Nurse Labs

Question 1

client with a history of ischemic heart disease who has been admitted to the ICU following a myocardial infarction. The client is currently receiving lidocaine I.V. to manage his ventricular ectopy, which has been persistent. Which of the following factors would be most important for the nurse to consider in relation to the administration of this medication?

A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter

B. Increase in systemic blood pressure

C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor

D. Increase in intracranial pressure (ICP)

E. A drop in serum potassium levels as indicated in the latest lab results

F. Observation of a widening QRS complex on the ECG

Answer 1

Correct Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.

Acute myocardial infarction, the priority is to manage life-threatening arrhythmias.

Lidocaine is specifically indicated for the treatment of ventricular arrhythmias, such as PVCs, which can be indicative of an increased risk for more serious arrhythmias like ventricular tachycardia or ventricular fibrillation.

Question 2

Recently diagnosed with osteoporosis. The patient leads a sedentary lifestyle, has a diet low in calcium, has undergone menopause ten years prior, and has a visibly kyphotic posture.

Which of the following complications should the nurse emphasize as the most significant risk associated with osteoporosis, especially considering the patient’s profile?

A. Increased susceptibility to bone fractures from minimal trauma

B. Consequences of long-term estrogen deficiency post-menopause

C. The impact of sustained negative calcium balance on bone density

D. The progression of spinal deformities such as a kyphotic curvature

E. Potential for height loss over time due to vertebral compression

F. Risk of developing chronic pain associated with skeletal weakness

Answer 2

Correct Answer: A. Increased susceptibility to bone fractures from minimal trauma.

Given the patient’s diagnosis of osteoporosis, a sedentary lifestyle, and poor dietary habits, the most significant and immediate complication is the risk of bone fractures, particularly hip, wrist, and spine fractures, which can result from minimal stress

Question 3

What is the primary goal of the Breast Self-Exam (BSE)

Answer 3

To notice any changes in the breast tissue from what is normal for each individual

Question 4

nurse is managing the care of a 32-year-old female client diagnosed with hyperthyroidism. The client reports experiencing palpitations, unintentional weight loss, and intermittent bouts of excessive sweating. The treatment plan includes antithyroid medications. In addition to administering medication, what nursing interventions should be prioritized to manage the client’s condition best?

A. Ensure the client is provided with extra blankets and clothing to maintain a warm environment due to heightened sensitivity to cold.

B. Closely monitor the client for increased signs of restlessness, sweating, and significant weight loss

C. Create a balance between the client’s periods of activity and rest to manage fatigue without exacerbating symptoms.

D. Encourage increased physical activity to counteract the sedative effects of the medication and prevent constipation.

E. Regularly check the client’s temperature as they are prone to developing fevers.

F. Offer a low-iodine diet and coordinate with a dietitian to manage dietary influences on thyroid function

Answer 4

C. Create a balance between the client’s periods of activity and rest to manage fatigue without exacerbating symptoms.

Clients with hyperthyroidism may experience symptoms like fatigue and muscle weakness. Balancing activity with rest helps to conserve energy and prevent exacerbation of symptoms.

Question 5

55-year-old client diagnosis of atherosclerosis. The client has a sedentary lifestyle, a high-stress job, and a diet high in saturated fats. As part of the client’s comprehensive care plan to manage and reduce the progression of atherosclerosis, which of the following lifestyle modifications should the nurse emphasize?

A. Emphasize the importance of not focusing solely on weight as a health measure, but rather on overall cardiovascular health.

B. Recommend an incremental increase in physical activity, starting with low-intensity exercises such as walking or swimming.

Advise adherence to a heart-healthy diet, rich in fruits, vegetables, whole grains, and lean proteins, while limiting saturated fats and cholesterol.

D. Counsel on stress management techniques and the importance of incorporating relaxation activities into daily routines.

E. Discuss smoking cessation strategies if applicable and avoid exposure to secondhand smoke.

F. Suggest regular monitoring of blood pressure and cholesterol levels with follow-up appointments to assess cardiovascular health.

Answer 5

B. Recommend an incremental increase in physical activity, starting with low-intensity exercises such as walking or swimming.

Increasing physical activity is a key intervention for a client with atherosclerosis in managing and slowing the disease’s progression. While the other options are valid health measures, they are less directly impactful on atherosclerosis than increasing physical activity

Question 6

Post cataract surgery which should be included in the education

A. Restrict fluids to limit the need for frequent urination.
B. Avoid lifting objects heavier than 5 lb (2.25 kg) and engage in light activities like walking.
C. Remain in a prone position while resting to facilitate healing.
D. Keep living spaces dimly lit to avoid glare and discomfort in the healing eye.
E. Refrain from straining during bowel movements and avoid bending at the waist.

Answer 6

E. Refrain from straining during bowel movements and avoid bending at the waist.

Lifting should not be more than 15lbs

Lying posistion should be on side on on back.

