Health and Wellness Final Exam
A patient with a history of asthma is having SOB. THe nurse discovers that a peak flow expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action?
- Administer rescue drug
Which assessment finding for an older adult patient does the nurse describe to the natural aging process?
- Decrease in respiratory muscle strength
Which are considered adventitious lung sounds?
-Wheezes -Crackles -Pleural friction rub
Which client who has just arrived in the emergency room does the nurse classify as emergent and needing immediate medical evaluation? A. 60-year old with veinous insufficiency who has new onset right calf pain and tenderness B. 64-year old with chronic veinous ulcers who has a temp of 100.1 C. 69-year old with a 40 pack year cigarette history who is reporting foot numbness D. 70-year old with a history of diabetes who has tearing back pain and diaphoretic
70-year old with a history of diabetes who has tearing back pain and diaphoretic
What is an expected side effect of a patient on radiation therapy? a. Local skin changes & hair loss b. Enhanced taste c. Energetic d. Increased appetite
A Local skin changes & hair loss
A client was admitted with iron deficiency anemia and blood streaked emisis. Which question is most appropriate for the nurse to ask in determining the extent of the cleients activity intolerance? a. "which activities were you able to do six months ago compared to the present?" b. "How long have you had this problem?' c. "have you been able to keep up with all your usual activities?" d. "are you more tired now than you used to be?"
A "which activities were you able to do six months ago compared to the present?"
what is the minimum urine output per day to excrete toxicities? A. 400-600ml B. 30-40ml C. 1000-1200ml D. 1500-2000ml
A 400-600ml
When planning pt. care for the day, the nurse is concerned that which patient has the greatest risk of developing heart failure? A. 69yo African American male with uncontrolled hypertension B. 75yo Caucasian male who is overweight C. 52yo Caucasian female with asthma D. 50yo Asian American female who drinks 2 glasses of wine per day
A 69yo African American male with uncontrolled hypertension
A nurse assess patients who are at risk for diabetes mellitus. Which patient is at greatest risk? A. A 48 year old american indian B. A 32 year old african american C. A 44 year old asian american
A A 48 year old american indian
The nurse is alerted to possible anaphylactic shock immediately after a patient has received intramuscular penicillin by the development of: a. Edema and itching of the injection site b. Sneezing and itching of the nose and eyes c. A wheal-and-flare reaction at the injection site d. Chest tightness ad production of thick sputum
A Edema and itching of the injection site
Which question is most important for the nurse to include when assessing the client for etiological factor related to cirrhosis? A. Have you been exposed to toxic substances where you work B. Do you smoke cigarettes or use nicotine containing products? C. Have you ever been told you have high blood pressure? D. Do you eat a lot of high protein foods on a regular basis
A Have you been exposed to toxic substances where you work
The nurse, teaching a pt. about lifestyle modifications to help manage hypertension determines that instruction has been effective when the pt. states... A. I know I need to work on giving up my cigarettes and alcohol B. My father had hypertension did nothing and lived to be 90 C. I wont be able to run in marathons anymore D. In need to get started on meds at some point
A I know I need to work on giving up my cigarettes and alcohol
A nurse cares for a patient with a deficiency of aldosterone. Which assessment finding would the nurse correlate with this defiecncy? A. Increased urine output B. Blood glucose of 98 C. Serum sodium of 144 D. Vasoconstriction
A Increased urine output
A client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record? A. Intermittent Claudication B. Peripheral venous insufficiency C. Deep vein thrombosis D. Dependent rubor
