Final
Identify the link in the chain of infection that each example represents: client with cancer cannot produce sufficient 1. blood cells after taking anticancer drugs. A microorganism becomes especially virulent 2. after developing resistance to multiple antibiotics. A chef uses an unwashed counter to cut both raw chicken that contains infectious microorganisms 3. and raw vegetables that they will incorporate into a salad. A person with a common cold sneezes in a 4. crowded elevator. After a flood, raw sewage contaminates an 5. aquifer for drinking water A health care provider receives a puncture from a 6. needle used to give an injection to an HIV-positive client.
(5) Portal of exit (5) Means of transmission x (2) Infectious agent .5.Reservoir .6-Portal of entry -1-Susceptible host1️⃣
The nurse is caring for a client who is 2 hours postoperative. The client states, "I am nauseated." Which action(s) should the nurse perform? Select all that apply1️⃣
->Provide an emesis basin. ->Obtain vital signs. →Check the medication record for antiemetic medication prescription →Encourage deep breathing
The LPN is to start (IV) intravenous therapy on a client newly admitted to the unit? The LPN is correct in stating which as the indications for IV therapy? Select all that apply1️⃣
->To administer blood and blood products ->To replace electrolytes. → administer drugs → To restore fluid balance ->Provide a source of calories and nutrients.
What are some of the risks of Menopausal Hormone Replacement Therapy (HRT)? Select all that apply5️⃣
-Breast Cancer -Blood clots -Heart disease -Dementia -Stroke
The nursing student is preparing a teaching presentation on disaster preparedness for a nursing class assignment. Which actionis) would the student include in the presentation? Select all that apply2️⃣
-Create a network of persons who can provide support during and after the disaster -Store a supply kit with extra batteries, flashlight, and radio -affix a tag to a pet's collar with contact information
The client states feeling weak and having experienced an 8-pound weight loss since admission. What condition does the nurse expect the client to be tested for?4️⃣
-Diabetes insipidus (DI)
A client who is Assigned Male at Birth (AMAB) presents to the clinic for an annual check-up. The nurse notices that the client wrote on a form that they identify as a woman and prefer the pronouns she/her. Which best practice(s) of gender diverse care should the nurse utilize? Select all that apply.5️⃣
-Entering the client's name, gender, and preferred pronouns in their health care record -Introducing oneself using name and pronouns -Remaining nonjudgmental while delivering care
A 21-year-old Assigned Female at Birth (AFAB) client has sought care because of "heavy periods" and has subsequently been diagnosed with menorrhagia. The nurse should recognize which of the following as the most likely cause of the client's health problem?5️⃣
-Hormonal disturbances
Name the acid-base condition and imbalance. Select all that apply. PH - 7.48 PACO2- 48 НС03- 304️⃣
-Metabolic Alkalosis -Partial Compensated
The public health nurse is teaching a local community group about warning signs of cancer. What should the nurse include in the teaching? Select all that apply.4️⃣
-Persistent indigestion -Unexplained weight loss -Sores that do not heal -Tenderness or pain -Unusual bleeding or discharge
The nurse is caring for a client who does not accept blood or blood products. Which nursing action(s) conserves blood? Select all that apply.2️⃣
-Reinfuse the client's own blood via closed circuit container. -Administer factor Vill to stimulate coagulation process -Draw minimum volume of blood for diagnostic test -Administer medication to stimulate bone marrow
Name the acid-base condition and imbalance. Select all that apply PH -129 PAC02- 50 HC03- 242️⃣
-Respiratory acidosis -Uncompensated
Diabetes insipidus is characterized by large volumes of urine sometimes up to 20 L/24 hours from a lack of antidiuretic hormone (ADH) by the posterior pituitary gland or an ineffective response to its secretion4️⃣
-The client's urine output is a normal amount.
