tube. Pt has bilateral upper lobe ronchi. Unable to cough up secretions. Intervention?

Answer 39

sterile suction

Question 40

pt dx with skull fracture post MVA, presents with increased drowsiness. Pt is at risk for?

Answer 40

concussion

Question 41

complication of trach tube

Answer 41

damage to laryngeal nerve

Question 42

pt with above knee amputation, develops dime size red spot on dressing 45 minutes post recovery.

Answer 42

reinforce dressing

Question 43

stroke pt, transferred to rehab. Neurological deficit that could lead to skin break down?

Answer 43

inability to express need r | incontinence

Question 44

Pt with right hip fracture, right hip pain, unable to move. Further assess right leg to determine..

Answer 44

Shorter than unaffected leg

Question 45

Humlin 70/30 contains what ?

Answer 45

70% NPH and 30% regular

Question 46

elderly pt thrombotic CVA, right side flaccid. When planning care rehab starts with?

Answer 46

on admission

Question 47

pt being treated for iron deficiency anemia with ferrous sulfate. Assess for use of which medicine? ( when anemia continues)

Answer 47

aluminum hydroxide

Question 48

pt receiving antibiotics to treat gram negative bacterial infection.pt having adverse effect d/t desctuction of norm flora in stomach

Answer 48

diahrea

Question 49

assessing a client with atrial septal defect (ASD). What requires immediate intervention?

Answer 49

bubbling in water chamber or | serous drainage in chamber

Question 50

Nurse planning a discharge, for stroke patient with right sided weakness. Family concerned about continued rehab on discharge

Answer 50

Inform case manager

Question 51

Client with COPD develops cor pulmonale. What assessment data would alert the nurse

Answer 51

Edema and neck vein distended

Question 52

Or undergoes cystoscope, which assessment is most appropriate

Answer 52

Asses urine for excessive bleeding

Question 53

Pt with chest tube. Chest tube accidentally disconnects. What to do?

Answer 53

Clamp it

Question 54

W/C Pt comes for follow up of pressure ulcers on buttocks. Family changing hydocolliod drsgs every 3-5 days. Past few weeks, less time in chair, use of cushion. During follow up, no cushion, dry dressing, how should nurse respond?

Answer 54

Ask client to explain treatment regimine

Question 55

After evaluating a pt for hypertension, doc orders 50mg atenol. What therapeutic effect is expected?

Answer 55

Decreased cardiac output, decrease systolic and diastolic

Question 56

Pt with abdominal distension, sharp pains, distinct rhythmic pulsation to mid line. Vss. Prioritiy intervention

Answer 56

Asculate for bruit and notify doc of findings

Question 57

Nurse teaches pt with type 1 diabetes, maintaining stable blood glucose levels. Nurse should suggest ? To minimize the rise in bold sugars post meals

Answer 57

Fiver Meats Dairy

Question 58

How long does iv Lasix take to work on heart failure

Answer 58

30-60 min

Question 59

Post transverse colectomy. Anxious, pain 8/10, sbg 7.8

Answer 59

Priority pain. Give morphine

Question 60

Developing a long term care plan for the client with multiple sclerosis, nurse should teach prevention of?

Answer 60

Contractures

Question 61

``` On admission PH 7.2 PA02 64, PaCO2 60 and HCO3-22. Chest tube inserted oxygen at 4l, 30 min post repeat abgs= Ph 7.3 pao2 76, paco2 50, hco3 22 ```

Answer 61

Improving resp status

Question 62

Colchine for gout, watch for ? adverse reaction

Answer 62

Diarrhea

Question 63

0xygen is at 2l/min for COPD.y?

Answer 63

Co2 retention---

Question 64

Terminal cancer patient in hospice. How to treat nausea and vomiting

Answer 64

Iv antiemetic

Question 65

Pt prescribed hydrochlorothizide | Tell patient to watch for

Answer 65

Weakness

Question 66

60yr old in ER. Substernal chest pain. Radiates to shoulder and left arm. Dx of acute MI. Admission rx of o2 4l/p nasal cannula, Cbc, 12 lead ecg, chest radiograph, 2mg morphine. First task?

Answer 66

Morphine

Question 67

Oxygen at 2l per min for COPD because? | Low therapy because

Answer 67

H

Question 68

The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?

Answer 68

B-type natriuretic peptide (BNP). The client's symptoms suggest heart failure. BNP is a neurohormone that is released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure; and, as the BNP level increases, the severity of heart failure increases. Potassium levels are not affected by heart failure. CRP is an indicator of inflammation. It is used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding or clotting abnormalities, such as those seen with an abnormal platelet count.

Question 69

a fourth hear sound indicates

Answer 69

failure of ventricle ( weak) to eject all blood

Question 70

pt day 3, post abd surgery. no bowel movement but passing gas.

Answer 70

ambulate 3x per day

Question 71

er patient acute heart failure. What lab values do you check prior to admin medication.

Answer 71

platelets

Question 72

pt with rib fractures, pneuomothroax, chest tube. fluid in water seal column fluctuating with each breath. A client’s chest tube is connected to a chest tube drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that

Answer 72

the chest tube system is functioning properly. Fluctuation of fluid with respirations in the water-seal column indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when bubbling occurs in the water-seal column.

Question 73

seeks medical attention after developing acute abdominal pain

Answer 73

auscultate with bell of stethoscope

Question 74

The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first?

Answer 74

older adult tia

Question 75

nurse is preparing to administer blood to a client who requires postoperative blood replacement. the nurse should use a blood administration set that

Answer 75

must be filtered

Question 76

newly diagnosed with radiation induced thrombocytopenia the nurse should include which intervention in the care plan

Answer 76

inspect skin for petechie

Question 77

doctor told my wife cervical cancer is curable. Is he just trying to make us feel better

Answer 77

true cure rate is almost 100%

Question 78

client has severe diarrhea that has lasted for two days nurse should assess for

Answer 78

arrhythmia