Final Exam Flashcards
Informed consent
Nurse is not responsible for obtaining consent but is responsible for witnessing.
Ensure the provider gave the necessary information
Ensure the client understood the information and is competent to give informed consent
Document questions the client has and inform the provider
A nurse is caring for a client who is scheduled for surgery. What is the nurse’s role in regard to informed consent?
Determine the clients level of understanding
Acute appendicitis- signs of perforation
Fever, severe abdominal pain and tenderness, vomiting
A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?
A. Maintain NPO status.
B. Monitor oral temperature every 4hr
C. Medicate the client for pain every
4hr as needed.
D. Administer sodium biphosphate sodium phosphate.
D. Administer sodium biphosphate sodium phosphate.
In a suspected case of appendicitis, administering a bowel preparation could potentially worsen the condition by increasing the risk of perforation if appendicitis is present.
Cholecystitis
Is an inflammation of the gallbladder wall
Most often caused by gallstones (cholelithiasis)
Can be acute or chronic, and can obstruct the pancreatic duct, causing pancreatitis.
When taking a health history for a new patient, which information given by the patient would indicate that screening for hepatitis C is appropriate?
a. The patient had a blood transfusion after surgery in 1998.
b. The patient reports a one-time use of IV drugs 20 years ago.
c. The patient eats frequent meals in fast-food restaurants.
d. The patient recently traveled to an undeveloped country.
b. The patient reports a one-time use of IV drugs 20 years ago.
Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.
Acute pancreatitis - What would you need to report immediately
A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?
A. Decreased mucus in stools.
B. Decreased black tarry stools.
C. Decreased watery stools.
D. Decreased fat in stools.
D. Decreased fat in stools.
D. Pancrelipase is a combination of pancreatic enzymes used to increase digestion of fats, carbohydrates and proteins. The client should expect a reduction of fat in stools.
Nasogastric tube and how to know they were effective
Gastric Decompression
Medication Administration
Enteral Feeding
Aspiration Prevention
Confirmation of Placement
A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the initial placement of the tube?
A. Obtain an x-ray.
B. Auscultate injected air.
C. Take a pH measurement of gastric aspirate.
D. Identify the color of gastric contents
A. Obtain an x-ray.
The nurse should identify that obtaining an x-ray is most effective method to verify initial placement of a nasogastric tube.
A nurse is checking the client’s nasogastric tube for placement. Which of the following procedures should the nurse implement?
A. Instill 20 mL of air into the tube and listen for a whooshing sound.
B. Aspirate stomach contents and check the pH.
C. Aspirate stomach contents and check their color.
D. Auscultate lung sounds.
B. Aspirate stomach contents and check the pH.
Checking the pH of stomach contents is recommended method for checking tube placement. The pH measurement of gastric aspirate is 4 or less. A pH measurement of gastric aspirate can be used to monitor placement after initial placement has been verified.
A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse’s priority?
A) Dietary recommendations
B) Incision Care
C) Coughing and deep-breathing exercises
D) Pain management
C) Coughing and deep-breathing exercises
Coughing and deep-breathing exercises
The greatest risk to the client is respiratory compromise.
A nurse is assessing a client who is 12hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider?
A) Hypoactive bowel sounds
B) Indwelling catheter output 25mL/hr
C) Heart rate of 96/min
D) Serous drainage at the surgical incision site
B) Indwelling catheter output 25mL/hr
A lower-than-expected urine output could indicate inadequate fluid intake, decreased renal perfusion, or other factors affecting renal function. In the postoperative period, maintaining adequate urine output is essential for monitoring renal function, ensuring proper hydration, and preventing complications such as acute kidney injury.
H2RBs - therapeutic use
Ex: Cimetidine
Used to treat GERD and ulcers
- works by reducing the amount of stomach acid secreted by the glands in the stomach
A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?
- Relief of heartburn
- Cessation of diarrhea
- Passage of flatus
- Absence of constipation
- Relief of heartburn
H2RAs are used to treat duodenal ulcers and prevent their return. In over-the-counter strengths, these medications, such as cimetidine and famotidine, are used to relieve or prevent heartburn, acid indigestion, and sour stomach.
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client
for which of the following alterations as indications that the client has an infection?
(Select all that apply.)
A. Bradycardia
B. An increase in neutrophils
C. An increase in RBCs
D. An increase in platelets
E. Localized edema
B. An increase in neutrophils
E. Localized edema
An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms.
Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.
A client is diagnosed with peptic ulcer disease and asks the nurse about the common risk factors for this condition. Which of the following responses should the nurse provide?
A. “Risk factors for peptic ulcer disease include a diet high in fiber and low in fat.”
B. “Smoking and alcohol consumption are not associated with an increased risk of peptic ulcer disease.”
C. “The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are common risk factors for peptic ulcer disease.”
D. “Peptic ulcer disease is primarily caused by stress and emotional factors.”
C. “The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are common risk factors for peptic ulcer disease.”
This statement is correct. The use of NSAIDs, such as aspirin and ibuprofen, and Helicobacter pylori infection are well-established risk factors for peptic ulcer disease.