A Intermittent Claudication
A nurse teaches a patient who is diagnosed with diabetes mellitus. Which statement would the nurse include in this patients plan of care to delay the onset of microvascular and macrovascular complications? A. Maintain tight glycemic control and prevent hyperglycemia B. Prevent hypoglycemia by eating a bedtime snack C. Limit your intake of protein to prevent ketoacidosis D. Restrict your fluid intake to no more the 2L a day
A Maintain tight glycemic control and prevent hyperglycemia
Which term describes nearsignedness? A. Myopia B. Hyperopia C. Presbyopia D. Astigmatism
A Myopia
A nurse is taking care of a patient who experiencing inflammation surrounding a surgical wound. What are the cardinal manifestations the nurse expects to see? Select all that apply. a. Redness b. Warmth c. Pallor d. Cold to touch e. Swelling f. Increased function g. Pain
A, B, E, G Redness Warmth Swelling Pain
To minimize the risk of aspiration during a procedure assess for; select all that apply. A. presence of nausea and vomiting B. ensure NOP 4-6 hours before test C. asses for capillary refill D. Assess for urinary retention
A, B presence of nausea and vomiting ensure NOP 4-6 hours before test
What changes in the eye and vision are related to aging? Select all that apply. A. tear production is reduced B. eyes appear sunken C. vision increases D. iris changes color E. Eyes become squared
A, B tear production is reduced eyes appear sunken
A nurse collaborates with an unlicensed assistive personel to provide care for a patient who is prescribed a 24-hour urine specimen collection. Which statement would the nurse include when delegating this activity to the uap? A. "start the collection by saving the first urine of the morning" B. "Note the time of the patients first void and collect urine for 24 hours" C. "It is okay if one urine sample during the 24 hours is not collected" D. "Add the preservative to the container at the end of the test"
B "Note the time of the patients first void and collect urine for 24 hours"
A nurse cares for a paitent experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? A. IV administration of 10% glucose B. Administration of IV insulin C. Administration of oxygen via face mask D. Implementation of seizure precautions
B Administration of IV insulin
A nurse evaluates laboratory results for a male patient who reports fluid secretion from his breasts. Which hormone value would the nurse assess first? A. Adrenal medulla hormones B. Anterior pituitary hormones C. Hypothalamus hormones d. Parathyroid hormone
B Anterior pituitary hormones
The nurse is using a pulse oximeter on a client with COPD which action should the nurse implement to ensure accurate oxygen saturation readings via the pulse ox? A. Keep sensor exposed to adequate lighting B. Assess adequacy of circulation prior to applying sense C. Remove the sensor when taking the bp D. Elevate extremity to which the sensor is attached
B Assess adequacy of circulation prior to applying sense
The nurse is planning care for a pt. with a seizure disorder. The nurse selects risk for injury as a nursing diagnosis. Which of the following nursing interventions is appropriate if the pt. has a seizure? Select all that apply. A. Restrain the pt. B. Stay with the pt. C. Insert a tongue blade into the pt.'s mouth D. Turn the pt. to a lateral position E. Call for help
B, D, E Stay with the pt. Turn the pt. to a lateral position Call for help
A patient asks a nurse "what is the difference between benign and malignant cell growth?" which statement is correct? a. Benign means cancerous, malignant means noncancerous b. A benign tumor spreads to other parts of the body c. A benign tumor means noncancerous and malignant means cancerous
C A benign tumor means noncancerous and malignant means cancerous
An older adult male reports to the nurse that he has difficult starting urination and is voiding several times during the night. The nurse suspects that this client has which condition? A. Cystitis B. Renal calculi C. Erectile dysfunction D. Benign prostatic hypertrophy
