Exam #1 Quiz Questions and Answers

A nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?

Alcohol (Alcohol can cause scarring and fibrosis of the liver. 85%-95% of acetaminophen is metabolized by the liver)

A patient with sickle cell anemia is admitted to the hospital in crisis with severe abdominal pain. While caring for the patient, it is most important for the nurse to:

evaluate the effectiveness of analgesics

A patient is taking hydrochlorothiazide for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as:

generalized weakness.

A student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse?

"Palliative care is the same as hospice care." (Palliative care can be done whenever in disease process, Hospice is death within 6 months)

The nurse is teaching a hospitalized patient to use imagery as a technique for stress management. Which statement by the nurse is appropriate?

"Pay attention to what you hear, smell, and feel at this place."

The nurse is teaching a client who is preparing for discharge after a bone marrow aspiration. The nurse provides which discharge instructions to the client?

"Place an ice pack over the site to reduce the bruising."

A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply. 1.Thready, weak pulse 2.Hyperactive deep tendon reflexes 3.Muscle weakness 4/Numbness and tingling of the hands and feet 5.Lethargy

1, 3, & 5

The nurse is teaching a group of students about neuromuscular manifestations of alkalosis with hypocalcemia. Which statements provided by a student nurse indicate the need for further learning? Select all that apply 1."The client would show signs of twitching." 2."The client would show signs of paresthesia." 3."The client would show signs of muscle cramping." 4."The client would show signs of hyporeflexia." 5."The client would show signs of skeletal muscle weakness."

2 & 4 (There would be twitching, weakness, cramping, hyperflexia)

A client reports increasing pain during dressing changes. Which interventions are recommended for the client? Select all that apply. 1.Assistance by the client with the 2.dressing change 3.Distraction 4.Epidural analgesic 5.Music therapy 6.Premedication 7.Transcutaneous electrical nerve 8.stimulation (TENS)

3, 5, & 6

A patient with thrombocytopenia bleeds profusely after cutting her finger while washing dishes and comes to the urgent care center for treatment when the bleeding has not stopped in 3 hours. The nurse anticipates which of the following platelet results?

75,000 ug/dL

An 82-year-old client with anemia is prescribed 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? Select all that apply. A. Hypotension B. Hypertension C. Decreased pallor D. Rapid, bounding pulse E. Flattened superficial veins F. Capillary refill less than 3 seconds

ABD

In the role of client advocate, what does the nurse do first for a client who reports pain?

Believes the client's report of pain (Nurse = advocate, priority role)

A client is receiving patient-controlled analgesia (PCA) after surgery. What does the nurse identify as the primary benefit with this type of therapy?

Client is able to self-administer pain-relieving drugs as necessary

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?

Elevates the head of the bed

Which of the following is NOT included in a routine assessment of a patient's pain?

Family history of addiction to pain medicaitons

A client develops iron-deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased?

Ferritin (Ferritin, a form of stored iron, is reduced with iron-deficiency anemia)

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that the client has an infection or an infection needs to be ruled out?

Fever of 102 degrees F (38.9 degrees C) or higher

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing?

Hemolytic (recipient's antibodies that are incompatible with transfused red blood cells)

An 8-year-old boy is crying with pain after a tonsillectomy. Which nursing intervention is most appropriate for this client?

Hold him and provide comfort.

A 32-year-old client is recovering from a sickle cell crisis. The client's discomfort is controlled with pain medications and discharge planning has been initiated. What medication will the nurse anticipate to be prescribed before discharge?

Hydroxyurea (Droxia) (reduced sickling of cells and pain)

The rapid response team (RRT) is called to the bedside of a client with a heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L. For which medication will the nurse anticipate a prescription?

Insulin

A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do?

Place the client in a side-lying position so secretions can drain. (due to gravity)

The nurse working in the emergency department (ED) admits a patient with renal failure and a serum potassium level of 8.0 mEq/L. All these orders are received from the health care provider. Which order will the nurse implement first?

Place the patient on a cardiac monitor.

A 22-year-old patient is brought to the emergency department (ED) with multiple abrasions and bruises after being assaulted in a shopping center parking lot. The patient's initial blood pressure (BP) is 180/98. Which of the following is an appropriate reaction by the nurse in response to the patient's blood pressure?

Recheck the blood pressure prior to the patient's discharge from the ED.

