310 Class Questions FINAL
Which of the following patients are at risk for developing Cushing's Syndrome? A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. A patient taking glucocorticoids for several weeks. A patient with a tuberculosis infection. A patient who is post-opt from an adrenalectomy
A patient taking glucocorticoids for several weeks.
Which clinical manifestations indicate to the nurse that the client has developed osteoporosis? The client has lost 1 inch in height. The client has last 12 pounds in the past year The client's hands are painful to the touch The client's serum uric acid levels are elevated
The client has lost 1 inch in height.
Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease? Decrease anxiety Enhance myocardial oxygenation (increasing supply and decreasing demand) Administer sublingual nitroglycerin Educate the client about his symptoms
Enhance myocardial oxygenation (increasing supply and decreasing demand)
A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? Pain in the UQ rating to the shoulder Report of pain being worse when sitting upright Pain relieved with defecation Epigastric pain radiating to the left shoulder
Epigastric pain radiating to the left shoulder
What are the complications of Cushing's syndrome? Select all that apply Hypertension Diabetes Frequent or unusual infections Loss of muscle mass and strength Addisonian Crisis Hypotension Hypoglycemia
Hypertension Diabetes Frequent or unusual infections Loss of muscle mass and strength Addisonian Crisis
A patient is diagnosed with osteomyelitis of the right leg. Which signs and symptoms does the nurse identify that are associated with this diagnosis? Select all that apply. Pain in the right leg Erythema in the right leg Fever Leukopenia Purulent drainage
Pain in the right leg Erythema in the right leg Fever
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? A patient with nausea who has a metoclopramide (Reglan) due A patient who is crying after receiving a diagnosis of esophageal cancer A patient with esophageal varices who has a blood pressure of 99/68 mm Hg A patient who is vomiting and reports of 6/10 pain
A patient with esophageal varices who has a blood pressure of 99/68 mm Hg
Which of the following patients most likely requires special preoperative assessment and treatment as a result of his or her existing medication regimen? A woman who takes daily anticoagulants to treat atrial fib. A woman who takes a daily thyroid supplement to treat her long standing hypothyroidism. A man who regularly treats his rheumatoid arthritis with OTC NSAIDs. A man who takes an angiotensin converting enzyme inhibitor because he has hypertension.
A woman who takes daily anticoagulants to treat atrial fib.
The nurse is discharging a patient after a total hip replacement. Which statement indicates the need for further teaching? "I should not cross my legs because my hip could become dislocated" "I will call my HCP if I have a sudden increase in pain" "I will sit on a chair with arms and a firm seat" "After 3 weeks, I do not need to worry about infection"
"After 3 weeks, I do not need to worry about infection"
A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? "Cushing's disease is characterized by an oversecretion of insulin. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones." "Cushing's disease is characterized by an undersecretion of corticotropic hormones." "Cushing's disease is characterized by an undersecretion of glucocorticoid hormones."
"Cushing's disease is characterized by an oversecretion of glucocorticoid hormones."
A female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? "I can take antacids between meals and right before bedtime" "I will sleep with my head elevated" "I will stop drinking soda and coffee" "I will eat multiple small meals a day and a snack before bed"
"I can take antacids between meals and right before bedtime"
The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching was effective? "I will take my lipid-lowering medicine at the same time each night." "I may experience some discomfort when I eat a high-fat meal." "I need someone to stay with me for about a week after surgery." "I should not splint my incision when I deep breathe and cough."
"I may experience some discomfort when I eat a high-fat meal."
The client diagnosed with a hiatal hernia is scheduled for a nissen fundoplication. Which statement indicates the nurse's teaching is effective? "I will have 4 to 5 small incisions." "I will be in the hospital for at least one week." "I will not have any pain because this is a laparoscopic surgery." "I will be returning to work the day after my surgery."
"I will have 4 to 5 small incisions."
