NUR 224 Possible Test Questions Final Part 2

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) "Be sure to practice meticulous foot care." B) "Consider cutting down on your smoking." C) "Reduce your activity level to accommodate your limitations." D) "Try to make sure you eat enough protein."

A) "Be sure to practice meticulous foot care."

The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment? A) "Lately, I have this cough that just never seems to go away." B) "I find that I don't have nearly the stamina that I used to." C) "I seem to get nearly every cold and flu that goes around my workplace." D) "I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair."

A) "Lately, I have this cough that just never seems to go away."

A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A) Assess pulse of affected extremity every 15 minutes at first. B) Palpate the affected leg for pain during every assessment. C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D) Perform Doppler evaluation once daily.

A) Assess pulse of affected extremity every 15 minutes at first.

A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.

A) Avoiding tight-fitting socks.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds

A) Diminished or absent breath sounds on the affected side

A nurse is caring for a patient who has had surgery for oral cancer. When addressing the patients long-term needs, the nurse should prioritize interventions and referrals with what goal? A) Enhancement of verbal communication B) Enhancement of immune function C) Maintenance of adequate social support D) Maintenance of fluid balance

A) Enhancement of verbal communication

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A) High levels of alcohol consumption B) History of bowel obstruction C) History of diverticulitis D) Longstanding psychosocial stress

A) High levels of alcohol consumption

A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the patient will be diagnosed? A) Iron deficiency anemia B) Pernicious anemia C) Sickle cell anemia D) Hemolytic anemia

A) Iron deficiency anemia

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

A) Pneumothorax

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patients condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence? A) Tachycardia, hypotension, and tachypnea B) Tarry, foul-smelling stools C) Diaphoresis and sudden onset of abdominal pain D) Sudden thirst, unrelieved by oral fluid administration

A) Tachycardia, hypotension, and tachypnea

A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding? A) The patient's pituitary function is compromised. B) The patient's adrenal insufficiency is not treatable. C) The patient has insufficient hypothalamic function. D) The patient would benefit from surgery.

A) The patient's pituitary function is compromised.

Your client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?

Avoid antihistamines and cold preparations for 48 to 72 hours before the test.

The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patient's care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis

B) Acute pain related to intermittent claudication

A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patient's immediate care? Select all that apply. A) Administering diuretics to prevent fluid overload B) Administering beta blockers to reduce heart rate C) Administering insulin to reduce blood glucose levels D) Applying interventions to reduce the patient's temperature E) Administering corticosteroids

B) Administering beta blockers to reduce heart rate D) Applying interventions to reduce the patient's temperature E) Administering corticosteroids

The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? A) Temperature and oxygen saturation B) Heart rate and BP C) Breath sounds and bowel sounds D) Color, warmth, movement, and sensation of extremities

B) Heart rate and BP

While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.

B) Implement interventions relevant to arterial narrowing.

You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury

B) Ineffective tissue perfusion

The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynaud's disease

B) Intermittent claudication

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient's initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patient's fluid balance C) Assessing the patient's level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

B) Maintaining and monitoring the patient's fluid balance

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport

B) Osmosis and osmolality

The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy

B) Unequal peripheral pulses between extremities

The nurse is assessing a patient who comes to the clinic reporting feeling constantly tired and very weak. The patient also has a very sore tongue, and upon observing the patients oral cavity, the nurse notices the tongue is beefy red. What type of anemia does the nurse know these symptoms indicate? A. Iron deficiency B. Megaloblastic C. Sickle Cell Disease D. Aplastic

B. Megaloblastic

A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurse's best response? A) "The type of treatment depends on the patient's age and health status." B) "The type of treatment depends on what the patient wants when given the options." C) "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." D) "The type of treatment depends on the discussion between the patient and the physician of which treatment is best."

C) "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."

The nurse caring for a patient with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. What does the nurse explain that this test will involve? A) Administration of dexamethasone orally, followed by a plasma cortisol level every hour for 3 hours B) Administration of dexamethasone IV, followed by an x-ray of the adrenal glands C) Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning D) Administration of dexamethasone intravenously, followed by a plasma cortisol level 3 hours after the drug is administered

C) Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning

A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patient's care? A) Decisional conflict related to treatment options B) Spiritual distress related to changes in cognitive function C) Disturbed body image related to changes in physical appearance D) Powerlessness related to disease progression

C) Disturbed body image related to changes in physical appearance

How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patient's legs flat and straight. B) Keep the patient's knees bent to 45-degree angle and supported with pillows. C) Elevate the patient's lower extremities. D) Dangle the patient's legs over the side of the bed.

