NUR 233 Exam 2 Practice

The nurse is examining an 18 year-old female who is complaining of pain, frequency, and urgency when urinating. Which question should the nurse ask the client first? A. "Are you usually sexually active?" B. "What have you taken for pain?" C. "When was your last menstrual cycle?" D. "Have you noticed any change in the color of the urine?"

A. "Are you usually sexually active?"

Which statements by the patient diagnosed with celiac disease indicate the need for further teaching? Select all that apply. A. "I am glad this can be cured with surgery" B. "I cannot have any gluten in my diet" C. "I wash all my dishes with water only" D. "I may become anemic because of this disease" E. "I am at risk for osteoporosis"

A. "I am glad this can be cured with surgery" C. "I wash all my dishes with water only"

The male client tells the nurse he has been experiencing "heartburn at night that awakens him. Which assessment question should the nurse ask? A. "What have you done to alleviate the heartburn?" B. "Do you consume many milk and dairy products?" C. "Have you been around anyone with a stomach virus?" D. "How much weight have you gained recently?"

A. "What have you done to alleviate the heartburn?"

The nurse correlates which data in a female patient's history to an increased risk of urinary tract infection (UTI)? Select all that apply. A. 25 year old who is sexually active B. Drinks 2L of water a day C. 28 weeks pregnant D. History of back strain E. History of renal calculi

A. 25 year old who is sexually active C. 28 weeks pregnant E. History of renal calculi

Which are the clinical manifestations of right sided heart failure? Select all that apply. A. Ascites B. Dyspnea C. Hepatomegaly D. Generalized edema E. Weak pulses

A. Ascites C. Hepatomegaly D. Generalized edema

The nurse is assessing a patient who is suspected to have left-sided heart failure. Which assessment provides specific information regarding the left-sided heart failure function? A. Auscultating lung sounds B. Monitoring for hepatomegaly C. Palpating for peripheral edema D. Assessing for jugular vein distention

A. Auscultating lung sounds

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? A. Daily alcohol intake B. Dietary protein intake C. Multivitamin with minerals D. Over-the-counter (OTC) laxative

A. Daily alcohol intake

1. The nurse is concerned that a patient with heart failure is decompensating. Which assessment finding requires an immediate intervention? A. Dyspnea at rest B. Dry persistent cough C. Weak peripheral pulses D. Jugular vein distention

A. Dyspnea at rest

Implementation of nursing care for a patient with hyponatremia includes: A. Fluid restriction B. Administration of hypotonic IV fluids C. Administration of cation-exchange renin D. Increased water intake for patients on nasogastric suction

A. Fluid restriction

A patient with a history of alcoholism is disoriented and vacillates between being calm and disruptive and loud. Vital signs are BP 138/84 mm Hg; pulse 135 beats/min, regular and strong; respiratory rate 22 breaths/min; temperature 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect this patient is experiencing? A. Hypomagnesemia B. Hypocalcemia C. Hyperkalemia D. Hypernatremia

A. Hypomagnesemia

Select the stool characteristics you would expect to see with each ostomy. (ILEOSTOMY) A. Liquid to semiliquid stool B. Formed stool C. Semiliquid to semiformal stool D. Semiformal stool E. Semiliquid stool

A. Liquid to semiliquid stool

Which action should the nurse take when beginning bladder training using scheduled voiding? A. Offer the patient a bedpan every 2 hours while awake B. Increase the voiding interval by 30-60 minutes each week C. Frequently ask the patient whether they have the urge to void D. Increase the frequency between voiding even if urine leakage occurs

A. Offer the patient a bedpan every 2 hours while awake

Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? A. Positive Trousseau's sign B. Positive Chvostek's sign C. Tetany D. Paresthesia

A. Positive Trousseau's sign

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? A. Prolonged bed rest B. Renal insufficiency C. Hyperparathyroidism D. Excessive ingestion of vitamin D

A. Prolonged bed rest

The nurse is caring for a client diagnosed with deep vein thrombosis. Which information reported to the nurse by the unlicensed assistive personnel (UAP) requires immediate intervention? A. The UAP informed the nurse the client is complaining of chest pain B. The UAP notified the nurse the client's blood pressure is 100/66 C. The UAP reported the client is requesting to be able to take a shower D. The UAP tells the nurse the client is asking for medication for a headache

A. The UAP informed the nurse the client is complaining of chest pain

Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective? A. The client prepares a scheduled voiding plan B. The client attempts to retain the vaginal cone in place the entire day C. The client explains how to perform pelvic floor exercises D. The client verbalizes the need to increase fluid intake

A. The client prepares a scheduled voiding plan

Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? Select all that apply: A. Thick, tough B. Thin, scaly C. Hairless D. Brown pigmented

A. Thick, tough D. Brown pigmented

Which describes symptoms of dehydration? Select all that apply. A. Thirst B. Increased blood pressure C. Rapid pulse D. Muscle fatigue E. Increased respiration

A. Thirst C. Rapid pulse D. Muscle fatigue

A client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." Which is the best action for the nurse to take?

