prn0291- final exam

The virus that is transmitted from one person to another by way of water, food, or medical equipment that has been contaminated with infected fecal matter is known as: A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D

A.

A 17-year-old client has fainted at school and is believed to be suffering from anorexia nervosa. What diagnostic tests are likely to be ordered? Select all that apply: a. Calcium b. Iron c. Vitamin B12 d. Folate

a, b, c, d.

The client being admitted from the emergency room department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? select all that apply. A. Perform bowel training every two hours B. Prepare for upper GI x-ray C. Administer antidiarrheal medication every day D. Administer an oil retention enema

a, b, c, d.

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to administer KCl safely? Select all that apply. a) Use a potassium infusion prepared by a registered pharmacist. b) Assessforburningorrednessduringinfusion. c) Infuse at a rate of no more than 10 mEq per hour. d) Administer only through a central venous catheter. e) Administer by IV push only during cardiac arrest.

a, b, c.

A nurse is caring for a patient with cirrhosis of the liver. What are some problems the nurse should address? Select all that apply. A. Inadequate nutrition B. Reduced activity tolerance C. Confusion D. Pain E. Inadequate ventilation

a, b, d, e.

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply. a) The client with renal failure b) The client with an ileostomy c) The client with chronic cirrhosis d) The client with a draining abdominal wound e) The client with a nasogastric tube to low suction

a, c

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply. a) Hypokalemia b) Hyperkalemia c) Hyponatremia d) Hypernatremia e) Hypomagnesemia f) Hypermagnesemia

a, c, e

Hyponatremia occurs when sodium levels drop below ________________mEq/L.

135

Normal PTT levels is from _____ to _____.

25-35

The normal lab values for creatinine is _____mg/dL to _____ mg/dL.

0.8- 1.3

The nurse usually is assigned multiple patients at one time. What should the nurse do to ensure individual patient satisfaction? Select all that apply. 1. Provide quality care to each patient. 2. Ensure that patients leave with a positive image of nursing. 3. Provide quick and hurried treatment to the less needy. 4. Manage time and approach all patients with compassion. 5. Minimize contact time with each patient to ensure care for all

1, 2, 4.

A patient with lung cancer is emotionally, economically, and socially disturbed. What is the role of the nurse as a caregiver? Select all that apply. 1. Provide financial aid. 2. Manage the disease and symptoms. 3. Help the patient establish and achieve goals. 4. Avoid the patient's personal and family problems. 5. Implement measures to restore emotional and social well-being.

2, 3, 5

A patient with psychiatric illness is prescribed antipsychotic medications. The nurse helps the patient decide whether to accept the treatment. Which role does the nurse play in this situation? 1. Educator 2. Advocate 3. Caregiver 4. Communicator

2. Advocate

The nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with the family. Which role is the nurse playing for the patient? 1. Educator 2. Advocate 3. Caregiver 4. Case manager

2. advocate

The normal therapeutic level for INR when a patient is taking Warfarin is from _____ to _____.

2.0 to 3.0

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking. a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"

A. "when was the last time you voided? "

The normal serum calcium level is between __________ mg/dL and ________ mg/dL.

9 and 10.5

Normal arterial blood pH ranges from ______ to ______ and is slightly alkaline.

7.35-7.45

3) A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? A. By inserting a nasopharyngeal airway. B. By inserting an oropharyngeal airway. C. By performing a jaw thrust maneuver. D. By performing the head-tilt, chin-lift maneuver.

C. By preforming a jaw thrust maneuver

The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of infection. Which sign/symptom is likely to present first? A. Fever B. Urgency C. Confusion D. Frequency.

C. Confusion.

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries. B. Call for an immediate chest x-ray. C. Immobilize the client's head and neck. D. Open the airway with the head-tilt-chin-lift maneuver.

C. Immobilize the clients head and neck.

A client with chronic kidney disease is receiving ferrous sulfate. The nurse would monitor the client for which common side effect associated with this medication? A. Diarrhea B. Weakness C. Headache D. Constipation.

D. Constipation.

A client who is paraplegic after a spinal cord injury has been taught muscle strengthening exercises for upper body. The nurse determines that the client will derive the least muscle strengthening benefit from which activity? A. Squeezing rubber balls. B. Doing push-ups in a prone position. C. Extending the arms while holding weights D. doing active range of motion to finger joints.

D. Doing active range of motion to finger joint

The client with spinal cord injury is prone to experiencing automatic dysreflexia. The least appropriate measure to minimize the risk of automatic dysreflexia is which action? A. strictly adhering to bowel retraining program. B. Keeping the linen wrinkle free under the client C. Avoiding unnecessary pressure on the lower limbs. D. Limiting bladder catheterization to once every 12 hours.

