nur 233: practice questions for exam 2
A patient expresses pain in the abdominal area. Which question should the nurse ask the patient to determine the severity of pain? "Can you sit for long periods?" "Can you describe your pain to me?" "Does walking make the pain worse?" "What do you believe is causing this pain?"
"Can you sit for long periods?"
A nurse is teaching about chronic pain. Which statements indicate effective teaching? Select all that apply. "Chronic pain can be easily localized." "Arthritis pain is an example of chronic pain." "Phantom limb pain is an example of chronic pain." "Chronic pain is pain that is present for more than 3 to 6 months." "Chronic pain is responsive to common pain management treatment."
"Phantom limb pain is an example of chronic pain." "Chronic pain is pain that is present for more than 3 to 6 months."
The nurse notes that a client's troponin level is elevated. What should this finding indicate to the nurse about the client? A) Has a high risk for Cardiovascular disease B) Experienced a recent myocardial infarction C) had a myocardial infarction several months ago D) reduced amount of oxygen carrying capacity in the blood
B) Experienced a recent myocardial infarction
Which finding in a client's medical history leads to an increased risk for euvolemic hyponatremia? Select all that apply. Someone who is taking a thiazide diuretic. A person with congestive heart failure. A client who is experiencing SIADH. Someone with a history of adrenal insufficiency. A person who is experiencing severe hypothyroidism.
A client who is experiencing SIADH. Someone with a history of adrenal insufficiency. A person who is experiencing severe hypothyroidism
You're assessing a patient's health history for peripheral vascular disease. What signs and symptoms reported by the patient would indicate the patient may be experiencing peripheral arterial disease? Select all that apply: A) "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." B) "If I stand or sit too long my legs start to feel heavy and achy." C) "It hurts to elevate my legs." D) "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."
A) "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." C) "It hurts to elevate my legs." D) "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."
A patient who rates abdominal pain as a 10 on a 1 to 10 numeric scale is experiencing nausea, vomiting, and restlessness. The nurse correlates this clinical presentation to which type of pain? A) Acute pain B) Chronic Pain C) Neuropathic Pain D) fribomyalgia pain
A) Acute pain
What are the clinical manifestations of right sided heart failure? select all A) Ascites B) Dyspnea C) Hepatomegaly D) Generalized edema E) Weak pulses
A) Ascites C) Hepatomegaly D) Generalized edema
The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect? A) Auscultating lung sounds B) monitoring for hepatomegaly C) palpating for peripheral edema D) Assessing for jugular vein distention
A) Auscultating lung sounds
The nurse is assessing a patient who is suspected to have left sided heart failure. Which assessment provides specific information regarding the left sided heart function? A) Auscultating lung sounds B) Monitoring for hepatomegaly C) Palpating for peripheral edema D) Assessing for JVT
A) Auscultating lung sounds
While planning care, the nurse identified interventions to reduce a patient's risk for developing heart failure. Which assessment findings did the nurse use to make this clinical determination? Select all that apply. A) Body mass index 31.3 B) Smokes half a pack of cigarettes C) Employed in a textile factory D) Blood pressure 168/90 mm Hg E)Fasting blood glucose 80 mg/dL
A) Body mass index 31.3 B) Smokes half a pack of cigarettes D) Blood pressure 168/90 mm Hg
The nurse is caring for a patient with congestive heart failure who is admitted to the medical-surgical unit with acute hypokalemia. Which prescribed medication may have contributed to the patient's current hypokalemic state? A) Cortisol B) Oxycodone C) Flexeril D) Nonsteroidal anti-inflammatory drugs (NSAIDs)
A) Cortisol
In providing care to a patient with an acute exacerbation of heart failure, the nurse prepares to administer prescribed medication that provide which actions? Select all that apply. A) Decreased preload B) Increased preload C) Decreased afterload D) Increased afterload E) Increased contractility
