N220L EAQ #3&4

Heart failure develops in a 4-month-old infant with a congenital heart defect, and the infant exhibits marked dyspnea at rest. What should the nurse immediately assess the infant for? 1. Hypovolemia 2. Bilateral crackles 3. A decreased red blood cell count 4. Decreased pH and carbon dioxide values

2

A 10-year-old child is admitted to the pediatric unit in vaso-occlusive sickle cell crisis. The nurse manager is planning to assign a room. Which child is the best roommate option for this client? 1. Child with thalassemia 2. Child with osteomyelitis 3. Child with viral pneumonia 4. Child with acute pharyngitis

1

A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause? 1. Warfarin 2. Nifedipine 3. Nitrofurantoin 4. Phenazopyridine

1

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding? 1. There is less chance of aspiration. 2. This procedure does not require a pump. 3. Self-administration of the feeding is possible. 4. More tube feeding mixture can be given each time.

1

A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate what about her toddler? 1. Has bulky, foul, frothy stools 2. Drinks large amounts of fluid 3. Is irritable throughout the day 4. Voids strong, concentrated urine

1

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to reeducate the client? 1. Whole milk with oatmeal 2. Garden salad with olive oil 3. Tuna fish with a small apple 4. Soluble fiber cereal with yogurt

1

Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client? 1. 1 to 3 minutes 2. 4 to 5 seconds 3. 30 to 45 seconds 4. 20 to 45 minutes

1

The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, which strategy should be included in the client's plan of care? 1. Instructing the client to drink at least 3L of fluid daily 2. Interventions to decrease the serum creatinine level 3. A urinary output goal of 2000 mL per 24 hours 4. Excluding milk products from the diet

1

Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. 1. Dyspnea 2. Dry cough 3. Diaphoresis 4. Mild chest pain 5. High temperature

1, 3, 5

A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order. 1. Stop the transfusion 2. Notify the primary healthcare provider and blood bank 3. Run 0.9% normal saline at a rapid rate 4. Change the intravenous (IV) administration set

1. Stop the transfusion 2. Change the intravenous (IV) administration set 3. Run 0.9% normal saline at a rapid rate 4. Notify the primary healthcare provider and blood bank

A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient? 1. Alignment of legs on x-ray 2. Warmth of the toes of both feet 3. Mobility of the knees when flexed 4. Presence of posterior tibial pulses

2

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess? 1. Weight gain 2. Dehydration 3. Hyperactivity 4. Hyperglycemia

2

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? 1. Snack daily in the evenings 2. Divide food into four to six meals a day 3. Eat the last of three daily meals by 8:00 PM 4. Suck a peppermint candy after each meal

2

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition? 1. Listing low-protein foods that may be included in the diet 2. Explaining that fatty foods may not be tolerated for several weeks 3. Teaching the importance of a low-calorie diet to promote weight reduction 4. Encouraging the intake of high vitamin C, vitamin A, and zinc foods at each meal

2

In order to ensure a quality specimen and an accurate test result, which instruction should the nurse give a client who is scheduled to undergo urine endocrine testing? 1. "Start the urine collection when the bladder is full." 2. "Store the urine specimen in a cooler with ice." 3. "Store the urine specimen in a home refrigerator." 4. "Save the urine specimen that begins the collection."

2

The nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment? 1. Drink fluids 2. Empty her bladder 3. Perform the Valsalva maneuver 4. Assume the semi-Fowler position

2

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? 1. Cerebral palsy 2. Cystic fibrosis 3. Muscular dystrophy 4. Multiple sclerosis

2

What would be the respiratory rate in two-year-old child? 1. 20 2. 30 3. 40 4. 50

2

A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do? 1. Reduce the intake of protein-rich foods 2. Drink 8 ounces (240 mL) of water with meals 3. Divide the daily caloric intake into six smaller meals 4. Remain in an upright position for one hour after eating

3

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1. Perform the procedure once in the morning and once at night. 2. Move the trunk to an upright position and then exhale while bending over. 3. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. 4. Place the mouthpiece between the lips and in front of the teeth before starting the procedure.

