NR340 Exam II Practice Questions
A client has arrived in your clinic complaining of dyspepsia and pain that occurs about 90 minutes after eating. The client also reports that the pain got worse this afternoon about 3 hours after eating a large bowl of spaghetti with tomato sauce. Which medications should the nurse anticipate that the health care provider will prescribe? Select all that apply. 1. Esomeprazole (Nexium) 40 mg daily, orally for 10 days 2. Metronidazole (Flagyl) 500 mg twice a day, orally for 10 days 3. Clarithromycin (Biaxin) 500 mg twice a day, orally for 10 days 4. Calcium carbonate (Tums) 2 tablets as needed for pain or dyspepsia 5. Hydrocodone 7.5 mg + ibuprofen 200 mg (Motrin IB) 1 tablet, orally every 6 hours as need for pain
ANS: 1,2,3 Rationale: The client is describing symptoms associated with a duodenal ulcer. A proton pump inhibitor (PPI), like esomeprazole is prescribed to help decrease gastric acid secretions. Metronidazole and clarithromycin are two of the antibiotics frequently prescribed to treat a Helicobacter pylori infection, which is a common cause of duodenal ulcers. Calcium carbonate (Tums) is contraindicated because it can trigger gastrin release resulting in rebound acid secretion and more pain. The ibuprofen (like all NSAIDs) can aggravate the ulcer.
A client who weighs 50 kg has arrived in the emergency department complaining of severe chest pain. The telemetry monitor shows an evolving anterior myocardial infarction (MI). The client has a history of uncontrolled hypertension, a hemorrhagic stroke earlier this month, and gout. The client's laboratory values are hemoglobin 12 mg/dL, hematocrit 36%, and platelets 100,000 cells/mm3. What medications should the nurse anticipate that the health care provider will prescribe? Select all that apply. 1. Oxygen 2 L, per nasal cannula 2. Nitroglycerin 0.4 mg, sublingual 3. Morphine sulfate (MS) 4 mg intravenously 4. Tirofiban (Aggrastat) 0.4 mcg/kg/min for 30 minutes, then 0.1 mcg/kg/min, intravenously 5. Tissue plasminogen activator (t-PA) 0.75 mg/kg for first hour, then 0.25 mg/kg/hr over next 2 hours (not to exceed 100 mg total), intravenously
ANS: 1,2.3 Rationale: Oxygen will be provided to help provide oxygenation to the heart muscle. Nitroglycerin will be administered in an effort to cause vasodilation. Morphine sulfate will be given to decrease the client's pain and to improve myocardial oxygenation. Tirofiban is contraindicated with a cerebral bleed in the last 30 days and with uncontrolled hypertension. A platelet count of less than 150,000 cells/mm3 is a relative contraindication. Tissue plasminogen activator is contraindicated if the client has any previous intracranial hemorrhage; it is a relative contraindication for a client with uncontrolled hypertension.
When planning the care of the client with thromboangiitis obliterans (Buerger's disease), the nurse incorporates measures to help the client cope with the lifestyle changes that are needed to control the disease process. The nurse can accomplish this by recommending which support service? 1. Consult with a dietician 2. Pain management clinic 3. Smoking cessation program 4. Referral to a medical social worker
ANS: 3 Rationale: Smoking is highly detrimental to the client with Buerger's disease, and clients are recommended to stop completely. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated when smoking stops. Options 1, 2, and 4 are not directly related to the physiology associated with this condition.
A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests that the client is in the denial phase? 1. Requests a sedative for sleep at 10:00 p.m. 2. Expresses a hesitancy to leave the hospital 3. Consumes 25% of foods and fluids given for supper 4. Walks up and down three flights of stairs unsupervised
ANS: 4 Rationale: Ignoring activity limitations and avoiding lifestyle changes are signs of the denial stage. Walking three flights of stairs should be a supervised activity during this phase of the recovery process. Option 1 is an appropriate client action on the evening before discharge. Option 2 may be a manifestation of anxiety or fear rather than denial. Option 3 is a manifestation of depression rather than denial.
