final exam nclex question

Keith has a diagnosis of lung cancer. If his tumor were to metastasize, in what area(s)does the nurse anticipate it to move? Select all that apply A. Adrenal glands B. Brain C. Liver D. Bone E. Kidneys

A. Adrenal glands B. Brain C. Liver D. Bone Rationale: As the growth rate of a tumor increases, invasiveness and metastasis increases. Cancer cells travel via lymph nodes and blood stream to, most frequently, the adrenal glands, brain, liver, and bone. To produce mets, tumor cells detach from the tumor, enter the blood stream, survive in circulation, rest in capillary beds, adhere to the capillary basement membrane, gain entrance to the parenchyma, respond to growth factors, proliferate, induce androgenesis, and invade host defenses.

A pregnant patient states the first day of her last menstrual cycle was July 18, 2022. using Naegle's rule what is the paient's due date? a. april 25, 2023 b. july 18, 2023 c. april 25, 2022 d. july 25 2023

A. April 25, 2023 Rationale: The calculation for Naegele's rule is to subtract 3 months from the 1st day of LI add 7 days, then add 1 year.

Which of the following diagnostic tests are associated with assessing impairment in gasexchange? (select all that apply). A. Arterial blood gas (ABG) B. X-ray C. Complete blood count (CBC) D. Allergy skin test E. Sputum examination

A. Arterial blood gas (ABG) C. Complete blood count (CBC) E. Sputum examination

A patient diagnosed with lung cancer can expect to see it spread to which area? (SATA) A. Brain B. Bone C. Lymph nodes D. Kidneys E. Throat

A. Brain B. Bone C. Lymph nodes Rationale: When lung cancer metastases it can spread to the brain, bone, andlymph nodes. As well as the liver and pancreas.

A patient is receiving Thoracentesis, a procedure to relieve a pleural effusion. The nurse isthere to assist the physician. Which of the following assessment findings should concern the nurse: A. Patient reports sharp, stabbing chest pain that worsens when trying to breathe in. B. Fluid output below 1000 mL C. Muffled lungs sounds D. SaO2 is 88

A. Patient reports sharp, stabbing chest pain that worsens when trying to breathe in. rationale: Acute chest pain is a sign of pneumothorax

What is the purpose of an amniocentesis test for a 36 old pregnant patient at her 35 weeks of pregnancy? A. To determine fetal lung maturity or hemolytic disease B. Identify size and placement of the fetus C. Evaluates fetal heart rate (FHR) accelerations D. Detect detachment of placenta

A. To determine fetal lung maturity or hemolytic disease Rationale: amniocentesis test is an aspiration of amniotic fluid from the sac for further examination. During Second trimester amniocentesis Performed between 15 and 20 weeks to check for Chromosomal or biochemical abnormalities. In Third trimester amniocentesis Performed to determine fetal lung maturity or hemolytic diseas

Which of the following conditions are a risk factor for ED? SATA a. Diabetes b. Parkinsons c. Obesity d. Hyperlipidemia e. Osteoporosis f. CHF

A. diabetes B. Parkinson's C. obesity F. CHF Rationale: ED can be caused by Diabetes, Parkinsons, Obesity, and CHF.

Inadequate gas exchange causes changes in the following vital signs: (select all that apply). A. increase in respiratory rate B. decrease in SaO2 C. Decreased PCO2 D. increase in heart rate E. increase in temperature.

A. increase in respiratory rate B. decrease in SaO2 D. increase in heart rate E. increase in temperature.

Which statement by a patient about a self breast exam would not require further teaching? A. "A yearly breast exam by a provider is an adequate substitute for self breast exams." B. "I should perform my self breast exam after my period." C. "The purpose of self breast exams is to prevent cancer." D. "Self breast exams should be done twice yearly."

B. "I should perform my self breast exam after my period." rationale: Self breast exams should be performed after a period in women who arestill menstruating. A yearly exam is not a substitute for self breast exams, the goal of self breastexams is early detection not prevention, self breast exams should be done monthly.

Which of the following is NOT a sign and symptom of diabetes mellitus? a. Polyuria b. Rapid breathing c. Blurred vision d. Polydipsia

B. Rapid breathing RATIONALE: rapid breathing is not a symptom of DM. Rapid breathing only occurs in a condition called DKA and not DM

Which of the following interventions is NOT part of the type 2 diabetes treatment? a. Smoking cessation b. Regular physical exercise c. Taking prescribed insulin d. Weight loss

B. Regular physical exercise RATIONALE: Type 2 diabetes is insulin resistant. Type 2 is usually managed by nonpharmacologic treatment interventions, like weight loss, improved dietary habits, smoking cessation, reduced alcohol consumption, and regular physical exercise. If medication is necessary, then medications like Metformin is an option

During a routine prenatal visit, the fetal heart tones are assessed. The nurse understands which of thes findings is normal? a. 100 bpm b. 165 bpm c. 145 bpm d. 90 bpm

C. 145 bpm Rationale: normal fetal heart tones are 110-160 bpm

A patient received a dose of regular insulin (Humulin R) this morning at 10:00 am. What time would the nurse likely anticipate the potential for a hypoglycemic reaction to occur? a. 10:30 am b. 11:00 am c. 2:00 pm d. 5:00 pm

C. 2:00 pm RATIONALE: Humulin R is a rapid acting insulin with peak of 2-4 hours after injection

A dark vertical line that appears on he skin of your stomach during pregnancy? a. hyperpigmentation b. melasma c. linea nigra d. stretch marks

C. Línea nigra Rationale: (ptt, slide 45) The linea nigra is a dark vertical line that appears on the skin of your stomach during pregnancy. It runs from your belly button to your public area but can extend towards your abdomen.

Positive Chadwick's sign in pregnant women means? a. a predictable pattern of uterine groweth b. increased vascularity c. the blueish color of the cervix in pregnancy d. softenin =g of the cervix

C. The blueish color of the cervix in pregnancy Rationale: Chadwick sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow

Most common side effect associated with the use of a copper IUD would the nurse discuss with the clinet during a teaching session? a. tubal pregnancy b. perforation of the uterus c. device falls out d. excessive menstrual flow

D. Excessive menstrual flow Rationale: With use of a copper IUD there may be excessive menstrual flow. Because the IUD is a foreign body, there is an increase in the blood supply, a result of the inflammatory process.

