NURS 420 Study Guide Q1-3
What is minimum size peripheral IV catheter through which a blood transfusion can be infused? Select one: a. 18 gauge b. 20 gauge c. 22 gauge d. 24 gauge
c. 22 gauge
A nurse reviews a patient's laboratory results. Which results from the patient's urinalysis should the nurse recognize as abnormal? Select one: a. pH 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color
b. Ketone bodies present
Anterior nosebleeds occur at the ____ plexus which is a group of blood vessels anterior to septal wall and close to mucosal surface. Select one: a. Nasopalatin artery b. Kiesselbach's c. Circle of willis d. Facial artery
b. Kiesselbach's
The nurse teaches the client that the major difference between angina and pain associated with myocardial infarction (MI) is that? Select one: a. Angina is relieved with nitroglycerin and rest. b. Angina can be fatal. c. MI pain always radiates to the left arm or jaw. d. MI pain cannot be treated.
a. Angina is relieved with nitroglycerin and rest.
A patient admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the patient questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? Select one: a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"
a. "Breathing so quickly can be dehydrating."
A child attending day camp has asthma, and her parent send with her all of her medicine in a small carry bag. The child has an asthma attack that is severe enough to warrant a rescue drug. Which medication from the child's bag is best to use for the acute symptoms? Select one: a. Albuterol b. Omalizumab c. Fluticasone d. Salmeterol
a. Albuterol
All of the members of the surgical team must perform a "surgical scrub" except which of the following? Select one: a. Anesthetist/anesthesiologist b. Surgical technologist c. Surgeon d. Scrub nurse
a. Anesthetist/anesthesiologist
Who is the most likely person to administer blood products in an operating suite? Select one: a. Circulating nurse b. Scrub nurse c. Specialty nurse d. Holding area nurse
a. Circulating nurse
Which description illustrates the beginning of the postoperative period? Select one: a. Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit (PACU) b. Providing care before, during, and after surgery c. Completion of the surgical procedure and arousal of the patient from anesthesia in the operating room (OR) d. Closure of the patient's surgical incision with sutures
a. Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit (PACU)
The nurse is caring for a patient with chronic bronchitis and notes the following clinical findings: fatigue, dependent edema, distended neck veins, and cyanotic lips. These assessment findings are consistent with which disease process? Select one: a. Cor pulmonale b. Lung cancer c. COPD d. Asthma
a. Cor pulmonale
Parkinson's disease and Parkinsonism result from a deficiency of neurotransmitter.............? Select one: a. Dopamine b. Acetylcholine c. Renin d. Angiotensin
a. Dopamine
The pt understands emphysema when the pt states. Select one: a. Getting air in is easier than getting it out. b. If I stop smoking, my emphysema will reverse itself. c. My bronchi and alveoli are small and constricted. d. It's easier to get air in than to get it out.
a. Getting air in is easier than getting it out. c. My bronchi and alveoli are small and constricted. d. It's easier to get air in than to get it out.
The nurse has just admitted a client to the telemetry floor with reports of acute chest pain radiating down the left arm. Which laboratory studies should not the nurse order to evaluate myocardial damage? Select one: a. Hemoglobin and hematocrit b. Creatine Kinase (CK-MB) c. Troponin T and troponin I d. Myglobulin
a. Hemoglobin and hematocrit
In which condition should a nurse take extra care to check for signs of bruising or bleeding? Select one: a. Hypocalcemia b. Hypercholesterolemia c. Hypokalemia d. Hyponatremia e. Dehydration
a. Hypocalcemia
A client tells the nurse that there is a family history of atherosclerosis. The nurse is aware that this history puts the client at risk for: I. Myocardial infarction II. Stroke III. Diabetes IV. Cancer V. Infection VI. Asthma Select one: a. I and II b. II and III c. IV and V d. III and IV e. V and VI
a. I and II
Medications to treat seizures include the following except? Select one: a. Imitrex b. Dilantin c. Depakote d. Tegretol e. Keppra
a. Imitrex
Which is major cause of hypomagnesemia? Select one: a. Inadequate intake of magnesium b. Inadequate intake of sodium c. Cessation of alcohol intake d. Decrease kidney excretion of magnesium
a. Inadequate intake of magnesium
When assessing the older postoperative patient for hydration status, where must the nurse assess for tenting of the skin? Select one: a. On the sternum b. On the femoral c. On the back of the hand d. On the abdomen
a. On the sternum
What is postoperative atelectasis often associated with? Select one: a. Retained airway secretions and mucous plugs b. Dehydration c. Poor circulation of cardiovascular system d. Microorganism invade
a. Retained airway secretions and mucous plugs
The patient is to receive regional anesthesia for injured knee repair surgery. Which type of regional anesthesia is this patient likely to receive? Select one: a. Spinal anesthesia b. Field block c. Epidural anesthesia d. Nerve block
a. Spinal anesthesia
Which are characteristics of asthma? Select one: a. Stimulation of disease process by allergies b. Increase secretions c. Increased eosinophils d. Loss of elastic recoil
a. Stimulation of disease process by allergies b. Increase secretions c. Increased eosinophils
The amount of air inspired and expired with each breath is called? Select one: a. Tidal volume b. Forced Expiratory volume c. Residual volume d. Total lung capacity
a. Tidal volume
The nurse teaches a patient with asthma to perform which intervention before exercising? Select one: a. Use the short-acting beta-adrenergic (SABA) medication b. Dress in extra clothing during cold weather c. Practice pursed lip breathing d. Rest for at least an hour
a. Use the short-acting beta-adrenergic (SABA) medication
The nurse is assessing a client for decerebrate posturing. The nurse should assess the client for: Select one: a. back arched and rigid extension of all four extremities b. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers c. Supination of arms and dorsiflexion of the feet d. Back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet
a. back arched and rigid extension of all four extremities
Which question is most important for the nurse to ask the client who has a serum potassium level of 2.9mEq/L? Select one: a. "Have you or any member of your family ever been diagnosed with lung disease?" b. "Do you use diuretics or laxatives?" c. "Do you use sugar substitutes?" d. "Have you had constipation?"
