CCN

Question 1

The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client?

Diabetes insipidus.
Crohns disease.
Narcotic addiction.
Peritonitis

Answer 1

Narcotic addiction.

Question 2

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit?

Hematochezia
Left upper abdominal pain
Ascites and peripheral edema
Temperature over 102o F (38.9o C)

Answer 2

Left upper abdominal pain

Question 3

The male client diagnosed with chronic pancreatitis calls and reports to the clinic nurse that he has been having a lot of “gas,” along with frothy and very foul-smelling stools. Which action should the nurse take?

Explain that this is common for chronic pancreatitis.
Ask the client to bring in a stool specimen to the clinic
Arrange an appointment with the HCP for today.
Discuss the need to decrease fat in the diet so that this won’t happen.

Answer 3

Arrange an appointment with the HCP for today.

Question 4

A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen’s sign. Which of the following is an appropriate action by the nurse to identify this finding?

Tap lightly at the costovertebral margin on the clients back
Palpate the client’s right lower quadrant
Inspect the skin around the umbilicus
Auscultate the area below the client’s scapula

Answer 4

Inspect the skin around the umbilicus

Question 5

A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider?

A. History of cholelithiasis
B. Serum amylase levels three times greater than the expected value
C. client report of severe pain radiating to the back that is rated at an “8”
D. Hand spasms present when blood pressure is checked

Answer 5

D. Hand spasms present when blood pressure is checked

Question 6

Pancreatitis is commonly characterized by:

Edema and inflammation
Pleural effusion.
Sepsis,
Disseminated intravascular coagulopathy.

Answer 6

Edema and inflammation

Question 7

Nursing measures for pain relief for pancreatitis include:

A. Encouraging bed rest to decrease metabolic rate,
B. Teaching the patient about the correlation between alcohol intake and pain.
C. Withholding oral feedings to limit the release of secretin.
D. All of the above.

Answer 7

D. All of the above.

Question 8

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient’s plan of care?

A. Immediately start enteral feeding to prevent malnutrition.
B. Insert an NG and maintain NPO status to allow pancreas to rest.
C. Initiate early prophylactic antibiotic therapy to prevent infection.
D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

Answer 8

B. Insert an NG and maintain NPO status to allow pancreas to rest.

Question 9

The client is diagnosed with acute pancreatitis. Which health care provider’s admitting order should the nurse question?

Bed rest with bathroom privileges
Initiate IV therapy at D5W 125 mL/hr.
Weigh client daily.
Low-fat, low-carbohydrate diet.

Answer 9

Low-fat, low-carbohydrate diet.

Question 10

A nurse is completing an admission assessment of a lient who has pancreatitis. Which of the following findings should the nurse expect?

Pain in the UG rating to the shoulder
Report of pain being worse when sitting upright
Pain relieved with defecation
Epigastric pain radiating to the left shoulder

Answer 10

Epigastric pain radiating to the left shoulder

Question 11

The cllent has just had an endoscopic retrograde cholangiopancreatogram (ERCP). Which post-procedure interyention should the nurse implement?

Assess for rectal bleeding.
Increase fluid intake.
Assess gag reflex
Keep in supine position.

Answer 11

Assess gag reflex

Question 12

The client with an acute exacerbation of chronic pancreatitis has a nasogastric tube and is NPO. Which interventions should the nurse implement? Select all that apply.

Monitor the bowel sounds
Weigh the client daily.
Assess the intravenous site.
Provide oral and nasal care.
Monitor the blood glucose

Answer 12

Monitor the bowel sounds
Weigh the client daily.
Assess the intravenous site.
Provide oral and nasal care.
Monitor the blood glucose

Question 13

Which of the following diagnostic studies could identify an increase in the diameter of the pancreas?

X-ray.
Hemoglobin and hematocrit levels.
Utrasound.
serum amylase

Answer 13

Utrasound

Question 14

.

Question 15

.

Question 16

A major symptom of pancreatitis that brings the patient to medical care is:

Severe abdominal pain.
Fever.
Jaundice.
Mental agitation.

Answer 16

Severe abdominal pain.

Question 17

The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?

Recommend lying in the prone position with legs extended.
Maintain a tripod position over the bedside table.
Place in side-lying position with knees flexed.
Encourage a supine position with a pillow under the knees.

Answer 17

Place in side-lying position with knees flexed

Question 18

The nurse is preparing to administer A.M. medications to the following clients. Which medication should the nurse question before administering?