Charley is receiving chemotherapy and begins to experience myelosuppression. What is the most appropriate nursing diagnosis for Charley? A. Hypothermia B. Powerlessness C. Risk for infection D. Acute pain

D. Risk for infection. Rationale: Myelosuppression is a reduction in RBC's, WBC's, and platelets making a patient in more danger of infection, hemorrhage, and overwhelming fatigue. Hypothermia, powerlessness, and acute pain are all appropriate nursing diagnoses but risk for infection is the most appropriate

During pregnancy, alterations in maternal blood glucose and fluctuations in Insulin production occur. Glucose levels are 10% to 20% lower than before pregnancy, and hypoglycemia may develop between meals and at night. The cause of this is due to? a. The mother ate too much food high in sugar during meals, causing Hypoglycemia b. The mother did not consume enough food, causing Hypoglycemia c. The mother worked out before going to bed d. The fetus draws glucose from the mother, causing hypoglycemia in the mother.

D. The fetus draws glucose from the mother, causing hypoglycemia in the mother. RATIONALE: pg 220 McKinney (Glucose levels are 10% to 20 % lower than before pregnancy, and Hypoglycemia may develop between meals and at night as the fetus draws glucose from the mother.)

Which barrier method provides the best protection against STIs? a. A cervical Cap b. Spermicides c. Birth Control d. Condoms

D. condoms Rationale: Condoms provide the most barrier from the body parts and fluids coming into contact with each other.

Who is at the greatest risk for problems with sexuality? SATA a. Adolescents b. Minorities c. Intellectually and developmentally disabled d. Those who are newly unpartnered

a. Adolescents b. Minorities c. Intellectually and developmentally disabled d. Those who are newly unpartnered Rationale: populations at greatest risk for problems with sexuality are adolescents, they are at risk for HIV, STIs, unintended pregnancies, and sexual violence, minorities because they are more at risk for high risk behavior, intellectually and developmentally disabled because they have poor decision making skills, loneliness, and are easily manipulated or forced into doing something, and those who are newly unpartnered

alpha-fetoprotein screening (AFP) assessment is preformed on meternal serum or amniotic fluid to identify? SATA a. open body wall defects (neural tube defects) b. size of fetus c. chromosomal anomalies (trisomy 21) d. position of the fetus e. determine fetal lung maturity or hemolytic disease

a. Open body wall defects ( neural tube defects) c. Chromosomal anomalies (trisomy 21) Rationale: AFP assessment is performed on maternal serum or amniotic fluid to identify Open body wall defects (neural tube defects), Chromosomal anomalies (trisomy 21). Ideally performed between 16 and 18 weeks of gestation. Requires only a blood sample and must be viewed as a first step in screening.

The nurse is caring for a patient with hyponatremia. Which of the following could be causes of the patient's hyponatremia. Select all that apply. a. SIADH b. Taking diuretics c. Consuming too much sodium d. Conn's syndrome

a. SIADH b. taking diuretics Rationale: SIADH is syndrome of inappropriate antidiuretic hormone secretion, which dilutes Na+. Patients taking diuretics have sodium loss along with the removal of excess fluid.

Which finding in a client who had coronary artery bypass graft (CABG) surgery 1day previously is most important for the nurse to communicate to the health care provider? a. Temperature of 102°F (38.9°C) b. 7/10 incisional pain (0 to 10 scale) c. Sinus rhythm with PR interval of 0.22 seconds d. 120 mL of blood in the chest tube collection chamber

a. Temperature of 102°F (38.9°C) rationale: Although mild temperature elevations are common after surgery due to the inflammatory response, a high temperature may indicate wound infection and a need for actions such as blood cultures and antibiotic administration. Incisional pain is common after cardiac surgery and would be addressed by the nurse with prescribed post-op analgesics and actions such as repositioning the client. The client's PR interval is mildly prolonged, but first-degree AV block does not affect cardiac output. A small amount of blood in the drainage device is common after cardiac or vascular surgery.

A nurse knows to assess which infant blood glucose level for Hypoglycemia? SATA a. The infant who is large for gestational diabetes. b. The Infant born Healthy c. The Infant who came out shivering d. The Infant mother has diabetes. e. The Infant who is small for gestational age.

a. The infant who is large for gestational diabetes. d. The Infant mother has diabetes. e. The Infant who is small for gestational age. RATIONALE: pg 323 Mckinney (Assessment of the blood glucose level is common for infants at increased risk for Hypoglycemia such as those large or small for gestational age and Infants of mothers with diabetes)

Which patient is at most risk for hypomagnesemia? a. A chronic alcoholic that is over 50 years old b. A patient with hyperthyroidism c. A patient that uses antacids and laxatives daily d. An adolescent with hypoglycemia

a. a chronic alcholic that is over 50 years old Rationale: Patients that have alcoholism secrete more magnesium.

The nurse should question which of the following orders from the physician regarding a pregnant woman with Eclampsia? A. Give 60 mg of magnesium sulfate within 24 hours. B. Give magnesium sulfate with lactated ringers. C. Keep calcium gluconate on stand-by D. Give the patient 10 mg of hydralazine if blood pressure continues to be elevated and push over 1 minute.

a. give 60mg of magnesium sulfate within 24 hrs. A is the correct answer, but the information is incorrect because magnesium sulfate should not exceed 30 to 40 mg in 24 hours. B is not the answer because magnesium sulfate can be given with lactated ringers or d5w as it is compatible. C is not the answer because calcium gluconate should be on standby since it is the antidote for magnesium sulfate. D is not the answer because starting out with 10 mg of hydralazine for the pregnant patient with elevated blood pressure is safe and effective and should be pushed over 1 minute.

A patient presents to the ER with hyperactive reflexes, convulsions, a prolonged QT interval, and muscle spasms. What do you suspect is the cause of the patient's symptoms? a. Hypocalcemia b. Hypomagnesemia c. Hypercalcemia d. Hypophosphatemia

a. hypocalcemia Ralionale: all of these are signs of hypocalcemia

A client is admitted with severe diarrhea and is positive for Chvostek's and Trousseau's signs. Which of the electrolyte imbalances would the nurse suspect with this client? a. Hypocalcemia b. Hyperchloremia c. Hyperphosphatemia d. Hypernatremia

a. hypocalcemia Rationale: When a client is admitted with severe diarrhea and is positive for Chvostek's and Trousseau's signs, the nurse should suspect that the electrolyte imbalance would be hypocalcemia. These symptoms are also seen with hyperphosphatemia. Other symptoms of hypocalcemia may include circumoral tingling and weak bones

What factors can cause/exacerbate sickle cell anemia? Select all that apply A. Stress B. Warm weather C. Dehydration D. Cold weather E. Low altitudes

a. stress c. dehydration d. cold weather rationale: - Stress, Dehydration, and cold weather can all exacerbate sickle cell anemia. High altitudes can also cause exacerbation. Warm weather and low altitudes do not.