A) Decreased preload C) Decreased afterload E) Increased contractility
Three days after cardiac surgery, the client's leg used for harvesting veins for the bypass is warm and tender and has a 3-cm area of erythema and swelling at the distal end of the incision. The incision staples are intact without drainage and vital signs are stable. Which type of complication is this client most likely experiencing? A) Deep vein thrombosis (DVT) B) Dehiscence of the wound C) Internal bleeding D) Infection at the incisional site
A) Deep vein thrombosis (DVT)
A physiologic indicator of acute pain is: A) Diaphoresis B) Bradycardia C) Hypotension D) Lowered respiratory rate
A) Diaphoresis
The nurse is concerned that a patient with heart failure is decompensating. Which assessment finding requires an immediate intervention? A) Dyspnea at rest B) Dry persistent cough C) Weak peripheral pulses D) Jugular vein distention
A) Dyspnea at rest
A patient with a history of alcoholism is disoriented and vacillates between being calm and disruptive and loud. Vital signs are BP 138/84 mm Hg; pulse 135 beats/min, regular and strong; respiratory rate 22 breaths/min; temperature 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect this patient is experiencing? A) Hypomagnesemia B) Hypocalcemia C) Hyperkalemia D) Hypernatremia
A) Hypomagnesemia
The nurse notes that a patient with heart failure (HF) has a normal ejection fraction (EF). What should this information indicate to the nurse? Select all that apply. A) It is known as HF with preserved EF. B) It is associated with older patients with obesity. C) It occurs in patients with diabetes mellitus and atrial fibrillation. D) It is exacerbated with invasive procedures and dental examinations. E)There is less blood in the ventricle to eject because of the impaired filling.
A) It is known as HF with preserved EF. B) It is associated with older patients with obesity. C) It occurs in patients with diabetes mellitus and atrial fibrillation. E)There is less blood in the ventricle to eject because of the impaired filling.
To promote airway clearance in the patient with pneumonia, what should the nurse instruct the patient to do? (Select all that apply.) A) Maintain adequate fluid intake B) Splint the chest C) Maintain a semi-Fowlers position D) Cough with expectoration
A) Maintain adequate fluid intake B) Splint the chest D) Cough with expectoration
A client is getting up for the first time after a period of bedrest. The nurse should first: A) Obtain a baseline blood pressure B) Assist the client to sit at the edge of the bed C) Assess the respiratory function D) Ask the client if he/she feels lightheaded
A) Obtain a baseline blood pressure
While admitting a client, the nurse has determined the client is a fall risk. What is a priority nursing intervention? A) Place a fall risk armband on the client B) Provide a walker C) Provide a cane D) Place a chair next to the bed
A) Place a fall risk armband on the client
Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? A) Postive Trousseau's sign B) Positive Chvostek's sign C) Tetany D) Paresthesias
A) Postive Trousseau's sign
The nurse is reviewing a client's laboratory report and notes that the Toal serum calcium level is 6.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? A) Prolonged bed rest B) Renal insufficiency C) Hyperparathyroidism D) Excessive ingestion of vitamin D
A) Prolonged bed rest
A nurse is reviewing the serum chemistry results on a patient who has a nasogastric tube to low intermittent suction secondary to a gunshot to the abdomen 2 days ago. Which electrolyte value does the nurse correlate to the NG suctioning? A) Serum chloride of 90 mEq/L B) Serum sodium of 148 mEq/L C) Serum potassium of 5.2 mEq/L D) Serum calcium of 11.3 mg/dL
A) Serum chloride of 90 mEq/L
The nurse is caring for a client diagnosed with DVT. Which information reported to the nurse by the UAP requires immediate intervention? A) The UAP informed the nurse the client is complaining of chest pain B) The UAP noticed the nurse the client's BP is 100/66 C) The UAP reported the client is requesting to be able to take a shower D) The UAP tells the nurse the client is asking for medication for a headache