A. Pancreatic enzymes to the client who has finished breakfast.
B. The pain medication, morphine, to the client who has a respiratory rate of 20.
C. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L.
D. The beta blocker to the client who has an apical pulse of 68 bpm,

Answer 18

A. Pancreatic enzymes to the client who has finished breakfast.

Question 19

The nurse is completing discharge teaching to the client diagnosed with acute pancre- atitis. Which instruction should the nurse discuss with the client?

A. Instruct the client to decrease alcohol intake.
B. Explain the need to avoid all stress.
C. Discuss the importance of stopping smoking
D. Teach the correct way to take pancreatic enzymes.

Answer 19

C. Discuss the importance of stopping smoking

Question 20

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:

Serum calcium
Serum lipase
Serum bilirubin
Serum amylase.

Answer 20

Serum lipase

Question 21

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient’s increased risk of bleeding. The nurse recognizes that this risk is related to the patient’s inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?

A. Alterations in glucose metabolism
B. Retention of bile salts
C. Inadequate production of albumin by hepatocytes
D. Inability of the liver to use vitamin K

Answer 21

D. Inability of the liver to use vitamin K

Question 22

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient’s liver?

A. Place hand under the right lower abdominal quadrant and press down lightly with the otherhand.
B. Place the left hand over the abdomen and behind the left side at the 11th rib.
C. Place hand under right lower rib cage and press down lightly with the other hand.
D. Hold hand 90 degrees to right side of the abdomen and push down firmly

Answer 22

C. Place hand under right lower rib cage and press down lightly with the other hand.

Question 23

.

Question 24

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Question 25

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Question 26

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Answer 27

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Question 28

W hich of the following is considered a “hallmark” symptom of pancreatitis?

Vomiting
Mid-epigastric pain that radiates to the back
Gradual onset of pain
Alcohol consumption

Answer 28

Mid-epigastric pain that radiates to the back

Question 29

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings?

Malnutrition
Osteomyelitis
Alcohol abuse
Diabetes mellitus

Answer 29

Alcohol abuse

Question 30

Which of the following can be used in the treatment of acute pancreatitis? Select all that apply.

Parenteral fluids
Nasogastric suctioning
Corticosteroids
H2 receptor antagonists
Narcotics or Demerol
Surgical resection of the pancreas

Answer 30

Parenteral fluids
Nasogastric suctioning
H2 receptor antagonists
Narcotics or Demerol

Question 31

Which lab test result would indicate that Mr. Walker has acute pancreatitis?

Elevated bilirubin levels
Elevated serum lipase and amylase levels
Low white blood cell count
Elevated blood alcohol level

Answer 31

Elevated serum lipase and amylase levels

Question 32

A nurse is completing nutritional teaching for a client who has pancreatitis, Which of the following statements by the client indicates an understanding of the teaching? (SATA)

A. plan to eat small, frequent meals.
B. I will eat easy-to-digest foods with limited spice
C. I will use skim milk when cooking
D. I plan to drink regular cola
E. I will limit alcohol intake to two drinkers per day

Answer 32

A. plan to eat small, frequent meals.
B. I will eat easy-to-digest foods with limited spice
C. I will use skim milk when cooking

Question 33

Nursing management of the patient with acute pancreatitis includes: (SATA)

A. Check for signs of hypocalcemia
B. Provide a diet low in carbohydrates
C. Observing stools for signs of steatorhea
D. Giving insulin based on sliding scale
E. Monitoring fot infection, particularly respiratory tract infection

Answer 33

A. Check for signs of hypocalcemia
E. Monitoring fot infection, particularly respiratory tract infection

Question 34

What client problem has a priority for the client diagnosed with acute pancreatitis?

A. Risk for fluid volume deficient
B. Alteration in comfort
C. Imbalanced nutrition: less than the body requires
D. Knowledge deficient

Answer 34

B. Alteration in comfort

Question 35

The patient with HHS presented with a glucose levetl of 800 mg/dL and is started on IV fluids and insulin. What action do you anticipate when the patient’s glucose reaches 250 mg/dL?

A. Administer an intravenous (IV) solution with 5% dextrose.
B Administer sodium polystyrene sulfate (Kayexalate).
C. Slow the IV infusion rate to 40 mL/hour.
D.Assess cardiac monitoring for peaked T waves.

Answer 35

A. Administer an intravenous (IV) solution with 5% dextrose.

Question 36

What is a typical finding of hyperosmolar hyperglycemic syndrome (HHS)?