3

A nurse is providing client teaching to a woman who has recurrent urinary tract infections. Which information should the nurse include concerning the reason why women are more susceptible to urinary tract infections than men? 1. Inadequate fluid intake 2. Poor hygienic practices 3. The length of the urethra 4. The continuity of mucous membranes

3

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? 1. Increased blood urea nitrogen (BUN) and hypotension 2. Hyperkalemia and poor skin turgor 3. Hyponatremia and decreased urine output 4. Polyuria and increased specific gravity of urine

3

Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? 1. Relax in a reclining position 2. Sit upright with legs extended 3. Walk around at least every hour 4. Sit in any position that relieves pressure on the legs

3

The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would be the best reply by the nurse? 1. "Why do you want to be out of bed?" 2. "Bed rest plays a role in most therapy." 3. "Rest helps your body direct energy toward healing." 4. "Would you like me to ask your primary healthcare provider to change the prescription?"

3

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? 1. Thermography 2. Plethysmography 3. Duplex venous doppler 4. Somatosensory evoked potential

3

Which organ-specific autoimmune disorder is associated with a client's kidney? 1. Graves' disease 2. Addison's disease 3. Goodpasture syndrome 4. Guillain-Barré syndrome

3

Which teratogenic effect is seen due to lithium? 1. Stillbirth 2. shortened limbs 3. Ebstein anomaly 4. Neural tube defects

3

Which type of breathing pattern alteration is manifested with hypercarbia? 1. Eupnea 2. Tachypnea 3. Hypoventilation 4. Kussmaul's respiration

3

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli? 1. Peas 2. Corn 3. Green beans 4. Mashed potato

3

A 3-month-old infant is admitted to the pediatric unit with a diagnosis of tetralogy of Fallot. The nurse's assessment reveals that the infant's weight has declined from the 25th percentile to the 5th. The nurse concludes that what is the most likely reason for this inadequate weight gain? 1. Cyanosis resulting in cerebral changes 2. Decreased arterial oxygen level resulting in polycythemia 3. Pulmonary hypertension resulting in recurrent respiratory infections 4. Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse

4

A 4-year-old child is undergoing a diagnostic workup for pulmonic stenosis. The mother asks the nurse about the diagnosis. How does the nurse describe pulmonic stenosis? 1. Narrowing of the valve between the left atrium and left ventricle 2. Hardening of the valve between the right atrium and right ventricle 3. Hardening of the valve between the right ventricle and the arch of the aorta 4. Narrowing of the valve between the right ventricle and the pulmonary artery

4

A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse most likely observe written in the client's medical record? 1. Chronic glomerulonephritis 2. Nephrotic syndrome 3. Pyelonephritis 4. Cystitis

4

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1. Urinary output 2. Sensation to touch 3. Neurologic status 4. Respiratory exchange

4

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? 1. Increased fiber intake 2. Bacterial contamination 3. Inappropriate positioning 4. High osmolarity of the feedings

4

A client's blood pressure increases dramatically six hours after a femoral-popliteal bypass graft. Which priority concern motivates the nurse to inform the primary healthcare provider? 1. Hypertension may cause the graft to occlude. 2. Hypervolemia may be the cause of the hypertension. 3. Extremely high blood pressure may cause a brain attack. 4. Rapidly increasing blood pressure may rupture the graft.

4

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? 1. Trimming toenails so that they are short and rounded 2. Checking bathwater temperature by putting the toes in first 3. Using alcohol to rub hands, feet, legs, and arms at least two times a day 4. Seeking professional treatment for any minor injuries to the extremities

4

A primary healthcare provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? 1. "The use of salt probably contributed to the disease." 2. "Excess weight will be gained if sodium is not limited." 3. "The loss of excess sodium and potassium in the urine requires less renal stimulation." 4. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

4

An infant with a diaphragmatic hernia undergoes corrective surgery. What nursing assessment indicates that the infant's respiratory condition has improved? 1. Cessation of crying 2. Retention of 1 oz (30 mL) of formula 3. Reduction of arterial blood pH to 7.31 4. Auscultation of breath sounds bilateraly

4

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? 1. Suggest that an antiemetic be prescribed 2. Change the feeding schedule to omit nights 3. Request that the type of solution be changed 4. Gather more data from the night nurse about the technique used

4

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? 1. Refer the client to a nutritionist after providing health teaching about a low-sodium diet. 2. Place the client in a recumbent position and call the paramedics for transport to the hospital. 3. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. 4. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

4