A) The UAP informed the nurse the client is complaining of chest pain
Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? Select all that apply: A) Thick, tough B) Thin, scaly C) hairless D) brown pigmented
A) Thick, tough D) brown pigmented
A patient presents in the emergency department (ED) with fever, nausea, and vomiting over the past 2 days. The nurse monitors for which laboratory result in this patient? A) Urine specific gravity of 1.040 B) Serum potassium of 4.8 mEq/L C) Serum sodium of 135 mEq/L D) Urine positive for glucose and ketones
A) Urine specific gravity of 1.040
When completing an admission assessment on an older adult, the nurse gives the patient a high fall risk score. Which action should the nurse take first? A) Use a bed/chair alarm system on the patient's bed/chair B) Administer the prescribed PRN sedative medication C) Ask the healthcare provider to order a vest restraint D) Place the patient in the geri-chair near the nurse's station
A) Use a bed/chair alarm system on the patient's bed/chair
Which of the following is a risk factor for falls in the elderly? A) Visual impairment B) Decreased bone mineral density C) Poor dental care D) (a) and (c)
A) Visual impairment
Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of the client? Select all that apply. A) location of the wound B) length width and depth C) nutritional status of the client E) number of dressing and supplies used F) drainage amount color consistency and odor
A) location of the wound B) length width and depth F) drainage amount color consistency and odor
Which describe symptoms of dehydration? Select all A) thirst B) increased BP C) rapid pulse D) muscle fatigue E) increased respirations
A) thirst C) rapid pulse D) muscle fatigue
The nurse plans care for a hospitalized patient. Which data necessitate the inclusion of interventions to address a fluid volume deficit? A) Urine output of 30 mL/hr B) Heart rate of 110 bpm C) Weight gain of 10 pounds in 3 days D) +3 edema in bilateral lower extremities
B) Heart rate of 110 bpm
Your patient has severe peripheral arterial disease. When the lower extremities are elevated you would expect them to appear _______________ and, when they are in the dependent position you would expect them to appear _________________. Fill in the blanks: A) cyanotic; rubor B) rubor; pallor C) cyanotic; pallor D) pallor; rubor
D) pallor; rubor
What causes fluid shift from osmotic pressure? Select all that apply. Isotonic fluids Albumin Hypertonic fluids Hypotonic fluids Mannitol
Albumin Hypertonic fluids Hypotonic fluids Mannitol
A client with a cardiac history is taking a potassium-wasting diuretic (furomeside) and is seen in the emergency department for complaints of weakness. You expect to evaluate which laboratory values? A) Albumin and protein B) sodium and chloride C) hemoglobin and hematocrit D) potassium and blood glucose
D) potassium and blood glucose
The nurse is creating a pain management plan using the three-step approach for a patient with intractable pain. Which interventions should the nurse include in this plan? Select all that apply. A) Administer opioid analgesic first B) Administer nonopioid analgesic first C) Administer mild opioid analgesic last D) Administer analgesics on patient request E) Administer a combination opioid/nonopioid second
B) Administer nonopioid analgesic first C) Administer mild opioid analgesic last E) Administer a combination opioid/nonopioid second
Which nursing intervention reduces the risk of clot formation in the legs? Select all that apply. A) Keep the patient's hips and knees flexed while the patient is in bed. B) Apply compression devices (e.g., sequential compression devices [SCDs]) C) Turn the patient frequently or encourage frequent position changes. D) Promote adequate hydration by encouraging oral intake. E) Elevate the patient's legs above the level of the heart.
B) Apply compression devices (e.g., sequential compression devices [SCDs]) C) Turn the patient frequently or encourage frequent position changes. D) Promote adequate hydration by encouraging oral intake. E) Elevate the patient's legs above the level of the heart.