The nurse is educating the client on peptic ulcer prevention. Which statement by the client shows correct understanding? Select all that apply. "I will not drink beer at the party this weekend" "I will avoid using naproxen" "I should avoid drinking excess coffee or soda" "I will start smoking cessation" "I will avoid spicy foods, but fried chicken is ok
"I will not drink beer at the party this weekend" "I will avoid using naproxen" "I should avoid drinking excess coffee or soda" "I will start smoking cessation"
The husband of a client who has cancer asks what is the difference between palliative and hospice care. Which response by the nurse is best? "In order to receive hospice care, the client must have a prognosis of six months or less to live." "In order to receive palliative care, the client must have a prognosis of six months or less to live." "In palliative care, clients are still able to receive treatments to manage their illness and seek curative measures and are reserved for those who are likely to expire soon. Whereas in hospice care, clients are unable to receive these treatments or cures for their condition." "In hospice care, clients are unable to receive treatments or cures for their condition. Instead, they receive comfort care to increase their quality of life during the last phases of their terminal illness. Whereas, in palliative care, clients are still able to receive treatments to manage their illness and seek curative measures."
"In hospice care, clients are unable to receive treatments or cures for their condition. Instead, they receive comfort care to increase their quality of life during the last phases of their terminal illness. Whereas, in palliative care, clients are still able to receive treatments to manage their illness and seek curative measures."
Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client? "Jaundice is associated with pressure ulcer formation." "Jaundice impairs urea production, which produces pruritus." "Jaundice produces pruritus due to impaired bile acid excretion." "Jaundice leads to decreased tissue perfusion and subsequent breakdown."
"Jaundice produces pruritus due to impaired bile acid excretion."
The client with unstable angina has received education about the acute coronary syndrome. Which of the following indicates that he understood the teaching? "This is a big warning. I must modify my lifestyle or risk having a heart attack next year." "Angina is just a temporary interruption of blood flow to my heart." "I need to tell my wife I've had a heart attack." "Because this was temporary, I will not need to take any medications for my heart."
"This is a big warning. I must modify my lifestyle or risk having a heart attack next year."
Which of the following patients is at most risk for Type 2 diabetes? A 6 year old girl recovering from a viral infection with a family history of diabetes. A 28 year old male with a BMI of 49. A 76 year old female with a history of cardiac disease. None of the options provided.
A 28 year old male with a BMI of 49.
A client who is diagnosed with Addison disease is hospitalized for a broken left femur. Which client data is most critical for the nurse to report the client's health care provider (HCP)? A Systolic blood pressure decline of 25 mm Hg Bronchovesicular breath sounds auscultated throughout the lung fields Electrocardiogram shows occasional premature ventricular contractions Report of stabbing pain of 8 in the left femur on a numeric scale of 1-10
A Systolic blood pressure decline of 25 mm Hg
Which client problem is a priority for a client diagnosed with rheumatoid arthritis? Alteration in comfort (pain and inflammation) Activity intolerance Fluid and electrolyte imbalance Excessive nutritional intake
Alteration in comfort (pain and inflammation)
The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to strain all urine and to: Report the pain level when the stone passed Collect the stone and bring it to the clinic Record the time that the stone passed. Save a urine specimen to check for blood.