b. "Do you use diuretics or laxatives?"
An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The patient is afebrile. The healthcare provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? Select one: a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the patient."
b. "Older people often have vague symptoms, so an x-ray is essential."
A nurse has just completed teaching a client with atherosclerosis about the disease. The nurse determines that further teaching is necessary when the client states: Select one: a. "plaque obstruct the coronary artery." b. "Plaque obstruct the coronary vein." c. "Hardened vessels can't dilate to allow blood to flow through." d. "Atherosclerosis can cause angina"
b. "Plaque obstruct the coronary vein."
A patient has a positive skin test result for tuberculosis (TB). What explanation does the nurse give to the patient? Select one: a. "There is active disease, but you are not yet infectious to others" b. "You have been infected, but this does not mean active disease is present" c. " A repeat skin test is necessary because the test could give a false-positive result" d. " There is active disease, and you need immediate treatment"
b. "You have been infected, but this does not mean active disease is present"
Mr. Headly was involved in a motor vehicle accident and sustained a cerebral injury. In the course of taking care of Mr. Headly, what nursing measures might increase his intracranial pressure? Select one: a. Turning head from side to side b. All of the above c. Valsava maneuvers of any type d. Endotracheal suctioning
b. All of the above
What is the priority nursing intervention in the postictal phase of a seizure? Select one: a. Provide tongue blade to patient's mouth b. Assess the client's pattern of breathing c. Assess the size of the client's pupil d. Assess the client's bowel sound
b. Assess the client's pattern of breathing
A nurse teaches a patient who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this patient's teaching? Select one: a. "You can use the arm with the central catheter for most activities of daily living." b. Avoid carrying your grandchild with the arm that has the central catheter c. "Be sure to place the arm with the central catheter in a sling during the day." d. "Flush the peripherally inserted central catheter line with normal saline daily."
b. Avoid carrying your grandchild with the arm that has the central catheter
The nurse assesses a patient and finds a dusk appearance with bluish mucous membranes and production of lots of mucous secretions. What illness does the nurse suspect? Select one: a. Emphysema b. Chronic bronchitis c. Acute pneumonia d. Asthma
b. Chronic bronchitis
All of the glomeruli are located in the renal Select one: a. Medulla b. Cortex c. Renal pelvis d. Ureters
b. Cortex
The types of aphasia in which a patient knows what they want to say but cannot get the words to form is called? Select one: a. Receptive b. Expressive c. Communicative d. Global
b. Expressive
"Acute pyelonephritis primary affects the renal tubules and is associated with sudden onset of fever, chills, and flank or groin rash" True or false? Select one: a. True b. False
b. False
Normal ejection fraction is 80-90% Select one: a. True b. False
b. False
What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease? Select one: a. Activity intolerance b. Fluid volume excess c. Knowledge deficit d. Pain
b. Fluid volume excess
A patient with an active nosebleed is admitted to the emergency department. Which intervention does the nurse use first to attempt to stop the nosebleed? Select one: a. Place a nasal catheter b. Have the patient sit upright with the head forward c. Insert nasal packing d. Apply direct lateral pressure to the nose
b. Have the patient sit upright with the head forward or d. Apply direct lateral pressure to the nose
Which of the following landmarks is the correct one for obtaining an apical pulse? Select one: a. Left intercostal space, midaxillary line b. Left fifth intercostal space, midclavicular line c. Left second intercostal space, midclavicular line d. Left seventh intercostal space, midclavicular line
b. Left fifth intercostal space, midclavicular line
what activities are the circulating nurse's responsibilities in the operating room? Select one: a. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine b. Monitor the position of the client, prepare the surgical site, and ensure the client's safety c. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments d. Give preoperative medication in the holding area and monitor the client's response to anesthesia
