NUR 414 Final Exam

A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports, "He's gotten more restless and agitated, and now he's nauseated." What should the nurse advise the partner to do? A. Bring the partner to the clinic for testing and a physical examination. B. Administer the medication to the partner at bedtime. C. Give the medication with food. D. Omit one dose today and start with a lower dose tomorrow.

A

The RN is performing a health hx for a new pt. Which should the nurse identify as a risk factor for cellulitis in an adult?

Cut, fracture, burn, scrape, weakened immune system, hx of obesity, PVD, or diabetes

A client with type 1 diabetes is transported via ambulance to the ED. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect the client is experiencing?

Ketoacidosis, which results in metabolic acidosis.

A pt is orally intubated and mechanically ventilated due to respiratory failure. Which item does the nurse ensure is kept next to the bedside at all times?

Manual resuscitation bag, extra ET tube

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit?

Metabolic acidosis

A pt is admitted with a diagnosis of emphysema and dyspnea. The RN should encourage the client to assume what position?

Orthopneic position

An RN provides oral care for a pt who is mechanically ventilated. What is the best rationale for providing this care?

To prevent VAP

a 2.5 y.o is admitted with a fever of 103, stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority intervention?

droplet precautions

Which lab results does the RN expect with respiratory alkalosis?

elevated pH low Pco2

A pt is admitted for respiratory distress and suspected pneumonia. Which assessment findings consistent with this diagnosis require continued monitoring?

fever, productive cough, dyspnea, pleuritic chest pain, increased respiratory rate, and chills Assessing for bronchophony (saying 99; shouldn't be able to hear the words clearly through auscultation). Complications of pneumonia: lung abscess, pleural effusion, and respiratory failure

An RN, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply

headache, confusion, sweating

The RN is caring for a client with diabetes. Which task can be delegated to the UAP?

obtaining blood glucose value and letting the nurse assess the value

The RN is assessing a pt diagnosed with upper arm cellulitis. Which manifestation should the RN anticipate?

pain, tenderness, erythema, warmth, edema, fever

What care is needed for a client experiencing HHNS?

the priority is to administer IVF. After IVF they can receive regular insulin IVP and D50

A client with cellulitis asks why bed rest has been prescribed. The RN explains that the primary purpose of bed rest for the client is to:

to prevent infection from spreading through movement

The RN is caring for a 3 y.o with meningitis. What are signs and symptoms of increased ICP?

vomiting, headache, irritability, decreased RR, increased BP

An RN assesses a pt who is recovering from a thoracentesis. Which assessment finding is most concerning?

A pneumothorax: diminished breath sounds, retractions, dyspnea, increased RR, cyanosis.

A 7 y.o who is about to have an IV line placed for ABs cries out that he's afraid of IVs. What's the most therapeutic response?

Allow the child to talk about what is frightening him

How does donepezil reduce the symptoms for clients with mild to moderate Alzheimer's disease? A. Reducing GABA action. B. Enhancing acetylcholine function C. Inhibiting serotonin uptake D. Anti-oxidating free radical

B

An RN is caring for a pt with GBS. The RN identifies that the pt is having difficulty expectorating respiratory secretions. What should be the RN's first intervention? A. Auscultate for breath sounds B. Administer O2 via NC C. Suction the pt's oropharynx D. Place the client in orthopneic postiion

C. Suction the pt's oropharynx

The RN instructs the pt admitted for an acute exacerbation of COPD about the importance of assessing for right-sided heart failure after discharge. The RN instructs the client to asses for: A. Clubbing of the nail beds B. HTN C. Weight gain D. Increased appetite

C. Weight gain

A pt with type 1 diabetes is diagnosed with DKA and initially treated with IVF followed by an IV bolus of regular insulin. The RN anticipates that the HCP will prescribe a continuous infusion of:

Regular insulin; which is the only insulin that can be administered intravenously

a 28 m.o is admitted with suspected meningitis. The mom says she has to leave but the child gets upset whenever she tries to go. What is the best action by the nurse?

Stay with the child to enable the mother to leave

a 2 y.o is admitted with cellulitis and given ABs and IVFs. The child's temp increaseed to 103. When notified, the HCP determined there wasn't a need to change treatment even though the child has hx of febrile seizures. Although concerned, the RN took no further action. Later, the child had a seizure that resulted in neurologic impairment. Legally, who is responsible for the child's injury?

