Final Exam Flashcards
A client is on long-term bed rest. Which condition does the nurse recognize as a risk to the client due to immobility?
Venous stasis
A bedridden client has frequent gastrointestinal reflux. For which condition does the nurse assess?
Aspiration Pneumonia
A nurse is providing care for a client who is prescribed to be on strict bed rest. Which intervention is best for the nurse to utilize in order to recognize a complication of immobility?
Frequent assessment of the client’s skin
A client is hospitalized due to complications of immobility. The laboratory results indicate the client has developed septicemia. Which factor does the nurse recognize as causing septicemia?
Open pressure injury
A client who is on prolonged bed rest develops kidney stones. Which factor does the nurse associate with the development of kidney stones?
Increase in parathyroid hormone
The nurse is providing care for a client who is experiencing prolonged bed rest. Which change in cardiac function does the nurse anticipate?
Increase in heart rate
A nurse is assessing the sleep history of different clients for OSA. Which client does the nurse recognize as exhibiting signs of OSA?
The client with excessive daytime sleepiness, snoring, and repetitive pauses in breathing during sleep.
A client is on prolonged bed rest. To which psychological changes will the client be susceptible?
Increased anxiety, mood swings, and altered tactile responses
Which gastrointestinal change does the nurse expect in clients on bed rest?
Slowed peristalsis, diminished appetite, and decreased abdominal and pelvic muscle strength.
A client has a pigmented rash on the sun-exposed areas of their skin. The nurse recognizes which nutrient deficiency causing this condition?
Niacin
Which nutrient deficiency causes beriberi?
Thiamin
A client displays behaviors that involve a desire for perfection and success in academics, psychiatric characteristics of being socially isolated and emotional, and having a severely restricted diet. Which possible eating disorder does the nurse associate with this client?
Anorexia nervosa
The nurse is preparing a class for women aimed at weight management. Which percentage of body fat does the nurse cite as being acceptable in women?
25% - 31%
What is the percentage of body fat for a man to be considered obese?
30%-40%
An adolescent client who is within the normal weight range admits to using laxatives and diuretics. The client displays increased symptoms of depression and report a sore throat and tooth decay. Which question does the nurse as the client to evaluate if the client is experiencing bulimia nervosa?
“Do you engage in self-induced purging?”
How to calculate a BMI
BMI= weight in lbs x 703/ (height in inches)squared
ex. 258lb pt whose 5ft 4
(258x703) / (64x64) = 44.3
Changes in levels of which electrolyte can reduce the body’s response to cardiac drugs?
Calcium
An adult client who has hypervolemia reports a headache, muscle cramps, and vomiting. The nurse
notices confusion. Which condition has the client developed?
Hyponatremia
The nurse is providing care for a client in chemotherapy. The client is experiencing nausea and
vomiting and reports numbness and tingling around the mouth. Before notifying the health-care
provider, which is the most important assessment for the nurse to perform?
Perform a chvostek’s and trousseau’s test
The nurse is providing care for a client who reports severe vomiting and diarrhea for 4 days. Clinical
manifestations and laboratory results indicate the client has hypokalemia. Which is the daily
potassium requirement of humans for optimal cell functioning?
40 to 50 mEq
A client is on digitalis, and the laboratory results show that the client is hypokalemic. Which effect
does hypokalemia have on the drug administered?
I can cause digitals toxicity
A health-care provider prescribes IV potassium infusion for a hypokalemic client who is NPO
(nothing by mouth). Which intervention by the nurse is correct when administering IV potassium?
Validate the preparation of diluted IV potassium solution
The nurse suspects a client has pseudohypocalcemia. Which laboratory result does the nurse monitor
as a probable cause of this condition?
Hypoalbuminemia
Which condition is called hypocalcemia?
Serum Calcium less than 8.5mg/dL
ABG Normal Ranges
ROME Ph 7.35-7.45 PO2 75-100 PCo2 35-45 Hco3 22-26
The nurse is analyzing an arterial blood gas report of a client with chronic obstructive pulmonary
disease and respiratory acidosis. Which compensation mechanism is likely to occur?