The nurse teaches a client with hypertension to recognize the signs and symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client needs additional teaching if the client states that which sign/symptom is associated with this condition? 1. Epistaxis 2. Dizziness 3. Blurred vision 4. A feeling of fullness in the head
ANS: 4 Rationale: A feeling of fullness in the head is more likely associated with a sinus condition. Cerebrovascular symptoms of hypertension include early morning headaches, occipital headaches, blurred vision, lightheadedness, vertigo, dizziness, and epistaxis. The client should be aware of these symptoms and report them if they occur. The client should also be taught to self-monitor the blood pressure.
The nurse is instructing a client with type 1 diabetes mellitus about the management of hypoglycemic reactions. The nurse instructs the client that hypoglycemia most likely occurs during what time interval after insulin administration? 1. Peak 2. Onset 3.Duration 4.Anytime
Ans: 1 Rationale: Insulin reactions are most likely to occur during the peak time after insulin administration, when the medication is at its maximum action. Peak action depends on the type of insulin, the amount administered, the injection site, and other factors.
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). What information about the balloon-tipped catheter should nurse plan to include when providing client education concerning the procedure 1. A mesh-like device within the catheter will be inflated causing it to spring open. 2. The catheter will be used to compress the plaque against the coronary blood vessel wall. 3. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade. 4. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
Ans: 2 Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization.
The nurse is providing instructions to a client with peptic ulcer disease about symptom management. Which statement by the client indicates they are learning about the disease? 1. "I should eat a snack at bedtime." 2."I can take aspirin to relieve gastric pain." 3. "It is important that I eat slowly and chew my food thoroughly." 4. "I should take my antacid and famotidine (Pepcid) at the same time."
Ans: 3 Rationale: Eating slowly and chewing thoroughly helps prevent overdistention and reflux. Bedtime snacks are avoided because they can promote nighttime acid secretion. Acetaminophen (Tylenol) is administered for routine pain relief during treatment. All nonsteroidal anti-inflammatory drugs and aspirin are avoided. Antacids will interfere with the absorption of the famotidine (Pepcid), a histamine-2 (H2) receptor antagonist, so they should not be taken at the same time.
A 52-year-old male client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches, and his weight is 220 pounds. Vital signs are temperature, 98° F orally; pulse, 86 beats per minute; and respirations, 18 breaths per minute. The blood pressure (BP) is 184/100 mm Hg. Random blood glucose is 122 mg/dL. Which question should the nurse ask the client first? 1. "Do you exercise regularly?" 2. "Are you considering trying to lose weight?" 3. "Is there a history of diabetes mellitus in your family?" 4. "When was the last time you had your blood pressure checked?"
Ans: 4 Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's non-modifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors.
A client who underwent peripheral arterial bypass surgery 16 hours ago complains of increasing pain in the leg at rest, which worsens with movement and is accompanied by paresthesias. Based on this data, which action should the nurse take? 1. Call the health care provider. 2. Administer an opioid analgesic. 3.Apply warm moist heat for comfort. 4. Apply ice to minimize any developing swelling.
Answer: 1 Rationale: Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs of compartment syndrome are pain at rest that intensifies with movement and the development of paresthesias. Compartment syndrome is an emergency, and the health care provider is notified immediately because the client could require an emergency fasciotomy to relieve the pressure and restore perfusion. Options 2, 3, and 4 are incorrect actions.
