N120 FINAL EXAM REVIEW

A nurse is reinforcing teaching w/ a pt regarding reduction of risk factors for coronary artery disease. Which of the following statements by the pt indicates an understanding of the teaching? (SATA) a. "I must stop smoking" b. "I should limit my exercise" c. "I will stop consuming alcohol" d. "I need to monitor my weight" e. "I am limiting my intake of fast foods"

A, D, E rationale - b: you don't want them to limit their exercise - c: you can still drink alcohol but moderately risk factors of CAD: - sedentary lifestyle - obesity - age - genetics

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis (SATA) a. night sweats b. low grade fever c. weight gain d. flushed cheeks e. blood in the sputum

A,B, E

A nurse is providing information to a group of surgical nurses for a treatment of malignant hyperthermia. Which of the following should the nurse include in the information? (select all that apply) a. infuse iced IV fluids b. provide 100% oxygen c. place on a cooling blanket d. treat the condition while continuing surgery e. administer IV dantrolene

A,B,C,E the first thing you need to do is to terminate surgery and administer dantrolene. Some s/s of malignant hyperthermia are tachycardia, tachypnea, and muscle rigidity

a nurse is providing instructions to a pt who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? a. "Place the tablet under your tongue, and then take a small sip of water." b. "The medication can take up to 15 minutes to take effect."" c. "Avoid taking the medication prior to exercising" d. "Stop taking the medication and notify the provider if you develop a headache"

a. "Place the tablet under your tongue, and then take a small sip of water." rationale: small sip of water is fine. we don't want them drinking it w/ an 8 oz of water - med can take up 1-3 mins to take effect - call 911 if there is still no relief after taking first dose - wait for 5 mins to take the 2nd dose - do not take more than 3 doses - change position slowly

a nurse is assessing a pt who is postop and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? a. fatigue b. HTN c. bradycardia d. diarrhea

a. fatigue rationale: s/s of anemia - fatigue, pallor, dyspnea, - we look at HgB

a nurse is caring for a pt who has stretococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 mins into the infusion of the 3rd dose, the pt reports that the IV site itches and that he feels dizzy and SOB. Which of the following actions should the nurse take first? a. stop the infusion b. call the pt's provider c. elevate the HOB d. auscultate the pt's breath sounds

a. stop the infusion rationale: think ABC's pt is exhibiting signs of anaphylaxis

a nurse is caring for a pt who has not voided for 8 hr. following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? a. increase fluids b. perform a bladder scan c. insert a straight catheter d. provide assistance to the bathroom

b. perform a bladder scan rationale: you want to assess first

A nurse is caring for a pt who has returned to the unit following a surgical procedure. The client's O2 sat is 85%. Which of the following actions should the nurse take first? a. administer O2 at 2L/min b. administer prescribed analgesic medication c. encourage coughing and deep breathing d. raise the HOB

d. raise the HOB rationale: start w/ the least invasive

a charge nurse is supervising a newly licensed nurse provide care for a pt who has a PCA pump. Which of the following statement made by the nurse requires further action by the charge nurse? a. "I discarded the remaining 2 mg of morphine from the PCA pump. Please document that you witnessed it" b. "I noted that my pt pushed the button 6 times during the last hour, and the PCA lockout is set for 10 mins" c. "I gave my pt a bolus dose of morphine when I initiated the PCA pump" d. "I told the pt's family that they must not push the PCA button for the pt"

a. "I discarded the remaining 2 mg of morphine from the PCA pump. Please document that you witnessed it" rationale: Do not ever document something you never witnessed.

A nurse is planning care for an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates FVE? (SATA) a. bounding pulse b. pitting edema c. swelling at the IV site d. urine-specific gravity greater than 1.030 e. crackles upon auscultation

A, B, E

A nurse is caring for a client who is post-op and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (SATA) a. slight pain at the insertion site b. serous drainage on the dressing c. movement of the pain at the insertion site d. elastic bandages secure around the traction ropes e. minimal edema around the pin

