old exams Flashcards
12.The Rn administering furosemide(lasix). The rn must monitor which of the following adverse effector
ototoxicity
13.The pt has been running a long distance marathon on a very warm day. the pt c/o dizziness and nausea, and is taken to the hospital where she becomes lethargic. The serum sodium level is 125mEq/l. what will bve the best plan of the RN?
preprare to administer NS IV
14.THe pt recvs dexxtran 40. pt c/o tachychardia,dyspnea, and cough. what is the best evaluation by the nurse?
.
IN evaluating laboratory data, the nurse corrlatres which result with the diagnosis of Myesthesis gravis?
a. elevated serum calciuk level
b. decreased thyroid hormone level
c. decreased complete blood count
d. elevated actylcholine receptor anitbody
Elevated acetlcholine receptor antibody levels.
A client is actively experiencing status epileptics. Which prescribed medication does the nurse prepare to administer
a. lorazepam
b. atropine
c. morphine sulfate
d. demerol
a.Lorazepam
The nurse is teaching the client who is newly diagnosed with epilepsy . which statement by the client indicates a need for fiuthjer concerning the drug regimen?
a. i will not drink any alcoholic beverages
b. i will ear a medical alert bracelet
c. I will let my doctor know about all my prescriptions
d. I can skip a couple of my pills if they make me ill
d. i can skin a couple of mu pills if they make me sick
A nruse is caring for a client who just experiences a seizure . While doing follow i[p documentation the nurse plans to include which items in the progress notes? SDelect a;; that apply:
a. reports of unusual sounds or smells prior to the seizure
b. what the client was doing prior to the seizure
c. food and intake prioir to the seruizure
d. the amount of lighting in the room when the seizure began
e. the part of the body where the seizure started
a. reports of unusual sounds or smells prior to the seizure
b. what the client was doing prior to the seizure
e. the part of the body where the seizure started
A client with multiple sclerosis tells the nurse, I am worried that trhis condition will maklemee too tired to do anything when I of home. Which response by the nurse support the goals of minting client independence?
a. maybe you can get a family member to hrlop you out in the eavenings
b. you are going to have to learn to be happy with doing less and taking more naps
c. you should go to the drug store to get asitive devices
d. Lets look at the things you do everyday and figure out how to space the activities throughout your day
d.Lets look at the things you do everyday and figure out how to space the activities throughout your day
The nurse is caring for the client who begins to experience seizure activity in bed. which of the following action by the nurse would be contraindicated?
a. staing with the patient
b. restraingin the client limbs
c. removin the pillow and raising padded side rails
d. positioning the client to the side, if possible
b.restraining the client limbs
the client is admitted to the hospital with a diagnosis of guillian barre syndrome. the nurse inquires during the client nursing admission interview if the client has a history of:
a. seizures and traumas to the brain
b. meneingitis during the last 5 years
c. back injury or trauma to the spinal cords
d. respiratory or GI infection during the previous month
d.respiratory or GI infection during the previous month
The nurse is planning to instate seizure precautions for a client who is being admitted from the emergency department. which of the following measures would the nurse include in the planning fir the clients safety ? select all that apply:
a. padding the side raise of the bed
b. placing an aurway ar the bedside
c. placin the bed i high position
d. placinfg oxygen and suctioning equip[kment at the beside.
e. putting apadded young blade at the head of the bed
a. padding the side raise of the bed
b. placing an aurway ar the bedside
d. placing oxygen and suction equipment at the bedside
when caring for an unconscious patient what nursing intervention tales highest priority?
a. inserting an indwelling urine catheter
b. mainting a patent airway
c. putting an NG tube
d. administering an enema daily
b.maintaing a patent airway
A patient who had been on long term phenytoin (dilantin) therapy has been admitted to your unit. you would be correct in assessing what adverse effect of this therapy?
a. bradychardia
b. diarrhea
c. gingival hperplasia
d. weight gain
c.gingival hyperplasia
while completing a health history on a newly diagnosed patient with general seizure disorder the nurse would asses for what characteristic associated with the posit octal state
a. epileptic cry
b. confusion
c. urinary incontinence
d. body rigidity
b.confusion
a patient with possible bacteria meningitis is admitted top the icu . what assessment data would the nurse know in an expected finding for a patient with bacterial meningitis:
a. pain apron ankle dorsilfexion of the foot
b. neck flexion produces flexion of the knees and hips
c. inability tos rand with eyes closed and arms extended without swaying
d. numbness and tingling int he lower extremities
b. neck flexion produces flexion of the knees and hips
your patient is newly diagnosed with MS. what basic information should you provide the patient?
a. it is a progressing demylenating disease of the nervous system
b. it usually occurs more frequently in men
c. it has an acute onset
d. it is caused by a bacterial infection.
a.it is a progressing demylenating disease of the nervous system
a male patient presents tot eh clinic complaining of a headache. the nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. the nurse suspects the patient may have meningitis. what is another well recognized sign pif this infection?
a. negative bradzinskies isgn?
b. positive kernigs sign?
c. hyperpatellar refelx
d. shiggish pupil reaction
b. positive kernigs sign
the nurse is assessing breath sounds, which assessment finding has been creectly linked to the primary intervention of the nurse?
