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%
the nurse is caring for 4 clients who had arterial blood gas ABG’s. which lab value warrants immediate intervention by the nurse?
a. HCO3=25mEq/L
b. SpO2 of 96%
c. H of 7.38
d. PaCO2 of 48mmhg
d.PaCO2 of 48mmhg
a client has COPD and as been placed on 2L nasal O2 while hospitalized. the client has only been on the oxygen for approx 30min when he suddenly seems even more short of breath than previously, although he is neither gray nor ashy in color. The nurse recognizes that the client is experiencing which pif the following?
a. oxygen enduced hypoventilation
b. hypoxemia
c. absorption atelectasis
d. hypercarbia
a.oxygen enduced hypoventilation
a client is known to have lung cancer and had been admitted for abdominal pain and jaundice. A CT scan reveals tumors in the clients liver. The clinet is distraught and ays, so now i have liver cancer too? which response by then nurse is most appropriate?
a. yes, liver cancer is common in people who already have lung cancer
b. yes, your chmo left you vil;nerable to a virus that causes liver cancer.
c. no the tumors are actually from your lung cancer, which has metastisiesz,
d. no having tumors in two different organs are rare, you probably have hepatitis
c.no the tumors are actually from your lung cancer, which has metastisiesz,
which measure is considered a secondary prevention for cancer?
a. yearly fecal occult blood testing in adults
b. avoidance of alcohol
c. teacing about vitamin therapy
d. using sunscreen when outdoors
a.yearly fecal occult blood testing in adults
the nurse is counseling a client who smokes and drinks heavily about cancer risk. the client is adamant that he or she will never stop smoking. which question byut he nurse is most appropriate?
a. would you be willing to stop drinking alcohol?
b. why won’t you try the nicotine patch?
c. whya re you so determined to continue smoking
d. do you understand that smoking si the leading cause of cancer
a. would you be willing to stop drinking alcohol?
a cancer invading the bone marrow can cause which effects?
a. hypokalemia
b. thrombocytopenia
c. degenerative joint disease
d. fluid overloiad
b.thrombocytopenia
the nurse counsels a wman who had BRCA 1 gene that she has what chance for developing breast cancer during her lifetime?
a. none; thi gene has protective effect
b. same as the general population
c. lower than the general population
d. higher than the general population
d. higher than the general population
then nurse is interested in the primary prevention for cancer. which activity does the nurse most likely participate in?
a. distributing occult fecla blood tests kist to people at the shopping mall
b. arrangin transportation volunteers for clients undergoing radiation therapy
c. teaching high school students the dangers pif using tobacco
d. schedulking women for an annual PAP smear
c.teaching high school students the dangers pif using tobacco
the most common cause of bleeding in cancer patients is
a. anemia
b. coagulation disorders
c. hypoxemia
d. thrombocytopenia
hypoxemia
A CLIENT SABSOLUTE NEUTROPHIL COUNT (and) is 550/mm3. what is the nurses best action?
a. use standard precautions
b. place the client on a low sodium diet
c. place client on a low sodium diet
d. administer chemotherapy
use standard precautions
the nurse receives a report that a clients lab results show a left shift or an increase in circulating band neutrophils. what is the nurses best action
a. keep the client o bed rest
b. preprare the clinet for surgery
c. increase the client oxygen flow rate
d. check the patients temperature
check the patients temp
a clients white blood cell (WBC) count value is 10,000 cell/mm3. the nurse reviews the differentia;l. which counts or percentages is the nurse sure to report to the provider?
a. eosinophils, 20/mm3
b. a left shift in the white count
c. neutrophils, 6000/mm3
d. basophils 100/mm3
b.a left shift in the white count
A client reports severe hay fever and allergic rhinitis. which finding does the nurse expect to see in the client lab resul;ts
a. band neutriphils outnumber segmented neutrophils
b. the basophil count is 50/mm3
c. the eosinophil count is 20%
d. the white count is 7500/mm3
c.the eosinophil count is 20%
a nurse is working with a client at a public health clinic. the clinic says to the nurse, the doctor said that my CD4+ count is 450. Is that good? what is the best response by the nurse?
a. your count is high so you can cut back on your medication
b. your count is normal because your medication are woprkingf well
c. your count is bait low and you are susceptible;e to infection
d. your count ius very low and your acutallyt now have aids
c.your count is bit low and you are susceptible; to infection
the nurse is caring for a young woman at he primary health care clinic. which assessment finding lead s the nrus to question the client about risk factor for hiv?