The kidneys will retain bicarbonate.
The nurse is caring for a client who has been diagnosed with renal failure. Which mechanism of
compensation for the acid–base disturbance does the nurse recognize in the client?
The client breathes rapidly to eliminate carbon dioxide.
A nurse is caring for a client who is anxious and dizzy after a traumatic experience. The arterial
blood gas findings include a pH level of 7.48, the partial pressure of oxygen at 110, partial pressure of
carbon dioxide at 25, and bicarbonate at 2D. Which initial intervention does the nurse implement?
Encourage the client to breathe into a paper bag
An unconscious client is brought to the hospital. The client’s arterial blood gases show a pH greater
than 7.45 and a bicarbonate level of 36 mEq/L. Which acid–base imbalance has the client
developed?
Metabolic alkalosis
An older adult client is exhibiting lethargy, confusion, and a respiratory rate of 8 breaths per minute.
The nurse sees that the last dose of medication administered through a client-controlled analgesia
pump was within the last 30 minutes. Which acid–base disorder might the client have developed?
Respiratory acidosis
Which factor does hyperventilation of the lungs increase?
Blood PH
The nurse is providing care for a client with an undiagnosed illness. Calculations of the anion gap
indicate an elevation, and the client is identified as being positive for metabolic acidosis. Which
question does the nurse ask the client?
“Are you taking regular doses of aspirin?”
The nurse is reviewing the laboratory results for a client, which are blood pH 7.36, PCO2 48 mm Hg,
PO2 96 mm Hg, HCO3 24 mEq/L, and SaO2 98% on room air. Which condition does the nurse
recognize based on the displayed values?
Hypercapnia
Which is an acidic pH of blood?
6
Which condition develops due to metabolic acidosis with an elevated anion gap?
Ketoacidosis
. A client who is taking a licensure examination is nervous and breathing rapidly in the examination
hall. Which acid–base imbalance is the client at risk for developing?
Respiratory alkalosis
A comatose client’s blood pH is 7.1, partial pressure of carbon dioxide is 16 millimeters of mercury,
and bicarbonate concentration is 5 milliequivalent/liter. Which acid–base imbalance has the client
developed?
Metabolic acidosis
. Which is a physical assessment finding of respiratory acidosis?
Cyanosis
The nurse is providing care for a client experiencing respiratory acidosis. The health-care provider
prescribes that the client be placed on mechanical ventilation and be administered sodium
bicarbonate. Which understanding does the nurse have regarding the prescribed treatment?
Kidney compensation for acidosis is a slow process
A client reports a persistent cough. The nurse suspects the client may have developed tuberculosis
(TB). Which diagnostic test does the nurse expect the primary health-care provider to prescribe to
confirm this condition?
X-ray of the lungs
The nurse is reviewing the complete blood count of a client who presents with fever. The white
blood cell count of the client is 15,000 cells/mL. Which condition has the client developed?
Leukocytosis
A client develops an infection after dental implant surgery. Which condition is the client likely to
develop if the infection is left untreated?
Septicemia
An older adult client is receiving care for a stage IV pressure injury. The client is below normal
weight, has an oxygen saturation of 90%, and has a history of type 1 diabetes mellitus. Which
nursing intervention does the nurse include in the client’s plan of care?
Implement a schedule for repositioning
The nurse recognizes which physiologic manifestation of acute inflammation?
The predominance of neutrophils
A registered nurse is teaching a client about the effects of nutrition on wound healing. Which
a statement made by the client indicates the need for further teaching?
“I will need dietary supplements for healing.”
A nurse is teaching a client with a decubitus ulcer about the nutrients required for wound healing.
Which statement made by the client indicates effective learning?
“Consuming orange juice will improve wound healing.”
Which component of the blood does the nurse associate with surrounding and consuming foreign
material?
White blood cells
A client was brought to the hospital with wounds sustained from a bicycling accident. Which initial
clinical intervention does the nurse carry out to facilitate optimal wound healing?
