Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Shaqra > Exit 15 > Flashcards

Exit 15 Flashcards

1
Q

Mrs. Chua, a 78-year-old client, is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear which sound when listening to the client’s lungs indicative of chronic heart failure?

A. Stridor
B. Crackles
C. Wheezes
D. Friction rubs

A

B. Crackles

Left-sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Patrick, who is hospitalized following a myocardial infarction, asks the nurse why he is taking morphine. The nurse explains that morphine:

A. Decreases anxiety and restlessness
B. Prevents shock and relieves pain
C. Dilates coronary blood vessels
D. Helps prevent fibrillation of the heart

A

B. Prevents shock and relieves pain

Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction; it also decreases apprehension and prevents cardiogenic shock.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Which of the following should the nurse teach the client about the signs of digitalis toxicity?

A. Increased appetite
B. Elevated blood pressure
C. Skin rash over the chest and back
D. Visual disturbances such as seeing yellow spots

A

D. Visual disturbances such as seeing yellow spots

Seeing yellow spots and colored vision are common symptoms of digitalis toxicity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help:

A. Retard rapid drug absorption
B. Excrete excessive fluids accumulated at night
C. Prevent sleep disturbances during night
D. Prevent electrolyte imbalance

A

C. Prevent sleep disturbances during night

When diuretics are taken in the morning, the client will void frequently during daytime and will not need to void frequently at night.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What would be the primary goal of therapy for a client with pulmonary edema and heart failure?

A. Enhance comfort
B. Increase cardiac output
C. Improve respiratory status
D. Decrease peripheral edema

A

B. Increase cardiac output

The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Nurse Linda is caring for a client with a head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?

A. Upper extremity flexion with lower extremity flexion
B. Upper extremity flexion with lower extremity extension
C. Extension of the extremities after a stimulus
D. Flexion of the extremities after stimulus

A

C. Extension of the extremities after a stimulus

Decerebrate posturing is the extension of the extremities after a stimulus, which may occur with upper brain stem injury.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following may be experienced as side effects of this medication:

A. GI bleeding
B. Peptic ulcer disease
C. Abdominal cramps
D. Partial bowel obstruction

A

C. Abdominal cramps

The most frequent side effects of Cascara Sagrada (laxative) are abdominal cramps and nausea.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?

A. Monitoring urine output frequently
B. Monitoring blood pressure every 4 hours
C. Obtaining serum potassium levels daily
D. Obtaining an infusion pump for the medication

A

D. Obtaining an infusion pump for the medication

Administration of intravenous nitroglycerin infusion requires a pump for accurate control of medication.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

During the second day of hospitalization of the client after a myocardial infarction, which of the following is an expected outcome?

A. Able to perform self-care activities without pain
B. Severe chest pain
C. Can recognize the risk factors of myocardial infarction
D. Can participate in cardiac rehabilitation walking program

A

A. Able to perform self-care activities without pain

By the second day of hospitalization after suffering a myocardial infarction, clients are able to perform care without chest pain.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

A 68-year-old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:

A. Apply elastic stockings to prevent flaccid muscles
B. Use a hand roll and extend the left upper extremity on a pillow to prevent contractions
C. Use a bed cradle to prevent dorsiflexion of feet
D. Do passive range of motion exercises

A

B. Use a hand roll and extend the left upper extremity on a pillow to prevent contractions

The left side of the body will be affected in a right-sided brain attack.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be:

A. Hourly urine output
B. Temperature
C. Ability to turn side to side
D. Ability to sip clear liquids

A

A. Hourly urine output

After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney and to detect renal failure early.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

A 64-year-old male client with a long history of cardiovascular problems, including hypertension and angina, is to be scheduled for cardiac catheterization. During pre-cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is to:

A. Determine the existence of CHD
B. Visualize the disease process in the coronary arteries
C. Obtain the heart chambers’ pressure
D. Measure oxygen content of different heart chambers

A

B. Visualize the disease process in the coronary arteries

The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

During the first several hours after a cardiac catheterization, it would be most essential for Nurse Cherry to:

A. Elevate the client’s bed at 45°
B. Instruct the client to cough and deep breathe every 2 hours
C. Frequently monitor the client’s apical pulse and blood pressure
D. Monitor the client’s temperature every hour

A

C. Frequently monitor the client’s apical pulse and blood pressure

Blood pressure is monitored to detect hypotension, which may indicate shock or hemorrhage. The apical pulse is taken to detect arrhythmias related to cardiac irritability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Kate, who has undergone mitral valve replacement, suddenly experiences continuous bleeding from the surgical incision during the postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?

