AH1 Final Review

A nurse is instructing a client with a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of anemia? - Intestinal malabsorption syndrome - Chronic blood loss - Intestinal parasites - Dietary

- Chronic blood loss

A nurse is caring for a client that PCP suspects may have pernicious anemia. The nurse should expect PCP to prescribe which of the following diagnostic tests? - Intrinsic factor blocking antibodies - antinuclear antibodies - haftoglobin - sweat test

- Intrinsic factor blocking antibodies

A nurse is providing care for 4 clients at med surg unit. Which of the following clients should the nurse identify as being at risk for development of pressure ulcer? SATA - a client that has fractured femur and uses crutches - a client that is ambulatory following cardiac catheterization - a client that has right sided heart failure and is obese - a client with protein calorie malnutrition - a client with post operative delirium

- a client that has right sided heart failure and is obese - a client with protein calorie malnutrition - a client with post operative delirium

An 89 year old client is admitted wit a diagnosis of acute pulmonary edema and complains of fatigue and dyspnea. The client has a history of anemia, HTN, cardiomegaly and osteoporosis. Cardiac catheterization reveals injection fraction of 35%. Based on this information which nursing diagnosis is the most appropriate? - anxiety - ineffective airway clearance - altered peripheral tissue perfusion - activity intolerance

- altered peripheral tissue perfusion

A client has been diagnosed with ulcerative colitis and the nurse is preparing for a discharge client education. What should be included in the client education plan regarding diet? - eat fruits that are high in water content - avoid diary and high fibroid food - eat large evenly spaced meals 3 times a day - avoid food that are high in fat residue

- avoid food that are high in fat residue

A nurse is providing instruction to a client with GERD about ways to manage this condition. Which of the following instructions should the nurse include ? - sleep on your left side - drink milk to soothe your stomach - wait to go to bed for 1 hour after eating - eat 4 small meals each day

- eat 4 small meals each day

5) A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates allergic transfusion reaction? - BP 184/92 - generalized urticaria - distended jugular veins - bilateral flank pain

- generalized urticaria

A young adult client has received a news that her treatment for Hodgkins lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the client receives regular health assessment in the future due to risk of what complication? - GU cancer - hematologic cancer - iron deficiency anemia - hemophilia

- hematologic cancer

A nurse is caring for a client with multiple lacerations. Which of the following factors are likely to delay wound healing? SATA - tea consumption - citrus allergy - low serum albumin - smoking and obesity

- low serum albumin - smoking and obesity

A Nurse is monitoring a client with peptic ulcer disease. Which of the following findings is an indication of perforation? - sudden abdominal pain - bradycardia - increased BP - hyperactive bowel sounds

- sudden abdominal pain

A nurse is caring for a client with a diagnosis of malnutrition and is started on TPN. The nurse should monitor the client for which of the following complications? SATA - electrolyte imbalances - infection at central line insertion site - fluid imbalances - nausea and vomiting - high blood glucose level

-electrolyte imbalances - infection at central line insertion site - fluid imbalances - high blood glucose level

A nurse is preparing to administer Benadryl 30mg IM STAT to a client with allergic reaction. Available is Benadryl 50mg in 1mL. How many mL should the nurse administer?

0.6 ML

The nurse is preparing the titrate morphine 6mg IV bolus to a patient. The amount available is morphine 8mg/mL.

0.8

A nurse is planning nutritious instructions for a client experiencing fatigue due to iron deficiency anemia. Which of the following food should the nurse recommend to the client? - 1 cup of canned black beans - 8oz of whole milk - 8oz of black tea - 1 egg whites

1 cup of canned black beans

A nurse is administering RBC's 350mL/ 3 hour to a client with anemia. The nurse should set the IV pump to deliver how many mL per hour?

117

A nurse is preparing to administer Narcan 1mg IV push. Available is Narcan 0.4mg/mL. How many mL should the nurse administer?

2.5 ML

A nurse on a cancer unit is caring for a client who has breast cancer. The nurse would consider implementing. The nurse would consider implementing neutropenic precautions when the client's WBC count is 11,500 -5800 -8400 -2000

2000

A nurse is preparing to instill 840mL of internal nutrition via client G tube over 24 hours using an infusion pump. The nurse should set up the infusion pump to deliver how many mL per hour?

35mL

The nurse is caring for a client who will receive medication via G tube. The provider prescribes ?? 250mg the amount available is 25mg/5mL. How much should the nurse administer ?

