NURS 341 Final Exam Review

Teaching about a high-calorie/high-protein diet is effective when which foods are selected? a. 2 poached eggs, hash brown potatoes, and whole milk b. 2 slices of toast w/ butter and jelly, orange juice, skim milk c. 3 pancakes with syrup/butter, 2 slices of bacon, apple juice d. Cream of wheat, 1/2 grapefruit, and a high protein milkshake

a. 2 poached eggs, hash brown potatoes, and whole milk

What does the progression of patients through phases of care in a PACU primarily depend on? a. Condition of patient b. Type of anesthesia used c. Preference of the surgeon d. Type of surgical procedure

a. Condition of patient

Which of the following blood components is decreased in anemia? a. Erythrocytes b. Granulocytes c. Leukocytes d. Platelets

a. Erythrocytes

What is the most reliable early indicator of infection in a neutropenic client? a. Fever b. Chills c. Tachycardia d. Dyspnea

a. Fever

Which of the following assessment findings would indicate the cancer has invaded the brain? a. Headache and vomiting b. Restlessness and tachycardia c. Hypervigilant and anxious behavior d. Increased heart rate and decreased blood pressure

a. Headache and vomiting

A client is to receive Epogen. What lab value should be assessed prior? a. Hematocrit b. Partial thromboplastin time c. Hemoglobin concentration d. Prothrombin time

a. Hematocrit

A patient taking digoxin and Lasix c/o nausea, HR 130 irregular. Which intervention is the BEST a. Hold the patient's digoxin and check the patient's potassium b. Remove the orange juice from the patient's tray c. Identify the patient as high risk for hyperkalemia d. Assess the patient for other signs of hypernatremia

a. Hold the patient's digoxin and check the patient's potassium

For which of the following conditions is a client with multiple myeloma monitored? a. Hypercalcemia b. Hyperkalemia c, Hypernatremia d. Hypermagnesemia

a. Hypercalcemia

Which statement explains the rationale for using a hypotonic solution for a patient with FVD? a. Hypotonic solution provides free water b. Hypotonic solution supplies an excess of sodium and chloride c. Excessive volumes are recommended in the early postop period d. A hypotonic solution is used to treat hyponatremia

a. Hypotonic solution provides free water

A patient in the PACU is thrashing and agitated. What should the nurse assess first? a. Hypoxemia b. Neurologic injury c. Distended bladder d. Cardiac dysrhythmias

a. Hypoxemia

During chemotherapy, hyperkalemia and hyperuricemia develops. The priority treatment will be to: a. Increase urine output with hydration therapy b. Establish ECG monitoring c. Administer a bisphosphonate d. Restrict fluid, administer 3% saline

a. Increase urine output with hydration therapy

When assessing a patient for metabolic alkalosis, the nurse would expect to find: a. Low serum potassium b. Changes in urine output c. Hypotension d. Increased CVP

a. Low serum potassium

The patient develops chills and 102.2*F during a blood transfusion. Which priority action does the RN take? a. Stop the transfusion and instill normal saline b. Notify the healthcare provider and blood bank c. Add a leukocyte reduction filter to the blood tubing d. Recognize this as a mild allergic reaction and slow the rate

a. Stop the transfusion and instill normal saline

Calcium is absorbed in the GI tract under the influence of: a. Vitamin D b. Glucose c. Hydrochloric acid d. Vitamin C

a. Vitamin D

Nursing care for hypertonic fluid admin includes monitoring for all of the following EXCEPT a. Water intoxication b. Fluid volume excess c. Cellular dehydration d. Cell shrinkage

a. Water intoxication

A client has anemia. Which question is MOST appropriate to ask regarding activity tolerance? a. What were you able to do 6 months ago compared to now? b. How long have you had this problem? c. Have you been able to keep up with all usual activities? d. Are you more tired now than you used to be?

a. What were you able to do 6 months ago compared to now?

