VN 22 Final Exam Flashcards
1) A nurse educates a group of clients with diabetes mellitus on the prevention of
diabetic nephropathy. Which suggestions would be most important?
- Control blood glucose levels.
- Take the antidiabetic drugs regularly.
- Eat a high-fiber diet.
- Drink plenty of fluids.
Control blood glucose levels
2) In addition to teaching a client with constipation to increase dietary fiber intake to
25 g/day, what would the nurse include as important?
- Avoiding bran cereals and beans in the diet.
- Minimizing activity levels for at least 2 months.
- Limiting fluid intake to 5 to 6 glasses per day.
- Adding fiber-rich foods to the diet gradually.
Adding fiber-rich foods to the diet gradually
3) You are caring for a client with chronic migraines. The client has been prescribed
sumatriptan. What drug-related instructions should the nurse give the client?
- Take medication just before going to bed at night.
- Take medication only during the morning when it’s calm and quiet.
- Take medication only when migraine is intense.
- Take medication as soon as symptoms of the migraine begin.
Take medication as soon as symptoms of the migraine begin
4) Client education following a hip dislocation or replacement should include which
instruction? Select all that apply
- Avoid crossing the legs
- Bending is OK if seated in a chair in a 30 degree angle
- Put a pillow between the legs while sleeping
- Keep the knees apart at all times (Abduction)
- Keep the knees together at all times (Adduction)
- avoid crossing the legs
- put pillow between the legs while sleeping
- keep the knees apart at all times (Abduction)
5) A client has just been diagnosed with an aneurysm. In planning discharge teaching
for this client, what instructions should be delivered by the nurse to the client?
- Avoid heavy lifting.
- Include peanut butter, bread, or tart foods in the diet.
- Take opioid analgesics.
- Take an herbal form of feverfew.
-Avoid heavy lifting
6) You are taking care of a client who is taking an anticonvulsant. Why should you
advise the client not to stop taking the drug abruptly?
- It may cause severe and ugly skin rashes.
- It may cause alopecia.
- It may trigger status epilepticus.
- It may cause loss in appetite.
-It may trigger status epileptics
7) A client realizes that regular use of laxatives has greatly improved his bowel pattern.
However, the nurse cautions this client against the prolonged use of laxatives for
which reason?
- The client may lose his appetite.
- The client may develop inflammatory bowel disease.
- The client’s natural bowel function may become sluggish.
- The client may develop arthritis or arthralgia.
The client’s natural bowel function may become sluggish
8) A client who is suspected of urinary tract infection is asked to collect a 24-hour urine
specimen for culture. What measure can the nurse suggest to the client that may
help prevent the urine specimen from becoming contaminated?
- Use the same receptacle for voiding and defecation.
- Collect the voided urine sample primarily before 5 a.m.
- Refrigerate the specimen until it is taken to the laboratory.
- Store the collected urine away from sunlight.
Refrigerate the specimen until it is taken to the laboratory
9) A client is being treated for prolonged diarrhea. Which foods should the nurse
encourage the client to consume?
- Protein-rich foods
- Foods high in Vitamin C
- Potassium-rich foods
- High-fat foods
Potassium rich foods
10) A client with type 2 diabetes asks the nurse why he can’t have a pancreatic
transplant. Which of the following would the nurse include as a possible reason?
- Increased risk for urologic complications
- Underlying problem of insulin resistance
- Need for lifelong immunosuppressive therapy
- Need for exocrine enzymatic drainage
Underlying problem of insulin resistance
11) A client with anorexia complains of constipation. What nursing measure would be
most effective in helping the client reduce constipation?
- Provide adequate quantity of food.
- Obtain complete food history.
- Obtain medical and allergy history.
- Assist client to increase dietary fiber.
Assist client to increase dietary fiber
12) The nurse is providing information about foot care to a client with diabetes. Which
of the following would the nurse include?
- “Wear well-fitting comfortable rubber shoes.”
- “Wash your feet in hot water every day.”
- “Be sure to apply a moisturizer to feet daily.”
- “Use a razor to remove corns or calluses.”
Be sure to apply a moisturizer to feet daily
13) A nurse is collecting data from a client who has diabetic ketoacidosis and ketones in
the urine. The nurse would expect what findings?
