Exam 2 NCLEX style questions

Tissue transplanted from donor tissue that includes blood vessels is called _______

A skin flap

Skip lesions, segments of normal bowel among segments of diseased bowel. A) ulcerative colitis B) Crohns Disease C) Both

B) Crohns Disease

A platelet-derived growth factor gel that stimulated cell proliferation and migration.

Becaplermin

The name of the assessment nurses use to assess pressure ulcer risk

Braden scale

Chronic inflammation of the GI tract characterized by periods of remission and exacerbation. A) ulcerative colitis B) Crohns Disease C) Both

C) Both

Usual age of at onset is teens to mid-30s or after 60. A) ulcerative colitis B) Crohns Disease C) Both

C) Both

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? A) Hematocrit of 46%46% B) Hemoglobin of 13.8 g/dL13.8 g/dL C) Elevated Elevated reticulocyte reticulocyte count D) Decreased white blood cell count

C) Elevated Elevated reticulocyte reticulocyte count reticulocytes are immature RBCs—there would be an increase in their production because of the hemorrhage.

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? A. Dyspnea. B. Precordial pain. C. Increased pulse rate. D. Elevated blood pressure.

C. Increased pulse rate. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.

Which of the following is not a risk factor for VTE? A) Vascular wall damage B) Hypercoagulability C) Venous stasis D) Hypoxia

D) Hypoxia

What is the process where dead or infected tissue is removed from a wound?

Debridement

Harmless, tiny white bumps that appear across a baby's chin, nose, or cheeks

Milia

This is the most common bony prominence for pressure ulcers to develop

Sacrum

Name two types of tissues or cells that rapidly regenerate

Skin, lymphoid organs, bone marrow, mucous membranes

Test involving a black light to detect certain fungal or bacterial infections

Wood's lamp

Therapy that delivers 100% oxygen at 1.5-3 times the normal atmospheric pressures

Hyperbaric oxygen therapy

A client's blood pressure (BP) is 145/90. According to the guidelines for determining hypertension, the nurse realizes that the client's BP is at which stage? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

c. Stage 1 hypertension

This type of healing takes place when wound margins are neatly approximated (think surgical wound)

Healing by primary intention

Test to assess for allergic reactions

The Patch test

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? A) Hemoglobin level B) Neutrophil count C) White blood cell count D) Platelet count

A) Hemoglobin level Pallor of skin and nail beds are a symptom of anemia, which would be assessed by looking at the Hemoglobin level.

Which of the following assessment findings would the nurse expect to find with mild hypothermia? A) Lethargy B) Bradypnea C) Fixed pupils D) Absent reflexes

A) Lethargy in mild hypothermia you would expect to see lethargy. What else? Confusion, shivering, rational behavior minor heart rate changes.

A 19-year-old college student was found unconscious by a popular college bar in winter. The student did not have a jacket or winter clothing on. The student was brought to the Emergency department and found to have a temperature of 34.8°C. Based on this temperature the client has A) Mild hypothermia B) Moderate hypothermia C) Severe hypothermia D) Minimal hypothermia

A) Mild hypothermia

Inflammation is limited to the colon A) ulcerative colitis B) Crohns Disease C) Both

A) ulcerative colitis

Incidence of toxic megacolon in more common in: A) ulcerative colitis B) Crohns Disease C) Both

A) ulcerative colitis toxic megacolon is where you have dilatation of the colon. The dilatation can be either total or segmental. Toxic megacolon is a life-threatening condition that needs immediate treatment.

A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include A. Core rewarming with warm fluids. B. Ambulation to increase metabolism. C. Frequent oral temperature assessment. D. Gastric tube feedings to increase fluids.

A. Core rewarming with warm fluids. Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including A. Stupor. B. Erythema. C. Increased anxiety. D. Rapid respirations.

A. Stupor. Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.

A pressure ulcer with eschar present; Unable to assess depth, undermining. Name this wound

An unstageable or unclassified ulcer

A patient with a venous thromboembolism (VTE) is started on IV heparin and oral warfarin (Coumadin). The patient asks the nurse why two medications are necessary. The nurse's best response to the patient is A) "Heparin will dissolve the clot, and Coumadin will prevent more clots." B) "Heparin will work immediately, and Coumadin will take several days to effect coagulation C) "Administering both medications will reduce the risk for recurrent DVT." D) "Because you are at risk for a pulmonary embolism, it is important for you to take both medications."

B) "Heparin will work immediately, and Coumadin will take several days to effect coagulation Heparin does not dissolve clots; it is an indirect thrombin inhibitor, which inhibits part of the clotting cascade from forming a fibrin clot Warfarin takes a few days to take effect. Further it takes more days to reach its maximum effectiveness. Therefore, Heparin will be used as well because it will work immediately until warfarin reaches max effectiveness. Could also use LMWH such as dalteparin with the warfarin

Increased incidence of small intestinal cancer. A) ulcerative colitis B) Crohns Disease C) Both

B) Crohns Disease With UA it is colorectal after 10 years of disease. Can see colorectal with Crohn's BUT more common in UA

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse A. Places a hypothermia blanket at the bedside. B. Adjusts the bed to the Trendelenburg position. C. Obtains electronic equipment for monitoring the vital signs. D. Secures a pump to administer the ordered intravenous fluids.

B. Adjusts the bed to the Trendelenburg position. It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.

All of the following interventions would be appropriate for a person with mild hypothermia except: A) Applying warm blankets B) Bair hugger C) Peritoneal lavage with warmed fluids D) Radiant lighting

C) Peritoneal lavage with warmed fluids would not need to do active internal warming for mild hypothermia

Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? A) Temperature of 100.4° F (38°C) B) Cool skin temperature of right lower leg C) Dependent rubor and pallor of right leg D) New onset of shortness of breath

D) New onset of shortness of breath New onset of shortness of breath is a symptom of a PE, which is a complication of a VTE. The other symptoms are more typical findings for VTE. Dependent rubor is a fiery to dusky-red coloration visible when the leg is in a dependent position but it is not red when it's elevated above the heart. When it is elevated it is pale

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? A) Hematocrit of 37% B) Hemoglobin of 11.8 g/dL C) Platelet count of 400,000/μLof 400,000/μL D) White blood cell (WBC) count of 2800/μL

D) White blood cell (WBC) count of 2800/μL The nurse is most concerned about the very low WBC count. WBC count remains the same in older adults. All other labs are within range.

A priority nursing intervention for a patient with hyperthermia would be A. Initiating seizure precautions. B. Limiting oral intake. C. Providing a blanket. D. Removing excess clothing.

D. Removing excess clothing. Rationale The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. Increased respirations. B. Rapid pulse rate. C. Red, sweaty skin. D. Slow capillary refill.

D. Slow capillary refill. With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.

This drainage consists of WBCs, dead and alive microorganisms, and other debris. Name this type of drainag

Purulent or pus

Healing process where lost cells and tissue are replaced with cells of the same type

Regeneration

The phenomenon with inflammation where one sees an increased WBC count with elevated band neutrophils

Shift to the Left

A pressure ulcer that involves non-blanchable erythema of intact skin. Name this wound

Stage 1

A type of pressure ulcer involving partial-thickness skin loss involving dermis

Stage II

A pressure ulcer with full-thickness skin loss involving damage or necrosis of subcutaneous tissue. Bone, tendon, & muscle not exposed. Name this wound

Stage III

A type of pressure ulcer involving a full-thickness skin loss with extensive tissue damage and necrosis. Muscle tendon, & bone exposed and directly palpable (slough or eschar may be present). Name this wound.

Stage IV (4)

The medical term for marks that appear on a pregnant woman due to rapid stretching of the skin

Straie gravidarum—reflect separation of collagen tissue

A nurse is caring for a client who is taking an angiotensin-converting enzyme inhibitor and develops a dry, nonproductive cough. What is the nurse's priority action? a. Call the health care provider to switch the medication. b. Assess the client for other symptoms of upper respiratory infection. c. Instruct the client to take antitussive medication until the symptoms subside. d. Tell the client that the cough will subside in a few days.

a. Call the health care provider to switch the medication. Angiotensin-converting enzyme inhibitors prevent the breakdown of bradykinin, frequently causing a nonproductive cough. Angiotensin receptor blocking agents do not block this breakdown, thus minimizing this annoying side effect. The client should be switched to a different medication if the side effect cannot be tolerated.

Which client assessment would assist the nurse in evaluating therapeutic effects of a calcium channel blocker? a. Client states that she has no chest pain. b. Client states that the swelling in her feet is reduced. c. Client states the she does not feel dizzy. d. Client states that she feels stronger.

a. Client states that she has no chest pain. The workload in the heart should be decreased with the vasodilatation from the calcium channel blocker. With less strain, the client should have fewer incidences of angina as afterload is decreased

An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: a. Left ventricular atrophy b. Irregular heartbeats c. Peripheral vascular occlusion d. Pacemaker placement

a. Left ventricular atrophy In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

A client's serum lipids are cholesterol 197mg/dl, low-density lipoprotein (LDL) 110 mg/dl, andhigh-density lipoprotein (HDL) 35 mg/dl. The nurseknows what about these values? a. Serum lipids are within desirable values. b. Cholesterol is within desirable value, but LDL and HDL are not. c. Cholesterol is not within desirable value, though LDL and HDL are. d. Cholesterol, LDL, and HDL are not within desirable values.

b. Cholesterol is within desirable value, but LDL and HDL are not.

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased premature ventricular contractions

b. Increased urine output Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias

A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? a. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." b. "The triglycerides are elevated and will not return to normal without these medications." c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." d. "The medications are not indicated since your lab values are all normal."

c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, post-menopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke.

A client taking spironolactone (Aldactone) [potassium-sparing diuretic] has been taught about the therapy. Which menu selection indicates that the client understands teaching related to this medication? a. Apricots b. Bananas c. Fish d. Strawberries

c. Fish Spironolactone is a potassium-sparing diuretic that could potentially cause hyperkalemia. Fish is an appropriate dietary choice, because it is low in potassium. The other foods are high in potassium.

A nurse who is giving a statin(Lipitor) realizes the importance of monitoring for which serious adverse reaction? a. Pharyngitis b. Rash/pruritus c. Rhabdomyolysis d. Agranulocytosis

c. Rhabdomyolysis

The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? a. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. b. a 43-year-old male with a family history of CAD and cholesterol level of 158 c. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor) d. A 65-year-old female who is obese with an LDL of 188

d. A 65-year-old female who is obese with an LDL of 188 The woman who is 65-years-old, over weight and has an elevated LDL is at greatest risk. Total cholesterol >200, LDL >100, HDL <40 in men, HDL <50 in women, men 45-years and older, women 55-years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity and high LDL cholesterol places this client at greatest risk.

Captopril (Capoten) has been ordered for a client. The nurse teaches the client that ACE inhibitors have which common side effects? a. Nausea and vomiting b. Dizziness and headaches c. Upset stomach d. Constant, irritating cough

d. Constant, irritating cough