Exam 2

Question 1

If a patient with heart failure who is taking both Furosemide and Digoxin develops
muscle cramps, nausea, vomiting, and anxiety. What order would the nurse expect to
receive from the HCP?

Answer 1

Give supplemental K+

Question 2

A patient is 24-hours post right leg injury caused by a shark attack.

Vitals at 0700 were: BP: 102/72, HR: 88, T: 98.2, RR: 12, and O2 96% on 2L

Vitals at 1200 were BP: 86/58, P: 126, T: 98.0, RR: 20, O2 90% on 2L.

The patient is also restless, agitated, and has cold/pale skin. Which interventions are
appropriate for the nurse do? SATA

Answer 2

Give 2 Units RBC
0.9% Normal Saline Bolus

Question 3

A Patient is diagnosed with a UTI, which medication will be ordered?

Answer 3

Bactrim (sulfamexazole)

Question 4

A diabetic patient comes into the office with a Hemoglobin A1C of 8. Their last A1C
was 5.5. Which question should you ask them related to their A1C increase?

Answer 4

“Can you demonstrate drawing up your insulin dose for me?”

Question 5

Which lab value would you report for risk of disseminated intravascular coagulopathy
(DIC)?

Answer 5

Fibrinogen = 85

Question 6

A client comes into the ED with chest pain. The
monitor shows this rhythm. Which intervention should the nurse take? (Strip Shows VTACH)

Answer 6

Evaluate the patient

Question 7

An EKG strip shows multiple PVCs Which intervention should the nurse take?

Answer 7

Check Potassium Levels

Question 8

A patient in end-stage renal disease has thirst, confusion, and dry, flushed skin. Which
intervention should the nurse do?

Answer 8

Give fluids
Restrict sodium intake

Question 9

Which EKG findings suggest an MI? SATA

Answer 9

ST-Elevation
Abnormal Q wave
T-wave inversion

Question 10

A Patient has left-sided heart failure. Which is the most appropriate assessment?

Answer 10

Lung Sounds

Question 11

When teaching a patient about their new hypertension diagnosis, which things would
you include? SATA

Answer 11

Keep a diary of BP readings
Instruct patient to bake, roast, or boil food
Avoid OTC medications

Question 12

With a uric acid kidney stone, which foods should be avoided? SATA

Answer 12

Scallops
Pork
Liver

Question 13

A Patient with known cardiac disease receives a prescription for Isosorbide
mononitrate for angina. He has a history of traumatic brain injury due to dizziness.
Which intervention would the nurse do first?

Answer 13

Perform orthostatic BP

Question 14

A patient has CKD. Which findings would you expect?

Answer 14

Decreased GFR
Azotemia
Increased BUN
Oliguria

Question 15

A child is diagnosed with glomerulonephritis. Which statement made by the parent is
associated with this diagnosis?

Answer 15

The child’s urine has been the color of cola

Question 16

Which vital sign would be vital to assess for a patient on a PCA pump?

Answer 16

RR of 6

Question 17

Which condition correlates to the following ABG results?
pH: 7.48 O2: 98% CO2: 28 HC03: 22

Answer 17

Anxiety-induced Hyperventilation

Question 18

A patient is on 15 different medications. What is the nurse’s priority?

Answer 18

Look for duplicates

Question 19

Which lab value is the most important for the nurse to report?

Answer 19

Increased troponin

Question 20

Which of these should the nurse include in a teaching plan for someone prescribed
Hydrochlorothiazide?

Answer 20

Take this medication at the same time everyday

Question 21

Which acid-base imbalance could Lasix (Furosemide) cause?

Answer 21

Metabolic Alkalosis

Question 22

A 78 year old patient appears restless, agitated, has mild decrease in LOC, which
intervention would the nurse recommend?

Answer 22

UA culture and sensitivity

Question 23

A pediatric patient is admitted with suspected Rheumatic Fever. Which question
should the nurse ask during the admission assessment?