- Weight gain
- Blood glucose of 52 mg/dL
- Fruity odor of breath
- Chest pain
Fruity odor of breath
14) A nurse is caring for a client who had an above-the-knee amputation 1 week ago.
The client reports a sharp, stabbing type pain (phantom limb pain). Which of the
following actions should the nurse take?
- Administer an antiepileptic medication
- Encourage the client to increase fluids
- Question whether the pain is real
- Administer an opioid medication
Administer an anti-epileptic medication
15) A nurse on an orthopedic floor is caring for a client following a knee arthroscopy
Which of the following actions by the nurse are appropriate? Select all that apply
- Check CPM passive motion device settings
- Apply heat therapy to incision
- Elevate heels off the bed
- Place a pillow behind/under the knee
- Palpate dorsal pedal pulses
- Check CPM passive motion device settings
- Elevate heels off the bed
- Palpate dorsal pedal pulses
16) A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would
the nurse expect to be administered intravenously for the treatment of DKA?
- Glargine
- Regular
- Lente
- NPH
Regular
17) The nurse is reviewing a client’s history which reveals that the client has had an
oversecretion of growth hormone (GH) that occurred before puberty. The nurse
interprets this as which of the following?
- Gigantism
- Hashimoto’s Disease
- Simmons’ disease
- Dwarfism
Gigantism
18) A client is found to be comatose and hypoglycemic with a blood sugar of 30mg/dL.
What would the nurse expect the primary care provider to order first?
- Order a urinalysis for the presence of sugar and acetone.
- Order 1000 mL D5W over a 12-hour period.
- Order (D5W) 50% glucose IV to be given immediately.
- Order orange juice with added sugar.
Order (D5W) 50% glucose IV to be given immediately.
19) Which of the following would the nurse expect the physician to order for a client
with hypothyroidism?
- Propylthiouracil
- Levothyroxine
- Methimazole
- Propranolol
Levothyroxine
20) A client with type 1 diabetes is to receive a short-acting insulin and an intermediate-
acting insulin subcutaneously before breakfast. The nurse would administer the
insulin at which site as the preferred site?
- Arms
- Upper buttock
- Thighs
- Abdomen
Abdomen
21) A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in
the gastrointestinal tract. The nurse would observe for what while assessing the
client during the procedure?
- Gag reflex
- Client’s tolerance for pain and discomfort
- Client’s ability to retain the barium
- Signs of perforation
Client’s tolerance for pain and discomfort
22) You are caring for a client admitted with a stroke. Imaging studies indicate an
embolus partially obstructing the carotid artery. What type of stroke is this client
experiencing?
- Right-sided
- Ischemic
- Hemorrhagic
- Left-sided
Ischemic
23) What part of the nervous system is responsible for digesting food and eliminating
body waste?
- Parasympathetic
- Central
- Peripheral
- Sympathetic
Parasympathetic
24) Which nervous system regulates the expenditure (use) of energy?
- Peripheral
- Sympathetic
- Parasympathetic
- Central
Sympathetic
25) A 52-year-old female client presents at the walk-in clinic complaining of feeling like a
mask is on her face. While doing the initial assessment, the nurse notes the
demonstration of a pill-rolling movement in the right hand and a stooped posture.
Physical examination shows bradykinesia and a shuffling gait. What would the nurse
suspect is the causative factor for these symptoms?
- Myesthenia gravis
- Parkinson’s disease
- Huntington’s disease
- Multiple sclerosis
Parkinson’s disease
26) A nurse is collecting data from a client who has increased intracranial pressure (ICP).
Which of the following is an expected finding in a client with increased ICP?
- Pupils equal and reactive to light bilaterally
- Sodium of 140mg/dL
- Hyperreflexia
- Change in the level of consciousness
Change in the level of consciousness
27) A nurse is reinforcing teaching for a client who has a new diagnosis of hypertension
The client has a new prescription for furosemide 40mg PO daily. The nurse should
instruct the client to take this medication at which of the following times of day?
- Morning
- Immediately after lunch
- Immediately before dinner
- Bedtime
Morning
28) A nurse is assisting in the care of a client who began having chest pain 2 hrs ago and
was diagnosed with a myocardial infarction. Which laboratory finding should the
nurse identify as an indication the client has sustained injury to the heart?
- BNP
- Calcium
- Troponin I
- Myoglobin
Troponin
29) A nurse is caring for a client with hyperglycemia. Which of the following would the nurse identify as a symptom of hyperglycemia?
