Exam 2 2214
A health care provider prescribes meperidine hydrochloride (Demerol), 40 mg stat, for a postoperative client in pain. The medication label states meperidine hydrochloride (Demerol), 50 mg/mL. How many milliliters will the nurse prepare to administer to the client?
0.8
Medication order: Heparin 2500 units, SubQ, q6h. Using the following drug label, how many milliliters of heparin would you give per dose?
0.25
Os-Cal 1.5 g is ordered daily. The patient should have the supplement in 3 divided doses. How many grams should the patient have every 8 hours?
0.5
The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCL) to an adult client. The label on the medication bottle reads 40 mEq of KCL per 15 mL. The nurse should prepare how many milliliters of KCL to administer the correct dose of medication? Round the answer to the nearest whole number.
11
The medication order is to add bretylium tosylate 500 mg (Bretylol) in 100 mL of D5W, and to infuse at the rate of 20 mg/kg/hour. The patient? 's weight is 40 kg.Calculate the flow rate in milliliters per hour.
160 or 100
A nurse is preparing to administer a 50-mcg dose of medication to a client. The medication is available in 100 mcg/5 mL. How many mL should the nurse administer?
2.5
Medication order: Regular insulin 5 units and Lente insulin 45 units, daily. Using the following drug labels, how many total units of insulin would you give?
50
You have an order to infuse ondansetron (Zofran) 4 mg diluted in 5 ml 0.9% sodium chloride solution over 5 minutes using a syringe pump. What will the rate be?
60
A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)
d. Methylprednisolone (Medrol)
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care? a. "Allow the client to be as independent as possible with activities." b. "Assess the client's ability to eat and swallow before each meal." c. "Assist the client with frequent and meticulous oral care." d. "Schedule appointments early in the morning to ensure rest in the afternoon."
a. "Allow the client to be as independent as possible with activities."
The student demonstrates a lack of understanding of palliative care when making which statement? a. "Palliative care is designed to promote a cure for chronic disease." b. "Palliative care is designed to promote comfort." c. "Palliative care is designed to reduce disease exacerbations." d. Palliative care is designed to decrease acute care hospital admissions."
a. "Palliative care is designed to promote a cure for chronic disease."
The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. "What pain rating would be acceptable to you?" b. "Do you attach any spiritual meaning to pain?" c. "Are you worried about addiction to pain pills?" d. "How high would you say your pain tolerance is?"
a. "What pain rating would be acceptable to you?"
Mobility for the patient changes throughout the life span; this is known as the process of? a. growth and development. b. illness and disease. c. health and wellness. d. aging and illness.
a. growth and development.
A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. A 74-year-old man who smokes and has a fractured pelvis b. An 18-year-old male athlete with a fractured clavicle c. A 36-year old female with type 2 diabetes and fractured ribs d. A 55-year-old woman prescribed aspirin for rheumatoid arthritis
a. A 74-year-old man who smokes and has a fractured pelvis
A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client's vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowler's position. c. Assess response to pain medications. d. Increase the intravenous flow rate.
a. Administer oxygen via nasal cannula.
A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.
a. Arrange a home safety evaluation.
A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the client's usual bedtime routine. b. Offer a massage or warm shower at night. c. Allow the client uninterrupted rest time. d. Limit environmental noise as much as possible. e. Request an order for a strong sleeping pill.
a. Assess the client's usual bedtime routine. b. Offer a massage or warm shower at night. c. Allow the client uninterrupted rest time. d. Limit environmental noise as much as possible.
A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Caffeine b. Carbonated beverages c. Vitamin D d. Fat e. Alcohol
a. Caffeine b. Carbonated beverages c. Vitamin D e. Alcohol
A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first? a. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale b. Client being discharged later on a complicated analgesia regimen c. Postoperative client who received oral opioid analgesia 45 minutes ago d. Client who has returned from physical therapy and is resting in the recliner
a. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Clustering many nursing activities b. Elevating the head of the bed 30 degrees c. Aligning the neck with the body d. Providing stool softeners or laxatives as ordered
a. Clustering many nursing activities
The lack of weight bearing leads to what effects on the skeletal system? a. Demineralization, calcium loss Co b. Thickened bones c. Increased range of motion d. Increased calcium deposition in the bones
a. Demineralization, calcium loss Co
A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.) a. Elevate the extremity on pillows. b. Keep the extremity in a dependent position. c. Apply ice to the fracture site. d. Place a heating pad at the site of the injury. e. Administer additional opioids as prescribed.
a. Elevate the extremity on pillows. c. Apply ice to the fracture site. e. Administer additional opioids as prescribed.