The RN

The RN is providing home care instruction to the pt with cellulitis. Which statement should concern the nurse?

They'll stop taking the ABs when they feel better

An RN is caring for a pt who has been taking several AB meds for a prolonged period of time. Long term ABs interfere with the absorption of fat. What order should the RN anticipate?

Vitamins ADEK

Which statement by the client with type 2 diabetes indicates to the RN that additional teaching about the diet is needed?

caloric intake should include 50% carbs, 20% protein, and 30% fat. 90% of fats should be unsaturated.

The RN is caring for a pt with cellulitis in the left leg. The pt has MRSA in the wound. What should the RN include when caring for a pt in isolation for MRSA.

contact precautions; gloves and gown

The RN cares for a client with diabetes. The client's blood glucose is 563 upon admission. Which physical characteristic does the nurse expect to assess?

dehydration, poor tissue perfusion, poor skin turgor

An RN plans to teach a 7 y.o with recently diagnosed type 1 diabetes how to give insulin injections. What should be included in the 1st lesson? Select all that apply.

A return demonstration. Children learn best when the learning is interactive.

Which factors are associated with developing guillain-barre syndrome? Select all that apply. A. Epstein-barr infection B. Recent upper respiratory infection C. Client is 4 y.o D. Recent flu vaccination E. diabetes

A. Epstein-barr infection B. Recent upper respiratory infection D. Recent flu vaccination Risk factors for developing GBS include: experiencing upper respiratory infection, GI infection, Epstein-Barr infection, HIV/AIDS, vaccination (flu/swine flu).

An 85 y.o with hx of CHF is experiencing dyspnea with a RR of 32. Crackles are noted bilaterally. The pt is in sim's position, receiving O2 at 2L/min via NC. Which action should the nurse do first? A. Raise client to high-fowler position B. Obtain the apical pulse and BP C. Call the HCP immediately D. Monitor the pulse oximeter to ascertain the oxygen level

A. Raise the client to high-fowler position

A pt with HTN is being discharged on captopril and spironolactone. What priority discharge teaching should the RN include? A. Be sure to avoid eating grapefruit or drinking grapefruit juice B. Be sure to avoid salt substitutes that contain potassium chloride C. Take these medications with food D. Be sure to include foods high in potassium

B. Be sure to avoid salt substitutes that contain potassium chloride

An ECG is prescribed for a pt who reports angina. What early finding does the RN expect on the lead over the infarcted area? A. Inverted p waves B. Absence of p waves C. Elevated ST segment D. Flattened T waves

C. Elevated ST segment

A pt on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the pt for which signs?

Cyanosis, PaO2 <90, increased restlessness or agitation, pale skin, cool and clammy, thick secretions when suctioned

The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? A. Amnesia B. Apraxia C. Aphasia D. Agnosia

D

An RN is admitting a 2 y.o who ingested half a bottle of aspirin to the ED. What acid-base imbalance is the client at risk for?

Metabolic acidosis

A 2.yo has bacterial meningitis. What is the most important safety measure for the RN to institute immediately after the child has a seizure

Side lying position

The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do? A. Prefill a weekly drug box that has separate sections for different times for the spouse to self-administer. B. Hang a list of medications with the times at which the spouse should take them. C. Provide the spouse with the medications at the appropriate times they should be taken. D. Remind the spouse in the morning which medications must be taken during the day.

A

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type? A. Managing the client's unsafe behaviors B. Restricting gross motor activity C. Preventing further deterioration D. Keeping the client oriented to time.

A

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. The nurse's best reply is: A. "All family members, including your child, need to wash their hands after using the bathroom." B. "I suggest that you buy a commode exclusively for your child's use." C. "You will need to clean the bathroom from top to bottom every time a family member uses it." D. "Your child may use the bathroom, but you need to use disposable toilet covers."

A. "All family members, including your child, need to wash their hands after using the bathroom." Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. It is not feasible to clean "from top to bottom" each time the bathroom is used. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Handwashing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

A client is admitted to the hospital with ascites. The client reports drinking a quart of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? A. "When was your last drink of vodka?" B. "Why do you mix the vodka with orange juice?" C. "What prompts your drinking episodes?" D. "Do you also eat when you drink?"