Collect the stone and bring it to the clinic
An elderly pt. with diabetes and history of hypertension is admitted to the hospital. He has been smoking cigarettes for 40 years, 1 pack per day. He complains of leg pain during ambulation (that is relieved by rest). He has a wound on his middle toe. What type of peripheral vascular disease does he have? Venous ulceration Intermittent claudication Deep vein thrombosis Arterial ulceration
Arterial ulceration
A client is admitted to the ER with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? Gabapentin Midazolam Alprazolam Aspirin
Aspirin
When assessing a patient's surgical dressing on the first post-op day, the nurse notices new bright red drainage about 5 cm in diameter. What is the priority nurse concern in the above findings? Assess the patient's blood pressure and pulse rate Recheck in 1 hour for increased drainage Notify the surgeon of potential hemorrhage Remove the dressing and assess the surgical site
Assess the patient's blood pressure and pulse rate
Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) Assessing the client's neurologic status every 2 hours Monitoring the client's hemoglobin and hematocrit levels Evaluating the client's serum ammonia level Monitoring the client's handwriting daily Preparing to insert an esophageal tamponade tube
Assessing the client's neurologic status every 2 hours Evaluating the client's serum ammonia level Monitoring the client's handwriting daily
Mr. Peterson is in end-stage liver failure. Which interventions should the nurse implement when assessing hepatic encephalopathy? (select all that apply) Assessing the patient's neurological status every 2 hours Monitoring patient's hemoglobin and hematocrit levels Evaluating the client's serum ammonia level Monitoring the patient's handwriting daily Preparing to insert an esophageal tamponade tube
Assessing the patient's neurological status every 2 hours Evaluating the client's serum ammonia level Monitoring the patient's handwriting daily
The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? Teaching the client to choose low-fat foods from the menu Assisting the client to turn, cough, and deep breathe every 2 hours Assisting the client to ambulate the evening of the operative day Performing range-of-motion (ROM) leg exercises hourly while the client is awake
Assisting the client to turn, cough, and deep breathe every 2 hours
A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse take first? Auscultate the abdomen Check the capillary refill Auscultate the breath sounds Ask the patient's allergies
Auscultate the breath sounds
The nursing student is delegated with patient education on PAD, which statement by the student needs intervention by the RN? Managing weight daily. Consuming more fresh fruits and vegetables. Do not skip medications when a patient is on anticoagulants. Consuming more bacon, canned tuna, dried apricots.
Consuming more bacon, canned tuna, dried apricots.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? Blood glucose levels of 480 mg/dl Right-sided carotid bruit Blood pressure of 220/120 mmHg The presence of bronchogenic carcinoma
Blood pressure of 220/120 mmHg
A patient is presenting with chronic obstructive pulmonary disease. The patient has a chronic productive cough with dyspnea on excretion. Arterial blood gasses show a low oxygen level and high carbon dioxide level in the blood. On assessment, the patient has cyanosis in the lips and edema in the abdomen and legs. Based on your nursing knowledge and the patient's symptoms, you suspect the patient suffers from what type of COPD? Emphysema Pneumonia Chronic bronchitis Pneumothorax
Chronic bronchitis
A nurse at a clinic received messages about 4 different clients. Which client should be assessed first? Client with nausea and diarrhea after taking amoxicillin-clavulanate Client with chronic kidney disease reporting nausea, vomiting, and a headache Client with nausea, vomiting, and diarrhea after eating tuna salad Client with celiac disease reporting diarrhea and foul-smelling stools
Client with chronic kidney disease reporting nausea, vomiting, and a headache
The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important to report to the HCP? Select all that apply. Cloudy outflow Low grade fever Oliguria Pruritus Tachycardia
Cloudy outflow Low grade fever Tachycardia
An alarm beeps notifying you that your patient's oxygen saturation is reading 88%. You arrive in the patient's room, and see the patient comfortably resting in bed watching television. The patient is already on 2L of oxygen via nasal cannula. The patient is admitted for COPD exacerbation. Your next nursing action would be: Continue to monitor Increase the patient's oxygen to 3L Notify the HCP for further orders Switch to venturi mask
Continue to monitor
A patient converts from normal sinus rhythm at 80bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mmHg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? Decrease SA node conduction Control ventricular heart rate Improve oxygenation Maintain anticoagulation
Control ventricular heart rate
When caring for a client with a chest tube that was placed in the OR 3 days ago, the chest tube becomes dislodged and removed from the client's chest, what is the nurse's priority intervention? Place a moist dressing over the insertion site and contact the HCP Attempt to replace the chest tube Complete a thorough respiratory assessment Cover the insertion site with an occlusive dressing and contact the provider
Cover the insertion site with an occlusive dressing and contact the provider
What are common nursing interventions for Peripheral arterial disease? Select all that apply. Providing analgesics to relieve pain and performing aPTT exam immediately Putting on T.E.D. anti-embolic stockings bilaterally. Keep ambulating to prevent further complications, such as pulmonary embolism. Dangling legs over the side of the bed No elevation of legs
Dangling legs over the side of the bed No elevation of legs
Conn's disease is characterized by overproduction of Aldosterone. What electrolytes imbalances can you expect when a patient has this condition? Select all that apply Decrease H+ (alkalosis) Hyponatremia Hypokalemia Hypernatremia Hypocalcemia
Decrease H+ (alkalosis) Hypokalemia Hypernatremia
The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor the effectiveness of this medication for this patient by assessing what? Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels
Decreased ammonia levels
A nurse is planning care for a client in an acute Addisonian crisis. Which nursing diagnosis should receive the highest priority? Risk for infection Decreased cardiac output. Impaired physical mobility Imbalanced nutrition: Less than body requirements
Decreased cardiac output.
