Exam 1-Prep U

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24 hours period, the client's weight increased by 2 lb. How much fluid is this client retaining? 1 L 500 mL 1500 mL 1250 mL

1 L

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 115 130 145 160

115

The nurse is caring for a client in the ICU following a near drowning even in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client serum sodium value would be 155 145 135 125

155

Adequate hourly urine output for a client with an indwelling urinary catheter is 0.5 mL/kg/h 1.0 mL/kg/h 1.5 mL/kg/h 2.0 mL/kg/h

2.0 mL/kg/h

The normal serum value for potassium is 135-145 96-106 3.5-5.0 8.5-10.5

3.5-5.0

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room? 5 6 7 8

8

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kubler Ross? Denial Anger Bargaining Acceptance

Anger

Which is the most common cause of symptomatic hypomagnesemia? Intravenous drug use Alcoholism Sedentary lifestyle Burns

Alcoholism

The nurse is caring for a client in the PACU. The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2 F, blood pressure 84/50. What should the nurse do first? Notify the physician Assess for bleeding Increase rate of IV fluids Review the client's preoperative vital signs

Assess for bleeding

A group of nursing students are studying for a test over acid base imbalance. One students asks another what the major chemical regulator of plasma pH is. What should the second student respond? Renin angiotensin aldosterone syste Bicarbonate carbonic acid buffer system Sodium potassium pump ADH ANP buffer system

Bicarbonate carbonic acid buffer system

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Liver Kidneys Lungs Brain

Brain

A patient complains of tingling int he fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned? Potassium Phosphorus Calcium Magnesium

Calcium

Which oncologic emergency involves the accumulation of fluid in the pericardial space? Cardiac tamponade DIC SIADH Tumor lysis syndrome

Cardiac tamponade

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? Cardiovascular system Endocrine system Gastrointestinal system Genitourinary system

Cardiovascular system

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased BUN levels

Confusion and seizures

The nurse assess the patient for the negative effect of IV nitroglycerin for shock management which is: Reduced preload Reduced afterload Increased cardiac output Decreased blood pressure

Decreased blood pressure

What action by the nurse best encompasses the preoperative phase? Educating clients on signs and symptoms of infection Documenting the application of SCDs Monitoring vital signs every 15 minutes Shaving the client using a straight razor

Educating clients on signs and symptoms of infection

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. A neighbor cals 911. Which nursing action is helpful while waiting for the ambulance? Place a cool compress on head Elevate the legs higher than the heart Shake the client to arouse Cover the client with a blanket

Elevate the legs higher than the heart

A fractured skull would be classified under which category of surgery based on urgency? Elective Required Urgent Emergent

Emergent

The nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? Apply moist heat to the client's abdomen Encourage the client to ambulate at least 3 times per day Administer a tap water enema Notify the physician

Encourage the client to ambulate at least 3 times per day

Which statement by the client indicates further teaching about epidural anesthesia is necessary? I will become unconscious I will lose the ability to move my legs I will be able to hear the surgeon during the surgery A needle will deliver the anesthetic into the area around my spinal cord

I will become unconscious

Which positioning strategy should be used for the client diagnosed with hypovolemic shock? Supine Modified trendelenburg Prone Semi fowlers

Modified trendelenburg

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role? Registered nurse first assistant Scrub role Circulating nurse Anesthetist

Scrub role

Which of the following electrolytes is the primary determinant of ECF osmolality? Sodium Potassium Calcium Magnesium

Sodium

A patient begins to vomit during surgery. Place the actions below in the order in which they would be performed. Turn the patient to the side Lower the head of the surgical table Provide a basin for collection Suction to remove saliva

Turn the patient to the side Lower the head of the surgical table Provide a basin for collection Suction to remove saliva

A patient is scheduled for surgery with spinal anesthesia. When explaining this type of anesthesia to the patient, which body area would the nurse describe as being affected first? Abdomen Legs Chest Perineum

Perineum

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? Blood products 5% albumin 6% dextran 6% hetastarch

5% albumin

A nurse is developing a care plan for bone marrow suppression, the major dose limiting adverse reaction to FUDR. How long after drug administration does bone marrow suppression become noticeable? 24 hours 2 to 4 days 7 to 14 days 21 to 28 days

7 to 14 days

What percentage of potassium excreted daily leaves the body by way of the kidneys? 20 40 60 80

80

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? A rapid bounding pulse A slow but steady pulse A weak and thready pulse A slow and imperceptible pulse