Answer 23

Has the child had a sore throat recently?

Question 24

Which statement made by the patient shows that they understand their Bone Marrow
Transplant procedure?

Answer 24

I will have to lay on my side for 60 minutes post-procedure

Question 25

Which assessment data indicated there is a complication associated with a patient’s chronic pain treatment?

Answer 25

Decreased appetite, thirst, and oral intake

Question 26

Which lab should be monitored if a patient is taking Simvastatin?

Answer 26

Liver enzymes

Question 27

Which statement by the patient shows that the teaching of their medication Captopril was effective?

Answer 27

I should take this medication 20-60 minutes before a meal

Question 28

A patient with hypertension has been diagnosed with Atrial Fibrillation. Which medication should be prescribed to prevent complications?

Answer 28

Warfarin

Question 29

A patient is in the Oliguric stage of AKD. Urine output has been 350 mL for 18 hours. What is the next action the nurse should take?

Answer 29

Continue to monitor patient

Question 30

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse complete with a therapeutic response to the treatment plan?

Answer 30

Decreased orthostatic light headedness and dizziness

Question 31

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment will be of most concern to the nurse?

Answer 31

Blood pressure is 90/40 mm Hg.

Question 32

A patient has a history of kidney disease due to diabetes mellitus. The patient is on peritoneal dialysis. After placing 1200 mL dialysate, only 400 mL drained. What should the nurse do next? SATA

Answer 32

Reposition client on their side Check for obstruction Call HCP for orders bag below the patient

Question 33

Which ABG result represents COPD?

Answer 33

pH: 7.32, O2: 85%, CO2: 57, HCO3: 26

Question 34

An infant is placed on diuretic therapy. Which method would you use to assess urine output?

Answer 34

Weigh wet diapers

Question 35

A patient who had surgery yesterday had the following vital sign changes from yesterday to 1000 this morning. Which change is the most important to assess?

Answer 35

Blood pressure decreased from 135/88 to 102/66

Question 36

Magnesium is given via IV. Which S/S would indicate the Magnesium level is too high?

Answer 36

Diminished deep tendon reflexes

Question 37

A patients lab values are taken once: BP: 114/64, HR: 110, RR: 14, Temp: 101.2, O2 92% 2L The patient becomes restless, and the labs are taken again: BP: 90/58, HR: 124, RR: 22, Temp: 101.4, O2 90% on 2L. Which lab value is the nurse most concerned with?

Answer 37

WBC = 30,000

Question 38

Which lab value is most concerning?

Answer 38

Platelet 128,000

Question 39

A patient has suspected anemia. Which lab value would confirm this?

Answer 39

Hgb 10

Question 40

A patient is post parathyroidectomy ( 2 days ago). The patient is irritable, has tingling and numbness in face and ears, potassium is 3.2, sodium is 138, calcium was normal. Which of these would be an appropriate lunch tray?

Answer 40

Grilled cheese sandwich, collard greens, yogurt

Question 41

A patient is semi-conscious, has a dry swollen tongue, temp 99.3 , and urine specific gravity 1.020. What would you expect the patient’s sodium level to be

Answer 41

165

Question 42

A patient with a history of renal impairment is given a medication that is excreted through the kidneys. How would you assess for an adverse reaction?

Answer 42

BUN & Creatinine

Question 43

A patient with diabetes mellitus has the following acid-base imbalance. Which manifestation would you see? pH: 7.36 PaO2: 98% PaCO2: 33 HCO3-: 18

Answer 43

Increase in RR and depthx

Question 44

A patient is in the Oliguric stage of AKD. Urine output has been 350 mL for 18 hours. What is the next action the nurse should take?

Answer 44

Continue to monitor patient/hourly output

Question 45

The nurse cares for a client admitted with pericarditis. Which symptoms should the nurse communicate to the healthcare provider immediately?

Answer 45

Jugular venous distention.

