NUR205 Flashcards
The student nurses are studying for a test on
diabetes mellitus. What should the students know is a complication of diabetes
termed “macrovascular”?
a. Nephropathy Incorrect
b. Renal failure
c. Stroke
d. Retinopathy
e. Liver failure
c. Stroke
A patient is prescribed corticosteroid therapy.
What would be important information for the nurse to give the patient who is
prescribed corticosteroid therapy?
a. The patient’s diet should be low protein with
ample fat.
b. There will be no change in appearance.
c. The patient is at increased falls risk
d. The patient is at a decreased risk of developing
thrombophlebitis and thromboembolism.
e. The patient is at an increased risk of
developing infection. Correct
e. The patient is at an increased risk of
developing infection.
The diabetic Nurse Educator is teaching a class for newly diagnosed diabetics and their families. In this class the Nurse Educator is teaching about “sick day rules.” What guideline applies to periods of illness (“sick day rules”) in a diabetic patient?
Select one:
a. Report elevated glucose levels greater than 7 mmol/L
b. Do not eliminate insulin when nauseated and
vomiting.
c. If nauseated, do not eat solid foods.
d. Eat three meals a day.
e. Eat small regular meals
b. Do not eliminate insulin when nauseated and
vomiting.
The PACU (theatre recovery) staff has brought a patient to the unit
following a thyroidectomy. To promote
comfort for this patient how would you position the patient?
Select one:
a. Side-lying (lateral) with one pillow under the
head
b. Side-lying (lateral) with no pillow under the head
c. Head of the bed elevated 30 degrees and no
pillows placed under the head Incorrect
d. Semi-Fowler’s with the head supported on one or two
pillows
e. Flat, with a small roll supporting the neck
d. Semi-Fowler’s with the head supported on one or two
pillows
You are conducting a class on how to self-manage insulin regimens. A patient asks you how long a vial of insulin can be stored at room temperature before it “goes bad.” What would be your best answer?
Select one:
a. It can only be taken out of the fridge when you are drawing it up
b. If a vial of insulin will be used up within 21
days, it may be kept at room temperature.
c. If you are going to use up the vial within 1
month it can be kept at room temperature.
d. If a vial of insulin will be used up within 2
weeks, it may be kept at room temperature.
e. If a vial of insulin will be used up within 1
week, it may be kept at room temperature.
c. If you are going to use up the vial within 1
month it can be kept at room temperature.
A patient has returned to the floor after having
a thyroidectomy for thyroid cancer. The nurse knows that sometimes during
thyroid surgery the parathyroid glands can be injured or removed. What
laboratory finding may be an early indication of parathyroid gland injury or
removal?
Select one:
a. Hyponatraemia
b. Hypocalcaemia
c. Hypophosphataemia
d. Hypokalaemia
e. Hyperkalaemia
b. Hypocalcaemia
While assisting with the surgical removal of an
adrenal tumour the operating room nurse is aware that the patient’s vital signs
may change upon manipulation of the tumour. What vital sign changes would the
nurse expect to see?
Select one:
a. Hypotension and hypothermia
b. Hyperthermia and tachypnoea
c. Hyperthermia and bradycardia
d. Hypertension and heart rate changes
e. Hyperthermia and bradycardia
d. Hypertension and heart rate changes
A patient has returned to the unit after having
a parathyroidectomy. What drug does the nurse ensure is immediately available?
Select one:
a. Calcium alginate
b. Digitalis
c. Ergocalciferol Incorrect
d. Amphojel
e. Calcium gluconate
e. Calcium gluconate
You are caring for a patient with advanced
cirrhosis. You know that the most significant source of bleeding in a patient
with cirrhosis is what?
Select one:
a. Oesophageal varices
b. Portal hypertension
c. Common bile duct haemorrhage
d. Ascites
e. Haemolytic jaundice
a. Oesophageal varices
A patient with a liver mass is undergoing a percutaneous
liver biopsy. After the procedure the nurse assists the physician in
positioning the patient. What position should they position the patient in?
