MIDTERM REVIEW Flashcards
A client who will have his last chemotherapy cycle in 11 days becomes neutropenic. The client understands his condition when he states which of the following? Select all that apply.
a. “I will carry hand sanitizer with me and use it often.”
b. “I need to avoid going to the movies or eating out while receiving my cancer treatment.”
c. “ have this new blender and plan to make fruit or vegetable Shakes for energy.”
d. “ill monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 100.1°F (38 °C).”
a. “I will carry hand sanitizer with me and use it often.”
b. “I need to avoid going to the movies or eating out while receiving my cancer treatment.”
d. ill monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 100.1°F (38 °C).
Which information should be included in the teaching plan for a client with cancer who is experiencing thrombocytopenia? Select all that apply.
a. Use an electric razor
b. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control
c. Monitor temperature daily
d. Use a soft-bristle toothbrush.
e. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional (HCP)
f. avoid frequent flossing for oral care
d. Use a soft-bristle toothbrush.
e. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional (HCP).
f. Avoid frequent flossing for oral care.
The nurse has reinforced a pressure dressing on a client who is post-operative mastectomy and notes there is considerable sanguineous drainage in the hemovac. Which of the following assessments should the nurse report to the physician? Select all that apply.
a. Weak thready pulse at 88 bpm; blood pressure 140/80 mm Hg
b. Fever of 102°F(30°C), no urine output for 2 hours
c. Blood pressure 86/50 mm Hg: pulse weak and thready at 120 bpm
d. Warm, dry skin; radial pulse of 86 bpm
e. Cold, clammy skin blood pressure 120/80 mm Hg
b. Fever of 102°F(30°C), no urine output for 2 hours
c. Blood pressure 86/50 mm Hg: pulse weak and thready at 120 bpm
A client with iron deficiency anemia is having trouble selecting food from the hospital menu. Which foods should the nurse suggest to meet the client’s need for iron? Select all that apply
a. Tea
b. Brown rice
c. Dark green vegetables
d. Eggs
e. oatmeal
b. Brown rice
c. Dark green vegetables
d. Eggs
e. oatmeal
which safety, measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood
a. Verity that the ABO and Rh of the 2 units are the same.
b. Inspect the blood bag for leaks, abnormal color, and clots.
c. Stop the transfusion if a reaction occurs but keep the line open.
d. Take vital signs every 15 minutes while the unit is transfusing.
e. Use a 22-gauge catheter for optimal flow of a blood transfusion
f. Infuse a unit of PRBCs in less than 4 hours.
b. Inspect the blood bag for leaks, abnormal color, and clots.
c. Stop the transfusion if a reaction occurs but keep the line open.
f. Infuse a unit of PRBCs in less than 4 hours.
The nurse is caring for a client newly diagnosed with human immunodeficiency virus (HIV) obtained from unprotected sex. The nurse is in the room when the client is explaining the disease to another person which statement by the client would the nurse clarify? Select all that apply
a. Medications can cure the disease.
b. “My sexual practices will have to change.”
c. The disease can also be spread by body fluids
d. “I am afraid that I will give this disease to my nephew.”
e. I could pass this on to a baby before I give birth
f. “I will have this for the rest of my life.
a. Medications can cure the disease.
d. “I am afraid that I will give this disease to my nephew.”
After undergoing a gastrectomy, a client develops pernicious anemia, which route should the nurse use to administer cyanocobalamin (vitamin B12
a. Parenteral route
b. Oral route
C. Buccal route
d. Transdermal route
a. Parenteral route
Rationale: A client who has undergone gastrectomy is no longer able to produce the intrinsic factor necessary for vitamin B12 absorption through the gastrointestinal tract; therefore, supplementation via parenteral route is required. This medication isn’t available for buccal or transdermal routes.
A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply.
a. Initiate an IV with normal saline.
b. Initiate an IV with dextrose.
c. Take baseline vital signs.
d. Warm the blood to room temperature,
e. Have two nurses check the blood type and identity
a. Initiate an IV with normal saline.
c. Take baseline vital signs.
e. Have two nurses check the blood type and identity
Rationale
Prior to administering blood, the unit must be checked by two registered nurses. Baseline vital signs are obtained before the transfusion is started so any changes would be identified. Blood is always transfused with normal saline as other IV fluids are incompatible with blood. Warming to room temperature is not necessary
Which is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
a. Replacing depleted blood products
b. Treating the underlying cause
c. Administering warfarin sodium
d. Administering heparin
c. Administering warfarin sodium
A client is scheduled for a renal arteriogram, No allergies are recorded in the client’s medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used?
a. Pruritus
b. Hypoventilation
C. Psoriasis
d. Nausea
a. Pruritus
While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client’s medication history. the nurse should determine if the client keeps which medication on hand?
a. Pseudoephedrine
b. Guaifenesin c Loperamide
d. Diphenhydramine
d. Diphenhydramine
Which is least likely a danger associated with pancytopenia?
a. Infection
b. Anemia.
c. Hypothyroidism.
d. Bleeding
c. Hypothyroidism.