A, B, E skeletal traction expected findings: - slight pain at the insertion site b/c there are pins inside the bone - serous drainage, but if there is any significant bleeding needs to be reported - we do not want those pins to move; they should be firmly secure in that bone - we don't want anything around those traction ropes - they should be attached to the weights - minimal edema, but if there is significant edema, we would report it right away

a nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the pt's post-op plan of care? (SATA) a. discontinue suction when assessing for peristalsis b. irrigate the NG tube w/ 0.9% NS irrigation soln c. place sequential compression devices on the bilateral lower extremities d. reposition the pt from side to side every 2 hr e. encourage the use of an IS every 3 hr while the pt is awake

A,B,C,D

a nurse is teaching a pt who has TB and is to start combination drug therapy. which of the following meds should the nurse plan to administer? a. rifampin b. isoniazid c. acyclovir d. pyrazinamide e. montekulast

A,B,D

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and echhymotic. While the client waits for the technician to take x-rays, which of the following actions should the nurse take? (SATA) a. apply ice to the ankle b. encourage ROM of the foot c. provide the client with a light snack d. apply a compression bandage e. elevate the foot

A,C,E Rationale: we want the patient to rest, ice, compress, and elevate - we do not want them to encourage ROM because it might cause more complications, instead we want them to rest - we don't want them to give them a light snack b/c the pt may need surgery, so we need them to be NPO

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside pulmonary complications. C. Encourage the use of an incentive spirometer D. Administer an expectorant

C. Encourage the use of an incentive spirometer Rationale: Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.

A nurse has administered midazolam (Versed) IV bolus to a client before a procedure. The client's blood pressure is 86/40 mm Hg and pulse is 134/min. Which of the following should the nurse administer? a. naloxone b. morphine c. flumazenil d. atropine

C. flumazenil flumazenil is the reversal agent for midazolam

a nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus? a. altered mental status b. reduced bowel sounds c. swelling of the toes distal to the injury d. pain w/ passive movement of the foot distal to the injury

a. altered mental status rationale: s/s of fat embolus are altered mental status, SOB, dyspnea, increase RR, decrease O2 sat

A nurse is teaching a pt who has HTN and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this med? a. bradycardia b. tremor c. cough d. constipation

a. bradycardia risk factors for HTN - obesity - sedentary lifestyle

While performing an admission assessment for a pt, the nurse notes that the pt has varicose veins w/ ulcerations and lower extremity edema w/ a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the pt's care? a. impaired tissue perfusion b. alteration in body image c. alteration in activity tolerance d. impaired skin integrity

a. impaired tissue perfusion

A nurse is caring for a pt who has TB and news prescriptions for rifampin and pyrazinamide. Which of the following lab tests should the nurse instruct the pt will be required while on this medication regimen? a. liver function tests b. gallbladder studies c. thyroid function studies d. blood glucose levels

a. liver function tests rationale: these meds can cause hepatic toxicity meds for TB: - rifampin - isoniazid - pyrazinamide - ethanbutol

a nurse is caring for a pt who had peripheral vascular disease and reports difficulty sleeping due to cold Which of the following should the nurse take to promote pt's comfort? a. obtain a pair of slipper-socks for the pt b. rub the pt's feet briskly for several minutes c. increase the pt's oral intake

a. obtain a pair of slipper-socks for the pt it provided warmth and comfort

a nurse is reviewing the lab results of a pt who takes furosemide. Which of the following results should the nurse identify as the priority finding? a. potassium 2.9 b. phosphorus 4.5 c. sodium 145 d. calcium 8.2

a. potassium 2.9

A nurse is caring for a client who is receiving TPN solution. The current bag of soln was hung 24h ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? a. remove the current bag and hang a new bag b. infuse the remaining soln at the current rate and then hang a new bag c. increase the infusion rate so the remaining soln is administered within the hour and hang a new bag d. remove the current bag and hang a bag of LR

a. remove the current bag and hang a new bag rationale: TPN solution bags must be changed every 24h. If our new bag isn't ready yet, you would put D10W. enteral feeding --> GI is still functional parenteral feeding --> GI is not functional and needs IV nutrition

a nurse is in a pt's room when the pt begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? a. turn the pt's head to the side b. check the pt's motor strength c. loosen the clothing around the pt's wasit d. document the time the seizure began

a. turn the pt's head to the side rationale: think of ABC's

A nurse is planning care for an older adult client who is at risk for developing pressure ulcer. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. use a transfer device to lift pt up in bed b. apply a cornstarch to keep sensitive areas dry c. massage the skin over the pt's bony prominences d. elevate HOB no more than 45 degrees

