PRACTICE Flashcards
The nurse is caring for a 45 year old woman with a herniated lumbar disc. The patient realizes that weight loss is necessary to lessen back strain. The patient is 5’6” tall and weighs 186 lb. with a body mass index of 28 kg/m2. The nurse explains this measurement places her in which weight category?
A: Overweight
B: Obese
C: Normal weight
D: Severely obese
A: Overweight
A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?
A: Check the surgical incision
B: Program the morphine pump
C: Ensure adequate airway D: Assess the client’s pain
C: Ensure adequate airway
The nurse is assessing a patient with ascites caused by liver failure. Which finding would require immediate follow-up by the nurse? A: Jaundice B: Increased abdominal girth C: Dyspnea D: Asterixis
B: Increased abdominal girth
A patient’s health care provider prescribed tenofovir to treat chronic hepatitis B, what information related to the side effects should be included in patient education for this medication?
A: Decreased bone density B: Excitability
C: Constipation
D: Increased appetite
A: Decreased bone density
- A student nurse is providing education to the family of a patient with hepatic encephalopathy. The patient’s treatment plan includes the drug lactulose. What is the
best explanation the student nurse can give to the patient’s family about why the medication is ordered?
A: It decreases water content to eliminate bacteria
B: It promotes elimination of ammonia in the stool
C: It reduces pressure in the portal veins
D: It absorbs blood from the GI tract
B: It promotes elimination of ammonia in the stool
- A nurse cares for a patient with hepatic portal-systemic encephalopathy. The patient is thin and cachectic in appearance and the family expresses distress that the patient is receiving little dietary protein. How should the nurse respond?
A: Low dietary protein is needed to prevent fluid from leaking into the abdomen
B: A low protein diet will help the liver rest and will restore liver function
C: Less protein in the diet will help prevent confusion associated with liver failure
D: Increasing dietary protein will help the patient gain weight and muscle mass.
Less protein in the diet will help prevent confusion associated with liver failure
7.
A client having exophthalmos from hyperthyroidism is upset because the eyes are dry, look funny, and wants to know when these symptoms will go away with treatment. What should the nurse respond?
A: The exophthalmos will not go away with treatment
B: Surgery will be necessary to correct the eyes
C: Exophthalmos will recede in about 1 year
D: Glasses will help the symptoms to subside
The exophthalmos will not go away with treatmen
- A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices, an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expects the care team to order first for this patient?
A: Heparin infusion
B: Oral anticoagulants C: Vitamin K PO
D: Packed red blood cells
D: Packed red blood cells
- The patient is being treated for hypothyroidism. Under which circumstances would the nurse monitor this patient for development of myxedema crisis? Select all that apply.
A: The patient with heart rate of 77 beats per min
B: The patient develops a urinary tract infection
C: The patient must have surgery for a ruptured appendix
D: The patients husband just filed for divorce
E: The patient is injured in an automobile accident.
B: The patient develops a urinary tract infection
C: The patient must have surgery for a ruptured appendix
D: The patients husband just filed for divorce
E: The patient is injured in an automobile accident.
- The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse’s response is based on knowledge that:
A: A lack of clotting factors promote the collection of blood in the abdominal cavity
B: Bile salts in the blood irritate the peritoneal membranes. Causing edema and pocketing of fluid
C: Decreased peristalsis in the GI tract contributes to gas formation and distension of the bowel
D: Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space
D: Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space
11. Patients receiving total parenteral nutrition therapy should be monitored closely. What interventions should the nurse perform when caring for a patient on TPN? Select all that apply. A: Daily weights B: Monitor intake and output C: Monitor infusion rate D: Change tubing weekly E: Monitor glucose and electrolytes
B: Monitor intake and output
C: Monitor infusion rate
E: Monitor glucose and electrolytes
- A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first?
A: Client with blood glucose level of 125mg/dL B: Client with foul smelling diarrhea
C: Client with a potassium of 2.6 mEq/L
D: Client with sodium level of 138 mEq/L
C: Client with a potassium of 2.6 mEq/L
- A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in
the patient’s plan of care?
A: Insert an NG and maintain NPO status to allow pancreas to rest B: Immediately start enteral feeding to prevent malnutrition
C: Prepare the patient for an emergency pancreatectomy
D: Administer acetaminophen every 4 hours for pain relief.