a. six vagianl yeasty infection in the past 12 months
b. unable to ebcome pregnant for the past 2 years
c. severe cramping and iregular periooids
d. √dry heavy periods and breakthrough bleeding
a. six vaginal yeast infections int eh past 12 months
during a mumps outbreak at a local school, a patient, who jus a school teacher, is exposed. she has previously been immunized for mumps. what type of immunity does she posses?
a. aquired immunity
b. passive immunity
c. phagocytic immunity
d. humoral immunity
a.aquired immunity
the nurse jus seeing clients at a drop in primary health clinic. which does the nurse trench about the risks of aquiring HIV?
a. middle aged woman with an new sexual partner
b. young male whole has male sexual partners
c. all client who come to the clinic
d. young woman having her first gynecologic examination.
c.all client who come to the clinic
The normal reference range for white blood cells in adults is
a. 1,000-3000
b. 5000-10000
c. 12,000-15000
d. 17,000-21,000
b.5000-10000
a patient is fearful that he has been infected with HIV. The nurse recognizes that which manifestation is the first sign of HIV symptomatic infection?
a. opportunitstic infections
b. fever, night sweats, muscle aches
c. lymphocytonpenia(decreased lymphocyte count)
d. anemia
b.fever, night sweats, muscle aches
dihenhydramine(benedryl) is an antihistamine . which of the following is an expected adverse effect?
a. headache
b. nasal stuffiness
c. drowziness
d. salivation
drowzines
S/S of anaphylaxis include all of the following except:
a. anxiety
b. tachychardia
c. pruritus and edmea
d. increased CD4 Tcells
d.increased CD4 Tcells`
when a patient is experience sing an allergic response , the nurse should initially asses the patient for:
a. dyspnea, bronchospams, and/or laryngeal edema
b. hypotension and tachychardia
c. the presence and location of pruritus
d. the severity of cutaneous warmth and flushing
a.dyspnea, bronchospams, and/or laryngeal edema
the nurse knows that a patient with HIV/AIDS needs at a least ________________g/kg of protein a day.
a. 0.6-0.8
b. 1.2-2.9
c. 0.4-0.6
d. 2.2-2.5
b.1.2-2.0
Diarrhea ands malabsporption are prominent clinical problems in patients with AIDS
True or False
TRUE
youa re doing an admission assesmne on a elderly patient newly admitted for end stage liver disease. you must asses the patients skin turgor. what should you remember when evaluating skin turgor?
a. overhydration causes skin to tent
b. dehydration causes skin too appear edematous and spongy
c. inelastic skin turgor is a normal part of aging
d. in addition to coffe, i drink at least one glass of water with each meal.
c.inelastic skin turgor is a normal part of aging
a client has been taught to restrict dietary sodium. which food selection by the client indicates to the nurse that teaching has been effective.
a. chineese take out including steamed rice
b. a grilled cheese sandwich with tomato soup
c. clices of ham and cheese on whole grain crackers
d. a chicken leg, one slice of bread with butter, steamed carrots
d.a chicken leg, one slice of bread with butter, steamed carrots
during assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts of liquids each day. which question b the nurse is best?
a. do you usually drink liquids hot r cold
b. how much salt do you add to your food
c. what kids of liquids do you usually drink
d. do you drink fluids with meals or between meals
c.what kids of liquids do you usually drink
a nurse is caring for several clients whoa re at risk for over hydration. the nurse assdes the older client with which findings first?
a. he has diabetes mellitus for 12 years
b. uses sodium containing
c. just received 3 units of packed red blood cells
d. had abdominal surgery and has a nasogastric tube
c.just received 3 units of packed red blood cells
the ruse assess distended neck veins in a client sitting in a chair to eat.what intervention is the priority of the nurse?
a. document the observation in the chart
b. measure urine specific gravity and volume
c. asses the pulse and blood pressure
d. asses the deep tendon reflexes of the client
c.asses the pulse and blood pressure
A client is taking furosemide(lasix) and becomes confused. which potassium level does the nurse correlate with this condition?
a. 2.9 mEq/L
b. 3.8 mEq/L
c. 5.0 mEq/L
d. 6.0 mEq/L
a.2.9 mEq/L
A client has hypokalemia. which question by the nurse obtains the most information on a possible cause?
a. do you use sugar substitutes ?
b. do you use diuretics or laxatives
c. do you have any kidney disease
d. have your bowel habits changed recently
b.do you use diuretics or laxatives
the nurse notes that the handgrip pif the client with hypokalemia has diminished since the previous assessment one hour ago. which intervention by by the nurse is a priority?
a. asses the respiratory rate, rhythm, and depth
b. measure the pulse and blood pressure
c. document findings and monitor the client
d. call the healthcare provider
a.asses the respiratory rate, rhythm, and depth
the nurse is caring for a client who has a sodium level of 128mEq/L. As part of the care, the nurse will restrict which item for this client?