b. Monitor the position of the client, prepare the surgical site, and ensure the client's safety
A patient has been compliant with drug therapy for tuberculosis (TB) and has returned as instructed for follow-up. Which result indicates that the patient is no longer infectious/communicable? Select one: a. Negative skin test b. Negative chest X-ray c. Three negative sputum cultures d. No clinical symptoms
b. Negative chest X-ray c. Three negative sputum cultures
A client experiencing angina pectoris with symptoms of burning pressure or a tight feeling in the chest, sweating with cool extremities, and fatigue would probably be prescribed which of the following medications? Select one: a. Antacid b. Nitrates c. Alpha-analgesic blocker d. Anxiolytics
b. Nitrates
A patient with asthma has been prescribed a fluticasone inhaler. What is the purpose of this drug? Select one: a. Reduces the histamine effect of the triggering agent b. Reduce obstruction of airways by decreasing inflammation c. Acts as bronchodilator in severe episodes d. Relax the smooth muscle of the airway
b. Reduce obstruction of airways by decreasing inflammation
A patient who can barely ambulate with a walker at home is having a left total knee replacement. What is the most appropriate category for this surgery? Select one: a. Simple b. Restorative c. Palliative d. Urgent
b. Restorative
Which characteristics are appropriate to moderate sedation drugs? Select one: a. Decrease level of consciousness b. Return to normal function is rapid c. Amnesia action is long d. Require placement of an artificial airway
b. Return to normal function is rapid (b) is the answer in iLearn, however (a) also seems appropriate, as the American Society of Anesthesiologists states: "Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness..."
Which nursing interventions are appropriate during stage 2 anesthesia? Select one: a. Close operating room doors and control traffic in and out of room. position patient securely with safety belt b. Shield patient from extra noise and physical stimuli. stay with patient c. Prepare for and assist in treatment of cardiovascular and/or pulmonary arrest d. Assist anesthesia personnel with intubation of patient. Place the patient in position for surgery. Prep the patient's skin in area of operative site
b. Shield patient from extra noise and physical stimuli. stay with patient
What level of consciousness is as follows when the client is drowsy or sleepy at inappropriate times but can be aroused easily, only to fall asleep again? Select one: a. Comatose b. Somnolent or lethargic c. Confused d. Stuporous
b. Somnolent or lethargic
A client with bacterial pneumonia is to be started on IV antibiotics. Which diagnostic test must be completed before antibiotics therapy begins? Select one: a. Urinalysis b. Sputum culture c. Chest radiograph d. Red blood cell counts
b. Sputum culture
A patient is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? Select one: a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.
b. Take a sample of the effluent and send to the laboratory.
Which is not the postoperative intervention will be the nurse typically teach a patient to prevent complications following surgery? Select one: a. Deep-breathing exercises b. Taking pain medication only when experiencing severe pain c. Incision splinting d. Range of motion exercises
b. Taking pain medication only when experiencing severe pain
A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Select one: a. Tell the client that smoking increases postoperative complications. b. Teach the importance of incentive spirometry c. Instruct the client to quit smoking. d. Teach about the dangers of tobacco.
b. Teach the importance of incentive spirometry
(1) Atelectasis is a type of restrictive pulmonary disorder. (2) Post-operative atelectasis can be prevented by deep breathing and coughing. Select one: a. 1 is true and 2 is false b. both 1 and 2 are true c. 1 is false and 2 is true d. both 1 and 2 are false
b. both 1 and 2 are true
The provider requests the nurse start an infusion of an inotropic agent on a patient. How does the nurse explain the action of this drug to the patient and spouse? Select one: a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."
c. "It increases the force of the heart's contractions."