A client who undergoes a gastric resection is at risk for developing dumping syndrome. Which manifestation should the nurse monitor the client for? 1. Dizziness 2. Bradycardia 3. Constipation 4. Extreme thirst
Answer: 1 Rationale: Dumping syndrome is the rapid emptying of the gastric contents into the small intestine that occurs after gastric resection. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Manifestations also include vasomotor disturbances such as dizziness, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
The nurse is assessing the client with left-sided heart failure. The client states that he needs to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding? 1. Orthopnea 2. Dyspnea at rest 3. Dyspnea on exertion 4. Paroxysmal nocturnal dyspnea
Answer: 1 Rationale: Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a "three-point" position while upright and use pillows to support the head and upper torso at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
The nurse is assigned to care for a client being admitted to the hospital with a diagnosis of cirrhosis and ascites. Which dietary measure should the nurse expect to be prescribed for the client? 1.Sodium restriction 2.Increased fat intake 3.Decreased carbohydrates 4.Calorie restriction of 1500 daily
Answer: 1 Rationale: If the client has ascites, sodium and possibly fluids would be restricted in the diet. Fat restriction is not necessary, and the client should maintain a normal amount of fat intake. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The total daily calories should range between 2000 and 3000. The diet should provide ample protein to rebuild tissue but not an amount that will precipitate hepatic encephalopathy.
The nurse is analyzing an electrocardiogram (ECG) rhythm strip on an assigned client. The nurse notes that there are three small boxes from the beginning of the "P" wave to "R" wave. What should the nurse record as the client's PR interval? 1. 0.12 second 2. 0.20 second 3. 0.24 second 4. 0.40 second
Answer: 1 Rationale: Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.
A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is most at risk of developing which type of acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4.Respiratory alkalosis
Answer: 1 Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options 2, 3, and 4 are incorrect. Reference(s): Ignatavicius, Workman (2013), pp. 202-203, 1456.
The clinic nurse instructs a client with diabetes mellitus about how to prevent diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the need for further teaching? 1. "I need to stop my insulin if I am vomiting." 2. "I need to eat 10 to 15 g of carbohydrates every 1 to 2 hours." 3. "I need to drink small quantities of fluid every 15 to 30 minutes." 4. "I need to call my health care provider if I am ill for more than 24 hours."
Answer: 1 Rationale: Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. The client needs to be instructed to take insulin, even if he or she is vomiting and unable to eat. It is important to self-monitor blood glucose more frequently during illness (every 2 to 4 hours). If the premeal blood glucose is more than 250 mg/dL, the client should test for urine ketones and contact the health care provider. Options 2, 3, and 4 are accurate interventions.
A client is resuming a diet after a Billroth II procedure. To minimize complications from eating, which actions should the nurse teach the client to do? Select all that apply. 1. Lay down after eating. 2. Eat a diet high in protein. 3.Drink liquids with meals. 4.Eat six small meals per day. 5.Eat concentrated sweets between meals only.
Answer: 1,2,4 Rationale: The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should lie down after eating and avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.
The nurse is getting a client out of bed for the first time after having abdominal surgery. What clinical manifestations should indicate to the nurse that the client may be experiencing orthostatic hypotension? Select all that apply. 1.Nausea 2.Dizziness 3. Bradycardia 4. Lightheadedness 5. Flushing of the face 6.Reports of seeing spots
Answer: 1,2,4,6 Rationale: Orthostatic hypotension occurs when a normotensive person develops symptoms of low blood pressure when rising to an upright position. Whenever the nurse gets a client up and out of a bed or chair, there is a risk for orthostatic hypotension. Symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of seeing spots are characteristic of orthostatic hypotension. A drop of approximately 15 mm Hg in the systolic blood pressure and 10 mm Hg in the diastolic blood pressure also occurs. Fainting can result without intervention, which includes immediately assisting the client to a lying position.
A client with a colostomy is complaining of gas building up in the colostomy bag. The nurse instructs the client that which food items should be consumed to best prevent this problem? Select all that apply. 1. Yogurt 2. Broccoli 3. Cabbage 4. Crackers 5. Cauliflower 6. Toasted bread
Answer: 1,4,6 Rationale: Consumption of yogurt, and toast or crackers can help prevent gas. Gas-forming foods include broccoli, mushrooms, cauliflower, onions, peas, and cabbage. These should be avoided by the client with a colostomy until tolerance to them is determined.