A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? a. "Your nausea will eventually go away after the third treatment" b. "Try eating several small meals a day" c. "Increase your intake of red meat as tolerated" d. "Cold food is better tolerated under these circumstances"

b. "Try eating several small meals a day" Rationale: Several small meals a day are usually better tolerated by the client who has nausea

It is important for the nurse providing care for a patient with sickle cell crisis to a. Limit the patient's intake for oral and IV fluids b. Evaluate the effectiveness of opioid analgesics c. Encourage the patient to ambulate as much as tolerated d. Teach the patient about high-protein, high-calorie foods

b. Evaluate the effectiveness of opioid analgesics rationale: Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized

What STI is spread through direct contact of warts, semen, and other fluids? a. HIV (Human immunodeficiency virus) b. HPV (Human Papillomavirus) c. Chlamydia d. Gonorrhea

b. HPV (Human Papillomavirus) Rationale: You can get HPV by having vaginal, anal, or oral sex with someone who has the virus. It is most commonly spread during vaginal or anal sex. It also spreads through close skin-to-skin touching during sex. A person with HPV can pass the infection to someone even when they have no signs or symptoms.

a clinet is in her thirsd trimester of pregnancy and the urse is assesing the results of a fetal sonogram reveling a small-for-gestational-age fetus and a low-lying placenta. WHich comlication does the nursee understnad as the cause? a. preterm labor b. placenta previa c. premature seperation of the placenta d. premature rupture of the membrane

b. Placenta previa Rationale: Placenta previa is defined as an abnormally implanted placenta in the thin lower-uterine segment (i.e., low-lying, partially covering, or completely covering the cervical os).

Which of the following are clinical manifestations of menopause? SATA a. Decrease in vaginal pH b. Reduced lubrication c. Vasomotor instability d. Risk for osteoporosis e. Dyspareunia

b. Reduced lubrication c. Vasomotor instability d. Risk for osteoporosis e. Dyspareunia Rationale: There is an increase in vaginal pH which puts them at risk for UTI, yeast or vaginal infections. There is reduced lubrication, putting them at risk for fungal infections and dyspareunia which is increased pain in the vaginal area. They will start to have vasomotor instability which causes hot flashes and diaphoresis and will be at risk for osteoporosis which increases the risk for fractures and kyphosis.

An elderly male adult presents to the ER c/o chest pain. He has a known hx of a MI. The nurse has orders to administer sublingual nitro, but before administering the Nitro which drug should she ask the patient if he has taken within the past 24 hrs? a. Aspirin b. Viagra c. Metoprolol d. Lexapro

b. Viagra Rationale: Viagra and Nitro both dilate a person's blood vessels and can increase the patient's risk for strokes or heart attacks or decrease in BP

A 64 year old male patient has been diagnosed with colorectal cancer. He comes into his oncology appointment so the oncologist can determine what stage of cancer the patient is in. A CT scan showed no abnormal masses in the liver, lungs, or brain and his colon showed only limited masses in the general area. His symptoms have not changed and there is no change in blood labs. What stage of cancer does the oncologist believe the patient is in? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

b. stage 2 Rationale: Stage 1 is tumor local to tissue growth. Stage 2 is limited local spread. Stage 3 extensive local and regional spread and Stage 4 is metastasis

A patient has just been given information on STIs. The nurse realizes that further teaching is required when the patient makes which of the following statements? a. "HSV and HIV are caused by a virus and cannot be cured." b. "I should use protection during sex because any contact with another person's bodily fluids can transmit an STI." c. "I'm going to have gonorrhea for the rest of my life since there is no treatment for it." d. "I should make sure that I get checked for an STI before having sex with a new partner since symptoms of an STI can go unnoticed or be absent."

c. "I'm going to have gonorrhea for the rest of my life since there is no treatment for it." Rationale: Gonorrhea is a bacterial infection. Other bacterial infections include chlamydia, syphilis, and pelvic inflammatory disease (PID). All of these STIs can normally be treated with a full course of antibiotics.

The nurse is reviewing data received during handoff communication. Which client should the nurse expect to have hypermagnesemia? a. A client who has hypothyroidism and a magnesium level of 1.6 mEq/L b. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L c. A client who has renal failure, takes antacids and has a magnesium level of 2.9 mEq/L d. A client who has congestive heart failure, takes a diuretic and has a magnesium level of 2.3 mEq/L

c. A client who has renal failure, takes antacids and has a magnesium level of 2.9 mEq/L Rationale: A normal serum magnesium level is 1.5-2.5 mEq/L. Risk factors for the development of elevated serum levels of magnesium include kidney damage and antacid use.

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness

c. Numbness of the extremities rationale: Extremity numbness is associated with cobalamin deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia

As the primary nurse, you are educating the patient that was diagnosed with anemia oncertain dietary options that are best for her diagnoses. Select which options would be bestfor a person who is anemic? a. Cheese, chicken, apples b. Bread, lunch meat, soda c. Spinach, liver, legumes d. Coffee, peaches, strawberries

c. Spinach, liver, legumes Rationale: foods high in protein and iron are ideal for anemia. Spinach, liver and legumes are high in protein and iron.

Which evaluation finding would lead a nurse to expect hyperthermia to be experienced by a patient on a summer day? A. bradypnea B. Decreased respiration C. dry flushed skin D. Slow capillary refill

c. dry flushed skin rationale: Hyperthermia symptoms include dry, flushed skin, increased respirations, and tachycardia. The other options are inconsistent with hyperthermia

A student nurse in the Med-Surg unit is caring for a client with a blood pressure of 135/88. According to the classification of hypertension, what category should this blood pressure be classified? a. Normal b. Elevated c. Hypertension, stage 1 d. Hypertension, stage 2

c. hypertension stage 1 rationale: Hypertension stage 1 is SBP 130-139 mm Hg and DBP 80-89 mm Hg (page 681)

A 1st time mother informs the Nurse that she is concerned that her 2 y.o is continuously fondling his penis. She is concerned that he is in pain. What is the best response to the mom? a. The fondling is most likely due to growing pains. b. I'll ask the doctor to check for an infection. c. You really should distract the child from fondling his privates, as it could continue into adulthood. d..This is completely normal and typical in the age range.