A. Occurs in type 1 diabetes as the presenting symptom
B. Slow onset resulting in a blood glucose level greater than 600 mg/dL
C. Ketone bodies higher than 4+ in urine
D. Signs and symptoms of diabetes insipidus

Answer 36

B. Slow onset resulting in a blood glucose level greater than 600 mg/dL

Question 37

A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessment of the patient, you suspect DKA rather than HHS based on the finding of

A. polyuria.
B. severe dehydration.
C. rapid, deep respirations.
D. decreased serum potassium.

Answer 37

C. rapid, deep respirations.

Question 38

What is a finding in DKA that is not seen in hyperosmolar hyperglycemic syndrome (HHS)?

A. Glucose level above 400 mg/dL
B. Hyperkalemia
C. Ketones in blood
D. Urine output of 30 mL/hr

Answer 38

C. Ketones in blood

Question 39

Which assessment is the most sensitive indicator that the lV fluid administration may be too rapid when treating a patient with DKA and a history of renal disease?

A. Pedal edema
B. Tachypnea
C. Urine output of 40 mL/hour
D. Change in the level consciousness

Answer 39

D. Change in the level consciousness

Question 40

The patient presents to emergency department with a glucose level of 400 rg/dL, ketone result of 2+, and rapid respirations with fruity odor. What finding do you anticipate?

A. pH below 7.30
B. Urine specific gravity below 1.005
C. High sodium bicarbonate levels
D. Low blood urea nitrogen (BUN) level

Answer 40

A. pH below 7.30

Question 41

The patient in the emergency department is diagnosed with diabetic ketoacidosis. Which laboratory value is essential for you to monitor?

A. Magnesium (Mg)
B. Hemoglobin (H)
C. White blood cells (WBCs)
D. Potassium (K)

Answer 41

D. Potassium (K)

Question 42

The patient with type 1 diabetes arrives in the emergency department with a glucose level of 390 mg/dL and positive result for ketones. Vital signs are 110/70 mm Hg, 120 beats/minute and 28 deep, sighing respirations/minute. What is the priority need for the patient?

A. Oxygen
B. Intravenous (IV) fluids
C. Albuterol (Ventolin)
D. Metformin (Glucophage)

Answer 42

B. Intravenous (IV) fluids

Question 43

The patient has type 1 diabetes mellitus and is found unresponsive with cool and clammy skin. What action is a priority?

A. Obtain a serum glucose level.
B. Give hard candy under the tongue.
C. Administer glucagon per standing order
D. Notify the health care provider.

Answer 43

C. Administer glucagon per standing order

Question 44

The client diagnosed with acute pancreatitis is being discharged home. Which statement by the client indicates the teaching has been effective?

1. “I should decrease my intake of coffee, tea, and cola.”
2. “I will eat a low-fat diet and avoid spicy foods.”
3. “I will check my amylase and lipase levels daily.”
4. “I will return to work tomorrow but take it easy.”

Answer 44

2. “I will eat a low-fat diet and avoid spicy foods.”

Question 45

The nurse is assessing a client with complaints of vague upper abdominal pain that is worse at night but is relieved by sitting up and leaning forward. Which assessment question should the nurse ask next?

1. “Have you noticed a yellow haze when you look at things?”
2. “Does the pain get worse when you eat a meal or snack?”
3. “Have you had your amylase and lipase checked recently?”
4. “How much weight have you gained since you saw the HCP?”

Answer 45

2. “Does the pain get worse when you eat a meal or snack?”

Question 46

The nurse caring for a client diagnosed with cancer of the pancreas writes the collaborative problem of “altered nutrition.” Which intervention should the nurse include in the plan of care?

1. Continuous feedings via PEG tube.
2. Have the family bring in foods from home.
3. Assess for food preferences.
4. Refer to the dietitian.

Answer 46

4. Refer to the dietitian.

Question 47

The client is being admitted to the outpatient department prior to an endoscopic retrograde cholangiopancreatogram (ERCP) to rule out cancer of the pancreas. Which pre-procedure instruction should the nurse teach?

1. Prepare to be admitted to the hospital after the procedure for observation.
2. If something happens during the procedure, then emergency surgery will be done.
3. Do not eat or drink anything after midnight the night before the test.
4. If done correctly, this procedure will correct the blockage of the stomach.

Answer 47

3. Do not eat or drink anything after midnight the night before the test.

Question 48

The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which should be the first intervention implemented by the nurse?

1. Start an IV with D5W.
2. Notify the health-care provider.
3. Perform a bedside glucose check.
4. Give the client some orange juice.