A client with anemia has been admitted to the medical surgical unit, which assessment findings are characteristic of iron deficiency anemia?
a. Dyspnea, tachycardia, and pallor
b. Nausea, vomiting, and anorexia
C Nights sweats, weight loss, and diarrhea
d. itching, rash, and jaundice
a. Dyspnea, tachycardia, and pallor
The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client says:
“Abrasions are small pinpoint red dots on the skin.
b. “Purpura is an open cut on the skin.” C “Petechiae are large, red skin bruises.”
d. “Ecchymoses are large, purple skin bruises.”
d. “Ecchymoses are large, purple skin bruises.”
The nurse knows that a specific classification of drugs leads to immunosuppression. What classification of drugs is this?
a. Nonsteroidal anti-inflammatory drugs (NSAIDs; in large doses)
b. Antibiotics in small doses
c. Antineoplastics
d. Antithyroid
c. Antineoplastics
Nursing students have learned that removal of specific organs may place the patient at risk for impaired immune function. The students are taught that it is important while taking the patient’s health history, to ask the patient if he or she had surgical removal of what organ that may lead to impairment of the immune system?
a. Lung
b . Spleen
c. Kidney
d. Pancreas
b . Spleen
Client teaching regarding infection prevention for the client with an immunodeficiency includes which of these guidelines?
a. Limit bathing.
b. People who have been vaccinated recently may visit.
c. Refrain from using creams or emollients on skin.
d. Get regular exercise and rest.
d. Get regular exercise and rest.
The nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
a. Frequent loose stools
b. Tachypnea and restlessness
c. Weight loss of 1/2 kg since yesterday
d. Oral temperature of 37.8°C
b. Tachypnea and restlessness
Your patient has an HIV infection complicated with severe diarrhea. When caring for this patient what is an appropriate nursing intervention to help alleviate the diarrhea?
a. Encourage the patient to eat three balanced meals and a snack at bedtime
b. Decrease the patient’s fluid intake
c. Encourage the patient to increase his or her activity.
d. Administer an anticholinergic antispasmodic as ordered by the physician.
d. Administer an anticholinergic antispasmodic as ordered by the physician.
The nurse suspects that a client with a GI bleed who is receiving a unit of packed red blood cells may be experiencing an incompatibility reaction. Which of these nursing actions should the nurse prioritize?
a. Assessment and protection of the client’s airway
b. Monitoring the client’s vital signs C Notifying the physician
d. Starting a bolus infusion of normal saline
a. Assessment and protection of the client’s airway
The nursing instructor is talking with the students about the care of a patient with multiple myeloma who is experiencing bone destruction. What would the instructor tell the students the patient should be assessed for signs of?
a. Hyperproteinemia
b. Hypercalcemia
C Elevated serum viscosity
d. Elevated RBC count
b. Hypercalcemia
You are assessing a new patient with complaints of a sore, red and smooth tongue. Based upon your assessment findings, you know that the patient is demonstrating symptoms associated with what?
Hemolytic anemia
b. Megaloblastic anemia
c. Sickle cell anemia
d. Aplastic anemia
b. Megaloblastic anemia
A gardener sustained a deep laceration while working and requires sutures. The patient.is asked about the date of her last tetanus shot which she tells the purse, is over 10 years ago. Based on this information the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what?
a. A bacteria
b. An antigen
c. A virus.
d. An antibody
d. An antibody
You are admitting an oncology patient to your unit prior to surgery. The patient has just finished radiation therapy. What does this put your patient at increased risk for?
a. Nutritional deficit
b. Tumour lysis syndrome
c. Cardiac tamponade
d. Impaired wound healing
d. Impaired wound healing
Adverse effects to chemotherapy are dealt with by patients and their caregivers every day. What would the nurse do to combat the most common adverse effects of chemotherapy?
a. Administer an antimetabolite
b. Administer an antiemetic
c. Administer an anticoagulant
d. Administer a tumour antibiotic
b. Administer an antiemetic
The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse would expect that the client has:
a. Hyperresonance on percussion.
b. Decreased breath sounds on the affected side.
c. Wheezing on auscultation
d. Normal bronchial breath sounds
b. Decreased breath sounds on the affected side.
