Concept Exam 3

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? A) pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) B) pH 7.35, CO 2 47 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) C) pH 7.46, CO 2 30 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) D) pH 7.50, CO 2 50 mm Hg, HCO 3 - 22 mEq/L (22 mmol/L)

A) pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) - Metabolic Acidosis

While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention? A) To promote bone density B) To prevent further edema C) To reduce pain perception D) To increase muscle strength

B) To prevent further edema

A 70-year-old retired man has difficulty remembering his daily schedule and finding the right words to express himself. He is found to have dementia of the Alzheimer type. What does the nurse know about symptoms of this disorder? A) Occurred fairly rapidly B) Have periods of remission C) Begin after a loss of self-esteem D) Demonstrate a progression of disintegration

D) Demonstrate a progression of disintegration

The primary healthcare provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question is priority that the nurse should ask the client? A) "Do you take antidepressants?" B) "Do you have any respiratory disorders?" C) "Do you wear contact lens?" D) "Do you have allergies to sulfonamides?"

A) "Do you take antidepressants?"

Two days after admission to the detoxification program, a client with a long history of alcohol abuse tells the nurse, "I don't know why I came here." What is the most therapeutic response by the nurse? A) "You feel that you don't need this program?" B) "You realize that you are trying to avoid your problem?" C) "I thought that you admitted yourself into the program." D) "Don't you remember why you decided to come here in the first place?"

A) "You feel that you don't need this program?"

The home healthcare nurse visits an elderly couple living independently. The wife cares for the husband who has dementia. Which interventions should the nurse implement for them? Select all that apply: A) Assess the wife for caregiver burden. B) Arrange hospice care for the husband. C) Make healthcare decisions for the couple D) Assess the husband for signs of physical abuse. E) Identify social support within the community.

A) Assess the wife for caregiver burden. D) Assess the husband for signs of physical abuse. E) Identify social support within the community.

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? A) Avoid leaning forward. B) Hesitate between steps. C) Rest when tremors are experienced. D) Keep arms close to the center of gravity.

A) Avoid leaning forward. - Tremors occurs at rest.

A client is admitted with cellulitis of the left leg and a temperature of 103° F (39.4° C). The primary healthcare provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics? A) Determine the client's allergies. B) Apply a warm, moist dressing over the cellulitis. C) Measure the amount of swelling in the client's left leg. D) Obtain the results of the culture and sensitivity tests.

A) Determine the client's allergies.

During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several conditions that may have precipitated the delirium. Select all that apply: A) Infection B) Dementia C) Dehydration D) Urine retention E) Restricted mobility

A) Infection C) Dehydration D) Urine retention

A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco 2 is 35 mm Hg, and HCO 3 - is 17 mEq/L (17 mmol/L). What complication does the nurse conclude has developed? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

A) Metabolic acidosis

Which medications are useful to treat psoriasis? Select all that apply: A) Psoralen B) Anthralin C) Isotretinoin D) Clindamycin E) Calcipotriene

A) Psoralen B) Anthralin E) Calcipotriene

Which fungal infection in a client is commonly referred to as athlete's foot? A) Tinea pedis B) Tinea cruris C) Tinea corporis D) Tinea unguium

A) Tinea pedis

A woman who abused drugs during pregnancy gave birth to a drug-dependent neonate. Which nursing interventions would be beneficial to the neonate? Select all that apply: A) To administer smaller doses of the dependent drug B) To administer pain relievers during delivery C) To monitor the neonate carefully and closely D) To educate the mother about the risks of drug abuse E) To stop the drug on which the neonate is dependent immediately to avoid dependence

A) To administer smaller doses of the dependent drug C) To monitor the neonate carefully and closely D) To educate the mother about the risks of drug abuse

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? A) Turn and reposition the client every 2 hours. B) Cover the ulcer with an occlusive transparent dressing. C) Clean the ulcer with hydrogen peroxide and leave it open to the air. D) Provide the client with a diet high in vitamin C, zinc, and protein.

A) Turn and reposition the client every 2 hours.