D Benign prostatic hypertrophy
After teaching a patient who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the patient's understanding. Which statement made by the patient indicates a correct understanding of the need for eye examination? A. I will see the eye doctor when I have a vison problem and yearly after age 40 B. My vision will change quickly. I should see the ophthalmologist twice a year C. At my age I should continue seeing the ophthalmologic as I usually do D. Diabetes can cause blindness, so I should see the ophthalmologist yearly
D Diabetes can cause blindness, so I should see the ophthalmologist yearly
Which statement is most accurately describes transmission of HIV? a. HIV transmission occurs as a result of sexual preferences b. HIV transmission can occur via sharing food c. HIV can be transmitted via inanimate objects such as toilet seats or computer keyboards d. HIV is transmitted from human to human via infected blood, semen, cervicovaginal secretions, and breast milk
D HIV is transmitted from human to human via infected blood, semen, cervicovaginal secretions, and breast milk
A nurse assess a patient who is prescribed a medication that stimulates beta1 receptors. Which assessment finding would alert the nurse to urgently contact the hcp? A. Blood pressure of 144/69 B. Oxygenation saturation of 92% C. Respiratory rate of 18 breathes/min D. Heart rate of 50 beats/min
D Heart rate of 50 beats/min
The electrolyte balance ----- is a possible complication after subtotal thyroidectomy. This complication occurs secondary to inadvertent damage to or removal of the parathyroid glands during surgery. A. Hyperkalemia B. Hypokalemia C. Hypocalcemia D. Hypercalcemia
D Hypercalcemia
A patient with a history of kidney disease is admitted with acute shoulder pain. Which order Should the nurse question? A. Digoxin 0.125mg po daily B. Metoprolol 50mg po twice daily C. Pan cultures for a temp of >38.5c D. Ibuprofen 800 mg po every 4 hours as needed for pain
D Ibuprofen 800 mg po every 4 hours as needed for pain
The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which monitoring is essential when administering the medication?
Heart rate
A pt. admitted with chronic venous insufficiency has an infected wound of the left lower extremity. Which of the following will the nurse find when assessing this wound?
Surrounding skin brown and purple in color
Which disorders are lung diseases that cause chronic airflow limitation? Select all that apply.
Intermittent asthma
Which chemical is responsible for a prolonged inflammatory response, leading to airway obstruction?
Leukotriene
What is the greatest priority once a crash cart has been brought to a room when responding to a patient in ventricular fibrillation?
Perform defibrillation
The head nurse is teaching the newly recruited nurses regarding the properties of the heart. Which term would she use that best describes the amount of blood ejected by the LV with each cardiac contraction?
Stroke volume
A nurse teaches a patient who has been prescribed a 24 hour urine collection to measure excreted hormones. The patient asks why do I need to collect urine for the 24 hours instead of providing a random specimen? How would the nurse respond? a. "This test will assess for a hormone secreted on a circadian rhythm." b. "The hormone is diluted in urine; therefore, we need a large volume." c. "We are assessing when the hormone is secreted in large amounts." d. "To collect the correct hormone, you need to urinate multiple times."
a. "This test will assess for a hormone secreted on a circadian
A nurse cares for a patient with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance would the nurse assess? A. Magnesium B. Calcium C. Potassium D. Sodium
b Calcium
which activity would NOT increase the intraocular pressure? A. bending from the waste B. straining to have a bowel movement C. obtaining form wearing a tight collared shirt D. vomiting
vomiting
The nurse caring for a patient with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply.