a. use a transfer device to lift pt up in bed Rationale: a. using a transfer device would prevent dragging the skin across the linens b. cornstarch can cause gritty and when it gets gritty, it can cause abrasions on the skin c. massaging the skin may cause injury d. elevating the HOB too high may cause shearing and cause injury to tissues. the HOB should be no more than 30 degrees other ways to prevent pressure ulcers - repositioning - ambulation - use different padding

a nurse is teaching a client who has acute kidney disease about fluid restrictions. which of the following statements by the pt should the nurse identify as understanding of the teaching? a. "I should consume most of the fluid during the evening" b. "I will make a list of my favorite beverages: c. "I will put beverages in large containers to give the appearance of drinking a lot" d. "I will not add ice cream to the amount of fluid intake"

b. "I will make a list of my favorite beverages"

a nurse assessing a pt who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications? a. fat embolism syndrome b. acute compartment syndrome c. pulmonary embolism d. osteomyelitis

b. acute compartment syndrome

a nurse is providing discharge teaching to a pt who has PAD. Which of the following instructions should the nurse include in the teaching? a. apply a heating pad on a low setting to help relieve leg pain b. adjust the thermostat so that the environment is warm c. wear anti embolic stocking during the day d. rest with the legs above the heart level

b. adjust the thermostat so that the environment is warm rationale: prevent vasoconstriction and further decreased arterial flow; wearing gloves and socks can help as well

A nurse is caring for a pt who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? a. replace the catheter every 3 days b. check the catheter tubing for kinks or twisting c. irrigate the catheter once each shift d. clean the perineal area w. an antiseptic soln daily

b. check the catheter tubing for kinks or twisting rationale: we want to check the tubing for kinks or twisting b/c it can cause back flow to urinary bladder which can lead to infection. d - clean it w/ soap and water

A nurse is completing discharge teaching w/ a client who has Chron's disease. Which of the following instructions should the nurse include in the teaching? a. decrease intake of calorie-dense foods b. drink canned protein supplements c. increase intake of high fiber d. eat high-residue foods

b. drink canned protein supplements Rationale: Chron's is a form of inflammatory bowel disease, so we want to teach the pt to increase protein intake. We don't want them to increase intake of high fiber because it will increase irritation and cause inflammation in their stomach. We want them to have low-residue foods to reduce inflammation. We want them to eat small frequent meals b/c this will help to reduce the occurrence of s/s. - eat high calories and high protein, low fiber

a nurse is assessing a pt who has chronic venous insufficiency. Which of the following findings should the nurse expect? a. dependent rubor b. edema c. hair loss d. thick, deformed toenails

b. edema rationale: increase in venous hydrostatic pressure, fluid accumulates in the veins, fluid leaks out into the tissues causing edema

a nurse is caring for a pt who has had a stroke in the right hemisphere. Which of the following alterations in function should the nurse expect? a. difficult reading b. inability to recognize family members c. right hemiparesis d. aphasia

b. inability to recognize family members rationale: rt. hemisphere has to do with visual spatial awareness. left has to do with language, math, skills, and analytic, logic - right side has to do with proprioception, impulse control

a nurse identifies a pressure ulcer after a pt had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? a. document what the nurse believes was the cause of ulcer development b. include any relevant statements the pt made about the ulcer c. document in the pt's medical record that she completed an incident report d. question the charge nurse about care deficits that might have contributed to the ulcer's development

b. include any relevant statements the pt made about the ulcer rationale: pt witness statements included using quotations

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? a. absence of saliva b. painful swallowing c. sweet taste in mouth d. absence of eructation

b. painful swallowing Rationale: GERD will have painful swallowing because they have an inflammation. Some other s/s of GERD are pain that worsens w/ position so bending if they strain when they lay down typically they'll have more pain, heartburn, indigestion, and burning sensation in esophagus, bitter taste in mouth, increase in flakiness and burping, irritation

a nurse is caring for a pt who had just undergone insertion of a femoral head prothesis. The nurse should instruct the pt to avoid which of the following activities? a. placing a large pillow between the legs while turning b. putting on shoes and socks c. using a raised toilet seat d. using a walker

b. putting on shoes and socks rationale: you don't want to bend

A nurse is performing an ECG on a pt who is experiencing chest pain. Which of the following statements should the nurse make? a. "You might feel a slight tingling while the test is being done" b. "The test will be complete in 30-60 mins" c. "I will need to apply electrodes to your chest and extremities" d. "The radioactivity from the dye only lasts a few hours"

c. "I will need to apply electrodes to your chest and extremities" Rationale: all the other choices are incorrect. You won't feel anything. The test is done in a few minutes. There is no radioactivity involved.