D. Limiting bladder catheterization to once every 12 hours.

A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When would the nurse plan to administer this medication? A. During dialysis. B. Just before dialysis. C. The day after dialysis D. On return from dialysis.

D. On return from dialysis

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expect the cervical collar will remain in place until which time? A. The client is taken for spinal x-rays. B. The family comes to visit after surgery. C. The nurse needs to provide physical care. D. The primary healthcare provider reviews the x-ray results.

D. The primary healthcare provider reviews the x-ray results.

True or False. The only cure for end-stage liver disease is liver transplantation, which requires life long treatment with antirejection drugs that suppress the immune system and put the patient at risk for infection.

True

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply a) Monitor vital signs. b) Monitorelect

a, b, c, d, e.

Signs of fluid volume deficit include: a. tachycardia b. hypotension c. oliguria d. confusion

a, b, c, d.

______________ occurs when serum potassium levels exceed 5.0 mEq/L.

hyperkalemia

What lab values should be monitored when administering Warfarin? __________

pt

True or False. A common sign of malabsorption is steatorrhea.

true

A client is prescribed Selective Serotonin Reuptake Inhibitors (SSRI) and is instructed to never mix SSRI with the following: (Select all that apply) a. St. Johns's wort b. Tetracyclines c. MAOI d. Lithium carbonate (Lithium)

a, c.

The nurse is planning care for a client and spinal shock. Which action would be least helpful and minimizing the effects of vasodilation before the level of injury? A. Moving the client quickly as one unit. B. Using vasopressor medication as prescribed. C. Applying compression stockings, as prescribed. D. Monitoring vital signs before and during position changes.

A. Moving the client quickly as one unit.

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

A. Unequal pupil size

The nursing team consists of one RN, one LPN, and one UAP. Which assignment should the RN delegate to the LPN? 1. Passing dinner trays 2. Emptying a foley bag 3. Administering daily am medications 4. Suctioning a patient who is one day post-op for a tracheostomy

3. Administering daily am medications

At the beginning of a shift, the team leader notices that all of the IV antibiotics for a patient are still in the medication room. What is the team leader's first action? 1. Ask the patient if they received their medication during the previous shift 2. Return the medication to the pharmacy to reduce hospital expenses 3. Ask the nurse assigned to this client about the medications 4. Notify the unit nurse manager

3. Ask the nurse assigned to this client about the medications

The nurse is monitoring a client with a C-5, spinal cord injury for spinal shock, which finding would be associated with spinal shock in this client select all that apply A. Bowel sounds are absent B. The clients abdomen is distended C. Respiratory exertion is diminished. D. The blood pressure rises when the clients sits up. E. Accessory muscles of respirations are areflexic

A, B, C, E.

A patient has been advised to have a total knee replacement because of osteoarthritis. The patient is not willing to undergo the surgery, but family members want to get the surgery done to relieve the disability. The nurse explains the details of the surgery and the risks associated with it, and also discusses the patient's wishes with the family. Which nursing role is the nurse playing here? 1. Educator 2. Caregiver 3. Case manager 4. Advocate

4. Advocate

The nurse is participating in a clinical care coordination conference for a patient with terminal cancer. The nurse talks with colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A non nursing colleague asks about this code. What does this code do? 1. Improves self-health care 2. Protects the patient's confidentiality 3. Ensures identical care to all patients 4. Defines the principles of right and wrong when providing patient care

4. Defines the principles of right and wrong when providing patient care

The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply. A. Elevated serum creatinine level. B. Elevated thrombocyte cell count. C. Decreased red blood cell (RBC) count. D. Decreased white blood cell (WBC) count. E. Elevated blood urea nitrogen (BUN) level.

A, C, E.

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

4. Implementation

6. When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL.

A.

Normal glucose levels are between _____ and _____.

70 and 100

An 18-year-old patient is in the emergency department with fever and cough. The nurse obtains vital signs, auscultates lung sounds, listens to heart sounds, determines a patient's level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed? 1. Diagnosis 2. Evaluation 3. Assessment 4. Implementation

Answer = 3. Assessment

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? A. Bloody drainage from the ears B. Frequent swallowing C. Guaiac-positive stools D. Hematuria

B. Frequent swallowing

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find. a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

B. Reddened irritated skin on the buttocks

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A. To hasten wound healing. B. To immobilize the cervical spine. C. To prevent autonomic dysreflexia. D. To hold bony fragments of the skull together.

B. To immobilize the cervical spine

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? A. Place her in a jacket restraint. B. Wrap her hands in soft "mitten" restraints. C. Tuck her arms and hands under the draw sheet. D. Apply a wrist restraint to each arm.

B. Wrap her hands in soft "mitten" restraints

The client is taking phenytoin for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result? a. 5 mcg/mL b. 15 mcg/mL c. 25 mcg/ml d. 30 mcg/dL

B.