In providing care to a patient who is diagnosed with hypertension, which assessment data are risk factors for this disease process? Select all that apply. A) BMI 28 B) History of cigarette smoking C) Glomerular filtration rate 58 mL/min D) Concurrent diagnosis of diabetes mellitus E) current age of 45
B) History of cigarette smoking C) Glomerular filtration rate 58 mL/min D) Concurrent diagnosis of diabetes mellitus
IV potassium chloride (KCl) 60mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? A) Administer KCl as a rapid IV Bolus B) Infuse the KCl at a rate of 10mEq/hour C) only give the KCl through a central venous line D) discontinue cardiac monitoring during the infusion
B) Infuse the KCl at a rate of 10mEq/hour
Which laboratory result should alert the nurse to a potential problem? A) Na+ = 137 mEq/L B) K+ = 5.2 mEq/L C) Ca2+ = 9.2 mg/dL D) Mg2+ = 1.8 mg/dL
B) K+ = 5.2 mEq/L
The patient diagnosed with cancer is experiencing severe pain. Which regimen would the nurse teach the patient to control the pain? A) Nonsteriodal anti-inflammatory drugs (NSAIDs) around the clock with narcotics used for severe pain B) Morphine sustained release, an opioid, administered on a routine schedule, with immediate release morphine for breakthrough pain C) Extra strength Tylonol nonnarcotic analgesic, plus therapy to learn alternative methods of pain control D) Demerol, an opioid narcotic, every 6 hours orally, with an opioid suppository when the pain is not controlled
B) Morphine sustained release, an opioid, administered on a routine schedule, with immediate release morphine for breakthrough pain
The nurse is preparing an educational session for members of a community health center that focuses on ways to maintain fluid balance during the summer months. Which interventions should the nurse recommend? Select all that apply. A) Drink diet soda B) Reduce the intake of coffee and tea C) Drink more fluids during hot weather D) Drink flat cola or ginger ale if vomiting E) Exercise during the hours of 10 am and 2 pm
B) Reduce the intake of coffee and tea C) Drink more fluids during hot weather D) Drink flat cola or ginger ale if vomiting
The most serious side effect of a opioid analgesic agents is: A) Renal toxicity B) Respiratory Distress C) Seizures D) Hypotension
B) Respiratory Distress
In reviewing healthcare provider admission orders for a patient admitted for treatment of a deep vein thrombosis of the left lower leg, which order should the nurse question? A) Compression stockings on both legs B) Sequential compression devices on both legs C) Elevate the legs 10 to 20 degrees above the heart D) Encourage fluid intake
B) Sequential compression devices on both legs
The nurse is preparing material about peripheral artery disease (PAD) for a community fair. What should the nurse include about modifiable risk factors for the disease? Select all that apply. A) History of chronic obstructive pulmonary disease B) Smoking C) Hypertension D) Family history of cardiovascular disease E) Sedentary life
B) Smoking C) Hypertension E) Sedentary life
Which nursing action could the nurse delegate to a UAP when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? A) Check the skin under the heating pad B) Take the respiratory rate every 2 hours C) Monitor sedation using the sedation assessment scale D) Ask the patient whether pain control is effective
B) Take the respiratory rate every 2 hours
The nurse educator is developing a class on pain assessment and incorporates which information regarding the Wong-Baker FACES tool? A) This tool is effective for patients who do not speak English B) This tool is effective for patients with expressive aphasia C) This tool is effective for patients from other cultures D) This tool is effective for patients with cognitive impairments
B) This tool is effective for patients with expressive aphasia
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? A) bananas B) antacids C) brocolli d) cantaloupe
B) antacids
You are assessing a patient suspected of having right-sided heart failure. What assessment finding may indicate right-sided heart failure? A) pulmonary edema B) distended neck veins C) Dry cough D) Orthopnea
B) distended neck veins
The nurse is teaching a class to clients diagnosed with hypertension. Which should the nurse teach the clients? A) The BP target range should be 120/80 B)Take the medication even when feeling well C) Get up quickly when rising from recumbent position D) Consume 3,000 mg sodium diet
B)Take the medication even when feeling well
The nurse is providing care to a postoperative patient who is getting out of bed for the first time since surgery. When conducting the pain assessment, the patient states, "It hurts, but I do not want to take any more drugs. I do not want to end up addicted." Which response by the nurse is most appropriate? A) "Don't worry about getting addicted. I will make sure you don't get addicted." B) "If you don't take the pain medication on a regular schedule, you won't get addicted." C) "Addiction typically requires taking the medication for weeks to months, and you should only need these medications for a few days." D) "You are wise to be concerned; it is probably time to stop taking narcotics if you can manage the pain in other ways."