A rapid bounding pulse

What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg A temperature reading between 97 F and 98 F Respirations between 20 and 25 breaths/min A hemoglobin of 13.6

A systolic blood pressure lower than 90 mm Hg

Which of the following characteristics should the nurse include when teaching the client about moderate sedation? Loss of consciousness Ability to respond to verbal commands Paralysis of the lower extremities Unable to maintain airway

Ability to respond to verbal commands

The nurse is concerned that a postoperative patient may have a paralytic ileum. What assessment data may indicate that the patient does have a paralytic ileus? Abdominal tightness Abdominal distention Absence of peristalsis Increased abdominal girth

Absence of peristalsis

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Hormone antagonist drugs Antimetabolite drugs Adrenergic drugs Anticholinergic drugs

Adrenergic drugs

Which type of shock occurs from an antigen antibody response? Septic Anaphylactic Neurogenic Cardiogenic

Anaphylactic

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? Assessing WBC count, temrpature, and wound appearance Obtaining dietary consultation for improved wound healing Educating the client on safe bed to chair transfer procedures Administering pain medication within 1 hour of the client's request

Assessing WBC count, temrpature, and wound appearance

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following? Baked chicken, mashed potatoes, broccoli, and strawberries Grilled salmon, rice pilaf, green beans, and cantaloupe Turkey breast, baked sweet potato, asparagus, and an orange Cheeseburger, french fries, coleslaw, and ice cream

Cheeseburger, french fries, coleslaw, and ice cream

A nurse is providing in home hospice care to a 75 year old client with lung cancer. The nurse determines that the client is eligible for Medicare hospice benefits based on which of the following? Client has a serious and progressive illness Client has a life expectancy of 6 months or less Client has family members to provide the care Client has no other insurance to pay for the care

Client has a life expectancy of 6 months or less

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse Begins the internal nutritional supplement at 100 mL/hr to ensure adequate calories Measures the nasogastric tube from earlobe to diploid process and marks the tube with tape at this level Consults with the physician about substituting lansoprazole for the prescribed dose of pantoprazole Obtains consent by a family member for placement of a PEG tube

Consults with the physician about substituting lansoprazole for the prescribed dose of pantoprazole

Which primary cancer treatment goal is prolonged survival and containment of cancer cell growth? Control Cure Palliation Prevention

Control

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Assisting the surgeon Coordinating the surgical team Setting up the sterile tables Passing instruments

Coordinating the surgical team

Which of the following interventions would be most appropriate for a client who has undergone surgery for a liver disorder and has started shivering? Provide the client with warm fluids Cover the client with a light blanket Ensure that the room temperature is below 70 F Place the client on a hypothermia blanket

Cover the client with a light blanket

A 73 year old female patient with cirrhosis of the liver is evaluated for clinical manifestations of FVE. Which of the following signs are consistent with that diagnosis? Select all that apply. Crackles Blood pressure of 90/60 CVP reading of 4 mm Hg Hematocrit level of 32% Blood pressure of 140/110 BUN of 8 mg/dL

Crackles Hematocrit level of 32% Blood pressure of 140/110 BUN of 8 mg/dL

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? Apply moist heat to the client's abdomen Encourage the client to ambulate at least three times per day Administer a tap water enema Notify the physician

Encourage the client to ambulate at least three times per day

The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which f the following nursing interventions should a nurse perform in such situations? Encourage the family members to express their feelings and listen to them in their frank communication Encourage conversations on the impending death of the patient Be a silent observer and allow the patient to communicate with the family members Encourage the patient's family members to spend time with the patient

Encourage the family members to express their feelings and listen to them in their frank communication

Which nerve is implicated in the Chvostek's sign? Facial Hypoglossal Optic Spinal accessory

Facial

The nurse concludes that teaching about pain management was effective when the client states: I will support my incision with my hands when I do my coughing and deep breathing exercises I will ask for pain medication when the pain becomes unbearable I will need to learn how to give myself pain medication by injection for when I go home The pain from my incision will be very similar to my arthritis pain

I will support my incision with my hands when I do my coughing and deep breathing exercises

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? Ignore the comment Report the resident to the attending surgeon Discuss concerns regarding the comments with the charge nurse Inform the resident that all communication needs to remain professional

Inform the resident that all communication needs to remain professional

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Lung sounds Skin perfusion Bowel sounds Mental status