Ask the client questions to determine the current understanding of high blood pressure

A patient is admitted to the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10 pain scale and diagnosed with gastroesophageal reflux disorder (GERD) secondary to hiatal hernia. Based on this data, what is the priority nursing diagnosis? A. Fluid volume deficit B. Acute pain C. Ineffective health maintenance D. Dysfunctional gastrointestinal motility

B. Acute pain

Which nursing intervention reduces the risk of clot formation in the legs? Select all that apply. A. Keep the patient's hips and knees flexed while the patient is in bed. B. Apply compression devices (e.g., sequential compression devices [SCDs]). C. Turn the patient frequently or encourage frequent position changes. D. Promote adequate hydration by encouraging oral intake. E. Elevate the patient's legs above the level of the heart.

B. Apply compression devices (e.g., sequential compression devices [SCDs]). C. Turn the patient frequently or encourage frequent position changes. D. Promote adequate hydration by encouraging oral intake. E. Elevate the patient's legs above the level of the heart.

A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed corn

B. Bananas and oranges

The nurse is caring for a patient admitted with severe dehydration secondary to gastroenteritis. Which item on the patient's meal tray does the nurse question? A. Apple juice B. Coffee C. Broth D. Caffeine-free soda

B. Coffee

In providing care to a patient who underwent a colostomy 2 days ago for the treatment of colon cancer, which finding requires an immediate intervention? A. Serosanguineous drainage from the stoma B. Dark red, purplish color of the stoma C. Slight edema of the stoma D. Reddish-pink, moist stoma

B. Dark red, purplish color of the stoma

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? A. Have the client remain upright at all times and walk for 30 minutes three (3) times a week B. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client C. Place the client prone in bed and administer non-steroidal anti-inflammatory medications D. Instruct the client to maintain a right lateral side-lying position and take antacids before meals

B. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client

The nurse monitors for which clinical manifestations in the patient diagnosed with acute gastritis? A. Eructation B. Epigastric pain C. Constipation D. Peripheral edema

B. Epigastric pain

In assessing pain in the patient with a urinary tract infection, which clinical manifestation does the nurse correlate to progression of the infection to pyelonephritis? A. Dysuria B. Flank pain C. Hematuria D. Urinary frequency

B. Flank pain

Select the stool characteristics you would expect to see with each ostomy. (SIGMOID COLOSTOMY) A. Liquid to semiliquid stool B. Formed stool C. Semiliquid to semiformal stool D. Semiformal stool E. Semiliquid stool

B. Formed stool

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? A. Administer the KCl as a rapid IV bolus. B. Infuse the KCl at a rate of 10 mEq/hour. C. Only give the KCl through a central venous line. D. Discontinue cardiac monitoring during the infusion.

B. Infuse the KCl at a rate of 10 mEq/hour.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? A. PO4-3 4.8 mg/dL (1.55 mmol/L) B. Na+ 154 mEq/L (154 mmol/L) C. K+ 3.4 mEq/L (3.4 mmol/L) D. Ca+2 7.8 mg/dL (1.95 mmol/L)

B. Na+ 154 mEq/L (154 mmol/L)

The nurse is teaching a class to clients diagnosed with hypertension. Which should the nurse teach to clients? A. The blood pressure target range should be 120/80 B. Take the medication even when feeling well C. Get up quickly when rising from a recumbent position D. Consume a 3,000 mg sodium diet

B. Take the medication even when feeling well

How would the nurse describe the exudate characteristic of a serosanguineous wound?

Blood-tinged amber fluid

Which statement by the patient diagnosed with gastritis indicates the need for further teaching? A. "I will eat bland, non spicy foods." B. "I will eat smaller, more frequent meals." C. "I will take aspirin for headaches." D. "I will take an antacid if my symptoms continue."