C) "Addiction typically requires taking the medication for weeks to months, and you should only need these medications for a few days."
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high sodium items to be avoided. The nurse instructs the client to avoid consuming which item? A) Bananas B) Broccoli C) Antacids D) Cantaloupe
C) Antacids
An immobile client has developed a pressure ulcer on his ankle from lying in the same position for too long. Which nursing intervention would be most appropriate in this situation? A) Increase the client's level of activity to promote circulation B) Check the client's skin for signs of incontinence C) Elevate the extremity to keep the ankle off of the bed D) Implement a positioning schedule to turn the client every 4 hours
C) Elevate the extremity to keep the ankle off of the bed
Edema is caused by excess of which type of fluid? A) Intracellular B) Extracellular C) Interstitial D) Transcellular
C) Interstitial
An adult patient is admitted to the hospital with a prolong PR interval and widened QRS complex on his EKG with symptoms of hyperkalemia. The nurse should plan to administer: A)0.9% sodium chloride B) Antidiuretic hormone C) Kayexalate enema D)Antihypertensive
C) Kayexalate enema
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? A) K+ 3.4 mEq/L (3.4 mol?L) B) Ca+2 7.8mg/dL (1.95 mol/L) C) Na+ 154 mEq/L (154 mmol/L) D) PO4-3 4.8mg/dL (1.55 mol/L)
C) Na+ 154 mEq/L (154 mmol/L)
The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client's electronic health record. Which one should the nurse question? A) Administer an IV of D5W at 125 mL/hr. B) Strict I&O monitoring. C) Restrict oral intake to 900 mL every 24 hr. D) Monitor serum electrolytes every 4 hr.
C) Restrict oral intake to 900 mL every 24 hr.
The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following orders were written in the clients electronic health record. Which one should the nurse question? A) administer an IV of D5W at 125mL/hr B) Strict I&O monitoring C) Restrict oral intake to 900mL every 24 hours D) monitor serum electrolytes every 4 hr
C) Restrict oral intake to 900mL every 24 hours
In reviewing laboratory results for a patient presenting to the Emergency Department with changes in level of consciousness, the nurse correlates which value as placing the patient at greatest risk for seizures? A) Serum calcium of 12 mg/dL B) Serum potassium of 3.0 mEq/L C) Serum sodium of 129 mEq/L (was 135 on our practice exam) D) Serum magnesium of 2.6 mEq/L
C) Serum sodium of 129 mEq/L
The nurse is caring for a patient with severe pain. An opioid is delivered. What assessment should the nurse make after the administration? Monitor weight. Monitor platelet levels. Monitor glucose levels. Monitor respiratory rate.
Monitor respiratory rate.
An older adult patient is admitted to the emergency dept for hypovolemia. After 500mL of 0.9% NaCl is delivered intravenously over 1 hour, the assessment shows: BP of 167/88, HR of 110, crackles bilaterally. What should the nurse determine from this situation? A) The patient has been properly rehydrated B) The patient has become hypovolemic C) The patient is showing signs of hypervolemia D) The patient is showing no change in condition
C) The patient is showing signs of hypervolemia
The nurse is working in the heart failure clinic will know that teaching for a 74-year-old, with newly diagnosed heart failure has been effective when the patient... A) weighs himself twice a week B) tells the home care nurse that Hydrodiuril (hydrochlorothiazide) is taken daily at bedtime C) calls the clinic when the weight increases from 124 to 130 pounds in a week D) says the nitro-bed (nitroglycerine ointment) will be used for any chest pain that develops
C) calls the clinic when the weight increases from 124 to 130 pounds in a week
The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient A) weighs himself twice a week B) tells the home care nurse that Hydrodiuril (hydrochlorothiazide) is taken daily at bedtime. C) calls the clinic when the weight increases from 124 to 130 pounds in a week. D) says that the nitroglycerin patch will be used for any chest pain that develops.