A. Protamine Sulfate
B. Quinidine Sulfate
C. Vitamin C
D. Coumadin

A

A. Protamine Sulfate

Protamine Sulfate is used to prevent continuous bleeding in a client who has undergone open-heart surgery.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

n reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care, a client with mitral stenosis should include proper use of:

A. Dental floss
B. Electric toothbrush
C. Manual toothbrush
D. Irrigation device

A

C. Manual toothbrush

The use of an electronic toothbrush, irrigation device, or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Among the following signs and symptoms, which would most likely be present in a client with mitral regurgitation?

A. Altered level of consciousness
B. Exertional dyspnea
C. Increased creatine phosphokinase concentration
D. Chest pain

A

B. Exertional dyspnea

Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Kris, with a history of chronic infection of the urinary system, complains of urinary frequency and a burning sensation. To figure out whether the current problem is of renal origin, the nurse should assess whether the client has discomfort or pain in the:

A. Urinary meatus
B. Pain in the labium
C. Suprapubic area
D. Right or left costovertebral angle

A

D. Right or left costovertebral angle

Discomfort or pain originating in the kidney is felt at the costovertebral angle on the affected side.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which sign as the best indicator of renal function?

A. Blood pressure
B. Consciousness
C. Distension of the bladder
D. Pulse rate

A

A. Blood pressure

Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

John suddenly experiences a seizure, and Nurse Gina notices that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?

A. Tonic seizure
B. Absence seizure
C. Myoclonic seizure
D. Clonic seizure

A

C. Myoclonic seizure

Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Smoking cessation is a critical strategy for the client with Buerger’s disease. Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?

A. Paracetamol
B. Ibuprofen
C. Nitroglycerin
D. Nicotine (Nicotrol)

A

D. Nicotine (Nicotrol)

Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by:

A. Episodic vasospastic disorder of capillaries
B. Episodic vasospastic disorder of small veins
C. Episodic vasospastic disorder of the aorta
D. Episodic vasospastic disorder of the small arteries

A

D. Episodic vasospastic disorder of the small arteries

Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involve the fingers and toes.

22
Q

Nurse Jamie should explain to a male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because:

A. It is more accurate
B. It can be done by the client
C. It is easy to perform
D. It is not influenced by drugs

A

A. It is more accurate

Urine testing provides an indirect measure that may be influenced by kidney function, while blood glucose testing is a more direct and accurate measure.

23
Q

Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost:

A. 0.3 L
B. 1.5 L
C. 2.0 L
D. 3.5 L

A

C. 2.0 L

One liter of fluid approximately weighs 2.2 pounds. A 4.5-pound weight loss equals approximately 2 liters.

24
Q

Nurse Donna is aware that the shift of body fluids associated with intravenous administration of albumin occurs through the process of:

A. Osmosis
B. Diffusion
C. Active transport
D. Filtration

A

A. Osmosis

Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.

25
Q

Myrna, a 52-year-old client with a fractured left tibia, has a long leg cast and is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates a complication associated with crutch walking?

A. Left leg discomfort
B. Weak biceps brachii
C. Triceps muscle spasm
D. Forearm weakness

A

D. Forearm weakness

Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.

26
Q

Which of the following statements should the nurse teach the neutropenic client and his family to avoid?

A. Performing oral hygiene after every meal
B. Using suppositories or enemas
C. Performing perineal hygiene after each bowel movement
D. Using a filter mask

A

B. Using suppositories or enemas

A neutropenic client is at risk for infection, especially bacterial infection of the gastrointestinal and respiratory tract.

