Adult 1 Final
[Obj. 5b, c] A client is getting ready to go home after a myocardial infarction (MI). The client is asking questions about his medications, and wants to know why metoprolol (Lopressor) was prescribed. The nurse's best response would be which of the following? "This medication helps make your heart beat stronger to supply more blood to your body." "Your heart was beating too slowly, and Lopressor increases your heart rate." "It slows your heart rate and decreases the amount of work the heart has to do so it can heal." "Lopressor helps to increase the blood supply to the heart by dilating your coronary arteries."
"It slows your heart rate and decreases the amount of work the heart has to do so it can heal."
A patient who was prescribed digoxin (Lanoxin) must learn to take his radial pulse before discharge. Which action will best help the patient remember proper technique? Providing feedback after the patient takes his radial pulse for the first time Allowing the patient to check his radial pulse along with the nurse before administering each dose of the drug Providing written instruction about obtaining radial pulse rate Instructing the patient about obtaining radial pulse rate
Allowing the patient to check his radial pulse along with the nurse before administering each dose of the drug
[Obj. 5b] During a head-to-toe assessment, the nurse notes the apical pulse is 128 and irregular. The patient is not in any distress and does not have any history of dysrhythmia. The nurse contacts the physician for an order to obtain a 12-lead EKG. Which of the following rhythms does the nurse anticipate being diagnosed? Ventricular fibrillation Junctional escape rhythm Sinus bradycardia Atrial fibrillation Ventricular tachycardia
Atrial fibrillation
Which of the following classes of medications protects the ischemic myocardium by blocking cathecholamines and sympathetic nerve stimuation? Calcium channel blockers Nitrates Beta-adrenergic blockers ACE Inhibitors
Beta-adrenergic blockers
[Obj. 4c,e; 5b,c] You are a nurse who has just finished receiving morning report. A 74-year-old female client two days post-op after knee-replacement surgery is having shortness of breath. She has a history of type II diabetes, chronic renal failure, and CHF. You auscultate crackles in all lung fields. Her respirations are 36/min. and O2 sats are 90% on 10L by venti-mask. Which of the following should the nurse do FIRST? Check patient's blood glucose Call respiratory therapist and ask for suctioning Check patient's ABGs from yesterday morning Check patient's intake & output (I&O)
Check patient's intake & output (I&O)
The nurse is caring for clients in a long term care facility. Which is a modifiable risk factor for the development of pressure ulcers? Constant perineal moisture Decreased elasticity of the skin Ability of the client's to reposition themselves Impaired cardiovascular perfusion of the periphery
Constant perineal moisture
The client has a tracheostomy secondary to head and neck surgery. The nurse monitors the client for complications related to the absence of which important protective mechanism? Decrease in oxygen-carrying capacity of the trachea The ability to cough The sneeze reflex initiated by irritants in the nasal passages Filtration and humidification of inspired air
Filtration and humidification of inspired air
Which of the following statements best explains how opening up collapsed alveoli improves oxygenation? Gaseous exchange occurs in the alveolar membrane. Alveoli need oxygen to live. Alveoli have no effect on oxygenation. Collapsed alveoli increase oxygen demand.
Gaseous exchange occurs in the alveolar membrane.
The client with emphysema has oxygen ordered at 1.5 liters per minute via nasal cannula. The client complains of shortness of breath. What action should be taken by the nurse? Lower the head of the client's bed to semi-Fowler's position. Encourage the client to breathe more rapidly. Increase the oxygen to 5 liters per minute via nasal cannula. Have the patient breathe through pursed lips.
Have the patient breathe through pursed lips.
The client is experiencing severe shortness of breath but is not cyanotic. What lab value would the nurse review in an attempt to understand the phenomenon? Blood sugar Hemoglobin and hematocrit Cardiac enzymes Serum electrolytes
Hemoglobin and hematocrit
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse: Place a mask on the client to limit the spread of microorganisms into the surgical wound Keep a box of tissues close to the client for the client's use during the dressing change Instruct the client to refrain from coughing and sneezing during the dressing change Keep the sterile field on the far side of the client's room away from the bedside
Place a mask on the client to limit the spread of microorganisms into the surgical wound
Which of the following is an appropriate nursing intervention for a client at risk for developing a pressure ulcer? Massaging directly over reddened areas to help improve circulation. Positioning the HOB at a 45 angle to improve tissue perfusion. Using hot, soapy water to clean the client to remove fecal/urine incontinence. Repositioning a bedfast client at least every 2 hours to minimize pressure. All of the above.
Repositioning a bedfast client at least every 2 hours to minimize pressure.
A client is being evaluated for a possible myocardial infarction. The nurse performs a 12-lead ECG for an episode of new chest pain. The nurse will monitor for which sign of acute myocardial injury? prolonged QRS complex PR depressions ST elevations prolonged PR interval
ST elevations
[Obj. 4b, 4e] Bilevel positive airway pressure (BiPAP) delivered through a special oxygen mask performs which of the following functions? The mask provides 100% oxygen at both inspiration and expiration. The mask maintains the same consistent level of pressurized oxygen throughout inspiration and expiration. The mask provides continuous positive airway pressure which keeps alveoli fully inflated. The mask provides pressurized oxygen at the end of expiration to open collapsed alveoli.