A: Insert an NG and maintain NPO status to allow pancreas to rest
A patient with acute cholecystitis is concerned about having the flu because of an oral temperature of 101.8 F. What should the nurse respond to the patient?
A: Your cholecystectomy cannot be performed laparoscopically now. B: I will call the surgeon and ask to postpone the cholecystectomy
C: Bacterial infection is often present in cholelithiasis
D: Tell me exactly what you ate for your last meal
C: Bacterial infection is often present in cholelithiasis
A patient with a brain traumatic injury is being treated for diabetes insidious. which fining would the nurse evaluate as indicating treatment?
A: Serum sodium level is increased
B: Potassium level has increased
C: Urine output has decreased
D: Blood pressure has decreased
C: Urine output has decreased
A patient with acute hepatic dysfunction is prescribed lactulose 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is
having its desired effect? Select all that apply?
A: The patient has had three stools in the last 24 hours B: The patient’s hemoglobin has increased
C: The patient has no more oozing from esophageal varices
D: The patient’s abdominal girth is smaller
E: The patient’s mental status is improving
A: The patient has had three stools in the last
D: The patient’s abdominal girth is smaller
E: The patient’s mental status is improving
- A nurse is providing medication teaching for a client who has Addison disease and is taking hydrocortisone. Which of the following instructions should the nurse include?
Select all that apply.
A: Do not discontinue meds suddenly
B: Eat a low sodium diet
C: Take the meds on a empty stomach
D: Notify the provider for any illness or stress
E: Report any manifestations of weakness or dizziness
A: Do not discontinue meds suddenly
E: Report any manifestations of weakness or dizziness
A patient being treated in the infectious disease clinic has a history of IV drug use and chronic kidney disease requiring dialysis. He presents today with jaundice and arthralgia.
Which of the following would the patient be at increased risk for? Select all that apply.
A: Hepatitis E
B: Hepatitis B
C: Hepatitis C
D: Hepatitis A
B: Hepatitis B
C: Hepatitis C
- After teaching a client who has a history of cholelithiasis, the nurse assesses the client’s understanding. Which menu selection made by the client indicates the client clearly
understand the dietary teaching?
A: Lasagna, tosses salad with Italian dressing, and low fat milk
B: Grilled cheese sandwich, tomato soup and coffee with cream C: Roasted chicken breast, baked potato with chives and a green tea
D: Cream of potato soup, Caesar salad with chicken and a diet cola
C: Roasted chicken breast, baked potato with chives and a green tea
- The patient with cholelithiasis asks why a nasogastric tube has to be inserted. What is the nurse’s best response?
A: You have not been able to follow your prescribed diet and exercise plan
B: The tube will prevent pancreatitis
C: Keeping your stomach empty allows your gallbladder to rest, reducing pain
D: We need to suck the bile out through your nose as it isn’t going to your duodenum
C: Keeping your stomach empty allows your gallbladder to rest, reducing pain
- A patient with severe acute pancreatitis has the following vital signs after fluid resuscitation. BP 84/53 mm Hg and HR 121 bpm. What should the nurse consider as the
next step of care for this patient?
A: Prepare to administer diuretics
B: Ask the physician if an antihypertensive would be indicated
C: Assess for hypovolemic shock
D: Prepare to administer potassium chloride
C: Assess for hypovolemic shock
. A patient with cirrhosis informs a student nurse that his skin is always itchy. Which abnormal lab result is the reason for the itching?
A: Elevated bilirubin level
B: Elevated alanine aminotransferase level C: Decreased albumin level
D: Prolonged INR
A: Elevated bilirubin leveL
A nurse cares for a client who has obstructive jaundice. The client asks why is my skin so itchy? How should the nurse respond?