The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?
a. Partial pressure of arterial oxygen (PaO2) of 69 mm Hg
b. Bicarbonate (HCO3-) of 28 mEq/L
c. Partial pressure of arterial carbon dioxide (Paco2) of 51 mm Hg pH of 7.29
a. Partial pressure of arterial oxygen (PaO2) of 69 mm Hg
The nurse is auscultating the lung sounds of a client with long standing emphysema. The nurse is most likely to detect:
pleural friction rub.
b. fine crackles.
c. stridor.
d. diminished breath sounds
d. diminished breath sounds
the nurse is assessing a client newly transferred from the recovery room and notes a low-grade temperature, tachycardia, tachypnea, and crackles. Which of the following is the nurse’s priority action?
a. Administer an albuterol inhaler
b. Administer an oxygen at 100% non-rebreather mask
c. Medicate with acetaminophen
d. Encourage client to cough and take a deep breath
d. Encourage client to cough and take a deep breath
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3- of 28 mEq/L. The nurse reports to the physician which finding?
a. Metabolic acidosis
b. Respiratory alkalosis
c. Metabolic alkalosis
d. Respiratory acidosis
d. Respiratory acidosis
Which of the following demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion?
a. Place the client in the semi-Fowler’s position.
b. Use povidone-iodine to clean the inner cannula when it is removed.
c. Monitor the client’s temperature after the procedure.
d. Use sterile gloves during the procedure
d. Use sterile gloves during the procedure.
A client is admitted to the hospital with a diagnosis of a pulmonary embolism, which problem should the nurse address first?
a. Activity intolerance
b. Impaired gas exchange
c. Difficulty breathing
d. Non-productive cough
b. Impaired gas exchange
Explanation:
Emboli obstruct blood flow, leading to a decreased perfusion of the lung tissue. Because of the decreased perfusion, a ventilation-perfusion mismatch occurs, causing hypoxemia to develop. Arterial blood gas analysis typically will indicate hypoxemia and hypocapnia. A priority objective in the treatment of pulmonary emboli is maintaining adequate oxygenation. A nonproductive cough and activity intolerance do not indicate impaired gas exchange. The client does not demonstrate an ineffective breathing pattern; rather, the problem of impaired gas exchange is caused by the inability of blood to flow through the lung tissue.
A physician orders prednisone to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:
a. GI bleeding
b. restlessness and seizures.
C. acute adrenocortical insufficiency.
d. hyperglycemia and glycosuria.
c. acute adrenocortical insufficiency.
A client with acute asthma is prescribed short-term corticosteroid therapy, which is the expected outcome for the use of steroids in clients with asthma?
a. Promote bronchodilation
b. Prevent development of respiratory infections.
c. Have an anti-inflammatory effect.
d. Act as an expectorant
c. Have an anti-inflammatory effect.
A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital, which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?
a. Activity intolerance
b. Impaired skin integrity
c. Impaired gas exchange
d. imbalanced nutrition: Less than body requirements
c. Impaired gas exchange
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?
2. PH: 7.42, PaCO2: 45 mm Hg, HCO3- 22 mEq/L
b. PH: 7.50, PCO2: 30 mm Hg, HCO3- 24 mEq/L C PH: 7.32, Paco2: 40 mm Hg, HCO3- 18 mEq/L
d. PH: 7.20, Paco2: 65 mm Hg, HCO3- 26 mEq/L
d. PH: 7.20, Paco2: 65 mm Hg, HCO3- 26 mEq/L
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
a. Inspection
b. Chest X-ray
C. Auscultation
d. Arterial blood gas (ABG) levels
C. Auscultation
A nurse consulting with a nutrition specialist knows it’s important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD), which diet is appropriate for this client?
a. Low-fat
b. Full-liquid
c. 1,800 calorie American Diabetes Association (ADA) diet
d. High protein
d. High protein
The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client’s oxygen therapy can be best determined by the:
client’s respiratory rate.
b. absence of cyanosis.
c. client’s level of consciousness.
d. arterial blood gas values
d. arterial blood gas values
A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for
a . moderate pain that worsens on inspiration
b. muscle spasm pain that accompanies coughing.