The mask provides pressurized oxygen at the end of expiration to open collapsed alveoli.
A patient has had a chest tube inserted in the left upper chest. It immediately begins to drain a large amount of sanguineous fluid. Which of the following explanations best describes what caused this? The patient had a large tension pneumothorax with a mediastinal shift. This always happens when a chest tube is inserted. The chest tube was inserted improperly. The patient had a hemothorax instead of a pneumothorax.
The patient had a hemothorax instead of a pneumothorax.
A patient is diagnosed with a large pulmonary embolism. In explaining to the patient what has happened to cause respiratory failure, the nurse understands that the mechanism involved is: Diffusion limitations because the blood gas membrane is thickened. Ventilation-perfusion mismatch because of ventilation to areas where blood flow is decreased. Shunting because the blood perfuses large areas of underventilated alveoli. Alveolar hypoventilation because of the obstruction in the small airways.
Ventilation-perfusion mismatch because of ventilation to areas where blood flow is decreased.
During a well-child visit, a mother tells the nurse that her 4-year old daughter typically goes to bed at 10:30 PM and awakens each morning at 7 AM. She does not take a nap in the afternoon. Which is the best response by the nurse? a. Encourage the mother to consider putting her daughter to bed between 8 and 9 PM. b. Recommend that her daughter be allowed to sleep later in the morning. c. Reassure the mother that it is normal for 4-year-olds to resist napping, but encourage her to insist that she rest quietly each afternoon. d. Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap.
a. Encourage the mother to consider putting her daughter to bed between 8 and 9 PM.
A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? a. The client has a history of bronchial asthma. b. The client has a history of hypertension. c. The client has a history of migraine headaches. d. The client has a history of hypothyroidism.
a. The client has a history of bronchial asthma.
You are the nurse on the surgical floor caring for Mr. Smith after a lobectomy. You are going to do teaching with him regarding the use of the incentive spirometer. Which instructions should be included in the teaching? a. close your lips tightly around the mouthpiece b. blow out into the canister slowly and evenly c. try not to cough after using the device d. You should use the device at least twice a shift
a. close your lips tightly around the mouthpiece
Your client has a Braden scale score of 17. Which is the appropriate nursing action? a. implement a turning schedule; the client is at increased risk of skin breakdown b. assess the client again in 24 hours; the score is within normal limits c. apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown d. request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown
a. implement a turning schedule; the client is at increased risk of skin breakdown
The nurse is preparing to change a client's dressing. The statement that best explains the basis of surgical asepsis that the nurse will perform in this procedure is: a. Keep the area free of microorganisms b. Protect the nurse from microorganisms in the wound c. Confine the microorganisms to the surgical incision site d. Keep the number of opportunistic microorganisms to a minimum
a. Keep the area free of microorganisms
Which learning activity reflects Bloom's affective domain? a. administering an injection b. accepting the loss of a limb c. inserting a catheter d. learning how to read
accepting the loss of a limb
In teaching a patient about coronary artery disease (CAD), the nurse explains that the changes that occur in this disorder involve diffuse involvement of plaque formation in coronary veins. formation of fibrous tissue around coronary artery orifices. chronic vasoconstriction of coronary arteries leading to permanent vasospasm. accumulation of lipid and fibrous tissue within the coronary arteries.
accumulation of lipid and fibrous tissue within the coronary arteries.
A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? a. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level." b. "Heparin does not dissolve clots. It stops new clots from forming." c. "The oral medication you will take after this IV will dissolve the clot." d. "A pharmacist is the person to answer that question."
b. "Heparin does not dissolve clots. It stops new clots from forming."
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? a. "Cardiac enzymes will identify the location of the MI. " b. "These tests help determine the degree of damage to the heart tissues." c. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." d. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."
b. "These tests help determine the degree of damage to the heart tissues."
The nurse is answering questions after a presentation on sleep at a local senior citizen's center. A woman in her late 70's asks for an opinion about the advisability of allowing her husband to nap for 15-20 minutes each afternoon. the nurse's BEST response would be which of the following? a. "encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon" b. "unless your husband has trouble falling asleep at night, a bief afternoon nap is fine" c. "he shouldn't need to take an afternoon nap if he's getting enough sleep at night" d. "Taking an afternoon nap will interfere with his being able to sleep at night. If he's tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake"
b. "unless your husband has trouble falling asleep at night, a bief afternoon nap is fine"
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? a. Assess the pedal pulses with a Doppler device. b. Assess the apical pulse for a full minute. c. Assess the apical pulse with a Doppler device. d. Assess the pedal pulses for a full minute.
b. Assess the apical pulse for a full minute.
A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? a. Have you had chest pain with or without activity? b. Do you have difficulty with daytime sleepiness? c. Do you have a history of cardiac irregularities? d. Do you have a history of any kind of nasal obstruction?
b. Do you have difficulty with daytime sleepiness?