C. "I will take aspirin for headaches."

The nurse has implemented a care plan for an adult patient with gastroesophageal reflux disorder (GERD). On the next clinic visit, which statement by the patient indicates adherence to the plan of care? A. "I still like wearing my Spandex camisoles." B. "I have switched from margaritas to wine." C. "I've lost 6 pounds because I eat every 3 hours and never before bed." D. "I lay down flat after eating to promote digestion."

C. "I've lost 6 pounds because I eat every 3 hours and never before bed."

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? A. Bananas B. Broccoli C. Antacids D. Cantaloupe

C. Antacids

The nurse working in the heart failure clinic will know that teaching for a 74 year-old patient with newly diagnosed heart failure has been effective when the patient A. Weighs himself twice a week B. Tells the home care nurse that Hydrodiuril (Hydrochlorothiazide) is taken daily at bedtime C. Calls the clinic when the weight increases from 124 to 130 pounds in a week D. Says that the Nitro-Bid (nitroglycerine ointment) will be used for any chest pain that develops

C. Calls the clinic when the weight increases from 124 to 130 pounds in a week

A patient has an arterial ulcer on the lower extremity. What risk factors for peripheral arterial disease are in the patient's health history? Select all that apply: A. Pregnancy B. Being Female C. High Cholesterol D. Diabetes Mellitus E. Uncontrolled hypertension F. Varicose veins G. Smoking

C. High Cholesterol D. Diabetes Mellitus E. Uncontrolled hypertension G. Smoking

In providing care to a patient who is diagnosed with hypertension, which assessment data are risk factors for this disease process? Select all that apply. A. Current age 45 B. BMI 28 C. History of cigarette smoking D. Elevated kidney function tests E. Concurrent diagnosis of diabetes mellitus

C. History of cigarette smoking D. Elevated kidney function tests E. Concurrent diagnosis of diabetes mellitus

An adult patient is admitted to the hospital with a prolonged PR interval and widened QRS complex on his EKG, and symptoms of hyperkalemia. The nurse should plan to administer: A. 0.9% Sodium chloride B. Antidiuretic hormones C. Keyexalate anemia D. Antihypertensive

C. Keyexalate anemia

After receiving change-of-shift report, which patient should the nurse assess first? A. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal B. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes D. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

The nurse is assessing a patient, who has many risk factors for the development of a DVT. What signs and symptoms below would possibly indicate a deep vein thrombosis is present? Select all that apply: A. Cool extremity B. Decreases pulses C. Redness D. Pain E. Warm extremity F. Swelling G. Cyanosis

C. Redness D. Pain E. Warm extremity F. Swelling

The nurse is caring for a patient with a medical diagnosis of hypernatremia. Thefollowing orders are written in the client's electronic health record. Which oneshould the nurse question? A. Administer an IV of D5W at 125 mL/hr B. Strict I&O monitoring C. Restrict oral intake to 900 mL every 24 hr D. Monitor serum electrolytes every 4 hr

C. Restrict oral intake to 900 mL every 24 hr

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client's electronic health record. Which one should the nurse question? A. Administer an IV of D5W at 125 mL/hr. B. Strict I&O monitoring. C. Restrict oral intake to 900 mL every 24 hr. D. Monitor serum electrolytes every 4 hr.

C. Restrict oral intake to 900 mL every 24 hr.

Select the stool characteristics you would expect to see with each ostomy. (TRANSVERSE COLOSTOMY) A. Liquid to semiliquid stool B. Formed stool C. Semiliquid to semiformal stool D. Semiformal stool E. Semiliquid stool

C. Semiliquid to semiformal stool

Your patient has a PEG tube and you are about to administer a feeding. What is not a symptom that would cause you to hold off the required feeding? A. Nausea B. Increased bloating C. Skin irritation D. Emesis

C. Skin irritation

An older adult patient is admitted to the emergency department for hypovolemia. After 500 mL of 0.9% NaCl is delivered intravenously over 1 hour, the assessment shows: blood pressure of 167/88 mm Hg, heart rate 110 beats per minute, and crackles bilaterally. What should the nurse determine from this situation? A. The patient has been properly rehydrated B. The patient has become hypovolemic C. The patient is showing signs of hypervolemia D. The patient is showing no change in condition

C. The patient is showing signs of hypervolemia

Which action would the home health nurse take when caring for a client with a pink and moist left venous stasis ulcer?

Clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly

A client has a large open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing?

