Final Exam Flashcards
Which diabetic complication is associated with neuropathy?
A. End stage renal disease
B. Permanent blindness
C. Muscle weakness
D. Eye hemorrhage
C
A client with asthma with an allergy to dogs has an acute asthma attack. What assessment does the nurse expect?
A. Slow, deep pursed breathing
B. Clubbing of fingers and cyanosis of nail beds
C. Shortness of air, and difficulty completing sentences
D. Bradycardia and irregular pulse
C
Based on the analysis of the clients rhythm (atrial fibrillation) the nurse should expect which treatment?
A. Diuretic therapy
B. Anticoagulation therapy
C. Pacemaker implantation
D. Cardiac catheterization
B
Atria is quivering and not ejecting -> blood is not ejecting properly
A=heart failure, HTN
C=bradycardia
D=heart attack/MI
Which lab result would best indicate that a client dx with diabetes is well controlled?
A. Arterial ph 7.4
B. Fasting BG <100
C. Urine negative for ketones
D. Hemoglobin A1C <7%
D
A client has a fasting BG levels consistently above 200. This could indicate which condition?
A. Metabolic acidosis
B. Resp acidosis
C. Metabolic alkalosis
D. Resp alkalosis
A
Which assessment indicates that the outcome for a client with pulm edema has been met?
A. Clear lung sounds
B. Less fatigue
C. No dysrhythmias
D. Presence of dependent edema
A
Tx for pulm edema = rapid acting diuretics
PH 7.55, cO2 24, HCO3 23
A. Resp acidosis
B. Resp alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
B
A client dx with diabetes type 2 urinalysis shows protein Uris. Which pathophysiology does the nurse suspect?
A. Nephropathy
B. Neuropathy
C. Retinopathy
D. Gastroparesis
A
Which client is at highest risk for developing pneumonia?
A. Client who has not recieved vaccine
B. Client discharged home with osteoporosis
C. Trauma client on a mechanical ventilator
D. 32 year old hospitalized client
C
When caring for an older client diagnosed with hypertension who lives alone, which frequency of drug therapy would be best?
A. Daily
B. BID
C. TID
D. QID
A
A nurse is caring for a client with COPD, which CM would be a priority to further assess?
A. Chronic, non productive cough
B. Barrel chest
C. Clubbing of fingers
D. Large amounts of thick mucous
D
This is the only acute symptom -> other options are all chronic
A nurse is providing education to a client regarding an upcoming EGD and colonoscopy. What education should be included?
A. Take only clear liquids the day prior t
B. Drink as much as tolerated of the bowel prep
C. Take meds with a sip of water morning of exam
D. Barium will be instilled into the colon
A
B=all bowel prep is needed to be drank before scopy
C=technically correct but A is better answer
D=barium is not apart of colonoscopy or EGD
Why does a nurse wear a dosimeter when caring for a client who is receiving brachytherapy?
A. Indicates an expertise in radiation therapy
B. Protects the nurse from absorbing radiation
C. Measures the nurses exposure to radiation
D. Ensures the radiation dose is accurate
C
Brachytherapy = internal
— patient emits radiation for a period of time and can be potential hazard to others
— radiation source is within the patient
Teletherapy = external
— radiation delivered from source outside of patient
— patient is NOT radioactive
— small doses on daily basis
When caring for a client with a chest tube, which is the correct nursing action?
A. Ensure bubbling in water seal chamber
B. Strip chest tube routinely to prevent obstruction
C. Encourage frequent position change
D. Position drainage unit upright and below client
D
Suction control chamber = gentle, steady, continuous bubbling
— vigorous/violent bubbling indicates suction is too high
Water seal chamber = steady rise and fall with breathing
— continuous bubbling indicates air leak
Collection chamber = bright red blood indicates active hemorrhage
— diminished lung sound are priority
PH 7.25, PCO2 36, HCO3 18
A. Resp acidosis
B. Resp alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
C
Which diagnostic test result would the nurse most likely find when caring for a client dx with pneumonia?
A. Hemoglobin 8.2
B. Pa02 73
C. WBC 3,000
D. BUN 34
B
A nurse is caring for a client with peptic ulcer disease. Which complication is the nurse alert for?
A. Barrett’s esophagus
B. H. Pylori
C. GI bleed
D. Inguinal hernia
C
Which lab result indicates the Epogen is having the desired effect?
A. Increased platelets
B. Increased WBC
C. Increased RBC
D. Increased iron
C
The nurse is assessing a client dx with osteoporosis. Which task can be delegated to a CNA?