C) calls the clinic when the weight increases from 124 to 130 pounds in a week.
Your patient reports experiencing dull and achy sensations in the lower extremities. You note that the lower extremities have edema and brownish pigmentation. Pulses are present bilaterally and the extremities feel warm to the touch. To help alleviate the patient's symptoms, the nurse will position the lower extremities in the? A) dependent position B) horizontal position C) elevated position above heart D) knee-flexed position
C) elevated position above heart
The nurse plans care for a patient who is admitted to the hospital for newly diagnosed left-sided heart failure. Which is the priority nursing diagnosis when planning care for this patient? A) Activity Intolerance B) deficient knowledge C) impaired oxygenation D) impaired tissue perfusion
C) impaired oxygenation
What conditions cause fluid volume excess? Select all that apply. Cirrhosis Diarrhea Adrenal gland disorder Hemorrhage Heart failure
Cirrhosis Adrenal gland disorder Heart failure
A client with chronic hyponatremia is receiving replacement therapy per protocol. Which finding requires immediate action by the nurse? 0.9% NaCl delivery per infusion pump. Correction rate calculated to 20 mEq/L/day. Client's medical history indicates alcohol abuse. Client takes a thiazide diuretic.
Correction rate calculated to 20 mEq/L/day
Which assessment changes can the nurse anticipate in a person experiencing fluid overload? Select all that apply. Crackles in lungs Weight gain Poor skin turgor Edema Thirst
Crackles in lungs Weight gain Edema
What is the best indicator of kidney function in a client who is experiencing fluid and electrolyte imbalances? Blood urea nitrogen level Creatinine level Urine output Urine pH level Absence of microalbuminuria
Creatinine level
Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium? A) 14 y/o taking diuretics B) 16 y/o with an ileostomy C) 16 y/o with metabolic acidosis D) 18 y/o with renal disease
D) 18 y/o with renal disease
Which sodium potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? A) 3.4 B) 5.5 C) 4.6 D) 2.9
D) 2.9 mEq
the nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange". Which is an expected outcome for this problem? A) performs chest physiotherapy three times a day B) Able to complete activities of daily living C) ambulates in the hall several times during each shift D) Alert and oriented to person, place, time and events
D) Alert and oriented to person, place, time and events
The nurse monitors for which clinical manifestation in a patient diagnosed with right-sided heart failure (HF)? A) Fatigue B) Shortness of breath C) Crackles with auscultation D) Edema in the lower extremities
D) Edema in the lower extremities
Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension? A) Most people are able to control BP through dietary changes B) Annual BP checks are needed to monitor treatment effectiveness C) Increasing physical activity alone controls BP for most people D) Hypertension is usually asymptomatic until target organ damage occurs
D) Hypertension is usually asymptomatic until target organ damage occurs
The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37°C (98.6°F). What disorder should the nurse suspect? A) Hypovolemia B) Hypercalcemia C) Hyperkalemia D) Hypervolemia
D) Hypervolemia
A patient is prescribed 20 mEq of potassium chloride because of excessive vomiting. The nurse includes which information in explaining the rationale for this medication? A) It controls and regulates water balance in the body B) It is used in the body to synthesize ingested protein C) It is vital in regulating muscle contraction and relaxation D) It is needed to maintain skeletal, cardiac, and neuromuscular activity
D) It is needed to maintain skeletal, cardiac, and neuromuscular activity
Which of the following is true regarding falls in the elderly? A) A patient should not use a walker to ambulate if their motor strength is intact. B) Hip fractures are not the most frequent type of fall-related fractures. C) A motorized scooter is a better option to prevent falls in the elderly. D) Medication use may contribute to increased fall risk.
D) Medication use may contribute to increased fall risk.