- Moist mucous membranes
- Oliguria
- Excessive thirst
- BP 120/80
Excessive thirst
30) A nurse is collecting data from a client for Chevostek’s sign. Which technique should
the nurse use to perform this test?
- Tap lightly on the client’s cheek area
- Ask the client to lower their chin to their chest
- Place the stethoscope bell over the client’s carotid artery
- Apply a BP cuff to the client’s arm
Tap lightly on the client’s cheek area
31) A student nurse is learning the manifestations of hyperthyroidism. Which of the following findings would the student identify? Select all that apply
- Palpitations
- Constipation
- Anorexia
- Heat intolerance
- Weight loss
Weight loss
Heat intolerance
Palpitations
32) A nurse is collecting data from a client who is suspected of having an endocrine
disorder and is scheduled for diagnostic testing that involves the use of a contrast
medium. The nurse would inform the physician if the client stated which of the
following?
- “My father had diabetes when he got older.”
- “I have an allergy to shrimp and shellfish’
- “I take a multivitamin every day.”
- “Years ago, I took a steroid for my asthma.”
I have an allergy to shrimp and shellfish
33) The nursing instructor is discussing cerebral aneurysms with the junior nursing class.
The instructor is talking about medications given to clients with aneurysms. What
substances would the instructor tell the students should not be administered to
clients with an aneurysm who experience pain?
- Oral antidiabetic medications
- Opioid analgesics
- Anticonvulsants
- Antimicrobials
Opioid analgesics
34) You are caring for a male client who is scheduled for a neurologic examination that
uses a radiopaque dye. Before the test, you assess the allergy history of the client
and find the client is allergic to seafood. What does the nurse relate the allergy to
seafood as?
- An allergy to iodine
- An allergy to morphine
- An allergy to radiation exposure
- An allergy to antihistamines
An allergy to iodine
35) A client is scheduled for a diagnostic examination for gastrointestinal disorder
tomorrow morning. The client is given polyethylene glycol/electrolyte solution as a
part of the test preparation. Which of the following measures should the nurse take
once the solution is administered?
- Instruct the client to have low-residue meals.
- Permit the client to drink only clear liquids the evening before & NPO after midnight
- Allow the client to ingest fat-free meal.
- Keep the client NO after the golytely prep is administered
Permit the client to drink only clear liquids the evening before & NPO after midnight
36) The nurse is providing care to a client who has had a percutaneous liver biopsy. The
priority action the nurse should monitor for in this client is what?
- Return of the gag reflex
- Passage of stool
- Signs and symptoms of bleeding
- Intake and output
Signs and symptoms of bleeding
37) A critical care nurse is caring for a client with a neurologic disorder. The nurse
observes a change in the vital signs of the client. What would be a priority action for
the nurse to take when a change in the vital signs is observed?
- Provide measures to normalize vital signs.
- Inquire about allergies to shellfish
- Note the change and inform the physician at the next occurrence about the change.
- Inform the physician immediately.
Inform the physician immediately
38) When administering insulin to a client with type I diabetes, which of the following
would be most important for the nurse to consider? Select all that apply
- Expiration date on the vial
- Use of a filter needle
- Type of insulin administered
- Accuracy of the dosage
- Duration of the insulin
- Expiration date on the vial
- Type of insulin administered
- Accuracy of the dosage
- Duration of the insulin
39) A nurse is assisting a client with a neurological deficit to have a bowel movement.
What nursing action encourages defecation and regulates the bowel to function on a
regular basis?
- Encourage liquids throughout the day
- Administer a low volume enema each day at the same time.
- Schedule bowel training for the same time every day
- Encourage a high fat diet
Schedule bowel training for the same time every day
40) In preparing a client with appendicitis for surgery, the nurse should anticipate which interventions? Select all that apply
- Administer a pre-operative enema
- Maintain PO status
- Start an IV as ordered
- Obtain surgical consent
- Apply heat to abdomen
- maintain NPO status
- Obtain surgical consent
- Start an IV as order
41) A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The
client is prescribed heparin for treatment. The nurse knows to monitor the client for
what adverse effects?
- Migraine attacks
- Respiratory distress
- High blood pressure
- Hemorrhage
Hemorrhage
42) A nurse is caring for a client following a below-the-knee amputation 1 day ago.