Answer 48

3. Perform a bedside glucose check.

Question 49

Which client problem is the nurse’s priority concern for the client diagnosed with acute pancreatitis?

1. Impaired nutrition.
2. Skin integrity.
3. Anxiety.
4. Pain relief.

Answer 49

4. Pain relief.

Question 50

Which laboratory data indicate the client’s pancreatitis is improving?

1. The amylase and lipase serum levels are decreased.
2. The white blood cell count (WBC) is decreased.
3. The conjugated and unconjugated bilirubin levels are decreased.
4. The blood urea nitrogen (BUN) serum level is decreased.

Answer 50

1. The amylase and lipase serum levels are decreased.

Question 51

The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

1. Deep tendon reflexes.
2. Arterial blood gases.
3. Skin turgor.
4. Capillary refill time.

Answer 51

1. Deep tendon reflexes.

Question 52

Inside the pancreas are special cells that secrete digestive enzymes and hormones. The cells that secrete digestive enzymes are known as ______________ cells.

A. Islet of Langerhans
B. Protease
C. Acinar
D. Amylase

Answer 52

C. Acinar

Question 53

From the pancreas and gallbladder, the common bile duct and pancreatic duct open into the ____________ where digestive enzymes and bile flow into the duodenum via the major duodenal papilla which is surrounded by a muscular valve that controls the release of digestive enzymes known as the ______________.

A. ampulla of vater, sphincter of Oddi
B. papilla of vater, sphincter of Oddi
C. minor duodenal papilla, ampulla of vater
D. jejunum, sphincter of pylori

Answer 53

A. ampulla of vater, sphincter of Oddi

Question 54

Select-ALL-that-apply: In the pancreas, the acinar cells release:

A. Amylase
B. Somatostatin
C. Lipase
D. Protease

Answer 54

A. Amylase
C. Lipase
D. Protease

Question 55

You’re caring for a 45 year old patient who is admitted with suspected acute pancreatitis. The patient reports having extreme mid-epigastric pain that radiates to the back. The patient states the pain started last night after eating fast food. As the nurse, you know the two most common causes of acute pancreatitis are:

A. High cholesterol and alcohol abuse
B. History of diabetes and smoking
C. Pancreatic cancer and obesity
D. Gallstones and alcohol abuse

Answer 55

D. Gallstones and alcohol abuse

Question 56

Which patient below is at MOST risk for CHRONIC pancreatitis?

A. A 25 year old female with a family history of gallstones.
B. A 35 year old male who reports social drinking of alcohol.
C. A 15 year old female with cystic fibrosis.
D. A 66 year old female with stomach cancer.

Answer 56

C. A 15 year old female with cystic fibrosis.

Question 57

Your patient with acute pancreatitis is scheduled for a test that will use a scope to assess the pancreas, bile ducts, and gallbladder. The patient asks you, “What is the name of the test I’m going for later today?” You tell the patient it is called:

A. MRCP
B. ERCP
C. CT scan of the abdomen
D. EGD

Answer 57

B. ERCP

Question 58

A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called?

A. Grey-Turner’s Sign
B. McBurney’s Sign
C. Homan’s Sign
D. Cullen’s Sign

Answer 58

D. Cullen’s Sign

Question 59

While assisting a patient with chronic pancreatitis to the bathroom, you note the patient’s stool to be oily/greasy in appearance. In your documentation you note this as:

A. Steatorrhea
B. Melena
C. Currant
D. Hematochezia

Answer 59

A. Steatorrhea

Question 60

A patient with acute pancreatitis is reporting excessive thirst, excessive voiding, and blurred vision. As the nurse, it is priority you?

A. Reassure the patient this is normal with pancreatitis
B. Check the patient’s blood glucose
C. Assist the patient with drinking a simple sugar drink like orange juice
D. Provide a dark and calm environment

Answer 60

B. Check the patient’s blood glucose

Question 61

A patient who received treatment for pancreatitis is being discharged home. You’re providing diet teaching to the patient. Which statement by the patient requires immediate re-education about the diet restrictions?

A. “It will be hard but I will eat a diet low in fat and avoid greasy foods.”
B. “It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week.”
C. “I will concentrate on eating complex carbohydrates rather than refined carbohydrates.”
D. “I will purchase foods that are high in protein.”

Answer 61

B. “It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week.”

Question 62

The physician orders a patient with pancreatitis to take a pancreatic enzyme. What assessment finding demonstrates the pancreatic enzymes are working properly?