A client with hepatic encephalopathy has been prescribed lactulose. Which of the following is the expected outcome of lactulose administration in this client? Increased serum ammonia level Increased blood glucose levels Decreased serum bilirubin levels Decreased serum potassium levels
Decreased serum bilirubin levels
For a patient with advanced cirrhosis, which assessment findings best indicates deterioration of liver function? Fatigue & muscle weakness Difficulty in arousal Nausea & vomiting Weight gain
Difficulty in arousal
client with a new diagnosis of asthma is scheduled for allergy skin testing to identify asthmatic triggers. The nurse instructs the client that certain medications should not be taken for a week prior to the test to ensure accurate results. Which medications should the client avoid in preparation for this test? Select all that apply. Acetaminophen Albuterol Diphenhydramine Enalapril Loratadine
Diphenhydramine Loratadine
Which of the following atypical symptoms may be present in the female client experiencing myocardial infarction (MI)? Select all that apply. Sharp, inspiratory chest pain Dyspnea Dizziness Extreme fatigue Anorexia
Dyspnea Dizziness Extreme fatigue
Which clinical manifestation should the nurse anticipate when providing care for a client who is diagnosed with Cushing syndrome? Select all that apply. Easy bruising. Increased blood glucose. Increased blood pressure. Increased potassium. Increased abdominal girth. Decreased weight.
Easy bruising. Increased blood glucose. Increased blood pressure. Increased abdominal girth.
Your patient arrives back to their room after having extracorporeal shock wave lithotripsy (ESWL) for treatment of a kidney stone. What will be included in the patient's plan of care? Select all that apply. Keep the patient in bed Encourage fluid intake of 3-4 liters per day Maintain nephrostomy tube Strain urine Keep dressing dry and intact
Encourage fluid intake of 3-4 liters per day Strain urine
Which nursing intervention is appropriate for a client with cirrhosis and ascites? Encouraging a low sodium diet Administering high doses of vitamin K Monitoring blood glucose levels every hour Restricting fluid intake to prevent fluid overload
Encouraging a low sodium diet
An adult patient with a third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristics will the ECG most likely show? Fewer QRS complexes than P waves PP interval and RR interval are irregular PP interval is equal to RR interval PR interval is constant
Fewer QRS complexes than P waves
One of the complications of PVD is known as Raynaud's disease. What are the manifestations of Raynaud's disease? Select all that apply. Finger numbness Warm fingers with rashes at fingertips Cold fingers and pallor Vasodilation Vasoconstriction
Finger numbness Cold fingers and pallor Vasoconstriction
A 20 year old client with diabetes mellitus type 1 is experiencing diabetic ketoacidosis. The nurse should expect which of the following findings? Select all that apply. Weight Gain Fruity Smelling Breath Metabolic Acidosis Kussmaul Respirations Seizures
Fruity Smelling Breath Metabolic Acidosis Kussmaul Respirations
A patient with diabetes has a morning glucose of 50. The patient is sweaty, cold, and clammy. Which of the following nursing interventions is the MOST important? Recheck the glucose level Give the patient ½ cup (4 oz) of fruit juice Call the doctor Keep the patient nothing by mouth
Give the patient ½ cup (4 oz) of fruit juice
A client who is diagnosed with Addison disease presents to the emergency department with abdominal pain. The client experiences a decline in systolic blood pressure of 30 mm Hg, a heart rate increase from 75 to 100 beats per minute, and developed new onset confusion. Which action should the nurse implement based on the current data? SELECT ALL THAT APPLY. Give the prescribed hydrocortisone, 100 mg by intravenous push. Administer the prescribed morphine 2 mg by intravenous push every 2 hours for pain Begin potassium 40 mEq PO every 12 hours as prescribed Start an intravenous infusion of normal saline with 5% dextrose, as prescribed Give 12.5 mg of promethazine every 4 hours as needed for nausea via intravenous push