The nurse is planning care for the patient with acute renal failure and incorporates the nursing diagnosis of Excess Fluid Volume. Which assessment data support this nursing diagnosis? A) Wheezing in the lungs B) Generalized weakness C) Urine output of 20 mL/hr D) Pitting edema in the lower extremities
D) Pitting edema in the lower extremities
Which electrolyte is the primary regulator of fluid volume? A) Potassium B) Calcium C) Magnesium D) Sodium
D) Sodium
The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment change related to this is most concerning? A) The patient feels lightheaded when getting out of bed B) The patient has tremors when stretching arms out straight C) The patient has bone pain and joint stiffness D) The patient feels palpitations and has an irregular pulse
D) The patient feels palpitations and has an irregular pulse
The nurse is teaching a patient about the interventions to prevent the development of a DVT. Which statement made by the patient indicated the need for further teaching? A) "I should take adequate fluids" B) "I should use compression stockings" C) "I should elevate my leg 10-20 degrees while at rest" D)"I should limit my physical activity and spend more time sitting"
D)"I should limit my physical activity and spend more time sitting"
The nurse is caring for a client with hypokalemia and knows to never deliver parenteral replacement of potassium via IV push due to the potential for which complications? Select all that apply. Death Hemorrhage Cardiac dysrhythmias Stroke Cardiac arrest
Death Cardiac Dysrhythmias Cardiac Arrest
The pain score of a patient experiencing acute pain is assessed as a 6 on a 0 to 10 scale. Which actions should the nurse take? Select all that apply. Document this in the patient's chart. Perform an immediate clinical assessment. Inform the physician immediately. Determine the appropriate pain management. Determine whether the patient is being truthful.
Document this in the patient's chart. Perform an immediate clinical assessment. Determine the appropriate pain management.
The nurse is caring for a patient with expressive aphasia. Which pain scale should the nurse use? FACES Visual Verbal Numerical
FACES
Which observations should the nurse anticipate for a client with hypernatremia? Select all that apply. Hallucinations Abdominal cramping Neuromuscular irritability Increased appetite Decreased urine output
Hallucinations Neuromuscular irritability Decreased urine out
Which lab values are impacted by fluid volume deficit? Select all that apply. Hemoglobin and hematocrit Urine specific gravity Sodium White blood cells Serum osmolality
Hemoglobin and hematocrit Urine specific gravity Sodium Serum osmolality
A client presents with muscle cramps, paresthesia, weakness, palpitations, and electrocardiogram changes. What electrolyte imbalance should the nurse suspect? Hypochloremia Hyponatremia Hypermagnesemia Hyperkalemia
Hyperkalemia
A client with a history of alcoholism is admitted to the nursing unit. The nurse knows that this client would be at risk for which electrolyte imbalance? Hypercalcemia Hypomagnesemia Hyperkalemia Hyperphosphatemia
Hypomagnesemia
A client is experiencing symptoms of fluid volume excess. Which actions should the nurse take? Select all that apply. Limit daily intake of fluid and sodium Monitor daily weight Eliminate sodium-containing IV fluids Administer diuretics, as ordered Offer oral fluids
Limit daily intake of fluid and sodium Monitor daily weight Eliminate sodium-containing IV fluids Administer diuretics, as ordered
How can the relationship of calcium and phosphorus in the body be classified? Increases in both ions occur in normal states. Calcium and phosphorus are dependent on the potassium level. There is a parallel relationship. Often, there is a reciprocal relationship.
Often, there is a reciprocal relationship.
