Final Exam Fun
A patient is prescribed spironolactone (Aldactone) for treatment of hypertension. Which foods should the patient be taught to avoid?A. Baked fishB. Low-fat milk C. Salt substitutes D. Green beans
C. Salt substitutes
Which side effect Furosemide (Lasix) causes?
Damage to the ear
A 54-year-old client with liver failure due to cirrhosis comes to the clinic complaining of a swollen abdomen and dizziness upon standing. The client is pale with weak radial pulses, delayed hand vein filling, and distended abdomen. The nurse develops a care plan identifying which of the following nursing diagnoses?
Deficient fluid volume: intravascular related to third space fluid shifts. Rationale: The failing liver does not make enough albumin to keep capillary oncotic pressure at normal levels, thus excess fluid is lost from vessels into the peritoneum, causing ascites and vascular fluid volume deficit. Orthostatic hypotension, weak peripheral pulses, and delayed hand vein filling are all signs of low circulating fluid volume.
The nurse applies bilateral wrist restraints to a client threatening to leave the hospital against medical advice. What is the nurse's action considered?
False imprisonment
A middle-aged Chinese American client, who is self-employed without health insurance, is recovering from heart surgery. Each day family members spend hours at the client's bedside. Which is the most important factor for the nurse to focus on when planning the client's discharge?
Family Support
A client asks the nurse to explain why he needed to get a blood draw; however, the nurse did not know. The nurse tells the patient "I don't know but I will find out" A short while later, the nurse returns to discuss the reasons for the blood draw. Which moral principle did the nurse demonstrate?
Fidelity
The nurse is reviewing the home medication list with the patient. The nurse recognizes that hydrochlorothiazide is used primarily for which condition? Hypertension Edema Diabetes insipidus Protection against postmenopausal osteoporosis
Hypertension
Upon initial assessment, the nurse notes bruises and scratches on the arms, legs, and trunk of an older client. With which state law is the nurse complying when the supervisor is notified regarding this patient as a potential victim of abuse?
Mandatory Reporting Law
Which recent change would indicate that the patient's hearing ability is decreasing? Mood swings Decreased appetite Can't follow directions Answer question incorrectly Dizziness
Mood swings Can't follow directions Answer question incorrectly Dizziness
The nurse is caring for a patient with heart failure who needs a diuretic. Which agent is likely to be chosen, because it has been shown to greatly reduce mortality in patients with heart failure Furosemide [Lasix] Hydrochlorothiazide [HydroDIURIL] Spironolactone [Aldactone] Mannitol [Osmitrol]
Spironolactone [Aldactone]
A patient is being discharged from the hospital on warfarin [Coumadin] for deep vein thrombosis prevention. Which instructions should the nurse include in the patient's discharge teaching plan? (Select all that apply.)
Wear a medical alert bracelet. -Check all urine and stool for discoloration. -Do not start any new medication without first talking to your healthcare provider.
A 17-year old client who sustained a head injury in a motorcycle collision two days ago is responsive only to pain. Which IV fluid order would the nurse question because it could increase the risk of complications? a. Ringer's solution b. 5% dextrose in water c. 0.9% sodium chloride d. lactated ringer's solution
b
which of the following client would be at risk for hypermagnesemia?a. alcholism b. renal failure
b. renal failure
26 years old client has normal saline IV running 75 mg/hr which is most important for the nurse to assess first?
breathing
Which of the following interventions does the nurse complete when caring for a client admitted with a sodium level of 152 mEq/L? a. provide extra blankets for warmth b. observe client for nausea and malaise c. observe and prepare for possible seizures d. restrict fluids to 1200 mL per day
c
A 78-year-old couple is moving out of state to be closer to family members. Which of the following residences is most appropriate for this couple? a) Second story apartment with safety bars in the bathrooms b) Small two-bedroom home close to shopping center and church c) One-level living area condominium with good lighting inside and outside d) Two-level living area condominium close to family members
c) One-level living area condominium with good lighting inside and outside
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?a. Skin turgorb. Daily weightc. Presence of edemad. Hourly urine output
daily weight
Hydrochlorothiazide (Microzide) causes which electrolytes disorder?
hypercalcemia
polyuria and polydipsia
hypercalcemia
a nurse tapes the front of a patient's ear on the same side began to contract
hypocalcemia
nurse is assessing patient with calcium imbalance. The nurse observes the clinical signs that expect after patient coughs
hypocalcemia
symptoms a patient report includes abdominal cramping and diarrhea, fatigue and muscle weakness, confusion and personality change
hyponatermia
the nurse is caring for a patient who is experiencing severe acute hypocalcemia with restless and muscle spasm
take measures to prevent seizure, minimize environmental stimuli
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?a. "Increase fluids if your mouth feels dry.b. "More fluids are needed if you feel thirsty."c. "Drink more fluids in the late evening hours."d. "If you feel lethargic or confused, you need more to drink."