D. This is completely normal and typical in the age range. Rationale: This is normal and expected behavior for this age group. Typically 1-3 y.o begin to "find" their privates.

case study: A 76 year old male presents to the ER with his caregiver for complaints of tightness in the chest that is not being relieved by his Albuterol inhaler. During the assessment the nurse noticed that he could barely speak to answer the assessment questions, and the lips were starting to turn blue. Upon listening to the lungs she noted wheezing. The caregiver stated that she had noticed more coughing and sneezing over the last few weeks, but thought he was just getting a cold. She stated ,"He hasn't had an attack this bad in years." - He loves to watch Family Feud with his family and play with his granddaughter's puppy who lives with him. They have only had him for a month and he's already fallen in love with him. Sometimes, the puppy falls asleep in the recliner with him after a long day. VITALS: 98.6 TEMP - 104 HR - 26 RESPIRATIONS - 108/63 BP - 89% SPO2 1) What is of most concern to the nurse from her assessment? A. Wheezing B. Lips turning blue C. Pulse of 104 D. 26 respirations 2. ) What medications and treatments can the nurse expect the doctor to order? A. Zosyn B. Ipratropium C. Oxygen D. Methylprednisolone E. Bronchodilator 3) What could have caused his recent asthma flare up? A. The rays that are being transmitted from the TV after hours of watching FamilyFeud. B. The smell from the granddaughter's shoes after school C. The new puppy (pet dander) D. His age is causing more flare up

1). b. lips turning blue rationale: The lips turning blue is a sign of hypoxia. Tissues in the body needenough oxygen to sustain bodily functions. Without proper oxygen, tissue deathcan occur. Of all of the above options, the absence of oxygen to tissues can killthe patient the fastest 2) b. ipratropium c. oxygen d. methylprednisolone e. bronchodilators rationale:Bronchodilators such as Albuterol is typically the 1st line of defense. Itwill help to make breathing easier by relaxing the muscles in the lungs and widening theairways. Ipratropium is an anticholinergic that dries out the body, decreasing secretionsand dilating the airway. Steroids such as methylprednisolone helps to reduce theinflammation caused in the lungs from an asthma attack. - Zosyn, which is a penicillinantibiotic, will not help in this situation. Oxygen therapy is a beneficial treatment inpeople experiencing a severe asthma attack. It can definitely increase the low spo2reading from 89% to a more therapeutic level. 3) c. the new puppy (pet dander) rationale: Asthma flare ups can be triggered by dust mites, cockroaches, pollen, mold,animal dander, rodents, allergies, air pollutants, other health conditions such asrespiratory infections, and physical activity. Weather, air temperature, strong emotions,medicines can also cause an asthma flare

Which are considered within normal range for a 55 y.o. female client? SATA. 1. Oral temperature of 98.2°F (36.8°C) 2. Apical pulse of 88 beats/min and regular 3. Respiratory rate of 30 breaths/min 4. Blood pressure of 116/78 mm Hg while in a sitting position 5. Oxygen saturation of 92%

1. Oral temperature of 98.2°F (36.8°C) 2. Apical pulse of 88 beats/min and regular 4. Blood pressure of 116/78 mm Hg while in a sitting position rationale: The client's temperature, pulse, and blood pressure are WNL for a 55-year-oldfemale. The client's respirations are mildly elevated, and the oxygen saturation level isdecreased. A normal respiratory rate for a female client in this age group would be 12 to 20breaths/min, and oxygen saturation level should be >95%

Which nursing interventions help prevent heat loss in newborns? SATA. 1. The nurse keeps the newborn covered in warm blankets. 2. The nurse keeps the newborn under the radiant warmer. 3. The nurse places the newborn on the mother's chest. 4. The nurse measures the newborn's temperature regularly. 5. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

1. The nurse keeps the newborn covered in warm blankets. 2. The nurse keeps the newborn under the radiant warmer. 3. The nurse places the newborn on the mother's chest. rationale: Newborns have impaired thermoregulation due to immaturity of the bodysystems. The nurse performs interventions to prevent heat loss in the newborn. Covering thenewborn with warm blankets helps prevent heat loss. The nurse keeps the newborn underthe radiant warmer to help maintain the body temperature. Placing the newborn on themother's chest helps promote warmth through skin-to-skin contact. Regular measurement oftemperature may help in assessing any significant change; however, it may not help preventheat loss. Ensuring that the newborn is fed well does not help prevent heat loss

An 85 year old female is taken to the emergency department by having frequent episodes of respiratory distress. The patient has reportedly moved in with her daughter and granddaughter who are both active smokers inside the home. The patient reports feeling fever, shivering and a productive cough that has lasted 5 days and also suffering from a history of asthma. She notices that her symptoms get worse when she lays down flat on the bed (supine) but she can not seem to get comfortable in any other position nor does she have the energy to get out of bed due to feeling restless. Due to her fear of hospitals and vaccines, the patient has not had a pneumonia vaccination in the last 15 years. Upon assessing the patient, while auscultating the lung fields, the nurse notices decreased breath sounds and asymmetrical chest expansion. 1. What finding is a priority for the nurse to report to the healthcare provider? a. Fever b. Productive cough c. Decreased breath sounds d. Asymmetrical chest expansion 2. What education can the nurse provide the patient's family regarding upon discharging the patient back home? Select all that apply a. Elevating the head of the bed b. Smoking cessation c. Use of incentive spirometer d. Letting the patient remind supine since she is comfortable. 3. Which are the greatest risk factors for this patient? a. Being an 85 year old female with a history of asthma b. Having symptoms for 5 days c. Being in the supine position all day d. Fear of hospitals and vaccines

1. d. asymmetrical chest expansion Rationale: Asymmetrical chest expansion could indicate that the patient has pneumonia. 2. a. Elevating the head of the bed b. Smoking cessation c. Use of incentive spirometer rationale: Elevating the head of the bed would help to encourage chest expansion, smoking cessation would prevent second hand smoke to the patient to improve her breathing, and use of incentive spirometer to encourage the patient to have deep and full respirations 3. a. Being an 85 year old female with a history of asthma rationale: Being an 85 year-old female with a history of asthma because asthma is a common cause for pneumonia.

