NU 325 Final Exam Review Questions

~What is the most indicative of post-op infection?

red, warm, tender incision

~Nurse is caring for patient with HHNS. Which nursing interventions are initiated for DKA but *NOT* for HHNS?

sodium bicarb one ampule for pH < 7.0

A patient is being seen in the clinic for possible kidney disease. What major sensitive indicator of kidney disease does the nurse anticipate the patient will be tested for?

Creatinine clearance level

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?

Extravasation

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?

Hypokalemia and hypoglycemia

The nurse is educating the client with diabetes on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include?

Increase frequency of glucose self-monitoring.

Which is the analgesic of choice for acute myocardial infarction (MI)?

Morphine

A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?

Nervousness, diaphoresis, and confusion

During the preoperative assessment, the client mentions allergies to avocados, bananas, and hydrocodone. What is the priority action by the nurse?

Notify the surgical team to remove all latex-based items.

Which finding is an early indicator of bladder cancer?

Painless hematuria

A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?

The client has an absence of bowel sounds.

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?

Tumor pressure against normal tissues

Which of the following is the only definitive way to diagnose testicular cancer?

Tissue biopsy

~Patient has an order for Lantus 30 units SQ. Nurse mistakenly gives Lantus 50 units SQ. Patient should be observed for which adverse reactions?

diaphoresis and disorientation

~Male patient undergoes renal angiogram. Which post-op interventions for patient who has already undergone a renal angiogram?

palpate pulses in legs and feet

~With acute ____________________, there could be proteinuria (frothy urine)

glomerulonephritis

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?

Withhold anticoagulant therapy.

~Immediate post-op period of a TURP, what is the priority nursing care?

adjust flow rate of the bladder irrigant to keep catheter patent

~What do you do first if your patient is on warfarin, and they have a nosebleed, labs are: INR- 7.5, HGB- 11, and HCT- 33?

administer Vitamin K

~Patient is discharged after a total hip, after ambulation they complain of new onset of pain at the surgical site. What is the best action?

assess surgical site and affected extremity

~patient is admitted with chest pain, which intervention is the priority?

assessing troponin I levels

~Acute glomerulonephritis, which assessment findings should the nurse anticipate?

tea colored urine (cola colored), hematuria

~Post-op high risk for DVT, what can you do to help reduce risk of DVT?

encourage early ambulation

~What SQ injection would you give your neutropenic patient?

filigrastim

~never exercise when insulin is at it's ____________

peak

A client has been receiving chemotherapy. Upon assessing the client during morning rounds, the nurse notes the client is now bleeding from intravenous and venipuncture sites. Stool is positive for occult blood. The client is requesting to sit in a chair for a meal. The nurse implements the following interventions: (Select all that apply.)

-Assess level of consciousness. -Apply pressure to the bleeding sites. -Check intake and output records.

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply.

-Regular bone density testing -A high-calcium diet -Use of falls prevention precautions -Weight-bearing exercise

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?

Administer oxygen.

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?

Continue with frequent client assessments.

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?

Obtain the attention of all members of the surgical team.

Which medication is an antidote to heparin?

Protamine sulfate

~Patient is admitted to the ICU with a diagnosis of hypertensive crisis. BP is 200/130. Upon assessment which finding requires immediate intervention by the nurse?

numbness and weakness in the left arm

~10 hours after the application of a cast for a fractured humerus, the patient complains of arm pain. Analgesics didn't work. Next action?

prepare patient for for opening or bivalving the cast

~Patient is in the PACU following a biopsy for small cell lung cancer. The patient complains of intense nausea and begins to gag. What to do next?

turn patient completely to one side

~Patient with HF is being prepared for discharge. The nurse should provide which instruction?

weigh yourself daily and report a gain of 2 pounds in one day or 5 pounds in a week

~Patient has just been diagnosed with type 1 diabetes. When teaching patients and family about how diet and exercise affect insulin requirements, the nurse should include?

you'll need less insulin when you exercise or reduce your food intake

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what?

"I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours."

Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply.

-Placing a trapeze on the bed -Ensuring that the weights are hanging freely -Assessing the client's alignment in the bed -Frequently assessing pain level

~Type 1 diabetic who exhibits confusion, light-headedness, and aberrant behavior. Patient is conscious. Nurse should first administer?

15-20g of fast acting carbs such as orange juice

~The nurse expects limited therapy response from a large tumor because?

large tumors contain more drug-resistant resting and non-cycling cells

~Examination of patient's bladder stones, they are primarily composed of uric acid. The nurse would expect to provide the patient with which type of diet?

low purine

~Treatment modalities for contusions, sprains, and strains include all EXCEPT? (answer choices were RICE and massage)

massage