"Increase fluids if your mouth feels dry
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?a. "I will try to drink at least 8 glasses of water every day."b. "I will use a salt substitute to decrease my sodium intake."c. "I will increase my intake of potassium-containing foods."d. "I will drink apple juice instead of orange juice for breakfast."
"I will drink apple juice instead of orange juice for breakfast."
A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best? 1)Explain that hospital policy does not allow nursing assignments based on the gender of the nurse. 2)Explore with the patient her beliefs and determine which might have caused her to make this statement. 3)Assure the patient that each nurse is capable of providing professional nursing care, regardless of their gender. 4)Comply with the patient's request and assign a female nurse to care for the patient.
2)Explore with the patient her beliefs and determine which might have caused her to make this statement.
nurse is providing discharge teaching for a client who has a new prescription for warfarin sodium (Coumadin). Which of the following should the nurse include in the teaching?Mild nosebleeds are common during initial treatment.He should use an electric razor while on this medication.If he misses a dose, he should double the dose at the next scheduled time.Coumadin increases the risk for deep vein thrombosis.
2.He should use an electric razor while on this medication.MY ANSWERCoumadin, an anticoagulant, increases the client's risk for bleeding. The nurse should teach the client safety measure, such as using an electric razor, to decrease the risk for injury and bleeding.EXTRA: If he misses a dose, he should double the dose at the next scheduled time.Coumadin, an anticoagulant, should be taken at the same time each day and the client should not adjust the dose. Doubling a dose increases the client's risk for bleeding.Coumadin increases the risk for deep vein thrombosis.Coumadin, an anticoagulant, is a medication for the prophylaxis and treatment of deep vein thrombosis.Coumadin, an anticoagulant, increases the client's risk for bleeding. The nurse should instruct the client to stop the medication and notify the provider if signs of bleeding are present.
a nurse caring for a patient who has dependent edema. which pressure has caused the excess fluid in the interstitial compartment ?1. oncotic pressure2. diffusion pressure3. hydrostatic pressure4. intraventricular pressure
3. hydrostatic pressure
A nurse is preparing to administer heparin to a client via the deep subcutaneous (intrafat) route. Which of the following is an appropriate action for administering this medication?Use a 22-gauge needle to inject the medication.Use a 1-inch needle to inject the medication.Inject the medication into the abdomen above the level of the iliac crest.Massage the injection site after administration of the medication.
3. Inject the medication into the abdomen above the level of the iliac crest.The nurse should inject the medication into the abdomen above the level of the iliac crest, at least 2 inches from the umbilicus.EXTRA:The nurse should use a small needle, 25- or 26-gauge, when administering a deep subcutaneous injection. The nurse should use a short needle, 1/2- to 5/8-inch, when administering a deep subcutaneous injection. The nurse should apply firm pressure without massage to the site for 1 to 2 min after administration. Massaging the area after injecting heparin can cause bleeding.
A nurse is preparing to administer digoxin (Lanoxin) to a client who has heart failure. Which of the following actions is appropriate?Withholding the medication if the heart rate is above 100/minInstructing the client to eat foods that are low in potassiumMeasuring apical pulse rate for 30 seconds before administrationEvaluating the client for nausea, vomiting, and anorexia
4 Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity.
When arriving to a client's room to provide care, the client is praying with family. What action should the nurse take? 1. Stand quietly just inside the room door until the prayer is completed. 2. Come to the bedside and join in with the prayer. 3. Politely ask the client to allow care to proceed. 4. Quietly shut the door and wait in the hall until asked to enter.
4. Quietly shut the door and wait in the hall until asked to enter.
The client who has sleep apnea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client? 1. Disturbed Sleep Pattern related to difficulty staying asleep 2. Risk for Impaired Gas Exchange related to sleep apnea 3. Disturbed Thought Processes related to chronic insomnia 4. Risk for Injury related to somnambulism
4. Risk for Injury related to somnambulism
A nurse is providing discharge teaching to a client who will be taking warfarin (Coumadin) at home. Which of the following statements indicates that the client understands the effects of this medication?"It's okay to have a couple of glasses of wine with dinner.""I'll be sure to eat foods with lots of vitamin K.""I'll take aspirin for my headaches.""I'll use my electric razor for shaving
4. "I'll use my electric razor for shaving."Because this medication prolongs clotting times, the client should avoid situations that put him at risk for bleeding, such as shaving with a straight razor or a razor blade.
food high in potassium
Bananas, oranges, cantaloupe
Hypervolemia Symptoms
Clinical Manifestations: OPPOSITE OF DEHYDRATION-Tachycardia-bounding pulse-Incrased bp-decreased temp-edema-pitting-distended neck veins-SOB, crackles-increased weight-increased urine output-HA, visual disturbances -orthopneic position-version of high fowlers 4 pts that have SOB
The nurse has just taken a job in a hospital that cares for an ethnically diverse population and is concerned about being culturally sensitive. How should the nurse plan to manage caring for patients in pain?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Treat all patients alike.2. Listen carefully as the patients comments about pain are translated.3. Show respect for the patients preferences even if they are very different from the nurses.4. Ask questions about the patients beliefs and customs regarding pain management.5. Watch how other nurses provide care to their patients.