A. Abdominal girth is decreased
B. Skin turgor is less than 2 seconds
C. Blood glucose is 250
D. Stools appear formed and solid

Answer 62

D. Stools appear formed and solid

Question 63

During a home health visit, you are assessing how a patient takes the prescribed pancreatic enzyme. The patient is unable to swallow the capsule whole, so they open the capsule and mix the beads inside the capsule with food/drink. Which food or drink is safe for the patient to mix the beads with?

A. Pudding
B. Ice cream
C. Milk
D. Applesauce

Answer 63

D. Applesauce

Question 64

Which of the following is not a sign or symptom of Diabetic Ketoacidosis?

Positive Ketones in the urine
Oliguria
Polydipsia
Abdominal Pain

Answer 64

Oliguria

Question 65

A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal regular insulin N bolus and then 10 Saline and 10 units of intravenous start an insulin drip, per protocol. The, the following. pH labs are Glucose 455, potassium 2.5 5. Which of the following is the most appropriate nursing intervention to perform next?

A. Start the IV fluids and administer the
B. Hold the insulin and notify the doctor of the potassium level of 2. 5.
C. Hold IV fluids and administer insulin as ordered

Answer 65

B. Hold the insulin and notify the doctor of the potassium level of 2. 5.

Question 66

When priming the tubing for, an Insulin infusion it is best practice to waste 50 cc to 100cc of insulin prior to starting the infusion because insulin absorbs into the plastic lining of the tubing.

True
False

Answer 66

True

Question 67

You are providing care to a patient experiencing diabetic ketoacidosis. The patient IS on an insulin drip and their current glucose level is 300. In addition to this, the patient also has 5% Dextrose 0.45% NS infusing in the right antecubital vein. Which of the following patient signs/symptoms causes concern?

A. Patient complains of thirst.
B. Patient has a potassium level of 2 3
C. Patient’s skin and mucous membranes are dry.
D. Patient is nauseous.

Answer 67

B. Patient has a potassium level of 2.3

Question 68

What type of insulin do you expect the doctor to order for treatment of DKA?*

A. IV Novolog
B. IV Levemir
C. IVN PH
D. IV Regular Insulin

Answer 68

D. IV Regular Insulin

Question 69

A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition?*

A. “I should not be alarmed if ketones are present in my urine because this is expected during illness.”
B. “It is normal for my blood sugar to be 250-350 mg/dL while I’m sick.”
C. “I will hold off taking my insulin while I’m sick.”
D. “It is important I check my blood glucose every 3-4 hours when I’m sick and consume liquids.”

Answer 69

D. “It is important I check my blood glucose every 3-4 hours when I’m sick and consume liquids.”

Question 70

Which patient is MOST likely to develop Diabetic Ketoacidosis?*

A. A 25 year old female newly diagnosed with Cushing’s Disease is taking glucocorticoids.
B. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin.
C. A 35 year old female newly diagnosed with Type 2 diabetes.
D. None of the options are correct.

Answer 70

B. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin.

Question 71

Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply:

A. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction.
B. A 55 year old female with a health history of asthma and hypoparathyroidism.
C. A 30 year old male with a history of endocarditis and has severe mitral stenosis.
D. A 45 year old female with lung cancer stage 2.
E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.

Answer 71

A. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction.
C. A 30 year old male with a history of endocarditis and has severe mitral stenosis.
E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.

Question 72

A patient is being discharged home after hospitalization of left ventricular systolic dysfunction. As the nurse providing discharge teaching to the patient, which statement is NOT a correct statement about this condition?

A. “Signs and symptoms of this type of heart failure can include: dyspnea, persistent cough, difficulty breathing while lying down, and weight gain.”
B. “It is important to monitor your daily weights, fluid and salt intake.”
C. “Left-sided heart failure can lead to right-sided heart failure, if left untreated.”
D. “This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema.”

Answer 72

D. “This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema.”

Question 73

Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply:

A. Jugular venous distention
B. Persistent cough
C. Weight gain
D. Crackles
E. Nocturia
F. Orthopnea

Answer 73

B. Persistent cough
D. Crackles
F. Orthopnea

Question 74

A patient is diagnosed with left-sided systolic dysfunction heart failure. Which of the following are expected findings with this condition?

A. Echocardiogram shows an ejection fraction of 38%.
B. Heart catheterization shows an ejection fraction of 65%.
C. Patient has frequent episodes of nocturnal paroxysmal dyspnea.
D. Options A and C are both expected findings with left-sided systolic dysfunction heart failure.

Answer 74

D. Options A and C are both expected findings with left-sided systolic dysfunction heart failure.

Question 75

Patients with left-sided diastolic dysfunction heart failure usually have a normal ejection fraction.