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of anti-tuberculosis medications. Which of the following information should the nurse include in the teaching? a. Medications will need to be taken for the rest of the client's life, even if the client feels better. b. Medications will need to be taken until the Mantoux test is negative. c. A typical course of treatment involves 6 to 9 months of consistent medication use. d. The client's family will also need to take medications to prevent infection.

c. A typical course of treatment involves 6 to 9 months of consistent medication use. rationale: compliance with long-term treatment is important to prevent drug resistance and disease complications

a nurse is caring for a pt who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose? a. Iron b. Glucagon c. Protamine d. Vitamin K

c. Protamine - for heparin, we need to monitor platelet, aPTT, and INR, signs of bleeding - for warfarin, monitor PTT/INR and signs of bleeding

A group of nurses are discussing risk factors for transmission of HIV from pts. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV? a. an occupational therapist who works w/ a pt who has HIV b. a personal trainer who works w/ a pt who has HIV c. a phlebotomist who collects blood from pts who have HIV d. a nurse who works for an insurance company and collects urine samples from clients who have HIV

c. a phlebotomist who collects blood from pts who have HIV rationale: HIV can be transmitted via bodily fluids such as blood, breast milk, semen, and vaginal secretions.

A nurse is caring for a pt who is post-op and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take? a. apply the stockings while the pt is sitting in a chair b. remove the stocking once each day c. check the stockings for wrinkles d. measure the size of the pt's foot

c. check the stockings for wrinkles

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick w/ a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client? a. bradycardia b. night sweats c. confusion d. narrowed pulse pressure

c. confusion

A nurse is caring for a client who has blood glucose 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? a. recheck blood glucose in 15 min b. provide a carbohydrate and protein food c. provide 15g of simple carbohydrates d. report findings to the provider

c. provide 15g of simple carbohydrates ex: 4 oz of juice, glucose tablets, 6-10 hard candies, a tbsp of honey we want to give them carb and protein if their glucose has come back to a normal range, but their next meal is more than an hour away. review the rule of 15!

a nurse is caring for a female pt who has recurrent kidney stones and is scheduled for an IV pyelogram. Which of the following statements by the pt should the nurse report to the provider? a. "I drink at least 2 quarts of fluid everyday" b. "The last time I voided it was painful and red-tinged" c. "My period ended 2 days ago" d. "I don't eat shellfish because it gives me hives"

d. "I don't eat shellfish because it gives me hives" rationale: iodine derivative in contrast dye

A nurse is caring for a pt who has UTI. Which of the following is the priority intervention by the nurse? a. offer a warm sitz bath b. recommend drinking cranberry juice c. encourage increased fluids d. administer an antibiotic

d. administer an antibiotic rationale: all the other choices are just educating the patient, it's not really an intervention. some other s/s of UTI are frequency, urgency of urination, lower back pain, fever. in older adult, we may see confusion.

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times? a. When the pt has finished eating lunch b. when the pt states he is ready to start the infusion c. 2 hr after obtaining blood from the blood bank d. as soon as the nurse can prepare the pt and administration set

d. as soon as the nurse can prepare the pt and administration set The bag needs to be empty within 4 hours

A nurse in the ED is assessing on older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? a. unequal pupils b. hypertension c. tympany upon chest percussion d. confusion

d. confusion rationale: in older adult patients who has hypoxia, we'll see confusion, hypotension, and dull upon chest percussion. s/s of pneumonia: - cough - fever - SOB

a nurse is assessing a pt who has peptic ulcer disease. Which of the following findings should the nurse identify as priority? a. epigastric discomfort b. dyspepsia c. nausea d. hematemesis

d. hematemesis rationale: they're vomiting w/ blood so there could be GI bleeding going on