1324 Exam 2

The nurse is attempting to wake a client from sleep and is having a difficult time arousing them. What stage of sleep does the nurse identify the client is experiencing?

REM sleep

Prodromal stage of infection

-Interval from onset of general symptoms to more distinct symptoms. -During this time, the pathogen is multiplying. -*Client is MOST INFECTIOUS during this stage.*

Glucose

70-110 mg/dl Some facilities: 60-120 mg/dl

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A) Without treatment, glaucoma can cause blindness. B) Double vision is a common symptom of glaucoma. C) Glaucoma is caused by inadequate production of fluid within the eye. D) Use of eye drops will improve vision over time.

A

A pedi client just came out of a surgical repair of an intussusception of her GI tract, resulting in a small portion of her bowel; what is the most important NI post operatively? A) Auscultating bowel sounds B) Palpating for masses C) Hydration and fluids D) Ambulation

A

Which of the following hormones is produced and secreted by the juxtaglomerular apparatus in response to low blood pressure? A) Renin B) Aldosterone C) Antidiuretic hormone D) Natriuretic peptide

A

What are three interventions that promote healthy sleep hygiene? Select all that apply A) Regular sleep/bed time B) Drink a glass-o-wine right before bed C) Eat a small, fatty snack? D) Avoid strenuous exercise

A, D

A nurse is caring for a client who has diverticulitis. What s/sx can she expect to find? Select all that apply. A) Nausea B) HTN C) Fever D) LLQ pain E) Vomiting

A, D, E

A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of?

Adhere to the medication regimen.

The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?

Administration of a sodium polystyrene sulfonate [kayexalate]

A very social female client comes to the clinic complaining of dribbling every time she sneezes, causing visual wet spots on clothes along with unpleasant odors. What nursing diagnosis would be a potential for this client?

At risk for isolation d/t complications from stress incontinence as evidenced by visual anxiety displayed during office visit along with elevated vital signs.

A 65 yo female w/ a hx of HTN, CAD, and DMII presents w/ inability to see the movements of her hands and blurry vision. What is the next priority action for you, the fabulous nurse? A) Take her to the handy, dandy, Snellen Chart. B) Perform arm movements to test her visual acuity and deficits. C) Talk loudly, in a high pitched voice. D) Dance like yankee-doodle dandee.

B

Priority nursing intervention for a client with an ankle sprain? A) Ice after the first two hours B) Compression with elastic wrap (ACE) C) Opioid use D) Rub some dirt on it

B

The clinic nurse is caring for a 60 year old client experiencing leg pain whenever walking several blocks. She has type 2 diabetes and is a ppd smoker for the past 40 years. The doctor diagnoses the patient w/ intermittent claudication. The nurse should provide what type of teaching regarding long-term care to the patient upon discharge? A) Consider cutting down on your smoking habits. B) Be sure to practice meticulous foot care and inspect feet daily. C) Reduce your activity level to accommodate your limitations. D) Try and make sure you eat enough protein and reduce your carbohydrate intake.

B

You notice your client is flushed and red while receiving IV vancomycin, and quickly realize it as Red Man Syndrome. What do you do as your *FIRST* priority? A) Administer Diiphenhydramine B) Slow infusion and monitor closely C) Slam him with Epi and pray it works D) Nothing, it's normal

B

A client is placed on a *CLEAR LIQUID* diet, which of the following should the nurse remove from the teaching prior speaking with the client? A) Popsicle's B) Broth C) Milk D) Tea

C

A nurse is caring for a client with progressive presbycusis. Which of the following actions should the nurse take? A) Speak loudly and into the client's good ear. B) Use sign language when communicating with the client. C) Speak directly to the client in a normal, clear voice. D) Sit by the client's side and speak very slowly.

C

A nurse is developing a POC for a patient with cellulitis of the left leg, what interventions should she include in her POC? A) Enforce strict bed rest for 3 days. B) Apply fresh ice packs q4h. C) Elevate the affected limb on two pillows. D) Apply abx ointment to the wound w/ drsg changes.

C

Again, you the fabulous nurse, knows that during which cycle of sleep is the most difficult to arouse the client? A) Deep sleep B) NREM C) REM D) Circadian

C

When performing an interview on a client with suspected BPH, what is a valid question? A) Is there any blood in your urine? B) Is there an odor to it? C) Do you have difficulty starting and stopping your stream? D) Is it cloudy?

C

A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home? A) Maintain bed rest for 1 week. B) Lie on the stomach while sleeping. C) Avoid bending the head below the waist. D) Lift weights to increase muscle strength.

C) Avoid bending the head below the waist. Explanation: The nurse should encourage the patient to avoid bending or stooping for an extended period. Keep activity light. Avoid lying on the side of the affected eye the night after surgery. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.

The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition? A) BUN of 18 mg/dL B) Glomerular filtration rate (GFR) of 100 mL/min C) Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20 D) Serum creatinine of 1.2 mg/dL

C) Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.

A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek's sign. What deficit does the nurse suspect the patient has?

Calcium

A client is diagnosed with BPH, what nursing intervention takes priority? A) Foley cath'em B) Anti-spasmotics C) Furosemide D) Create a schedule to void at the same time daily, and keep a log.

D

A client is experiencing an allergic reaction to amoxicillin. Which immunoglobulin will be elevated in his or her lab work results? A) IgM B) IgG C) IgA D) IgE

D

A nurse is caring for a client who has Crohn's disease. Which of the following food choices would follow the recommended diet for clients who have Crohn's disease? A) Vanilla milkshake B) Buttered popcorn C) Tossed green salad D) Toast with jelly

D

Which physiologic change in the elderly population contributes to urinary incontinence?

Decline in detrusor muscle fx.

The nurse is caring for a client with polydipsia and large amounts of urine with a specific gravity of 1.003. Which disorder is anticipated?

Diabetes Insipidus

The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom?

Diminished erythropoietin production

Standard precautions include... Select all that apply. A) Gloves B) Gown C) Mask D) E) All of the above

E

What is the mechanism of action of Prilosec?

Slows production of gastric acid secretion of parietal cells in stomach.

A nurse is helping a client ambulate when the client says, "I had trouble sleeping last night." What is the nurses next intervention?

Finding out more information about the sleeping problem.

One of the leading causes of death in geriatric clients is pneumonia, what is a contributing factor?

Their s/sx are not the typical picture - temperature is not a reliable source of information for infection.

Innate immunity

Immunity that is present before exposure and effective from birth.

What is a leading contributor to blindness?

Not treating visual disturbances/problems when they first occur.

Convalescent period

Recovery from the infx

A patient is describing difficulty with urinating and informs the nurse that every time she coughs or laughs, she urinates and has begun to wear a thin pad. Which of the following types of urinary incontinence is the patient describing?

Stress incontinence

A client is diagnosed with otitis media and prescribed antibiotic therapy. What is the most important teaching that you, the nurse, can give to them before going home?

To follow the directions and finish all antibiotic therapy as directed.

Incubation period

The period between exposure to an infection and the appearance of the first symptoms.

The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication?

With food

A client with Clostridium difficile should be placed on...

contact precautions

For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep?

playing soft or soothing music.