A. "When was your last drink of vodka?" The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important, but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

A school health nurse is teaching a health class to 12-year-olds about hepatitis C. Which statement by a student indicates an understanding of the origin of the disease? A. "You can catch it while you're getting a tattoo." B. "The disease is passed from person to person by casual contact." C. "People working at restaurants can give it to you if they don't wash their hands." D. "You're more likely to get it in crowded living conditions.

A. "You can catch it while you're getting a tattoo." The hepatitis C virus (HCV) is a bloodborne pathogen; it can be acquired during the application of a tattoo with equipment that is contaminated with the hepatitis C virus. Hepatitis C is not transmitted by close contact in crowded spaces; HCV is a bloodborne pathogen. HCV is not transmitted by casual contact; it is a bloodborne pathogen. The fecal-oral route of transmission is associated with hepatitis A, not hepatitis C.

During the morning assessment of a client with cirrhosis, you note the client is disoriented to person and place. In addition, while assessing the upper extremities, the client's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Ammonia level of 68 µ/dL B. Creatinine level of 2.9 mg/dL C. Potassium level of 3.7 mmol/L D. Calcium level of 10.9 mg/dL

A. Ammonia level of 68 µ/dL Based on the assessment findings and the fact the client has cirrhosis, the client is experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm these abnormal assessment findings (Normal ammonia: 10-80)

A pt is admitted with heart failure. Which lab value supports this diagnosis? A. An elevated brain natriuretic peptide B. Increased creatinine kinase C. Elevated troponin I D. Decreased c-reactive protein

A. An elevated BNP

A pt with GBS has been hospitalized for 3 days. Which assessment finding indicates a need for more frequent monitoring? A. Ascending weakness B. Skin desquamation C. Localized seizures D. Hyperactive reflexes

A. Ascending weakness

A pt is admitted to the ED with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The RN expects that the pt's initial treatment will include which medication? A. Aspirin B. Lidocaine C. Alprazolam D. Meperidine

A. Aspirin

2 hr after a cardiact cath that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? A. Check pedal pulses B. Take BP C. Call HCP D. Recognize the response is expected

A. Check pedal pulses

The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which findings warrant the postponement of the procedure? Select all that apply. A. Hemoglobin less than 9 g/dL B. Platelet count of 160,000/mm3 C. Marked ascites D. Ecchymosis and purpura E. Hepatic cirrhosis

A. Hemoglobin less than 9 g/dL C. Marked ascites D. Ecchymosis and purpura To do a liver biopsy when a client has marked ascites increases the risk of leakage of ascitic fluid. The liver biopsy should be postponed. A client with a hemoglobin of less than 9 g/dL should not have a liver biopsy because the client cannot take the risk of the puncture of a hepatic blood vessel. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy, because it is done to detect the presence of hepatic cirrhosis. Although a platelet count of 160,000/mm3 is within the low range of the expected platelet count for an adult, a liver biopsy is not contraindicated. A count of less than 50,000/mm3 is critical and requires postponement of the test. Ecchymosis and purpura are signs of bruising and If the client has numerous bruises it may indicate deficient thrombocytes or prolonged clotting; both are contraindications for a percutaneous liver biopsy.

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? A. Hyperkalemia B. Tachycardia C. Hypoglycemia D. Ecchymosis

A. Hyperkalemia Spironolactone (Aldactone) is a potassium-sparing diuretic that is used to treat clients with ascites; therefore, the nurse should monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.

The physician orders Lactulose 30 mL by mouth per day for a client with cirrhosis. What finding below demonstrates the medication is working effectively? A. Improvement in level of consciousness B. Presence of asterixis C. Decreased albumin levels D. Absence of fruity breath

A. Improvement in level of consciousness A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands). This is due to the buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would have improving mental status, decreased ammonia blood level, decreasing or absence of asterixis, and decreased ammonia blood level. Fruity breath is associated with DKA not hepatic encephalopathy.