Irrigating vigorously
Which is a key symptom of meningitis when the nurse is assessing a client suspected of the
condition?
Nuchal rigidity
Which is the diagnostic goal for malaria considering that the pathogen multiplies in the red blood
cells (RBCs)?
Identify specific antibodies
Which symptom does the nurse specifically expect in a client diagnosed with variant
Creutzfeldt-Jakob disease?
Problems with hearing, seeing, and smelling
Which is the predominant immunoglobulin produced after a host’s re-exposure to an antigen?
Immunoglobulin G (IgG)
A 27-year-old client is pregnant. The blood group of the client and the fetus are incompatible. Which
antibodies produced by the mother against the fetus’s blood cells do not affect the fetus?
Immunoglobulin M (IgM)
The nurse is providing care for a client who is recovering from hepatitis A. The nurse is aware that
which immunity is developed by the client after experiencing this illness?
Active acquired adaptive immunity
Which is an example of passive acquired adaptive immunity?
Newborns receiving immunity through breast milk
The nurse is aware immunoglobulin A (IgA) is mostly found in which body fluid?
Tears
A registered nurse is teaching nursing students about passive acquired adaptive immunity. Which
statement made by a student nurse indicates the need for additional learning?
It is activated after the administration of a vaccine.”
A registered nurse is teaching a student nurse about assessing the results of a Mantoux test
administered to an adolescent client. The results exhibit a 5-mm tissue induration. Which statement
made by the student nurse indicates effective learning?
“The client has had an exposure to TB.”
A nurse is assessing four clients who are suspected of having systemic lupus erythematosus. Which
client, does the nurse recognize as having developed the disease?
Client 1 - Fever, butterfly rash on face, and joint inflammation
. A nurse is reviewing the prescriptions of four clients in the hospital. Comparing the effects of the
medications prescribed to the clients, the nurse identifies which client is most likely being treated for
the systemic lupus erythematosus (SLE)?
Client 2- Hydrocortisone, hydroxychloroquine, and methotrexate
A client with scleroderma reports painful ulcers on the knees. Which condition does the nurse
recognize?
Calcinosis
The nurse is preparing a community presentation for clients about autoimmune disease. Which
disease does the nurse use as an example in the presentation?
RA
Which characteristic does the nurse associate with secondary polycythemia?
High erythropoietin level
The nurse is providing care for an African American client who is a carrier of the sickle cell anemia
(SCA) trait. The client carries a small amount of Hgb S and is usually asymptomatic for the disease.
Which question does the nurse ask the client to determine the cause of current manifestations of the
condition?
“Which stressors are currently in your life?”
A school-age client with sickle cell anemia experiences vaso-occlusive episodes. Which is the
the primary nursing objective while caring for this client?
Managing pain
The nurse is providing care for a client with chronic anemia. The client states, “Why don’t they just
give me transfusions when I need them?” Which factor does the nurse consider before giving the
client a response?
Slow blood loss requires iron, vitamin B12, and folic acid.
An adult client tells a nurse about siblings with sickle cell anemia. The client’s greatest concern is
about offspring being affected by the disease in the future. Which is the most appropriate advice the
nurse provides to the client?
“You and your partner need to seek genetic counseling.”
The nurse is caring for a client who reports severe bleeding. The primary health-care provider
prescribes a diagnostic test that would measure the time taken for the blood to clot and examine the
extrinsic pathway of the coagulation cascade. Which diagnostic test does the nurse expect to be
performed?
Prothrombin time test
A client reports shortness of breath and severe pain in the back, chest, and muscles. Which condition
does the nurse recognize as a possible diagnosis for the client?
DIC
Which statement made by an attending nursing staff member indicates effective learning about the
coagulation factors and intrinsic pathway?
“The clotting time is measured by activated partial thromboplastin time (aPTT).”
Which is a supportive treatment for a client with disseminated intravascular coagulation?
Transfuse fresh frozen plasma
A nurse hears a bruit while assessing the carotid artery of a client. Which is the most probable reason
behind the bruit?