Intravenous therapy with a hypotonic fluid is ordered for the patient. The nurse would plan to start which solution? Select one: a. 5% dextrose and 0.9% saline b. Lactated Ringer's solution c. 0.45% NaCl d. 0.9% NaCl
c. 0.45% NaCl
Which clinical manifestations are not found in a malignant hyperthermia (MH) crisis? Select one: a. Sinus tachycardia b. An extremely elevated temperature at onset c. A decrease in end-tidal carbon dioxide level d. Hypotension
c. A decrease in end-tidal carbon dioxide level
The charge nurse is orienting a float nurse to an assigned patient with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? Select one: a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm
c. Administering intravenous fluids through the AV fistula
Which description best explains residual volume (RV)? Select one: a. Amount of air in the lungs at the end of maximal inhalation b. Amount of air remaining in the lungs after normal exhalation c. Amount of air remaining in lungs at the end of full forced exhalation d. Maximal amount of forced air that can be exhaled after maximal inspiration
c. Amount of air remaining in lungs at the end of full forced exhalation
The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? Select one: a. Foley catheter in place with clear yellow urine b. patient's eyes open on verbal stimulation. Pupils are equal, reactive to light, and diameter is 3mm c. Apical pulse 85 beats/minute d. patient' hand grasps are equal and strong
c. Apical pulse 85 beats/minute
Point of maximal impulse is: Select one: a. Area where you listen for bowel sounds b. Area where you feel the pedal pulse c. Area where the pulsation of the heart is felt on the chest wall d. Area where you hear rhonchi
c. Area where the pulsation of the heart is felt on the chest wall
Which of the following is an appropriate nursing action when evaluating a client with coronary artery disease (CAD)? Select one: a. Assess the client's mental and emotional status b. Assess the skin of the client c. Assess the characteristics of chest pain d. Assess for any kind of drug abuse
c. Assess the characteristics of chest pain
A nurse assesses a patient recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the healthcare provider? Select one: a. Tolerating oral fluids b. Prescription for metformin c. Blood clots present in the urine d. Burning sensation when urinating e. Palpate the kidney with a for blow at the posterior costovertebral angle
c. Blood clots present in the urine
A client is admitted to the telemetry unit after a right-sided cardiac catheterization. What is the nurse's priority when caring for this client? Select one: a. Assess the intensity and quality of the client's pain b. Position the client in a sitting position to improve breathing c. Check client's arterial insertion site d. Apply oxygen at 2L/min via nasal cannula
c. Check client's arterial insertion site
An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the nurse should observe the client for which finding? Select one: a. Vertigo b. Loss of gag reflex c. Hypoventilation d. Bell's palsy
c. Hypoventilation
The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to find on assessment? Select one: a. Hypoventilation, because the respiratory system is trying to compensate for low pH b. Normal respiratory rate, but a decreased oxygen saturation c. Increased respiratory rate, because the body perceives hypovolemia as hypoxia d. No changes, because the respiratory system is not involved
c. Increased respiratory rate, because the body perceives hypovolemia as hypoxia
When blood passes through the lungs, what happens to oxygen? Select one: a. It increases concentration in the alveoli b. It decreases concentration in the blood c. It diffuses from the alveoli into the red blood cells d. If diffuses from the red blood cells into the alveoli
c. It diffuses from the alveoli into the red blood cells
A client with acute pulmonary edema, caused by heart failure, asks the nurse which area of the heart has caused this condition. What is the nurse's best response? Select one: a. Left atrium b. Rt atrium c. Left ventricle d. Right ventricle
c. Left ventricle
Which of these tests is done to identify the causative agent of encephalitis or meningitis? Select one: a. Serum electrolyte b. Blood culture c. Lumbar puncture d. Complete blood test
c. Lumbar puncture
On assessment of the patient with a renal calculi passing down the ureter, the nurse would expect the patient to report Select one: a. Dull, costovertebral flank pain b. A history of chronic urinary tract infection c. Severe, colicky back pain radiating to the groin d. A feeling of bladder fullness with urgency and frequency Your answer is correct.
c. Severe, colicky back pain radiating to the groin
What is the primary purpose of a postanesthesia care unit (PACU)? Select one: a. Arousal of patient following the use of conscious sedation b. Follow-through on the surgeon's postoperative orders c. Ongoing critical evaluation and stabilization of the patient d. Prevention of lengthened hospital stay
c. Ongoing critical evaluation and stabilization of the patient
The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent reoccurrence? Select one: a. Beer and colas b. Asparagus and cabbage c. Organ meat and sardines d. Cheese and eggs
c. Organ meat and sardines
Which is the main purpose of asthma treatment? Select one: a. Improve blood circulation b. Avoid secondhand smoke c. Prevent asthma episode d. Improve exercise tolerance
c. Prevent asthma episode
Your patient is experiencing peripheral edema, hepatomegaly, ascites, and splenomegaly. Which of the following conditions would be consistent with the patient's findings? Select one: a. Endocarditis b. Myocardial infaction c. Right sided hear failure d. Left-sided heart failure
c. Right sided hear failure
What type of urinary tract calculi related to always associated with UTI and urea-splitting bacteria Select one: a. Calcium oxalate b. Calcium phosphate c. Struvite d. Uric acid
c. Struvite
If a patient experiences a wound dehiscence, which description best characterizes what is happening with the wound? Select one: a. Extreme pain is present at incision site b. A partial or complete separation of outer layers is present at incision site c. The inner and outer layers of the incision are separated d. Purulent drainage is present at incision site because of infection
c. The inner and outer layers of the incision are separated
Soft and low-pitched breath sounds normally heard over most of both lungs are Select one: a. Bronchovesicular b. Tracheal c. Vesicular d. Bronchial
c. Vesicular
When the patient comes to the medical clinic with complaints of urgency, frequency, pain in the area of the symphysis pubis, and dark cloudy urine, the nurse suspects that this patient has Select one: a. a urinary calculi, probably located in the ureter. b. a kidney infection, most likely pyelonephritis. c. cystitis, probably from bacterial contamination. d. interstitial cystitis, although this is rare in a male.