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply) a. Increased hematocrit b. Increased blood pressure c. Increased respiratory rate d. Increased heart rate e. Increased temperature
b. Increased blood pressure c. Increased respiratory rate d. Increased heart rate
A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? a. slows intestinal motility b. prevents dysrhythmias c. relieves pain d. dissolves blood clots
b. prevents dysrhythmias
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? a. Direct the client to perform exercises of the ankle and toes. b. Instruct the client on use of crutches. c. Medicate the client for pain. d. Perform neurovascular checks of the extremities.
d. Perform neurovascular checks of the extremities.
Which laboratory test is the BEST resource for determining the preoperative status of a client's liver function? a. serum electrolytes b. blood urea nitrogen (BUN) and creatine c. serum albumin d. alanine aminotransferase (ALT), aspirate aminotransferase (AST), and bilirubin
d. alanine aminotransferase (ALT), aspirate aminotransferase (AST), and bilirubin
Which of the following are primary risk factors for pressure ulcers? SELECT ALL THAT APPLY a. insomnia b. sleeping on a water bed c. lengthy surgical procedures d. fever e. low protein diet
lengthy surgical procedures fever low protein diet
Which of the following is not a function of water in the body a solvent for chemical processes promotes electrical conduction in the heart transports substances in the blood fills in spaces in the tissue maintains body temperature
promotes electrical conduction in the heart
[Obj. 4c, e] The care plan for a 42-year-old patient with a deep vein thrombosis (DVT) in his left leg includes monitoring the patient for complications. Which of the following pulmonary complications is the patient most at risk for developing? Pulmonary edema Pulmonary embolism Pneumothorax Pneumonia
pulmonary embolism
Which of the following assessment findings would indicate development of a wound infection? (SELECT ALL THAT APPLY.) Purulent drainage Decreased pulse and respiratory rate Increased pulse and respiratory rate Fever Low white blood cell count
purulent drainage increased pulse and respiratory rate fever
The nurse determines that a field remains sterile if which of the following conditions exist? a. tips of wet forceps are held upward when held in ungloved hand b. the nurse reaches over the field rather than around the edges c. sterile items are 1 inch from the edge of the field d. the sterile field was set up 1 hour before the procedure
sterile items are 1 inch from the edge of the field
A male client is beginning an antidepressant medication. Which of the following should be included in the teaching? "Your partner will be pleased because your sexual functioning is going to improve." "You may find that your desire for sex will decrease while on this medication." "Retrograde ejaculation is a common problem when taking antidepressants." "Your skin will probably become supersensitive to touch, so you may need to change your activity during sex."
"You may find that your desire for sex will decrease while on this medication."
which of the following is the minimum urinary output in a healthy adult 0.5 ml/kg/hr 1 ml/kg/hr 3 ml/kg/hr 5 ml/kg/hr
0.5 ml/kg/hr
the body is comprised of both INTRAcellular and EXTRAcellular fluid. The INTRAcellular distribution is what part of the body fluid? 1/4 1/3 1/2 2/3
2/3
Which of the following clients should the nurse monitor closely for the development of pulmonary edema? 76-year-old client with history of heart failure 46-year-old client with abdominal surgery 51-year-old client with leg fracture 33-year-old client with asthma attack
76-year-old client with history of heart failure
Your 25 year old male patient arrives to the emergency department with an alcohol level of 0.3 and is responsive to only to a sternal rub. You insert an oral airway and start a large bore IV. Which IV fluid is the best choice for this patient? A. isotonic B. hypotonic C. hypertonic D. colloid
A. isotonic
Your patient comes to the emergency department after running a 5K the day prior. Which of the following symptoms is not a symptoms of fluid volume deficit hyperthermia decreased blood pressure decreased urinary output elevated blood pressure
elevated blood pressure
The nurse is caring for a patient with atelectasis. While auscultating lung sounds, the nurse will note which of the following findings? Crackles Wheezes Rhonchi Absent lung sounds
Absent lung sounds
You receive and admission to the medical floor. The patient is an 80 year old female who is type 2 diabetic. She was seen in the emergency department for a blood sugar of 20 and admitted to your floor. The admitting doctor is writing admission orders. Which of the following fluids would you expect the physician to order? A. Normal Saline B. Lactated Ringers C. Dextrose 5% 1/2 NS (D%.45NS) D. Albumin
C. Dextrose 5% 1/2 NS (D%.45NS)
The nurse who is assessing a client's chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take? Reinforce the chest tube dressing. Collaborate with the client's physician. Mark the area involved and remove the tube. Discontinue the chest tube suction.
Collaborate with the client's physician.
Which teaching technique is best for teaching a nursing assistant how to perform bedside fingerstick glucose testing? Demonstrate the procedure; then ask for a return demonstration Explain how to perform testing Suggest that the assistant watch a video Provide a manufacturer's pamphlet that provides detailed instruction
Demonstrate the procedure; then ask for a return demonstration
The nursing diagnosis "Diarrhea related to stress" is identified for a patient. Which of the following nursing interventions can help the patient relieve the cause of the diarrhea? Encourage the patient to verbalize about stressors and anxiety. Monitor and record the frequency of stools on the graphic record. Administer prescribed antidiarrheal medications as needed. Provide skin care after each bowel movement. Provide oral fluids.
