PCC Exam 3 Questions
The nurse is assigned to the care of a 64-year-old patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, what should be the nurse's initial intervention? A. Assess patient's perception of what it means to have diabetes. B. Ask the patient to write down current knowledge about diabetes. C. Set goals for the patient to actively participate in managing his diabetes. D. Assume responsibility for all of the patient's care to decrease stress level.
A. Assess patient's perception of what it means to have diabetes.
The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? A. Cheese B. Broccoli C. Chicken D. Oranges
A. Cheese
The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? A. Chooses a puncture site in the center of the finger pad. B. Washes hands with soap and water to cleanse the site to be used. C. Warms the finger before puncturing the finger to obtain a drop of blood.
A. Chooses a puncture site in the center of the finger pad.
Which of the following types of diarrhea is commonly seen in malabsorption syndromes because the intestine cannot absorb nutrients or electrolytes? A. Chronic B. Secretory C. Acute D. Intractable diarrhea of infancy
A. Chronic
A 2-month-old breastfed infant is successfully rehydrated with oral rehydration solutions for acute diarrhea. Instructions to the mother about breastfeeding should include which of the following? A. Continue breastfeeding. B. Stop breastfeeding until the breast milk is cultured. C. Stop breastfeeding until diarrhea is absent for 24 hours. D. Express breast milk and dilute it with sterile water before feeding it.
A. Continue breastfeeding.
An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which of the following is also important in her immediate care? A. Cool with a single application of tepid water. B. Encourage her to drink clear liquids. C. Remove her burned clothing and jewelry. D. Leave the rug in place until the ambulance arrives.
A. Cool with a single application of tepid water.
4. A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include A. Core rewarming with warm fluids B. Ambulation to increase metabolism C. Frequent oral temperature assessment D. Gastric tube feedings to increase fluids
A. Core rewarming with warm fluids
The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient is considered one of the classic clinical manifestations of diabetes? A. Excessive thirst B. Gradual weight gain C. Overwhelming fatigue D. Recurrent blurred vision
A. Excessive thirst
11. It is most important for the nurse to include in a teaching plan which risk factors associated with the development of type 2 diabetes mellitus? (Select all that apply): A. Hypertension. B. History of pancreatic trauma. C. Weight gain of 30 pounds during pregnancy. D. Body mass index greater than 25 kg/m. E. Triglyceride levels between 150 and 200 mg/dL. F. Delivery of a 4.99-kg baby.
A. Hypertension. D. Body mass index greater than 25 kg/m. F. Delivery of a 4.99-kg baby.
Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? A. Increased triglyceride levels B. Increased high-density lipoproteins (HDL) C. Decreased low-density lipoproteins (LDL) D. Decreased very-low-density lipoproteins (VLDL)
A. Increased triglyceride levels
What type of dehydration is defined as "dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion?" A. Isotonic dehydration B. Hypotonic dehydration C. Hypertonic dehydration D. All types of dehydration in infants and small children
A. Isotonic dehydration
5. Based on the nurse's assessment of a diabetic patient, which finding indicates the need for avoidance of exercise at this time? A. Ketone bodies in the urine. B. Blood glucose level of 155 mg/dL. C. Pulse rate of 66 beats per minute. D. Weight gain of 1 pound over the previous week's weight.
A. Ketone bodies in the urine.
Which of the following occurs in septic shock? A. Massive vasodilation B. Increased respiratory rate C. Decreased capillary permeability D. Increased systemic vascular resistance
A. Massive vasodilation
The nurse is caring for a 12-year-old boy who sustained major burns when he put charcoal lighter on a campfire. The nurse observes that he is "very brave" and appears to accept pain with little or no response. The most appropriate nursing action related to this is which of the following? A. Request a psychologic consultation. B. Ask the child why he doesn't have pain. C. Praise the child for ability to withstand pain. D. Encourage continued bravery as a coping strategy.