Give the prescribed hydrocortisone, 100 mg by intravenous push. Start an intravenous infusion of normal saline with 5% dextrose, as prescribed
The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control? Prealbumin level Urine ketone level Fasting glucose level Glycosylated hemoglobin level
Glycosylated hemoglobin level
What is the biggest concern of Conn's syndrome ? Hypokalemia Alkalosis HTN Tetany Glucose intolerance
HTN
A nurse is completing the admission assessment of a client who has acute pancreatitis. Which finding is the first priority? History of cholelithiasis Elevated serum amylase levels Decrease in bowel sounds upon auscultation Hand spasms present when blood pressure is checked
Hand spasms present when blood pressure is checked
A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patient's admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply. Diarrhea High fever Hematuria Urinary frequency Acute pain
Hematuria Urinary frequency Acute pain
A client with type 2 diabetes was admitted to the hospital last night due to a very high blood sugar level of 700 mg/dl, confusion, frequent urination and mental status changes. What is a possible complication that this client might be experiencing? Diabetic ketoacidosis Neuropathy Cerebrovascular accident (CVA) Hyperosmolar hyperglycemic state (HHS) Myocardial infarction
Hyperosmolar hyperglycemic state (HHS)
The nurse is performing a discharge teaching on nutritional therapy for a client with chronic kidney disease. Which statement indicates that further teaching is needed? I can use a salt substitute because I am required to restrict both sodium and potassium The popsicles I eat should be counted in my daily fluid intake because they become fluid at room temperature Because I have CKD, I should avoid canned soups and cold-cut sandwiches I must avoid eating raw carrots and tomatoes on my salads because I take hemodialysis treatment
I can use a salt substitute because I am required to restrict both sodium and potassium
When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? I feel my heart beating in my abdominal area I just started to feel a tearing pain in my belly I have a headache, may I have some acetaminophen? I have had hoarseness for a few days
I just started to feel a tearing pain in my belly
A 65 year old client with ESRD comes to the ED after missing 5 hemodialysis sessions. The serum potassium level is 7.5 and the ECG shows tall, peaked T waves. Which prescription will work immediately to protect the client from experiencing dysrhythmias associated with hyperkalemia? IV regular insulin with dextrose Transport to hemodialysis unit IV calcium gluconate Oral sodium polystyrene sulfonate
IV calcium gluconate
The nurse is providing a cardiac class for a women's group. The nurse emphasizes that which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. Premenopausal Increasing age Family history Abdominal obesity Breast cancer
Increasing age Family history Abdominal obesity
What are some of the signs and symptoms that women with Cushing syndrome may experience:? Select all that apply Irregular or absent menstrual period Decreased libido Decreased fertility Hirsutism
Irregular or absent menstrual period Hirsutism
A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke team is initiated. The nurse takes which priority action? Determine onset of symptoms Ensure that the client has 2 large bore IV lines Maintain patent airway Prepare for a head CT scan
Maintain patent airway
A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. For what type of surgery would the nurse prepare this patient? Minor, diagnostic Minor, elective Major, emergency Major, palliative
Major, emergency
The nurse is admitting a client diagnosed with secondary adrenal cortex insufficiency (cushing's disease). Which clinical manifestations should the nurse expect to assess? Moon face, buffalo hump, and hyperglycemia Hirsutism, fever, and irritability. Bronze pigmentation, hypotension, Anorexia. Tachycardia, bulging eyes, and goiter.