C. severe mid-sternal pain.
d. a mild but constant aching in the chest.
a . moderate pain that worsens on inspiration
When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?
a. Respirations unlabored
b. Hollow sound on chest percussion
c. Breath sounds clear on auscultation
d. Decreased mucus production
c. Breath sounds clear on auscultation
A client has the following arterial blood gas values: PH. 7.52: PaO2, 50 mm Hg (6.7 kPa) Paco2, 28 mm Hg (3.72 kPa): HCO3., 24 mal (24 mmol/L). Based upon the client’s PaO2, which conclusion would be accurate?
a. The oxygen level is low but poses no risk for the client
b. The client’s Pao2 level is within normal range.
c. The client is severely hypoxic.
d. The client requires oxygen therapy with very low oxygen concentrations.
c. The client is severely hypoxic.
A client is diagnosed with a chronic respiratory disorder. After assessing the client’s knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
a. Impaired swallowing
b. Imbalanced nutrition: More than body requirements
c. Unilateral neglect
d. Anxiety
d. Anxiety
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of:
a. metabolic acidosis
b. acute CNS disturbances
c. increased Paco2
d. respiratory alkalosis
d respiratory alkalosis
A clients undergoing a thoracentesis. What should the nurse monitor the client for during and immediately after the procedure? Select all that apply.
a. Subcutaneous emphysema
b. Pulmonary edema
c. Pneumothorax
d. Tension pneumothorax
e. Infection
a. Subcutaneous emphysema
b. Pulmonary edema
c. Pneumothorax
d. Tension pneumothorax
A client with newly diagnosed chronic obstructive pulmonary disease (COPD) is to be discharged home with oxygen per nasal prongs. which teaching points should the nurse include in this clients discharge plan. Select all that apply.
a. Avoid use of a microwave oven when using oxygen.
b. Increase oxygen flow at night during hours of sleep.
c. Apply Vaseline or petroleum jelly on lips and nose to prevent dryness and irritation.
d. Place gauze between the ears and oxygen tubing to prevent skin irritation
e. Avoid areas where people are smoking cigarettes or cigars.
f. Request a large, pressurized oxygen tank for use during car travel.
a. Avoid use of a microwave oven when using oxygen.
d. Place gauze between the ears and oxygen tubing to prevent skin irritation
e. Avoid areas where people are smoking cigarettes or cigars.
A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. Which initial assessment data would the nurse anticipate? Select all that apply.
a. Fever
b. Decreased respiratory rate
c. Shortened expiratory phase
d. Clubbed fingers and toes
e. Barrel chest
f. Dyspnea on exertion
d. Clubbed fingers and toes
e. Barrel chest
f. Dyspnea on exertion
Which of the following assessment findings would the nurse consider to be most indicative of right-sided heart failure?
A. client has experienced recent weight gain and complains of swollen ankles
b. A client claims a 3-month history of dry cough which has become productive in recent days. C A dent’s ECG on admission lacks a Q wave.
d. A client reports increased urination at night
A. client has experienced recent weight gain and complains of swollen ankles.
A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply.
a. “I should keep my oxygen away from direct heat.
b. “No one can smoke within 10 feet (3 meters) of the oxygen.”
c. “I can carry my oxygen in a bag for easy portability.”
d. I will keep my oxygen out of the sun in all circumstances.”
e. “I need to keep my oxygen away from electrical sources.
a. “I should keep my oxygen away from direct heat.
b. “No one can smoke within 10 feet (3 meters) of the oxygen.”
e. “I need to keep my oxygen away from electrical sources.
The physician has ordered a peripheral IV to be inserted before the patient goes to the operating room. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
a. Have the patient hold his arm over his head
b. Leave the tourniquet on for at least 5 minutes
C. Choose a distal site
d. Choose a proximal site
C. Choose a distal site
A client is being treated for dilated cardiomyopathy. Which medication would this client most likely receive?
a. Calcium channel blockers
b. Beta-adrenergic blockers
c. Nitrates
d. Anticoagulants
d. Anticoagulants
A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: Select all that apply.
a. nail bed color
b. skin temperature
c. fluid intake
d. nausea
e. pain in extremity
a. nail bed color
b. skin temperature
e. pain in extremity
The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The nurse is confident that the client has understood the teaching when the client identifies which of the following potential complications Select all that apply.
a. High intake of sodium for breakfast
b. Weight gain of 2 lb (0.9 kg) or more in 1 day.
c. Weight loss of 2 lb (0.9 kg) in 1 day.
d. Becoming increasingly short of breath at rest.
e. Having to sleep sitting up in a reclining chair.
b. Weight gain of 2 lb (0.9 kg) or more in 1 day
d. Becoming increasingly short of breath at rest.