c. cystitis, probably from bacterial contamination.
The nurse is teaching a patient how to interpret peak expiratory flow (PEF) reading and to use this information to manage drug therapy at home. Which statement by the patient indicates a need for additional teaching? Select one: a. "Red is 50% below my 'personal best.' I should try a rescue drug and seek help " b. "If frequent yellow reading occur, I should see my doctor for a change in medications." c. "If the reading is in the green zone, there is no need to increase the drug therapy" d. "if the reading is in the yellow zone, I should increase my use of my inhalers."
d. "if the reading is in the yellow zone, I should increase my use of my inhalers."
A patient has a peripherally inserted central catheter (PICC) placed by an IV therapy nurse at bedside. Before using the catheter, how is its placement verified? Select one: a. The provider who ordered the procedure verifies placement b. The line is slowly flushed with 10mL of saline while the nurse notes the ease of flow c. The line is aspirated gently, and the nurse watches for blood return d. A chest x-ray is taken, which shows the catheter tip in the lower superior vena cava
d. A chest x-ray is taken, which shows the catheter tip in the lower superior vena cava
Which of the following clients would be most likely to develop hyperkalemia? Select one: a. A client with intestinal and nasogastric suctioning b. A client who has had diarrhea for the last four days c. A client just diagnosed with cirrhosis d. A client with chronic renal failure
d. A client with chronic renal failure
What is the resistance to ejection during systole? Select one: a. Preload b. Cardiac output c. Stroke volume d. Afterload
d. Afterload
The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement? Select one: a. Droplet precaution b. Standard precaution c. Contact precaution d. Airborne precaution
d. Airborne precaution
The nurse is caring for a patient with an arteriovenous fistula. What instructions are given to unlicensed assistive personnel regarding the care of this patient? Select one: a. Palpate for thrills and auscultate for bruits every 4hrs b. Check for bleeding at needle insertion sites c. Assess the patient's distal pulses and circulation d. Avoid taking blood pressure readings in the arm with the fistula
d. Avoid taking blood pressure readings in the arm with the fistula
An adult client in the clinic complains of a cough, fever, nausea, and vomiting for three days. Examination reveals dry tongue and oral mucosa and concentrated urine. The client also reports feeling weak and dizzy. Which vital sign measurement would provide the best indicator of current fluid status? Select one: a. Pulse oximetry reading at rest b. Respiratory rate and depth c. Temperature d. BP and pulse in lying and standing positions
d. BP and pulse in lying and standing positions
Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? Select one: a. Potassium, 3.9 mEq/L (3.9 mmol/L) b. Fasting glucose, 80 mg/dL (4.4 mmol/L) c. Sodium, 140 mEq/L (140 mmol/L) d. Creatinine, 1.9 mg/dL (168 mcmol/L)
d. Creatinine, 1.9 mg/dL (168 mcmol/L)
An appendectomy is being performed on a patient with appendicitis. What is the correct classification for this surgery? Select one: a. Radical b. Urgent c. Diagnostic d. Curative
d. Curative
A nurse is evaluating a patient who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? Select one: a. Decreased skin turgor on the patient's posterior hand and forehead b. Increased urine specific gravity from 1.012 to 1.030 g/mL c. Increased respiratory rate from 12 to 22 breaths/min d. Decreased orthostatic light-headedness and dizziness
d. Decreased orthostatic light-headedness and dizziness
A nurse cares for a patient who has elevated levels of antidiuretic hormone (ADH). Which disorder should the nurse identify as a trigger for the release of this hormone? Select one: a. Patient drinks an excessive amount of fluid b. Patient becomes anxious and nervous c. Renal failure d. Dehydration
d. Dehydration
The nurse is preparing to transfuse 2units of Packed Red blood cell. How often does the nurse change the blood transfusion tubing? Select one: a. Every 30min b. Every 2 hours c. Every 1 hour d. Every 4 hours
d. Every 4 hours
The nurse must insert a short peripheral IV catheter. To decrease the risk of deep vein thrombosis or phlebitis, Which area of the arm should be chosen for insertion of the IV catheter? Select one: a. Antecubital area b. Wrist c. Hand d. Forearm
d. Forearm
Which factors may lead to an anesthetic overdose in a patient? Select one: a. Younger age of patient b. Fast metabolism and drug elimination c. An uncooperative patient d. Liver or kidney disease
d. Liver or kidney disease
Which patient is at risk for excess insensible water loss? Select one: a. Patient with slow, deep respirations b. Patient receiving oxygen therapy c. Patient with hypothermia d. Patient with continuous GI suctioning
