NUR 114 Example Questions 2

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

Assess the cause of the agitation.

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?

Assess the clients bowel sounds.

A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first?

Assess the clients endotracheal tube with 40% FiO2.

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.)

Attend local Alcoholics Anonymous (AA) meetings weekly. Use cooking spray when you cook rather than margarine or butter. We can talk to your doctor about a prescription for nicotine patches.

A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond?

Bile salts accumulate in the skin and cause the itching.

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.)

Body mass index of 46 Pregnant with twins Glycosylated hemoglobin level of 15%

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

Broiled chicken with brown rice, steamed broccoli, glass of apple juice

A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first?

Determine whether the client feels like talking about his or her feelings.

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, What can I do to help prevent these infections? How should the nurse respond?

Drink more water and empty your bladder more frequently during the day.

A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, Will my children develop this disease? How should the nurse respond?

Each of your children has a 50% risk of having ADPKD.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort?

Maintain nothing by mouth (NPO) and administer intravenous fluids.

A nurse prepares to administer 12 mg/kg of 5-fluorouracil chemotherapy intravenously to a client who has colon cancer. The client weights 132 lb. How many milligrams should the nurse administer? (Record your answer using a whole number.) _____ mg

ANS: 720 mg132 lb = 60 kg.60 kg 12 mg/kg = 720 mg.

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.)

Direct inguinal hernia A peritoneum sac passes through a weak point in the abdominal wall Ventral hernia Results from inadequate healing of an incision Incarcerated hernia Contents of the hernia sac cannot be reduced back into the abdominal cavity

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge?

Do you have a one- or two-story home?

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider?

Drainage from a fistula

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first?

Assess and maintain a patent airway.

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the clients lower abdomen. Which action should the nurse take first?

Assess for abdominal guarding or rigidity.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)

Acknowledge the frightening nature of the illness. Delegate a back rub to the unlicensed assistive personnel (UAP). Give simple explanations of what is happening. Stay with the client and speak in a quiet, calm voice.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client?

Add vegetables such as broccoli and cauliflower to your new diet.

he nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)

Adherence to proper hand hygiene Administering anti-ulcer medication Elevating the head of the bed Providing oral care per protocol

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

Assess for other manifestations of hypoxia.

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.)

Assess for proper placement of the tube every 4 hours. Disconnect suction when auscultating bowel peristalsis. Monitor the clients skin around the tube site for irritation.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)

Allow visitors at the clients bedside. Ensure the client can communicate if awake. Provide back and hand massages when turning. Turn the client every 2 hours or more.

A client in the emergency department has several broken ribs. What care measure will best promote comfort?

Allowing the client to choose the position in bed

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?

Alteplase (Activase)

A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond?

Ambulating in the hallway twice a day will help.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)

Chest wall stiffness Decreased muscle strength Less lung elasticity

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?

Choosing an 18-gauge, 2-inch needle

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

Client with a new spinal cord injury on a rotating bed Older client who is 1-day post hip replacement surgery Young obese client with a fractured femur

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take?

Contact the provider and recommend computed tomography.

A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.)

Contact the provider immediately. Lower the head of the bed.

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take?

Determine when the client last voided.

A nurse cares for a client who has a new colostomy. Which action should the nurse take?

Empty the pouch frequently to remove excess gas collection.

A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, When I wake up I am in pain. Which action should the nurse take?

Encourage the client to use the PCA pump upon awakening.

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take?

Encourage the client to verbalize feelings about the diagnosis.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Ensure a patent airway.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?

Ensuring there is a bag-valve-mask in the room

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)

Exercise on a regular basis. Maintain a healthy weight. Stop smoking cigarettes.

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes Feels frightened Cant catch my breath Laboratory Analysis Physical Assessment pH: 7.12PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate?

Facilitate a STAT pulmonary angiography.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.)

Make sure the client receives a protein shake. Do not allow caffeine-containing beverages Make sure the foods are bland with little spice.

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?

Have you been experiencing any constipation?

A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply?

Have you passed any flatus or moved your bowels?

A nurse cares for a client with end-stage pancreatic cancer. The client asks, Why is this happening to me? How should the nurse respond?

I dont know. I wish I had an answer for you, but I dont.

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?

I must increase my intake of dietary fiber and fluids.

After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?

I will decrease the amount of fatty foods in my diet.