-Fatigue -Anorexia -Sinus Bradycardia
An emergency nurse cares for a patient who is experiencing an acute adrenal crisis. What action would the nurse take first? A. Obtain IV access B. Assess blood glucose C. Administer insulin and dextrose D. Administer hydrocortisone succinate
A Obtain IV access
The nurse is assessing a client with chronic renal failure which finding is most important for the nurse to reappoint to first A. Potassium 6.0 B. 24 urine output of 400ml C. Peripheral neuropathy D. WBC 15
A Potassium 6.0
A patient with hyperaldosteronism is being treated with spironolactone before surgery. Which precautions does the nurse teach this patient? A. Read the label before using salt substitutes B. Take Tylenol instead of aspirin for pain C. Avoid exposure to sunlight D. Do not add salt to your food when you eat
A Read the label before using salt substitutes
A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient s serum sodium level is 114 mEq. What action would the nurse take first? A. Restrict the patient's fluid intake to 600 mL/day b. Handle the patient gently by using turn sheets for repositioning C. Consult with the dietitian about increased dietary sodium D. Instruct UAP to measure intake and output
A Restrict the patient's fluid intake to 600 mL/day
The nurse is preparing to admit a child who presents with a history of absence seizures. After one such episode the nurse correctly documents that, "the patient: A. Sat very still and was unresponsive with a blank stare for 2 minutes B. Pulled her arms in toward her body and flexed her hands over her chest. This lasted 2 minutes C. Repeatedly moved from the chair to the bed while touching her arms for a length of 2 minutes D. Became unconscious, and all 4 extremities were jerking uncontrollably for 2 minutes
A Sat very still and was unresponsive with a blank stare for 2 minutes
A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? A. The clothing protects me from accidentally absorbing these drugs B. The policy for any nurse giving these drugs to wear a gown, gloves, and mask C. I am preventing the spread of infection from you to me or any other client here D. These coverings protect you from getting an infection from me
A The clothing protects me from accidentally absorbing these drugs
What should the nurse instruct an older pt. diagnosed with chronic venous insufficiency to do in order to help relieve symptoms? A. Wear elastic hose as prescribed B. Keep the legs dependent as much as possible and elevate only when asleep C. Standing will prevent the progression of the disease D. Cross legs only at the knees
A Wear elastic hose as prescribed
Which is the earliest sign of neurologic deterioration? A. change in level of consciousness B. change in RR C. decreased urine output D. extremities are cool to touch
A change in level of consciousness
A client who was previously diagnosed with a UTI and started on antibiotics returns to the clinic 3 days later with the same symptoms. When asked about the previous UTI and medication regimen the client states "I only took the first dose because after that I felt better." How does the nurse respond? A. not completing your medication can lead to the return of your infection B. That means your treatment will be prolonged with this new infection C. This means you will now have to take 2 drugs instead of one D. What you did was okay; however, let's get you started on something else.
A not completing your medication can lead to the return of your infection
The nurse is caring for a group of clients. Which client will the nurse carefully observe for signs and symptoms of hyperkalemia? A. the client who has metabolic acidosis B. the client receiving total parenteral nutrition C. the client taking a thiazide diuretic D. the client who has perfuse vomiting
A the client who has metabolic acidosis
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia. A. Nausea, vomiting, anorexia B. Sweating, trembling, tachycardia C. Polyuria polydipsia polyphagia D. Fruity breath, tachypnea, chest pain
B Sweating, trembling, tachycardia
A nurse cares for a patient who has excessive catecholamine release. Which assessment finding would the nurse correlate with this condition? A. Decreased blood pressure B. Increased pulse C. Decreased respiratory rate D. Increased urine output
B increased pulse
A pt recently diagnosed with Multiple sclerosis has steady and gradual neurologic deterioration without remission of symptoms. which of the four types of MS is this patient presenting? A. relapsing-remitting B. primary progressive C. secondary progressive D. progressive- relapsing
B primary progressive
When a nurse is caring for a patient with myasthenia gravis, the nurse should monitor and prepare for what complication? A. seizure activity B. respiratory distress C. decreased circulation D. ipsilateral hearing loss
B respiratory distress