Question 7

Match the following

Biots Breathing, Kussmaul, Cheyenne Strokes, Tachypnea

A. Progressively deeper breaths followed by shallower breaths with apneic periods.

B. Rapid, deep breathing with abrupt pauses between each breath.

C. Rapid, deep breathing and irregular breathing without pauses.

D. Shallow breathing with an increased respiratory rate.

Answer 7

Cheyenne Strokes (Associated with conditions that affect the medulla oblongada, strokes)

A. Progressively deeper breaths followed by shallower breaths with apneic periods.

Biots Breathing- Causes damage to the medulla oblongada, strokes, meningitis
B. Rapid, deep breathing with abrupt pauses between each breath.

Kussmaul- DKA
C. Rapid, deep breathing and irregular breathing without pauses.

Tachypnea
D. Shallow breathing with an increased respiratory rate.

Question 8

Type of lung sound most likely to ausculate for patients with Heart Failure

Answer 8

Fine crackles. Due to fluid build up in the lungs

Question 9

42-year-old patient with no significant medical history presents to the clinic with a recent positive Mantoux tuberculin skin test. The patient reports a productive cough and night sweats that have persisted for the past three weeks. The nurse understands that a chest X-ray has been ordered. The nurse considers that this diagnostic test is most crucial for which of the following reasons?

A. To confirm the presence of active pulmonary tuberculosis.

B. To determine if there is a need for a repeat Mantoux test due to potential false-positive results.

C. To assess the size and spread of any lesions within the lung tissue.

D. To differentiate between a primary TB infection or a reactivation of a latent TB infection.

Answer 9

Correct Answer: C. To determine the extent of lesions

If the lesions are large enough, the chest X-ray will show their presence in the lungs.

Option A: Sputum culture confirms the diagnosis. It is a test to detect and identify bacteria or fungi that infect the lungs or breathing passages.

Question 10

condition of the large intestine that causes difficulty passing stool.

Missing nerve cells in the muscles of part or all of the large intestine.

Present at birth, it causes difficulty passing stool.

The main symptom is a newborn’s failure to have a bowel movement within 48 hours after birth.

Other symptoms include a swollen belly and vomiting.

Surgery is needed to bypass the affected part of the colon or remove it entirely

Name the disease

Answer 10

Hirschsprung’s disease

Question 11

Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:

A. Elevated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia, elevated antinuclear antibody (ANA) titer
D. Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels

Answer 11

Pancytopenia, elevated antinuclear antibody (ANA) titer

Laboratory findings for clients with SLE usually show pancytopenia ( red and white blood cells and platelets in the blood is lower than normal) elevated ANA titer(Amount of antibodies- used to diagnose autoimmune disease), and decreased serum complement levels.

B. Elevated Sed rate is correct (Indicates inflammation SLE, RA, Cancer

Question 12

S &S

Red Rash across the nose & cheeks (Resembles a butterfly) - commonly after exposure to sunlight.

Weakness, fatigue, SOB, joint pain.

Answer 12

SLE, Systemic lupus erythematosus

Question 13

When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?

A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
B. Emergent; the client is poorly oxygenated.
C. Normal.
D. Significant; the client has alveolar hypoventilation.

Answer 13

Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).

normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels.

Option B: Oxygenation is evaluated through Pao2 and oxygen saturation.

Option C: The normal PaCO2 level is between 35 to 45 mmHg. PaCO2 or the partial pressure of carbon dioxide is the measure of carbon dioxide within arterial or venous blood.

Option D: Alveolar hypoventilation would be reflected in an increased Paco2. Alveolar hypoventilation is defined as insufficient ventilation leading to hypercapnia, which is an increase in the partial pressure of carbon dioxide as measured by arterial blood gas analysis.

Question 14

When prioritizing care, which of the following clients should the nurse Olivia assess first?

A. A 17-year-old client 24-hours post appendectomy.

B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome.

C. A 50-year-old client 3 days post myocardial infarction.

D. A 50-year-old client with diverticulitis.

Answer 14

Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation.

Question 15

JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?

A. Replaces estrogen.
B. Decreases infection.
C. Decreases inflammation.
D. Decreases bone demineralization.

Answer 15

C. Decreases inflammation.

The action of colchicines is to decrease inflammation by reducing the migration

form of arthritis that causes severe pain, swelling, redness and tenderness in joints.

Caused by too much uric acid that crystallizes and is deposited in joints.

Medications that block uric acid production include xanthine oxidase inhibitors like allopurinol (Aloprim, Lopurin, Zyloprim) and febuxostat (Uloric). According

Question 16

Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?

A. Osteoarthritis is rarely debilitating.
B. Osteoarthritis is a rare form of arthritis.
C. Osteoarthritis is the most common form of arthritis.
D. Osteoarthritis affects people over 60.

Answer 16

C. Osteoarthritis is the most common form of arthritis

Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.

Question 17

Ruby is receiving thyroid replacement therapy, develops the flu, and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following life-threatening complications?