Both clients and nurses have misconceptions about pain. Which statement reflects a misconception about pain?

Regular administration of analgesics leads to addiction.

The nurse is assessing several clients who are receiving transfusions of blood components. Which assessment finding requires immediate action by the nurse?

Respiratory rate of 36 breaths/min in a client receiving red blood cells (possible hemolytic reaction)

A client who is receiving a blood transfusion suddenly tells the nurse, "I don't feel right!" What is the nurse's first action?

Stop the transfusion

Which of the following correctly describes the stress response?

Stress activates the HPA axis, ACTH is released which stimulates the adrenal cortex to secrete corticosteroids

A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate anti-diuretic hormone (SIADH). The nurse will monitor carefully for:

decreased serum sodium level.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for

edema

A patient who enjoys active outdoor activities develops arthritis in the knees. To help the patient cope with the diagnosis, the most helpful intervention by the nurse is to:

encourage the patient to think about activities to stay active without exacerbating the arthritis.

Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to contact the health care provider immediately is:

gradually decreasing level of consciousness (LOC).

When assessing patients for the possible health impact of stressors, the most important information to obtain is:

how long the patient has been exposed to the stressor

A patient with leukemia undergoing chemotherapy has a nursing diagnosis of risk for infection. The most important nursing intervention is the prevention of transmission of harmful pathogens to the patient is:

strict and frequent handwashing by all persons having contact with the patient

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for:

the presence of Chvostek's sign.

A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit? Select all that apply. 1.Hypotension 2.Dyspnea 3.Pulmonary crackles 4.Tenting tissue turgor 5.Oliguria

1, 4 & 5

Which statement is true regarding cortisol?

Cortisol stimulates gluconeogenesis (Cortisol maintains the blood glucose concentration by stimulating the liver)

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate?

Place the client on a cardiac monitor

The nurse is caring for a client who is in sickle cell crisis. What action would the nurse perform first?

Provide pain medications as needed. (pain management is #1)

A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective?

"I have to be careful about which over-the-counter cold preparations I take when I have a cold." (Many over the counter cold medication include acetaminophen, should not exceed 3000-4000mg)

The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet?

Facilitating a peaceful death for the client

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? Select all that apply. 1. Erythema 2. Constipation 3. Seizures 4. Confusion 5. Thirst

3 & 4

Severe cancer pain is most effectively treated with analgesics given

Around the clock, with extra doses available as needed

A nurse evaluates if patient-controlled analgesia (PCA) is effective by doing which of the following?

Asking the patient, "Is your pain level where you would like it to be right now?"

A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce this physiological response to stress?

Assisting client in developing new coping mechanisms

The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse?

Bleeding from the nose

A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity?

Blowing the nose (Thrombocytopenia patients have a greater risk of bleeding)

A pregnant client tells the nurse in the prenatal clinic that although she and her husband do not have the disease, she has a 1-year-old daughter with sickle cell anemia. She asks the nurse, "Will this baby also have sickle cell anemia?" How should the nurse respond?

Child has a 25% chance (gene is recessive)

A patient with diabetes complains of "burning" pain in his legs. Which of the following medications is most likely to be effective for this type of pain?

Gabapentin (neurotin)

The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5mg of hydromorphone (Dilaudid) IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What action does the nurse take initially?

Gives the client a dose of naloxone (0.4 mg IV initially, reversal agent)

A patient with a history of iron-deficiency anemia is experiencing increased fatigue and dizziness. The nurse would expect the patient's laboratory findings to include:

Hbg 8.6

A patient had a splenectomy to control bleeding from a lacerated spleen following an automobile accident. The nurse recognizes that the patient's loss of the spleen is most likely to result in:

Impaired immunity

To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of hypocalcemia the nurse should assess for is:

Lip numbness

A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first?

Morphine sulfate (Roxanol) 5-10mg sublingually as needed (standard treatment for dyspneic client near death)

A client who is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?

Naloxone administration (narcan) (Is an opioid antagonist and reserve respiratory depression)

A postoperative client is prescribed acetaminophen (Tylenol) with codeine at discharge. When performing discharge teaching, the nurse should:

Recommend that the client increase fluid and fiber intake

During discharge teaching for the patient with sickle cell anemia, the nurse instructs the patient to avoid precipitating factors for sickle cell crisis, such as:

Dehydration

After receiving change-of-shift report, which client does the RN assess first?