The pt is admitted for left heart failure. Which S/S correlate with this condition? Select all that apply. A. Orthopnea B. Crackles in bilateral bases C. Peripheral edema D. Restlessness E. Hepatomegaly

A. Orthopnea B. Crackles in bilateral bases D. Restlessness S/S of LHF include pulmonary symptoms such as orthopnea, SOB, crackles, change in LOC, and tachycardia. RHF includes peripheral edema, hepatomegaly, splenomegaly, ascites, and JVD.

An RN is caring for a client newly diagnosed with GBS. The RN expects that which procedure will be considered as a treatment option? A. Plasmapheresis B. Hemodialysis C. Immunosuppression therapy D. Thrombolytic therapy

A. Plasmapheresis Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of the solution. A pt with GBS, in the absence of kidney disease, does not need dialysis. GBS is not a hematological disorder; thrombolytic therapy isn't required. GBS is not an autoimmune disorder; immunosuppression therapy isn't required.

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to: A. Stop the transfusion B. Monitor the hourly urinary output C. Obtain the vital signs D. Assess the pain further

A. Stop the transfusion Flank pain is an adaptation associated with a hemolytic transfusion reaction; it is caused by agglutination of red cells in the kidneys and renal vasoconstriction. The infusion must be stopped to prevent further instillation of blood, which is being viewed as foreign by the body. Although obtaining the vital signs, assessing the pain further, and monitoring the hourly urinary output will be done eventually, they are not the priority actions.

A pt with coronary obstruction is experiencing angina and distress. The RN administers O2 to: A. increase O2 concentration to heart cells B. increase O2 tension in the circulating blood C. prevent dyspnea D. prevent cyanosis

A. increase O2 concentration to heart cells

An older client is admitted to the hospital with the diagnosis of dementia of the Alzheimer type and depression. Which signs of depression does the nurse identify? Select all that apply. A. Neglect of personal hygiene B. Loss of memory C. Decreased appetite D. "I can't remember" answers to questions E. "I don't know" answers to questions

ACDE

What methods support cognitive ability in clients with Alzheimer dementia? Select all that apply. A. Providing a limited number of choices to support decision making B. Quizzing the client regularly to assess orientation to person, place, and time C. Administering prescribed rivastigmine to the client with severe Alzheimer dementia D. Using calendars, clocks, and pictures to support memory E. Encouraging caregivers to support protected independence

ADE

The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education? A. "I will avoid alcohol." B. "I will take acetaminophen for pain" C. "I will be sure to take naps throughout the day." D. "I will eat small frequent meals."

B. "I will take acetaminophen for pain." Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis. Clients should avoid alcohol, eat small frequent meals, and be sure to get plenty of rest.

A pt is admitted with suspected pneumonia. VS include: temp of 101.2, HR of 112, RR of 24, BP 130/78, and O2 sat of 95% on 3L NC. The pt has the following rhythm on the monitor. Which interventions should the nurse implement? Select all that apply. *more than 6 QRS waves/min* A. Administer the PRN adenosine B. Administer the initial dose of Ceftriaxone IVPB C. Administer PRN Acetaminophen D. Promote use of incentive spirometer E. Encourage pt to drink fluids

B. Administer the initial dose of Ceftriaxone IVPB C. Administer PRN Acetaminophen D. Promote use of incentive spirometer E. Encourage pt to drink fluids

The RN is caring for a pt with heart failure. The pt is scheduled to receive lisinopril and carvedilol in the next 30 min. The UAP reports the following VS: Temp of 98.9, HR of 52, RR of 18, and BP of 136/72. What is the most appropriate action for the RN? A. Administer the lisinopril and carvedilol as scheduled B. Administer the lisinopril and hold the carvedilol and notify HCP C. Administer carvedilol but hold the lisinopril and notify HCP D. Hold both and notify HCP

B. Administer the lisinopril and hold the carvedilol and notify HCP RN should hold carvedilol with a HR of 52 and notify the HCP. Carvedilol is a beta blocker and may reduce both HR and BP. Lisinopril is an ace inhibitor and will not lower the HR and would be appropriate to adminsiter.

A pt undergoes a cardiac catherization via a femoral artery. What is the most important nursing action after the procedure? A. Check for a pulse deficit B. Assess the groin for bleeding C. Keep the pt NPO D. Elevate HOB

B. Assess groin for bleeding Most complications after cardiac cath involve the puncture site; included are localized hemorrhage and hematomas, as well as thrombosis of the femoral artery. Although checking for a pulse deficit is important, it isn't the priority. The client should remain supine to avoid disturbing the insertion site. It isn't necessary for the pt to remain NPO.