SATA what hormones help regulate fluid and electrolyte balance A. Aldosterone. B. Antidiuretic hormone C. Natriuretic peptide D. Thyroid stimulating hormone E. Growth hormone
A, B, C Aldosterone. Antidiuretic hormone Natriuretic peptide
What are common causes of anemia? Select all that apply. a. Sickle-cell disease b. Iron deficiency c. Vitamin B12 deficiency d. Smoking
A, B, C Sickle-cell disease Iron deficiency Vitamin B12 deficiency
Following a stapedectomy, what teaching should be included to prevent injury? A. ambulate with assistance 1- 2 days following the procedure B. keep top bed side rails up C. instruct the patient to move the head slowly to avoid vertigo D. hearing will improve in 2 weeks E. clean the ear with small objects following procedure
A, B, C ambulate with assistance 1- 2 days following the procedure keep top bed side rails up instruct the patient to move the head slowly to avoid vertigo
Sickle-cell disease is one of several related genetic hemoglobin disorders that result in what? Select all that apply? a. Chronic anemia b. Pain c. Disability d. Decreased risk for infection e. Organ damage
A, B, C, E Chronic anemia Pain Disability Organ damage
A nurse prepares to palpate a patients thyroid gland. What action would the nurse take when performing this assessment? A. Palpate the right lobe with the nurses left hand B. Place the patient in a sitting position with the chin tucked down C. Ask the patient to swallow after palpating the thyroid D. Stand in from of the patient instead of behind the patient
B Place the patient in a sitting position with the chin tucked down
The nurse is caring for a patient with polycystic kidney disease. Which assessment finding requires immediate nursing intervention? A, Temp of 99 B. Blood pressure of 170/90 C. Heart rate of 100 beats/min D. Urine output less than 33ml/hr
B Blood pressure of 170/90
A nurse assesses a patient diagnosed with adrenal hypofunction. Which patient statement would the nurse correlate with this diagnosis? A. I cannot seem to drink enough water B. I have a terrible craving for potato chips C. I get hungry even after eating a meal D. I no longer have an appetite for anything
B I have a terrible craving for potato chips
A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The patient has no know drug allergies and no significant health history. Which action would the nurse include in this patients plan of care? A. Initiate airborne precautions B. Offer fluids every hour or two C. Palpate the patient's thyroid gland D. Place an indwelling urinary catheter
B Offer fluids every hour or two
A patient is disoriented to time, place, and event, they are becoming increasingly dependent in ADL's and is experiencing episodes of wandering with trouble sleeping. What stage of Alzheimer's disease is this patient in? A. stage I; early(mild) B. stage II; middle(moderate) C. stage III; late (severe) D. dementia phase
B stage II; middle(moderate)
A beta blocking agent (Metoprolol) Lopressor has been started. Which parameters should be assessed each time prior to administering the beta blocker while the client is inpatient? Select all that apply. A. Crackles and wheezes in the lungs B. Heart rate C. Blood pressure D. Echocardiogram E. Oxygen liter flow
B, C o Heart rate o Blood pressure
A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse understands the client is describing which of the following? A. A period of sleepiness following a seizure when the client is difficult to arouse B. A continuous seizure n which seizures occur in rapid succession C. A sensory warning that seizure activity is imminent D. A brief loss of consciousness accompanied by starin
C A sensory warning that seizure activity is imminent
A nurse cares for a patient newly diagnosed with graves disease. The patients mother asks, "I have diabetes mellitus. Am I responsible for my daughter's disease?" How does the nurse respond? A. Graves' disease is associated with autoimmune diseases such as rheumatoid arthritis, but with a disease such as diabetes mellitus B. Unfortunately, Graves' disease is associated with diabetes, and your diabetes could have led to your daughter having graves' disease C. An association has been noted between graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have graves' disease D. The fact that you have diabetes did not cause your daughter to have graves' disease. No connection is known between graves' disease and diabetes
C An association has been noted between graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have graves' disease
A nurse assess a patient who has a 15 year history of diabetes and notes decreased tactile sensation in both feet. Which action would the nurse take first? A. Notify HCP B. Document the finding in the patients chart C. Assess tactile sensation in the patients hands D. Examine the patients feet for signs of injury
C Assess tactile sensation in the patients hands