A client receiving IV diuretics whose blood pressure is 88/52 mm Hg

During treatment of the patient with DIC, the nurse would expect that the primary goal of therapy would include:

treatment of the underlying disease process contributing to DIC

Following surgery, a client has great difficulty getting out of bed, walking, and coughing/deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used, even when suggested by the nurse. This concerns the nurse. Which statement is the best way to address this concern with the client?

"I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant."

A nurse is teaching a 12-year-old child about a bone marrow aspiration. What statement indicates that the preadolescent needs further explanation of the procedure?

"I'll have to rest after my procedure" (There usually is sedation in the procedure, activity is not restricted after recovering from sedation)

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?

"I'll start to have symptoms when I drink less fluid." (Dehydration precipitates sickling of red blood cells and therefore is a major causative factor for painful episodes associated with sickle cell anemia)

The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond?

"Let's ask your father about your request" (It is up to the patient)

The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement?

"Red blood cells appear normal in size and color; however, there is a decreased amount produced." (anemia = decrease in RBC in response to chronic inflammation)

The husband of a patient who is recovering from a heart attack tells the nurse, "My wife doesn't seem like the same person. She is so forgetful and irritable and she has always been well-organized and calm before this." Which response by the nurse is most appropriate?

"Stress frequently causes transient changes in concentration and mood."

A diabetic patient who is hospitalized tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up." Which response by the nurse is appropriate?

"Stressors such as illness cause the release of hormones that increase blood sugar."

A patient who has fibromyalgia tells the nurse, "My life feels very chaotic and out of my control. I will not be able to manage if anything else happens." Which response by the nurse will be helpful?

"Tell me more about how your life has been recently."

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information would the nurse explain to the parents about the risk of a child having sickle cell disease?

"The sickle cell trait will be inherited by your children."

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. 1. Chemotherapy 2.Radiation therapy 3.Repositioning 4.Blood transfusion 5.Regular oral care

1, 2, & 4

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply. 1.Irregular heart rate 2.Anorexia 3.Vomiting 4.Constipation 5.Muscle weakness

1, 3 & 5

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply. 1.Hematuria 2.Fever 3.Diarrhea 4.Headache 5.Ecchymosis

1, 4, & 5

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first?

Slow the rate of the IV infusion

The nurse obtains all of the following assessment data about a patient with fluid-volume deficit caused by a massive burn injury. Which of the following assessment data will be of greatest concern?

The blood pressure is 90/40 mm Hg.

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective?

The client is free from adventitious breath sounds

In a patient with an acute bacterial infection of the kidney, the nurse would expect the patient's CBC to reveal:

WBC 20,000

A 28-year-old male patient who is diabetic is hospitalized for a gangrenous foot infection. The patient's wife visits the patient for a few minutes every other day. The patient tells the nurse that his wife is angry about being married to an invalid. The nurse identifies the nursing diagnosis of:

compromised family coping related to insufficient support from wife.

Which client is at greatest risk for experiencing a hemolytic transfusion reaction?

A 34-year-old client with type O blood

A client with anemia asks the nurse, "Why am I feeling tired all the time?" What is the nurse's best response?

"Your cells are delivering less oxygen than you need"

A nurse is assessing a client for dehydration. The client has had diarrhea and vomiting for 48 hours. Which assessment findings alert the nurse that the client is dehydrated? Select all that apply. 1.The client reporting eating an average of three meals daily 2.The skin on the client's forehead remains tented after being pinched 3.Protruding eyeballs 4.Postural hypotension 5.Within four days, the client gained two pounds (0.9kg) of weight

2 & 4

The nurse reviews the medical record of a client who is eligible to receive end-of-life care. What are the criteria for a client to receive this type of care? Select all that apply. 1. When the client is nearing death 2.When the client seeks no aggressive disease management 3.When a family member has signed an informed consent form 5.When the expected death of the client is within 6 months 6.When the client has been issued a "do not resuscitate" order

2 & 4

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what symptoms of bleeding they should be looking for in the future. What symptoms should the nurse list? Select all that 1.Fast clotting injuries 2.Hemarthrosis 3.Frequent fevers 4.Hematuria (blood in urine) 5.Epistaxis (nose bleeds) 6.Dark-colored tarry stools 7.Easy bruising

2, 4, 5, 6, & 7

The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. 1. Pruritis 2.Nausea and vomiting 3.Constipation 4.Respiratory rate 5.Sedation

4 & 5

The nurse is starting the shift by making rounds. Which client would the nurse assess first?