Select one:
a. On the left side with a pillow under the knees
b. Supine position
c. Reverse Trendelenberg
d. Trendelenberg
e. On the right side with a pillow under the costal
margin
e. On the right side with a pillow under the costal
margin
The critical care nurse is caring for a patient
with cirrhosis. What is an essential nursing function when caring for a patient
with cirrhosis?
Select one:
a. Monitoring the patient for signs of hypervolemia
b. Monitoring the patient’s oral intake
c. Monitoring the patient’s support network
d. Monitoring the patient’s mental status
e. Monitoring for constipation
d. Monitoring the patient’s mental status
A nurse is assessing an elderly patient with
gallstones. The nurse is aware that the patient may not exhibit typical
symptoms and that symptoms that may be exhibited in the elderly patient may
include what?
Select one:
a. Chills and jaundice
b. Spontaneous haemorrhage
c. Nausea and vomiting
d. Septic shock and oliguria
e. Fever and pain
d. Septic shock and oliguria
The nurse is caring for a patient with liver failure. The
nurse understands that patients in liver failure often require vitamin therapy.
Which vitamin does the liver require for the synthesis of prothrombin?
Select one:
a. Vitamin B12
b. Vitamin A
c. Vitamin K
d. Vitamin B6
e. Vitamin D
c. Vitamin K
You are caring for a patient admitted with a diagnosis of renal failure. When you
review your patient’s laboratory reports, you note that the patient’s magnesium
levels are high. What would be important for you to assess?
Select one:
a. Cool, Clammy skin
b. Visual acuity
c. Diminished Deep tendon reflexes
d. Increased Serum magnesium
e. Tachycardia
c. Diminished Deep tendon reflexes
You are working on a burn unit. One of your patients is exhibiting signs and
symptoms of third spacing, which occurs when fluid moves out of the intravascular
space but not into the intracellular space. Based upon this fluid shift, what
would you expect the patient to demonstrate?
Select one:
a. Hypervolaemia
b. Hypertension
c. Decreased oxygen saturations
d. Bradycardia
e. Hypovalaemia
e. Hypovalaemia
A patient with anxiety 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 which acid-base imbalance?
Select one: a. Respiratory acidosis b. Increased PaCO2 c. None of the above d. Respiratory alkalosis e. CNS disturbances
d. Respiratory alkalosis
<p>You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: PH 7.26, PaCO2 28, HCO3 11 mmol/L. How would you interpret these results? Select one: a. Respiratory acidosis with no compensation b. Respiratory alkalosis c. Metabolic acidosis with no compensation d. Metabolic acidosis with a compensatory respiratory alkalosis e. Metabolic alkalosis with a compensatory alkalosis</p>
<p>d. Metabolic acidosis with a compensatory respiratory alkalosis</p>
<p>metabolic alkalosis because pH is low so is HCO3 low</p>
<p>respitory compensation becauseCO2 is low</p>
A nurse in the medical ICU has orders to infuse a hypertonic solution into her
patient with low blood pressure. This solution will increase the number of
dissolved particles in the patient’s blood, creating pressure for fluids in the
tissues to shift into the capillaries and increase the blood volume. Which term
or terms is/are associated with this process?
Select one: a. Rhubarb b. Hydrostatic pressure c. Active transport d. Diffusion e. Osmosis and osmolality Correct
e. Osmosis
and osmolality Correct
The nursing instructor is discussing renal failure with her senior nursing class.
The instructor states, “A patient in renal failure partially loses the ability
to regulate changes in pH.” What is the cause of this partial inability?
Select one:
a. The
kidneys buffer acids through electrolyte changes.
b. The kidneys produce carbonic acid to act in the buffering process
c. The
kidneys regulate and reabsorb carbonic acid to change and maintain pH.
d. The
kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
e. The
kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
e. The
kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
While admitting a new patient to your medical-surgical unit, you note that the
patient is oliguric. You notify the medical officer who orders a
fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes.