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. The nurse recognizes that it is important to monitor the client for what signs of complications that may occur immediately after the procedure? Select all that apply. A. Temperature of 100.1 B. Blood pressure of 90/40 C. Heart rate of 110 D. Pulmonary congestion E. Hypoactive bowel sounds

B. Blood pressure of 90/40 C. Heart rate of 110 Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia; a rapid, thready pulse compensates for this shift. Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia; the decrease in blood pressure is evidence of hypovolemia. Decreased peristalsis is not the priority. After a paracentesis, intravascular fluid shifts into the abdominal cavity, not the lungs. Fever is not a concern at this time. If the client were to develop an infection as a result of the procedure, a fever will occur several days after the procedure.

What is the priority intervention for this rhythm? *squiggly line* A. Elective cardioversion B. Immediate defibrillation C. Administer digoxin IVP D. Administer adenosine IVP

B. Defibrillation The rhythm is v-fib. CPR should be initiated immediately once the client is found pulseless. Immediate defibrillation increases the likelihood that the client will establish a normal rhythm. Digoxin and adenosine aren't appropriate meds for this dysrhytmia.

The RN is caring for a pt with myasthenia gravis. The RN expects which test to be ordered to differentiate between a myasthenic crisis from a cholinergic crisis? A. Lumbar puncture B. Edrophonium cholride C. MRI D. CBC

B. Edrophonium chloride (IV) The Tensilon test is used in the pt with myasthenia gravis to distinguish between myasthenic crisis and cholinergic crisis. Symptoms of flaccid paralysis improve if the cause is myasthenic crisis and worsen if it's cholinergic crisis. In the event the symptoms are the result of a cholinergic crisis, atropine must be readily available at the bedside

What feeding instruction should the RN give the mom of a 2 m.o with the diagnosis of heart failure? A. Refrain from feeding until crying from hunger begins B. Feed slowly while allowing time for adequate periods of rest C. Avoid using a preemie nipple D. Use double-strength formula

B. Feed slowly while allowing for rest periods

The respiratory status of a client with GBS progressively deteriorates and a tracheostomy is performed. NG tube feedings are prescribed. The RN should manage the trach cuff by: A. Deflating the cuff after the tube feeding B. Inflating the cuff before the feeding and 30 min after each feeding C. Deflating the cuff before starting each feeding D. Inflating the cuff for one hour before and after each feeding

B. Inflating the cuff before the feeding and for 30 min after each feeding

A client diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which of these measures should the healthcare provider include in this client's plan of care? A. Provide high-protein feedings B. Monitor the blood glucose C. Institute droplet precautions D. Weigh once a week

B. Monitor the blood glucose Interventions for this patient include blood glucose monitoring (because of decreased glycogen synthesis and storage), monitoring PT and INR (because of decreased clotting factors), checking reflexes (because of the neurological effects of increased ammonia), providing diet/feedings that are low in protein (to decrease ammonia levels), and following standard precautions. The client should be weighed every day.

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: A. Determine the client's reasons for drinking. B. Monitor the client's vital signs C. Improve the client's nutritional status. D. Increase the client's fluid intake.

B. Monitor the client's vital signs A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is contraindicated initially because it may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.

A client with guillain-barre syndrome has a feeding tube for nutrition. What priority actions should the nurse perform prior to starting the tube feeding? Select all that apply. A. Don sterile gloves B. Raise HOB to 30 degrees C. Assess the client's bowel sounds D. Check tube placement E. Check the client's gastric residual

B. Raise HOB to 30 degrees C. Assess bowel sounds D. Check tube placement E. Check gastric residual Some pts who experience GBS will need a feeding tube because they're no longer able to swallow safely d/t paralysis of the cranial nerves that help with swallowing. GBS can lead to a decrease in gastric motility and paralytic ileus. Therefore, before starting a scheduled feeing the nurse should always assess for bowel sounds, check gastric residual, placement of the tube. Elevation of the HOB helps to decrease risk of aspiration.