A client diagnosed with acute leukemia states "I am much less likely to get an infection because my white blood cell count is so high." Which is the most appropriate response by the nurse? A. "Even though you have many white blood cells, they are too immature to fight infection." B. "For now your risk is low, but chemotherapy will greatly increase your risk for infection." C. "These white blood cells are too old to adequately fight infection." D. "Red blood cells fight infections. You are still at risk for infection."

A. "Even though you have many white blood cells, they are too immature to fight infection." Rationale: For clients that know WBCs are supposed to fight off infections it is important to educate them that during leukemic WBCs are too immature to fight infection.

The nurse is assessing a newborn. She knows that these risk factors predisposethe newborn to heat loss. (select all that apply) A. Blood vessels are close to the surface B. Thin skin C. Newborns have more body mass D. Because the are kicking and screaming E. Newborns have less subcutaneous fat (White Fat) F. small body size

A. Blood vessels are close to the surface B. Thin skin E. Newborns have less subcutaneous fat (White Fat) F. small body size rationale: Heat loss in newborns is 4 times greater than adults. Because the newborn is still in the same flexed position as they were while in the amniotic fluid, this makes it hard to warm the baby because you cannot get to all their skin

A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which findings is the nurse most likely to observe in this client? Select all that apply: a. Excessive thirst b. Weight gain c. Constipation d. Excessive hunger e. Urine retention f. Frequent, high-volume urination

A. Excessive thirst D. Excessive hunger F. Frequent, high-volume urination RATIONALE: Classic signs of diabetes mellitus include polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (excessive urination). Because the body is starving from the lack of glucose the cells are using for energy, the patient has weight loss, not weight gain. Clients with diabetes mellitus usually don't present with constipation. Urine retention is only a problem if the patient has another renal-related condition

What would the nurse expect to find in the assessment of a patient with peripheral artery disease? Select all that apply A. Loss of hair on legs, feet, or toes B. Visible varicose veins C. Ulcers on tips of toes of foot that look round and smooth that appear "punched out" D. Bronze - brown pigmentation of the skin on the legs E. Cool temperature of the legs

A. Loss of hair on legs, feet, or toes C. Ulcers on tips of toes of foot that look round and smooth that appear "punched out" E. Cool temperature of the legs rationale: - Loss of hair on lower extremities, rounded "punched out" ulcers, and cool temperature of legs are all characteristics of peripheral artery disease. Visible varicose veins and bronze- brown pigmentation are characteristics of peripheral venous disease.

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct. A. Providing oxygen B. Assessing vital signs C. Obtaining a 12-lead EKG D. Drawing blood for cardiac enzymes E. Auscultating heart sounds F. Administering nitroglycerin

A. providing oxygen B. assessing vital signs C. obtaining a 12-lead EKG D. drawing blood for cardiac enzymes E. auscultating heart signs F. administering nitroglycerin rationale: - The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital sign, obtain a 12-lead EKG, and auscultate heart signs to determine rhythm changes r/t cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enzymes. Changes in the levels of these enzymes (including troponin, creatine, kinase, and myoglobin) can indicate damage to the heart. Nitroglycerine is administered to promote coronary vasodilation.

When administering insulin, what is the typical insulin to carb ratio? a. 1 unit of insulin per 10 carbohydrates b. 1 unit of insulin per 12-15 carbohydrates c. 1 unit of insulin per 19-21 carbohydrates d. 1 unit of insulin per 25 carbohydrates

B. 1 unit of insulin per 12-15 carbohydrates RATIONALE: When administering insulin, the general rule of thumb is that one unit of insulin should be given for every 12-15 carbs. This can vary based on the individual patients needs but 12-15 is the typical range.

A patient with diabetes is admitted due to severe hyperglycemia. Upon assessment, the patient lists medications that they are currently taking. What medication should the nurse educate the patient on avoiding or changing? a. Novolin b. Furosemide c. Tylenol d. Metformin

B. Furosemide RATIONALE: Loop diuretics such as furosemide, interferes with the effectiveness of insulins in the body and can increase blood sugar. Novolin is a common short acting insulin commonly given prescribed to diabetic patients. Tylenol has no contraindications in diabetic patients. Metformin is a common diabetic drug to help lower blood sugar and increase effectiveness of insulin.

A pregnant woman presented to the clinic for her first obstetric checkup appointment. She has a 10-year-old daughter and a 9-year-old son born at full term and had two other pregnancios that terminated at 4 weeks and 6 weeks. What are the patient gravida and para? a. gravida 4 para 3. B. grávida 5 para 2 C. gravida 4 para 2 D. gravida 5 para 3

B. Gravida 5 para 2 Rationale: (pt slide 44) Gravida Term births 38-42 weeks, Preterm births 20-38 weeks, Abortions (less than 20 weeks), Living children. Gravida: refers to a woman who is or has been pregnant regardless of the duration of pregnancy. She has had 5 pregnancies, including the current one (gravida 5). She had two pregnancies that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion, which is not included in the gravida-para classification.

A 36 weeks pregnant patient presented to the ER with possible Abruption Placenta ( Separation of a normally implanted placenta before the fetus is born ) . As a nurse , what are some signs and symptoms of Abruption Placenta that you are aware of ? ( Select all that apply ) A. Decrease in fundal height B. Hard , board - like abdomen C. Low uterine baseline tone on electronic monitoring strip D. Persistent abdominal pain E. Tender uterus F. Fetal distress G. Slight Vaginal bleeding

B. Hard , board - like abdomen D. Persistent abdominal pain E. Tender uterus F. Fetal distress G. Slight Vaginal bleeding Rationale: ( ppt slide 38 , an increase in fundal height in noted , and a high uterine tone on electronic monitoring strip , hard , board like abdomen , persistent abdominal pain , systemic signs of early hemorrhage ( tachycardia , failing blood pressure , restlessness ) , persistent late deceleration in fetal heart rate , vaginal bleeding can be slight or absent .