Turbulent blood flow in the artery
The registered nurse is teaching staff nurses the relationship between cardiac output (CO), blood
pressure (BP), and peripheral vascular resistance (PVR). A nurse is asked to recap the mathematical
equation that relates the three factors. Which equation provided by the nurse indicates the need for
further teaching?
“PVR / CO = BP”
correct equation is CO x PVR = BP
Which is a risk factor for hypertension?
Insufficient vitamin D in the diet
A registered nurse is preparing an in-service education session for nursing staff about the diagnostic
tests for cardiovascular diseases (CVDs). Which information does the nurse correctly include?
Hypothyroidism is a risk factor for atherosclerosis.
A client presents to the emergency room with reports of severe back pain described as a ripping
sensation. Further assessment reveals a different blood pressure in the right arm than in the left arm
of 20 mm Hg, generalized pallor, and tachycardia. Which possible condition causes the nurse to
immediately notify the health-care provider?
. Aortic dissection
The nurse is providing teaching to a client diagnosed with hypertension. When the nurse presents
information about smoking cessation, the client states, “I don’t plan to quit unless someone
convinces me of the connection between smoking and high blood pressure.” Which information does
the nurse present?
Nicotine increases blood pressure by causing vasoconstriction
Which is the most common type of vasculitis of small-sized arterioles?
Raynaud’s disease
The nurse is providing care for a client with chronic hypertension who presents with chest pain. The
client is diagnosed with left ventricular hypertrophy. Which manifestation of the condition accounts
for the client’s symptoms?
An extra supply of coronary artery blood flow is unavailable.
An older adult client presents with complaints of crushing pain on the left side of the chest. After the
client is examined, it is found that the client has unstable angina. Which intervention to reduce the
pain is appropriate for the client?
Administering nitroglycerin
The nurse is presenting teaching to a client with stable angina. Which information is vital for the
nurse to teach and validate?
Consider angina pain that is more severe than usual to be a medical emergency
A client whose neck vein has bulged presents with a sharp pain in the chest. The electrocardiogram
shows an elevated ST segment, and the laboratory report shows an increase in the serum creatinine
and blood urea nitrogen. Which condition has the client developed?
Pericarditis
A client visits the hospital with chest pain, and the vital signs are 101.5°F body temperature and
125/85 mm Hg blood pressure. The echocardiogram of the client shows valve perforation, and a new
regurgitant murmur is heard during chest auscultation. Which condition has the client developed?
Infective endocarditis
A nurse is caring for a client with infective endocarditis. Which is the specific nursing intervention
for this client?
Administering ampicillin
A client is experiencing chest pain. On examination, a scratchy sound is heard through the
stethoscope. Which intervention does the nurse initiate?
Administering glucocorticoids
A client reports myalgia and fever. On physical examination, an S3 gallop rhythm was heard through
the stethoscope, and the client is diagnosed with myocarditis. For which reason is the client
prescribed angiotensin-converting enzyme (ACE) inhibitors?
To treat heart failure
A client is experiencing severe chest pain unrelieved by nitroglycerine. Which diagnostic testing
supports the possibility of a myocardial infarction instead of unstable angina?
Blood tests indicate the elevation of specific enzymes
Which condition is characterized by the deposition of immune complexes, causing inflammation and
fluid accumulation in the pericardial sac?
Dressler’s syndrome
The nurse is assessing a client with pericarditis. Which assessment findings indicate pericarditis?
Muffled or distant heart sounds, Pericardial friction rub
and Dyspnea
The nurse is caring for four clients with chest pain. Which client is treated for infective endocarditis?
The client with a dental implant and pacemaker
A middle-aged adult is diagnosed with Class III (moderate) heart failure. In which way is Class III
heart failure different from other classes of heart failure in the client, according to the New York
Association of Classification of Heart Failure?
The client with Class III (moderate) heart failure will have fatigue, palpitations, or
dyspnea while doing less-than-normal physical activities.
In which manner does the heart function when a client is diagnosed with heart failure?
The contractility and stroke volume decrease.
In which way is chronic heart failure different from acute heart failure?