What do you know this intervention will do?
Select one:
a. Help provide an effective treatment for hypertension induced oliguria
b. Help distinguish reduced renal blood flow from decreased renal function
c. Very little
d. Help evaluate pituitary gland function
e. Help distinguish hyponatraemia from hypernatraemia
b. Help distinguish reduced renal blood flow from decreased renal function
A diabetic patient with renal failure has been admitted to your unit. What is the most life-threatening effect of renal failure you will monitor for?
Select one:
a. Lack of blood pressure control Incorrect
b. Polyuria
c. Depletion of calcium
d. Retention of potassium
e. Accumulation of wastes
d. Retention of potassium
What function does the kidney perform to assist
in maintaining acid–base balance within the necessary normal range?
Select one:
a. Return acid to the body’s circulation
b. Excrete acid in the lungs
c. Excrete bicarbonate in the urine
d. Excrete alkali from the body’s circulation
e. Return bicarbonate to the body’s circulation
e. Return bicarbonate to the body’s circulation
The nurse is caring for a patient receiving haemodialysis treatments. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
Select one:
a. The patient shouldn’t feel pain during
initiation of dialysis
b. Using a stethoscope for auscultating the fistula is contraindicated.
c. The patient feels best immediately after the
dialysis treatment.
d. Taking a blood pressure reading on the affected
arm can cause clotting of the fistula.
e. All of the above
d. Taking a blood pressure reading on the affected
arm can cause clotting of the fistula.
Renal failure can have prerenal, renal, or postrenal
causes. A patient presents with acute renal failure and is being assessed to
determine where, physiologically, the cause is. If the cause is found to be
prerenal, which condition most likely caused it?
Select one:
a. Heart failure
b. Ureterolithiasis
c. Aminoglycoside toxicity
d. Glomerulonephritis
e. UTI
a. Heart failure
A patient is receiving patient education prior
to beginning continuous ambulatory peritoneal dialysis. What would the nurse
teach the patient that the most common complication associated with this
procedure is?
Select one:
a. Constipation
b. Dehydration
c. Peritonitis
d. Blood loss
e. DVT
c. Peritonitis
- Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. The nurse bases this nursing diagnosis on the finding of:
a) SpO2 of 85%
b) respiratory rate of 28 breaths/min
c) presence of greenish sputum
d) crackles in the right and left lower lobes
d) crackles in the right and left lower lobes
- A patient experiences a flail chest as a result of a motor vehicle accident. During the respiratory assessment the nurse would expect to find:
a) bloody sputum
b) laryngeal stridor
c) deep, irregular respirations
d) paradoxical chest movement
d) paradoxical chest movement
- A patient has a chest tube following a thoracotomy. Continuous bubbling in the -suction chamber of the collection device would alert the nurse that:
a) an air leak may be present
b) the lung has fully expanded
c) the unit is functioning normally
d) a tension pneumothorax is developing
a) an air leak may be present
- A patient is scheduled for a thoracentesis to obtain pleural fluid for diagnosis of a large pleural effusion. She asks the nurse to explain what causes the fluid in her lung. The nurse explains that:
a) the pleural effusion could be caused by a tumour or other growth
b) a pleural effusion is not a disease but rather a sign of some other disease
c) pleural effusions occur when there is any inflammation or infection in the lung
d) the cause of pleural effusions is not known but they can be treated by removing the fluid with a needle or tube
b) a pleural effusion is not a disease but rather a sign of some other disease
(Smeltzer and Bares pg 542 “Pleural effusion is usually secondary to other disease processes).