A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism (may experiencing nose bleed due to excessive anticoagulation)

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? Select all that apply. A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion. C. Infuse at a rate of no more than 20 mEq/hour. D. Administer only through a central venous catheter. E. Administer by IV push only during cardiac arrest.

A, B, & C

The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? Select all that apply. A. Assess daily weights. B. Encourage consumption of citrus fruits. C. Weigh the client weekly. D. Monitor serum potassium. E. Discourage intake of spinach. F. Monitor for bradycardia.

A, B, & D

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? Select all that apply. A. Place the client on bed rest. B. Evaluate the electrolyte levels. C. Administer the ordered diuretic. D. Assess for orthostatic hypotension. E. Initiate cardiac monitoring.

A, B, D, & E

The nurse is teaching a client with newly diagnosed anemia about conserving energy. Which instructions would the nurse give to the client? Select all that apply. A. "Provide yourself with 4-6 small, easy-to-eat meals daily." B. "Perform you care activities in groups to conserve your energy." C. "Stop activity when shortness of breath or palpitations is present." D. "Allow others to perform your care during periods of extreme fatigue." E. "Drink small quantities of protein shakes and nutritional supplements daily." F. "Perform a complete bath daily tor educe your chance of getting an infection."

A, C, D, & E

A postoperative client reports, "I have pain from a mile headache." Which PRN medication does the nurse administer?

Acetaminophen (Tylenol) (1st line therapy for mild-mod pain)

A client with cancer is receiving low-dose oral morphine but is reporting both "sharp, tingly" pain and constipation. What intervention does the nurse implement first?

Administers ordered docusate sodium (Colace) and gabapentin (Neurontin) (Gabapentin helps with neuropathic pain)

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?

Client behavior that changes from anxious to lethargic

What is the most definitive test to confirm a diagnosis of multiple myeloma?

Bone marrow biopsy (plasma cell malignancy with widespread bone destruction)

After a surgical thyroidectomy a client exhibits carpopedal spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations?

Calcium Gluconate (exhibiting signs and symptoms of hypocalcemia, calcium gluconate is treatment)

A nurse assesses a patient for pain. The patient says she has severe arthritis pain and rates it as a "10." Vital signs are 138/80, 16, 80, and 92%. The client is calmly watching television. Which of the following nursing diagnoses is most appropriate at this time?

Chronic Pain

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat?

Dairy products

A patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. The laboratory data that will be of most concern to the nurse is:

Na+ 154 mEq/L.

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention would the nurse implement first?

Obtain prescribed blood cultures

A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?

Placing child in a private room, restricting ill visitors, strict hand washing techniques

The nurse is mentoring a recent graduate registered nurse about administering blood and blood products. What action does the nurse perform before starting the transfusion?

Verify with another RN all of the data on blood products

A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client?

"Use a soft-bristled toothbrush."

A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What does the nurse say to the visitor?

"Please allow the client to push the button when needed"

The nurse should assess the client with which hematologic condition first?

An 81-year-old with thrombocytopenia and an increase in abdominal girth (possible hemorrhage)

While waiting to perform x-rays on an injured right hand, according to non-pharmacological pain management practice, pain can be modulated if the nurse:

Applies ice to the right elbow

How should a nurse expect a client's anxiety to be manifested physiologically?

Increase blood glucose level (flight-or-fight response of the sympathetic nervous system is stimulated)

Which of the following is a correct "stress response" by the body:

Increased blood glucose

A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L. The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question?

Infuse 5% dextrose in water at 125 ml/hr.

The nurse is assessing a client with a sodium level of 118 mEq/L. Which activity takes priority?

Instructing the client not to ambulate without assistance

When the nurse discusses foods high in iron with a patient who has iron-deficiency anemia, the patient tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. An appropriate goal for the patient would be to increase dietary intake of:

Legumes and whole-grain cereals

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first?

Reparations (Always be questioned id reparations is below 12)

While caring for a patient with secondary polycythemia, the nurse recognizes that causes of the disorder can be related to:

decreased oxygenation