e. Having to sleep sitting up in a reclining chair
A client is receiving intravenous heparin for the treatment of thrombophlebitis. Which laboratory value should the nurse monitor throughout heparin therapy? Select all that apply.
a. Partial thromboplastin time (PTT)
b. Platelet count
International Normalized Ratio (INR)
d. Prothrombin time (PT)
e. Sodium level
a. Partial thromboplastin time (PTT)
b. Platelet count
While learning about the cardiovascular system in the pre-nursing anatomy and physiology class, the students are studying positive chronotropy. What is this?
a. The constriction of peripheral blood vessels
b. Stimulation of the sympathetic system that increases heart rate
c. Conduction through the AV node
d. The force of myocardial contraction
b. Stimulation of the sympathetic system that increases heart rate
The nurse is caring for a client with a third heart sound, which action is indicated?
a. Assess the client’s lungs for crackles
b. Place the client on a cardiac monitor
c. Observe for sluggish skin turgor
d. Place the client flat in bed
a. Assess the client’s lungs for crackles
Rationale:
A third heart sound indicates fluid volume excess (FVE) or heart failure; crackles are an additional finding and will further refine the assessment. Placing the client with FVE or heart failure flat in bed may cause respiratory distress by decreasing expansion. A cardiac monitor will determine heart rhythm, but it will not give information related to FVE. Sluggish skin turgor is a sign of fluid volume deficit or dehydration
To assess the client’s dorsalis pedis pulse, the nurse should palpate the:
a. lateral surface of the ankle.
b. b ventral aspect of the top of the foot.
c. medial aspect of the dorsum of the foot.
d. medial surface of the ankle.
c. medial aspect of the dorsum of the foot.
Which is the most appropriate diet for a client during the acute phase of myocardial infarction?
a. Liquids as desired .
b. Small easily digested meals
C. Nothing by mouth
d. Three regular meals per day
b. Small easily digested meals
A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic
a. “A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into
interstitial spaces.”
b. “A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.
C. “Generally caused by decreased blood volume.”
d. It is due to severe hypersensitivity reaction resulting in massive systemic vasodilation.”
b. “A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.
A client with unstable angina is scheduled to have a cardiac catheterization. The nurse explains to the client that this procedure is being used to:
a. assess the extent of arterial blockage.
b. open and dilate blocked coronary arteries
c. bypass obstructed vessels
d. assess the functional adequacy of the valves and heart muscle.
a. assess the extent of arterial blockage.
A client with a history of cardiac problems reports severe chest pain. What should be the nurse’s first response?
o a. Administer an analgesic to control the pain
b. Assess the client’s pain.
c. Start oxygen at 2 L/min via nasal cannula. d Notify the health care provider (HCP).
b. Assess the client’s pain.
When assessing a client with left sided heart failure, the nurse expects to note:
a. air hunger.
b. pitting edema of the legs. c jugular vein distention
d, ascites.
a. air hunger.
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
a. administer oxygen.
b. perform chest physiotherapy.
c. have the client take deep breaths and cough.
d. place the client in high Fowler’s position.
d. place the client in high Fowler’s position.
A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client’s family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was:
a. blood clot formed in the kidneys.
b. a decrease in the blood flow through the kidneys.
c. an obstruction of urine flow from the kidneys
d. structural damage to the kidney resulting in acute tubular necrosis.
b. a decrease in the blood flow through the kidneys.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
a. Confusion, urine output 15 ml over the last 2 hours, orthopnea.
b. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
c. SpO2 92% on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
d. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
a. Confusion, urine output 15 ml over the last 2 hours, orthopnea.
Patients in shock can experience fluid replacement complications. What does the nurse monitor the patient for? Select all that apply.
a. Hypoglycemia
b. Cardiovascular overload
c. Pulmonary edema
d. Difficulty breathing
e. Hypovolemia
b. Cardiovascular overload
c. Pulmonary edema
d. Difficulty breathing
What part of an ECG is used to identify the presence of myocardial ischemia or injury?
a. ST segments
b. QRS complex
c. Inverted P Wave d. PVC
a. ST segments
The nurse in the emergency department is assessing a 64 year old client experiencing substernal chest pain. The client’s electrocardiogram shows evidence of myocardial ischemia which statement should indicate to the nurse that the client may be a candidate for thrombolytic therapy?
a. “I have had chest pain for 2 days.”
b. ‘My chest pain started 3 hours ago
C. “I have had chest pain on and off all week
d. “My chest pain stops when I take a nitroglycerin pill.