- A patient with an acute exacerbation of COPD has the following ABG analysis: pH 7.32, PaO2 58 mmHg, PaCO2 55 mmHg and SaO2 86%. The nurse recognises these values as evidence of:
a) respiratory acidosis
b) respiratory alkalosis
c) normal acid–base balance with hypoxaemia
d) normal acid–base balance with hypercapnia
a) respiratory acidosis
- The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by:
a) promoting atherosclerosis and damage of the walls of the arteries
b) thickening capillary membranes, leading to hypoxia of organ systems
c) causing direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue
d) increasing the viscosity of the blood, contributing to intravascular coagulation and necrosis of tissue distal to occlusions
a) promoting atherosclerosis and damage of the walls of the arteries
- During the assessment of a 50-year-old patient who has newly diagnosed stage 1 hypertension, the patient admits he uses a lot of salt on his food and has not been able to lose the 14 kg he has gained in the last 10 years. He does not understand why he has hypertension because he is not an anxious person. An appropriate nursing diagnosis for the nurse to identify for the patient is:
a) non-compliance related to lack of motivation
b) disturbed self-esteem related to diagnosis of hypertension
c) altered health maintenance related to lack of knowledge of disease process and management
d) anxiety related to complexity of management regimen and lifestyle changes associated with hypertension
c) altered health maintenance related to lack of knowledge of disease process and management
- A 45-year-old man is admitted to the emergency room after developing severe chest pain while raking leaves. On admission he has mid-chest dullness and a normal electrocardiogram (ECG). The doctor schedules the patient for cardiac catheterisation with coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that, in his case, it is used to:
a) determine whether there are any structural defects in the walls or chambers of his heart
b) determine whether any obstructions are present in his coronary arteries and to test for an allergy to thrombolytic agents
c) measure the amount of blood being pumped from his heart with each contraction to determine whether there is heart damage
d) visualise any blockages in the coronary arteries and, if necessary, to dilate an obstructed artery with the use of a small balloon
d) visualise any blockages in the coronary arteries and, if necessary, to dilate an obstructed artery with the use of a small balloon
While observing the ECG monitor of a patient admitted to the emergency department with chest pain, the nurse suspects that the patient is having a myocardial infarction rather than angina upon finding:
a) sinus tachycardia
b) depressed R wave
c) ST segment elevation
d) occasional premature ventricular contractions
c) ST segment elevation
- CK-MB and troponin levels are evaluated for a patient who has experienced chest pain and aching for the last 4 days. The nurse expects:
a) myoglobin levels will be needed to confirm myocardial damage
b) CK-MB will be the most reliable indicator of any myocardial necrosis that has occurred
c) any serum cardiac marker will be inconclusive in determining myocardial injury that is several days old
d) the presence of myocardial damage occurring several days earlier can be validated best by the troponin level
d) the presence of myocardial damage occurring several days earlier can be validated best by the troponin level
- During assessment of a 72-year-old man with swelling in his ankles, the nurse finds jugular venous distension with the head of the bed elevated 45 degrees. The nurse knows this finding indicates:
a) decreased fluid volume
b) elevated right atrial pressure
c) incompetent jugular vein valves
d) atherosclerosis of the jugular veins
b) elevated right atrial pressure
- In analysing a patient’s electrocardiogram (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibres is represented by the:
a) P wave
b) PR interval
c) QT interval
d) QRS complex
b) PR interval – Rationale: The PR interval represents depolarization of the atria, AV node, bundle of His, bundle branches, and the Purkinje fibers, up to the point of depolarization of the ventricular cells.
- A patient has been receiving intravenous heparin therapy for 6 days for treatment of deep vein thrombosis. The doctor now orders warfarin without discontinuing the heparin. The patient questions the nurse about the use of both drugs. The nurse’s best response to the patient is:
a) ‘I will check with the doctor about this. You could be at risk of bleeding with both drugs.’
b) ‘Because of the potential for a pulmonary embolism, it is important for you to have additional anticoagulants.’
c) ‘It takes several days for the warfarin to have an effect, so we need to keep you on the heparin for a few more days.’
d) ‘Because you are allowed more activity now, the heparin is metabolised faster and needs to be supplemented with the warfarin.’
c) ‘It takes several days for the warfarin to have an effect, so we need to keep you on the heparin for a few more days.’