What items should the nurse have available when a client recovers after a thyroidectomy? Select all that apply.4️⃣
-Tracheostomy tray -Pulse oximeter -Calcium gluconate -Ice bag
Name the acid-base condition and imbalance. Select all that apply PH - 7.25 PACO2- 50 НС03- 244️⃣
-Uncompensated -Respiratory Acidosis
Diagnostic Test used to determine the function of Endocrine glands. Select all that apply.4️⃣
-culture sensitivity -CT -Radiation -Radionuclide studies -Radiography -MRI -Hormone levels
While completing an admission assessment. the client reports a family history of breast cancer among a maternal wrandmother, aunt. and sister. The nurse knows that these cancers are most likely associated with what etiolory?2️⃣
-inherited gene mutation
The primary care provider orders doxycycline 0.3 g p.o. bid. Calculate the number of capsules to administer when the supplied dose is 200 mg/capsule.5️⃣
1.5 capsules
Using the formula for calculating fluid intake requirements according to weight, how much oral fluid per day is considered adequate for a client who weighs 176 lb?4️⃣
2130mL/day
Using the formula for calculating, fluid intake requirements according, to weight, how much oral fluid per day is considered adequate for a client who weighs 176 lb?2️⃣
2130mL/day
Physician Orders: 4mg/kg/dose Client Weight: 140lbs How many mg/dose will be given?5️⃣
254.4mg
The physician orders Amoxicillin 500 mg p.o. q6h x 7 days. Amoxicillin for oral suspension is available 250mg per 5ml. How much will be given?4️⃣
4mL
The physician orders Amoxicillin 500 mg p.o. q6hIx 7 days. Amoxicillin for oral suspension is available 250mg per 5ml. How much will be given?3️⃣
4ml
A nurse is preparing to use microdrip tubing. What is the standard volume that this device delivers?1️⃣
60
A medical order states meperidine hydrochloride 50 to 100 mg IM q3h prn for pain. If a client does not experience adequate pain relief after receiving 50 mg, what dose should the nurse administer?1️⃣
75mg-100mg
The nurse is caring for four clients on a medical unit. Which client's laboratory reports does the nurse review first for an electrolyte imbalance?2️⃣
A 52-year-old with diarrhea
According to the U.S. Preventive Task Force, what is the recommended mammography screening for women aged 40-49 years?5️⃣
Decision to start screening should be an individual one
Which of the following medications is used in the treatment of diabetes insipidus to control fluid balance?3️⃣
Desmopressin (DDAVP) p1510 Explanation: DDAVP is a synthetic vasopressin used to control fluid balance and prevent dehydration. Other medications that are used in the treatment of patients with diabetes insipidus include Diabinese, thiazide diuretics (potentiate action of vasopressin), and/or prostaglandin inhibitors such as ibuprofen and aspirin.
During physical examination of a client with a suspected endocrine disorder, the nurse assesses the body structures. The nurse gathers this data based on the understanding that it is an important aid in which process?3️⃣
Detecting evidence of hormone hypersecretion
A client sustained a head injury when falling from, ladder. While in the hospital, the client begins voiding large amounts of clear urine and reports being very thirsty. The client states feeling weak and having experienced an 8-pound weight loss since admission. What condition does the nurse expect the client to be tested for?3️⃣
Diabetes Insipidus (DI)
The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock2️⃣
Distributive Explanation: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?2️⃣
Elevate the legs higher than the heart.
A client is going to transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?1️⃣
First 5-15 minutes
The nurse is caring for a client having chronic pain from arthritis. What type of hormone is released in response to the stress of this pain that suppresses inflammation and helps the body withstand stress?3️⃣
Glucocorticoids
A client has a dysfunction in one of his glands that is causing a decrease in the level of calcium in the blood. The nurse knows which gland should be evaluated for dysfunction?3️⃣
Parathyroid gland
The nurse in the ICU is admitting a 57-year-old with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary,conclusion?2️⃣
The client is in the compensatory stage of shock.
