Nursing 1 Final Exam

The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (Select all that apply.) a. Assessing for symptoms of nausea and malaise b. Encouraging the intake of low-sodium liquids c. Monitoring neurologic status d. Encouraging the use of salt substitute instead of salt e. Restricting tap water intake

a. assessing for symptoms of nausea and malaise c. monitoring neurologic status e. restricting tap water intake

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. a. Respirations that are abnormally deep b. Respirations that are increased in rate c. Respirations that are abnormally slow d. Respirations that cease for several seconds e. Respirations that are shallow

a. Respirations that are abnormally deep b. Respirations that are increased in rate

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient has numbness and tingling of the lips. c. The patient complains of generalized fatigue. d. The patient's bowels have not moved for 4 days.

a. The patient is experiencing laryngeal stridor

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Apply oxygen by mask or nasal cannula. b. Place the client in a high-Fowler's position. c. Increase the IV flow rate to 250 mL/hr d. Measure intake and output every 4 hours.

a. apply oxygen by mask or nasal cannula

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

a. client with pancreatitis who has continuous nasogastric suctioning

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. a. cyanosis b. tachycardia c. crackles on auscultation d. shoulder pain e. dyspnea f. hypertension

a. cyanosis b. tachycardia d. shoulder pain e. dyspnea

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Decreased peripheral edema b. Absence of skin tenting c. Blood pressure 110/72 mm Hg d. Hematocrit 28%

a. decreased peripheral edema

Which of the following assessments would indicate that a patient's IV has infiltrated? (Select all that apply.) a. edema of the extremity near the insertion site b. skin cool to the touch c. skin blanched or pale in appearance d. reddish streak proximal to the insertion site e. purulent drainage from the insertion site f. pain and warmth at the insertion site

a. edema of the extremity near the insertion site b. skin cool to the touch c. skin blanched or pale in appearance

A nurse carefully monitors an obese patient after a hysterectomy for the peculiar postoperative complications. Which postoperative complications are associated with obesity? (Select all that apply.) a. Hypertension b. Respiratory difficulties c. Nausea d. Wound infection e. Hemorrhage

a. hypertension b. respiratory difficulties c. nausea d. wound infection

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism? a. Increased rate and depth of respirations b. Increased release of acids from the kidneys c. Increased thirst and hunger d. Increased urinary output

a. increased rate and depth of respirations

A patient has an extensive bowel preparation of oral laxatives and enemas for a colon resection. What rationales should the nurse list when asked about the rigorous preparation? (Select all that apply.) a. Reduces possibility of fecal contamination of the operative site b. Avoids postoperative constipation c. Decreases straining at stool d. Decreases postoperative distention e. Flattens the colon

a. reduces possibility of fecal contamination of operative site b. avoids postoperative constipation c. decreases straining at stool d. decreases postoperative distention

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) a. tachypnea b. hypertension c. bradycardia d. tachycardia e. oliguria

a. tachypnea d. tachycardia e. oliguria

An elderly patient has developed Clostridium difficile-related diarrhea and been subsequently diagnosed with fluid volume deficit (FVD). The nurse providing care for this patient should anticipate: a. The administration of hypotonic or isotonic IV solution b. The administration of a hypertonic IV solution c. A decreased level of blood urea nitrogen (BUN) d. An increased level of serum potassium

a. the administration of hypotonic or isotonic IV solution

A patient received a tuberculosis skin test injection of purified protein derivative (PPD) 72 hours ago. Which assessment finding of the test site does the nurse interpret as a positive reaction? a. The skin is red and very hard for 12 mm around the injection site b. The injected area has a blister-like swelling about 2 mm high and 2 mm in diameter. c. The injection site is puffy and soft with pus oozing from the needle hole. d. There is a large bruise surrounding the injection site.

a. the skin is red and very hard for 12 mm around the injection site

A patient in the immediate postoperative period is experiencing significant hypotension. What are the most likely causes? Select all that apply. a. vasodilation related to anesthesia b. Blood or fluid loss c. acute renal failure d. severe hypothermia e. early hypoxemia

a. vasodilation related to anesthesia b. blood or fluid loss d. severe hypothermia

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. a. Weakness b. Headache c. Seizures d. Lethargy e. Hyperactivity f. Confusion

a. weakness b. headache d. lethargy f. confusion

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the tube becomes disconnected from the drainage system b. When the insertion site becomes red and warm to the touch c. When the client experiences pain at the insertion site d. When the tube drainage decreases and becomes sanguineous

a. when the tube becomes disconnected from the drainage system

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Reinsert the tube using sterile technique. b. Cover the insertion site with sterile gauze. c. Assess for drainage from the site. d. Contact the provider and obtain a suture kit.

b. Cover the insertion site with sterile gauze

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations? a. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles b. Increased pulmonary pressure creating a higher workload on the right side of the heart c. Left ventricular hypertrophy creating a decrease in cardiac output d. Increased number and size of mucus glands producing large amounts of thick mucus

b. Increased pulmonary pressure creating a higher workload on the right side of the heart

