HR 222 Final exam review 100Qs

A client who has received a poor prognosis tells the nurse, "I have not been to church in decades even though I was raised catholic. Can you arrange for a priest to come see me?" What is the nurse's best response?

"We will try to get in touch with one and ask him to come see you"

A patient experienced an episode of vision loss and right sided weakness that lasted 4 hours before totally resolving. What information should the nurse provide to this patient?

"While these symptoms have resolved, your risk for stroke is higher"

Addisons crisis, what statement supports the need for more teaching?

"I had the flu earlier this week, so I couldn't take hydrocortisone"

A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statement by the client would indicate that client teaching has been effective?

"I need to call my doctor to discuss my steroid needs before I have dental work"

*SATA* Contraindications for thrombolytic therapy?

*ALL POSSIBLE CONTRAINDICATIONS* A. Prior intracranial hemorrhage, b. known structural cerebral vascular lesions (AV malformation), c. known malignant intracranial neoplasm, d. ischemic stroke within 3 months, E. suspected aortic dissection, F. its been over 3 hours, active bleeding, G. significant closed-head or facial trauma, H. excessive bleeding, HTN, I. use of anticoagulants, pregnancy, J. peptic ulcer, surgeries. *RECENT intracranial patho, current anticoagulant therapy, 3 hours since symptom onset*

The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1.Hypotension 2.Weak pedal pulses 3.Redness at the pin sites 4.Drainage at the pin sites

2.Weak pedal pulses

You are caring for a client with multiple injuries sustained during a head on car collision. Which assessment finding takes priority?

A deviated trachea

7.The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A)"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B)"The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C)"Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." D)"The sudden, severe headache increases muscle tone and can cause further nerve damage."

A)"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

29. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse do first?

A. Auscultate the breath sounds

20. A patient diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status with the nurse attribute to the patients metastatic brain disease?

A. Personality changes

30. A 53-year-old patient is scheduled for an annual physical examination. The nurse will plan to teach the patient about the purpose of

A. Prostate Specific Antigen (PSA) testing

*SATA* The nurse is planning care for the client with systemic lupus erythematosus and chronic disseminated intravascular coagulation. Which assessment findings require immediate follow up? A. Petechiae on lower arms, B. oozing from intravenous site, C. altered mental state, D. abdominal distention

ABCD

During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client's multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom). A. Assess the client's skin and circulation for impairment related to the restrains. B. Assign unlicensed assistive personnel to remove restrains and remain with client. C. Evaluate the client's mentation to determine need to continue the restrains. D. Contact the client's surgeon and primary healthcare provider.

ACBD

The nurse is preparing to administer medication to a client with acute hemorrhagic stroke. Which prescription requires immediate follow up by the nurse?

Administer oral platelet inhibitor medication

Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic?

Administering meperidine (Demerol)

What to do first for bright red blood drainage after cardiac cath?

Apply pressure to stop bleeding

Patient with acute CAD what is the priority intervention?

Apply supplemental oxygen

A client in the ED has symptoms of anxiety, a racing heart, and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse?

Assess the clients vital signs and oxygen saturation

A triage nurse in a busy emergency department assesses a patient who complains of 7/10 abdominal pain and states, I had a temperature of 103.9 F at home. The nurses first action should be to

Assess the patients current vital signs

A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A)Decrease SA node conduction B)Control ventricular heart rate C)Improve oxygenation D)Maintain anticoagulation

B)Control ventricular heart rate

*REPEATED Question* What med is used to treat spasticity?

Baclofen

Patient with MS had an advanced directive: how should the nurse respond?

Bring it up every admission so they know they have it

10.A 29-year-old patient in the outpatient clinic will be scheduled for blood cortisol testing. Which instruction will the nurse provide? A. "Avoid adding any salt to your foods for 24 hours before the test." B. "You will need to lie down for 30 minutes before the blood is drawn." C. "Come to the laboratory to have the blood drawn early in the morning." D. "Do not have anything to eat or drink before the blood test is obtained."

C. "Come to the laboratory to have the blood drawn early in the morning."

28. Which question will provide the most useful information to a nurse who is interviewing a patient about a possible thyroid disorder? A. "What methods do you use to help cope with stress?" B. "Have you experienced any blurring or double vision?" C. "Have you had a recent unplanned weight gain or loss?" D. "Do you have to get up at night to empty your bladder?"