Chronic heart failure gradually develops over a long period.
The registered nurse is reviewing information with coronary staff nurses about the
renin-angiotensin–aldosterone system (RAAS). Which statement made by an attending nurse
indicates understanding?
“RAAS is a mechanism that regulates arterial blood pressure.”
The nurse is reviewing instructions with a client being discharged home after experiencing heart
failure. When reviewing medications, the client asks about the addition of captopril to the previous
medication regimen. Which action of captopril will the nurse explain to the client?
Captopril lowers resistance against the left ventricle.
An older adult client presents with swollen ankles and fingers and reports that low-level activity
causes fatigue and heart palpitations. The client is diagnosed with heart failure. Which symptom
indicates the client’s condition is considered to be a Class III, moderate heart failure?
Dyspnea
At which intercostal space does the nurse place the stethoscope for auscultation of the pulmonic
valve?
The second intercostal space in the left sternal border
The registered nurse is teaching a client about medical treatment to prevent thromboemboli. Which
response by the client indicates effective learning?
“Anticoagulants work to prevent clotting.”
In which manner does the nurse document a client’s heart murmur that begins just before S2 and ends
at S2
Late systolic
The nurse evaluates a client’s heart murmur and determines the murmur to be loud. In which manner
does the nurse rate the heart murmur?
6/6
A left ventricular impulse is seen through the chest wall of a client. On palpation, a diastolic thrill is
palpated along the left sternal border, and a systolic thrill is palpable in the jugular notch. To which
pathological condition are these symptoms attributed?
Aortic valve insufficiency
. The nurse is auscultating a client’s heart sounds and notices a murmur. Which differentiates a heart
murmur that is caused by mitral valve stenosis from one that is caused by other mitral valves
disorders?
Opening snap followed by a diastolic murmur
While evaluating a client for a heart murmur, the nurse auscultates the murmur with the bell of a
stethoscope. For which type of heart murmur is the nurse assessing?
A low-pitched murmur
In which manner does the nurse distinguish a grade 5 heart murmur from a grade 6 heart murmur?
A grade 5 heart murmur may be heard when a stethoscope is partly off the chest
wall, whereas a grade 6 heart murmur is heard when a stethoscope is completely
off the chest wall.
. Which does the nurse hear when auscultating heart sounds in a client who has hypertrophic
cardiomyopathy?
A harsh, diamond-shaped systolic murmur
The nurse is caring for a client with aortic valve stenosis and ineffective diuretic treatment. The
client is not a candidate for surgery. Which procedure is likely to be prescribed for the client next?
Percutaneous aortic balloon valvuloplasty
The nurse is providing care for an older adult client after a left knee joint replacement. The client is
resisting offers for frequently assisted ambulation. Which manifestation during assessment causes the
nurse to suspect the formation of a deep venous thrombus?
Palpable warmth over a leg vein
A client with left lower extremity swelling and tenderness along a vein has to be assessed to rule out
deep vein thrombosis (DVT). Which criteria would rule out DVT?
A negative D-dimer assay and Wells criteria score of less than 2
What is the purpose of a Greenfield filter?
To prevent a blood clot from traveling
A client reports to the hospital with a swollen mass on the left leg. Physical examination reveals that
the swollen mass is red, tender, and is textured like a rope. A review of the client’s records shows that
the client has recently undergone orthopedic surgery on the right leg. Which condition has the
client developed?
Deep venous thromboembolism (DVT)
Which drug administered to clients with deep venous thromboembolism (DVT) requires
international normalized ratio (INR) monitoring?
Warfarin
The nurse is providing care to a client diagnosed with deep vein thrombosis (DVT) who is
prescribed anticoagulant therapy. The client asks the nurse about the reason for the medication.
Which condition does the nurse address as being a risk if the DVT is not treated appropriately?
Pulmonary embolism
The nurse is assessing four clients for deep vein thromboembolism (DVT). Which client does the
Does the nurse identify as being at risk of developing DVT?
The client with an elevated D-dimer level and a Well’s criteria score of 2
