Nursing Fundamentals Final Exam Practice Questions 4

Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:

Laminectomy (The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning.)

Diagnostic assessment of Francis would probably not reveal:

Leukocytosis

A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?

Liver (The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain.)

Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is:

Loose, bloody

Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should:

Make sure that the client takes food and medications at prescribed intervals.

Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:

Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.

A 51-year-old female client tells the nurse-in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?

Nonmobile mass with irregular edges (Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges.)

Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn't taken quickly, she might have which of the following reactions?

Respiratory arrest

A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?

The white blood cell count is 2300/mm3.

Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse's next action?

Call for help and note the time

Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply. A. Assist the patient to reposition every 2 hours. B. Reapply pneumatic compression boots. C. Remind the patient to perform active ROM. D. Check extremities for redness and edema

A. Assist the patient to reposition every 2 hours. C. Remind the patient to perform active ROM.

All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson's disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply. A. Check for orthostatic changes in pulse and blood pressure. B. Monitor for improvement in tremor after levodopa (L-dopa) is given. C. Remind the patient to allow adequate time for meals. D. Monitor for abnormal involuntary jerky movements of extremities. E. Assist the patient with prescribed strengthening exercises.

A. Check for orthostatic changes in pulse and blood pressure. C. Remind the patient to allow adequate time for meals. E. Assist the patient with prescribed strengthening exercises.

Mark, a 7-year-old client, is brought to the emergency department. He's tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?

Acute asthma

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? Select all that apply. A. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. B. Administer phenytoin (Dilantin) 200 mg PO daily. C. Teach the patient about the need for good oral hygiene. D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation. E. Gather information about the seizure activity

B. Administer phenytoin (Dilantin) 200 mg PO daily E. Gather information about the seizure activity

A 37-year-old client with uterine cancer asks the nurse, "Which is the most common type of cancer in women?" The nurse replies that it's breast cancer. Which type of cancer causes the most deaths in women? A. Breast cancer B. Lung cancer C. Brain cancer D. Colon and rectal cancer

B. Lung cancer

When caring for a female client who is being treated for hyperthyroidism, it is important to:

Balance the client's periods of activity and rest.

George should be taught about testicular examinations during:

Before age 20 (Testicular cancer commonly occurs in men between ages 20 and 30)

Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:

Bone fracture

Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?

Bronchodilators

A client underwent ileostomy, when should the drainage appliance be applied to the stoma?

In the operating room

A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited?

Chills, fever, night sweats, and hemoptysis

Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like "it's racing out of the chest". She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using? A. Barbiturates B. Opioids C. Cocaine D. Benzodiazepines

Cocaine

Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

Place the client on his side, remove dangerous objects, and protect his head.

Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to the administration of this medication?

Presence of premature ventricular contractions (PVCs) on a cardiac monitor

Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:

Progressively deeper breath followed by shallower breaths with apneic periods.

A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

Sigmoidoscopy

Nurse Maureen is talking to a male client, the client begins choking on his lunch. He's coughing forcefully. The nurse should:

Stay with him but not intervene at this time. (If the client is coughing, he should be able to dislodge the object or cause complete obstruction. If a complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing.)

The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. The reason for this change is that:

The airways are so swollen that no air cannot get through.

While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?

The client is oriented when aroused from sleep and goes back to sleep immediately.

Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?

The client wears a watch and wedding band

Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?

To determine the extent of lesions

Vic asks the nurse what PSA is. The nurse should reply that it stands for:

Prostate-specific antigen, which is used to screen for prostate cancer.

A 35-year-old client with vaginal cancer asks the nurse, "What is the usual treatment for this type of cancer?" Which treatment should the nurse name?

Radiation

After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:

Raise the side rails

Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

"Keep the stoma moist."

What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block? A. "Avoid drinking liquids until the gag reflex returns." B. "Avoid eating milk products for 24 hours." C. "Notify a nurse if you experience blood in your urine." D. "Remain supine for the time specified by the physician."

"Remain supine for the time specified by the physician."

Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?

46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due.

Nurse Oliver is working in an outpatient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today is most likely to have TB?

A 43-year-old homeless man with a history of alcoholism

Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

Clipping the hair in the area

During a breast examination, which finding most strongly suggests that the Luz has breast cancer?

A fixed nodular mass with dimpling of the overlying skin

Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

Avoid foods high in vitamin K (The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation.)

A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?

Avoiding straining during a bowel movement or bending at the waist (The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure)

A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

Continue treatment as ordered.

Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis.

An 89-year-old female patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer's disease. The patient's husband reports to you that he rarely gets a good night's sleep because he needs to make sure his wife does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?

Caregiver Role Strain related to continuous need for providing care

Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:

Changes from previous examinations

As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer's disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?

Check for improvement in resident memory after medication therapy is initiated.

A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse? A. Check respiration, circulation, neurological response B. Align the spine, check pupils, and check for hemorrhage C. Check respirations, stabilize the spine, and check the circulation D. Assess level of consciousness and circulation

Check respirations, stabilize the spine, and check the circulation

Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

Chronic obstructive bronchitis

During routine care, Francis asks the nurse, "How can I be anemic if this disease causes increased white blood cell production?" The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:

Crowded red blood cells

Nurse Ron is taking the health history of an 84-year-old client. Which information will be most useful to the nurse for planning care?

Current health promotion activities (Recognizing an individual's positive health measures is very useful.)

A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?

Decreased vital capacity

In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:

Decreasing venous return through vasodilation

Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn't able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician and asks her to prepare the client for surgery. As the nurse enters the client's room to prepare him, he states that he won't have any more surgery. Which of the following is the best initial response by the nurse?

Explain the risks of not having the surgery

Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

Fine crackles

A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

Flat on back

After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

Kinked or obstructed chest tube

Nurse Kris is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

Increase his activity level

You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first? A. Administer codeine 15 mg orally for the patient's headache. B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.

Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.

Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?

Joint flexion of less than 50% (Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections.)

During the endorsement, which of the following clients should the on-duty nurse assess first? A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute. B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a "do not resuscitate" order. C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin. D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem).

The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem). (The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring.)

You are caring for a patient with recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?

The patient does not recognize family members.

Situation: Francis, age 46 is admitted to the hospital with a diagnosis of Chronic Lymphocytic Leukemia. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?

The patient is under local anesthesia during the procedure. (During the transplant, the patient is placed under general anesthesia.)

Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?

The recommended daily allowance of calcium may be found in a wide variety of foods

While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?

Turn the patient to the side and protect the airway.