Practice Exam 1
The nurse understands that the client should be given human papillomavirus (HPV) vaccine per the health care provider's orders. What does this vaccine help prevent?
cervical cancer
When a client who has been taking opioids becomes less sensitive to the drug's analgesic properties, that client is said to have developed a(n)
tolerance
During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?
Brain
A client has been reading the paper about "emerging infectious diseases" and asks the nurse why these are a growing problem. How would the nurse respond? Select all that apply.
Mutations among existing organisms, Ecologic changes in human and animal habitats, Antimicrobial resistance
A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing?
Neurogenic shock
A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing?
Neurogenic shock
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?
Potassium
The nurse is working the triage, answering phone questions about the radiologic disaster. When in the fallout period of the disaster, which suggestion is most appropriate?
Remove all outer garments before entering a house or shelter.
The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for?
Respiratory compromise
After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority?
Risk for infection
When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)
Urinary output, Mental status, Vital signs
A nursing instructor is instructing on the infectious process. The instructor explains that older adults are more susceptible to serious infections because they:
can have less efficient defense mechanisms than younger adults.
The patient diagnosed with thrombocytopenia is at risk for which of the following adverse effects:
Bleeding
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. What response by the nurse would best reassure this patient?
"These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and X-ray studies."
A nurse on the unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow?
Be tested for disease antibodies at appropriate intervals.
In which instance may a surgeon operate without informed consent?
Emergency situations
While completing an admission assessment, the client reports a family history of breast cancer among a maternal grandmother, aunt, and sister. The nurse knows that these cancers are most likely associated with what etiology?
Inherited gene mutation
Which type of shock is caused by an infection?
Septic
When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)?
Smallpox spreads rapidly and requires immediate isolation.
While a patient is receiving IV doxorubicin hydrochloride, the nurse observes that there is swelling and pain at the IV site. The nurse should:
Stop the administration of the drug immediately.
When a client is in the compensatory stage of shock, which symptom occurs?
Tachycardia
The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
Thorough handwashing
The nurse is caring for a client who has just had total parenteral nutrition (TPN) ordered. The LPN is correct when informing the client that TPN is used for what?
To meet the client's caloric and nutritional needs
A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?
Wear personal protective equipment when handling blood, body fluids, and feces.
Following a disaster, a client's condition is serious, but she is stable enough to survive if treatment is delayed 6 to 8 hours. What category of triage would the nurse place this client?
Yellow
To combat the most common adverse effects of chemotherapy, a nurse should administer an:
antiemetic
It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to
avoid aspiration
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?
electrocardiogram (ECG) results
A client with congestive heart failure must be weighed daily and have the results entered in the medical record. What is the best time of day for this client to be weighed?
same time each day
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct?
"The client is in shock because the blood volume has decreased in the system."
The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?
"What are your concerns?"
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
A rapid, bounding pulse
During a disaster, the nurse triages a victim with a fractured wrist. Which color triage tag should the nurse apply?
Green
A nurse is attending to a client with an infectious disease. After changing the linen and caring for the patient, the nurse does a hand antisepsis with an alcohol-based hand rub. Which of the following is a reason for the nurse to use an alcohol-based hand rub?
It provides the greatest reduction in microbial counts.
During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply.
infectious agent, portal of entry, susceptible host
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should:
instruct the client to breathe into a paper bag.
A client is in full-blown pulmonary edema and needs the appropriate medication to take effect as quickly as possible. Which medication route will be the quickest to give this client a fighting chance?
intravenous
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.
pH, PaCO2, HCO3
Palliation refers to
relief of symptoms associated with disease and promotion of comfort and quality of life.
When assessing the client postoperatively, which nursing consideration is essential before offering oral fluids?
Assess ability to swallow
A client is scheduled for an invasive procedure. What priority documentation is needed regarding the procedure?
A signed consent form from the client
What can the nurse do to meet the challenges in caring for a patient with cancer?
Identify own perception of cancer and set realistic goals
The community health nurse is performing a home visit to an 84-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response?
"Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids."
The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the client indicates an understanding of the diagnosis?
"My cancer has now spread to my liver."
The nurse knows which is the normal serum value for potassium?
3.5-5.0 mEq/L (3.5-5.0 mmol/L).
Which procedure uses liquid nitrogen to freeze tissue, thereby destroying cells?
Cryoablation
A client has been using NSAIDs daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?
Gastrointestinal bleeding
The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state?
Tachycardia