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. Which description describes this assessment finding. 1.Waves of loud gurgles auscultated in all four quadrants 2. Soft gurgling or clicking sounds auscultated in all four quadrants 3. Low-pitched swishing sounds auscultated in one or two quadrants 4. Very high-pitched loud rushes auscultated, especially in one or two quadrants
Answer: 2 Rationale: Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (borborygmi) indicate hyperperistalsis. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. No aortic bruits should be heard. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction.
Acetylsalicylic acid (aspirin) is prescribed for a client with coronary artery disease before a percutaneous transluminal coronary angioplasty (PTCA). The nurse administers the medication, understanding that it is prescribed for what purpose? 1. Relieve postprocedure pain 2. Prevent thrombus formation 3. Prevent postprocedure hyperthermia 4.Prevent inflammation of the puncture site
Answer: 2 Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure because the aspirin inhibits platelet aggregation. Options 1, 3, and 4 are unrelated to the purpose of administering aspirin to this client.
A client has undergone angioplasty of the iliac artery. Which technique should the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery? 1.Palpate the pedal pulses. 2.Measure the abdominal girth. 3.Ask the client about mild pain in the area. 4. Auscultate over the iliac area with a Doppler device.
Answer: 2 Rationale: Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency. Assessment of pain is routinely done, and mild regional discomfort is expected.
A client who recently experienced a myocardial infarction is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). The nurse should plan to teach the client about which aspect of a balloon-tipped catheter? 1. A meshlike device will be inflated that will spring open. 2. The catheter will be used to compress the plaque against the coronary blood vessel wall. 3. The catheter will cut away the plaque from the coronary vessel wall using a cutting blade. 4. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
Answer: 2 Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization.
The nurse is providing diet teaching to a client with heart failure. The nurse tells the client to avoid which food item? 1.Sherbet 2. Steak sauce 3.Apple juice 4.Leafy green vegetables
Answer: 2 Rationale: Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with heart failure should monitor sodium intake.
A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further teaching if which statement was made by the client? 1. "I need to eat a balanced diet." 2. "A heating pad on my leg will help soothe the leg pain." 3. "I need to take special care of my feet to prevent injury." 4."I should walk daily to increase the circulation to my legs."
Answer: 2 Rationale: The application of heat directly to the extremity is contraindicated. The limb may have decreased sensitivity and be more at risk for burns. Additionally, the direct application of heat raises the oxygen and nutritional requirements of the tissue even further. The long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition).
A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? 1. Repositions side to side every 2 hours 2. Elevates the head of the bed 60 degrees 3. Auscultates the lung fields every 4 hours 4. Encourages deep breathing exercises every 2 hours
Answer: 2 Rationale: The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid in the abdomen. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures in the care of a client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.
The postmyocardial infarction client is scheduled for a technetium-99m ventriculography (multigated acquisition [MUGA] scan). The nurse should ensure that which item is in place before the procedure? 1. A Foley catheter 2. Signed informed consent 3. A central venous pressure (CVP) line 4.Notation of allergies to iodine or shellfish
Answer: 2 Rationale: MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary. A Foley catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergy to iodine and shellfish is not a concern.
he nurse teaches a client at risk for coronary artery disease about lifestyle changes needed to reduce his risks. The nurse determines that the client understands these necessary lifestyle changes if the client makes which statements? Select all that apply. 1. "I will cut down on my smoking habit." 2. "I will be sure to include some exercise such as walking in my daily activities." 3. "I will work at losing some weight so that my weight is at normal range for my age." 4. "I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs." 5. "It is acceptable to eat red meat and cheese every day as I have been doing, as long as I cut down on the butter." 6. "I will schedule regular health care provider appointments for physical examinations and monitoring my blood pressure."