Question 46

During a home visit to an 88-year-old client who is taking digoxin 0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most important to communicate to the health care provider?

Answer 46

Vision that is becoming "fuzzy"

Question 47

The nurse is providing care for several patients who are at risk for acid-base imbalance. Which patient is most at risk for respiratory acidosis?

Answer 47

A 68-year-old patient with chronic emphysema

Question 48

Biopsy instruct client too..

Answer 48

lie on their right side for a minimum of 2 hours to splint the puncture site.

Question 49

Stage 1 HTN education SATA

Answer 49

diet, exercise, low sodium, no 2 cups coffee in AM, 4/5 veggies daily

Question 50

the client is developing dig toxicity if which of the following is noticed on visit?

Answer 50

anorexia, nausea, yellow vision

Question 51

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

Answer 51

U waves Inverted T waves Depressed ST segment

Question 52

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

Answer 52

Tall peaked T waves Widened QRS complexes

Question 53

38-Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

Answer 53

The client who has sustained a traumatic burn

Question 54

An adult female client has a hemoglobin level of 10.8 g/ dL (108mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Answer 54

Iron deficiency anemia

Question 55

When vfib on occurs in a CCU , the first person reaching the client should

Answer 55

Defibrillate the client

Question 56

What do you monitor in a patient with celiac disease?

Answer 56

Magnesium, Give IV mag if low

Question 57

How do you know a Brudzinski's sign is positive?

Answer 57

Flexes hip and knee in response to neck flexion

Question 58

What might positive brudzinski sign mean?

Answer 58

may be developing menengitis

Question 59

Patient is confused and suspected UTI, what orders are anticipated?

Answer 59

UA culture and sensitivity

Question 60

Patient just had a cholecystectomy T-Tub, what is the proper diet for this client?

Answer 60

Take fat soluble vitamins Small low fat meals Avoid gassy foods such as beans, broccoli, cauliflower, cabbage

Question 61

What s/s should you report of a client who just underwent a parathyroidectomy?

Answer 61

Tetany and Paresthesia

Question 62

What is the 15-15 rule of hypoglycemia?

Answer 62

when sugar drops give 15g of simple carbs and recheck in 15 minutes

Question 63

What is the greatest risk for post op illeostomy?

Answer 63

Electrolyte imbalance

Question 64

Which ostomy is at highest risk for skin breakdown?

Answer 64

Ileostomy

Question 65

What is the nurse's role during a bedside GI endoscopy?

Answer 65

Ensure equipment is readily available

Question 66

What should be done when a patient is having EMG done?

Answer 66

ask about OTC herbal use evaluate muscle weakness d/c muscle relaxants

Question 67

What is priority of a Guillain Barre Syndrome?

Answer 67

Respiratory management have intubation tray ready and EKG

Question 68

What assessment should be done for a client with a CVA?

Answer 68

NIH and NIHSS

Question 69

What are priority post craniotomy interventions?

Answer 69

measure head circumference apply nail bed pressure if unconscious

Question 70

What are two early signs of increased ICP?

Answer 70

Decreased LOC and vomiting

Question 71

What is a late sign of increased ICP?

Answer 71

Bradycardia

Question 72

What are normal ammonia levels?

Answer 72

10-80

Question 73

How do you lower ammonia levels?

Answer 73

Give lactulose

Question 74

What is a early sign of high ammonia levels?

Answer 74

Increased confusion, if confusion is getting better lactulose therapy is effective

Question 75

What are s/s of a bone metastasis emergency?

Answer 75

Facial edema calcium of 12 numbness and tingling

Question 76

What is calcitonin for?

Answer 76

given for high calcium levels

Question 77

What is an adverse reaction of carbamazepine?

Answer 77

WBC 3000

Question 78

What is isosorbide mononitrate for?

Answer 78

Chest pain Headache is a sign the med is working take first thing in the am side effects are dizziness, flushing, nausea