27
Q

A female client is experiencing a painful and rigid abdomen and is diagnosed with a perforated peptic ulcer. A surgery has been scheduled, and a nasogastric tube is inserted. The nurse should place the client before surgery in:

A. Sims position
B. Supine position
C. Semi-Fowler’s position
D. Dorsal recumbent position

A

C. Semi-Fowler’s position

The Semi-Fowler’s position will localize the spilled stomach contents in the lower part of the abdominal cavity.

28
Q

Which nursing intervention ensures adequate ventilating exchange after surgery?

A. Remove the airway only when the client is fully conscious
B. Assess for hypoventilation by auscultating the lungs
C. Position the client laterally with the neck extended
D. Maintain humidified oxygen via nasal cannula

A

C. Position the client laterally with the neck extended

Positioning the client laterally with the neck extended does not obstruct the airway, allowing drainage of secretions and oxygen and carbon dioxide exchange to occur.

29
Q

George, who has undergone thoracic surgery, has a chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in the water-seal chamber, the nurse should:

A. “Strip” the chest tube catheter
B. Check the system for air leaks
C. Recognize the system is functioning correctly
D. Decrease the amount of suction pressure

A

B. Check the system for air leaks

Excessive bubbling indicates an air leak that must be eliminated to permit lung expansion.

30
Q

A client who has been diagnosed with hypertension is being taught to restrict the intake of sodium. The nurse would know that the teachings are effective if the client states that:

A. I can eat celery sticks and carrots
B. I can eat broiled scallops
C. I can eat shredded wheat cereal
D. I can eat spaghetti on rye bread

A

C. I can eat shredded wheat cereal

Shredded wheat cereal has a low sodium content.

31
Q

A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulting from ascites. The nurse should be aware that the ascites is most likely the result of increased:

A. Pressure in the portal vein
B. Production of serum albumin
C. Secretion of bile salts
D. Interstitial osmotic pressure

A

A. Pressure in the portal vein

An enlarged cirrhotic liver impinges on the portal system, causing increased hydrostatic pressure resulting in ascites.

32
Q

A newly admitted client diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?

A. Vital signs
B. Incision site
C. Airway
D. Level of consciousness

A

A. Airway

Assessing for an open airway is the priority. The procedure involves the neck; the anesthesia may have affected the swallowing reflex, or the inflammation may have closed in on the airway, leading to ineffective air exchange.

33
Q

A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?

A. Systolic blood pressure less than 90mm Hg
B. Pupils unequally dilated
C. Respiratory rate of 4 breaths/min
D. Pulse rate less than 60 bpm

A

A. Systolic blood pressure less than 90mm Hg

Typical signs and symptoms of hypovolemic shock include a systolic blood pressure of less than 90 mm Hg.

34
Q

Nurse Lucy is planning to give preoperative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?

A. Results of the surgery will be immediately noticeable postoperatively
B. Normal saline nose drops will need to be administered preoperatively
C. After surgery, nasal packing will be in place for 8 to 10 days
D. Aspirin-containing medications should not be taken 14 days before surgery

A

D. Aspirin-containing medications should not be taken 14 days before surgery

Aspirin-containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.

35
Q

Paul is admitted to the hospital due to metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem?

A. Regular insulin
B. Potassium
C. Sodium bicarbonate
D. Calcium gluconate

A

A. Regular insulin

Metabolic acidosis is anaerobic metabolism caused by the inability of the body to use circulating glucose. Administration of insulin corrects this problem.

36
Q

Dr. Marquez tells a client that an increased intake of foods that are rich in Vitamin E and beta-carotene is important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:

A. Fish and fruit jam
B. Oranges and grapefruit
C. Carrots and potatoes
D. Spinach and mangoes

A

D. Spinach and mangoes

Beta-carotene and Vitamin E are antioxidants that help to inhibit oxidation. Vitamin E is found in wheat germ, corn, nuts, seeds, olives, spinach, asparagus, and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots , mangoes, and tomatoes.

37
Q

A client has gastroesophageal reflux disease (GERD). The nurse should teach the client that after every meal, the client should:

A. Rest in a sitting position
B. Take a short walk
C. Drink plenty of water
D. Lie down for at least 30 minutes

A

A. Rest in a sitting position

Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.