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? 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,

B. Administer phenytoin (Dilantin) 200mg PO daily

A client with a history of spinal cord injury is receiving baclofen for muscle spasms. The nurse determines that the client is experiencing a side effect of this medication, if the client experiences which sign/symptom. A. Muscle pain. B. Drowsiness C. Hypertension. D. Photosensitivity.

B. Drowsiness.

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record would the nurse identify as a risk factor for this diagnosis? A. Hypoglycemia. B. Diabetes mellitus C. Coronary artery disease. D. Orthostatic hypotension.

B. diabetes mellitus.

When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.

B. urinary catheter.

An elderly client receiving treatment for pneumonia appears drowsy and confused. When reviewing the clients labs, the nurse notes a steadily rising blood urea level. What action is most important to take? a) Review the MAR b) review bacterial culture and sensitivity report c) Review the intake and output d) Review serum glucose levels

c- review the intake and output

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? A. "Watch him for a keyhole pupil the next 24 hours." B. "Expect profuse vomiting for 24 hours after the injury." C. "Wake him every hour and assess his orientation to person, time, and place." D. "Notify the physician immediately if he has a headache."

C. "Wake him every hour and assess his orientation to person, time, and place."

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? A. Extent of intracranial bleeding. B. Sites of brain injury. C. Activity of the brain. D. Percent of functional brain tissue.

C. Activity of the brain. An EEG measures the electrical activity of the brain. An electroencephalogram (EEG) is an essential tool that studies the brain's electrical activity. It is primarily used to assess seizures and conditions that may mimic seizures. It is also useful to classify seizure types, assess comatose patients in the intensive care unit, and evaluate encephalopathies, among other indications.

A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

C. Assess for bladder distention

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client's feelings about the injury

C. Pulse ox readings

The nurse is caring for a client who has suffered a spinal cord injury. The nurse further monitors the client for signs of automatic dysreflexia and suspects this complication if which signs/symptoms are noted? A. sudden tachycardia. B. pallor of the face and neck. C. severe throbbing headache. D. severe and sudden hypotension.

C. severe, throbbing headache

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level would the nurse collect? Select all that apply. a) Presence of Chvostek's sign b) Presence of muscle weakness c) Presence of decreased deep tendon reflexes d) Presenceofelectrocardiogramabnormalities e) Presence of tingling in the fingertips and around the mouth f) Presence of carpal spasm when blood pressure cuff is inflated ab

a, d, e, f.

Which of the following are difficulty swallowing? a. Dysphagia b. Dysarthria c. Aphasia d. Dyspraxia

a, dysphagia

What does the "F" stand for in the acronym "Fast" when indemnifying the symptoms of a stroke? a. Facial Droop b. Feeling week c. Facial expressions d. Forgetfulness

a, facial droop

Which underlying cause relates to hemorrhagic stroke? a. A rupture in a vessel in the brain b. Damage to a vessel the brainstem c. Damage to an artery in the brainstem d. A blood clot lodging in a vessel in the brain

a. A rupture in a vessel in the brain

A client with schizophrenia is exhibiting delusions, hallucinations, minimal self-care, and hyperactive behavior. Which of these observations would the nurse document as a negative symptom of schizophrenia? a. Minimal self-care b. Delusions c. Hallucinations d. Bizarre behavior

a. Minimal self-care

1) A lack of appetite, which may be caused by illness, drugs, or emotional factors is called? a. Anorexia b. Bulimia c. Dyspepsia d. Belching

a. anorexia.

The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client develops signs and symptoms of automatic dysreflexia, which is the initial nursing action. a. Elevate is the head of the bed b. Digitally examine the rectum. c. Check the clients blood pressure. d. Place the client in the prone position.

a. elevate the head of the bed.

The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from spinal shock? a. Reflexes b. Pulse rate. c. Temperature d. Blood pressure.

a. reflexes.

Which disorder is caused when a blood clot or plaque fragment is "traveling" through a blood vessel from an area outside the brain until it lodges in a cerebral artery? a. Thrombotic stroke b. Atrial fibrillation c. Hemorrhagic stroke d. Myocardial infarction

a. thrombotic stroke

The nurse in the ED is admitting a client after a motor vehicle accident. The client has a large hematoma over forehead, responds to voice commands but lethargic, pupils are sluggish with papilledema noted. Which intravenous fluids should the nurse anticipate to initiate for this client a) 0.45% saline b) 3%saline c) 0.9% normal saline d) Dextrose 5% in water

b, 3% normal saline

A client experiencing a panic attack would display which physical symptoms? Select all that apply: a. Decreased pulse b. Diaphoresis c. Dizziness d. Chest pain

b, c, d.