A nurse caring for a client who presents with herpes zoster conducts extensive research on the disease to formulate the care plan. In addition, the nurse adds photos of the client's infected area to the electronic health record (EHR) to evaluate progress toward recovery. The nurse also educates the client on maintaining proper hygiene to prevent the spread of the infection. Which competencies does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Select all that apply: A) Using informatics B) Applying quality improvement C) Using evidence-based practice D) Providing patient-centered care E) Working in an interdisciplinary team

A) Using informatics C) Using evidence-based practice D) Providing patient-centered care

The nurse is teaching a group of students about the manifestation of alkalosis in the central nervous system. Which statements by a student nurse are accurate? Select all that apply: A) "The client's Chvostek sign would be negative." B) "The client's Trousseau sign would be positive." C) "The client would be suffering from paresthesias." D) "The client would show signs of anxiety and irritability." E) "The client's central nervous system should have a decrease activity in case alkalosis."

B) "The client's Trousseau sign would be positive." C) "The client would be suffering from paresthesias." D) "The client would show signs of anxiety and irritability."

What instruction would the nurse be most likely to give a client with reduced sensory perception to prevent injury from scalding? A) "Apply moisturizers." B) "Use a bath thermometer." C) "Dress warmly in cold weather." D) "Avoid frequent bathing with hot water."

B) "Use a bath thermometer."

What does a nurse understand by the Quality and Safety Education for Nurses (QSEN) competency called informatics? A) A nurse should ensure that the risk of harm to clients and healthcare workers is decreased by improving professional performance. B) A nurse should use information and technology to communicate, manage knowledge, mitigate error, and support decision-making. C) A nurse should integrate best current evidence with clinical expertise and client preferences and values to deliver quality health care. D) A nurse should use data to monitor the outcomes of health care processes and implement improvement methods to design and test changes to improve quality of health care.

B) A nurse should use information and technology to communicate, manage knowledge, mitigate error, and support decision-making.

Which type of immunity will clients acquire through immunizations with live or killed vaccines? A) Natural active immunity B) Artificial active immunity C) Natural passive immunity D) Artificial passive immunity

B) Artificial active immunity

A nurse is caring for a community-dwelling older adult with dementia. What interventions should the nurse take to ensure the client's well-being? Select all that apply: A) Obtain the client's drug history and educate the older adult about safe medication storage B) Foster human dignity and maintain the best possible functioning, protection, and safety C) Teach the client to be cautious of false advertisements that promise a cure for the disease D) Show the caregiver techniques to dress, feed, and toilet the older adult E) Protect the client's rights and provide support to maintain the physical and mental health of family members

B) Foster human dignity and maintain the best possible functioning, protection, and safety D) Show the caregiver techniques to dress, feed, and toilet the older adult E) Protect the client's rights and provide support to maintain the physical and mental health of family members

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? A) Determine the client's emotional state. B) Give prescribed drugs to promote bronchiolar dilation. C) Provide education about the impact of a family history. D) Encourage the client to use an incentive spirometer routinely.

B) Give prescribed drugs to promote bronchiolar dilation.

A school nurse is teaching a group of parents about pediculosis capitis (head lice). What common secondary infection does the nurse teach the parents to identify? A) Eczema B) Impetigo C) Cellulitis D) Folliculitis

B) Impetigo

The community health care nurse uses emails to remind the community about vaccines and regular diabetic checkups. Which Quality and Safety Education for Nurses (QSEN) competency does the nurse address? A) Safety B) Informatics C)Quality improvement D) Evidence-based practice

B) Informatics

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply: A) Limiting fluid intake B) Instilling saline nose drops C) Maintaining contact precautions D) Suctioning mucus with a bulb syringe E) Administering warm humidified oxygen

B) Instilling saline nose drops C) Maintaining contact precautions D) Suctioning mucus with a bulb syringe

A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse? A) Placing the client in restraints B) Sedating and placing the client in a controlled environment C) Encouraging the client to play table tennis with another client D) Setting firm limits on the client's behavior and enforcing adherence to them

B) Sedating and placing the client in a controlled environment

Which test helps a primary healthcare provider distinguish between conductive and sensorineural hearing loss? A) Whisper test B) Weber test C) Tympanometry D) Electrocochleography

B) Weber test

A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse? A) "It should return in several months." B) "You will have to ask the primary healthcare provider." C) "It is hard to say how much improvement will occur." D)"Unfortunately, your spouse will no longer be able to speak."

C) "It is hard to say how much improvement will occur."

While assessing an older adult with decreased perception of touch, the nurse provides instructions to the client to reduce the risk associated with falling. Which statements made by the nurse are beneficial to the client? Select all that apply: A) "Move slowly when changing positions." B) "Hold on to handrails while ambulating." C) "Look where your feet are placed while walking." D) "Wear shoes that give good support while walking." E) "If you are unable to change your position frequently request assistance."