A nurse cares for a client with colon cancer who has a new colostomy. The client states, I think it would be helpful to talk with someone who has had a similar experience. How should the nurse respond?

I will make a referral to the United Ostomy Associations of America.

After teaching a client who has a femoral hernia, the nurse assesses the clients understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss?

I will put on the truss before I go to bed each night.

client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?

Increase the heparin rate.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

Interrupt the procedure to give oxygen.

A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?

It is hypoxemia that persists even with 100% oxygen administration.

A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?

It will prevent ulcers from the stress of mechanical ventilation.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

Large chefs salad and muffin

A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond?

Lets talk to the ostomy nurse to help you and your husband work through this.

A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?

Light-colored stools

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?

Listen to the clients lung sounds.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

Notify the Rapid Response Team.

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.)

Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders Checks for correct placement by checking the pH of the fluid aspirated from the tube Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider?

Periorbital edema

A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.)

Place the client in a private room. Wear a lead apron when providing client care. Bundle care to minimize exposure to the client.

A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take?

Place the client in semi-Fowlers position.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

Prepare preoperative teaching for an inferior vena cava (IVC) filter.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?

Prepare to assist with intubation.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide frequent oral care per protocol.

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.)

Registered dietitian Clinical pharmacist Health care provider

After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching?

Roasted chicken breast, baked potato with chives, and orange juice

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.)

Serum potassium of 2.8 mEq/L Abdominal pain in upper quadrants Serum sodium of 121 mEq/L

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, I need to have a bowel movement. Which action should the nurse take?

Stay with the client while providing privacy.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

Strict vegetarian

A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.)

Substernal chest pain Shortness of breath Lack of bowel sounds or flatus Urine output of 20 mL/6 hr

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this clients plan of care?

Take a stool softener to promote softer stools for ease of defecation.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?

Teach the client about factor V Leiden testing.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

The best time to take the enzymes is immediately after I have a meal or a snack.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

The blood clot interferes with perfusion in the lungs.

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, The stool in my pouch is still liquid. How should the nurse respond?

The stool will always be liquid with this type of colostomy.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?

The upper peak airway pressure limit alarm is on.

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help? How should the nurse respond?

Unfortunately, lubiprostone is approved only for use in women.

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this clients plan of care? (Select all that apply.)

Using premoistened disposable wipes for perineal care Turning the client from right to left every 2 hours Applying a barrier cream to the skin after cleaning

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this clients assessment? (Select all that apply.)

Which food types cause an exacerbation of symptoms? Where is your pain and what does it feel like? Do you experience nausea associated with defecation?

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider?

White blood cell (WBC) count of 1500/mm3

A nurse cares for a client who has a family history of colon cancer. The client states, My father and my brother had colon cancer. What is the chance that I will get cancer? How should the nurse respond?

You should have a colonoscopy more frequently to identify abnormal polyps early.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

Platelet count: 82,000/L

A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer?

A 50-year-old who has the BRCA2 gene mutation

A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer?

A 66-year-old who smokes cigarettes

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer?

A 72-year-old who eats fast food frequently

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I dont think I need the colonoscopy and would like to cancel it. How should the nurse respond?

A negative fecal occult blood test does not rule out the possibility of colon cancer.

A nurse cares for a client with acute pancreatitis who is prescribed gentamicin (Garamycin) 3 mg/kg/day in 3 divided doses. The client weighs 264 lb. How many milligrams should the nurse administer for each dose? (Record your answer using a whole number.) ____ mg/dose

ANS: 120 mg/dose 264 lb (2.2 lb/kg) = 120 kg.3 mg/kg/day 120 kg = 360 mg/day.360 mg/day 3 divided doses = 120 mg/dose.

A nurse cares for a client who is prescribed 4 mg of calcium gluconate to infuse over 5 hours. The pharmacy provides 2 premixed infusion bags with 2 mg of calcium gluconate in 100 mL of D5W. At what rate should the nurse administer this medication? (Record your answer using a whole number.) ____ mL/hr

ANS: 40 mL/hr

242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL

ANS: 660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury.242 pounds = 110 kg.110 kg 6 mL/kg = 660 mL.

After teaching a client who is recovering from a colon resection, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.)

I will use warm water and a soft washcloth to clean around the stoma. I might start bicycling and swimming again once my incision has healed. Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown.

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

Encouraging ambulation three times a day Encouraging normal urination Providing ice bags and scrotal support