- In planning care for a patient with a venous stasis ulcer on the right lower leg, the nurse understands that the most important intervention in promoting healing of the ulcer is:
a) adequate dietary intake of proteins and vitamins
b) prevention of infection with prophylactic antibiotics
c) application of external compression to decrease venous stasis and oedema
d) keeping the ulcer moist with hydrocolloid or damp gauze dressings to promote epithelialisation
a) adequate dietary intake of proteins and vitamins
List the 4 components of a physical examination of the respiratory system and list 2 abnormalities that may affect the results from each component:
I – Inspection
Abnormalities: Skeletal deformities may limit thoracic cage excursion: scoliosis, kyphosis , broken ribs, thoracic cage abnormalities.
P – Palpation
Abnormalities: Thickness of the chest wall and relative location of bronchi to the chest wall will affect the normal intensity of tactile fremitus.
P – Percussion
Abnormalities: The resonant note may be modified somewhat in the athlete with a heavily muscular chest wall and in the heavily obese adult in whom subcutaneous fat produces scattered dullness.
A – Auscultation
Abnormalities: Noises may be modified by obstruction within respiratory passageways or by changes in the lung parenchyma, the pleura or the chest wall.
(Note: it is Respiratory Assessment pneumonic - HIPPA from 105 minus the H for History – Remember HIPPA minus the H so just IPPA)
Spinal and Rib abnormalities - Abnormalities in the skeletal system or chest wall itself can result in a restrictive ventilatory defect.
- Give the normal adult male values of the following:
Tidal volume –
Vital Capacity –
Anatomical Dead Space Volume -
Tidal volume – 500ml or 5-10mL/kg
Vital Capacity – 4,600 mL
Anatomical Dead Space Volume - The anatomic dead space is equal to the volume exhaled during the first phase plus half that exhaled during the second phase and is about 150 ml on the average in humans which is a third of the Tidal volume
- Name three types of validity:
- Content validity
- Criterion related validity
- Construct validity
List the five first line response drugs used in the event of a cardiac arrest. Give a brief description of each drug’s specific mechanism of action:
Oxygen – improves tissue oxygenation and corrects hypoxaemia
Adrenaline – increases systemic vascular resistance and BP, improves coronary and cerebral perfusion and myocardial contractility
Vasopressin – increases systemic vascular resistance
Atropine – blocks parasympathetic action, increases SA node automaticity and AV conduction
Sodium bicarbonate – corrects metabolic acidosis
Magnesium – promotes adequate functioning of cellular sodium-potassium pump
The coronary artery blood flow is mainly regulated by pressure within the:
Aorta
The hydrogen ion concentration of a solution is measured as it’s:
pH
Define and explain the pathophysiology of intermittent claudication:
A muscular cramp-like pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. This pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients during exercise. As the tissues are forced to compete the energy cycle without nutrients, muscle metabolites aggravate the nerve endings of the surrounding tissue. Usually about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced. This subsides by rest because it deceases the metabolic needs of the muscles and the pain subsides.
- List the 3 components of Virchow’s triad
- Venous stasis (Slow/Stagnant blood flow)
- Hypercoagulability
- Endothelial injury/damage (e.g. hypertension)
Following assessment of a patient with pneumonia, you identify a nursing diagnosis of
ineffective airway clearance. You base this nursing diagnosis on the finding of:
a) 5po2 of 85%
b) respiratory rate of 28 breaths/min
c) presence of greenish sputum
d) crackles in the right and left lower lobes
d) crackles in the right and left lower lobes
A patient with an acute exacerbation of COPD has the following ABG analysis: pH 7.32,
Pao2 58 mmHg, Paco2 55 mmHg and Sao2 86%. You recognise these values as evidence
of:
a) respiratory acidosis
b) respiratory alkalosis
c) normal acid-base balance with hypoxaemia
d) normal acid-base balance with hypercapnia
a) respiratory acidosis