During report you learn that the pt you will be caring for has GBS. As the RN you know this disease tends to present with: A. S/S that are symmetrical and ascending that star in the upper extremities B. S/S that are symmetrical and ascending that start in the lower extremities C. S/S that are asymmetrical and ascending that start in the upper extremities D. S/S that are unilateral and descending that start in the lower extremeties

B. S/S that are symmetrical and ascending that start in the lower extremities

A pt is admitted to the coronary care unit with a-fib and a rapid ventricular response. The RN prepares for cardioversion. What RN action is essential to avoid the potential danger of inducing v-fib during cardioversion? A. Energy level is set at maximum level B. Synchronizer switch is in the on position C. Skin electrodes are applied after the T wave D. Alarm system of the cardiac monitor is functioning simultaneously

B. Synchronizer is in the on position

Which of the following are risk factors for Alzheimer's disease? Select all that apply. A. Increased serum calcium B. Father and Aunt had Alzheimer's disease C. Use of aluminum products D. Previous head trauma E. Advancing age

BDE

A 70-year-old retired man has difficulty remembering his daily schedule and finding the right words to express himself. He is found to have dementia of the Alzheimer type. What symptoms are included in this disorder? A. Occur fairly rapidly B. Have periods of remission C. Demonstrate a progression of disintegration D. Begin after a loss of self-esteem

C

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? A. Portal hypotension B. Kidney malfunction C. Diminished plasma protein level D. Decreased production of potassium

C. Diminished plasma protein level The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the liver's ability to man

A HCP determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. A. Intention tremors of the hands B. Nonintention tremors of the extremities C. Drooping of the upper eyelids D. Double vision E. Problems with cognition F. Difficulty swallowing saliva

C. Drooping of the upper eyelids D. Double vision F. Difficulty swallowing saliva Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves are often affected; difficulty with swallowing is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial III (oculomotor) dysfunction. Myasthenia gravis is a neruomuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention gtremors of the extremities are associated with Parkinson disease.

A health care provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan? A. Consume a diet low in fat for three days before the procedure. B. Stay on a liquid diet for 24 hours after the procedure. C. Empty the bladder immediately before the procedure. D. Maintain a supine position during the procedure.

C. Empty the bladder immediately before the procedure. The bladder must be emptied immediately before the procedure to decrease the chance of puncture with the trocar used in a paracentesis. A paracentesis usually is performed with the client in the Fowler position to assist the flow of fluid by gravity. Eating a diet low in fat for three days before the procedure is not necessary for a paracentesis. Staying on a liquid diet is not necessary for a paracentesis.

A pt is diagnosed with primary HTN. When taking the client's hx, the HCP anticipates the pt will report which of the following? A. Sometimes I get pain in my lower legs when I take my daily walk B. I'm starting to get out of breath when I climb a flight of stairs C. I haven't noticed any significant changes in my health D. Every once in a while I wake up covered in sweat

C. I haven't noticed any significant changes in my health

What does the RN understand that clients with myasthenia gravis, GBS, and amyotrophic lateral sclerosis (ALS) share in common? A. Involuntary twitching of small muscle groups B. Progressive deterioration until death C. Increased risk for respiratory complications D. Deficiencies of essential neurotransmitters

C. Increased risk for respiratory complications

The RN reviews the health record of a pt with coronary artery disease. When assessing the client risk, which elevated lab value is most likely to cause the progression of CAD? A. Microalbuminuria B. Blood glucose C. Low-density lipoproteins D. High-density lipoproteins

C. LDL

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? A. Keeping pt in trendelenburg position for at least 2 hr. B. Placing the client in high fowlers immediately after the procedure C. Maintaining the client in supine position for several hours. D. Encouraging the client to ambulate every hr for at least 6 hours

C. Maintaining the client in the supine position for several hours

A nurse is caring for a client with ascites who is to receive intravenous (IV) albumin. The nurse expects that the albumin replacement will decrease the: A. Capillary perfusion and blood pressure B. Ascites and blood ammonia levels C. Peripheral edema and hematocrit level D. Venous stasis and blood urea nitrogen level