A: Toxins released from an inflamed gallbladder lead to itching
B: Bile salts accumulate on the skin and cause the itching
C: Itching is caused by the release of calcium into the skin
D: Itching is caused by a hypersensitivity reaction
B: Bile salts accumulate on the skin and cause the itching
A patient has a gallstone lodged in the common bile duct that has resulted in dark colored urine, light colored stools, and jaundice. Which of the following would the nurse expect to teach the patient about? A: ursodiol, Actigall B: hepatitis B surface antigen C: ERCP D: Extracorporeal shock wave lithotripsy
A: ursodiol, Actigall
A patient with acute gallstone induced pancreatitis is recovering from an endoscopic retrograde cholangiopancreatogram. Which observation indicates that the patient’s
condition is deteriorating after this procedure? Select all that apply
A: Nausea and vomiting
B: Fever and chills
C: Increased pain
D: Reduced gastric distention E: Normal body temperature
A: Nausea and vomiting
B: Fever and chills
C: Increased pain
You are preparing Marion Smith who has a diagnosis of Diabetes Insipidus for discharge from your medical unit. Which statement by her would indicate that she needs
additional teaching regarding the disease?
A: I will gradually wean myself off the vasopressin
B: I will wear my medical bracelet at all times
C: I will drink fluids equal to the amount of my urine output D: I will weigh myself every day using the same scale
A: I will gradually wean myself off the vasopressin
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. Which should the nurse advise the individuals to obtain immediately who ate at this restaurant and never received the hepatitis A vaccine?
A: The hepatitis A and B vaccines B: The hepatitis A vaccine
C: Albumin infusion
D: An immune globulin injection
D: An immune globulin injection
. Which diagnostic procedure is the most reliable to confirm a diagnosis of Diabetes Insipidus?
A: Fasting blood glucose
B: Urine osmolarity
C: Thyroid stimulating hormone D: Water deprivation test
B: Urine osmolarity
After teaching a client who has plans to travel to a non-industrialized country the nurse assesses the client’s understanding regarding the prevention of viral hepatitis. Which
statement made by the client indicates a need for additional teaching?
A: I should drink bottled water during my travels
B: I will not eat off another’s plate or share utensils
C: I will wash my hands frequently and thoroughly
D: I should eat plenty of fresh fruits and vegetables.
D: I should eat plenty of fresh fruits and vegetables.
The nurse is reviewing information in the medical record of a patient with syndrome of inappropriate antidiuretic hormone secretion. Which of these manifestations should the
nurse investigate first when assessing this patient?
A: The patient states I have a headache
B: The patient is lethargic and difficult to wake
C: The patient states I feel thirsty
D: The patient’s urine is dark amber in color
A: The patient states I have a headache
A patient is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?
A: Imbalanced nutrition: Less than body requirements
B: Fluid volume excess
C: Ineffective breathing pattern
D: Fatigue
C : Ineffective breathing pattern
A patient recovering from Whipple’s procedure is being transferred to the medical surgical care area. On which intervention should the nurse focus to determine if the
patient is developing a complication from the surgery? Select all that apply
A: Measuring blood pressure every 2 hours B: Assisting to a standing position every 4 hours
C: Assessing heart rate every 2 hours
D: Monitoring urine output every hour
E: Turning and repositioning every 2 hours
A: Measuring blood pressure every 2 hours
C: Assessing heart rate every 2 hours
D: Monitoring urine output every hour
- Which of the following assessment findings would be most important for indicating dumping syndrome in a post gastrectomy patient?
A: Constipation, rectal bleeding following bowel movements
B: Persistent loose stools, chills, hiccups after eating
C: Weakness diaphoresis, diarrhea 50 minutes after eating
D: Abdominal distention, elevated temperature, weakness before eating
C: Weakness diaphoresis, diarrhea 50 minutes after eating
- A student nurse is preparing to administer spironolactone to a client with ascites as ordered by the health care provider. When the client asks why this drug is being used
what is the best response by the student nurse?
A: This medication is a diuretic and does not make the kidneys excrete potassium
B: This will help your body excrete more bilirubin
C: This drug will increase the production of androgens by your body
D: This drug will help increase the level of albumin in your blood.
A: This medication is a diuretic and does not make the kidneys excrete potassium
35. The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is: A: A sigmoid colostomy B: a descending colostomy C: an ascending colostomy D: a transverse colostomy
A: A sigmoid colostomy
A serum potassium level of 3.0 mEq/L is reported for a patient with cirrhosis who has scheduled doses of spironolactone and furosemide due. Which action should the nurse take? A: Withhold both drugs B: Administer the furosemide C: Administer the spironolactone D: Administer both drugs
C: Administer the spironolactone
Which of the following blood test would be checked to evaluate a client with manifestations of exophthalmos, weight loss, heat intolerance and palpitations? A: Amylase and lipase B: Hemoglobin and hematocrit C: ALT and AST D: T4 and thyroid stimulating hormone
D: T4 and thyroid stimulating hormone
Which statement is appropriate for the nurse to use during education about pancreatic enzyme replacement therapy for a patient with chronic pancreatitis?