Encourage the patient to verbalize about stressors and anxiety.
Inflammation is a local and nonspecific defensive response of the tissues to an injurous or infectious agent. Which of the following is NOT a sign of inflammation? (SELECT ALL THAT APPLY.) Redness Fatigue Pain Coolness Swelling
Fatigue and Coolness
Which of the following assessment findings by the nurse indicates RIGHT ventricular failure in a client? Paroxysmal nocturnal dyspnea. Crackles. Jugular venous distension. Pink frothy sputum.
Jugular venous distension
Which statement best describes why a spontaneous pneumothorax occurs? Collapse of lungs secondary to small bronchial collapse. Obstruction of alveoli and alveolar sacs by mucoid secretions. Disruption of normal blood pressure within the bronchial tree. Rupture of blebs or blisters on the lung surface.
Rupture of blebs or blisters on the lung surface.
Which of the following interventions would be the first priority when treating a client experiencing anginal chest pain while walking? Obtain an electrocardiogram (ECG). Administer sublingual nitroglycerine. Get the client back to bed. Sit the client down.
Sit the client down.
A __________________ pressure ulcer is defined as "full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as tendon or joint capsule." Stage I Stage II Stage V Stage III Stage IV
Stage IV
It is an extremely busy day on the medical surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently utilize her time and provide this teaching? Call the patient on the phone at home after the shift Quickly write down instructions so the patient can take them home with him Hold a teaching session while assisting the patient with his bath Teach the patient about his medications as each one is given
Teach the patient about his medications as each one is given
The paraplegic client is admitted to a medical unit from home with a stage IV pressure ulcer over the sacrum. What assessment tool should be completed on the admission to the hospital? Monitor the client on the Glasgow Coma Scale Assess for the Babinski Sign The Braden Scale Initiate a Brudzinski Flow Sheet
The Braden Scale
The nurse is assessing a wound and notes that the exudate is purulent. What would you expect the exudate to look like? The exudate is clear and appears blood-tinged. The exudate is bright red and bloody. The exudate is thick with the presence of pus is yellow in color. The exudate is red to pink and watery.
The exudate is thick with the presence of pus is yellow in color.
This "keyhole surgery" enters the chest cavity through a small incision. Thoracotomy Tracheostomy Bronchoscopy Thoracoscopy
Thoracoscopy
Your patient is admitted to the ICU and is unable to eat by mouth. The physician has ordered Total Parenteral Nutrition. The physician has ordered the following to be given D10% as the base. He also orders amino acids, electrolytes, and insulin to be added to the solution. Prior to administering the TPN you need to have which of the following? a peripheral line with an 18 g or larger a blood glucose done 1 minute before administering it a central line Lipids
a central line
Because a client reports having dyspareunia, it is most appropriate to ask which question? a. "Have you talked with your partner about this discomfort?" b. "Do you have pain before your period begins?" c. "Do your breasts swell large enough to need a larger bra?" d. "Have you had these spasms since you became sexually active?"
a. "Have you talked with your partner about this discomfort?"
A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? a. Review the results of serum electrolytes. b. Start an infusion of IV fluids c. Administer an antiemetic d. Offer the woman foods that are high in sodium and potassium content.
a. Review the results of serum electrolytes.
The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has a. A fractured rib b. A tumor of the medulla c. An infection d. Anemia
anemia
A young man is admitted to the emergency department with a stab wound to the right chest. He has moderate bleeding from the site, and his vital signs show symptoms of shock. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should administer high-flow oxygen using a non-rebreather mask. cover the sucking chest wound with a petroleum gauze dressing. position the patient on his uninjured side. apply a nonporous dressing taped on three sides to the chest wound.
apply a nonporous dressing taped on three sides to the chest wound.
An older Asian client has mild dysphagia from a recent stroke. The nurse plans the client's meals based on the need to: a. Have at least one serving of thick dairy (e.g., pudding, ice cream) per meal. b. Include as many of the client's favorite foods as possible. c. Eliminate the beer usually ingested every evening. d. Increase the calories from lipids to 40%.
b. Include as many of the client's favorite foods as possible.
Which of the following is most likely to validate that a client is experiencing intestinal bleeding? a. Brown, formed stools b. Semisoft tar-colored stools c. Large quantities of fat mixed with pale yellow liquid stool d. Narrow, pencil-shaped stool
b. Semisoft tar-colored stools
What is the best indication of proper placement of a nasogastric tube in the stomach? a. Client gags during insertion. b. pH of the aspirate is less than 5. c. Client is unable to speak. d. Fluid is easily instilled into the tube.
b. pH of the aspirate is less than 5.
