NURS 398

Which of the following findings would cause the nurse to halt/stop a respiratory exam? A. Eupnea B. Extreme SOB C. Cough D. Anxiety

B

A patient with kidney failure reports dyspnea. The patient's pulse oximeter reading is 95% on room air, but is visibly distressed with a respiratory rate of 32 breaths/min. What is the priority intervention? A.Notify the respiratory therapist. B.Administer oxygen by nasal cannula. C.Elevate the head of bed to 90 degrees. D.Administer a respiratory nebulizing treatment.

b

The nurse is assessing a patient's skin. Which lesion finding requires further nursing intervention? A.Symmetry B.Consistent color C.Diameter of 8 mm D.Regular border

c

A patient with a history of kidney disease is admitted with acute shoulder pain. Which order should the nurse question? A.Digoxin 0.125 mg by mouth daily B.Metoprolol 50 mg by mouth twice daily C.Pan cultures for a temperature >38.5º C D.Ibuprofen 800 mg by mouth every 4 hours as needed for pain

d

Which patient is most likely to experience renal compromise assessed by decreased urine production? A.10-year history of diabetes mellitus B.White blood cell count of 12,000/mm3 C.Recent history of myocardial infarction D.Blood pressure of 92/46 mm Hg for 12 hours

d

Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? A."I don't like the taste of spicy foods." B."I got dentures four years ago." C."I experience occasional constipation." D."I take ibuprofen three times daily for arthritis."

d

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sitting upright

A

The nurse teaches a client with newly diagnosed hyperthyroidism. The nurse instructs the client to seek immediate medical care for which signs or symptoms? A. The client develops restlessness and insomnia B. The client develops eye swelling and photophobia. C. The client develops increased stools and diarrhea. D. The client develops fever and palpations.

D

A nurse cares for a 15-year old primigravida. When providing education, the mother asks about the soft spot on the newborn's head. What is the most appropriate response? A. The anterior fontanelle will close between 12-18 months of age B. The posterior fontanelle will remain open until about 2 years of age C. This separation of bones occurs due to prolonged labor and pushing D. This is an unusual finding that the pediatrician will follow up on

A

Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process? A.Tightening of the vocal cords B.Decrease in residual volume C.Decrease in the anteroposterior diameter D.Decrease in respiratory muscle strength

D

Which of the following patients would you prioritize first? A. Patient with a pedal pulse of +1 bilaterally B. Patient with bilaterally cool feet C. Patient with SBP of 130 D. Patient with +2 on the right, 0 on the left

D

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? A. Arterial insufficiency B. Venous insufficiency C. Within the expected range D. Thrombus formation in the vein

A

While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? A. Assess for symptoms of left-sided heart failure. B. Document this as a normal finding. C. Call the healthcare provider immediately. D. Transfer the patient to the intensive care unit.

A

The nurse assesses a client who reports fever, chills, headache and malaise. The client has firm, tender cervical lymph nodes. What laboratory findings does the nurse expect? Select all that apply. A. Positive Epstein-Barr virus antibody test B. WBC 15.9 C. Negative heterophile antibody test D. RBC 3.2 E. Lymphocytes 5.2

A B C E

The nurse assesses a client with hyperthyroidism. What symptoms might be expected? Select all that apply. A. Increased appetite B. Photophobia C. Progressive weight gain D. Hand tremors E. Edema in lower extremities

A B D

After providing education, which patient statement does the nurse identify that reflects an older patient's understanding of musculoskeletal health interventions? A."I should use a cane when I walk. "B."I should drink 8 oz of orange juice daily. "C."I should try to exercise at least five times a week." D."I should ignore my pain and adapt to moving more slowly."

A or C

The nurse is auscultating at the left 3rd intercostal space. What is the associated valve area? A. Aortic B. Erb's Point C. Pulmonic D. Tricuspid E. Mitral

B

The nurse is caring for four female patients. Which patient is identified as being at greatest risk for low bone density? A.22 year old Asian American B.39 year old Caucasian American C.44 year old Native American D.50 year old African American

B

The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule? A.25% B.50% C.75% D.100%

B

A patient is scheduled for an electromyography (EMG) to evaluate diffuse or localized muscle weakness. What question will the nurse ask the patient before the test? A."When did you last eat or drink? B."Have you completed your exercise for the day? C."What herbs and over-the-counter medicines do you take? D."Did you take your cyclobenzaprine (Flexeril) this morning?"