A: Mix enzymes fully with protein foods
B: Take enzymes with food and a full glass of water
C: Take enzymes before antacids
D: Chew tablets thoroughly
B: Take enzymes with food and a full glass of water
After thyroid surgery the nurse suspects damage or removal of the parathyroid glands when the patient develops
A: muscle weakness and weight loss
B: hypertension and elevated blood glucose levels C: laryngospasms and hypocalcemia
D: hyperthermia and severe tachycardia
D: hyperthermia and severe tachycardia
- A 33 year old female client who is recovering from thyroid storm has been started on methimazole prior to discharge. Which statement by the client indicates that additional
teaching is needed?
A: I will attend a concert at the stadium in 2 weeks
B: I will take my medication at the same time each day
C: I will check for heat intolerance
D: I will monitor my weight closely
A: I will attend a concert at the stadium in 2 weeks
- The nurse is caring for a client 5 hours after a pancreatectomy for cancer of the pancreas. Upon arrival to the patient’s bedside, the nurse notes that there is minimal
drainage from the nasogastric tube. It is most important for the nurse to take which of the following actions?
A: Notify the doctor
B: Replace the NG tube
C: Check the tubing for kinks
D: Monitor vital signs every 15 minutes
C: Check the tubing for kinks
An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? A: Fever B: Hypertension C: Flushed skin D: Tachycardia
D: Tachycardia
Which finding by the nurse when assessing a patient with thyroiditis and a goiter will require the most immediate action?
A: Resting apical pulse rate 112 bpm
B: Bruit audible bilaterally over the thyroid gland
C: New onset changes in the patient’s voice
D: Elevation in the patient’s T3 and T4 levels
C: New onset changes in the patient’s voice
A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client’s plan of care? A: Oxygen therapy B: Physical therapy C: Fluid restriction D: Prone position
A: Oxygen therapy
The health care provider suspects a diagnosis of myasthenia. Gravis in a patient who presented with progressive proximal muscular weakness, ptosis and dysphagia. Which
test does the nurse expect will be ordered to confirm the diagnosis?
A: Lumber puncture
B: MRI
C: Repetitive nerve stimulation test
D: CT scan
C: Repetitive nerve stimulation test
- Which information will the nurse teach a patient who has been newly diagnosed with Graves’ disease?
A: Exercise is contraindicated to avoid increasing metabolic rate
B: Antithyroid medications may take several months for full effect
C: Surgery will eventually be required to remove the thyroid gland
D: Restriction of iodine intake is needed to reduce thyroid activity
B: Antithyroid medications may take several months for full effect
- The nurse is providing care to a patient admitted with hematemesis, melena and abdominal pain. Which nursing diagnosis is the highest priority for this patient?
A: Risk for anxiety related to fear of bleeding
B: Risk for Aspiration related to potential changes in level of consciousness
C: Risk for fatigue related to decreased oxygenation
D: Pain related to disruption of gastrointestinal tissues.
A: Risk for anxiety related to fear of bleeding
The nurse who has not been immunized for hepatitis B has a needle stick injury. What is the best recommended treatment should this nurse receive?
A: Hepatitis B vaccine
B: Hepatitis B vaccine and hepatitis B immune globulin
C: Evaluation of liver function tests in 10 days
D: Hepatitis B immune globulin
B: Hepatitis B vaccine and hepatitis B immune globulin
What is the priority nursing intervention for an older patient with chronic hyperparathyroidism?
A: Prevent injury
B: Encourage fluids
C: Encourage small frequent meals
D: Administer pain medications as ordered
A: Prevent injury
Which statement by a client post bariatric surgery demonstrates more teaching is needed about self-care management at home prior to discharge?
A: I will eat six small meals daily
B: I will limit my fluids to 1000 ml a day
C: I will drink fluids after I eat
D: I will eat meals high in proteins and carbohydrates.
B: I will limit my fluids to 1000 ml a day