When administering insulin to a patient, which insulin is the deadliest? a. Glargine (Lantus) b. Humalog (Lispro) c. Humulin R d. Levemir (Detemir)

B. Humalog (Lispro) RATIONALE: HUMALOG (LISPRO) is a rapid acting insulin and considered the deadliest insulin due to it having a fast onset of 15 mins. Glargine (Lantus) and Levemir (Detemir) are long-acting insulins which has an onset of 2 hours. Humulin is an intermediate insulin which has an onset of 2 hours.

a woman is 17 weeks pregnant and is scheduled for a alpha-fetoprotein test. She asks the nurse, " What is this testing for?" The nurse states this test can predict which of the following? a. gender of fetus b. cardiac murmurs c. chromosomal anomalies d. fetal blood type

C. Chromosomal anomalies Rationale: AFP assessment is performed on maternal serum or amniotic fluid to identify open body wall defects (neural tube defects) and chromosomal anomalies (trisomy 21.)

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) happens mainly in type 2 diabetes and presents with what type of signs and symptoms? Select all that apply. a. Kussmal respirations b. Ketones that are present in urine c. Mental status changes d. Extreme dehydration e. High blood glucose over 600 High blood glucose greater than 250

C. Mental status changes D. Extreme dehydration E. High glucose over 600 RATIONALE: The other options are not related to HHNS. They are signs and symptoms of DKA (diabetic ketoacidosis)

Which mother is more at risk for Gestational diabetes? a. The mother who walks 30 mins a day b. The mother is 23 years old c. The mother has a BMI of 40. d. The mother who is a vegetarian

C. The mother has a BMI of 40. RATIONALE: pg 553 McKinney (Risk Factors for GDM: Overweight body mass Index Obese- 30 to 39, Morbidly obese >40, Maternal age 25 years old)

Francis is receiving radiation therapy for head and neck cancer. Which precautions would be the most important to teach francis? a. to assist in preventing fatigue, pace your leisure activities b. dont use headsets and/or headphones until your hair grows back C. During treatment, avoid eating red meat. D. Visit your dentist biannually for the rest of your life.

D. Visit your dentist biannually for the rest of your life. Rationale: Radiation therapy that is directed in or around the oral cavity has a variety of actions that increase the risk for cavities and tooth decay. The salivary glands may be affected, which can change the composition of a person's saliva and could cause dry mouth. As a result, bacteria could grow rapidly which contributes to cavity formation. The radiation can also interfere with the enamel of the teeth and damage the living cells of the teeth

The nurse is caring for a client who is to receive a blood transfusion. How will the nurse respond when the client expresses fear that acquired immunodeficiency syndrome (AIDS) may be acquired as a result of the blood transfusion? A. "The blood is treated with radiation to kill the virus." B. "The ability to directly identify human immunodeficiency virus [HIV] has eliminated this concern." C. "Consideration should be given to donating your own blood for transfusion." D. "Screening for the human immunodeficiency virus [HIV] antibodies has minimized this risk."

D. "Screening for the human immunodeficiency virus [HIV] antibodies has minimized risk." rationale: - Although blood is screened for the antibodies, there is a period between the time a potential donor is infected and the time when antibodies are detectable; there is still a risk, but it is minimal. There is no current method of destroying the virus in a blood transfusion. The screening tests involve identification of the antibody, not the virus itself; the virus can be identified by the polymerase chain reaction test but is not part of the routine screening. Although many people consider autotransfusion for elective procedure, a trauma victim does not have an option.

The nurse should give further education to the father of a newborn baby when heperforms this action A. Swaddles the newborn B. Places the baby in a radiant warmer C. Feeding the newborn D. Places the incubator in front of the window so the baby can get some fresh air

D. Places the incubator in front of the window so the baby can get some fresh air rationale: Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. Placing cribs and incubators away from windows and outside walls minimizes this type of heat loss. Use of radiant warmer transfers heat from the warmer to the cooler infant.

Which action would the nurse include in the post-procedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram? A. Elevate the foot of the bed. B. Place in the high-Fowler position. C. Perform urinary catheter care every 12 hours. D. Check pedal pulses every 15 minutes post-procedure.

D. check pedal pulses every 15 minuets post-procedure rationale: - Because of the risk for bleeding or obstruction of femoral artery flow after femoral angiograms, pedal pulses are checked every 15 minutes for the first hour post-procedure. Client with peripheral arterial disease should keep the feet slightly lower than the heart to promote perfusion. Urinary catheters are not typically needed after a femoral angiogram procedure. Keeping the client in the high fowler position is unsafe; this position increases pressure in the groin area, which can dislodge clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.

A patient is being treated with chemotherapy and radiation for stage 4 breast cancer. She has been prescribed toremifene (Fareston) for the chemo and teletherapy for the radiation. What side effects of both treatments will the nurse need to be aware of? SATA a. Bone marrow suppression & GI disturbances b. Cyanosis & increased platelets c. Hair growth & increased appetite d. Fatigue & nausea e. Rash & itching

a. Bone marrow suppression & GI disturbances d. Fatigue & nausea e. Rash & itching Rationale: chemo and teletherapy can cause bone marrow suppression, GI disturbances such as nausea, vomiting, diarrhea, constipation, fatigue, rash, and itching. Chemo drugs can cause hair to fall out and a decrease in platelets as well as loss of appetite. Cyanosis would not occur from chemo drugs or teletherapy radiation.

A pregnant patient with a blood pressure of 154/94 mm Hg, 3+ proteinuria, and edema of the hands and face is diagnosed with severe preeclampsia. Which other clinical findings support this diagnosis? SATA a. Headache b. Constipation c. Abdominal pain d. Vaginal bleeding e. Blurred vision f. Pruritus

a. Headache C. Abdominal pain E. Blurred vision Rationale: Headache in severe preeclampsia is related to cerebral edema. Abdominal pain in severe preeclampsia is related to decreased circulating blood volume and generalized edema. Blurred vision in severe preeclampsia is related to retinal edema.