C. Peripheral edema and hematocrit level Serum albumin is administered to maintain serum levels and normal oncotic (osmotic) pressure; it does this by pulling fluid from the interstitial spaces into the intravascular compartment. Serum albumin does affect blood ammonia levels; fluid accumulated in the abdominal cavity is removed via a paracentesis. The administration of albumin results in a shift of fluid from the interstitial to the intravascular compartment, which probably will increase the blood pressure. Albumin administration does not affect venous stasis or the blood urea nitrogen

An RN enters the room of a pt with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first? A. Call HCP B. Perform tracheal suctioning C. Raise HOB D. Administer O2

C. Raise the HOB

A pt. with myasthenia gravis improves and is discharged. Discharge meds include pyridostigmine 10 mg orally every 6 hr. The RN evaluates that the drug regimen is understood when the client says, "I should: A. Count my pulse before taking the drug B. Drink milk with each dose C. Set my alarm clock to take my medication D. Take this med on an empty stomach

C. Set my alarm clock to take my medication

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed an an anticholinergic medication is prescribed. The RN is planning care with the client and spouse. Which instruction is the priority? A. Take a stool softener daily B. Eat foods that are pureed C. Take the medication according to a specific schedule D. perform range of motion exercises

C. Take the med according to a specific schedule Anticholinergic medications should be taken before meals because it enhances chewing and swallowing. Dysphagia usually isn't an initial problem with myasthenia gravis. A variety of foods in texture and taste should be encouraged. Mechanical soft foods or chopped foods should be eaten until the dysphagia progresses to the point that pureed foods are necessary. Although movement and mobility are important, ROM exercises prevent joint contractures rather that promote muscle strength. Anticholinergic meds taken for myasthenia gravis cause a relaxation of smooth muscle, resulting in diarrhea rather than consitpation.

A patient diagnosed with hepatitis develops splenomegaly. When reviewing the laboratory report, which of the following results will the healthcare provider anticipate? A. Polycythemia B. Leukocytosis C. Thrombocytopenia D. Neutrophilia

C. Thrombocytopenia The spleen acts as a reservoir for platelets. When the spleen is enlarged, as with splenomegaly, up to 90 percent of a person's thrombocytes can be sequestered within the enlarged spleen.

The family member of a pt with newly diagnosed GBS comes out to the nurse's station and informs that nurse that the client states he is having difficulty breathing. What is the first action the nurse should do? A. Notify HCP B. Assure the family member that this is a normal response C. Call a code, as this client with need endotracheal intubation D. Inform the family member the RN will be in to assess the client

D. Inform the family member the RN will be in to assess the client

A pt with a 5 yr hx of myasthenia gravis is admitted to the hospital because of exacerbation. When assessing the pt, the RN identifies ptosis, dysarthria, dysphagia, and muscle weakness, The nurse expects what client response? A. Strength improves immediately after meals B. Weakness improves with muscle use C. Weakness decreases after hot baths D. Strength decreases with repeated muscle use

D. Strength decreases with repeated muscle use Because of the myoneural junction defect, repeated muscle contraction depletes acetylcholine, elevates cholinesterase, or exhausts acetylcholine receptor sites, resulting in decreased muscle strength. Hot baths tend to increase, not decrease, muscle weakness. Muscle weakness decreases, not improves, with muscle use. There is no evidence that eating meals will bring about improvement.

An RN cares for a pt with COPD. Which instruction does the RN use when teaching the pt about breathing techniques?

Diaphragmatic breathing exercises assist in strengthening breathing stability and improves the contraction of the diaphragm. Exhale slowly through the mouth using pursed lips.

A 12 y.o with type 2 diabetes is scheduled for abdominal surgery. Which factors are most important for the RN to consider during the post-op period? Select all that apply.

During states of stress the blood glucose level will increase, thus requiring more insulin

A pt is receiving ABs and antifungal meds for treating recurring cellulitis. What should the RN encourage the client to do to compensate for the effect of these meds?

Eat yogurt

A pt is on a ventilator. The RN asks another RN, "what should be done when condensation resulting from humidity collects in the ventilator tubing?" What is the best response?

Emptying the fluid from the tubing is necessary to prevent fluid from entering into the trachea; some systems have receptacles attached to the tubing to collect fluid, others have to be temporarily disconnected while the fluid is emptied.

An RN cares for a pt suspected of having acute respiratory distress syndrome. Which assessment data supports the diagnosis?