Answer: 2,3,4,6 "cut down" is not appropriate patient needs to stop smoking
A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which actions should the nurse implement in the postprocedure period? Select all that apply. 1. Restricting visitors 2. Checking the client's groin for bleeding 3. Encouraging the client to increase fluid intake 4. Placing the client's bed in the high Fowler's position 5. Instructing the client to move the toes when checking circulation, motion, and sensation
Answer: 2,3,5 Rationale: Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high Fowler's position (flexion) increases the risk of occlusion or hemorrhage.
The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. Which action should the nurse take? 1. Prepare for defibrillation. 2. Continue to monitor the rhythm. 3. Notify the health care provider immediately. 4. Prepare to administer lidocaine hydrochloride (Xylocaine).
Answer: 2. Rationale: As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the health care provider needs to be notified. Defibrillation is done to treat ventricular fibrillation. Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output Reference(s): Ignatavicius, Workman (2013), p. 728.
The home care nurse is developing a plan of care for an older client with type 1 diabetes mellitus who has gastroenteritis. To maintain food and fluid intake to prevent dehydration, which action should the nurse plan to take? 1.Offer water only until the client is able to tolerate solid foods. 2.Withhold all fluids until vomiting has ceased for at least 4 hours. 3. Encourage the client to take 8 to 12 ounces of fluid every hour while awake. 4. Maintain a clear liquid diet for at least 5 days before advancing to solids to allow inflammation of the bowel to dissipate.
Answer: 3 Rationale: Dehydration needs to be prevented in the client with type 1 diabetes mellitus because of the risk of diabetic ketoacidosis (DKA). Small amounts of fluid may be tolerated, even when vomiting is present. The client should be offered liquids containing both glucose and electrolytes. The diet should be advanced as tolerated and include a minimum of 100 to 150 g of carbohydrates daily. Offering water only and maintaining liquids for 5 days will not prevent dehydration but may promote it in this client.
A client with a gastric tumor is scheduled for a subtotal gastrectomy (Billroth II procedure). The nurse explains the procedure to the client and tells the client that the procedure will entail which surgical tasks? 1. Proximal end of the distal stomach is anastomosed to the duodenum. 2.Entire stomach is removed and the esophagus is anastomosed to the duodenum. 3. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. 4. Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum.
Answer: 3 Rationale: In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options 1, 2, and 4 are incorrect descriptions.
The nurse is reviewing the assessment data of a client. Which finding would be most important for the client to modify to lessen the risk for coronary artery disease (CAD)? 1. Elevated triglyceride levels 2. Elevated serum lipase levels 3. Elevated low-density lipoprotein (LDL) levels 4. Elevated high-density lipoprotein (HDL) levels
Answer: 3 Rationale: LDLs are more directly associated with CAD than are other lipoproteins. LDL levels, along with levels of cholesterol, have a higher predictive association with CAD than levels of triglycerides. Additionally, HDL is inversely associated with the risk of CAD. Lipase is a digestive enzyme that breaks down ingested fats in the gastrointestinal tract.
The Nurse determined that the client's fluid volume deficit from HHNS has resolved. Which serum laboratory finding led to the nurse's conclusion? 1. Decreased glucose 2. Decreased Sodium 3. Decreased Osmolality 4. Decreased potassium
Answer: 3 Rationale: Extreme hyperglycemia produces serve osmotic diuresis; loss of sodium, potassium, and phosphorus; and profound dehydration. Consequently, hyperosmolality occurs. A normalizing of serum osmolality indicates that the fluid volume deficits is resolving.
The nurse is applying electrocardiogram (ECG) electrodes to a diaphoretic client. Which intervention should the nurse take to keep the electrodes from coming loose? 1. Secure the electrodes with adhesive tape. 2. Place clear, transparent dressings over the electrodes. 3. Apply lanolin to the skin before applying the electrodes. 4. Cleanse the skin with alcohol before applying the electrodes.
Answer: 4 Rationale: Alcohol defats the skin and helps the electrodes adhere to the skin. Placing adhesive tape or a clear dressing over the electrodes will not help the adhesive gel of the actual electrode make better contact with the diaphoretic skin. Lanolin or any other lotion makes the skin slippery and prevents good initial adherence.