Which of the following actions should the nurse take? Select all that apply
- Maintain shrinkage intervention (ace wraps) of the residual limb
- Monitor for feelings of body image changes
- Palpate the residual limb (stump) for warmth
- Inspect for presence and amount of drainage
- Wrap the stump in a circular manner using gauze
- monitor for feelings of body images changes
- palpate the residual limb (stump) for warmth
- inspect for presence and amount of drainage
43) A nurse is preparing to administer an initial dose of prednisone. The nurse should
monitor for which of the following adverse effects of this medication? Select all that
apply
- Anorexia
- Fluid retention/weight gain
- Hypokalemia
- Irritability
- Increased appetite
- fluid retention/weight gain
- hypokalemia
- increased appetite
44) A nurse is assisting with the care of a client who has an Sa02 of 91%, exhibits
audible wheezes and is using accessory muscles when breathing. Which of the
following classes of medications should the nurse expect to administer?
- Beta blocker
- Antiviral
- Antibiotic
- Short acting beta2 antagonist (SABA)
Short acting beta2 antagonist
45) A nurse is reinforcing dietary teaching about calcium-rich foods to a client who has
osteoporosis. Which of the following foods should the nurse include in the
instructions?
- Brown rice
- Kale
- White bread
- Apples
Kale
46) A nurse is assisting the charge nurse with the administration of a blood transfusion.
Which actions by the nurse indicates an understanding of the procedure? Select all
that apply
- Obtains vital signs frequently throughout the transfusion per protocol
- Ensures the administration of dextrose 5% (D5NS) IV with the transfusion
- Verifies blood compatability and expiration date of the blood with the UAP (unlicensed assistive personnel)
- Observes for fluid overload and transfusion reactions
- Ensures that the client has an 25 gauge IV catheter
- Obtains vital signs frequently throughout the transfusion per protocol
- Observes for fluid overload and transfusion reactions
47) A nurse is caring for a client who has an new prescription for oxygen therapy of
4L/min using a nasal cannula. Which action should the nurse take?
- Establish an alternative means of communication
- Lubricate the nares with normal saline 0.9%
-Remove the cannula during meal times - Provide humidification
Provide humidification
48) A nurse is collecting data from a client who is dehydrated. Which finding would the
nurse expect?
- Tachycardia
- Moist mucous membranes
- Distended neck veins
- Increased urinary output
Tachycardia
49) A nurse is caring for a client who has a new prescription for heparin therapy.
Which statement by the client should indicate an immediate concern for the nurse?
- “I had a blood clot in my leg 10 years ago”
- “am allergic to morphine”
- “I take antacids several times a day for my peptic ulcer”
- “It hurts to bend my knee”
I take antacids several times a day for my poetic ulcer
50) A nurse is caring for a client with anemia and has a new prescription for ferrous
gluconate. Which laboratory value will the nurse be most concerned about
monitoring?
- Troponin I
- Hemaglobin
- Potassium
- Triglycerides
Hemaglobin
51) A nurse is caring for a client who has a blood glucose of 52 mg/dL. The client is
lethargic but arousable. Which of the following actions should the nurse perform
first?
- Report findings to the provider
- Provide 15 g of simple carbohydrate
- Provide a carbohydrate and protein food
- Recheck blood glucose in 15 minutes
Provide 15g of simple carbohydrates
52) A nurse is caring for a client with cancer who has had several rounds of
chemotherapy. The client’s latest WBC is 2,000 mm3 or 2.0. Which of the following
should the nurse be most concerned about?
- Client’s risk for infection
- Client’s emotional status
- Client’s self esteem
- Client’s risk for fall
Client risk for infection
53) A client is caring for a client with Cushing’s Syndrome (Oversecretion of
mineralcorticoids). Which of the following is an expected finding for a client with
Cushing’s Syndrome?
- Hypotension and bradycardia
- Hypoglycemia
- Moon face and buffalo hump
- Weight loss and decreased appetite
Moon face and buffalo hump
54) A nurse is caring for a client who has heart failure and reports increased shortness of
breath. Which action should the nurse take first?
- Auscultate the client’s breath sounds
- Assist the client into a high-Fowler’s position
- Obtain the client’s weight
- Check oxygen saturation with pulse oximeter
Assist the client into a high-FOWLER’S position
