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Hecaress Midterms > Drill 4 > Flashcards

Drill 4 Flashcards

1
Q
  1. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
    a. destroys the odor-proof seal
    b. won’t affect the colostomy system
    c. is appropriate for relieving the gas in a colostomy system
    d. destroys the moisture barrier seal
A

a. destroys the odor-proof seal

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2
Q
  1. When assessing the client with celiac disease, the nurse can expect to find which of the following?
    a. Steatorrhea c. clay-colored stools
    b. jaundiced sclerae d. widened pulse pressure
A

a. Steatorrhea

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3
Q
  1. 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?
    a. deficient fluid volume related to osmotic diuresis
    b. decreased cardiac output related to elevated heart rate
    c. imbalanced nutrition: Less than body requirements related to insulin deficiency
    d. ineffective thermoregulation related to dehydration
A

a. deficient fluid volume related to osmotic diuresis

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4
Q
  1. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Thenurse should expect the dose’s:
    a. onset to be at 2 p.m. and its peak at 3 p.m.
    b. onset to be at 2:15 p.m. and its peak at 3 p.m.
    c. onset to be at 2:30 p.m. and its peak at 4 p.m.
    d. onset to be at 4 p.m. and its peak at 6 p.m.
A

c. onset to be at 2:30 p.m. and its peak at 4 p.m.

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5
Q
  1. A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
    a. Social worker c. occupational therapist
    b. registered dietician
    d. enterostomal nurse therapist
A

d. enterostomal nurse therapist

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6
Q
  1. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?
    a. fluid intake for the last 24 hours
    b. baseline arterial blood gas (ABG) levels
    c. prior outcomes of weaning
    d. electrocardiogram (ECG) results
A

b. baseline arterial blood gas (ABG) levels

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7
Q
  1. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:
    a. esophageal perforation
    c. portal hypertension b. pulmonary hypertension d. peptic ulcers
A

c. portal hypertension

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8
Q
  1. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
    a. A skin rash. C. A dry cough.
    b. Peripheral edema. D. Postural hypotension.
A

b. Peripheral edema.

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9
Q
  1. Which assessment finding indicates dehydration?
    a. Tenting of chest skin when pinched.
    b. Rapid filling of hand veins.
    c. A pulse that isn’t easily obliterated.
    d. Neck vein distention
A

a. Tenting of chest skin when pinched.

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10
Q
  1. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
    a. Avoid focusing on his weight.
    b. Increase his activity level.
    c. Follow a regular diet.
    d. Continue leading a high-stress lifestyle.
A

b. Increase his activity level.

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11
Q
  1. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has:
    a. poor peripheral perfusion
    b. a possible Hematologic problem
    c. a psychosomatic disorder
    d. left-sided heart failure
A

b. a possible Hematologic problem

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12
Q
  1. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?
    a. Putting on sterile gloves then opening a container of sterile saline.
    b. Cleaning the wound with a circular motion, moving from outer circles toward the center.
    c. Changing the sterile field after sterile water is spilled on it.
    d. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.
A

b. Cleaning the wound with a circular motion, moving from outer circles toward the center.

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13
Q
  1. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?
    a. high volumes of fluid intake
    b. aerobic exercise programs
    c. caffeine-containing products
    d. foods rich in protein
A

c. caffeine-containing products

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14
Q
  1. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which organ?
    a. adrenal cortex c. adrenal medulla
    b. pancreas d. parathyroid
A

a. adrenal cortex

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15
Q
  1. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes mellitus, hypertension, pernicious anemia, and appendectomy. She’s admitted to the hospital and undergoes mitral valve replacement surgery. After discharge, the client is scheduled for a tooth extraction. Which history finding is a major risk factor for infective endocarditis?
    a. Appendectomy c. diabetes mellitus
    b. pernicious anemia d. valve replacement
A

d. valve replacement

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16
Q
  1. A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb (4.5 kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?
    a. Let the client eat as desired during the hospitalization.
    b. Weight the client daily.
    c. Ask the client to list what she eats during a typical day.
    d. Place the client on I & O status & draw blood for electrolyte levels.
A

c. Ask the client to list what she eats during a typical day.

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17
Q
  1. When instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave’s disease?
    a. Keep an accurate record of intake and output.
    b. Use nasal desmopressin acetate DDAVP).
    c. Be sure to get regulate follow-up care.
    d. Be sure to exercise to improve cardiovascular fitness.
A

c. Be sure to get regulate follow-up care.