Hypoxemia, respiratory acidosis, crackles, confusion, tachypnea, increased work of breathing, nasal flaring

The RN is admitting an 8 m.o with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that would be taken.

Implement droplet precautions (gown, gloves, mask), Obtain a circulatory access device to administer IVF and meds., obtain a sample of CSF via LP, start antibiotics if culture shows bacteria, monitor for increased ICP and seziures

A pt is admitted with pneumonia. Which interventions does the nurse start to assist with airway clearance?

Incentive spirometry Frequent position changes Deep breathing before controlled coughing Adequate hydration Semi fowler's position

An RN mixes a short acting and intermediate acting insulin in the same syringe to a client with diabetes. List the actions in the order the nurse should perform them.

Inject air into intermediate acting (NPH; cloudy), inject air into short acting (regular; clear), draw up regular, draw up NPH. *cloudy, clear, clear, cloudy

A 40 y.o male is prescribed Metformin to control his type 2 DM. Which statement made by the client indicates a need for further education?

Metformin should be withheld 48 hours prior to using iodinated contrast materials.

An RN is caring for a 9 m.o who was diagnosed with meningitis. An LP is performed. What's the most appropriate explanation to the parents for the purpose of this procedure?

Organisms that cause meningitis are harbored in spinal fluid. The LP helps determine if meningitis is present and if it is viral or bacterial.

An RN cares for a pt whose ET tube is being removed after successful weaning off mechanical ventilation. Which immediate post-extubation actions does the nurse perform?

Position pt in high-fowler's Place pt on continuous pulse oximetry Administer 100% oxygen by mask after extubation Assess breath sounds: high pitch inspirations can indicate stridor, which is an emergency

What is the priority nursing intervention for these ABG values? pH 7.30 Po2 60 Pco2 55 HCO3 23

Priority is administering oxygenation because the Po2 indicates hypoxia. For respiratory acidosis the potassium level may be high and cardiac monitoring may be indicated, may also need bicarbonate

An RN notes a pt's RR is 24 breaths/min on 3 LPM oxygen. The client reports SOB. Which action should the RN perform first?

Respiratory assessment and obtain vital signs.

A 10 y.o girl with diabetes joins the school's soccer team. Her mom is unsure whether to tell the coach of her child's condition. The mom asks the school RN for guidance. On what information should the nurse base the response?

The adult who is with the child should watch for signs of hypoglycemia and have snacks/juice readily available

A HCP prescribes a peak and trough for an AB for a client receiving vancomycin IVPB. The med is scheduled for 0900 and will take 1 hr to infuse. When should the RN have the lab obtain a blood sample to determine the peak level?

The blood level will be at its highest between 30 and 60 min after a dose is administered

What should the RN emphasize when teaching insulin self-administration to a 10 y.o child with recently diagnosed diabetes?

Wash hands before preparing injection. Do not shake vial, instead roll it gently between palms. Rotate injection sites on the abdomen. Do not rub the injection site.

A 13 yo with type 1 diabetes is receiving 15 units of Novolin R insulin and 20 units of Novolin N insulin at 7 am each day. At what time should the RN anticipate a hypoglycemic reaction from the Novolin N to occur?

between 1 and 3pm Novolin N (NPH) is intermediate acting and peaks in 6-8hr. During the evening or night is when a reaction from a long acting insulin is expected. Long acting (glargine/detemir)insulin has a peak 10-16 hours after administration. Short acting (regular) 2-4 hours. Rapid acting (lispro/aspart)30-60 min.

A pt who is taking an oral hypoglycemic daily for type 2 DM develops the flu and is concerned about the need for special care. What should the nurse advise the client?

diabetic medications and glucose monitoring are still necessary, drink fluids, attempt to eat food

The RN is performing an assessment on a client with type 2 DM. The nurse notes bilateral pedal cap refill of 3-5 seconds. Which factor does the RN recognize as contributing to this finding?

over time diabetes causes microvascular damage, which results in decreased blood flow to the extremtities

The RN is providing instructions about foot care for a client with diabetes. What should the RN include in the instructions? Select all that apply.

wear shoes with clean socks. dry between toes after bathing, do not soak feet, don't self treat ingrown toenails, calluses, or warts, don't use heating pads or hot water