During admission to a hospital unit, the clinet tells the nurse that her sleep tends to be very light and that is is difficult for her to get back to sleep if she is awakened at night. which interventions should the nurse implement? SELECT ALL THAT APPLY a. increase the temperature in the room b. remind colleagues to keep their converstions to a minimum at night c. deliver necessary medications and procedures at 1.5 to 3 hour intervals betwen 11pm and 6am d. encourage the client's family members to bring in a radio to play soft music at night e. encourage the client to ask family members to bring in a fan to provide white noise
b. remind colleagues to keep their converstions to a minimum at night c. deliver necessary medications and procedures at 1.5 to 3 hour intervals betwen 11pm and 6am e. encourage the client to ask family members to bring in a fan to provide white noise
A semiconscious client in the postanesthesia care unit (PACU) is experiencing dyspnea (difficulty breathing). Which action should the nurse perform FIRST? a. place a pillow under the client's head b. reposition the client to keep the tongue forward c. remove the oralpharyngeal airway d. administer oxygen by mask
b. reposition the client to keep the tongue forward
A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? a. Ataxia b. Anorexia c. Photosensitivity d. Jaundice
b. anorexia
Which of the following would a nurse NOT expect to see in a patient with cardiac tamponade? bradycardia tachypnea jugular vein distension (JVD) rapid hypotension
bradycardia
Which would most likely be included in the evaluation of the client goal of "Demonstrated adequate tissue perfussion"? symmetrical chest expansion use of pursed lip breathing brisk capillary refill activity intolerance
brisk cap refill
Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? a. "Intake of cranberry juice may help decrease the risk of infection." b. "I should use clean technique when emptying the collecting bag." c. "Soaking in a warm tub bath may ease the irritation associated with the catheter." d. "I will keep the collecting bag below the level of the bladder at all times."
c. "Soaking in a warm tub bath may ease the irritation associated with the catheter."
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? a. "I will call the provider to get a prescription for discontinuing the IV heparin today." b. "Both heparin and warfarin work together to dissolve the clots." c. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." d. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."
c. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."
Including at least some sexual health history questions would be most relevant for clients taking which category of drugs? a. Hypnotics (sleeping pills) b. Anti-inflammatories (such as aspirin or ibuprofen) c. Antihypertensives (blood pressure medications) d. Antihistamines (cold medications)
c. Antihypertensives (blood pressure medications)
A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? a. Apply the transdermal patch in the same location as the previous patch. b. Apply a new transdermal patch once a week. c. Apply the transdermal patch in the morning d. Apply a new transdermal patch when chest pain is experienced.
c. Apply the transdermal patch in the morning
What is the proper technique with gravity tube feeding? a. Nurse administers the next feeding only if there is less than 25 mL of residual volume from the previous feeding. b. Place client in the left lateral position. c. Feeding bag is hung 1 foot higher than the tube's insertion point into the client. d. Feeding is administered directly from the refrigerator.
c. Feeding bag is hung 1 foot higher than the tube's insertion point into the client.
Proper technique for performing a wound culture includes which of the following? a. swabbing for the specimen in the area with the largest collection of drainage b. removing crusts or scabs with sterile forceps and then culturing the site beneath c. cleansing the wound prior to obtaining the specimen d. waiting 8 hours following a dose of antibiotic to obtain the specimen
cleansing the wound prior to obtaining the specimen
Which of the following clients are at risk for the development of dysrhythmias? (SELECT ALL THAT APPLY.) A client with a serum potassium level of 4.3 mEq/L A client 3 hours post myocardial infarction Metabolic acidosis A client with COPD A client with an SaO2 of 96%
client 3 hours post myocardial infarction metabolic acidosis client with COPD
Which of the following statements about cortisol is TRUE? Cortisol decreases the body's use of excess amino acids Cortisol decreases inflammation Cortisol decreases protein catabolism (breakdown) Cortisol decreases the body's use of fats
cortisol decreases inflammation
A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? a. Prepare to irrigate the colostomy. b. Assess bowel sounds and administer antiemetic. c. Administer a bulk-forming laxative, and encourage increased fluids and exercise. d. After assessing the stoma and surrounding skin, notify the surgeon.
d. After assessing the stoma and surrounding skin, notify the surgeon.
A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? a. Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend. b. Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible. c. Discontinue taking the pills. d. Continue taking the pills and discuss tapering the dose with the primary care provider.
d. Continue taking the pills and discuss tapering the dose with the primary care provider.