Exocrine glands release secretions into a duct.3️⃣
True
When performing hand sanitizer onto the palm of one hand and rub the hands together covering all surfaces of hands and fingers until dry usually 15 seconds or more.1️⃣
•False
Matching. Identify the electrolyte imbalance each client is most likely manifesting. 1.Client A is nauseous and weak. The ECG shows a U wave. 2.Client B has muscle twitching and tingling around the mouth. 3.Client C is thirsty, lethargic, and excreting only scant urine.4️⃣
(3)hypernatremia (1)hypokalemia (2)hypocalcemia
A client is scheduled for a hypophysectomy for the management of a pituitary tumor. What is the nurse's priorities) in caring for this client? Select all that apply.4️⃣
-Pace activities to accommodate the client's fatigue -Help the client cope with changes in physical appearance -Relieve discomfort from headaches, abdominal distention, and skeletal pain -Encourage self-care and activities as client's endurance permits
Name the acid-base condition and imbalance. Select all that apply. PH -7.48 PACO2- 48 HCO3- 302️⃣
-Partial Compensated -Metabolic Alkalosis
A client with acromegaly is complaining of severe headaches. What does the nurse suspect is the cause of the headaches that is related to the acromegaly?3️⃣
A pituitary tumor Explanation: When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica, a bony depression in which the pituitary gland rests, are common. There is actually an increase in the secretion of the growth hormone. The headaches would not be caused by decreases in glucose levels. The client does not have cerebral edema.
A client with acromegaly is complaining of severe headaches. What does the nurse suspect is the cause of the headaches that is related to the acromegaly?4️⃣
A pituitary tumor Explanation: When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica, a bony depression in which the pituitary gland rests, are common. There is actually an increase in the secretion of the growth hormone. The headaches would not be caused by decreases in glucose levels. The client does not have cerebral edema.
The nurse is obtaining data regarding medications the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving?1️⃣
Adjuvant drug therapy
The nurse is caring for a client scheduled for a transrectal ultrasonography. Which instruction is essential in obtaining an accurate test?5️⃣
Administer an enema prior to arrival.
The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?1️⃣
Opportunistic Explanation: An opportunistic or superinfection occurs among immunocompromised hosts. Examples would be yeast infections in the mouth, bladder infections, gastroenteritis, and Pneumocystis carinii. An acute infection has a sudden onset with serious and sometimes life-threatening manifestations. A chronic infection is an extended infection that resists treatment. A secondary infection is a complication of some other disease process that occurred first.
Which phase of pain transmission occurs when the one is made aware of pain?1️⃣
Perception Perception is the pain process where one becomes aware of the pain as a result of neural activity. Modulation involves the response to noxious stimuli. Transduction refers to the processes by which noxious stimuli activate primary afferent neurons called nociceptors. Transmission describes the action potential that is created by transduction being transmitted along fibers.
The nurse is caring for a client needing emergency surgery. Which preoperative teaching can be omitted when preparing the client for surgery?1️⃣
Post-discharge diet
What items should the nurse have available when a client recovers after a thyroidectomy? Select all that apply.3️⃣
Pulse oximeter, tracheostomy tray, ice bag, calcium gluconate
The nurse is caring for an older adult client receiving dopamine therapy for the treatment of shock. For which complication should the nurse monitor?4️⃣
Rapid increase in blood pressure
A client is scheduled for a hypophysectomy for the management of a pituitary tumor. What is the nurse's priorities) in caring for this client? Select all that apply.3️⃣
Relieve discomfort from headaches, abdominal distention, and skeletal pain Encourage self-care and activities as client's endurance permits Help the client cope with changes in physical appearance Pace activities to accommodate the client's fatigue
The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing. what is the nurse simultaneously assessing for?2️⃣
Respiratory compromise A person exposed to a blistering agent or vesicant must be decontaminated immediately, with clothing removed and bagged. Irrigation of the victim's eyes and application of topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse is assessing the respiratory system for airway obstruction because blisters from inhaled toxics can swell obstructing respiratory passages.
The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:1️⃣
Respond verbally during the procedure
A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client?3️⃣
Semi-Fowler with the head supported on two pillows
A client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. Which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms?3️⃣
Sodium level of 150 mEq/L
The nurse in the ICU is admitting a 57-year-old with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion?4️⃣
The client is in the compensatory stage of shock.