C

The nurse is assessing a patient's heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate? A.Listen at the base of the heart. B.Listen only for higher pitched sounds. C.Ask the patient to lay on his left side. D.Ask the patient to hold their breath for 15 seconds.

C

A nurse assesses a patient's respiratory status. Which information is of highest priority for the nurse to obtain? A.Average daily fluid intake B.Neck circumference C.Height and weight D.Occupation and hobbies

D

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D

The nurse hears a blowing/swooshing sound when auscultating the heart. How should this be documented in the patient's chart? A. Irregular rhythm B. Normal heart sounds C. Bruit D. Murmur

D

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increased hematocrit E. Increased temperature

a b c

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute. B. Assess the apical pulse with a Doppler device. C. Assess the pedal pulses for a full minute. D. Assess the pedal pulses with a Doppler device.

A

A patient who smokes asks the nurse, "Smoking just hurts my lungs, not my heart, right?" Which nursing response is appropriate?A."Smoking is a major risk factor for coronary artery disease and peripheral vascular disease. " B."You are correct, smoking only hurts the lungs." C."The primary impact of smoking is only on the heart." D."What concerns you most about smoking?"

A

The emergency department nurse is caring for a 78-year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition? A."Tell me what this fable means to you." B."Please count backward from 100 by 7s." C."Tell me how you were transported to the hospital today." D."I will write a word on this paper, and you copy it."

A

The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention? A.Enable the bed alarm safety system. B.Place all items directly in front of the patient. C.Use a picture board to assist with communication. D.Instruct the patient to use a call light prior to getting out of bed.

A

After abdominal surgery, which question should the nurse ask the patient to determine whether peristaltic movement is returning? A."Have you passed flatus?" B."Are you hungry" C."Do you have any nausea?" D."Is your pain level manageable?"

a

A patient with dandruff asks the nurse for information about this condition. What is the appropriate nursing response? (Select all that apply.) A."It is a cosmetic problem." B."It is a symptom of a dry scalp." C."Untreated severe dandruff can lead to hair loss." D."Your scalp is very oily, which contributes to dandruff." E."Dandruff looks like patchy or diffuse white or gray scales on the scalp surface."

a c d e

The nurse explains to the patient that the surgeon will inject a local anesthetic and then use a small circular instrument to cut and remove a small plug of tissue. Which procedure has the nurse described? A.Unroofing B.Punch biopsy C.Shave biopsy D.Excisional biopsy

b

When administering a new GI medication to an older patient, the nurse anticipates what? A.A higher-than-normal dose may be needed. B.Close monitoring is needed because toxic levels may develop. C.Older adults always require a lower-than-normal dose than younger patients. D.Nausea and vomiting may develop rapidly and are common side effects in older adults.

b

When obtaining a health history from a 22-year-old female client who has new-onset urinary incontinence, which finding or factors does the nurse consider significant? Select all that apply. A. Chemical exposure in the workplace B. A burning sensation occurring on urination C. Urinating 10 times daily although fluid intake remains unchanged D. A recent change in the client's oral contraceptive prescription E. A new inability to hold urine (urgency) F. A "stinky" odor from the urine

b c e f

A student nurse is assessing a patient's head, neck and upper lymphatics. Which of the following actions would cause the instructor to intervene? A. Palpating the temporal arteries bilaterally for equal strength and pattern at the same time. B. Assessing for intactness of CN V (Trigeminal) by having the patient clench their teeth. C. Palpating the preauricular lymph nodes, superficial to mastoid process in a circular motion with the pads of their fingers. D. Assessing the patient's range of motion for their neck using flexion, lateral flexion and hyperextension.

c

The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, for which common cause does the nurse initially assess? A.Infection B.Use of sedatives C.Oxygen insufficiency D.Electrolyte imbalance

c