What is the most prominent goal of palliative care? a. Integrate into chronic disease management sooner rather than later. b. Reserve this type of care until the patient is actively dying. c. Ensure that the patient has a 6-month prognosis. d. Enroll the patient into the Medicare Hospice Benefit.
a. Integrate into chronic disease management sooner rather than later.
A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.) a. It promotes healing. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It leads to minimal blood loss.
a. It promotes healing. b. It allows for early ambulation. e. It leads to minimal blood loss.
The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Loop diuretics b. Antibiotics c. Corticosteroids d. Antianxiety agents e. Barbiturates
a. Loop diuretics c. Corticosteroids e. Barbiturates
A client has a bone density score of -2.8. What action by the nurse is best? a. Planning to teach about bisphosphonates b. Asking the client to complete a food diary c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months
a. Planning to teach about bisphosphonates
Surgical closure of the ductus arteriosus would: a. Prevent the return of oxygenated blood to the lungs. b. Decrease the edema in legs and feet. c. Increase the oxygenation of blood. d. Stop the loss of unoxygenated blood to the systemic circulation.
a. Prevent the return of oxygenated blood to the lungs.
Controlling pain is important to promoting wellness. Unrelieved pain has been associated with complication? a. Prolonged stress response and a cascade of harmful effects system-wide b. Decreased tumor growth and longevity c. Decreased carbohydrate, protein, and fat destruction d. Large tidal volumes and decreased lung capacity
a. Prolonged stress response and a cascade of harmful effects system-wide
A nurse obtains the health history of a client with a fractured femur. Which factors identified in the client's history should the nurse recognize as an aspect that impede healing of the fracture. Select all that apply a. Tobacco use?? b. Osteoporosis?? c. Weight bearing exercise?? d. Sedentary lifestyle??
a. Tobacco use?? b. Osteoporosis?? c. Weight bearing exercise?? d. Sedentary lifestyle??
The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be? a. change in level of consciousness. b. loss of primitive reflexes. c. inability to focus visually. d. unequal pupil size.
a. change in level of consciousness.
An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include? a. herbs, vitamins, and tai chi. b. alternating ice and heat to relieve pain and inflammation. c. Pilates, breathing exercises, and aloe vera. d. guided imagery, relaxation breathing, and meditation.
a. herbs, vitamins, and tai chi.
Palliative care does everything except? a. promote a cure for chronic disease. b. decrease acute care hospital admissions. c. promote comfort. d. reduce disease exacerbations.
a. promote a cure for chronic disease.
The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates? a. red, sweaty skin. b. low pulse rate. c. slow capillary refill. d. decreased respirations.
a. red, sweaty skin.
A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurse's best response is which of the following? a. "Stand up slowly so you don't feel faint." b. "Talk with your physician about a calcium supplement." c. "Wear proper fitting shoes to prevent tripping." d. "Walk at least 5 miles every day for exercise."
b. "Talk with your physician about a calcium supplement."
An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess the skin under the abduction pillow straps. b. Apply an abduction pillow to the client's legs. c. Monitor cognition to determine when the client can get up. d. Take and record vital signs per unit/facility policy. e. Place pillows under the heels to keep them off the bed.
b. Apply an abduction pillow to the client's legs. d. Take and record vital signs per unit/facility policy. e. Place pillows under the heels to keep them off the bed.
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Increase the rate of the IV fluid administration. b. Call the provider or Rapid Response Team. c. Prepare to give IV pain medication. d. Notify respiratory therapy for a breathing treatment.
b. Call the provider or Rapid Response Team.