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 35-year-old client who has a longer expiratory phase than inspiratory phase b. A 27-year-old client with a heart rate of 120 beats/min c. A 66-year-old client with a barrel chest and clubbed fingernails d. A 48-year-old client with an oxygen saturation level of 92% at rest

b. a 27-year-old client with a heart rate of 120 beats/min

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state? a. Uncompensated respiratory alkalosis b. Compensated respiratory alkalosis c. Compensated metabolic alkalosis d. Compensated metabolic acidosis

b. compensated respiratory alkalosis

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Place the client in high-Fowler's position. b. Contact the provider and prepare for intubation. c. Administer prescribed albuterol nebulizer therapy. d. Ask the client to perform deep-breathing exercises

b. contact the provider and prepare for intubation

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems? a. cool, clammy skin b. diminished deep tendon reflexes c. acute flank pain d. tachycardia

b. diminished deep tendon reflexes

Which assessment is most important for the nurse to perform before administering a bronchodilator by inhalation? a. Asking questions to assess the patient's cognition and mental status b. Listening with a stethoscope to the patient's breath sounds c. Measuring blood pressure in the sitting and standing positions d. Checking the oral mucous membranes for white or cream-colored patches

b. listening with a stethoscope to the patient's breath sounds

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Respiratory acidosis

b. metabolic alkalosis

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis? a. magnesium b. potassium c. phosphorus d. sodium

b. potassium

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action? a. assess the client's blood pressure on the right arm b. Send the client for a chest x-ray. c. obtain written consent for the procedure d. administer the prescribed IV fluids

b. send the client for a chest x-ray

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. serum hematocrit of 42% b. serum sodium level of 120 mg/dL c. reported weigh gain d. total urinary output of 280 mL during the past 8 hours

b. serum sodium level of 120 mg/dL

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. There is sediment and blood in the patient's urine. b. There are crackles audible throughout both lung fields. c. The blood pressure increases from 120/80 to 142/94. d. The patient's radial pulse is 105 beats/minute.

b. there are crackles audible throughout both lung fields

A nurse reviews the results of an electrocardiogram (ECG) for a patient who is being assessed for hypokalemia. Which of the following would the nurse notice as the most significant diagnostic indicator? a. flat P wave b. widened QRS wave c. elevated U wave d. peaked T wave

c. elevated U wave

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? a. Provides long-term pH regulation b. Decreases arterial pH c. Increases arterial pH d. No effect

c. increases arterial pH

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Sit the client upright. b. Apply direct pressure. c. Initiate Standard Precautions. d. Loosely pack the nares with gauze.

c. initiate standard precautions

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? a. Magnesium level of 1.8 (0.74 mmol/L) b. Sodium level of 145 mEq/L (145 mmol/L) c. Potassium level of 3.0 mEq/L (3.0 mmol/L) d. Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

c. potassium level of 3.0

A patient's most recent arterial blood gases reveal pH = 7.5; HCO3- = 29 mEq/L, and PaCO2 = 51 mm Hg. What health problem could account for these findings? a. Hyperventilation b. Diabetic ketoacidosis (DKA) c. Volume depletion from vomiting d. Atelectasis

c. volume depletion from vomiting

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client's heart rate is 55 beats/min. - Nurse withholds pain medication. b. Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate c. Client states he is dizzy. - Nurse applies oxygen and pulse oximetry. d. Client has reduced breath sounds. - Nurse calls physician immediately.

d. Client has reduced breath sounds. - Nurse calls physician immediately

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. Pulse oximetry is 93% on 2 liters of oxygen c. A small amount of drainage from the site is noted d. The trachea is deviated toward the opposite side of the neck.

d. The trachea is deviated toward the opposite side of the neck

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. There is prolonged skin tenting over the sternum. b. Oral fluid intake is 100 mL for the last 8 hours. c. Urine output is 30 mL over the last hour. d. Blood pressure is 90/40 mm Hg

d. blood pressure is 90/40 mm Hg

The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? a. renal failure b. red blood cell hydroloysis c. red blood cell crenation d. cerebral edema

d. cerebral edema

A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings? a. Blood pressure 188/120, nausea, vomiting b. Headache, blood pressure 190/104, dry skin c. Confusion, respiratory rate 8 breaths/min, dry skin d. Clammy skin, blood pressure 86/46, headache

d. clammy skin, blood pressure 86/46, headache

You are working on a burn unit. One of your patients is exhibiting signs and symptoms of third spacing, which occurs when fluid moves out of the intravascular space but not into the intracellular space. Based upon this fluid shift, what would the nurse expect the patient to demonstrate? a. hypervolemia b. hypertension c. bradycardia d. hypovolemia

d. hypovolemia

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? a. encourage oral fluids b. suggest a fluid restriction c. remove the hemovac d. offer a prescribed antiemetic medication

d. offer a prescribed antiemetic medication

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Report any new onset of cough. c. Monitor temperature every 4 hours. d. Provide oral care every 4 hours

d. provide oral care every 4 hours

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask b. Call the operating room to inform them of a pending emergency case. c. No action is needed at this time; this is a normal finding in some clients. d. Stay with the client and have someone else call the provider immediately

d. stay with the client and have someone else call the provider immediately

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? a. The lungs are unable to breathe in sufficient oxygen. b. The lungs have ineffective cilia from years of smoking. c. The lungs are unable to exchange oxygen and carbon dioxide. d. The lungs are not able to blow off carbon dioxide.

d. the lungs are not able to blow off carbon dioxide