Which of the following ABG values indicated uncompensated metabolic alkalosis? a. pH 7.48, PaCO2 42, HCO3 30 b. pH 7.48, PaCO2 46, HCO3 30 c. pH 7.48, PaCO2 34, HCO3 20 d. pH 7.48, PaCO2 34, HCO3 26

a. pH 7.48, PaCO2 42, HCO3 30

What is the rationale for using preoperative checklists on the day of surgery? a. The patient is correctly identified b. All pre-op orders are carried out, records are complete c. Family is informed where they can wait for the patient d. Pre-op meds are the last procedure before going to the OR

b. All pre-op orders are carried out, records are complete

If a patient with blood type O+ is given AB Rh- blood, what would the nurse expect to happen? a. Rh factor will react with the RBCs of the donated blood b. Anti- A&B antibodies in patient will hemolyze the donor blood c. Anti- A&B antibodies in donor blood will hemolyze patient's blood d. No adverse reaction is expected b/c the patient has no antibodies

b. Anti- A&B antibodies in patient will hemolyze the donor blood

Which of the following foods should a client with leukemia avoid? a. White bread b. Carrot sticks c. Stewed apples d. Well-done steak

b. Carrot sticks

The respiratory system regulates acid-base balance by: a. Increasing mucus production b. Changing the rate and depth of respirations c. Forming bicarbonate d. Reabsorbing bicarbonate

b. Changing the rate and depth of respirations

The body's compensation of metabolic alkalosis involves: a. Increasing the respiratory rate b. Decreasing the respiratory rate c. Increasing urine output d. Decreasing urine output

b. Decreasing the respiratory rate

The RN includes which priority intervention in the plan of care for a patient with multiple myeloma a. Coughing and deep breathing b. Encouraging fluids c. Monitoring red blood cell count d. Providing frequent oral care

b. Encouraging fluids

When teaching the patient with cancer about chemotherapy, which approach should the nurse take? a. Avoid talking about side effects to prevent anxiety b. Explain that antimetics and pain meds will be given for side effects c. Assure that side effects from chemo are never life threatening d. Inform that chemotherapy related alopecia is permanent

b. Explain that antimetics and pain meds will be given for side effects

Which of the following diagnoses is most appropriate for a patient with hypocalcemia a. Constipation b. High risk for injury; bleeding c. Airway clearance; ineffective d. High risk for injury; confusion

b. High risk for injury; bleeding

The patient was told she has carcinoma in situ. How should the nurse explain this? a. Evasion of the immune system by cancer cells b. Lesion with histologic features of cancer except invasion c. Capable of causing cellular alterations associated with cancer d. Tumor cell surface antigens that stimulate immune response

b. Lesion with histologic features of cancer except invasion

The nurse could expect which of the following to be present in impending septic shock? a. Flushing, decreased oxygen saturation, mild hypotension b. Low-grade fever, chills, tachycardia c. Elevated temperature, oliguria, hypotension d. High-grade fever, normal BP, increased respirations

b. Low-grade fever, chills, tachycardia

While administering an infusion of packed RBCs, which actions can the RN delegate to the UAP? a. Verify that the IV is patent b. Obtain the blood products from the blood bank c. Monitor the blood transfusion rate and adjust as needed d. Obtain vital signs before and after the first 15 mins

b. Obtain the blood products from the blood bank d. Obtain vital signs before and after the first 15 mins

During physical assessment of a patient with thrombocytopenia, what would the nurse expect to find? a. Sternal tenderness b. Petechia and purpura c. Jaundiced sclera and skin d. Tender, enlarged lymph nodes

b. Petechia and purpura

What is the definitive method for determining if a lesion is malignant? a. Lung scan b. Tissue biopsy c. Oncofetal antigens in the blood CT of positron emission tomography (PET) scan

b. Tissue biopsy

In staging and grading neoplasm TNM system is used. What does TNM stand for? a. Time, neoplasm, mode of growth b. Tumor, node, metastasis c. Tumor, neoplasm, mode of growth d. Time, node, metastasis

b. Tumor, node, metastasis

Patient X is to receive an isotonic solution. What is an example of isotonic solution? a. Dextrose 10% in water b. 0.45% saline c. 0.9% saline d. 3% saline

c. 0.9% saline

The RN determines the patient has residual vasodilating effects of anesthesia when what is assessed? a. A urinary output of > 30 mL/hr b. An oxygen saturation of 88% c. A normal pulse with warm, dry, pink skin d. A narrowing pulse pressure with a normal pulse

c. A normal pulse with warm, dry, pink skin

The nurse would analyze that an elevated body temperature during a blood transfusion as: a. A normal physiologic process b. Evidence of sepsis c. A possible transfusion reaction d. An expected response to the transfusion

c. A possible transfusion reaction

When caring for a client with a CVC, the following actions should be implemented EXCEPT a. Verify patency of the line b. Inspect the insertion site for swelling, erythema, drainage c. Administer chemo to keep on schedule even w/o blood return d. If unable to aspirate blood, reposition, encourage to cough

c. Administer chemo to keep on schedule even w/o blood return

Which of the following orders should the nurse question if a client is on radiation therapy? a. Analgesics before meals b. Saline rinses every 2 hours c. Aspirin every 4 hours d. Bland diet