The public health nurse is teaching a local community group about warning signs of cancer. What should the nurse include in the teaching? Select all that apply.2️⃣
Unexplained weight loss Sores that do not heal Tenderness or pain Persistent indigestion Unusual bleeding or discharge
A client is admitted to the ED reporting severe abdominal pain and vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery. When can the client most likely anticipate that the surgery will be scheduled1️⃣
Without delay
The nurse is caring for a client having chronic pain from arthritis. What type of hormone is released in response to the stress of this pain that suppresses inflammation and helps the body withstand stress?4️⃣
Glucocorticoids
Diagnostic Test used to determine the function of Endocrine glands. Select all that apply.3️⃣
Hormone levels Radiography Radionuclide studies CT Radiation MRI culture sensitivity
A client diagnosed with cancer has the tumor staged and graded based on what factors?2️⃣
How they tend to grow and the cell type
A nurse is assessing a clients reflexes. Which condition does the nurse need to confirm when tapping the Facial nerve of a cient who has dysphagia2️⃣
Hypomagnesemia
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia4️⃣
Hypomagnesemia - If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
A client with a 20-year history of hypothyroidism who has not been compliant with taking thyroid replacement therapy is brought into the ED with a diagnosis of myxedema coma. What client symptoms are consistent with this life-threatening event? Select all that apply.3️⃣
Hypothermia Hypoventilation Hypotension
A client is brought to the emergency department with full-thickness burns to 27% of the body. The nurse knows to prepare intravenous (IV) fluid administration from which solution group1️⃣
Lower osmolarity solution
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption2️⃣
Maintain activity restriction to bedrest.
The nurse performs a breast exam on a client and finds a firm, non-moveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest?2️⃣
Malignant tumor Explanation: A fast-growing lump is suggestive of a malignant tumor. Metastasis can only be determined by cytology, not by palpation.
A client has a history of dysmenorrhea. During monthly menses, the client experiences incapacitating cramping and passes large clots. The client's primary care physician initiates conservative treatment. What interventions would the physician to recommend?5️⃣
NSAIDs Dysmenorrhea is treated with mild non-narcotic analgesics and by treating the underlying cause if one is identified. Symptomatic relief is accomplished with NSAIDs, which reduce prostaglandins. Prostaglandins are biologic chemicals that exist in endometrial tissue, where they exert a stimulating effect on the uterus, producing cramping and pain.
What does the nurse understand will be released to maintain a relatively constant level of blood sugar in a client with normal function of the pancreas?3️⃣
somatostatin
Match the hypothalamic neurohormones with each function. 1. Thyrotropin-releasing hormone, 2. Corticotrophin-releasing hormone (CRH) 3. Gonadotropin-releasing hormone 4. Growth hormone-releasing hormone (GHRH) 5. Somatostatin, 6. Hypothalamic dopamine3️⃣
stimulates the release of thyroid- ___ (1) stimulating hormone (TSH) from tha anterior pituitary gland 4 results in the release of somatotropin (growth hormone) from the anterior pituitary gland.. 1inhibits the release of prolactin from the anterior pituitary gland Dopamine 2causes the anterior pituitary gland to secrete adrenocorticotropic hormone triggers sexual development at the onset of puberty and continues to 3) cause the anterior pituitary gland to secrete luteinizing hormone and follicle-stimulating hormone which inhibits GHRH and TSH and 3 (5) also blocks the secretion of several gastrointestinal
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?2️⃣
weight
Match the following agents with its antidote 1. Amyl nitrite 2 atropine sulfate 3. dimercaprol2️⃣
x _ 3. (1) used to treat cyanide poisoning used to treat victims exposed to * 1. (3) lewisite a blstering agent + 2used to treat poisoning with a nerve agent such as sarin
The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply.1️⃣
• "How long have you experienced this pain?" • "Please point to where you are experiencing pain." • "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." • "What aggravates your chest pain?"
The nurse gently palpates the neck of a client diagnosed with a thyroid disorder. The client asks why the nurse's touch is so gentle. What response by the nurse is most appropriate?3️⃣
"Forceful palpation can result in excessive release of thyroid hormone from the gland."
The nurse is teaching a client who is to receive lypressin nasal spray as treatment for neurogenic diabetes insipidus about administration. Which client statement indicates the need for additional teaching?3️⃣
"I'll inhale fully after spraying the drug."
The nurse is caring for a client with a newly discovered tumor that may be benign or malignant. The client asks, "What makes a malignant tumor different from a benign one?" What should the nurse include in the response? Select all that apply.2️⃣
"The cells of the tumor bear little resemblance to the cells in the tissue where the tumor started." "It grows by invasion and infiltrates the surrounding tissues."