True
False

Answer 75

True

Question 76

A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation?

A. “I’ve noticed that I’ve gain 6 lbs in one week.”
B. “While I sleep I have to prop myself up with a pillow so I can breathe.”
C. “I haven’t noticed any swelling in my feet or hands lately.”
D. Options B and C are correct.
E. Options A and B are correct.
F. Options A, B, and C are all correct.

Answer 76

E. Options A and B are correct.

Question 77

Patients with heart failure can experience episodes of exacerbation. All of the patients below have a history of heart failure. Which of the following patients are at MOST risk for heart failure exacerbation?

A. A 55 year old female who limits sodium and fluid intake regularly.
B. A 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation.
C. A 67 year old female who is being discharged home from heart valve replacement surgery.
D. A 78 year old male who has a health history of eczema and cystic fibrosis.

Answer 77

B. A 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation.

Question 78

A 74 year old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure?

A. K+ 5.6
B. BNP 820
C. BUN 9
D. Troponin <0.02

Answer 78

B. BNP 820

Question 79

Which of the following tests/procedures are NOT used to diagnose heart failure?

A. Echocardiogram
B. Brain natriuretic peptide blood test
C. Nuclear stress test
D. Holter monitoring

Answer 79

D. Holter monitoring

Question 80

What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath.

A. Left ventricular systolic dysfunction
B. Left ventricular ride-sided dysfunction
C. Right ventricular diastolic dysfunction
D. Left ventricular diastolic dysfunction

Answer 80

D. Left ventricular diastolic dysfunction

Question 81

A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention?

A. Encourage the patient to cough and deep breathe.
B. Place the patient in Semi-Fowler’s position.
C. Assist the patient into High Fowler’s position.
D. Perform chest percussion therapy.

Answer 81

C. Assist the patient into High Fowler’s position

Question 82

You’re providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching?

A. “I will limit my sodium intake to 5-6 grams a day.”
B. “I will be sure to incorporate canned vegetables and fish into my diet.”
C. “I’m glad I can still eat sandwiches because I love bologna and cheese sandwiches.”
D. “I will limit my consumption of frozen meals.”

Answer 82

D. “I will limit my consumption of frozen meals.”

Question 83

A patient taking Digoxin is experiencing severe bradycardia, nausea, and vomiting. A lab draw shows that their Digoxin level is 4 ng/mL. What medication do you anticipate the physician to order for this patient?

A. Narcan
B. Aminophylline
C. Digibind
No medication because this is a normal Digoxin level.

Answer 83

C. Digibind

Question 84

Which of the following is a late sign of heart failure?

A. Shortness of breath
B. Orthopnea
C. Edema
D. Frothy-blood tinged sputum

Answer 84

D. Frothy-blood tinged sputum

Question 85

These drugs are used as first-line treatment of heart failure. They work by allowing more blood to flow to the heart which decreases the work load of the heart and allows the kidneys to secrete sodium. However, some patients can develop a nagging cough with these types of drugs. This description describes?

A. Beta-blockers
B. Vasodilators
C. Angiotensin II receptor blockers
D. Angiotensin-converting-enzyme inhibitors

Answer 85

D. Angiotensin-converting-enzyme inhibitors

Question 86

A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings?

A. Na+ 135
B. BNP 560
C. K+ 8.0
D. K+ 1.5

Answer 86

C. K+ 8.0

Question 87

You are assisting a patient up from the bed to the bathroom. The patient has swelling in the feet and legs. The patient is receiving treatment for heart failure and is taking Hydralazine and Isordil. Which of the following is a nursing priority for this patient while assisting them to the bathroom?

A. Measure and record the urine voided.
B. Assist the patient up slowing and gradually.
C. Place the call light in the patient’s reach while in the bathroom.
D. Provide privacy for the patient.

Answer 87

B. Assist the patient up slowing and gradually.

Question 88

A patient is taking Digoxin. Prior to administration you check the patient’s apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5 ng/mL. Which of the following is the correct nursing action?

A. Hold this dose and administer the second dose at 1800.
B. Administer the dose as ordered.
C. Hold the dose and notify the physician of the digoxin level.
D. Hold this dose until the patient’s potassium level is normal.

Answer 88

C. Hold the dose and notify the physician of the digoxin level.

Question 89

Which of the following is a common side effect of Spironolactone?
A. Renal failure
B. Hyperkalemia
C. Hypokalemia
D. Dry cough

Answer 89

B. Hyperkalemia

Question 90

The physician’s order says to administered Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0, and BUN 10. Which of the following is a nursing priority?