The client is admitted to the emergency department with the chief complaint of "my heart is racing." Upon initiated cardiac monitoring the nurse discovers the client has a sustained heart rate of 170 beats per minute. The nurse then assesses the client for which of the following? a. Increased cardiac output b. Increased preload c. Decreased afterload d. Decreased cardiac output e. both A & B
d. Decreased cardiac output
The nurse assesses a postoperative client who has a rapid, weak pulse; urine output less than 30 mL/hr; and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect? a. wound dihiscense b. pneumonia c. thrombophlebitis d. hypovolemic shock
d. hypovolemic shock
Mrs. Jones has been prepped for surgery and has just arrived to the operating room. You assist Mrs. Jones to the table and begin to prepare for the surgery. You know that Mrs. Jones is in which operative phase at this time? a. preoperative phase b. perioperative phase c. postoperative phase d. intraoperative phase
d. intraoperative phase
Mrs. Jones just finished her rotator cuff repair and is brought into your unit. Your responsibilities include monitoring her vital signs, ensuring patient safety, and monitoring her airway until she is fully awake. You know that she is now in what operative phase? a. preoperative phase b. intraoperative phase c. perioperative phase d. postoperative phase
d. postoperative phase
Mrs. Jones just arrived to the same day surgery unit where she is scheduled to have a rotator cuff repair. You are to complete her teaching regarding the surgery, start her IV and discuss aftercare. What phase is this referring to? a. postoperative phase b. perioperative phase c. intraoperative phase d. preoperative phase
d. preoperative phase
Your patient was admitted to the hospital and you are reviewing their lab values. You note that the hemoglobin is normal however the hematocrit is very high. What condition would these values indicate? anemia leukemia dehydration overhydration
dehydration
which of the following are signs and symptoms of autonomic dysreflexia (SELECT ALL THAT APPLY) all of the above diaphoresis tachycardia sudden severe headache blurred vision
diaphoresis sudden severe headache blurred vision
In caring for a client on contact precautions for a draining foot ulcer, which action should the nurse perform? a. provide disposable meal trays and silverware b. follow standard precautions in all interactions with the client c. use surgical aseptic technique for all direct contact with the client d. wear a mask during dressing changes
follow standard precautions in all interactions with the client
Which of the following are allowed on a full liquid diet? SELECT ALL THAT APPLY a. oatmeal cereal b. scrambled eggs c. hard candy d. cream of wheat cereal e. fruit "smoothies" f. tomato juice g. mashed potatoes h. chocolate pudding
hard candy cream of wheat cereal fruit "smoothies" tomato juice chocolate pudding
Match the following terms with their function Question Correct Match Selected Match hypertonic isotonic hypotonic Osmosis All Answer Choices A. moves water across a membrane from an area of less concentration B. fluid remains in the vascular space C. moves water OUT of cells into the vascular space D. moves water INTO cell from vascular space E. moves solute molecules across a membrane from an area of greater concentration
hypertonic: C. moves water out of cells into vascular space isotonic: B. fluids remains in the vascular space hypotonic: D. moves water into cell from vascular space osmosis: A. moves water across a membrane from an area of less concentration
a client who was informed of a cancer diagnosis assures the nurse she is fine. which of the following is the most indicative physical evidence to the nurse of the client's stress? a. constricted pupils b. dilated peripheral blood vessels (flush) c. hyperventilation d. decreased heart rate
hyperventilation
The nurse recognizes that the primary pathophysiologic problem initiating the pulmonary changes occurring in Adult Respiratory Distress Syndrome (ARDS) is injury to the alveolar-capillary membrane increased production of surfactant remodeling of the lung by fibrous tissue capillary damage from pulmonary hypertension
injury to the alveolar-capillary membrane
Which of the following is false regarding pyridium it can be crushed or chewed if needed it relieves painful urination it is available over the counter it may discolor contact lenses and stain underwear
it can be crushed or chewed if needed
Cardiac tamponade is a life-threatening condition that is usually treated by diuretics chest tube placement needle aspiration all of the above
needle aspiration
A patient experiences a flail chest as a result of an automobile accident. During the respiratory assessment the nurse would expect to find deep, irregular respirations. paradoxic chest movement. laryngeal stridor. bloody sputum.
paradoxic chest movement.
Your patient is receiving TPN. Which of the following guidelines for administering TPN is NOT correct. change the IV tubing daily attach an extension with a filter to the IV tubing piggyback lipids above the filter in the TPN tubing notify the pharmacist as soon as possible with any change in the order for the TPN
piggyback lipids above the filter in the TPN tubing
The ____________________ phase, the second phase of healing, extends from day 3 or 4 to about day 21 postinjury. Maturation Proliferative Remodeling Inflammatory
proliferative
Pursed lip breathing is effective because it... decreases the use of accessory muscles to breathe causes a recurrent cough which removes secretions from bronchioles prolongs inhalation and forces air deeper into alveoli which limits pulmonary edema prolongs exhalation and prevents bronchiolar collapse
prolongs exhalation and prevents bronchiolar collapse
This type of diet is used to mange electrolytes and fluids diabetic high protein low fat renal
renal
afterload
resistance LEFT ventricle must overcome to circulate blood
Which action by the nurse represents proper nasopharyngeal suctioning? hyperoxygenate with 100% oxygen for 30 minutes prior to suctioning rotate the catheter while applying suction apply suction intermittently while inserting the suction catheter lubricate the suction catheter with petroleum jelly before and between insertions
rotate the catheter while applying suction
Which of the following diagnostic tests is relevant for assessing the risk of developing a pressure ulcer for an older adult client who has no major health issues? Red blood cells (RBC) Serum albumin Serum potassium White blood cells (WBC)
serum albumin
A __________________ pressure ulcer is defined as "partial-thickness skin loss (abrasion, blister, or shallow crater) involving epidermis & possibly dermis." Stage I Stage II Stage III Stage IV Stage V
stage II
Mrs. Johnson has had a gastrostomy tube placed. Prior to using her tube for feedings that are ordered you must check for placement of the tube. What are the 2 MOST ACCURATE methods for confirming gastrointestinal tube placement?