A nurse is planning care for a client undergoing chemotherapy and is on neutropenicprecautions. Which of the following interventions should be included in the plan of care? a. Remove plants from the room b. To eat fresh fruits c. Have a client where a mask when leaving the room d. To be around a large group of people e. Have client specific equipment remain in room

a. Remove plants from the room c. Have a client where a mask when leaving the room e. Have client specific equipment remain in room Rationale: Neutropenic precautions include the client not having contact with flowers and plants due to the presence of surface infectious agents in the water and soil. Neutropenic precautions include having the client wear a mask when leaving the room to reduce the incidence of infection. Neutropenic precautions include having equipment available that is only for use in caring for the client to reduce the incidence of infection

A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange? a. Sitting up at the bedside in a chair and leaning slightly forward b. Resting in bed with the head elevated to 45 to 60 degrees c. In the Trendelenburg's position with several pillows behind the head d. Resting in bed in high-Fowler's position with the knees flexed

a. Sitting up at the bedside in a chair and leaning slightly forward rationale: Patients with COPD improve the mechanics of breathing by sitting up in the patient wasconfined to bed, but sitting in a chair allows better ventilation. The Trendelenburg'sposition or sitting upright in bed with the knees flexed would decrease the patient 'sability to ventilate well

What does frequent, involuntary spasms of the hand and wrist when wearing a blood pressure cuff over systolic blood pressure indicate? a. Trousseau's Sign b. Conn's Syndrome c. Cushing's Syndrome d. SIADH

a. Trousseau's sign Rationale: When the calcium level reaches 1.75-2.25, the hand will go into a characteristic position of Trousseau's Syndrome when the blood pressure cuff over the systolic blood pressure is inflated and left for 2-3 minutes.

A patient is seen in an emergency department with postural hypotension, a normal pulse rate, diaphoresis, and muscle weakness. This patient is said to be experiencing symptoms consistent to A. Heat exhaustion B. Heat stroke C. Hyperthermia D. Hypothermia

a. heat exhaustion rationale: The patient shows indications of heat exhaustion (a fluid volume deficit). The client wouldn't be sweating and would have a higher pulse if they were suffering from heatstroke. Heatstroke and cramps are connected. The client is not displaying symptoms of heatstroke. Shivering, memory loss, or cyanosis are indicators of hypothermia or distorted vision, dizziness, rapid heartbeat or breathing which is associated with hyperthermia

In the ED, a patient is noticed shivering and looking cyanotic. When he is first admitted, the nurse notices that he is confused, lethargic, and unable to speak coherently; his utterances are slow or incoherent, and words flow together. This person is A. Hypothermic B. Hyperthermic C. Hypotensive D. Hypertensive

a. hypothermic rationale: Signs and symptoms of hypothermia include shivering, exhaustion or feeling very tired, confusion, fumbling hands, memory loss, slurred speech, and drowsiness. Other options are wrong

An 85- year- old patient arrived in the ER department. Which assessment findings by the nurse are expected for this age group. Select all that apply. a. Increase collagen and scarring, decrease elastin b. Fast recovery from activity c. Arterial stiffening d. Number of pacemakers cells increases

a. increase collagen and scarring, decrease elastin c. arterial stiffening rationale: these are due to the combined effect of aging process, disease, lipid accumulation and lifetime health behaviors. Recovery from activity is slow and the number of pacemaker cells decreases. (Page 660)

The nurse is caring for a client with an electrolyte imbalance. Which should the nurse consider as contributing to this client's health problem? Select all that apply. a. Vomiting b. Constipation c. Medications d. Imaging studies e. Cosmetic procedures

a. vomiting c. medications Rationale: An electrolyte imbalance is an abnormality in the concentration of electrolytes in the body. Many factors can affect electrolyte imbalances such as vomiting and certain medications.

When the nurse is administering whole blood and Lasix to a patient. In what order should the patient receive them? a. Whole blood then Lasix b. Administer them at the same time c. Never administer Lasix if the patient is receiving whole blood d. None of the above

a. whole blood then lasix Rationale: Lasix is used before of after giving whole blood to help prevent circulatory overload.

A nurse is assessing patients at a health clinic. What clients should receive further testing for type 2 diabetes? (Select all that apply) a. 54-year-old African American male. b. 31-year-old female who has had gestational diabetes with 2 pregnancies. c. 44-year-old female who works at a desk and gets little exercise. d. 39-year-old male who injured his head in a fall due to blurred vision. e. 29-year-old with a BMI of 28.

all correct RATIONALE: African Americans are at increased risk of having type 2 diabetes especially if over the age of 45. Having a history of gestational diabetes as well as a giving birth to neonates weighing 9 pounds or more increases chances of developing diabetes. Living a sedentary lifestyle increases chances of developing or having diabetes. Blurred vision can occur when blood sugar increases rapidly over a short time, a symptom that is common among diabetes. Any BMI that is over 25 increases the risk for type 2 diabetes and any BMI over 30 significantly increases the risk of developing type 2 diabetes.

A nurse is educating a female patient, who has just started birth control for the first time, on some things that could decrease the effectiveness of her BC. Select all that apply. a. Alcohol b. Abx c. Warfarin d. Beta blockers e. HTN drugs

b. Abx c. Warfarin d. Beta blockers Rationale: Several drugs can decrease the effectiveness of birth controls include: abx, penicillin, rifampin, beta blockers, warfarin, antidepressants, vitamins, anticonvulsants, theophylline, and certain anti-diabetic drugs, It is important for the nurse to educate their patients.

A mother just delivered her baby at 28 weeks, the nurse suspects that the baby is experiencing cold stress. What are the hazards of cold stress? a. Hyperglycemia b. Increased oxygen need c. Decreased surfactant production d. Metabolic alkalosis e. Jaundice f. Respiratory distress

b. Increased oxygen need c. Decreased surfactant production e. Jaundice f. Respiratory distress rationale: hazards of cold stress include: increased oxygen need, decreased surfactant production, respiratory distress, hypoglycemia, metabolic acidosis, jaundice

Which antihypertensive drug would the nurse expect to give the patient with COPD, normal potassium level, and whose heart rate needs to be lowered? A. Beta blockers B. Calcium Channel Blockers C. Vasodilators D. Potassium sparing diuretics

b. calcium channel blockers Rationale: A is incorrect because you should not give beta blockers to patients with COPD as it blocks the beta 2 receptors. B is correct because calcium channel blockers lower heart rate and blood pressure and can be given to patients with COPD and it does not affect potassium levels at all. C is incorrect because this patient needs their heart rate lowered as well and vasodilators do not lower your heart rate, only your blood pressure. D is incorrect because the patient has a normal potassium level so they do not need to spare potassium as this could cause an elevation in potassium.