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained? Select all that apply. a) Increasing pulse b) Decreasingbodyweight c) Decreasing urine output d) Decreasingabdominalgirth e) Increasing central venous pressure

b, d

Which of the following are modifiable risk factors for stroke? (Select all that apply.) a. Age b. Obesity c. Gender d. Hypertension e. Cigarette smoking

b, d, e.

Which client should the nurse expect the HCP to prescribe methadone? a. A client addicted to cocaine. b. A client addicted to heroin. c. A client addicted to amphetamines. d. A client addicted to hallucinogens.

b. A client addicted to heroin.

The backward flow of gastric contents from the stomach into the esophagus is known as a. Gastritis b. GERD c. Peptic ulcer d. Crohn disease

b. GERD

The nurse is screening the patient with a stroke for tPA eligibility. Which factor would likely prevent the patient from receiving the drug? a. The patient is 18 years old. b. The patient's symptoms suggest a hemorrhagic stroke. c. Stroke symptoms started 2 hours ago. d. The patient had intracranial surgery 10 years ago.

b. The patient's symptoms suggest a hemorrhagic stroke.

Inflammation of the lining of the stomach is known as: a. Crohn disease b. Gastritis c. Peptic ulcer d. IBD

b. gastritis

A client has been diagnosed with metabolic alkalosis. Which laboratory values are most important for the nurse to monitor for this client? Select all that apply. a) Red blood cells b) Serum bilirubin c) Serum electrolytes d) Arterialbloodgases(ABGs) e) Complete blood count (CBC)

c, d.

Which underlying cause is responsible for the effects that a cerebrovascular accident (CVA) has on the body? a. Nerve damage b. Muscle deterioration c. Oxygen deprivation d. Neurotransmission deficit

c, oxygen deprivation

A patient was admitted to the hospital yesterday morning with complaints of sudden onset of dizziness, slurred speech, and numbness and tingling on the left side of the body. The patient is now resting without complaints of the previous symptoms. Which disorder is associated with these symptoms? a. MI b. Intracranial hemorrhage c. TIA d. CVA

c- TIA

A nurse assesses a patient receiving Haldol. The nurse notices the patient is shifting in the chair, rocking back and forth, and tapping both feet constantly. What is the most accurate term to document this finding? a. Dystonia b. Tardive dyskinesia c. Akathisia d. Parkinsonism

c- akathisia

The nurse is caring for a client diagnosed with peptic ulcer. Which test would be used to confirm this diagnosis?

c- endoscopy

Which of the following is a stroke caused by obstruction of a blood vessel by an embolus or a thrombus? a. Hemorrhagic Stroke b. TIA c. Ischemic Stroke d. CVA

c- ischemic stroke

Immediately after taking a dose of alprazolam, the client says, "I know I shouldn't feel this guilty, but I don't want to take medicine that makes me feel this way." What would be the most appropriate response by the nurse? a. "You can't worry about what people say about the medicine you take." b. "Once the medication begins to work, you'll feel differently about taking it." c. "Let's talk about how you're feeling about taking alprazolam." d. "Your long-term mental

c. "Let's talk about how you're feeling about taking alprazolam."

The LPN recognizes symptoms of a TIA in a patient. Why is it important for the nurse to recognize a TIA? a. Because TIA is a symptom of a brain tumor b. Because TIA can cause permanent disability c. Because TIA is a warning sign of future stroke d. Because TIA occurs shortly before a hemorrhage

c. Because TIA is a warning sign of future stroke

client is admitted to the emergency department with a C5 spinal cord injury, the nurse performs which intervention first when collecting data on the client? a. Taking the temperature. b. Observing for dyskinesia. c. Monitoring the respiratory rate. d. Checking extremity muscle strength.

c. Monitoring the respiratory rate.

What should be the nurse's highest priority when caring for a client who, after withdrawing from alcohol, is beginning to use disulfiram [Antabuse]? a. Becoming socially reintegrated b. Learning about the disease process c. Remaining abstinent d. Remaining in the rehab unit

c. Remaining abstinent

A client with acute renal failure is demonstrating a widening QRS complex and peaked T waves on electrocardiogram readings. Which electrolyte level is most important for the nurse to assess? a) Calcium b) Sodium c) Hemoglobin d) Potassium

d, potassium

The client diagnosed with depression is prescribed isocarboxazid [Marplan]. Which statement by the client indicates to the nurse the medication teaching is effective? a. "I am taking the herb ginseng to help my attention span." b. "I drink extra fluids, especially coffee and ice tea." c. "I am eating three well-balanced meals a day." d. "At a family cookout I had chicken instead of a hot dog."

d. "At a family cookout I had chicken instead of a hot dog."

If an overdose of benzodiazepines is suspected, the nurse should anticipate what medication order to reverse that drug's effect? a. Diazepam b. Triazolam c. Fluvoxamine d. Flumazenil

d. flumazenil