x-ray or radiograph and pH testing of the aspirate
The surgeon ordered sequential compression devices (SCDs) to be applied postoperatively. The client asks why the SCDs are needed. Which is the best response by the nurse when teaching the client about the purpose of SCDs? they promote arterial circulation they promote venous return from the legs they decrease afterload they decrease postoperative pain
they promote venous return from the legs
Which is the MOST effective nursing action for controlling the spread of infection? a. administering broad-spectrum phophylactic antibiotics b. wearing gloves and masks when providing direct patient care c. implementing appropraite isolation precautions d. thorough hand washing
thorough hand washing
match the age or stage of development with the correct sexual development phrase Question Correct Match Selected Match toddler (1-3 years) preschooler (4-5 years) school age (6-12 years) adolescence (12-18 years) young adult middle adulthood late adulthood A. can identify own gender B. explores own and classmates' body parts C. increased modesty and desire for privacy D. quality rather than number of occurrences becomes important E. homosexual identity is usually established F. vaginal secretions and sperm production is decreased G. may experiment with homosexuality
toddler (1-3 years) Correct A. can identify own gender preschooler (4-5 years) Correct B. explores own and classmates' body parts school age (6-12 years) Correct C. increased modesty and desire for privacy adolescence (12-18 years) Correct G. may experiment with homosexuality young adult Correct E. homosexual identity is usually established middle adulthood Correct D. quality rather than number of occurrences becomes important late adulthood Correct F. vaginal secretions and sperm production is decreased
specialized fluids including cerebrospinal, pleural, and peritoneal are considered what type of extracellular fluid interstitial intracellular intravascular transcellular
transcellular
[Obj. 4b] You are admitting Mrs. June, a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician orders supplemental oxygen at 24% FiO 2. What is the most appropriate oxygen delivery method for this patient? Nasal cannula Simple face mask Venturi mask Nonrebreather mask
venturi mask
preload
volume of blood in ventricles at end of DIASTOLE
An adult women's urethra is how long? A. 2-4 cm B. 3-4 cm C. 5-8 cm D. 10 cm
B. 3-4 cm
Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? a. "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." b. "I need to drink one and a half to two quarts of liquids each day." c. "Eating my meals at regular times is likely to result in regular bowel movements." d. "If my bowel pattern changes on its own, I should call you."
a. "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day."
A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? a. "I need to urinate a small amount in the toilet before collecting the sample." b. "I will wipe from the back to front with the cleansing cloth." c. "I should not collect a urine sample when I am menstruating." d. "I should let the urine cool to room temperature before sending it to the lab."
a. "I need to urinate a small amount in the toilet before collecting the sample."
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values a. Amylase b. Magnesium c. Calcium d. Red blood cell count
a. Amylase
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? a. Check the tubing for kinks b. Notify the provider c. Adjust the rate of bladder irrigant d. Irrigate the catheter
a. Check the tubing for kinks
A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a NG tube into the client, which of the following findings should the nurse anticipate? a. Dark amber drainage b. Coffee-ground drainage c. Greenish-yellow drainage d. Frothy pink drainage
b. Coffee-ground drainage
During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to this client? a. Caution him not to drink or take sleeping pills since they may make his snoring worse. b. Refer him to a sleep disorders center for evaluation and treatment of his symptoms. c. Refer him to a dietitian for a weight loss program. d. Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife.
b. Refer him to a sleep disorders center for evaluation and treatment of his symptoms.
A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? SELECT ALL THAT APPLY a. Limit fluids to avoid the burning sensation on urination. b. Review symptoms of UTI with the client. c. Wipe the perineal area from back to front. d. Wear cotton underclothes. e. Take baths rather than showers.
b. Review symptoms of UTI with the client. d. Wear cotton underclothes.
A nurse receives information that a client is transgender. Appropriate care is based on the knowledge that which of the following is most representative of this client? a. Gonadal gender, internal organs, and external genitals are contradictory b. Sexual anatomy is not consistent with gender identity. c. Sexual attraction is to individuals of both genders. d. Gender identity is altered by acute psychosis.
b. Sexual anatomy is not consistent with gender identity.
The catheter slips into the vagina during a straight catheterization of a female cinet. The nurse does which action? a. removes the catheter, wipes it with a sterile gauze and redirects it to the urinary meatus b. leaves the catheter in place and gets a new sterile catheter c. removes the catheter ad redirects it to the urinary meatus d. leaves the catheter in place and asks another nurse to attempt the procedure
b. leaves the catheter in place and gets a new sterile catheter
The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? a. Urine becomes more concentrated. b. The bladder distends and its capacity increases. c. The amount of urine retained after voiding increases. d. Older adults ignore the need to void.
c. The amount of urine retained after voiding increases.
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? a. An ascending colostomy delivers liquid feces. b. The skin under the appliance looks red briefly after removing the appliance. c. The stoma color is a deep red-purple. d. 1. The stoma extends 1/2 in. above the abdomen.
c. The stoma color is a deep red-purple.
The purpose of the salem NG decompression tube's blue lumen is to a. provide a port for continuous feeding b. allow siphoning of gastric contents if they stagnate c. prevent tube adherence to the gastric mucosa d. prevent esophageal reflux of gastric contents
c. prevent tube adherence to the gastric mucosa
Which of the following classes of medications causes ARTERIAL vasodilation, which lowers afterload, systemic vascular resistance (SVR) and thus the workload of the heart? Alpha-adrenergic agonists Beta-adrenergic blockers Calcium channel blockers Cardiac glycosides (digoxin)
calcium channel blockers
[Obj. 4a] Which of the following blood levels normally provides the primary stimulus for breathing? pH Oxygen Carbon dioxide Carbon monoxide
carbon dioxide
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning? a. Abdominal distention b. Hypoactive bowel sounds in two quadrants c. Request for a cup of tea and some toast d. Passage of flatus
d. Passage of flatus
Ally is a senior in high school and reports that she doesn't like to use the bathroom at school, especially if she needs to have a bowel movement. With this being known you know that resisting the urge to defecate can lead to which of the following? a. diarrhea b. hemorrhoids c. incontinence d. constipation
d. constipation
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? a. Hyperthermia b. Ototoxicity c. Muscle pain d. Hypotension
d. hypotension
Your patient was diagnosed with dilated cardiomyopathy with an ejection fraction of 40%. What is the best nursing diagnosis for this patient? a. Ineffective tissue perfusion (peripheral) b. Pain c. Impaired gas exchange exchange d. Decreased cardiac output e. both A & B
decreased cardiac output
The nurse establishes the presence of a tension pneumothorax with a mediastinal shift when assessment findings reveal severe inspiratory wheezes a shift of the point of maximal impulse (PMI) to the left, with high blood pressure and bounding pulses. deviation of the trachea toward the side opposite the pneumothorax. all of the above.
deviation of the trachea toward the side opposite the pneumothorax.
The client's postoperative orders state "diet as tolerated." The client has been NPO. The nurse will advance the client's diet to clear liquids based on which assessment? SELECT ALL THAT APPLY. a. does not complain of nausea or vomiting b. expresses feeling "hungry" c. passing flatus d. ambulates with minimal assistance e. pain is maintained at a 2-3 on a scale of 10
does not complain of nausea or vomiting passing flatus
Which of these measures to prevent pulmonary embolism after lower extremity surgery is best? Frequent chest X-rays to find a pulmonary embolism Frequent lower extremity scans Encourage patient to use incentive spirometer every two hours Early ambulation
early ambulation
The adult male urethra is approximately this long A. 6 inches B. 8 inches C. 12 inches D. 20 inches
B. 8 inches
An IV solution that contains large proteins and molecules is considered what category of IV solution? A. extravascular B. colloid C. crystalloid D. hypotonic
B. colloid
During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? SELECT ALL THAT APPLY a. History of frequent urinary tract infections b. A fecal impaction c. Fluid intake of less than 1,500 mL/day d. History of antihistamine intake e. Perineal skin irritation
a. History of frequent urinary tract infections b. A fecal impaction c. Fluid intake of less than 1,500 mL/day e. Perineal skin irritation
In conducting client teaching, the nurse bases content on knowing that which of the following is true regarding masturbation? a. Masturbation is a way people learn about their sexual response b. Most people do not masturbate past the teenage years. c. Teenage masturbation interferes with academic achievement. d. People who masturbate are psychologically disturbed.
a. Masturbation is a way people learn about their sexual response
Which goal is the MOST appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? a. The client will return to his or her previous fecal elimination pattern. b. The client will increase intake of insoluble fiber such as grains, rice, and cereals. c. The client verbalizes the need to take an antidiarrheal medication prn. d. The client will wear a medical alert bracelet for antibiotic allergy.
a. The client will return to his or her previous fecal elimination pattern.
A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching? a. Supply nutrients via tube feedings b. Decompress the stomach. c. Administer medications. d. Determine the pH of the gastric secretions.
b. Decompress the stomach.
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? a. Cataract extraction b. Hip arthroplasty c. Myringotomy d. Laparoscopic appendectomy
b. Hip arthroplasty
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? a. Different blood pressures in the upper limbs. b. Differences in upper and lower lung sounds. c. Differences between oral and axillary temperatures. d. Different apical and radial pulses.
d. Different apical and radial pulses.
A nurse is admitting a client who was prescribed antibiotic therapy and now has a Clostridium difficile infection. Which of the following actions should the nurse take? a. Use alcohol hand sanitizer after completing tasks for the client. b. Have the client wear a mask when out of the room. c. Place the client in a protective environment. d. Disinfect equipment in the client's room daily.
d. Disinfect equipment in the client's room daily.