A. Exophthalmos
B. Thyroid storm
C. Myxedema coma
D. Tibial myxedema

Answer 17

C. Myxedema coma

Option A: Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. If a person’s immune system attacks the thyroid gland, it may react by producing extra hormones. The autoimmune antibodies can attack the muscles and soft tissue surrounding the eyes, which can cause them to protrude from the sockets.
Option B: Thyroid storm is life-threatening but is caused by severe hyperthyroidism. It is also referred to as thyrotoxic crisis, an acute, life-threatening hypermetabolic state induced by excessive release of thyroid hormones.
Option D: Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn’t life-threatening

Question 18

Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately?

A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination

Answer 18

B. An irregular apical pulse

Because Cushing’s syndrome causes aldosterone (control the balance of water and salts in the kidney by keeping sodium in and releasing potassium from the body.) Over production.

Which increases urinary potassium loss, the disorder may lead to hypokalemia

Option A: Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention.
Option C: Dry mucous membranes is not a symptom of Cushing’s syndrome. Thinning of the skin and mucous membranes occur because cortisol causes the breakdown of some dermal proteins along with the weakening of small blood vessels.
Option D: Frequent urination signals dehydration, which isn’t associated with Cushing’s syndrome. Short term administration of adrenocorticotropic hormone or glucocorticoids causes an increased glomerular filtration rate. Glomerular dysfunction leads to proteinuria and albuminuria.

Question 19

Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

A. Above-normal urine and serum osmolality levels.
B. Below-normal urine and serum osmolality levels.
C. Above-normal urine osmolality level, below-normal serum osmolality level.
D. Below-normal urine osmolality level, above-normal serum osmolality level.

Answer 19

D. Below-normal urine osmolality level, above-normal serum osmolality level

In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level.

Option A: Urine osmolality level should be below normal because of excessive polyuria.
Option B: Serum osmolality levels should be above normal because of dehydration.
Option C: For the same reasons, diabetes insipidus doesn’t cause above-normal urine osmolality or below-normal serum osmolality levels.

Question 20

(serum / urine) osmolality is used to evaluate the body’s regulation of water and sodium balance
(serum / urine) osmolality evaluates the kidney’s ability to concentrate urine

Answer 20

Serum osmolality is used to evaluate the body’s regulation of water and sodium balance

Urine osmolality evaluates the kidney’s ability to concentrate urine

Question 21

Nurse Lourdes is teaching a client recovering from Addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

A. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
C. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
D. “I’ll take the entire dose at bedtime.”

Answer 21

Correct Answer: C. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”

Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body’s own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.

Question 22

Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?

A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels

Answer 22

C. High corticotropin and high cortisol levels

A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels.

Question 23

male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?

A. Testing for ketones in the urine.
B. Testing urine specific gravity.
C. Checking temperature every 4 hours.
D. Performing capillary glucose testing every 4 hours.

Answer 23

D. Performing capillary glucose testing every 4 hours.

The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia.

Question 24

Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s:

A. Onset to be at 2 p.m. and its peak to be at 3 p.m.
B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. Onset to be at 4 p.m. and its peak to be at 6 p.m.

Answer 24

. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.

Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

Question 25

The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test.

B. A decreased TSH level.

C. An increase in the TSH level after 30 minutes during the TSH stimulation test.

D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay.

Answer 25

A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test

In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism.

Question 26

Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

A. Elevated serum acetone level.
B. Serum ketone bodies.
C. Serum alkalosis.
D. Below-normal serum potassium level.

Answer 26

D. Below-normal serum potassium level.

A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency.

Option A: An elevated serum acetone level is a symptom of diabetic ketoacidosis. Hepatic metabolism of free fatty acids as an alternative energy source results in accumulation of acidic intermediate and end metabolites (ie, ketones). Ketone bodies have generally included acetone, a true ketone.

Option B: Serum ketone bodies are characteristic of diabetic ketoacidosis. Ketone bodies are produced from acetyl coenzyme A mainly in the mitochondria within hepatocytes when carbohydrate utilization is impaired because of relative or absolute insulin deficiency, such that energy must be obtained from fatty acid metabolism.
Option C: Metabolic acidosis, not serum alkalosis, may occur in HHNS. A wide anion gap can be observed in patients with HHNS. The mild acidosis in HHNS is often multifactorial and results, in part, from the accumulation of minimal ketoacids in the absence of effective insulin activity.

Question 27

What is a Colles’ fracture?

A. Fracture of the distal radius.
B. Fracture of the olecranon.
C. Fracture of the humerus.
D. Fracture of the carpal scaphoid.

Answer 27

A. Fracture of the distal radius.

Colles’ fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It’s most common in women.

Question 28

Smoke Inhalation can cause which

A. Adult respiratory distress syndrome (ARDS)
B. Atelectasis
C. Bronchitis
D. Pneumonia

Answer 28

ARDS

Question 29

Corticotropin-secreting pituitary adenoma, also known as a corticotroph adenoma, is a benign tumor in the pituitary gland that produces adrenocorticotropic hormone (ACTH).

ACTH causes the adrenal glands to produce excess steroid hormones, such as cortisol, which can lead to a condition called _____

Answer 29

Cushing’s - an excess of steroid production in the body.