Lung sounds

A client experiences an acute myocardial infarction. Current blood pressure is 90.58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Oxygen at 2 L/min by nasal canula Morphine 2 mg intravenously NS at 60 mL/hr via an intravenous line Dopamine intravenous solution

Oxygen at 2 L/min by nasal canula

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? Blood pressure of 94/62 Respiratory rate of 12 breaths per minute Oxygen saturation of 82% Urine output of 60 mL/hr

Oxygen saturation of 82%

Which health care profession has the ultimate responsibility to provide appropriate information regarding a non emergent surgery? Nurse Physician Case manager Certified nurse's aide

Physician

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue

Pink to red and soft, bleeding easily

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, noting that it bleeds easily White with long, thin areas of scar tissue

Pink to red and soft, noting that it bleeds easily

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which of the following values would be of greatest concern to the nurse? Sodium 138 Calcium 9.8 White blood cell count 7.2 cells/mm Potassium 6.2

Potassium 6.2

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? The difference between an apical and radial pulse The difference between an upper extremity and lower extremity blood pressure The difference between the systolic and diastolic pressure The difference between the arterial and venous blood pressure

The difference between the systolic and diastolic pressure

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statements, made by the client, would indicate that further instruction is needed? If i do not follow the instructions, my surgery could be cancelled The nurse will explain the details of the surgery before I sign a consent My medical records will be sent to the ambulatory care center prior to my surgery The physician will update my family after the procedure and provide specific discharge instructions

The nurse will explain the details of the surgery before I sign a consent

A patient is scheduled for cryosurgery for cervical cancer and tells the nurse, "I am not exactly sure what the doctor is going to do." What is the best response by the nurse? The physician is going to use medication to inject the area The physician is going to use liquid nitrogen to freeze the area The physician is going to use a laser to remove the area The physician is going to use radio frequency to ablate the area

The physician is going to use liquid nitrogen to freeze the area

The nurse is evaluating the client's risk for cancer and recommends changes when the client states she uses the treadmill for 30 minutes on 5 days each week eats red meat such as steaks or hamburgers every day works as a secretary at a medical radiation treatment center drinks 1 glass of wine at dinner each night

eats red meat such as steaks or hamburgers every day

A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through: inhalation of aerosols absorption through the gown absorption through the gloves absorption through the goggles

inhalation of aerosols

The nurse is to administer a vesicant chemotherapeutic drug to a client who had a right mastectomy and inserts the intravenous line in the clients left hand with a butterfly needle in the client's right forearm with a soft plastic catheter

with a soft plastic catheter

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? The client can be discharged from the PACU The client must remain in the PACU The client should be transferred to an intensive care area The client must be put on immediate life support

The client can be discharged from the PACU

The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? The principle of justice The principle of nonmaleficence The principle of fidelity The principle of autonomy

The principle of autonomy

While talking with a client who has been diagnosed with a terminal illness, the client asks, "Am I dying?" Which response from the nurse would be appropriate? Select all that apply. I know just how you must feel This must be very difficult for you Tell me more about what's on your mind You still have time for a good life Let's focus on what your doctor has planned

This must be very difficult for you Tell me more about what's on your mind

A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation? Tingling or twitching sensation in the fingers Confusion and depression Dyspnea and laryngospasm Hyperactive bowel sounds

Tingling or twitching sensation in the fingers

Which of the following does a nurse have to assess during the BMT procedure? Psychological status Blood pressure status Urine gravity status Electrolyte levels

Psychological status

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Discuss the risk for infection caused by wearing the ring Allow the client to wear the ring and cover it with tape Notify the surgeon to cancel surgery Remove the ring once the client is sedated

Allow the client to wear the ring and cover it with tape

Which statement, made by the nurse, can be most helpful when caring for a client in the third stage of Kubler-Ross emotional reactions to dying? Let's review the laboratory results and compare them with the diagnostic tests I understand that it would be wonderful to see your daughter's graduation What makes you most angry about getting the disease I like your idea of living for today and enjoying those around you

I understand that it would be wonderful to see your daughter's graduation

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Intracellular fluid Extracellular fluid Interstitial fluid Intravascular fluid

Intracellular fluid

A client who experienced shock is now non responsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to Encourage the family to touch and talk to the client Inform the family that everything is being done to assist with the client's survival Open up discussion among the family members about nursing home placement Contact a spiritual advisor to provide comfort to the family

Encourage the family to touch and talk to the client

Stress ulcers occur frequently in acutely ill patients. Which of the following medications would be used to prevent ulcer formation? Select all that apply. Famotidine Ranitidine Lansoprazole Desmopressin Furosemide