Risk factors for PUD
H. pylori NSAID & corticosteroid use
Severe stress
Familial tendency
Hypersecretory states
Gastrin-secreting benign or malignant tumors of the pancreas
Type O blood
Excess alcohol consumption
Chronic pulmonary or kidney disease
Zollinger-Ellison syndrome, pernicious anemia
What are the risk factors associated with peptic ulcer disease?
(Select All that Apply.)
A. Family history
B. Blood type A
C. Acetaminophen (Tylenol) intake for pain
D. Smoking tobacco
E. Drinking caffeine
A. Family history
D. Smoking tobacco
E. Drinking caffeine
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?
a. “Sleep on your left side.”
b. “Drink milk to soothe your stomach.”
c. “Eat four small meals each day.”
d. “Wait to go to bed for 1 hour after eating.”
c. “Eat four small meals each day.”
Diabetes type 1 what is your priority if there is a mix up with insulin dose
Assessment
- Immediately check the patient’s blood glucose level using a glucometer.
- Assess the patient for signs and symptoms of hypo- or hyperglycemia, such as sweating, tremors, confusion, weakness, dizziness, or rapid heartbeat.
a nurse is teaching a child who has type 1 DM about self care. which of the following statements by the child indicates understanding of the teaching?
A. I should skip breakfast when I am not hungry
B. I should increase my insulin with exercise
C. I should drink a glass of milk when I am feeling irritable
D. I should draw up the NPH insulin into the syringe before the regular insulin
C. I should drink a glass of milk when I am feeling irritable.
An early manifestation of hypoglycemia is irritability. Drinking a glass of milk, which is approximately 15g of carbohydrates, indicates understanding of the teaching.
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus.
Which statement made by the client indicates an understanding of the teaching?
A. “A weight reduction program will make me hypoglycemic.”.
B. “Insulin allows me to eat ice cream at bedtime.”.
C. “I give the insulin injections in my abdominal area.”.
D. “I am to take my blood sugar reading after meals.”.
C. “I give the insulin injections in my abdominal area.”.
Insulin injections are often given in the abdominal area due to its high vascularity, promoting faster absorption.
A nurse is teaching about self-monitoring to a client who has Type 1 DM. Which of the following statement by the client indicates an understanding of the teaching?
A. “ I will check my urine once a day for ketones”
B. “ I will notify my provider if per-meal glucose is 120 mg/dL”
C. “ I will check my blood glucose every 4 hours when I am sick”
D. “ I will check blood glucose every 5 minutes when lightheaded”
C. “ I will check my blood glucose every 4 hours when I am sick”
Self- monitoring for type 1 diabetes
COPD with asthma- assessment findings
Angina pectoris– propranolol and hydrochlorothiazede
History of comorbidities – which one is important to notify physician
A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?
a. take the med on an empty stomach to decrease gastrointestinal irritation
b. take the med with orange juice to enhance absorption
c. take the med with milk
d. rinse the mouth before taking the iron
b. take the med with orange juice to enhance absorption
vitamin C and other fruit juices (except grape juice) enhance the absorption of oral iron supplements in the gastrointestinal tract. Therefore, the clients are encouraged to take the supplements along with such fruit juices.
A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.)
A. Assessing the peripheral pulses in the affected extremity
B. Checking the insertion site for hematoma formation
C. Evaluating temperature and color in the affected extremity
D. Assisting the patient to the bathroom after the procedure
E. Assessing vital signs every 8 hours
A. Assessing the peripheral pulses in the affected extremity
B. Checking the insertion site for hematoma formation
C. Evaluating temperature and color in the affected extremity
Clinical manifestations for DVT
Limb Pain
- feeling of fullness or heaviness in the legs after standing
Edema, redness, and warmth
Calf tenderness or pain
-May be asymptomatic
A nurse is performing a home safety assessment for a client who had a stroke. The nurse notes that the stairs in the client’s home are in disrepair and pose a safety risk. The client states, “I cannot afford to have the stairs repaired.” Which of the following actions should the nurse take?
A. Refer the client to a social worker.
B. Provide the client with information about the American Red Cross.
C. Ask the client’s provider to postpone discharge until the stairs are repaired.
D. Recommend a long-term care facility for the client.
A. Refer the client to a social worker.
Referring the client to a social worker is the best course of action because social workers can help the client explore financial assistance options or community resources to address the issue of the disrepair of the stairs. Social workers are trained to assist clients in accessing various support services, including financial aid programs, grants, or community organizations that may provide assistance for home modifications or repairs.
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?