The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? a. Peripheral edema b. Crackles ½ way up the lung fields c. Serum osmolarity of 294 mOsm/kg d. Urine output of 1300 mL over 24 hours

b. crackles 1/2 way up the lung fields Rationale: When a hyperosmotic IV solution such as 3% saline is infused, the interstitial fluid is pulled into the circulation in an attempt to dilute the blood. As a result, the plasma volume expands. The nurse needs to evaluate the client for fluid volume excess and symptoms of heart failure including crackles.

What should the nurse include in teaching a client who has a history of coronary artery disease (CAD) on Risk Factors for CAD that are modifiable or controllable? a. Women over 55 b. High serum lipid, obesity, inactivity, smoking c. Gender, diabetes, Tobacco Use d. Stress, family history, substance abuse

b. high serum lipid, obesity, inactivity, smoking rationale: The nurse should educate the client regarding these factors. (Page 701) other choices are mix of modifiable and nonmodifiable risk factors for CAD

A 64 year old man that farms for a living presents to the Emergency Department with a temperature of 104.2 F, what interventions and medications would you expect? SATA a. Antipyretics b. Ice packs c. Antibiotics d. Cooling blanket

b. ice packs d. colling blankets rationale: Antipyretics and antibiotics are ineffective in a heat stroke

A nurse is caring for a 3 year old that has a temperature of 102.1 , the nurse would be concerned by which of the following statements made by the mother? a. "I have been giving my daughter ibuprofen to help the fever." b. "I am using ice packs and a fan." c. "I am giving my daughter aspirin to help the fever." d. "I am giving my child pedialyte to help with dehydration that may be accompanied by the fever."

c. "I am giving my daughter aspirin to help the fever." rationale: infants and children should not receive aspirin due to Reye's Syndrome which is anacute condition that causes swelling in the brain and liver.

A nurse is teaching high school students about sexually-transmitted infections. Which statement made shows the class has been effective? a. "STIs mostly affect people with a lower socioeconomic status and less education." b. "Signs and symptoms of an STI are always obvious." c. "STIs are most common in adolescents and young adults" d. "I won't get an STI because I take oral contraceptives."

c. "STIs are most common in adolescents and young adults" Rationale: STIs are most common in adolescents and young adults. STIs affect people of all economic statuses and backgrounds. Signs and symptoms of STIs can sometimes be unnoticed or dormant until something makes them flare up. While oral contraceptives will help to reduce chances of an unwanted pregnancy, they are not effective against protection from an STI.

What fluid would you expect to be given to a patient that is hyponatremic and is experiencing hypotension? a. LR b. D10W c. 0.9% NS d. D5W

c. 0.9 % NS Rationale: 0.9% NS is indicated for patients who are hyponatremic and experiencing hypotension because it replaces the ECF.

Which patient would the nurse expect to give a vasodilator to? A. 45-year-old male on Viagra B. 55-year-old female with blood pressure of 110/72 C. 60-year-old male who is already on another hypertensive D. 75-year-old obese female with no history of hypertension

c. 60-year-old male who is already on another hypertensive rationale: A is incorrect because vasodilators should not be given to patients who are also on Viagra. B is incorrect because you do not want to give an antihypertensive drug to a patient with a low blood pressure. C is correct because nitroprusside is an antihypertensive drug and can be given in combination with other antihypertensive drugs. D is incorrect because this medication treats hypertension, not hypotension and could cause the blood pressure to become too low if given.

A nurse is planning care for a client who has a platelet count of 5,000. Which of thefollowing interventions should the nurse include in the plan of care? a. Place the client in a private room b. Administer epoetin alfa as prescribed c. Apply prolonged pressure to puncture site after blood sampling d. Place the client on neutropenic precautions

c. Apply prolonged pressure to puncture site after blood sampling Rationale: PLT count ranges from 150,000-400,000. In the question, the patient hasan extremely low platelet count which indicates he has an increased risk for bleeding.

A 50 year old male presents to his primary care physician with concern regarding his type 1 diabetes mellitus and it's affect on his sexual performance. He admits to neglecting to follow his prescribed regimen. What can his poorly controlled diabetes put him at a greater risk for? a. STI's b. Premature Ejaculation c. Erectile dysfunction d. HIV

c. Erectile dysfunction Rationale: Diabetes mellitus is a significant risk factor for erectile dysfunction. Retarded or premature ejaculation is less likely, since these problems do not have vascular etiology. Diabetes does not have an appreciably increased risk of developing STIs, though persons with diabetes do have an increased susceptibility to infections of all kinds.

While caring for a 72 year old man in the ER. He reports that he was working in the yard all day in temperatures of 100 degrees. The nurse know that a consequence to hyperthermia can be A. Liver disease B. Frostbite C. Cardiovascular collapse D. Hypertension

c. cardiovascular collapse rationale: Cardiovascular collapse is when the body temperature increases which leads to sweating, loss of sodium, dehydration which leads to hypotension, then tachycardia, decreased cardiac output, decreased tissue perfusion, coagulation in the microcirculation leading to blood clots, then cardiovascular collapse which is when the heart stops.

Which of the following is a life-threatening condition that complicates approximately 10% of pregnancies in women with severe hypertension? A. Chronic hypertension B. Preeclampsia C. Eclampsia D. HELLP syndrome

d. HELLP syndrome

An elderly couple who have just arrived at an assisted living facility have not been able to be placed in a shared room. Another nurse at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse respond to this individual's assertion? a. Resources have shown that sexual activity changes with age but that it actually becomes more frequent. b. That is true, but it's important for us to give them the accommodations they need in order to resume this part of their relationship. c. That is true, but it's important for them to have one another in the new place so their adjustment may be easier. d. That is not always the case. It is fairly common that with older age, sexual activity increases, even though sex hormones are reduced.

d. That is not always the case. It is fairly common that with older age, sexual activity increases, even though sex hormones are reduced. Rationale: Sexual activity need not be hindered by age. There's no evidence, however, that it becomes increasingly frequent and late adulthood.

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? a. Restrict the client's intake of sodium b. Administer a diuretic c. Monitor the serum osmolarity d. Encourage fluid intake

d. encourage fluid intake Rationale: When caring for an older adult with hypernatremia, the nurse first encourages the client to take more fluid. Encouraging fluids in the older adult is important to prevent dehydration with resulting concentrated sodium levels.

The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder? a. Calcium b. Magnesium c. Phosphorous d. Potassium

d. potassium Rationale: Because the kidneys are the principal organs involved in the elimination of potassium, renal failure