b. ‘My chest pain started 3 hours ago
Rationale:
Because it takes 4 to 6 hours for myocardial cells to die, thrombolytic therapy should be given within 6 hours of the onset of chest pain to achieve the best results in an acute myocardial infarction. The client who has waited 2 days to be treated for chest pain won’t benefit from thrombolytic therapy. Chest pain that’s relieved by nitroglycerin is most likely due to angina and not an indication for thrombolytic therapy. Chest pain for 1 week is also beyond the 6-hour time limit
You are receiving a patient with aortic regurgitation from the critical care unit into the step down unit. You are aware that aortic regurgitation causes what?
a. Obstruction of blood flow from the left ventricle
b. Blood to flow back from the aorta to the left ventricle
c. Blood to flow back from the left atrium to the left ventricle
d. Obstruction of blood from the left atrium to left ventricle
b. Blood to flow back from the aorta to the left ventricle
The nurses administering captopril an ACE inhibitor, to a client with heart failure. Which assessment finding would prompt the nurse to withhold the next dose and notify the physician?
a. Dyspnea and crackles
b. Hypertension
c Third (s3) heart sound
d. Hyperkalemia
d. Hyperkalemia
A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left sided heart failure? Select all that apply.
a. Cough
b. Jugular vein distention
c. Ascites
d. Crackles
e. Orthopnea
f. Hepatomegaly
a. Cough
d. Crackles
e. Orthopnea
The nurse is caring for a client during the post-surgical period after having a right femoral popliteal bypass graft. The nurse enters the room to conduct a nursing assessment and care. Order the nurse’s actions according to priority. All options must be used.
i. Assess peripheral pulses
ii. il. Assess incision site ii
iii. l. Assess lung fields
iv. iv. Assess pain using 0-10 scale
v. V. Instruct on client positioning
vi. vi. Offer clear fluids
a. iv. iii. I ii. v. vi
b. iii.ii. Ii. Iv. V. vi
c. v. ii. I. iii. V. vi I ii. d. I. ii. Iv. v. vi
e. I. ii. Iii. Iv. v. vi
e. I. ii. Iii. Iv v vi
The nurse is evaluating the cardiac function of a client with history of left ventricular hypertrophy and new diltiazem administration. Which client statements indicate adequate cardiac functioning? Select all that apply.
a. “My blood pressure has been consistently in the 130/70 range.”
b. “I am completing all of my activities of daily living independently.”
c. “My lab results reveal a serum potassium of 3.5 mEq/L (3.5 mmol/L.)”
d. ‘I am tolerating my new low-fat diet.”
e. “In the morning, I notice 2 plus edema in my ankles.”
f. “ I am sleeping well in the second-floor bedroom.
a. “My blood pressure has been consistently in the 130/70 range.”
b. “I am completing all of my activities of daily living independently.”
f. “ I am sleeping well in the second-floor bedroom.
Large quantities of frothy blood-tinged sputum would indicate which of the following?
a. Respiratory infection
b. Pneumothorax
c. Severe pulmonary edema
d. Suctioning required
c. Severe pulmonary edema
You are caring for a patient with leg ulcers. You have taken a careful nursing history. What should this nursing history include? Select all that apply.
a. History of CAD is documented as a co-morbidity
b. Location of pain
c. Limitation of mobility is identified
d. Quality of peripheral pulses are assessed
e. Temperature of skin of both legs is compare
b. Location of pain
c. Limitation of mobility is identified
e. Temperature of skin of both legs is compare
A client has a foot ulcer that has not shown signs of improvement over the past several months. Which medical condition is most likely causing the delay in wound healing? Select all that apply.
a. Multiple myeloma
b. Parkinson’s disease с. Hepatitis
d. Peripheral vascular disease
e. Diabetes
d. Peripheral vascular disease
e. Diabetes
During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client’s skin for erythematous, slightly edematous areas on the client’s back posterior lower legs, and posterior elbows. The health care provider’s diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? Select all that apply.
a. The skin is infected wherever the rash has developed.
b. Washing with antibacterial soap will help the rash.
c. Based on the location; it is likely that detergents in the bed linens caused the rash.
d. Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved.
e. The disorder is contagious.
f. This is an allergic reaction
c. Based on the location; it is likely that detergents in the bed linens caused the rash.
d. Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved.
f. This is an allergic reaction
A client returns from the first session of scheduled physical therapy following total knee replacement surgery. The nurse assesses that the client’s knee is swollen, slightly erythematous, and painful, the client rates the pain as 7 out of 10 and has not had any scheduled or PRN pain medication today. What should the nurse do? Select all that apply.
a. Call physical therapy to cancel the next treatment.
b. Elevate the leg and apply a cold pack.
c. Notify the health care provider (HCP).
d. Gently massage the area to increase circulation to reduce pain.
e. Administer pain medication as prescribed.
b. Elevate the leg and apply a cold pack.
e. Administer pain medication as prescribed.