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18
Q
  1. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?
    a. Deficient knowledge related to interventions used to treat acute illness
    b. Impaired physical mobility related to complete bed rest
    c. Social isolation related to restricted visiting hours in the intensive care unit
    d. Anxiety related to the threat of death
A

d. Anxiety related to the threat of death

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19
Q
  1. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the plan of care?
    a. Putting on a mask when entering the client’s room.
    b. Instructing the client to wear a mask at all times
    c. Wearing a gown and gloves when providing direct care
    d. Keeping the door to the client’s room open to observe the client
A

a. Putting on a mask when entering the client’s room.

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20
Q
  1. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:
    a. Apply suction to the NG tube every hour.
    b. Clamp the NG tube if the client complains of nausea.
    c. Irrigate the NG tube gently with normal saline solution.
    d. Reposition the NG tube if pulled out.
A

c. Irrigate the NG tube gently with normal saline solution.

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21
Q
  1. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
    a. administer 2 to 3 L of IV fluid rapidly
    b. administer 6 L of IV fluid over the first 24 hours
    c. administer a dextrose sol’n containing normal saline solution
    d. administer IV fluid slowly to prevent circulatory overload and collapse
A

a. administer 2 to 3 L of IV fluid rapidly

22
Q
  1. Which of the following is an adverse reaction to glipizide (Glucotrol)?
    a. Headache c. Hypotension
    b. Constipation d. Photosensitivity
A

d. Photosensitivity

23
Q
  1. The nurse is caring for four clients on a stepdown intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who:
    a. has a respiratory infection
    b. is intubated and on a ventilator
    c. has pleural chest tubes
    d. is receiving feedings through a jejunostomy tube
A

b. is intubated and on a ventilator

24
Q
  1. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
    a. Make inhalation longer than exhalation.
    b. Exhale through an open mouth.
    c. Use diaphragmatic breathing.
    d. Use chest breathing.
A

c. Use diaphragmatic breathing

25
Q
  1. A physician orders gastric decompression for a client with small bowel obstruction. The nurse should plan for the suction to be:
    a. low pressure and intermittent
    b. low pressure and continuous
    c. high pressure and continuous
    d. high pressure and intermittent
A

a. low pressure and intermittent

26
Q
  1. Because diet and exercise have failed to control a 63 yr-old client’s blood glucose level, the client is prescribed glipizide (Glucotrol). After oral administration, the onset of action is:
    a. 15 to 30 minutes c. 1 to 1 ½ hours
    b. 30 to 60 minutes d. 2 to 3 hours
A

a. 15 to 30 minutes

27
Q
  1. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?
    a. Apnea c. Respiratory alkalosis
    b. Anginal pain d. Metabolic acidosis
A

a. Apnea

28
Q
  1. A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He’s being converted to continuous subcutaneous insulin therapy. While teaching the client bout continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:
    a. intermediate and long-acting insulins
    b. short and long-acting insulins
    c. short-acting only
    d. short and intermediate-acting insulins
A

c. short-acting only

29
Q
  1. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac stepdown unit (CSU). While giving report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:
    a. Hypertension c. dry mucous membranes
    b. high urine output d. pulmonary crackles
A

d. pulmonary crackles

30
Q
  1. For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?
    a. Hypocalcemia c. Hypokalemia
    b. Hypercalcemia d. Hyperkalemia
A

a. Hypocalcemia

31
Q
  1. In a client with enteritis and frequent diarrhea, the nurse should anticipate an acid-base imbalance of:
    a. respiratory acidosis c. metabolic acidosis
    b. respiratory alkalosis d. metabolic alkalosis
A

c. metabolic acidosis

32
Q
  1. Which statement is true about crackles?
    a. They’re grating sounds.
    b. They’re high-pitched, musical squeaks.
    c. They’re low-pitched noises that sound like snoring.
    d. They may be fine, medium, or course.
A

d. They may be fine, medium, or course.