The nurse is caring for a client scheduled to undergo a cardiac catheterization for the first time. Which information should the nurse share with the client? 1. "The procedure is performed in the operating room." 2. "The initial catheter insertion is quite painful; after that, there is little or no pain." 3. "You may feel fatigue and have various aches because it is necessary to lie quietly on a hard x-ray table for about 4 hours." 4. "You may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations."
Answer: 4 Rationale: Cardiac catheterization is an invasive test that involves the insertion of a catheter and the injection of dye into the heart and surrounding vessels to obtain information about the structure and function of the heart chambers and valves and the coronary circulation. Access is made by the insertion of a needle in either side of the groin into an artery and the catheter is advanced up to the heart through the abdomen and chest. Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so there is little to no pain with catheter insertion. The x-ray table is hard and may be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.
The nurse is assisting the client with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree items that could aggravate the client's condition? 1. Tomato soup 2. Fresh fruit plate 3. Vegetable lasagna 4. Ground beef patty
Answer: 4 Rationale: Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, milk, peanut butter, and gelatin. The food items in options 1, 2, and 3 are acceptable to eat.
A client has just been admitted to the emergency department with chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis? 1. Stable angina 2. Unstable angina 3. Prinzmetal's angina 4. New-onset myocardial infarction (MI)
Answer: 4 Rationale: Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise 3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Troponin I is particularly sensitive to myocardial muscle injury; therefore, the client's results are compatible with new-onset MI. Options 1, 2, and 3 all refer to angina. These levels would not be elevated in angina.
The nurse is instructing a client with diabetes mellitus regarding hypoglycemia. Which statement by the client indicates the need for further teaching? 1."Hypoglycemia can occur at any time of the day or night." 2."I can drink 6 to 8 ounces of milk if hypoglycemia occurs." 3."If I feel sweaty or shaky, I might be experiencing hypoglycemia." 4."If hypoglycemia occurs, I need to take my regular insulin as prescribed."
Answer: 4 Rationale: Hypoglycemia occurs when the blood glucose level falls below 70 mg/dL. Insulin is not taken as a treatment for hypoglycemia because the insulin will lower the blood glucose level. Hypoglycemic reactions can occur at any time of the day or night. If a hypoglycemic reaction occurs, the client will need to consume 10 to 15 g of carbohydrate; 6 to 8 ounces of milk for example, contain this amount of carbohydrate. Tremors and diaphoresis are signs of mild hypoglycemia.
The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client? 1."When the doctor says so." 2."When I can tolerate food without vomiting." 3. "When my gastrointestinal (GI) system is healed." 4. "When my bowels begin to function again and I begin to pass gas."
Answer: 4 Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the health care provider determines when the NG tube will be removed, option 1 does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.
The nurse is performing an admission assessment for a client admitted to the hospital with a diagnosis of Raynaud's disease. The nurse assesses for the symptoms associated with Raynaud's disease by performing which actions? 1. Checking for a rash on the digits 2. Observing for softening of the nails or nail beds 3. Palpating for a rapid or irregular peripheral pulse 4. Palpating for diminished or absent peripheral pulses
Answer: 4 Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method should the nurse use to cover the dressing? 1. Apply a Kerlix roll and tape it to the skin. 2. Apply a large, soft pad and tape it to the skin. 3. Apply small Montgomery straps and tie the edges together. 4. Apply a Kling roll and tape the edge of the roll onto the bandage.
Answer: 4 Rationale: Standard dressing technique includes the use of Kling rolls on circumferential dressings. With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps should not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway).
The nurse assists the health care provider with a liver biopsy performed at the bedside. Which position should the nurse place the client in after the biopsy? 1. Supine with the head elevated on one pillow 2.Semi-Fowler's with two pillows under the legs 3. Left side-lying with a small pillow under the puncture site 4. Right side-lying with a folded towel under the puncture site
Answer: 4 Rationale: The liver is located on the right side of the body. After a liver biopsy, the nurse positions the client on the right side with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the abdominal wall at the biopsy site to tamponade bleeding from the puncture site.