d. Patient with continuous GI suctioning
Which is not the symptom of meningococcal meningitis? Select one: a. Nuchal rigidity b. Photophobia c. Petechiae d. Ptosis
d. Ptosis
The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? Select one: a. Fluid and electrolyte imbalance b. Potential for infection c. Alteration in comfort d. Risk for depressed respiratory pattern
d. Risk for depressed respiratory pattern
A patient reports having crushing chest pain that radiates to the jaw. You administer sublingual nitroglycerin and obtain a 12 lead EKG. Which of the following EKG findings confirms your suspicion of a possible myocardial infraction? Select one: a. Absent Q wave b. QRS widening c. Absent P-wave d. ST segment elevation
d. ST segment elevation
In arteriosclerosis, commonly referred to as hardening of the arteries, the rigid arterial vessels fail to stretch. This has the potential for what? Select one: a. Decreasing the flow of unoxygenated blood through the body b. Increasing flow of unoxygenated blood throughout the body c. Increasing the flow of blood throughout the body d. Sending a reduced volume of oxygenated blood to the major organs of the body
d. Sending a reduced volume of oxygenated blood to the major organs of the body
A client is to begin collecting a 24-hour urine sample. Which of the following would the nurse instruct the client to do? Select one: a. Keep the collection bottle at room temperature. b. Collect the first voided urine specimen for two consecutive mornings. c. Collect all the urine passed for a complete 24 hours. d. Start collecting urine for 24 hours after discarding the initial specimen.
d. Start collecting urine for 24 hours after discarding the initial specimen.
A patient has been diagnosed with airway obstruction during sleep. The nurse will likely include patient education about which device for home use? Select one: a. Oxygen via face mask to prevent hypoxia b. Nebulizer treatments with bronchodilators c. Neck brace to support the head and facilitate breathing d. continuous positive airway pressure (CPAP) to deliver a positive airway pressure
d. continuous positive airway pressure (CPAP) to deliver a positive airway pressure
Which the signs/symptoms are not considered postoperative complications? Select one: a. Pulmonary embolism b. Wound evisceration c. Infection d. pain at the surgical site
d. pain at the surgical site
Which of the following serum potassium levels would most likely be seen in a client in the Emergency department with a three-day history of diarrhea? Select one: a. 6.2 mEq/L b. 3.6 mEq/L c. 4.1 mEq/L d. 9.2 mEq/L e. 3.0 mEq/L
e. 3.0 mEq/L
Which of the following conditions contribute to a calculus forming environment in nephrolithiasis Select one: a. Urinary stasis b. Urinary retention c. Immobilization d. Dehydration e. All of the above
e. All of the above
After administering 40 mEq of potassium chloride, a nurse evaluates the patient's response. Which manifestations indicate that treatment is improving the patient's hypokalemia? Select one: a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. No bowel sounds d. e. Strong productive cough
e. Strong productive cough
Fill in the following blanks: S1 is best heard at the .................of the heart, whereas S2 is loudest at the ....................of the heart. Select one: a. Apex/base b. Base/apex
a. Apex/base
A client asks the clinic nurse what the difference is between arteriosclerosis and atherosclerosis. What is the nurse's best response? Select one: a. Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age; atherosclerosis is the fatty deposits in the lumen of arteries b. Atherosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age; arteriosclerosis is the fatty deposits in the lumen of arteries c. Arteriosclerosis is a formation of clots in the inner lining of the arteries; atherosclerosis are the blood clots in the arteries d. Atherosclerosis are the blood clots in the arteries; arteriosclerosis is the formation of clots in the inner lining of the arteries.
a. Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age; atherosclerosis is the fatty deposits in the lumen of arteries
A client asks the clinic nurse what the difference is between arteriosclerosis and atherosclerosis. What is the nurse's best response? Select one: a. Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age; atherosclerosis is the fatty deposits in the lumen of arteries b. Atherosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age; arteriosclerosis is the fatty deposits in the lumen of arteries c. Arteriosclerosis is a formation of clots in the inner lining of the arteries; atherosclerosis are the blood clots in the arteries d. Atherosclerosis are the blood clots in the arteries; atherosclerosis is the formation of clots in the inner lining of the arteries.
a. Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age; atherosclerosis is the fatty deposits in the lumen of arteries
A nurse is assessing a patient with hypokalemia, and notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? Select one: a. Assess the patient's respiratory rate, rhythm, and depth. b. Document findings and monitor the patient. c. Call the healthcare provider. d. Measure the patient's pulse and blood pressure.
a. Assess the patient's respiratory rate, rhythm, and depth
nurse reviews laboratory results for a patient who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? Select one: a. Blood urea nitrogen (BUN) of 52 mg/dL (18.6 mmol/L) b. Creatinine of 2.3 mg/dL (203 mcmol/L) c. BUN of 10 mg/dL (3.6 mmol/L) d. BUN/creatinine ratio of 8:1
a. Blood urea nitrogen (BUN) of 52 mg/dL (18.6 mmol/L)
You are providing care to a patient who is post op day 1 thyroidectomy. Which laboratory value requires close monitoring? Select one: a. Calcium level b. Sodium level c. C-reactive protein d. Potassium level
a. Calcium level
A client comes to the Emergency Department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would you suspect in this client? Select one: a. Coronary artery disease b. Cardiogenic Shock c. Raynaud's Disease d. Venous Occlusive Disease
a. Coronary artery disease
The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? Select one: a. Mask-like faces and a shuffling gait b. Crackles in the upper lung fields and jugular vein distention c. Exaggerated arm swing and scanning speech d. Muscle weakness in the upper extremities and ptosis
a. Mask-like faces and a shuffling gait
The nurse is preparing to deliver IV infusion therapy through an implanted port. What technique does the nurse use to access the port? Select one: a. Palpate the port. scrub skin, and access with a noncoring (Huber) needle b. Palpate the port, scrub skin, and access with a winged butterfly needle c. Scrub the port with Betadine and flush using a 10-mL syringe d. Scrub the port with alcohol and access with needleless device
a. Palpate the port. scrub skin, and access with a noncoring (Huber) needle
A patient is admitted to the hospital with pneumonia. What does the nurse expect the chest x-ray results to reveal? Select one: a. Patchy areas of increased density b. Tension pneumothorax c. Thick secretion causing airway obstruction d. Large hyperinflated airways
a. Patchy areas of increased density
In which circumstance would vasopressin be released to maintain blood osmolality? Select one: a. Person exercises for a long period without drinking any fluid b. Person receives an intravenous fluid bolus too rapidly c. Person is on a severely restricted protein diet for several days d. Person becomes anxious and hyperventilates for several minutes
a. Person exercises for a long period without drinking any fluid
A patient has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the patient's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? Select one: a. Allow the patient to rest quietly. b. Assess the patient for bleeding. c. Document the findings in the chart. d. Medicate the patient for pain.
b. Assess the patient for bleeding.
The nurse is caring for a patient with increased intracranial pressure. Select the vital signs the patient is most likely to exhibit Select one: a. BP80/50, HR 50 and Kussmauls respirations b. BP190/84, HR 50 and and slow, irregular respiratory pattern c. BP: 190/84, HR 150 and irregular respirations d. BP 80/50, HR 150 and Cheyne Stokes respirations
b. BP190/84, HR 50 and and slow, irregular respiratory pattern
A patient had an inferior wall myocardial infarction (MI). The nurse notes the patient's cardiac rhythm as shown below: What action by the nurse is most important? Select one: a. Assess the patient's blood pressure and level of consciousness. b. Call the healthcare provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.
b. Call the healthcare provider or the Rapid Response Team.
Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis? Select one: a. Jaundice and flank pain b. Costovertebral angle tenderness and chills c. Burning sensation on urination d. Polyuria and nocturia
b. Costovertebral angle tenderness and chills
A client with a cerebrovascular accident (CVA) is prescribed heparin for treatment. For which of the following adverse effects should the nurse monitor in the client? Select one: a. Migraine attacks b. Hemorrhage c. High blood pressure d. Respiratory distress
b. Hemorrhage
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find Select one: a. vesicular breath sounds b. Increased tactile fremitus. c. Dry, nonproductive cough. d. Hyperresonance to percussion.
b. Increased tactile fremitus.