a,hollow sound heard over the trachea
b.crackle heard in even bases; have the client cough forcefully
c.wheezes heard in central areas; administer inhaled bronchodialator
d.vesicular sounds over the periphery; have the client breathe deeply
c.wheezes heard in central areas; administer inhaled bronchodialator
a client has sever gadget’s disease. which factor has the highest priority when the nurse intervenes in the care of the client?
a. dietary education
b. exercise program
c. bedrest
d. relief of pain
d.relief of pain
a client with a history of chronic obstructive disease COPD presidents to the clinic with increased cough and low grade temp. which question by the nurse el;icits the most useful information?
a. how loing have you been sick
b. has sputum changed color?
c. is anyone else in your house sick
d. do you take any medications
b.has sputum changed color?
the nurse is caring or a client after a thoracentisis. which assessment finding bvy the nurse warrants immediate action?
a. client rates pain a 3/10 at the site of the procedure
b. small amount of drainage s noted form the site
c. pulse oximetry is 96% on 2L of oxygen
d. trachea is deviated toward the opposite side of the neck
d.trachea is deviated toward the opposite side of the neck
a client had a bronchoscopy 2 hours ago and is requesting water to drink. which action but he nurse is most appropriate?
a. call the MD for an order for food and drink
b. give the client ice chips instead of drinking water
c. asses the gag reflex of the client befiore giving anything
d. let the client have water.
c.asses the gag reflex of the client befiore giving anything
which person it at greater risk for developing a community acquired pneumonia?
a. middle aged teacher who typically eats a diet of asian foods
b. older adults who smokes and has a substance abuse problem
c. older adult otherwise in good health
d. young adult aerobics instructor who is a vegetarian.
b.older adults who smokes and has a substance abuse problem
a nurse is caring for a 76 y/o female client brought into an outpatient clinic by her husband. the husband states that his wife woke up this morning and did n to recognize him or know where she was. the client reports chills and chest pain that worsen with inspiration. which of the following is the highest priority nursing task?
a. obtain baseline vital signs and oxygen saturation
b. opbtian sputum culture
c. obtian a medical history
d. provide a pneumoccoal injection
a.obtain baseline vital signs and oxygen saturation
the client tells the nurse that hue usually expectorates about 2 ounces of thin clear colorless sputum each day mostly in the morning after getting out of bed. what is the initial action of the nurse after gaining this information?
a. ask the client to provide a morning sputum sample for lab analysis
b. obtain a specimen of sputum in a sterile container for culture
c. monitor for an increase in sputum production or change in color
d. notify the healthcare provider and prepare the client for possible bronchoscopy.
c.monitor for an increase in sputum production or change in color
The client has recently been started on flovent which assessment finding would require the nurses immediate intervention
a. oral lesions
b. dry eyes
c. heart rate of 100
d. headache
a.oral lesions
which statement indicates that the client understands teachings about the correct use of corticosteroid medication?
a. this drug can reverse my symptoms during an asthma attack
b. this drug is effective in decreasing the frequency of my asthma attacks
c. this drug can be used most effectively as a rescue agent
d. this drug can safely be used on a long term basis for multiple applications daily
b.this drug is effective in decreasing the frequency of my asthma attacks
a nurse is caring for a client who has dyspnea. in which of the following positions should the nurse place the client?
a. supine
b. dorsal recumbent
c. high fowlers
d. lateral
c.high fowlers
The nurse observes that the middle afed clients anteropostrerioir(AP) chest diameter is the same as her lateral chest diameter. What si the most important question for the client in response to this finding?
a. no questions are needed regarding this normal finding
b. do you have any chronic breathing problems?
c. how often do you perform aerobic excersise?
d. what are your hobbies ?
b.do you have any chronic berating problems?
the nurse is assessing a client who has a serum potassium level of 4.5 mEq/L after coronary artery bypass graft(CABG) surgery. What action does the nurse take?
a. notiofy the healthcare provider
b. document the finding
c. administer perscribed diuretics
d. administer prescribed potassoium replacments
b.document the finding
the nurse is caring for 4 clients with asthma. which client does the nurse asses first
a. the client with the barrel chest and clubbed fingernails
b. client with Sa02 level of 94% at rest
c. client with explatory phase is loner thant he inspiratory phase
d. client who’s heart rate is 120 beats/min
d.client who’s heart rate is 120 beats/min
a client with COPD is lying flat in bed and reports shortness of breath. what action does the nurse take first?
a. notiofy the healthcare provider
b. elevate the head of the bed
c. asses oxygen saturation
d. have the client take deep breathes
b.elevate the head of the bed
an older adult admitted to the ER with respiratory symptoms. which client symptom requires the nurse to intervene immediately :
a. new onset confusion
b. scattered wheezing
c. crackles
d. flushed cheeks
a.new onset confusion
which is the highest priority goal to set for a client with pneumonia
a. absence of cyanosis
b. maintanence of SaO2 of 95%
c. walking 20 feet three time daily
d. blood pressure of 120/80
b.maintanence of SaO2 of 95%