The home care nurse visits a client who was recently diagnosed with cirrhosis and provides home care management instructions to the client. Which statement by the client indicates the need for further teaching? 1."I will obtain adequate rest." 2."I should monitor my weight regularly." 3."I should include sufficient carbohydrates in my diet." 4."I will take acetaminophen (Tylenol) if I get a headache."
Answer: 4 Rationale: Cirrhosis is a chronic progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Acetaminophen (Tylenol) is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored regularly. The diet should supply sufficient carbohydrates with a total daily intake of 2000 to 3000 calories.
The nurse in an outpatient diabetes clinic is monitoring a client with type 1 diabetes mellitus. Today's blood work reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the understanding that this result indicates which finding? 1. A normal value that indicates that the client is managing blood glucose control well 2. A value that does not offer information regarding the client's management of the disease 3. A low value that indicates that the client is not managing blood glucose control very well 4. A high value that indicates that the client is not managing blood glucose control very well
Answer: 4 Rationale: Glycosylated hemoglobin is a measure of glucose control during the 6 to 8 weeks before the test. It is a reliable measure for determining the degree of glucose control in diabetic clients over a period of time, and it is not influenced by dietary management a day or two before the test is done. The glycosylated hemoglobin level should be 7.0% or less for a client with diabetes mellitus, with elevated levels indicating poor glucose control.
The nurse is providing home care instructions to a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. What instruction should the nurse provide to this client? 1. Avoid sexual intercourse for at least 4 months. 2.Replace sublingual nitroglycerin tablets yearly. 3. Participate in an exercise program that includes overhead lifting and reaching. 4. Recognize the adverse effects of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss.
Answer: 4Rationale: After an acute MI, many clients are instructed to take an aspirin daily. Adverse effects include tinnitus, hearing loss, epigastric distress, gastrointestinal bleeding, and nausea. Sexual intercourse usually can be resumed in 4 to 8 weeks after an acute MI if the health care provider agrees and if the client has been able to achieve traditional parameters such as climbing two flights of steps without chest pain or dyspnea. Clients should be advised to purchase a new supply of nitroglycerin tablets every 6 months. Expiration dates on the medication bottle should also be checked. Activities that include lifting and reaching over the head should be avoided because they reduce cardiac output.
The nurse notes this cardiac rhythm on the cardiac monitor. What should the nurse interpret that the client is experiencing? 1. Atrial fibrillation 2. Sinus bradycardia 3. Ventricular fibrillation (VF) 4. Premature ventricular contractions (PVCs)
Answers: 4 Rationale: PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy. In atrial fibrillation, no definitive P wave usually can be observed, only fibrillatory waves before each QRS complex are observed. In sinus bradycardia, atrial and ventricular rhythms are regular, and the rates are less than 60 beats per minute. In ventricular fibrillation, impulses from many irritable foci in the ventricles fire in a totally disorganized manner, which appears as a chaotic rapid rhythm in which the ventricles quiver.
The nurse is caring for a client with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions should the nurse teach the client to follow? 1.Monitor the urine for acetone. 2. Report any feelings of drowsiness. 3. Keep glucose tablets and subcutaneous glucagon available. 4. Omit the evening dose of NPH insulin if the client has been exercising
ans: 3 Rationale: Glucose tablets are taken if a hypoglycemic reaction occurs. Glucagon (GlucaGen) is administered subcutaneously or intramuscularly if the client loses consciousness and is unable to take glucose by mouth. Glucagon releases glycogen stores and raises the blood glucose levels of hypoglycemic clients. Family members can be taught to administer this medication and possibly to prevent an emergency department visit. Acetone in the urine may indicate hyperglycemia. Although signs/symptoms of hypoglycemia need to be taught to the client, drowsiness is not the initial and key sign of this complication. The nurse would not instruct a client to omit insulin.