The client, diagnosed with a form of angina, presents with a predictable level of pain that occurs during physical or emotional stress.What form of angina should the nurse focus on when preparing educational information? Select one: a. Microvascular angina b. Stable angina c. Unstable angina d. Variant angina
b. Stable angina
While assessing patient's IV site, the nurse identifies signs and symptoms of infiltration. What is the first action that the nurse implement for this patient? Select one: a. Apply a sterile dressing if weeping from the tissue has occurred b. Stop the IV infusion c. Remove the IV access d. Elevate the extremity
b. Stop the IV infusion
The nurse is counseling a group of women about triglyceride levels. For women, what is a normal triglyceride level? Select one: a. Over 150mg/dL b. Under 135mg/dL c. Over 100 mg/dL d. Under 70mg/dL
b. Under 135mg/dL
Which type of urinary incontinence can be attribute to muscle overactivity? Select one: a. Stress incontinence b. Urge incontinence c. Overflow incontinence d. Functional incontinence
b. Urge incontinence
The nurse is preparing the patient for surgery. Which is not the common laboratory test does the nurse anticipate to be ordered? Select one: a. Clotting studies b. Uric acid c. Serum creatinine d. Electrolytes
b. Uric acid
Which of the following parameters are graded when using the Glasgow Coma Scale Select one: a. Eye opening, sensory level, best verbal response b. Pupillary signs, orientation and wakefulness, BP and P c. Eye opening, best motor response, best verbal response d. Motor response, pupillary signs, orientation
c. Eye opening, best motor response, best verbal response
A nurse is assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs, and increasing peripheral edema. What fluid disorder do these findings reflect? Select one: a. Fluid volume deficit b. Fluid dehydration c. Fluid volume excess d. Fluid homeostasis
c. Fluid volume excess
Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? Select one: a. Massage the client's feet and ankles regularly b. Have the client wear soft shoes at throughout the day c. Reposition the client every 2hrs d. Place the client's feet against a footboard
??? A is incorrect.
The nurse reviewing laboratory values of a client diagnosed with hyperlipidemia 6 months previously. Which results indicate that the client has been following his therapeutic regimen? Select one: a. Total cholesterol level increases from 250 mg/dL to 275 mg/dL b. Low-density lipoproteins (LDL) increase from 180 mg/dL to 190 mg/dL c. High-density lipoproteins (HDL) increase from 25 mg/dL to 40 mg/dL d. Triglycerides increase from 225 mg/dL to 250 mg/dl e. Increase in total cholesterol, decrease HDL, increase LDL, increase triglycerides
c. High-density lipoproteins (HDL) increase from 25 mg/dL to 40 mg/dL
A patient has chest pain and is admitted to the hospital. The procedure that the client undertakes is described as a balloon-tipped catheter inserted through the skin and threaded from a peripheral artery into the diseased coronary artery. The inflation of the balloon compresses the atherosclerotic plaque against the arterial wall, increasing the diameter of the artery. What is the procedure called? Select one: a. Coronary stent b. Atherectomy c. Percutaneous transluminal coronary angioplasty (PTCA) d. Coronary artery bypass grafting (CABG)
c. Percutaneous transluminal coronary angioplasty (PTCA)
A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? Select one: a. mood b. appetite c. muscle rigidity d. alertness
c. muscle rigidity
A 76-year old patient is having a bilateral cataract removal. What is the correct classification for this surgery? Select one: a. Emergent b. cosmetic c. Major d. Elective
d. Elective
A patient is receiving IV therapy via an infusion pump. What is the priority nursing responsibility related to the equipment? Select one: a. Monitor the patient's infusion site and rate b. Check the equipment at the end of the infusion c. Position the container for gravity flow d. Ensure the IV pump is programmed correctly
d. Ensure the IV pump is programmed correctly
A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? Select one: a. Hypercalcemia—Positive Trousseau's and Chvostek's signs b. Hyperphosphatemia—Paresthesia with sensations of tingling and numbness c. Hyponatremia—Decreased level of consciousness/seizure d. Hypokalemia—muscle weakness followed by flaccid paralysis
d. Hypokalemia—muscle weakness followed by flaccid paralysis
The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse anesthetist's initial action? Select one: a. Administer cardiopulmonary resuscitation. b. Continue as normal. c. Inform the surgeon. d. Immediately stop all inhalation anesthetic agents and succinylcholine
d. Immediately stop all inhalation anesthetic agents and succinylcholine
A nurse contacts the healthcare provider after reviewing a patient's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL (12.5 mmol/L) and a creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure does the nurse consult the provider about? Select one: a. Fluid restriction b. Urine culture and sensitivity c. Hemodialysis d. Intravenous fluids
d. Intravenous fluids
A nurse prepares to administer a blood transfusion to a patient, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal barcoding system to ensure the right blood for the right patient. Which components must be present on the blood label in bar code and in eyereadable format? Select one: a. Blood type of the patient receiving blood b. Name of the patient receiving blood c. Donor's home address d. Lot number related to the donor
d. Lot number related to the donor
Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? Select one: a. facial grimaces, patting motions, and lip smaking b. Jerking in one extremity that spreads gradually to adjacent areas c. Focal motor, sensory, or autonomic symptoms without loss of consciousness d. loss of consciousness, body stiffening, and violent muscle contractions
d. loss of consciousness, body stiffening, and violent muscle contractions