A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) a. Pallor - Increased blood blow to the area b. Cyanosis - Anaerobic metabolism c. Unequal pulses - Increased production of lactic acid d. Tingling - A release of histamine e. Edema - Increased capillary permeability
b. Cyanosis - Anaerobic metabolism c. Unequal pulses - Increased production of lactic acid e. Edema - Increased capillary permeability
What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Disparity in blood pressure between the upper and lower extremities c. Blood pressure higher on the left side of the body d. Systolic hypertension in the lower extremities
b. Disparity in blood pressure between the upper and lower extremities
A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with suspected bone tumor who just returned from having a spinal CT b. Post-microvascular bone transfer client whose distal leg is cool and pale c. Client with osteoporosis and a white blood cell count of 27,000/mm3 d. Client with osteoporosis and a bone fracture who requests pain medication
b. Post-microvascular bone transfer client whose distal leg is cool and pale
Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7 C (101 F). The nurse should: a. Keep the child warm with blankets. b. Report findings to physician. c. Apply a hypothermia blanket. d. Record the temperature on nurses' notes.
b. Report findings to physician.
A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.) a. Supplements b. Tai chi c. Acupuncture d. Stretching e. Vigorous aerobics
b. Tai chi c. Acupuncture d. Stretching
An infant with coarctation of the aorta that has a right to left shunt is receiving Prostaglandin E1. What is the purpose of this medication? a. To decrease inflammation b. To improve oxygenation c. To control pain d. To decrease respirations
b. To improve oxygenation
An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Skin color d. Pupil reaction e. Blood pressure
b. Urinary output c. Skin color e. Blood pressure
The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when she states, "Patients with impaired bed mobility...? a. like to have extra visitors." b. have an increased risk for pressure ulcers." c. are prone to constipation." d. need to have a mechanical soft diet."
b. have an increased risk for pressure ulcers."
When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes? a. hypotension, and tachycardia. b. hypertension, and bradycardia. c. hypertension, and tachycardia. d. hypotension, and bradycardia.
b. hypertension, and bradycardia.
What information does the nurse teach a women's group about osteoporosis? a. "Women and men have an equal chance of getting osteoporosis." b. "There is no way to prevent or slow osteoporosis after menopause." c. "For 5 years after menopause you lose 2% of bone mass yearly." d. "Men actually have higher rates of the disease but are underdiagnosed."
c. "For 5 years after menopause you lose 2% of bone mass yearly."
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease? a. "This disease is associated with anxiety causing increased perspiration." b. "He should not socialize outside of the house due to uncontrollable drooling." c. "He may have trouble chewing, so I will offer bite-sized portions." d. "His mask like face makes it difficult to communicate, so I will use a white board."
c. "He may have trouble chewing, so I will offer bite-sized portions."
A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "Hopefully things will improve gradually over time." b. "With respite care and support, I think I can do this." c. "I know I can take care of all these needs by myself." d. "I need to seek counseling because I am very angry."
c. "I know I can take care of all these needs by myself."
A phone triage nurse speaks with a client who has an arm cast. The client states, "My arm feels really tight and puffy." How should the nurse respond? a. "Continue to take ibuprofen (Motrin) until the swelling subsides." b. "Elevate your arm on two pillows and get ice to apply to the cast." c. "Please come to the clinic today to have your arm checked by the provider." d. "This is normal. A new cast will often feel a little tight for the first few days."
c. "Please come to the clinic today to have your arm checked by the provider."
A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first? a. Client taking ibandronate (Boniva) who cannot remember when the last dose was b. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago c. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia
c. Client taking raloxifene (Evista) who reports unilateral calf swelling
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a moderate brain injury who is amnesic for the event b. Client who is requesting pain medication for a headache c. Client with a Glasgow Coma Scale score that was 10 and is now is 8 d. Client with a Glasgow Coma Scale score that was 9 and is now is 12
c. Client with a Glasgow Coma Scale score that was 10 and is now is 8
A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury? a. Infection b. Constipation c. Hematuria d. Hypertension
c. Hematuria
A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action? a. Swollen extremity at the injury site b. Feeling cold while lying in bed c. Numbness in the extremity d. Pain of 4 on a scale of 0 to 10
c. Numbness in the extremity
Which structural defects constitute tetralogy of Fallot? a. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy c. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy d. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
c. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
A nurse is assessing pain in an older adult. What action by the nurse is best? a. Give the client a picture of the pain scale and come back later. b. Ask only "yes-or-no" questions so the client doesn't get too tired. c. Sit down, ask one question at a time, and allow the client to answer. d. Question the client about new pain only, not normal pain from aging.
c. Sit down, ask one question at a time, and allow the client to answer.