C. "Have you had a recent unplanned weight gain or loss?"

14.When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including SIADH. What nursing interventions would the nurse most likely initiate if the patient developed SIADH? a.Transfuion of platelets b.Transfusion of FFP C. Fluid restriction D. Electrolyte restriction

C. Fluid restriction

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?

Cardiac Rhythm

*?* Findings that require immediate follow up by nurse for patient with a concussion?

Change in mental status?

34. Which finding from the nurses physical assessment of a 42 year-old male patient should be reported to the HCP?

Clear discharge is present at the penile meatus

27. A patient who was diagnosed with Parkinsons disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patients medication regimen? A) The patient is in a honeymoon period when adverse effects of levodopa-carbidopa are not yet evident. B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. C) The patients temporary improvement in status is likely unrelated to levodopa-carbidopa. D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

26. What should the nurse suspect when hourly assessment of urine output on a post craniotomy patient exhibits a urine output from a catheter of 1,500 mL for 2 consecutive hours? A.Cushing's syndrome B.Syndrome of inappropriate antidiuretic hormone (SIADH) C.Adrenal crisis D. Diabetes insipidus

D. Diabetes insipidus

What drug is expected to reduce edema surrounding a brain tumor?

Dexamethasone

Common side effect of Levodopa-carbiopa (Simenet)?

Dyskinesia

Unable to pee, PSA level 12, what condition is suspected?

Enlarged prostate

A client with a SCI says he has difficulty recognizing the symptoms of an UTI. Which symptom is an early sign of UTI in a client with SCI?

Fever and change in urine clarity

Apply what equipment first to the patient in cardiac arrest?

Heart monitor

A 55-year-old patient with ESKD is scheduled to receive to a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication?

Hemoglobin level 13 g/dL

What electrolyte disturbance follows thyroid surgery?

Hypocalcemia

Clinical manifestations of autonomic dysreflexia?

Increase of BP, Altered HR (reflex bradycardia), blurred vision, anxiety, flushing and sweating (above level of injury), headache

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)?

Increased T4 level

Which assessment finding indicates to the nurse that vasopressin has been effective?

Increased urine specific gravity

Which information will the nurse include when teaching a 50-year-old male patient about somatropin (Genotropin)?

Inject the medication subcutaneously every day

Started on Pradaxa, what information will you provide to the client?

It is important to not crush, chew, or open capsules of Pradaxa or It helps blood clots from forming in the presence of afib

The administration of narcotics to a client with a traumatic brain injury may have which effect?

It may mask neurological changes in the client

*SATA* What finding is the greatest concern for a patient following cardiac surgery? JVD, muffled heart sounds, hypotension.

JVD muffled heart sounds hypotension.

What diagnostic test is contraindicated for a patient with increased ICP?

Lumbar puncture

What is the priority outcome for Addisons disease?

Maintenance of medication compliance

8.A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?

Meningitis

The most appropriate for UAP for morning care?

Nothing that is education, assessment, and teaching

The most appropriate for UAP for morning care? *REPEATS*

Nothing that is education, assessment, and teaching

The nurse is caring for a patient with ICP. The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion". What would be an expected outcome that the nurse would document for this diagnosis?

Obeys commands with appropriate motor responses

During the primary assessment of a victim of a motor vehicle collision the nurse demonstrates that the patient is breathing and has an obstructed airway. Which action should the nurse take next?

Observe the patients respiratory effort

A patient recovering from heart surgery develops pericarditis and complains of a 6 out of 10 chest pain with deep breathing. Which PRN medication will be the most appropriate for the nurse to give?

Oral ibuprofen (Motrin) 600 mg

What medication will halt a seizure?

Phenobarbital or Diazepam

What medication do you give propholatically for seizures prevention?

Phenytoin

What finding indicates complication whiles assessing pin insertion site?

Pin moves slightly at insertion site

What is performed first for Autonomic Dysreflexia?

Place in fowlers position

33. A 42-year-old patient admitted with AKI due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first?

Place the patient on a cardiac monitor

Well recognized diagnosis sign of meningitis?

Positive Brudzinski's Sign

Older adult with electrolyte imbalance: What lab value is priority?

Potassium (K+)

A client is admitted to the hospital with an exacerbation of MS after a MRI revealed progressive demyelination. The nurse should assess for what symptom?

Progressive weakness of the extremities

A client with a T2-T3 SCI suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first?

Raise the head of the bed.

What finding for a patients EKG requires immediate investigation?

ST segment elevation

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider?