50 ML

A group of nurses is discussing risk factors for transmission of HIV for clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV? A. A phlebotomist that collects blood from clients with HIV B. A nurse that works for an insurance company who collects urine samples from clients with HIV C. An occupational therapist who works with a client who has HIV D. A personal trainer that works with a client who has HIV

A. A phlebotomist that collects blood from clients with HIV

A nurse is providing instructions to a client with a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the instructions? A. Aplastic anemia results from the decrease bone marrow production in RBCs B. Aplastic anemia results in an inability to absorb vitamin B12 C. Aplastic anemia is associated with a decrease intake of iron D. Aplastic anemia results in an increase rate of RBC destruction

A. Aplastic anemia results from the decrease bone marrow production in RBCs

A client has an ileostomy created for his history of IBD, but the client is now preparing for discharge. What should the client be taught about changing this device in a home setting? A. Apply a skin barrier to the parastomal skin pouch prior to applying the pouch B. Apply antibiotic ointment as ordered, after cleaning the stoma C. Cleanse the area surrounding the stoma with alcohol or chlorhexidine D. Dispose of the clamp with each bag change

A. Apply a skin barrier to the parastomal skin pouch prior to applying the pouch

After receiving a diagnosis of acute lymphocytic leukemia, the client is visibly distraught stating "I have no idea where to go from here". How should the nurse prepare to meet this clients' psychosocial needs? A. Assess the clients specific needs for education and ? B. Identify the clients plan for medical care C. Assess the clients previous experience with the health care system D. Reassure the client that the treatment will be challenging, but successful

A. Assess the clients specific needs for education and ?

. A nurse is assessing a client's immune function by reviewing laboratory value of the cellular response of the T cells. The nurse should recognize which of the following condition is affected by T cells? A. Bacterial phagocytosis B. Hay fever allergy C. Anaphylaxis D. Transplant rejection

A. Bacterial phagocytosis

A nurse is preparing to perform a blood transfusion for a client. Which of the following actions should the nurse take? SATA A. Check the expiration date of the blood product with a second nurse B. Prime the blood tubing with Dextrose D5W C. Transfuse the blood product within 5 hours after removing it from refrigeration D. Insert an IV with a 19-gauge needle E. Check vital signs before transfusion

A. Check the expiration date of the blood product with a second nurse E. Check vital signs before transfusion

A nurse is creating a structure plan for a client with thrombocytopenia. Which of the following instructions should the nurse include? SATA A. Lubricate lips with water soluble ointment B. Brush teeth with a soft toothbrush C. Limit fruit consumption D. Use a straight edge razor to shave E. Blow nose gently

A. Lubricate lips with water soluble ointment B. Brush teeth with a soft toothbrush C. Limit fruit consumption

A nurse is planning care for a client with pernicious anemia. Which of the following interventions should the nurse care to implement? A. Vitamin B 12 injections B. Iron supplements C. Blood transfusions D. Vitamin B6

A. Vitamin B 12 injections

The client nurse educator is presenting health promotion education to a client who will be treated for non-Hodgkin's lymphoma on an out-client basis. The nurse should recommend which of the following actions? A. Avoiding direct sun exposure in excess of 15 minutes daily B. Avoiding grapefruit juice and fresh fruit C. Using an electric shaver rather than a razor D. Avoid highly crowded public places

B. Avoiding grapefruit juice and fresh fruit

The nurse is caring for a client who is two days post op following abdominal surgery. The nurse notices that the clients wound has eviscerated. After calling for help, what should the nurse do next? A. Place the client supine with knees bent B. Cover the area with a sterile dressing moistened with 0.9% sodium chloride C. Raise the head of the client's bed D. Assess the client for manifestations of shock

B. Cover the area with a sterile dressing

Imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should be noted? A. Prolonging confinement to bed B. Decrease wound healing time C. Masking the sx of acute infection D. Contributing the shorter hospital stays

B. Decrease wound healing time

A client has been newly diagnosed with a wound infection; he questions the nurse how to immune system functions. The nurse discuss that the immune system is activated after the failure of which body defense? A. Antigen/Antibody response B. Integumentary system C. Phagocytosis D. Inflammatory response

B. Integumentary system

Which lab test would the nurse consider most important in planning care for a client with Chron's disease who exhibits severe weight loss, dry skin, and muscle wasting? A. Serum Iron B. Serum Sodium C. Hemoglobin D. Serum Albumin

B.Serum Sodium

The nurse is providing care for a client whose IBD has necessitated hospital treatment. Which of the following will most likely be included in the patient's medication regimen? A. Antiemetics on a PRN basis B. Betablockers to reduce bowel motility C. Anticholeretic medications 30 minutes before a meal D. Vitamin B12 injections to prevent pernicious anemia