A. Administer the Lasix as ordered
B. Notify the physician of the BNP level
C. Assess the patient for edema
D. Hold the dose and notify the physician about the potassium level

Answer 90

D. Hold the dose and notify the physician about the potassium level

Question 91

A 55-year-old female arrives to the ER with a right leg fracture. An x-ray is performed and shows a closed tibia fracture. A closed reduction is performed and a cast is put in place. The patient is ordered Morphine 2 mg IV every 4-6 hours as needed for pain. The patient calls on the call light to tell you the pain medication is not working and that it even hurts to slightly stretch the leg. What is your response to this statement by the patient? Select all that apply:

A. Reassure the patient that this is normal after a bone fracture, and reposition the cast.
B. Re-adjust the cast to ensure it fits snugly against the fracture.
C. Perform neurovascular checks.
D. Elevate the leg above heart level.
E. Loosen and remove restrictive items.
F. Notify the physician.

Answer 91

C. Perform neurovascular checks.
E. Loosen and remove restrictive items.
F. Notify the physician.

Question 92

A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse’s first intervention?

a. Assess pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Document the finding.

Answer 92

a. Assess pedal pulses.

Question 93

The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse?

a. Reported pain of 4 on a scale of 0 to 10
b. Numbness and tingling in the extremity
c. Swollen extremity where the injury occurred
d. Reports of being cold in bed

Answer 93

b. Numbness and tingling in the extremity

Question 94

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient’s toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to

a. Notify the patient’s health care provider.
b. Check the patient’s blood pressure.
c. Assess the external fixator pins for redness or drainage.
d. Elevate the extremity and apply ice over the wound site.

Answer 94

a. Notify the patient’s health care provider.

Question 95

The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse’s response is based on the understanding that:

a. A bone fragment has injured the nerve supply in the area
b. An injured artery causes impaired arterial perfusion through the compartment
c. Bleeding and swelling cause increased pressure in an area that cannot expand
d. The fascia expands with injury, causing pressure on underlying nerves and muscles

Answer 95

c. Bleeding and swelling cause increased pressure in an area that cannot expand

Question 96

A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse’s best response?

a. “Elevate your arm on two pillows and apply ice to the cast.”
b. “Continue to take ibuprofen (Motrin) until the swelling subsides.”
c. “It is normal for a new cast to feel a little tight for the first few days.”
d. “Please come to the clinic today to have your arm checked by the health care provider.”

Answer 96

d. “Please come to the clinic today to have your arm checked by the health care provider.”

Question 97

Which patient below is at MOST risk for developing a condition called autonomic dysreflexia?

A. A 24-year-old male patient with a traumatic brain injury.
B. A 15-year-old female patient with a spinal cord injury at C7.
C. A 35-year-old male patient with a spinal cord injury at L6.
D. A 42-year-old male patient recovering from a hemorrhagic stroke.

Answer 97

B. A 15-year-old female patient with a spinal cord injury at C7.

Question 98

Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action?

A. Perform a bladder scan
B. Perform a rectal digital examination
C. Assess the patient’s blood pressure
D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.

Answer 98

C. Assess the patient’s blood pressure

Question 99

You’re performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient’s blood pressure and heart rate. The patient’s blood pressure is 140/98 and heart rate is 52. You look at the patient’s chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST?

A. Reassess the patient’s blood pressure.
B. Check the patient’s blood glucose.
C. Position the patient at 90 degrees and lower the legs.
D. Provide cooling blankets for the patient.

Answer 99

C. Position the patient at 90 degrees and lower the legs.

Question 100

You’re providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service:

A. Hypoglycemia
B. Distended bladder
C. Sacral pressure injury
D. Fecal impaction
E. Urinary tract infection

Answer 100

B. Distended bladder
C. Sacral pressure injury
D. Fecal impaction
E. Urinary tract infection

Question 101

After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition?

A. Skin break down
B. Blood glucose
C. Possible bladder irritant
D. Last bowel movement

Answer 101

C. Possible bladder irritant

Question 102

The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician?

A. The patient’s blood pressure is 130/80.
B. The patient reports a throbbing headache.
C. The patient’s lower extremities are pale and cool.
D. The patient states they took Sildenafil 12 hours ago.

