Adult I Final: Practice Questions

Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. His ABG results are pH 7.35, PaCO2 72 mmHg and HCO3 38 mEq/L. What acid-base disorder is shown?

B. Respiratory Acidosis, Fully Compensated

Which nursing diagnosis carries the highest priority for a patient with an indwelling Foley catheter?

B. Risk for Infection

A patient's urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment?

B. Urinary Tract Infection

A client with left-sided heart failure has decreased cardiac output related to altered contractility. Which nursing actions are appropriate for improving cardiac pump effectiveness? (Select all that apply).

A, D, E A. Closely monitor fluid intake and output D. Monitor orthostatic blood pressure E. Monitor for dyspnea at night

What are the steps of using an ABC fire extinguisher?

A. Aim, Pull, Squeeze, Sweep

A client with an indwelling urinary catheter needs a urine specimen. To obtain a specimen from a Foley catheter, the nurse should FIRST:

A. Clamp the drainage tubing below the aspiration port

Which of the following statements is true regarding Type 2 diabetes treatment?

A. Insulin and oral diabetic medications are administered routinely in the treatment of Type 2 diabetes

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function?

A. Listening to lung sounds

Sally has been hypoventilating. When the ABGs were done, it was inferred that Sally has:

A. Respiratory Acidosis

The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the health care health care provider (HCP) immediately?

A. Stridor

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify?

A. Support systems that can assist the client at home

A nurse performs a physical assessment on a client with Type 2 DM. Findings include a fasting blood glucose of 120 mg/dl, temp = 101, pulse = 88, resps = 22 and a BP = 140/84. Which finding would be of most concern for the nurse?

A. Temperature of 101

**** ON FINAL !!! **** Lab tests revealed that your patient's Na+ is 170 mEq/L. Which clinical manifestation would the nurse expect to assess.

A. Tented skin turgor and thirst

What is the most important for the patient to do to prevent post-Op respiratory complications?

B. I.S and deep breathing

Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Which of the following observation would prompt you to call the doctor?

B. Left foot is cold to touch and pedal pulse is absent

John Joseph was scheduled for a physical assessment. When percussing the client's chest, the nurse would expect to find which assessment data as a normal sign over his lungs?

B. Resonance

A nurse is taking care of a 54 year old male with a history of right sided heart failure. Which of the following assessment findings is consistent with systemic congestion related to the patient's diagnosis? (Select All That Apply)

B, C, D. -Increased blood pressure -Weight gain -Jugular vein distention

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST:

B. Apply warm blanket and continue oxygen

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

B. Attempt to arouse the client

A 74 year old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, RR = 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure?

B. BNP 820 - lab serum test for heart failure

An hour before the next dose of sliding-scale insulin is scheduled, a patient tells the nurse, "I guess I am really nervous about giving myself injections, look how sweaty and shaky I am". What is priority nurse actions?

B. Check the patient's blood glucose

What is an indicator of chronic hypoxia?

B. Clubbing of fingernails

A clinical feature that distinguishes a hypoglycemic reaction from a ketoacidosis reaction is:

B. Diaphoresis

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention?

B. Elevate legs higher than the heart

Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease?

B. Enhance myocardial oxygenation

Which of the following nursing actions is the first priority care for a client exhibiting signs and symptoms of CAD?

B. Enhance myocardial oxygenation

The nurse is caring for a client with a back injury sustained 1 year ago. To obtain the most complete assessment data about the client's chronic pain pattern, what should the nurse ask the client?

C. "Can you describe your daily activities in relation to your pain?"

The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess first?

C. A 46-year-old patient who is complaining of dyspnea after having a thoracentesis an hour previously

The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?

C. A 78 year old client with pressure ulcers who has a temperature of 102.3 F

A diabetic patient has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. Which of the following actions by the healthcare provider is the priority?

C. Administer 50% Dextrose IV per protocol

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea with temp of 100.6 F. Which outcome is a priority for the client?

C. Alleviation of Pain

A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?

C. Diaphoresis

Which of the following patient factors provides the greatest risk for bowel incontinence?

C. Disoriented to person, place, or time

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?

C. Leave the catheter in place and reattempt with another catheter

All of the following are non-modifiable risk factors for breast cancer EXCEPT:

C. Long term use of hormone replacement therapy (HRT)

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

C. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

The nurse completed diabetic teaching for a client who has been newly diagnosed with diabetes mellitus. Which statement by the client would indicate to the nurse that further teaching needed?

D. "When I exercise, I should plan to increase my insulin dosage"

Which client situation requires the nurse to discuss the importance of avoiding food high in potassium?

D. 8-year-old Albert who has renal disease

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

D. A sedentary 65 year old woman who smokes cigarettes

A patient with a history of asthma is admitted to the emergency department with dyspnea, respiratory rate of 35 breaths per minute, nasal flaring, use of accessory muscles, and greatly diminished breath sounds. What action should the nurse take first?

D. Administer bronchodilators as ordered

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem?

D. Alert and oriented to person, place, time, and events

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

D. Determine if pain is causing the client's tachypnea

Assessment of the diabetic client for common complications should include examination of the:

D. Eyes

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?

D. Observe client's skin color and take another set of vital signs

The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis?

D. PCO2 28, HCO3 18, pH 7.28

Which of the following medications may cause hyperglycemia?

D. Prednisone

A client is hospitalized for open reduction of a fractured femur. During postoperative assessment, the nurse monitors signs and symptoms of fat embolism, which include:

D. Restlessness and Petechiae