A nurse assesses a patient who takes lithium. Which assessment finding should alert the nurse to a side effect of this therapy A. Increased heat intolerance and weight loss B. Positive Chvostek's and trousseaus sign c. Bradycardia and loss of eyebrow hair d. Loss of bone density and recent fractures
C Bradycardia and loss of eyebrow hair
A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. Which action does the nurse take first? A. Reassure the patient that the voice change is temporary B. Document the findings and assess the patient hourly C. Contact the provider and prepare for intubation D. Place the patient in a high-fowlers position and apply oxygen
C Contact the provider and prepare for intubation
The nurse is reviewing laboratory results of a client diagnosed with multiple myeloma. Which of the following would the nurse expect to note specifically in this disorder? a. Decreased number of plasma cells n the bone marrow b. Increased WBC c. Increased calcium levels d. Decreased blood urea nitrogen
C Increased calcium levels
A client with peripheral arterial disease has undergone percutaneous transluminal angioplasty of the lower extremity. What is essential for the nurse to assess after the procedure. A. Ankle brachial index B. Dye allergy C. Pedal pulses D. Gag reflex
C Pedal pulses
Which clinical manifestation in a client with paralysis of one coal cord alerts the nurse to the possibility of aspiration? A. An audible wheeze is present on exhalation B. Voice is weak and tremulous C. The client coughs immediately after swallowing D. Oxygen saturation is decreased
C The client coughs immediately after swallowing
Which clinical data requires immediate nursing intervention to prevent progression of acute kidney injury? A. A heart rate of 120 B. Blood pressure of 156/88 C. Urine specific gravity of 1.001 mm Hg D. Intake of 200ml and output of 1500 ml in the past 24 hours
C Urine specific gravity of 1.001 mm Hg
End stage renal disease is the last stave in the progressive clinical syndrome of CKD what is the best description of CKD A. There are frequent exacerbations since half of all nephrons are damaged B. The condition ahs rapid onset with frequent remissions C. Symptoms are reversible with lifelong medications D. It is fatal disorder unless renal replacement therapy is received
D It is fatal disorder unless renal replacement therapy is received
During assessment of the client with ALS which finding does the nurse expect to find A. Decline in cognitive function B. Involuntary movement C. Urinary frequency D. Muscle weakness
D Muscle weakness
A nurse reviews lab results for a patient with diabetes mellutus who presents with polyuria, letharty, and blood glucose of 560 mg/dL. Which laboratort result would the nurse correlate with the patients polyuria A. Serum sodium 163 B. Serum creatinine 1.6 C. Presence of urine ketone bodies D. Serum osmolarity 375
D Serum osmolarity 375
an older adult woman confides in the nurse "I am so embarrassed about buying adult diapers for myself." How does the nurse respond? A. Don't worry about it, you need them B. Shop at night when the stores are less crowded C. tell everyone that they are for your husband D. That is though, what do you think may help
D That is though, what do you think may help
A nurse plans care for a patient with Cushing's disease. Which action would the nurse include in the patients plan ocare to prevent injury? A. Pad the side rails of the patient bed B. Assist the patient to change positions slowly C. Keep suctioning equipment at the patient's bedside D. Use a lift sheet to change the patient's position
D Use a lift sheet to change the patient's position
what patient has the greater risk for Alzheimer's? A. a 18 year old male who works in construction B. A 30 year old female who is a librarian C. a 26 year old male who works in fast food D. a 67 year old female who resides in a nursing homes
D a 67 year old female who resides in a nursing homes
What are the common risk factors for osteoarthritis? Select all that apply. a. Older age b. Obesity c. Genetics d. Being a female e. All of the above
E All the above
A student nurse is discussing the characteristics of cardiac muscle cells with other students. Which characteristic of cardiac cells muscle is least likely to be important to the discussion?
Elasticity
A nurse cares for a patient who is prescribed a drug that blocks a hormone's receptors site. Which therapeutic effect would the nurse expect? A. Uncharged hormone response B. Increased hormone activity C. Decreased hormone activity D. Greater hormone metabolism
c Decreased hormone activity
A nurse teaches an older adult with a decreased production of estrogen. Which statement would the nurse include in this patient teaching to decrease injury? a. "Drink at least 2 liters of fluids each day." b. "Walk around the neighborhood for daily exercise." c. "Bathe your perineal area twice a day." d. "You should check your blood glucose before meals."
b Walk around the neighborhood for daily exercise."
