Questions Missed in N454
The nurse is caring for a 90-year-old client who has never completed an advance directive. The client has a child but has not seen the child in several years. A neighbor has assisted the client with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged offspring wants the client to be treated aggressively. Which would be the nurse's initial step? -Notify the physician of the discrepancy. -Follow the neighbor's directive. -Assess the client's ability to state wishes. -Follow the child's directive.
Assess the client's ability to state wishes.
Which term refers to inflammation of the renal pelvis? -Urethritis -Pyelonephritis -Cystitis -Interstitial nephritis
Pyelonephritis
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? -QRS complex -PR interval -QT interval -P wave
QRS complex
The nursing student asks the nurse how to tell the difference between ventricular tachycardia and ventricular fibrillation on an electrocardiogram strip. What is the best response? -"The P-R interval will be prolonged in ventricular fibrillation, while in ventricular tachycardia the P-R interval is normal." -"The two look very much alike; it is difficult to tell the difference." -"The QRS complex in ventricular fibrillation is always narrow, while in ventricular tachycardia the QRS is of normal width." -"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes."
"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes."
Which of the following are early manifestations of liver cancer? Select all that apply. -Increased appetite -Vomiting -Abdominal pain -Fever -Jaundice -Continuous aching in the back
-Abdominal pain -Continuous aching in the back -jaundice
The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. -Absence of pain response -Apnea -Coma -Absence of brain stem reflexes -Absence of deep tendon reflexes
-Apnea -Coma -Absence of brain stem reflexes
While providing care to a client near death, the nurse is helping the family to prepare by teaching them what to expect. Which of the following would the nurse include in the teaching plan as a sign of approaching death? Select all that apply. -Increase in visual and auditory abilities -Decrease in amount of urine produced -Gurgling as the client breathes through the mouth -Breathing that is very rapid -Refusal to ingest food or fluids
-Gurgling as the client breathes through the mouth -Decrease in amount of urine produced -Refusal to ingest food or fluids
When assessing a client with a liver trauma, the nurse would anticipate seeing: Select all that apply -Nausea/vomiting -Abdominal guarding -Increased urine output -Left upper abdominal quadrant pain
-abdominal guarding -nausea/vomiting
A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? -Risk for infection -Imbalanced nutrition: Less than body requirements -Acute pain -Impaired urinary elimination
Acute pain
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? -Dinner roll -Fried chicken -Tapioca pudding -Mashed potatoes
Fried chicken
A nurse is caring for a client with a BMI of 35 kg/m2 who is wanting to lose weight. What is the initial recommendation the nurse will expect from the client's health care provider? -Surgical interventions -Lifestyle modification -Nonsurgical interventions -Pharmacological management
Lifestyle modification
The nurse is providing care for an 82-year-old client whose signs and symptoms of Parkinson disease have worsened over the past several months. The client reports no longer being able to do as many things as in the past. Based on this statement, what issue is of most concern to the client? -Age-related changes -Loss of independence -Neurologic deficits -Tremors and decreased mobility
Loss of independence
A client is undergoing testing to assess for a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? -Increased tactile fremitus, egophony, and the chest wall dull on percussion -Lung fields dull to percussion, absent breath sounds, and a pleural friction rub -Normal tactile fremitus, decreased breath sounds, and the chest wall resonant on percussion
Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V4? -Mid-clavicular line, fifth intercostal space -Right side of sternum, fourth intercostal space -Left side of sternum, fifth intercostal space -Midway between V3 and V5
Mid-clavicular line, fifth intercostal space
A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client? -Monitor the client's physical condition. -Monitor the client's heart rate. -Monitor the client to prevent sepsis. -Monitor the client's toilet patterns.
Monitor the client to prevent sepsis.
Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? -Perform pin site care -Notify the Neurosurgeon of the occurrence -Stabilize the head in a lateral position -Reattach the pin to prevent further head trauma
Notify the Neurosurgeon of the occurrence
A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply. -Use of accessory muscles to breathe -Tympany percussed bilaterally over the lung bases -Hypoventilation breathing pattern -Respiratory rate of 10 breaths per minute -Purulent sputum with frequent coughing
Use of accessory muscles to breathe Purulent sputum with frequent coughing
Which is the most common report by clients with pancreatitis? -Increased and painful urination -Severe, radiating abdominal pain -Increased appetite and weight gain -Tarry, black stools and dark urine
Severe, radiating abdominal pain
A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? -Slow the infusion rate and monitor the client closely. -Pause the transfusion and administer a 250 mL bolus of normal saline. -Discontinue the transfusion and administer a beta-blocker, as prescribed. -Discontinue the transfusion and begin resuscitation.
Slow the infusion rate and monitor the client closely.
A client's electrocardiogram reveals an irregular rhythm of 75 bpm with a normal QRS and P wave. The nurse who is caring for the client should anticipate: -administration of epinephrine. -a bolus of warmed normal saline. -no immediate treatment. -administration of a beta-adrenergic blocker.
no immediate treatment.
A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? -Sclerotherapy -Balloon tamponade -Vasopressin (Pitressin) -Transjugular intrahepatic portosystemic shunting (TIPS)
Transjugular intrahepatic portosystemic shunting (TIPS)
The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia? -hypothyroidism -vagal stimulation -digoxin -hypovolemia
hypovolemia