33
Q
  1. A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include:
    a. scheduling her for annual tuberculin skin testing
    b. placing her in quarantine until sputum cultures are negative
    c. gathering a list of persons with whom she has had recent contact
    d. advising her to begin prophylactic therapy with isoniazid (INH)
A

d. advising her to begin prophylactic therapy with isoniazid (INH)

34
Q
  1. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which fact should the nurse include in the teaching plan?
    a. TIA symptoms may last 24 to 48 hours.
    b. Most clients have residual effects after having a TIA.
    c. TIA may be a warning that the client may have cerebrovascular accident (CVA)
    d. The most common symptom of TIA is the inability to speak.
A

c. TIA may be a warning that the client may have cerebrovascular accident (CVA)

35
Q
  1. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
    a. Notify the health care provider (HCP).
    b. Administer the prescribed pain medication.
    c. Call and ask the operating room team to perform surgery as soon as possible.
    d. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
A

a. Notify the health care provider (HCP).

36
Q
  1. The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?
    a. Promote air and pleural drainage
    b. Prevent kinking of the tube
    c. Eliminate the need for a dressing
    d. Eliminate the need for a water-seal drainage
A

d. Eliminate the need for a water-seal drainage

37
Q
  1. The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse?
    a. Decreased pain in the fetal position
    b. Urine output of 35mL/hr
    c. CVP of 12 mmHg
    d. Cardiac output of 5L/min
A

c. CVP of 12 mmHg

38
Q
  1. The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?
    a. Eating mainly bland food and milk or dairy products
    b. Reducing intake of high-fiber foods
    c. Eating small, frequent meals and a bedtime snack
    d. Eliminating intake of alcohol and coffee
A

d. Eliminating intake of alcohol and coffee

39
Q
  1. A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?
    a. NPO
    b. Small feedings of bland food
    c. A regular diet given frequently in small amounts
    d. Frequent feedings of clear liquids
A

b. Small feedings of bland food

40
Q
  1. The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the client?
    a. Orange juice. C. Ginger ale.
    b. Whole milk. D. Black coffee.
A

b. Whole milk.

41
Q
  1. The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that immediately following pneumonectomy; the client should be in what position?
    a. Supine on the unaffected side
    b. Low-Fowler’s on the back
    c. Semi-Fowler’s on the affected side
    d. Semi-Fowler’s on the unaffected side
A

c. Semi-Fowler’s on the affected side

42
Q
  1. The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during the immediate postoperative period following a thyroidectomy?
    a. Assess extremities for weakness and flaccidity
    b. Support the head and neck during position changes
    c. Position the client in high Fowler’s
    d. Medicate for restlessness and anxiety
A

b. Support the head and neck during position changes

43
Q

John is diagnosed with Addison’s disease and admitted in the hospital. What would be the appropriate nursing care for John?
A. Reducing physical and emotional stress
B. Providing a low-sodium diet
C. Restricting Fluids to 1500ml/day
D. Administering insulin-replacement therapy

A

A. Reducing physical and emotional stress

44
Q
  1. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching?
    a. Sleep Pattern disturbance
    b. Impaired physical mobility
    c. Noncompliance
    d. Fluid volume excess
A

c. Noncompliance

45
Q
  1. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective?
    a. Place the client in a lateral position every 2 hour
    b. Splint the patient’s chest with pillows when coughing
    c. Use humified oxygen
    d. Offer fluids at regular intervals
A

d. Offer fluids at regular intervals

46
Q
  1. The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least:
    a. 5 minutes
    b. 60 seconds
    c. 30 seconds
    d. 2 minutes
A

d. 2 minutes

47
Q

A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?
a. Expanding ecchymosis
b. Ascites and serum albumin of 3.2g/dl
c. Slurred speech
d. hematocrit of 37% and hemoglobin of 12g/dl

A

a. Expanding ecchymosis

48
Q

Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will reccomend to:
a. allow plenty of time after the insulin injection and before beginning the match
b. eat a carbohydrate snack before and during the badminton match
c. drink plenty of fluids before, during, and after bed time
d. take insulin just before starting the badminton

A

b. eat a carbohydrate snack before and during the badminton match

49
Q

Mrs. Moore, 62 year old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object peirced the skin until later that evening. What problem does the client most probably have?
a. nephropathy
b. macroangiopathy
c. carpal tunnel syndrome
d. peripheral neuropathy

A

d. peripheral neuropathy

50
Q

After a right lower lobectomy on a 55 year old client, which action should the nurse initiate when the client is transferred from the post anethesia care unit?
a. notify the family to report the client’s condition
b. immediately administer the narcotic as ordered
c. keep client on right side supporteed by pillows
d. encourage coughing and deep breathing every 2 hours

A

d. encourage coughing and deep breathing every 2 hours

Hecaress Midterms (3 decks)

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