A. A reddened area over the sacrum
B. Stiffness in the lower extremities
C. Difficulty moving the upper extremities
D. Difficulty hearing some types of sounds
A. A reddened area over the sacrum
Complications of immobility, particularly in older adult clients who are unable to move independently, often include pressure ulcers or bedsores, which commonly occur over bony prominences such as the sacrum, heels, and elbows.
Hypoglycemia- adverse effects
A nurse is reviewing discharge instructions w/ a client who has RA & a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching?
A. “I should take my flu vaccine within one week of starting this medication.”
B. “I should eat more bananas while taking this medication.”
C. “I should take aspirin for minor aches and pains while taking this medication.”
D. “I can expect a sore throat for the first week after starting this medication.”
I should eat more bananas when taking this medication
A nurse is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication?
a-Reduces risk of infection
b-Decreases inflammation
c-Improves peripheral blood flow
d-Increases bone density
b-Decreases inflammation
A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?
-Place sandbags to maintain right plantar flexion.
-Position soft pillows against the bottom of the feet.
-Apply a protective boot to the right ankle.
-Splint the right lower extremity to maintain proper alignment.
-Apply a protective boot to the right ankle.
A nurse is reviewing the laboratory result of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?
LDL 172 mg/dL
A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?
The client will walk for 30 min 5 days a week
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. which of the following actions is the nurse’s priority?
Position the child side-lying.
This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.
- A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.)
A. Provide privacy.
B. Ease the client to the floor if standing.
C. Move furniture away from the client.
D. Loosen the client’s clothing.
E. Protect the client’s head with padding.
F. Restrain the client.
A. Provide privacy.
B. Ease the client to the floor if standing.
C. Move furniture away from the client.
D. Loosen the client’s clothing.
E. Protect the client’s head with padding.
A nurse is caring for a client who is experiencing a seizure which of the following action should the nurse take? (Select all that apply)
A. Loosen restrictive clothing.
B. Insert a bike stick into the client’s mouth.
C. Place the client into a supine position.
D. Place a pillow under the client’s head.
E. Apply restraints.
A. Loosen restrictive clothing.
D. Place a pillow under the client’s head.
You are assessing a PT with Left sided heart failure. What manifestation should you expect to find?
- Increased abdominal girth
- Weak peripheral pulses
- Jugular venous neck distention
- Dependent edema
- Weak peripheral pulses
A nurse is assessing a client who is restricted to bedrest for manifestations of right-sided heart failure. Which of the following findings should the nurse expect?
Weak peripheral pulses
Angina
Sacrum edema
Crackles in the lungs
Sacrum edema
A nurse is assessing a client who has left-sided heart failure with decreased cardiac output. Which of the following manifestations should the nurse expect?
A. Flushing of the skin on exertion
B. Nocturia at night
C. Warm lower extremities
D. Respiratory rate of 16/min
B. Nocturia at night
This is likely to occur due to the redistribution of fluid when the patient lies down, causing increased urine output at night.
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?
A. Evaluating the client for nausea, vomiting, and anorexia
B. Withholding the medication if the heart rate is above 100/min
C. Instructing the client to eat foods that are low in potassium
D. Measuring apical pulse rate for 30
seconds before administration
A. Evaluating the client for nausea, vomiting, and anorexia
(Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity.)
A nurse is preparing to administer digoxin to a client who has heart failure.
Before administering this medication, which of the following actions should the nurse take?
A.Check the client’s blood pressure.
B. Measure the client’s apical pulse.
C. Offer the client a light snack.
D. Weigh the client.
B. Measure the client’s apical pulse.
A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?
A oral mucosa
B. conjunctivae
C. earlobes
D soles of the feet
Oral Mucosa
A nurse is collecting data about the fluid status of four clients.
Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
A. A client who has NPO status since midnight for an endoscopy.
B. A client who has heart failure and is receiving diuretic therapy.
C. A client who has gastroenteritis and is receiving oral fluids.
D. A client who has end-stage kidney disease who will undergo dialysis.
B. A client who has heart failure and is receiving diuretic therapy.
A client who has heart failure and is receiving diuretic therapy is at a high risk for fluid volume deficit. Diuretics are used in heart failure to remove excess fluid from the body, but they can also lead to fluid volume deficit if not properly managed. This is because diuretics increase urine output, which can lead to a loss of fluid and electrolytes.
A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?
A. It requires lying quietly on one side.”
B. It might cause slight discomfort in the chest area.”
C. “It is best to have no food or beverages the day of the test.”
D. “It takes about 5 or 10 minutes.”
A. It requires lying quietly on one side.”
During an echocardiogram, the client is typically asked to lie on their left side to obtain clear images of the heart. The test is non-invasive and involves using ultrasound waves to create images of the heart’s structures.
Echocardiogram instruction
Inform the patient about the approximate duration of the test, typically between 30 to 60 minutes.
Explain that the patient will need to lie on their back on an examination table. They may also be asked to lie on their side at certain points during the procedure to obtain different views of the heart.
Emphasize the importance of remaining still during the test to obtain clear images of the heart.