When planning for risk management for clients who are at risk for development of pressure ulcers, the nurse should first:
a place at risk clients on an every 2-hour turning schedule.
b. identify at-risk clients on admission to the health care facility.
c. automatically place clients in specialty beds.
d provide at-risk clients with a high protein, high-carbohydrate diet.
a place at risk clients on an every 2-hour turning schedule.
A nurse assesses wound evisceration in a client that had abdominal surgery. In what position should the nurse place the client?
a. Knees flexed, supine
b. Left lateral Sims
c. Feet elevated, semi-Fowler’s
d. Trendelenburg
a. Knees flexed, supine
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should
a. monitor serum albumin
b monitor the white blood cell count.
c. insert an indwelling urinary catheter.
d. have the client walk at least twice a day.
a. monitor serum albumin
Explanation:
The nurse should monitor the client’s serum albumin. A decreased serum albumin indicates malnutrition and is considered a risk factor in the development of pressure ulcers.
When developing teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing?
a. Scheduled periods of rest
b. Adequate circulatory status
c. Fluid intake of 1,500 ml/day
d. Balanced nutritional diet
b. Adequate circulatory status
Which one of the following nursing measures would be most important to implement to decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning?
a. Inserting an indwelling urinary catheter to prevent possible soiling of the dressing,
b. Accurately measuring drainage from the surgical drainage tube.
c. Changing the surgical dressings using sterile technique.
d. Monitoring the incision for signs of redness, swelling, and warmth.
c. Changing the surgical dressings using sterile technique.
A nurse is caring for a client with a postoperative wound evisceration which action should the nurse perform first?
a. cover the protruding internal organs with sterile gauze, moistened with sterile saline solution.
b Request the client remain on bedrest until the health care provider is notified.
c. Push the protruding organs back into the abdominal cavity.
d. Calm the client, as the client is very upset and crying.
a. cover the protruding internal organs with sterile gauze, moistened with sterile saline solution.
A client with arterial insufficiency undergoes below knee amputation of the right leg, which action should the nurse include in the postoperative care plan?
Applying heat to the stump as the client desires
b. Removing the pressure dressing after the first 8 hours Maintaining the client on complete bed rest
d. Elevating the stump for the first 24 hours
d. Elevating the stump for the first 24 hours
A nurse is caring for an elderly bedridden adult in the long-term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
Use two people when sliding the client up in bed.
b. Tum and reposition the client every 4 hours.
c Massage lotion over bony prominences when turning.
d. Develop a written individual turning schedule.
d. Develop a written individual turning schedule.
Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?
a. The client’s skin is intact with non-blanchable redness of a localized area over a bony prominence.
b. The client’s skin has partial loss of dermis presenting as a shallow open ulcer with a red pink wound bed.
c. The client’s skin is a shiny, dry ulceration with bruising noted.
d. The client’s subcutaneous tissue is visible with a blood blistered wound bed.
a. The client’s skin is intact with non-blanchable redness of a localized area over a bony prominence.
Which nursing intervention is essential in caring for a client with compartment syndrome?
a. Wrapping the affected extremity with a compression dressing to help decrease the swelling
b. Starting an IV. line in the affected extremity in anticipation of venogram studies
c. Keeping the affected extremity below the level of the heart
d. Removing all external sources of pressure, such as clothing and jewelry
d. Removing all external sources of pressure, such as clothing and jewelry
Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.
A client is receiving sulfonamide cream as topical treatment for bums. When reviewing the daily laboratory tests, the nurse notices that the client’s white blood cell (WBC) count has decreased. The nurse reviews the data and determines that:
a. this is normal an increased WBC would be a concern.
b. this is abnormal the health care provider needs to be alerted
c. the WBC count should be observed over several days to look for a trend.
d. it is normal to have this response from immunosuppression
a. this is normal an increased WBC would be a concern.
Leukopenia, or a decreased WBC count, is an adverse reaction to sulfonamide cream. A decreased WBC count should be reported to the health care provider immediately. Sulfonamide cream should be discontinued until WBC count returns to normal.