C) "Look where your feet are placed while walking." D) "Wear shoes that give good support while walking." E) "If you are unable to change your position frequently request assistance."

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? A) Red blood cell count B) Sputum culture C) Arterial blood gas D) Total hemoglobin

C) Arterial blood gas

A nurse is caring for a client who has been admitted to a healthcare facility for the treatment of sinus disorders. The nurse discovers that the client is a cocaine addict. What task followed by the nurse is the best way to deal with the situation? A) Teach the client about safe medication storage and the danger of polypharmacy. B) Educate the client about his or her correct body mechanics and promote stress management. C) Assess the client's drug intake and ensure that the individual does not leave the healthcare facility. D) Assist with adequate personal hygiene, nutrition, and hydration and provide emotional support to the family.

C) Assess the client's drug intake and ensure that the individual does not leave the healthcare facility.

What is the priority nursing action for a client with delirium? A) Maintaining skin integrity B) Planning for behavioral interventions C) Creating a calm and safe environment D) Maintaining personal contact through touch

C) Creating a calm and safe environment

A nurse caring for a client post-surgery takes necessary steps to achieve quality client care. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called informatics? Select all that apply: A) Washing the hands before handling the client's incision site B) Implementing a new method of monitoring the client's incision site for infections C) Documenting in the electronic health record (EHR) after performing wound debridement D) Locking the electronic health record (EHR) after every entrance of necessary information E) Using computer-assisted instruction (CAI) program to provide better quality of care to the client

C) Documenting in the electronic health record (EHR) after performing wound debridement D) Locking the electronic health record (EHR) after every entrance of necessary information E) Using computer-assisted instruction (CAI) program to provide better quality of care to the client

A) Wearing bilateral hearing aids B) Being an insulin-dependent diabetic C) Experiencing progressive macular degeneration D) Requiring the weekly help of a home health aide E) Living alone since a spouse's death 3 years ago F) Employing a neighbor to provide assistance with grocery shopping

C) Experiencing progressive macular degeneration E) Living alone since a spouse's death 3 years ago

A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing? A) Kidney failure B) Mild dehydration C) Metabolic acidosis D) Respiratory alkalosis

C) Metabolic acidosis

After an infant completes a week of antibiotic therapy, the nurse finds white, adherent patches on the tongue, palate, and inner aspects of the cheeks that the provider identifies as thrush. Which medication does the nurse expect to be prescribed? A) Acyclovir B) Vidarabine C) Nystatin D) Fluconazole

C) Nystatin

The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect? A) Cerebral palsy B) Neonatal syphilis C) Opioid drug withdrawal D) Fetal alcohol syndrome

C) Opioid drug withdrawal

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? A) Urinary retention B) Gastric hyperacidity C) Rebound tenderness D) Increased lower bowel motility

C) Rebound tenderness

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

C) Respiratory acidosis

Which complications does the nurse anticipate in the client who has blue-colored nail beds? A) Thrombocytopenia B) Polycythemia vera C) Methemoglobinemia D) Cardiopulmonary disease

D) Cardiopulmonary disease

What is the first activity of daily living (ADL) that the nurse should help teach a developmentally disabled 8-year-old child? A) Dressing B) Toileting C) Self-feeding D) Combing hair

C) Self-feeding

The nurse is providing care to an infant diagnosed with Down syndrome. Which parental statement related to the infant's growth indicates the need for further education? A) "My baby will have growth deficiencies during infancy." B) "My child will have accelerated growth during adolescence." C) "My child will most likely be overweight by 3 years of age." D) "My baby will have reduced growth in both height and weight.

B) "My child will have accelerated growth during adolescence."

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. Which information should the nurse share with the family? A) Speak louder than usual during visits while looking directly at the client. B) Encourage the client to speak while allowing time to respond. C) Give positive reinforcement for correct communication. D)Tell the client to use the correct words when speaking.

B) Encourage the client to speak while allowing time to respond.

A nurse teaches a client scheduled for a tracheostomy about ways to prevent aspiration during swallowing. Which statement of the client indicates the need for further teaching? A) "I should eat smaller and more frequent meals." B) "I should avoid eating meals when I am fatigued." C) "I should drink more water and other thin liquids." D) "I should keep emergency suctioning equipment close at hand."

C) "I should drink more water and other thin liquids."

A nurse is providing preoperative teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is what? A) Viral B) Fungal C) Bacterial D) Rickettsial

C) Bacterial