Cleanse the wound with wet sterile gauze from the center of the wound outward

The nurse is teaching a patient about the interventions to prevent the development of deep-vein thrombosis (DVT). Which statement made by the patient indicates the need for further teaching? A. "I should take adequate fluids" B. "I should use compression stockings" C. "I should elevate my legs 10-20 degrees while at rest" D. "I should limit my physical activity and spend more time sitting"

D. "I should limit my physical activity and spend more time sitting"

Which serum potassium result best supports the rationales for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? A. 3.4 mEq/L B. 5.5 mEq/L C. 4.6 mEq/L D. 2.9 mEq/L

D. 2.9 mEq/L

Which of these clients seen at a health fair will be most at risk for hypertension? A. 23-year-old white man B. 44-year-old white woman C. 50-year-old Mexican-American woman D. 62-year-old African American man

D. 62-year-old African American man

Which problem is most appropriate for the nurse to identify for the client with diarrhea A. Fluid volume excess B. Ineffective coping C. Chronic pain perception D. Alteration in skin integrity

D. Alteration in skin integrity

Which information is most important to the nurse to include when teaching a patient with newly diagnosed hypertension? A. Most people are able to control BP through dietary changes B. Annual BP checks are needed to monitor treatment effectiveness C. Increasing physical activity alone controls blood pressure for most people D. Hypertension is usually asymptomatic until target organ damage occurs

D. Hypertension is usually asymptomatic until target organ damage occurs

The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37°C (98.6°F). What disorder should the nurse suspect? A. Hypovolemia B. Hypercalcemia C. Hyperkalemia D. Hypervolemia

D. Hypervolemia

A patient is prescribed 20 mEq of potassium chloride because of excessive vomiting. The nurse includes which information in explaining the rationale for this medication? A. It controls and regulates water balance in the body B. It is used in the body to synthesize ingested protein C. It is vital in regulating muscle contraction and relaxation D. It is needed to maintain skeletal, cardiac, and neuromuscular activity

D. It is needed to maintain skeletal, cardiac, and neuromuscular activity

Select the stool characteristics you would expect to see with each ostomy. (DESCENDING COLOSTOMY) A. Liquid to semiliquid stool B. Formed stool C. Semiliquid to semiformal stool D. Semiformal stool E. Semiliquid stool

D. Semiformal stool

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? A. Seating the client with arm bared, supported, and at heart level. B. Measuring the blood pressure after the client has been seated quietly for 5 minutes. C. Using a cuff with a rubber bladder that encircles at least 80% of the limb. D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment change related to this is most concerning? A. The patient feels light headed when getting out of bed B. The patient has tremors when stretching arms out straight C. The patient has bone pain and joint stiffness D. The patient feels palpitations and has an irregular pulse

D. The patient feels palpitations and has an irregular pulse

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply.

Diuretics Low-salt diet Daily weight checks Fluid restriction Intake and output Oxygen administration

Select the stool characteristics you would expect to see with each ostomy. (ASCENDING COLOSTOMY) A. Liquid to semiliquid stool B. Formed stool C. Semiliquid to semiformal stool D. Semiformal stool E. Semiliquid stool

E. Semiliquid stool

When an obese client receives a diagnosis of high blood pressure, which topic would be the most important to include in teaching?

Effect of weight loss in hypertension

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern?

Electrolyte imbalance

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. For which potential life-threatening complication should the nurse assess the client postoperatively?

Fluid deficit and electrolyte imbalance

When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? Select all that apply.

Intake of salty food Medication compliance Recent travel

When a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb (2.7 kg), which nursing action has the highest priority?

Listen to the client's breathe sounds

Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke?

Maintain an open airway

Which collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehydration, a heart rate of 100 beats/minute, and blood pressure of 104/62 mm Hg?

Offer frequent oral fluids for several hours

Which action will the urgent care clinic nurse anticipate taking for a 24-year-old client who is dehydrated after a long run and has a pulse rate of 103 and blood pressure of 102/56 mm Hg?

Offer oral fluids at frequent intervals

After obtaining client blood pressures of 172/107 mm Hg and 164/98 mm Hg during a blood pressure screening, which action would the nurse take next?

Refer the client to a primary health care provider

Which clinical finding would the nurse expect for a client with hypertensive emergency?

Severe pounding headache

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?

Urinary output every hour

When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving?

Weighing the client

The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics?

Wound culture