A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. The nurse's best response is "You are weak because: a. of your medications. This is known as drug induced weakness." b. your iron level is low. This is known as anemia." c. of your immobility in the hospital. This is known as deconditioning." d. of your poor appetite. This is known as malnutrition."
c. of your immobility in the hospital. This is known as deconditioning."
The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n)? a. oral thermometer. b. tympanic membrane sensor. c. rectal thermometer. d. temporal thermometer scan.
c. rectal thermometer.
An 80-year-old male patient is in the ICU status fractured femur and MVA. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to? a. call the anesthesia provider on call. b. call the primary hospitalist in charge of patient. c. stop opioid; anticipate administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. d. call a Code Blue.
c. stop opioid; anticipate administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status.
The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a. "Patients should always have a two-person assist to move in bed." b. "Patients should move themselves in bed to prevent immobility." c. "Patients must have a trapeze over the bed to move properly." d. "Patients must be moved correctly in bed to prevent shearing."
d. "Patients must be moved correctly in bed to prevent shearing."
When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm b. The left arm c. Both arms while the child is crying d. All four extremities
d. All four extremities
A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test? a. Provide preprocedure pain medication. b. Administer sedation as prescribed. c. Ensure that the client has no metal on the body. d. Assess for seafood or iodine allergy.
d. Assess for seafood or iodine allergy.
Which defect results in increased pulmonary blood flow? a. Tricuspid atresia b. Transposition of the great arteries c. Pulmonic stenosis d. Atrial septal defect
d. Atrial septal defect
A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Encourage the client to use ibuprofen (Motrin). b. Have the client perform hip range of motion. c. Place the client in a rigid cervical collar. d. Consult with the provider about an x-ray.
d. Consult with the provider about an x-ray.
Jan is a 70-year-old retired nurse who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a. Acupuncture and attending church services b. Chamomile tea and IcyHot gel c. Stationary exercise bicycle, free weights, and spinning class d. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy
d. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy
A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Heat intolerance b. Hyperresponsive reflexes c. Excessive somnolence d. Nystagmus
d. Nystagmus
The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Pulmonary stenosis b. Coarctation of the aorta c. Ventricular septal defect d. Patent ductus arteriosus
d. Patent ductus arteriosus
A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this client's pain? a. Morphine 4 mg intravenous push every 2 hours PRN for pain b. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain c. Meperidine (Demerol) injections every 4 hours around the clock d. Patient-controlled analgesia (PCA) pump with morphine
d. Patient-controlled analgesia (PCA) pump with morphine
A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect b. Patent ductus arteriosus c. Ventricular septal defect d. Tetralogy of Fallot
d. Tetralogy of Fallot
Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on knowing that: a. Constant parental supervision is needed to avoid overexertion. b. The child needs to understand that peers' activities are too strenuous. c. Parents can meet all the child's needs. d. The child needs opportunities to play with peers.
d. The child needs opportunities to play with peers.
In which situation is there the greatest risk that a newborn infant will have a congenital heart defect (CHD)? a. Father has type 1 diabetes mellitus b. Family history of myocardial infarction c. Older sibling born with Turner's syndrome d. Trisomy 21 detected on amniocentesis
d. Trisomy 21 detected on amniocentesis
Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of? a. chronic pain. b. mixed pain syndrome. c. neuropathic pain. d. nociceptive pain.
d. nociceptive pain.
The priority nursing intervention for a patient suspected to be hypothermic would be to? a. assess vital signs. b. hydrate with intravenous (IV) fluids. c. provide a warm blanket. d. remove wet clothes.
d. remove wet clothes.
A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about temperatures. The nurse's best response is that older people have a diminished ability to regulate body temperature because of? a. increased circulation. b. peripheral vasodilation. c. active sweat glands. d. slower metabolic rates.
d. slower metabolic rates.
Morphine sulfate, 2.5 mg, intravenous piggyback, is prescribed for a child with a complete fracture. The safe pediatric dose is 0.05 to 0.1 mg/kg per dose. The child weighs 50 kg. Is the dose prescribed within the safe range?
yes