38
Q

After gastroscopy, an adaptation that indicates a major complication would be:

A. Nausea and vomiting
B. Abdominal distention
C. Increased GI motility
D. Difficulty in swallowing

A

B. Abdominal distention

Abdominal distension may be associated with pain and may indicate perforation, a complication that could lead to peritonitis.

39
Q

A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:

A. “Most people need to eat a high protein diet for 12 months after surgery.”
B. “I should not eat those foods that upset me before the surgery.”
C. “I should avoid fatty foods as long as I live.”
D. “Most people can tolerate a regular diet after this type of surgery.”

A

D. “Most people can tolerate a regular diet after this type of surgery.”

It may take 4 to 6 months to eat anything, but most people can eat anything they want.

40
Q

Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to hepatitis that may develop. The one that should be reported immediately to the physician is:

A. Restlessness
B. Yellow urine
C. Nausea
D. Clay-colored stools

A

D. Clay-colored stools

Clay-colored stools are indicative of hepatic obstruction.

41
Q

Which of the following antituberculosis drugs can damage the 8th cranial nerve?

A. Isoniazid (INH)
B. Para-aminosalicylic acid (PAS)
C. Ethambutol hydrochloride (Myambutol)
D. Streptomycin

A

D. Streptomycin

Streptomycin is an aminoglycoside, and damage to the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides.

(Vestibulocochlear Nerve)

42
Q

The client asks Nurse Annie about the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following:

A. Genetic defect in gastric mucosa
B. Stress
C. Diet high in fat
D. Helicobacter pylori infection

A

D. Helicobacter pylori infection

Most peptic ulcers are caused by Helicobacter pylori, a gram-negative bacterium.

43
Q

Ryan has undergone a subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

A. Bile green
B. Bright red
C. Cloudy white
D. Dark brown

A

D. Dark brown

12 to 24 hours after subtotal gastrectomy, gastric drainage is normally brown, indicating digested food.

44
Q

Nurse Joan is assigned to care for a client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the postoperative period. Which of the following is best recommended for the client?

A. Watching a circus
B. Bending over
C. Watching TV
D. Lifting objects

A

C. Watching TV

Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.

45
Q

A client suffered a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter than the other leg. The affected leg is painful, swollen, and beginning to become ecchymotic. The nurse interprets that the client is experiencing:

A. Fracture
B. Strain
C. Sprain
D. Contusion

A

A. Fracture

Common signs and symptoms of a fracture include pain, deformity, shortening of the extremity, crepitus, and swelling.

46
Q

Nurse Jenny is instilling an otic solution into an adult male client’s left ear. Nurse Jenny avoids doing which of the following as part of the procedure?

A. Pulling the auricle backward and upward
B. Warming the solution to room temperature
C. Placing the tip of the dropper on the edge of the ear canal
D. Placing the client in a side-lying position

A

C. Placing the tip of the dropper on the edge of the ear canal

The dropper should not touch any object or any part of the client’s ear.

47
Q

Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptoms?

A. Absence of drainage from the ileostomy for 6 or more hours
B. Passage of liquid stool in the stoma
C. Occasional presence of undigested food
D. A temperature of 37.6 °C

A

A. Absence of drainage from the ileostomy for 6 or more hours

Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has developed.

48
Q

Jerry is diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The nurse suspects which of the following complications?

A. Intestinal obstruction
B. Peritonitis
C. Bowel ischemia
D. Deficient fluid volume

A

B. Peritonitis

Complications of acute appendicitis include peritonitis, perforation, and abscess development.

49
Q

Which of the following complications should the nurse carefully monitor in a client with acute pancreatitis?

A. Myocardial infarction
B. Cirrhosis
C. Peptic ulcer
D. Pneumonia

A

D. Pneumonia

A client with acute pancreatitis is prone to complications associated with the respiratory system.

50
Q

Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to exhibit?

A. Watery stool
B. Yellow sclera
C. Tarry stool
D. Shortness of breath

A

B. Yellow sclera

Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.

Shaqra (25 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions