Exam Study Guide
21. A client with COPD tells the nurse, "At home, I only have to use an albuterol (Proventil) inhaler. Why did the doctor add an ipratropium (Atrovent) inhaler while I'm in the hospital?" The appropriate response by the nurse is:
"Atrovent works differently to dilate the bronchi, and the two drugs together are more effective."
59. A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe?
"Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."
9. The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?
0.45% Normal Chloride
45. The nurse has been assigned 3 patients. Choose in what order the nurse should assess her patients after receiving report.
1. A 30 year old with a tracheotomy 2. An 80 year old with a potassium level of 3.4 mEg/L. BP 140/85, P. 80 regular, R. 16. 3. A 70 year old 5 days post admission for emphysema who is anxious about her planned discharge.
65. A client with chemotherapy induced anemia has a prescription for 75mg of iron dextran to be given intramuscularly (IM). The pharmacy sent 2 mL single-dose vials that are labeled 50mg/mL. How many mL of medication does the nurse need to prepare in the syringe?
1.5
76. A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia?
10 am
10. The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?
Crackles in the lung bases
40. The nurse determines that complications of influenza are developing in a patient who experiences the following symptoms.
Crackles in the lungs and productive cough
100. A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis?
Encourage the patient to engage in a moderate amount of exercise as tolerated.
58. An adult patient has been diagnosed with iron deficiency anemia. What nursing diagnosis is most likely to apply to this patient's health status?
Fatigue related to decreased oxygen carrying capacity.
30. A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and her respiratory distress. Which of the following chest disorders should be suspected?
Flail chest
60. An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?
Fluid and electrolyte replacement
25. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity very 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health?
Fluid volume status
90. Which laboratory data should the nurse monitor for the patient receiving the intravenous Methylprednisolone (a corticosteroid)?
Glucose level
8. An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
HYPOKalemia
52. A client is receiving steroids to manage Addison's disease. Which side effects of this medication would the nurse assess for in this client?
Hyperglycemia and weight gain
6. The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermediate spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse suspect?
Hypocalcemia
63. A client diagnosed with meningitis says, "I'm just so thirsty. I keep drinking and drinking but I just can't seem to get enough. I've been urinating a lot, too" The nurse checks the client's urine specific gravity and finds it to be very dilute. The nurse suspects that the client may be developing diabetes insipidus. Which assessment finding would support the nurse's suspicion? Select all that apply.
Hypotension, Dry mucous membranes, and Poor Skin turgor
1. A client has a history of chronic obstructive pulmonary disease(COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important to assess?
Lung sounds
18. A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7,50, partial pressure of arterial carbon dioxide (PaCO;) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO,) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic Alkalosis
49. A patient is diagnosed with neutropenia, but the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient?
Meticulous hand hygiene
19. A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications.
74. The nurse assesses a client with Addison disease. Which finding will the nurse expect the client to exhibit?
Muscle cramps, fatigue, and hypotension
42. The nurse is caring for a 79-year-old man who has returned to the post surgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what post surgical complication?
Pulmonary embolism
85. A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment?
Purplish-red streaks on the abdomen (striae)
67. A nurse is caring for a client with hypothyroidism. The nurse is teaching him the signs he needs to watch for in monitoring his response to levothyroxine sodium. What symptoms would the nurse teach the client to watch for that would indicate a need to decrease the dosage?
Rapid or racing heart rate
53. The nurse plans to teach the client about a diagnosis of hypoparathyroidism, secondary to a thyroidectomy 6 weeks ago. What would be important to teach the client to prevent complications?
Report any painful spasms in smooth and skeletal muscles.
17. A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCOg) of 24 mEq/L. What disorder is indicated by these findings?
Respiratory Alkalosis
7. A patient in the ICU starts complaining of being "short of breath". An ABG is drawn. The ABG has the following values pH=7.21, PaCO2=64 mm Hg. HCO3= 24
Respiratory acidosis
39. You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
See if there are leaks in the system.
26. A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patient's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?
Silver nitrate application
14. A patient in an acute-care setting is being monitored closely after recently experiencing status asthmaticus. The nurse who is providing care for the patient has been assessing the patient's respiratory status frequently and has just completed auscultation of the patient's breath sounds. The nurse notes that the patient's breath sounds are significantly quieter than during the previous assessment. How should the nurse best interpret this assessment finding?
The patient's airflow may be severely limited.
62. A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding?
The patient's glucose levels are inadequate
22. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to
Try to drink 3 liters of fluid a day
31. The nurse is caring for a client with suspected Acute Respiratory Distress Syndrome (ARDS) with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?
Unresponsive (Refractory) hypoxemia
80. A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:
sodium and potassium abnormalities
98. A 55-year-old patient comes to the clinic for a routine check-up. The patient's BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurse's best response?
"Hypertension greatly increases your risk of stroke and heart disease."
78. After teaching a client about taking daily oral iron preparations for a moderate iron deficiency anemia, which statement by the client indicates to the nurse that additional instruction is needed?
"I will call the doctor if my stools turn black."
46. A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what?
"I will make sure to follow the weight loss plan designed by the dietician."
64. What statement made by a client who just received discharge teaching on polycythemia indicates the need for further education?
"I will make sure to restrict how much water I drink."
33. A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheotomy?
"Tell my wife about it, I do not want to touch it."
41. A patient admitted with COPD who is a pack-a-day smoker tells the nurse, "I am just not ready to quit smoking yet." The most appropriate response by the nurse is:
"What do you think keeps you from quitting?"
55. The nurse visits a client who is taking thyroid medication and is having trouble sleeping. The client asks for a "sleeping pill." Which is an appropriate first response by the nurse?
"What time of day are you taking your thyroid medication?"
72. The nurse teaches a client newly diagnosed with type 2 diabetes mellitus (DM) about exercise. Which statement is appropriate for the nurse to include in the teaching session?
"You need to wear appropriate footwear when exercising"
87. The physician orders Imferon 100 mg IM every other day for your patient with pernicious anemia. The drug is supplied in ampules containing 25 mg/0.5 mL. How many milliliters will you administer?
2
43. Mr Russell, who has alcoholism, has an order for magnesium sulfate 2g in 100 mL of DSW. The pharmacy recommends the magnesium be infused at a rate of 1 g/hour with an IV pump. How many milliliters per hour should the IV pump be programed for?
50
44. A patient with hypokalemia has an order for 40 miL of potassium to be infused intravenously now. The potassium is diluted in 200 mL of D5W. The facility's policy states to infuse IV potassium at a rate of 10 mEq/hour. How many milliliters per hour should the IV pump be programmed for?
50
95. A patient with hypokalemin has an order for 40 miL of potassium to be infused intravenously now. The potassium is diluted in 200 mL of D5W. The facility's policy states to infuse IV potassium at a rate of 10 mEq/hour. How many milliliters per hour should the IV pump be programmed for?
50
96. Mr Russell, who has alcoholism, has an order for magnesium sulfate 2g in 100 mL of DSW. The pharmacy recommends the magnesium be infused at a rate of 1 g/hour with an IV pump. How many milliliters per hour should the IV pump be programed for?
50
66. A client sustains a brain injury subsequent to a motor vehicle accident. The client is being treated with vasopressin, Which would indicate that the medication is effective?
A reduction in urine output
89. A patient with sickle cell disease is brought to the emergency department by a parent. The patient has a fever of 101.6° F, HR 116, RR 32. The nurse auscultates bilateral wheezes in both lung fields. What does the nurse suspect this patient is experiencing?
Acute chest syndrome
88. A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patient's immediate care? Select all that apply.
Administering beta blockers to reduce heart rate, Applying interventions to reduce the patient's temperature
57. A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote?
Always carry fast acting sugar.
4. The preoperative nurse is preparing a client for a robotic assisted cholecystectomy. The client is asked why they last had anything to eat or drink and admits to having eggs with coffee for breakfast. Which of the following risks is the nursing priority for the Postoperative nurse?
Apiration
82. A client is brought to the ED reporting fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the client has been treated for a sore throat three times in the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client's diagnosis?
Aplastic anemia
12. A client with COPD tells the nurse, "At home I only have to use an albuterol (Poventil) inhaler. Why did the doctor add an ipratropium (Atrovent ) inhaler while in the hospital?" The appropriate response by the nurse is?
Atrovent works differently to dilate the bronchi, and the two drugs together are more effective
38. The surgical unit nurse has just received a patient with a history of smoking from the post anesthesia care unit. Which action is most important at this time?
Auscultate for adventitious breath sounds.
83. A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms?
B12
97. A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?
Begin ECG monitoring
77. The nurse is assessing a patient diagnosed with Graves' disease. What physical characteristics of Graves' disease would the nurse expect to find?
Bulging eyes
5. The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take?
Call the physician to review the procedure with the client.
84. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?
Changes in diet and exercise may control blood glucose levels for some individuals with type 2 diabetes
86. The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take first?
Check the blood glucose during the night between 2am and 4am
51. A client is hospitalized with diabetic ketoacidosis (DKA), given insulin, and started on intravenous fluids. The nurse completes an assessment and finds the client breathing rapidly, has a rapid pulse, and poor skin turgor. His breath has a fruity odor. What priority action should the nurse next make?
Check to see that the IV fluids are running as prescribed
54. An 18-year-old with a body mass index (BMI) of 30 kg/m enters the clinic with a four-week history of fatigue, frequent urination, and weight loss. Which laboratory study is most critical at this time?
Complete Blood Count (CBC)
37. The major advantage of a Venturi mask is that it can:
Deliver a precise concentration of oxygen.
29. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypnea. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what?
Diminished or absent breath sounds on the affected side
70. A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patient's care?
Disturbed body image related to changes in physical appearance
56. A diabetes nurse educator is teaching a group of patients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic patient?
Do not eliminate insulin when nauseated and vomiting.
69. A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a patient with this condition is what?
Excessive fluid volume
61. A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support the diagnosis of diabetes mellitus?
Fasting plasma glucose greater than or equal to 126 mg/dL
2. A nurse has established a nursing diagnosis of ineffective airway clearance. The assessment findings that best support the diagnosis is that the client?
He wheezes and crackles in the right lung lobes
15. The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute, After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs?
Hypovolemic shock
3. The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs of?
Hypovolemic shock
47. Following a thyroidectomy, a client exhibits signs of tetany. The nurse anticipates administering which medication?
IV calcium gluconate
20. The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?
Incentive spirometry
73. The nurse notes that a client with type 2 diabetes mellitus has a glycosylated hemoglobin A1c level of 6.5% (0.065). Which action will the nurse implement based on the current data?
Inform the client that the current treatment is effective
75. A patient with possible disseminated intravascular coagulation (DIC) arrives in the emergency department with a blood pressure of 82/40, temperature of 101° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first?
Infuse normal saline 500 mL over 30 minutes.
94. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to
Insert IV Catheter
81. A client receiving thyroid replacement therapy develops influenza and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication?
Myxedema coma
99. An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?
Nitroglycerin, oxygen, and bed rest
24. A patient is having pulmonary-function studies performed. The patient performs a spirometry test, revealing ail FEV1/FVC ratio of 60%. How should the nurse interpret this assessment finding?
Obstructive lung disease
27. A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?
Obstructive sleep apnea
36. A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?
Patient's breath sounds are clear to auscultation.
48. A patient's blood work reveals a platelet level of 17,000/mm3. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level?
Petechiae
35. The nurse enters a dent's room to find that the client has pulled out her chest tube. Which of the following actions by the nurse is most appropriate?
Place an occlusive dressing taped on three sides over the wound
68. A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the patient's bleeding and established that his vital signs are stable. What should be the nurse's next action?
Prepare for the administration of factor VIII.
28. A nurse teaches a client with COPD how to perform pursed-lip breathing by explaining that this technique will assist respiration by:
Preventing airway collapse and air trapping in the lungs during expiration.
23. Which client should the medical unit nurse assess first after receiving shift report?
The 84-year-old client diagnosed with pneumonia who is febrile but getting restless and confused.
16. The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?
The client may be at risk for malignant hyperthermia.
34. A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?
The client with continuous bubbling in the drainage chamber
50. A nurse enters the room of a client with type 1 diabetes. The client is diaphoretic, lethargic, and has a decreased level of consciousness. Which assessment assists the nurse to plan the next nursing action?
The client's rapid acting insulin is peaking at the time of this encounter.
11. A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problems. The nurse's priority for patient education should be?
The importance of complying with CPAP despite the inconvenience associated with its use
91. The nurse is preparing to administer morning medications. Which medication is most time sensitive?
The insulin aspart to the patient who just finished breakfast
93. A patient's electronic health record notes that he has previously undergone treatment for secondary polycythemia. How should this aspect of the patient's history guide the nurse's subsequent assessment?
The nurse should assess for evidence of lung disease.
92. A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy?
The patient is at an increased risk for developing infection.
71. A patient with hypothyroidism and a diagnosis of myxedema coma is admitted to the critical care unit. Which assessment data warrants immediate intervention by the nurse?
The patient's ABG values are pH, 7.30; Pa02, 78; PaCO2, 50; HCO3, 25
32. The nurse in a long-term-care facility is aware of the importance of preventing upper respiratory infections (URs) among the residents of the facility. How is this best accomplished?
Vigilant hand washing by staff and residents
79. Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction experiences:
heat intolerance and systolic hypertension
13. A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?
third-spacing