a. sports drinks, such as gatoraide
b. eggs and cheese products
c. salt of the dietary trait
d. water
d.water
a patient with congestive heart failure is recieving a loop diuretic. the nurse monitors a patient closely for which electrolyte imbalance
a. hypernatremia
b. hypokalemia
c. hypercalcemia
d. fluid overload
b.hypokalmeia
which treatment option does the nurse anticipate will be the most appropriate for a client with a potassium level of 3.5mEq/L
a. Give sodium polystryene sulfate(kayexalate) per rectum
b. use salt in the diet
c. administer oral potassium chloride(KCL)
d. continue to monitor and offer foods high in potassium
d. continue to monitor and offer foods high in potassium
The nurse assessing the client for signs of hypocalcemia would conclude that this electrolyte misbalance nexists after noting which finding?
a. negative chvosteks sign
b. positive trousseaus sign
c. positive kernigs sign
d. hypoactive bowel sounds
b.positive trousseaus sign
a clinicial manefistation not found in hypovolemia is:
a. muscle weakness
b. oliguria
c. postural hypotension
d. bradychardia
d.bradychardia
a patient shows a positive trousseau's or chvosteks sign. the nurse prepares to give what urgent treatment a.IV gluconate b.calcitonin c.IV potassium chloride D.large dose of oral calcium
a.IV calcium gluconate
the nurse administering potassium to a patient carefully monitored the infusion because of the risk of wha condition ?
a. poulmoary edema
b. cardiac dysrhthmiua
c. postural hypotension
d. renal failure
b.cardiac dysrhythmia
the patients potassium level is 2.5 mEq/L. which clinical findings does that nurse expect to see when assessing this patient
a. generalized skeletal muscle weakness
b. moist crakcles and tachypnea
c. decreased urine output
d. strong handgrip
a.generalized skeletal muscle weakness
a client is admitted with hjyponatremia. four hours after the initial assessment the nurse notes that the client has new hyperactive bowel sounds in all four quadrants. what analysis about the condition of the client is correct?
a. the hyponatremia is worse
b. the hyponatremia is the same
c. the hyponatremia is better
d. the client now has hypernatremia
a.the hyponatremia is worse
which alteration in mental status functioning will alert the nurse to the possibility of hypokalemia
a. somnolence
b. insomnia
c. confusion
d. combative behavior
c.confusion
When monitoring a patient receiving a potassium chloride KCL piggyback, the nurse is monitoring for all off the following except:
a. cardiac dysrhythmias
b. phlebitis
c. extravasation
d. insomnia
d.insomnia
which of the following questions should the nurse ask a client who is preparing to receive a varicella vaccine?
a. are you allergic to aluminium
b. are you allergic to bakers yeast
c. are you pregnant
d. have you had a recent blood transfusion
b. are you allergic to bakers yeast
c. are you pregnant
the nurse wishes to present a cancer program to a group of people at high risk for cancer. i the planning the program, which group dies the nurse consider the priority?
a.older adults
b.people with sedentary lifestyles
clients with family histories of cancer
c.clients with family histories of cancer
d.people with poor immune function
a.older adults
surgery that are done to remove lesions that era likely to develop into cancer is known as: ]a.diagnostic b.palliative c.prophylactic d.resconstructive
c.prophylactic
a major disadvantage of chemotherapy is that it:
a. attacks cancer cells during the vulnerable phase
b. functions against disseminated disease
c. is systemic
d. targets normal body cells as well as cancer cells
d.targets normal body cells as well as cancer cells
the nurse is planning a cancer education event in an asian community center. the nurse plans to present information specifically on which types of cancer?
a. breast and colorectal
b. skina dn lymphoma
c. liver and stomach
d. uterin and ovarian
a.breast and colorectal
in preparing a cancer risk reduction pamphlet for african ameriucan clients, it is most important that the nurse include information on prevention and early detection for which types of cancer?
a. lung and prostate
b. boe and lukemeia
c. skin and lymphoma
d. stomach and esophegela
a.lung and prostate
the nurse is seeing clients in a clinic. which client sdoes the nurse asses further for the development of cancer?
a. client with a cough that has lasted for 4 months
b. client who’s mother dies of lung cancer
c. clientwith a ten pound weight gain
d. woman who’s last mammogram was ten years ago
a.client with a cough that has lasted for 4 months
- the nurse is administering lasix, the nurse should monitor which of the following side effects:
a. hypertoxicity
b. ototoxicity
c. edema
d. acidosis
b.ototoxicity