Serum potassium level 3.0 mEq/L after 1 week of therapy

*REPEATED QUESTION* A patient with increased ICP has mannitol prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? The LOC improves

The LOC improves

A patient with increased ICP has mannitol prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects?

The LOC improves

Which client to assess first with a new admit coming?

The new admit

Teach parents of a child with enuresis that is taking desmopressin acetate is given for what reason?

This medication will reduce bedwetting by reducing the amount of urine produced during the night.

Symptoms to monitor for response to Synthroid?

Thyroid function

Most important equipment at bedside post thyroidectomy?

Tracheostomy tray

During dialysis, the nurse observes that the flow of dialysate stops before all the solution has drained out. The nurse should:

Turn the client from side to side

A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse explains that the client may experience which disadvantage?

Urine drains from it continuously

What symptom to assess for post peritoneal dialysis?

Weight loss

A patient with suspected Parkinson's disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?

When the patient is resting

After receiving report who does the nurse assess first?

a pt reporting SOB and dyspnea

Pt best assigned to novice nurse

a pt with anemia who reports sob

22. Which patient will the nurse plan on teaching about the Gardasil vaccine?

a. A 24-year-old female who has not been sexually active

15. What medication would be prescribed to a patient to treat spasticity? a. Baclofen b. Terazosin c. Tamsulosin d. Doxazosin

a. Baclofen

23. A 19-year-old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not sought treatment until now because "the warts are so disgusting." Which nursing diagnosis is most appropriate?

a. Disturbed body image related to feelings about the genital warts

31. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

a. Give the scheduled aspirin and lipid-lowering medication.

21. A 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert a urinary retention catheter. b. Schedule an intravenous pyelogram (IVP). c. Draw blood for a serum creatinine level. d. Administer lorazepam (Ativan) 0.5 mg PO.

a. Insert a urinary retention catheter.

25. What is the antidote for Heparin? a. Protamine Sulfate B. Vitamin K C. Epinephrine D. Narcan

a. Protamine Sulfate

16. The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?

a. The client's activities immediately prior to the seizure.

6.A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient? a. promote rest to decrease myocardial oxygen demand b. teach the patient about the need for anticoagulant therapy c. teach the patient to use sublingual nitroglycerin for chest pain d. raise the head of the bed 60 degrees to decrease venous return

a. promote rest to decrease myocardial oxygen demand

18. A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first?

a.Electrocardiogram (ECG)

17. Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider?

a.The patient has seen clots in the urine.

24. The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patients nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours d. Apply cold packs intermittently to face.

b. Insert nasogastric tube to low suction.

9.An 18-year-old female patient who has been admitted to the emergency department after a motor vehicle crash is scheduled for chest and abdominal x-rays. Which information is most important to report to the health care provider before the x-rays are obtained? a. Severity of abdominal pain b. Positive result of hCG test c. Blood pressure 172/88 mm Hg d. Temperature 102.1° F (38.9° C)

b. Positive result of hCG test

12. Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30? a. Persistent skin tenting b. Rapid, deep respirations c. Hot, flushed face and neck d. Bounding peripheral pulses

b. Rapid, deep respirations

11.A patient whose heart monitor shows sinus tachycardia, rate 132 bpm, is apneic, and has no palpable pulses. which action should the nurse take next? a. perform synchronized cardioversion b. start CPR c. give atropine per agency dysrhythmia protocol d. provide supplemental oxygen via non-rebreather mask

b. start CPR

13.Which question should the nurse ask when assessing a 60-year-old patient who has a history of benign prostatic hyperplasia (BPH)? a. "Have you noticed any unusual discharge from your penis?" b. "Has there been any change in your sex life in the last year?" c. "Has there been a decrease in the force of your urinary stream?" d. "Have you been experiencing any difficulty in achieving an erection?"

c. "Has there been a decrease in the force of your urinary stream?"

5.Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus? a. Generalized edema. b. Fluid volume overload. c. Disturbed sleep pattern. d. Decreased gas exchange.

c. Disturbed sleep pattern.

1. A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

c. Purplish streaks on the abdomen

32. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?

d. A patient with paradoxic chest movements.

19. After a 26-year-old patient has been treated for pelvic inflammatory disease, the nurse will plan to teach about a. use of hormone therapy (HT). b. irregularities in the menstrual cycle. c. changes in secondary sex characteristics. d. possible difficulty with becoming pregnant.

d. possible difficulty with becoming pregnant.