A patient tells the nurse, "This pain is much worse than when I broke my arm." Which characteristic of pain is the patient describing? Onset of pain Quality of pain Severity of pain Radiation of pain
Severity of pain
The nurse is caring for a patient with pain. Which functions are impacted by chronic or acute pain? Select all that apply. Sleep Activity Anxiety Depression Nutrition pattern
Sleep Activity Nutrition pattern
A client with bipolar disorder is receiving lithium therapy. Which electrolyte disturbance should the nurse anticipate? Select all that apply. Chloride imbalance Potassium imbalance Calcium imbalance Sodium imbalance Magnesium imbalance
Sodium imbalance- Magnesium imbalance
The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect? a) Asymptomatic b) SOB c) Visual disturbance d) Frequent nosebleeds
a) Asymptomatic
In a patient with prolonged vomiting, the nurse monitors for fluid volume deficit because vomiting results in a) fluid movement from the cells into the interstitial space and blood vessels b) excretion of large amounts of interstitial fluid and depletion of extracellular fluids c) overload of extracellular fluid with a significant increase in intracellular fluid volume d) fluid movement from the vascular system into the cells, causing cellular swelling and rupture
a) fluid movement from the cells into the interstitial space and blood vessels
Implementation of nursing care for a patient with hyponatremia includes a) fluid restriction b) administration of hypotonic IV fluids c) administration of cation- exchange renin d) increased water intake for patients on nasogastric suction
a) fluid restriction
The HCP prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. a) instruct the patient how to cough b) place in high Fowler's position for eating c) encourage increased oral intake of water daily d) place thigh- length elastic stockings on the client e) place sequential compression boots on the clients unaffected leg f) encourage the intake of dark green leafy vegetables
a) instruct the patient how to cough d) place thigh- length elastic stockings on the client e) place sequential compression boots on the clients unaffected leg
The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? a) prolonged best rest b) renal insufficiency c) hyperparathyroidism d) excessive ingestion of vitamin D
a) prolonged best rest
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin/mineral use d. Over-the-counter (OTC) laxative use
a. Daily alcohol intake
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.
a. The patient is experiencing stridor.
The nurse is caring for a patient with a potassium level of 6.0 mEq/L. What is the nurse's priority action? a. place the patient on a cardiac monitor b. obtain a baseline weight c. deliver spironolactone only d. assess the LOC
a. place the patient on a cardiac monitor
The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. a) Soak the feet in hot water daily b) Be careful not to injure the legs or geet c) Use a heating pad on the legs to aid vasodilation d) Walk each day to increase leg circulation e) Cut down on the amount of fats consumed in the diet
b) Be careful not to injure the legs or geet d) Walk each day to increase leg circulation e) Cut down on the amount of fats consumed in the diet
A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? a) Bilateral edema b) Increased calf circumference c) Diminished distal peripheral pulses d) Coolness and pallor of the affected limb
b) Increased calf circumference
A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.
b. Check the patient's blood pressure.
The nurse is assessing a patient with a positive Chvostek's sign. Which actions are a priority? Select all that apply. a. assess the lung sounds b. request a soft diet c. evaluate the phosphorus level d. assess for thrombosis and clots e. monitor for cardiac dysrhythmia
b. request a soft diet c. evaluate the phosphorus level d. assess for thrombosis and clots
A home care nurse is visiting a client to provide following up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? a) stage 1 ulcer b) vascular ulcer c) arterial ulcer d) venous stasis ulcer
c) arterial ulcer
Clinical assessment of dehydration would be confirmed if you identified: a) a-1 pound weight loss b) encouraged neck veins c) dry mucous membranes d) full bounding pulse
c) dry mucous membranes
After receiving change-of-shift report, which patient should the nurse assess first? a) patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal b) patient with serum sodium level of 145 mEq/ L who has dry mouth and is asking for a glass of water c) patient with serum magnesium level of 1.1 mEq/ L who has tremors and hyperactive deep tendon reflexes d) patient with serum phosphorus level of 4.5 mg/ dL who has multiple soft tissue calcium- phosphate precipitates
c) patient with serum magnesium level of 1.1 mEq/ L who has tremors and hyperactive deep tendon reflexes
It is important for the nurse to assess for which clinical manifestation in a patient who has undergone a total thyroidectomy a) weight gain b) depressed reflexes c) positive chvostek's sign d) confusion and personality changes
c) positive chvostek's sign
A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment change related to this is most concerning? a) The patient feels lightheaded when getting out of bed b) The patient has tremors when stretching out arms c) The patient has bone pain and joint stiffness d) The patient feels palpitations and has irregular pulse
d) The patient feels palpitations and has irregular pulse