Answer 102

D. The patient states they took Sildenafil 12 hours ago.

Question 103

A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply:
A. Headache
B. Low blood glucose
C. Sweating
D. Flushed below site of injury
E. Pale and cool above site of injury
F. Hypertension
G. Slow heart rate
H. Stuffy nose

Answer 103

A. Headache
C. Sweating
F. Hypertension
G. Slow heart rate
H. Stuffy nose

Question 104

What is the BEST position for a patient experiencing autonomic dysreflexia?
A. High Fowler’s with legs lowered
B. Low Fowler’s with legs lowered
C. Semi-Fowler’s with legs at heart level
D. Prone

Answer 104

A. High Fowler’s with legs lowered

Question 105

In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury?

A. Flushed lower body
B. Pale and cool lower extremities
C. Low blood pressure
D. Absent reflexes

Answer 105

B. Pale and cool lower extremities

Question 106

Which statements are TRUE about autonomic dysreflexia? Select all that apply:

A. “Autonomic dysreflexia is an exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury.”
B. “Autonomic dysreflexia causes a slow heart rate and severe hypertension.”
C. “Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury.”
D. “The first-line of treatment for autonomic dysreflexia is an antihypertensive medication.”

Answer 106

B. “Autonomic dysreflexia causes a slow heart rate and severe hypertension.”
C. “Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury.”

Question 107

The nurse is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. The nurse makes it priority to?

A. Avoid using lubricants
B. Stimulate the bowel with rectal manipulation
C. Slowly administer a saline solution prior to assessment
D. Instill an anesthetic jelly prior to assessment

Answer 107

D. Instill an anesthetic jelly prior to assessment

Question 108

Select the main structures below that play a role with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater

Answer 108

A. Brain
C. Cerebrospinal Fluid
D. Blood
F. Dura mater

Question 109

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply:

A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
D. Leaking proteins into the brain barrier

Answer 109

B. Vasodilation of cerebral vessels
D. Leaking proteins into the brain barrier

Question 110

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees

Answer 110

A. Coughing
B. Sneezing
D. Valsalva maneuver
E. Vomiting

Question 111

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will?

A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP

Answer 111

C. cause vasodilation and increase the ICP

Question 112

You’re providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, “What is a normal cerebral perfusion pressure level?” Your response is:

A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg

Answer 112

B. 60-100 mmHg

Question 113

Which patient below is at MOST risk for increased intracranial pressure?

A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.

Answer 113

B. A patient who is admitted with a traumatic brain injury.

Question 114

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 ‘F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?

A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
C. Remove extra blankets and give the patient a cool bath
D. Perform suctioning

Answer 114

C. Remove extra blankets and give the patient a cool bath

Question 115

A patient has a ventriculostomy. Which finding would you immediately report to the doctor?

A. Temperature 98.4 ‘F
B. CPP 70 mmHg
C. ICP 24 mmHg
D. PaCO2 35

Answer 115

C. ICP 24 mmHg

Question 116

External ventricular drains monitor ICP and are inserted where?

A. Subarachnoid space
B. Lateral Ventricle
C. Epidural space
D. Right Ventricle

Answer 116

B. Lateral Ventricle

Question 117

Which of the following is contraindicated in a patient with increased ICP?

A. Lumbar puncture
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications

Answer 117

A. Lumbar puncture

Question 118

You’re collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient’s temperature?

A. Rectal
B. Oral
C. Axillary

Answer 118

A. Rectal

Question 119

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?

A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size

Answer 119

C. Restlessness

Question 120

You’re maintaining an external ventricular drain. The ICP readings should be?

A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg

Answer 120

A. 5 to 15 mmHg

Question 121

Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:

A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12

Answer 121

C. BP 200/60, HR 50, RR 8

Question 122

The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient’s cerebral perfusion pressure, and how do you interpret this as the nurse?

A. 90 mmHg, normal
B. 62 mmHg, abnormal
C. 36 mmHg, abnormal
D. 56 mmHg, normal

Answer 122

A. 90 mmHg, normal

Question 123

During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out and toes pointed downward. You will document this as:

A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing

Answer 123

B. Decerebrate posturing

Question 124

While positioning a patient in bed with increased ICP, it important to avoid?

A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips

Answer 124

D. Flexion of the hips

Question 125

During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find?

A. The eyes will roll down as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved side to side.
C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to side

Answer 125

D. The eyes will be in a fixed mid-line position as the head is moved side to side

Question 126

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?

A. Mannitol will remove water from the brain and place it in the blood to be removed from the body.
B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion.
D. Mannitol is not for patients who are experiencing anuria.

Answer 126

B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.