Famotidine Ranitidine Lansoprazole

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Second intention Third intention Fourth intention

First intention

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium of 12, potassium 3.9, chloride 101 and sodium 140. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? Hyperkalemia Hypocalcemia Hypokalemia Hypercalcemia

Hypercalcemia

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9. Which statement made by the client indicated the need for further teaching? I can use laxatives and enemas but only once a week A good breakfast for me will include milk and a couple of bananas I will be sure to buy frozen vegetables when I grocery shop I will take a potassium supplement daily as prescribed

I can use laxatives and enemas but only once a week

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000. Which statement by the client indicates a need for additional teaching? I floss my teeth every morning I use an electric razor to shave I take a stool softener every morning I removed all the throw rugs from the house

I floss my teeth every morning

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Nausea or vomiting Abdominal pain or diarrhea Hallucinations or tinnitus Light headedness or paresthesia

Light headedness or paresthesia

The nurse is caring for a client with a central venous line in place for the treatment of shock. Which nursing interventions are essential for the nurse to complete in order to reduce the risk of infection? Select all that apply. Maintain sterile technique when changing the central venous line dressing Always perform hand hygiene before manipulating or accessing the line ports Apply clean gloves before accessing the line port Perform a 10 second hub scrub using chlorhexidine and friction in a twisting motion on the access hub Instruct the client to wear a face mask and gloves while the central venous line is in place

Maintain sterile technique when changing the central venous line dressing Always perform hand hygiene before manipulating or accessing the line ports Apply clean gloves before accessing the line port

You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply? Many people have diagnostic or short therapeutic surgical procedures Lots of people have cancer and need tumors removed You know, we have a lot of sick people in the world Not everyone has to go to the hospital to have surgery anymore

Many people have diagnostic or short therapeutic surgical procedures

A client has the following ABG values: pH 7.12, CO2 40, HCO3 15. These ABG values suggest which disorder? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Metabolic acidosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. HIs arterial blood gas analysis shows a pH of 7.50, CO243, O2 75, and HCO3 42. Based on these findings, the nurse documents that the client is experiencing which types of acid base imbalance? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic alkalosis

How would the operating room nurse place a client in the Trendelenburg position? Flat on his back with his arms next to his sides On his back with his head lowered so that the plane of his body meets the horizontal on an angle On his back with his legs and thighs flexed at right angles On his side with his uppermost leg adducted and flexed at the knee

On his back with his head lowered so that the plane of his body meets the horizontal on an angle

The nurse is caring for the postoperative client in the post anesthesia care unit. Which of the following is the priority nursing action? Monitor vital signs for early detection of shock Assess the incisional dressing to detect hemorrhage Position the client to maintain a patent airway Administer antiemetics to prevent nausea and vomiting

Position the client to maintain a patent airway

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium is 7.6. Which physical examination finding is consistent with this electrolyte imbalance? Presence of Trousseau sign Slurred speech Negative Chvostek sign Muscle weakness

Presence of Trousseau sign

The nurse at the clinic explains to the patient that the surgeon will be removing a mole on the patient's back that has the potential to develop into cancer. The nurse informs the patient that this is what type of procedure? Diagnostic Palliative Prophylactic Reconstructive

Prophylactic

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Elevating the head of the bed Reinforcing the dressing or applying pressure if bleeding is frank Monitoring vital signs every 15 minutes Encouraging the client to breathe deeply

Reinforcing the dressing or applying pressure if bleeding is frank

What does the nurse recognize as one of the indicators of the patient's renal function? Blood urea nitrogen Serum creatinine Specific gravity Urine osmolality

Serum creatinine

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage I: beginning anesthesia Stage II: excitement Stage III: surgical anesthesia Stage IV: medullary depression

Stage II: excitement

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? Stage I Stage II Stage III Stage IV

Stage IV

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia? Subacute Hypoxic Episodic Anemic

Subacute

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? The client has been lying on his side for 2 hours with the drain positioned upward. The client has a NG tube in place that drained 400 mL The Hemovac drain isn't compressed; instead it's fully expanded There is a moderate amount of dry drainage on the outside of the dressing

The Hemovac drain isn't compressed; instead it's fully expanded

The client is experiencing intractable hiccups following surgery. The nurse expects the surgeon to order: chlorpromazine metoclopramide omeprazole ranitidine

chlorpromazine