The nurse is providing client education during the rehabilitation phase of a burn injury, Which of the following statements by the client indicates that more instruction is required
a. “I will use mild soap and water when bathing.”
b. “I will massage my burn scar with mild lotion or cream.”
c. will take prescribed oral pain medications 30 minutes prior to wound care procedures.”
d. “I will report any skin discoloration to the primary healthcare provider immediately.”
b. “I will massage my burn scar with mild lotion or cream.”
A nurse who is caring for a client’s wound that is chronic, but not infected, should:
a. clean the wound with alcohol .
b. apply the same type of dressing throughout the healing process. c change the dressing based on assessment of the wound.
d. change the dressing every 4 hours.
c change the dressing based on assessment of the wound.
Which of these problems is a priority in the client who has been burned and suffered smoke inhalation?
a. Pain
b. Airway management
c. Anxiety and fear
d. Fluid balance
b. Airway management
A client returns from the operating room with a partial thickness skin graft on his left arm. The donor tissue was taken from his left hip. in planning his immediate postoperative care, which interventions would the nurse include? Select all that apply.
a. Administer pain medication every 4 hours as ordered for pain in the donor site.
b. Perform range of motion (ROM) exercises to the left arm every 4 hours.
c Monitor the pulse in the left arm every 4 hours.
d. Change the dressing on the graft site every 8 hours.
e. Encourage the client to ambulate as desired on the first postoperative day.
f. Elevate the left arm and provide complete rest of the grafted area.
a. Administer pain medication every 4 hours as ordered for pain in the donor site.
c Monitor the pulse in the left arm every 4 hours.
f. Elevate the left arm and provide complete rest of the grafted area.
The nurse is assessing a patient newly admitted to the floor. The nurse notes involuntary twitching of muscle groups. How would the nurse document this observation in the patient’s chart?
a. Muscle spasm
b. Fasciculation
c. Tetany
d. Clonus
b. Fasciculation
A client is preparing for discharge from the hospital after undergoing an above-the-knee amputation. Which instructions should the nurse include in the teaching plan for this client Select all that apply.
a. Rub the stump with a dry washcloth for 4 minutes three times per day if the stump is sensitive to touch
b. Be sure to perform the prescribed exercises.
c. Report twitching, spasms, or phantom limb pain immediately.
d. Avoid using heat application to ease pain
e. Avoid exposing the skin around the stump to excessive perspiration.
f. Massage the stump away from the suture line.
a. Rub the stump with a dry washcloth for 4 minutes three times per day if the stump is sensitive to touch
b. Be sure to perform the prescribed exercises.
e. Avoid exposing the skin around the stump to excessive perspiration.
RATIONALES: The nurse should advise the client to avoid exposing the skin around the stump to excessive perspiration, which can be irritating. She should tell him to perform prescribed exercises to help minimize complications. In addition, the nurse should tell the client that if the stump is sensitive to touch, he should rub the stump with a dry washcloth for 4 minutes three times per day. The nurse should tell the client to massage the stump toward — not away from — the suture line to mobilize the scar and to prevent its adherence to bone. The client may experience twitching, spasms, or phantom limb pain while his muscles adjust to the amputation. This is a normal reaction and doesn’t need to be reported. The nurse should advise the client that he can ease these symptoms with heat, massage, or gentle pressure.
Which of these laboratory results would most clearly signal a risk of impaired skin integrity?
a. Increased creatinine and blood urea nitrogen.
b. Low platelets and a high PTT *
c. Increased neutrophils.
d. Low hemoglobin and low serum albumin
c. Increased neutrophils.
The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment?
A) Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery
b. Postoperative confusion is common in the elderly, but it could also indicate a significant blood loss.
c. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery.
d. Confusion restlessness, and agitation are normal postoperative findings and will diminish in time
b. Postoperative confusion is common in the elderly, but it could also indicate a significant blood loss
The client has been diagnosed with septic arthritis in a hip joint, which outcomes are desired from a client-focused teaching plan? Select all that apply.
a. Describe how the application of a heating pad set on “high” readily resolves edema.
b. Report pain that is severe enough to limit activities.
c. Discuss how to take prescribed medications.
d. Explain the importance of supporting the affected joint
e. Describe the septic arthritis physiologic process.
F.Describe how to use ambulatory aids and assistive devices.
b. Report pain that is severe enough to limit activities.
c Discuss how to take prescribed medications.
d. Explain the importance of supporting the affected joint
e Describe the septic arthritis physiologic process.
F.Describe how to use ambulatory aids and assistive devices.