Correct Answer: 2,3,4Rationale 1: Not all patients respond identically to interventions.Rationale 2: Even if the nurse has to use the services of a translator, careful listening is an important step in providing culturally sensitive care.Rationale 3: Showing respect is important in providing culturally sensitive care in all areas, including pain management.Rationale 4: The nurse cannot practice what the nurse does not know. Asking questions is the method used to gain information to facilitate sensitive care.Rationale 5: Other nurses may not be providing the care needed for this nurses patients.
When teaching the patient about the signs and symptoms of cardiac glycoside toxicity, the nurse should alert the patient to watch for?
Flickering lights or halos around lights.
A 78-year-old client is admitted with dehydration and urinary tract infection. After IV infusion of 750 mL NS, the client begins to cough and asks for the head of the bed to be raised to ease breathing. The nurse assesses jugular vein distention (JVD) and increased respiratory rate. The nurse interprets that
Hypervolemia is developing. Rationale: This client presented with deficient fluid volume because of dehydration. Older adults have less cardiac and renal reserve to compensate for acute fluid imbalances and thus are more susceptible to overcorrection when being treated for them. JVD, tachypnea, cough, and dyspnea indicate that this client has received too much IV fluid at too rapid a rate. Older adult clients cannot tolerate rapid rehydration due to decreased cardiac and renal function.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?a. K+ 3.4 mEq/L (3.4 mmol/L)b. Ca+2 7.8 mg/dL (1.95 mmol/L)c. Na+ 154 mEq/L (154 mmol/L)d. PO4-3 4.8 mg/dL (1.55 mmol/L)
Na+ 154 mEq/L (154 mmol/L)d
A 28-year-old client is admitted with severe bleeding from a fractured femur. Which IV fluid does the nurse anticipate as the most appropriate for use to replace potential fluid losses? a. 0.9% sodium chloride b. 3% sodium chloride c. 5% dextrose in waterd. 5% dextrose in 0.22% sodium chloride
a
When caring for a 79-year old client who has a sodium level of 149 mEq/L, the nurse identifies the client will be at increased risk to develop dehydration because of which factor? a. a diminished thirst drive b. an increased level of aldosterone c. a decrease in muscle mass d. ADH is no longer produced
a
The nurse caring for the following group of clients considers which client to be at highest risk for developing deficient fluid volume? a. a thin, 52-year-old female receiving corticosteroid therapy for bronchitisb. a 60-year old male who had a left inguinal herniorrhaphy 12 hours agoc. a 76-year old male who has a nasogastric tube to intermittent suction following colon resection d. a 68-year old female who is NPO for a flexible sigmoidoscopy procedure
a 76-year old male who has a nasogastric tube to intermittent suction following colon resection
Which document patient states his or her wishes regarding medical treatment, especially treatment that sustains or prolongs life by extraordinary means, in the event that the patient becomes mentally incompetent or unable to communicate?a) Living Willb) Advanced directivec) Power of attorney
a) Living Will
Which of the following is most important to include with instructions for a client taking warfarin? a) client must have to check up every 3 weeks b) client should brush using a soft bristle and an electric razor
b) client should brush using a soft bristle and an electric razor
A client with hypercalcemia is receiving digoxin. The nurse plans to incorporate which of the following in client assessments? a. checking for Trousseau sign b. frequent pulse checks c. auscultation of bowel sounds d. inspection of skin for signs of bleeding
b. frequent pulse checks
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?a. Oral temperature of 100.1° Fb. Serum sodium level of 138 mEq/L (138 mmol/L)c. Gradually decreasing level of consciousness (LOC)d. Weight gain of 2 pounds (1 kg) above the admission weight
c. Gradually decreasing level of consciousness (LOC)
A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate?Select one:a. Assume the patient is confused and give the blood anyway.b. Request a psychological evaluation to ensure that the patient understands the risk.c. Request a psychological evaluation to ensure that the patient understands the risk.d. Follow the patient's wishes and do not administer a blood transfusion.
d. Follow the patient's wishes and do not administer a blood transfusion.
the nursing caring for a patient who has chronic kidney failure and hypothyroidism. they have been admitted for 5 days and complaining about muscle cramps and tingling around the mouth
hypocalcemia