C) Elevate the patient's lower extremities.

The nurse is caring for a patient with a diagnosis of Addison's disease. What sign or symptom is most closely associated with this health problem? A) Truncal obesity B) Hypertension C) Muscle weakness D) Moon face

C) Muscle weakness

A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient? A) Presence of acute pain and anxiety B) Tissue integrity and color of the operative site C) Respiratory status and airway clearance D) Self-esteem and body image

C) Respiratory status and airway clearance

A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynaud's phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE

C) Upper extremity arterial occlusive disease

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

D) Fluid and electrolyte replacement

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynaud's phenomenon C) VTE D) PAD

D) PAD

A 54-year-old man has just been diagnosed with small cell lung cancer. The patient asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurse's response? A) The cells in small cell cancer of the lung are not large enough to visualize in surgery. B) Small cell lung cancer is self-limiting in many patients and surgery should be delayed. C) Patients with small cell lung cancer are not normally stable enough to survive surgery. D) Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

D) Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a "one day on, one day off" schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points

D) The importance of ensuring the stockings are applied evenly with no pressure points

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

D) Use Doppler ultrasound to identify the pulses.

Which disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks?

Systemic lupus erythematosus (SLE)

A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? a) Slow the infusion rate and monitor the patient closely. b) Discontinue the transfusion and begin resuscitation. c) Pause the transfusion and administer a 250 mL bolus of normal saline. d) Discontinue the transfusion and administer a betablocker, as ordered.

a) Slow the infusion rate and monitor the patient closely.

On auscultation, which finding suggests a right pneumothorax? a) Bilateral inspiratory and expiratory crackles b) Absence of breaths sound in the right thorax c) Inspiratory wheezes in the right thorax d) Bilateral pleural friction rub

b) Absence of breaths sound in the right thorax (s/s of pneumothorax include decreased lung sounds, SOB, sharp pain, unequal chest rise)

A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? a) Apply an icepack to the blood that remains to be infused. b) Discontinue the remainder of the PRBC transfusion and inform the physician. c) Disconnect the bag of PRBCs, cool for 30 minutes and then administer. d) Administer the remaining PRBCs by the IV direct (IV push) route.

b) Discontinue the remainder of the PRBC transfusion and inform the physician.

A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction? a) Antibodies to donor leukocytes remained in the blood. b) The donor blood was incompatible with that of the patient. c) The patient had a sensitivity reaction to a plasma protein in the blood. d) The blood was infused too quickly and overwhelmed the patient's circulatory system.

b) The donor blood was incompatible with that of the patient.

The client is admitted to the emergency department with chest trauma. When assess- ing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? a) Bronchovesicular lung sounds and bradypnea. b) Unequal lung expansion and dyspnea. c) Frothy bloody sputum and consolidation. d) Barrel chest and polycythemia.

b) Unequal lung expansion and dyspnea.

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium level of 120 mg/dL c. Reported weight gain of 2.2 lb (1 kg) d. Urinary output of 280 mL during past 8 hours

b. Serum sodium level of 120 mg/dL

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? a) Obtain an order for a stat chest x-ray. b) Increase the amount of wall suction. c) Check the tubing for kinks or clots. d) Monitor the client's pulse oximeter reading.

c) Check the tubing for kinks or clots.

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Pulmonary embolism b) Myocardial infarction (MI) c) Pneumothorax d) Heart failure

c) Pneumothorax

A patient's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action? a) Assess for signs of myelosuppression. b) Review the patient's platelet level. c) Assess the patient's capillary refill time. d) Review the patient's international normalized ratio (INR).

d) Review the patient's international normalized ratio (INR).

Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? a). A 35 year old pregnant client with placenta previa b). A 42 year old client with a pulmonary embolus c). A 60 year old client receiving hemodialyasis 3 days a week d). A 78 year old client with sepsis

d). A 78 year old client with sepsis (also, placental abruption)

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?

ineffective airway clearance r/t airway alterations

The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?

intradermal

A client is admitted to the unit with diabetic keto acidosis (DKA). Which insulin would the nurse expect to administer intravenously?

regular