A. Inspecting vertebrae
B. Taking height and weight
C. Compare observations to previous findings
D. Asking client if they have gained or lost weight
B
A client is repeatedly admitted with urolithiasis and UTI. Which action should the nurse recommend for both?
A. Clean peri area from front to back
B. Empty bladder from sexual intercourse
C. Avoid bubble baths
D. Increase fluid intake
D
A client arrives in the PACU, what is the first assessment done?
A. Assess for patent airway and circulation
B. Put them in supine postion
C. Assess pain
D. Ask them to cough and deep breathe
A
Which disorder creates the highest risk for the client to develop bleeding complications?
A. Thrombocytopenia
B. Anemia
C. Neutropenia
D. Neuropathy
A
May require platelet transfusions; bleeding precautions
What is needed to be done prior to giving medications before surgery?
Withhold drug until client validates understanding of procedure and signs consent
A client is recovering from the PACU, during his post-op assessment the nurse notices the client is slurring his speech. Which action should the nurse take?
A. Assess VS
B. Determine anxiety level and allow them to sleep
C. Review pre-op hx and alcohol use
D. Continue to monitor
A
A client with type 2 DM arrives at the clinic with a BG of 50. The nurse provides client with 6oz of orange juice. In 15 minutes the BG reads 74. What action should the nurse take next?
A. Obtain specimen for serum glucose
B. Admin insulin
C. Provide cheese and bread to eat
D. Obtain specimen for A1C
C
Which statement by a client with DM indicates an understanding of self care management?
A. I dont like sticking myself so I dont do it often
B. I plan to measure the sugar in my urine 4x daily
C. I plan to get my spouse to exercise with me to keep me company
D. If I get a cold, I can take my regular cold meds until I feel better
C
A nurse is caring for a client with chronic bronchitis and notes the following: fatigue, dependent edema, distended neck veins and cyanotic lips. What condition is this?
A. Pleural effusion
B. Asthma
C. Lung cancer
D. Cor pulmonale
D
A female client is taking oral contraceptives and reports to the nurse that she is experiencing calf pain. What action should the nurse implement?
A. Notify HCP immediately
B. Determine if she has breast tenderness and weight gain
C. Encourage her to begin program of walking and exercise
D. Tell her to stop taking the medication for a week to see if symptoms subside
A
A client with a hx of angina is on the med surg unit. The client reports acute chest pain. Which action should the nurse implement first?
A. Inform HCP
B. Obtain 12 lead EKG
C. Admin analgesic
D. Give sublingual nitroglycerin
D
A small bowel obstruction is a condition characterized by which of the following?
A. Metabolic acidosis
B. Vomiting and abdominal pain
C. Ribbon like stools
D. Intermittent lower abdominal cramping
B
The nurse is caring for a client with small bowel obstruction, the client is vomiting and foul fecal smelling material is coming out of the clients mouth. What action should the nurse implement next?
A. Admin IV fluid and electrolytes
B. Admin antiemetics
C. Tell the patient everything is going to be okay
D. Give the client some juice to replenish fluids
A
The nurse is working with a 71 year old obese client with bilateral osteoarthritis of the knees. What recommendation should the nurse make that is most beneficial in protecting the clients joints?
A. Increase calcium in diet
B. Apply alternating heat and cold therapies
C. Initiate a weight loss program
D. Use a walker for ambulation to lessen weight bearing
C
An 89 year old patient is admitted with altered mental status and dehydration. Vital signs are: BP 91/53, HR 108, RR 22, SPO2 95% on RA. What dx test does the nurse anticipate the doctor will order?
A. CT of head
B. ABGs
C. EKG
D. UA
D
A client who is receiving a third unit of packed RBCs is demonstrating s/s of a hemolytic reaction. What assessment findings is most important for the nurse to identify?
A. Anxiety since transfusion began
B. Back pain, fever and headache, feeling of impending doom
C. Drowsiness
D. Complaints of feeling cold
B
What are requirements to be admitted from PACU to the main floor?
Gag reflex, stable VS, limited bleeding, adequate urine output
Complications of trach suctioning
Tissue trauma, hypoxia, infection, bronchospasm
What are CM of DKA?
- electrolyte loss
- dehydration
- abdominal pain
- nausea
- fruity breath
- kussmaul respirations
What are nursing interventions for HF?
- fluid restriction
- daily weights
- low sodium diet
- measure I&O
- rest
- assess exercise tolerance
CM of urolithiasis
- severe pain
- hematuria
- nausea/vomiting
- diaphoresis
- pallor
Key features of anemia
- dyspnea
- fatigue
- tachycardia
- pallor
- cold skin
- orthostatic hypotension
What is TACO?
Transfusion associated circulatory overload
Prevention = transfuse blood slowly