Moon face, buffalo hump, and hyperglycemia
A patient presents to the ER with chest pain. An EKG is performed and displays an inverted T wave. What is the interpretation? Myocardial ischemia Myocardial infarction Atrial fibrillation Normal finding
Myocardial ischemia
Which signs and symptoms would you expect to see in a patient with compartment syndrome? Select all that apply.**** Capillary refill less than 2 seconds Pallor Pain relief with medication Tingling sensation in the extremity Affected extremity feels cool to the touch in comparison to the unaffected extremity
Pallor, Tingling sensation in the extremity, Affected extremity feels cool to the touch in comparison to the unaffected extremity
A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action? Give the client plenty of water to aid digestion Document what foods the client ate. Cancel the surgery Notify the surgeon.
Notify the surgeon.
A caucasian female patient is admitted to an acute care facility with a diagnosis of a cerebrovascular accident. Her past medication history reveals bronchial asthma, exogenous obesity, and iron deficiency. Which history finding is a risk factor for CVA? Caucasian race Female sex Obesity Bronchial asthma
Obesity
A client is scheduled for a coronary artery by-pass. The client cannot sign the operative consent form for this procedure due to sedation of opioids analgesics administered. the nurse should intervene with which of the most appropriate ac,ons in the care of this client. Sign the consent on behalf of the client since he cannot sign it himself Obtain a court order for the surgery Obtain a telephone consent from a family member following agency policy Send the client to surgery without a consent since it is an emergency
Obtain a telephone consent from a family member following agency policy
The nurse is caring for a client with chronic kidney disease who just received hemodialysis for the first time. The client vomits once, reports a headache, and also appears restless and disoriented. What is the priority nursing action? Administer antihypertensive medications that were held prior to the hemodialysis Obtain the client's current blood pressure reading Request a prescription for ondansetron to relieve nausea Collect a blood specimen to check serum electrolyte levels
Obtain the client's current blood pressure reading
To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about? The presence of blood in the urine Any erectile dysfunction (ED). Occurrence of a weak urinary stream Lower back and hip pain.
Occurrence of a weak urinary stream
A client receiving hospice care for her terminal disease reports pain on a scale of 5, but requests she not be given medication because she does not want to be oversedated. Which action by the nurse is most appropriate? Provide pain relief through medication anyways since pain relief is a priority. Explain to the client, there is no need to be concerned about addiction, since she is in a terminal state. Encourage the client to take pain medication to alleviate her pain. Offer to meditate with the client and utilize guided imagery to help relieve the client's pain.
Offer to meditate with the client and utilize guided imagery to help relieve the client's pain.
A client diagnosed with Addison's disease has been prescribed hydrocortisone, a glucocorticoid. Which information should the nurse include in the teaching? SELECT ALL THAT APPLY. Hydrocortisone should be taken on an empty stomach. Periods of stress may require an increase in steroid replacement. The medication can be stopped as soon as you begin to feel better. Blood glucose levels should be routinely monitored. Clients being Treated with hydrocortisone should not receive live virus vaccines.
Periods of stress may require an increase in steroid replacement. Blood glucose levels should be routinely monitored. Clients being Treated with hydrocortisone should not receive live virus vaccines.