c. Aspirin every 4 hours

The expected side effects of external radiation include the following except: a. Hair loss b. Ulceration of oral mucous membranes c. Constipation d. Headache

c. Constipation

Postop: Hct < from 36% to 34% even though RBC & Hgb are stable. Which intervention is BEST? a. Check the dressing and drains for frank bleeding b. Call the physician c. Continue to monitor vitals d. Start oxygen at 2L/min per NC

c. Continue to monitor vitals

The following are characteristics of a malignant tumor except: a. Metastasis b. Infiltrates surrounding tissues c. Encapsulated d. Poorly differentiated cells

c. Encapsulated

Which statement is correct about the rate of cell growth in relation to chemotherapy? a. Faster growing cells are less susceptible to chemotherapy b. Non-dividing cells are more susceptible to chemotherapy c. Faster growing cells are more susceptible to chemotherapy d. Slower growing cells are more susceptible to chemotherapy

c. Faster growing cells are more susceptible to chemotherapy

A patient is experiencing stress from the effects of surgery. What can this stress cause? a. Diuresis b. Hyperkalemia c. Fluid retention d. Impaired blood coagulation

c. Fluid retention

A patient with which disorder is at high risk for developing hyperphosphatemia? a. Hyperkalemia b. Hyponatremia c. Hypocalcemia d. Hyperglycemia

c. Hypocalcemia

Normal calcium levels must be analyzed in relation to: a. Sodium b. Glucose c. Protein d. Fats

c. Protein

Which of the following cells is the precursor to the RBC? a. B cell b. Macrophage c. Stem cell d. T cell

c. Stem cell

Which of the following symptoms would the nurse expect to assess in fluid volume deficit? a. Rales b. Bounding pulse c. Tachycardia d. Bulging neck veins

c. Tachycardia

To promote radiation skin integrity, the nurse should promote all EXCEPT a. Avoiding the use of powders and lotion to the area b. Using soft cotton fabrics for clothing c. Washing the area with a mild soap and water, patting it dry d. Avoiding direct sunshine or cold

c. Washing the area with a mild soap and water, patting it dry

What are characteristics of neutrophils? a. Also know as "segs" b. Band is an immature cell c. First WBC at the site of injury d. All of the above

d. All of the above

Which cells are classified as granulocytes? a. Basophil b. Eosinophil c. Neutrophil d. All of the above

d. All of the above

Which instructions should the nurse include in teaching about skin care and external radiation? a. Moisturize the skin with lotion b. Keep the area covered if sore c. Dry the skin thoroughly after cleansing d. Avoid extreme temps to the area

d. Avoid extreme temps to the area

A client has neutropenia. Which of the following functions must be frequently assessed? a. Blood pressure b. Bowel sounds c. Heart sounds d. Lung sounds

d. Lung sounds

Name the tumor; embryonal mesoderm tissue of origin, in the meninges, has malignant behavior a. Meningitis b. Meningioma c. Meningocele d. Meningeal sarcoma

d. Meningeal sarcoma

36 hours post-op, a patient has a temp of 100*F. What is the most likely cause? a. Dehydration b. Wound infection c. Lung congestion and atelectasis d. Normal surgical stress response

d. Normal surgical stress response

Which of the following assessment findings may suggest leukemia? a. Abdominal pain b. Increased activity level c. Increased appetite d. Petechiae

d. Petechiae

What will the nurse do to prevent airway obstruction in the postop patient who is semiconscious? a. Encourage deep breathing b. Elevate the head of the bed c. Administer oxygen per mask d. Position the patient in a side-lying position

d. Position the patient in a side-lying position

The most common cause of disseminated intravascular coagulation (DIC) is: a. Underlying liver disease b. Brain metastasis c. Intravenous heparin therapy d. Sepsis

d. Sepsis

Which instruction about prescribed ferrous gluconate should the nurse teach? a. Take the medication with an antacid b. Take the medication with a glass of milk c. Take the medication with cereal d. Take the medication on an empty stomach

d. Take the medication on an empty stomach

Which lab result should be immediately brought to the attention of the surgeon? a. Serum K+ 3.8 mEq/L b. Hemoglobin of 15 g/dL c. Blood glucose of 100 mg/dL d. WBC 18,500/uL

d. WBC 18,500/uL

The nurse establishes the highest priority for the nadir of chemo is related to: a. Diarrhea b. Grieving c. Risk for infection d. Inadequate nutritional intake

C. Risk for infection