Matching, Identify the electrolyte imbalance each client is most likely manifesting. 1Client A is nauseous and weak. The ECG shows a 1 U wave. 2client B has muscle twitching and tingling around the mouth 3 Client C is thirsty, lethargic, and excreting only scant urine 2️⃣
(3) hypernatremia (2) hypocalcema (1) hypokalemia
How often should nurse monitor the clients IV site?1️⃣
At least one hour per shift and anytime the client is symptomatic or reports localized discomfort
A nurse assesses a client immediately following a thyroidectomy and documents that the dressing over the incision is dry and intact. In what other location should the nurse check for signs of bleeding and hemorrhage?3️⃣
At the back of the neck with a gloved hand
A nurse assesses a client immediately following a thyroidectomy and documents that the dressing over the incision is dry and intact. In what other location should the nurse check for signs of bleeding and hemorrhage?4️⃣
At the back of the neck with a gloved hand
The nurse is providing education to a client who will be having a hypophysectomy. What should the nurse be sure to include to prevent complications?3️⃣
Avoid sneezing and coughing.
Discharge instructions from the nurse following a D&C should include notifying the primary provider if what sign or symptom develops?5️⃣
elevated temperature
To reduce infection IV solutions should be replaced when?1️⃣
every 24 hours or when they finish infusing, whichever comes first
When should IV tubing be changed?1️⃣
every 72 hours depending on agency policy
A client has been diagnosed with nephrogenic diabetes insipidus (DI), and the physician is initiating treatment. What medication does the nurse prepare to administer for this client?3️⃣
hydrochlorothiazide
Which sodium imbalance is likely in a client who manifests mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes?4️⃣
hyponatremia
The nurse is preparing to administer the solution in the attached image to a client. Which of the following types of solution is the nurse going to administer?1️⃣
isotonic
The intensive care unit nurse is caring for a client with a transmissible spongiform encephalopathy. The nurse knows that this type of encephalopathy is caused by what type of infectious agent?1️⃣
prion
A group of students is reviewing for a test on hormones. The students demonstrate understanding of the material when they state which of the following as being secreted by the kidneys?
renin
A nurse on the unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow1️⃣
Be tested for disease antibodies at appropriate intervals.
Which compensatory mechanism, during the first stage of shock, does the nurse identify as responsible for stabilization of fluid balance?2️⃣
Corticosteroid hormone
The emergency department nurse is caring for a client who has just been admitted by ambulance for a suspected myocardial infarction. The physician orders IV fluids of normal saline to be hung at 100 ml/hr The nurse knows that this is what type of IV solution?1️⃣
Crystalloid
Which condition is a downward displacement of the bladder toward the vaginal orifice?5️⃣
Cystocele A cystocele results from damage to the anterior vaginal support structures. A rectocele is a bulging of the rectum into the vagina. Vulvodynia is a painful condition that affects the vulva. A fistula is an abnormal opening between two organs or sites.
The nurse is caring for an older adult client in the home setting who is experiencing decreased thirst. Which type of fluid imbalance should the nurse anticipate?2️⃣
Dehydration
A client diagnosed with parathormone deficiency is admitted to the hospital. As the nurse initiates the care plan, what body system should be the focus of care?4️⃣
skeletal
A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply.1️⃣
• Temperature of 102°F • Heart rate of 120 beats/minute • Respiratory rate of 24 breaths/minute Explanation: Two or more of the following characterize sepsis: temperature greater than 100.4°F (38°C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000 cells/mm3, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis, and a PaCO2 of 42 mm Hg is not an indicator. (less)
The nurse would expect to hang which of the following intravenous (IV) solution to a client with cerebral edema?1️⃣
→ Hypertonic solution
The primary provider orders an IV infusion of 1000 ml of 5% dextrose in water (D5W) in a container that will infuse over 8 hours by gravity. The nurse asks you to collect the fluid infusion supplies. Select all that apply.1️⃣
→IV pole → labels and time strips • a 1-L container of the prescribed solution →IV pole ->primary, unvented, macrodrip tubing