A patient presents to the emergency room with acute shortness of breath. After listening to the patient's lungs, the nurse finds wheezes bilaterally. The nurse should anticipate performing the following actions: Select all that apply. Administer ipratropium (Atrovent) by rapid IV push Place the patient on continuous SpO2 monitoring Prepare the patient for a chest x-ray Prepare the nebulizer treatment with albuterol (Ventolin, Proair) Gather supplies for chest tube insertion
Place the patient on continuous SpO2 monitoring Prepare the patient for a chest x-ray Prepare the nebulizer treatment with albuterol (Ventolin, Proair)
The nurse monitors the 3-day post op client who underwent abdominal surgery. Vital signs are 102 F, HR 104 bpm, 24 breaths per min 128/76 mm Hg, and O2 sat is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which post op problem? Hypoxia Atelectasis Pneumonia Fluid overload
Pneumonia
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 ° F (38.8 ° C). What should the nurse do in response to this reported assessment data? Promptly assess the client for potential perforation. Tell the assistant to change the thermometers and retake the temperature. Plan to give the client acetaminophen (Tylenol) to lower the temperature. Ask the assistant to bathe the client with tepid water.
Promptly assess the client for potential perforation.
A hospice nurse is caring for her client who is receiving palliative care for congestive heart failure (CHF). The nurse observes the client is dyspneic. Which actions by the nurse are most appropriate? Select all that apply. Raise the head of the bed. Place a fan blowing cool air to the client's face. Contact the health care provider (HCP). Administer a diuretic Administer a benzodiazepine.
Raise the head of the bed. Place a fan blowing cool air to the client's face. Administer a diuretic Administer a benzodiazepine.
Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? Performs the same responsibilities as the anesthesiologist. Releases or discharges patients from the post anesthesia care area Administers intraoperative anesthetics ordered by the anesthesiologist. Manages a patient's airway under the direct supervision of the anesthesiologist.
Releases or discharges patients from the post anesthesia care area
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured? Sudden shortness of breath and hemoptysis Gradually increasing substernal chest pain and diaphoresis Sudden, severe low back pain and bruising along his flank Sudden, patchy blue mottling on feet and toes, and rest pain
Sudden, severe low back pain and bruising along his flank
A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The healthcare provider prescribes ECG and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction? QRS complex ST segment (elevation or depression) P wave R wave
ST segment (elevation or depression)
A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease? Blood urea nitrogen (BUN) level of 12 mg/dl Blood glucose level of 90 mg/dl Serum sodium level 134 mEq/L Serum potassium level of 5.8 mEq/L
Serum potassium level of 5.8 mEq/L
Which is one of the typical PVD laboratory results? Serum triglyceride of 140 mg/dL Serum triglyceride of 280 mg/dL Serum triglyceride level of 40 mg/dL Serum triglyceride level of 80 mg/dL
Serum triglyceride of 280 mg/dL
A nurse went to a patient's room to do routine vital signs monitoring and found out that the patient's bedtime snack was not eaten. This should alert the nurse to check and assess for: Elevated serum bicarbonate and decreased blood pH Signs of hypoglycemia earlier than expected Signs of hyperglycemia during the peak time of NPH Glucose in the urine
Signs of hypoglycemia earlier than expected
The nurse provides care for a client who is diagnosed with Addison's disease. Which clinical manifestation does the nurse anticipate for this client due to primary adrenocortical insufficiency? SELECT ALL THAT APPLY. Skin color that is tanned in appearance Anorexia and weight loss Increased body or facial hair Orthostatic hypotension Purple or red striae on abdomen
Skin color that is tanned in appearance Anorexia and weight loss Orthostatic hypotension
Which assessment findings should the nurse expect from providing care for a client who is diagnosed with Addison's disease? SELECT ALL THAT APPLY Dark, velvety patches on the skin Excessive hair growth on the back, chest, face Skin hyperpigmentation Muscle weakness Thin extremities Weight loss
Skin hyperpigmentation Muscle weakness Weight loss
A client with hyperthyroidism is to be treated with radioactive iodine. Following treatment, what should the nurse teach the client to do? Monitor for s/s of hyperthyroidism Rest for 1 week to prevent complications of the medication Take thyroxine replacement for the remainder of the client's life Assess for hypertension and tachycardia resulting from altered thyroid activity
Take thyroxine replacement for the remainder of the client's life
A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? Review the hemoglobin and hematocrit as ordered Take vital signs and notify the surgeon immediately Release the traction on the three-way catheter. Remind the client not to pull on the catheter.