C. Anticholeretic medications 30 minutes before a meal

A nurse is reviewing the primary health care providers prescriptions for a client experiencing paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take? A. Providing ______ agent? B. Administer antiacid C. Start an NG tube D. Apply a truss

C. Start an NG tube

The nurse is caring for a client who needs a daily increase of calcium intake to reduce the risk of osteoporosis. Choose the food that would be the best for a vegetarian client? A. Fresh citrus fruit B. Raw carrots C. Steamed broccoli D. Steamed zucchini

C. Steamed broccoli

A nurse is caring for a client with HIV. Which of the following lab values should the nurse report to the PCP? A. CD4 T Cell count of 180 cells B. Platelets of 150,000 C. WBC count of 5,000 D. Positive western blot test

C. WBC count of 5,000

The nurse is completing dietary instructions on consuming a low fiber diet for a client with ulcerative colitis, which of the following foods should be eliminated in the client's diet? A. Ice Cream B. Cooked Cabbage C. Ripe Bananas D. Dry Apricots

Cooked Cabbage

The nurse is planning the care of a client with sickle cell disease who has been admitted for the treatment of an acute Vaso occlusive crisis. What nursing diagnosis should the nurse prioritize in the clients plan of care? A. Functional urinary incontinence related to urethral occlusion B. Risk of disuse syndrome related to ineffective peripheral circulation C. ineffective tissue perfusion related to thrombosis D. Ineffective thermoregulation related to hypothalamic dysfunction

D. Ineffective thermoregulation related to hypothalamic dysfunction

A nurse is assessing a client with a puncture wound on the right foot. Which of the following findings is a manifestation of acute osteomyelitis? A. Numbness of toes on the affected foot B. Bradycardia C. Hypothermia D. Localized erythema

D. Localized erythema

A client with poorly controlled diabetes has developed end stage renal failure and consequent anemia. When reviewing this client's treatment plan the nurse should anticipate the use of which drug? A. Magnesium sulfate B. Abaton Alfa? C. Vitamin K D. Low molecular weight at brand?

D. Low molecular weight at brand?

A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the disease. What should the nurse explain to this client? A. There could be impaired communication between platelets B. There can be an auto immune process causing platelet malfunction C. There can be an attack on the platelets by antibodies D. There could be decrease production of platelets

D. There could be decrease production of platelets

A nurse is reviewing a medical record of a client with a peptic ulcer. Which f the following findings should the nurse recognize as a risk factor for this condition? - History of NSAID use - History of Bulimia - Drinks green tea - Has a glass of wine with dinner each day

History of NSAID use

A nurse is admitting a client who is exhibiting signs and symptoms of nutritious deficit. An inadequate intake of what intake increases the client susceptibility of infection? - proteins - complex carbs - vit B12 - saturated fats

Protiens

A client admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient? - multigrain bagel - tofu - blueberries - spinach

Tofu

The medical nurse is aware that a client with sickle cell anemia benefits from understanding what situation can precipitate sickle cell crisis. When teaching a client with sickle cell anemia about the strategies to prevent crisis what measures should the nurse recommend? - using prophylactic antibiotics and performing meticulous hygiene - avoiding cold temperatures and ensuring sufficient hydration - maximizing physical activity and using OTC iron supplement - limiting psychosocial stress and eating high protein diet

avoiding cold temperatures and ensuring sufficient hydration

A woman who is in her third trimester of pregnancy is experiencing an exacerbation of iron deficiency anemia in recent weeks. When providing the client with nutritional guideline as a meal suggestion what food would be most likely to increase the woman iron stores? - mixed vegetables and brown rice - beef liver accompanied by OJ - salmon accompanied by a whole milk - yoghurt, almond and whole grain oats

beef liver accompanied by OJ

A nurse is caring for a client that is HIV positive and is 1 day post op following appendectomy. The nurse should wear a gown as a PPE when taking which of the following actions? - completing a dressing change - talking to the client at the bedside - administering intermittent IV bolus medication - administering IM injection

completing a dressing change

A nurse on a tele unit is caring for a client who has Crohn's disease and a calcium level of 8mg. Which of the following changes on the client ECG will the nurse expect to see? SATA - prolonged ST segment - short QT interval - Prolonged QT interval - widened T wave - Prominent U wave

prolonged ST segment Prominent U wave

A nurse is providing patient education to a client with RA about increasing physical rest as part of the treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client? - maintenance of joint function - reduced joint stress - suppression of the ambulatory process - decreased stiffness

reduced joint stress

A nurse is assessing a client that is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction? - HTN - report of metallic taste - report of low back pain - pallor

report of low back pain