Take vital signs and notify the surgeon immediately
The nurse is preparing the care plan for a client in the hospital for a fracture to their lower extremity. Which outcome is most appropriate for the client? The client will ambulate with assistance. The client will remain free of infection The client will be turned every two hours The client will maintain function of the leg
The client will maintain function of the leg
The nurse is instructing the client with hypothyroidism who takes levothyroxine 100 mcg, digoxin, and simvastatin. The nurse judges that the teaching regarding the use of these medications is effective if the client will take: The levothyroxine with breakfast and the other medications after breakfast. The levothyroxine before breakfast and the other medications 4 hours later. All medications together 1 hour after eating breakfast. All medications before going to bed.
The levothyroxine before breakfast and the other medications 4 hours later.
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? An intestinal obstruction has developed. The ulcer has perforated. Additional ulcers have developed. The esophagus had become inflamed
The ulcer has perforated.
Type 1 diabetics typically have the following clinical characteristics: Thin, young with ketones present in the urine Overweight, young with no ketones present in the urine Thin, older adult with glycosuria Overweight, adult-aged with ketones present in the urine
Thin, young with ketones present in the urine
A patient arrives at the emergency department complaining of numbness of the face and an inability to speak. While awaiting examination, the symptoms disappear and the patient requests to be discharged. The nurse stresses the importance of being evaluated to the patient primarily because the patient probably experienced what? Transient ischemic attack Ischemic stroke Hemorrhagic stroke Myocardial infarction
Transient ischemic attack
The nurse has just assessed the condition of the post op patient who was admitted an hour ago to the OR. The nurse should give priority to which post op complication assessment finding about this patient in the next hour after the procedure? Serous drainage at the surgical dressing Blood pressure of 102/72 Urinary output of 20 ml/hr Temperature 37.2 C
Urinary output of 20 ml/hr
Which of the following nursing interventions is the most likely to prevent respiratory complications such as pneumonia and atelectasis in a post-surgical patient? Control anxiety and agitation Adequate nutrition and fluids Adequate pain control Use of incentive spirometry
Use of incentive spirometry
Which statement should the nurse include when providing education to the client who is diagnosed with Addison disease and prescribed steroid therapy twice per day? SELECT ALL THAT APPLY. You should check your blood sugar before meals and at bedtime. During stressful times, the dosage may need to be decreased. Have your eyes checked yearly while on hydrocortisone. Immediately stop hydrocortisone if you feel emotional or irritable. Take your prescribed hydrocortisone by mouth with the meal.
You should check your blood sugar before meals and at bedtime. Have your eyes checked yearly while on hydrocortisone. Take your prescribed hydrocortisone by mouth with the meal.
A 34-year-old female is diagnosed with hypothyroidism. What information should the nurse obtain from conducting a focused assessment? Select all that apply. rapid pulse decreased energy and fatigue weight gain of 10 lb (4.5 kg) fine, thin hair with hair loss constipation menorrhagia
decreased energy and fatigue weight gain of 10 lb (4.5 kg) constipation menorrhagia
Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon gaining consciousness. the client is not able to make a sound. The nurse determines that the client is experiencing which complication of the surgery? internal hemorrhage decreasing level of consciousness laryngeal nerve damage upper airway obstruction
laryngeal nerve damage
A 54-year-old client is scheduled for a hip replacement surgery, at which period of time should the nurse initiate patient teaching? teaching begins at discharge as the client is preparing to go home teaching begins before going into surgery teaching begins right post surgery teaching begins at the time of admission
teaching begins at the time of admission
A 60-year-old female is diagnosed with hypothyroidism. What additional information should the nurse obtain when conducting a focused assessment? Tachycardia weight gain diarrhea nausea
weight gain