A. Request a psychologic consultation.
6. A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including A. Stupor B. Erythema C. Increased anxiety D. Rapid respirations
A. Stupor
The nurse is assessing an infant brought to the clinic with diarrhea. He is lethargic and has dry mucous membranes. Which of the following should the nurse recognize as an early sign of dehydration? A. Tachycardia B. Bulging, tense fontanel C. Decreased blood pressure D. Capillary refill of less than 3 seconds
A. Tachycardia
A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply)? A. The level may be increased as a result of dehydration that accompanies hyperglycemia. B. The patient may be excreting extra sodium and retaining potassium because of malnutrition. C. The level is consistent with renal insufficiency that can develop with renal nephropathy. D. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. E. This level demonstrates adequate treatment of the cellulitis and effective serum glucose control.
A. The level may be increased as a result of dehydration that accompanies hyperglycemia. C. The level is consistent with renal insufficiency that can develop with renal nephropathy. D. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.
2. the nurse reminds the staff that standard precautions should be used when providing care for which type of patient? A. all patients regardless of diagnosis B. pediatric and gerontologic patients C. patients who are immunocompromised D. patients with a history of infectious diseases
A. all patients regardless of diagnosis
A young child is brought to the emergency department with SEVERE dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child begins with A. intravenous fluids. B. oral rehydration solution. C. clear liquids, 1 to 2 oz at a time. D. administration of antidiarrheal medication.
A. intravenous fluids.
The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? A. "I should only walk barefoot in nice dry weather." B. "I should look at the condition of my feet every day." C. "I am lucky my shoes fit so nice and tight because they give me firm support." D. "When I am allowed up out of bed, I should check the shower water with my toes."
B. "I should look at the condition of my feet every day."
1. A 54-year-old patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? A. "With type 2 diabetes, the body of the pancreas becomes inflamed." B. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." C. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." D. "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."
B. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased."
To prevent burns from hot water in the home, the nurse should recommend that families set their water heater thermostat to A. 38º C (100º F). B. 49º C (120º F). C. 60º C (140º F). D. 71º C (160º F).
B. 49º C (120º F).
3. A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should INTERVENE immediately when the child's nurse A. Places a hypothermia blanket at the beside B. Adjusts the bed to the Trendelenburg position C. Obtains electronic equipment for monitoring the vital signs D. Secures a pump to administer the ordered intravenous fluids
B. Adjusts the bed to the Trendelenburg position Rationale: It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.
A pregnant patient experiences thyroid storm following delivery of her infant. What interventions would the nurse anticipate to be ordered by the physician? (Select all that apply.) A. Restriction of intravenous fluids to prevent fluid overload B. Administration of oxygen C. Antipyretics D. Synthroid E. PTU
B. Administration of oxygen C. Antipyretics E. PTU
A nurse is working with a diabetic patient who recently found out she is pregnant. In coordinating an interdisciplinary team to help manage the patient throughout the pregnancy, the nurse would include: (Select all that apply.) A. Family practice physician B. Dietician C. Perinatologist D. Occupational therapist E. Nephrologist F. Speech therapist
B. Dietician C. Perinatologist E. Nephrologist
Rapid replacement of fluid is essential in the treatment of which of the following types of dehydration? A. Isotonic, osmotic B. Hypotonic, isotonic C. Osmotic, hypertonic D. Hypertonic, hypotonic
B. Hypotonic, isotonic
The priority assessment in evaluating a pregnant woman with severe nausea and vomiting is: A. Fasting blood glucose level. B. Ketonuria. C. Bilirubin. D. White blood cell count.
B. Ketonuria.
Which of the following findings is not likely to be seen in a pregnant patient who has hypothyroidism? A. Miscarriage B. Macrosomia C. Gestational hypertension D. Placental abruption
B. Macrosomia
The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. What information is appropriate for the nurse to include? A. Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. C. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. D. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.
B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin.
A 51-year-old patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time? A. 6:00 PM on the evening before the test B. Midnight before the test C. 4:00 AM on the day of the test D. 7:00 AM on the day of the test
B. Midnight before the test
A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? A. Avoid sick people and wash hands. B. Obtain comprehensive dental care. C. Maintain hemoglobin A1c below 7%. D. Coughing and deep breathing with splinting
B. Obtain comprehensive dental care.
2. The nurse recommends the pen-injector insulin delivery system for the client with which clinical presentation? A. Confusion and reliance on another person for insulin injections. B. Requirements for intensive therapy with small, frequent insulin doses. C. Visual impairment affecting the ability to draw up insulin accurately. D. Frequent episodes of hypoglycemia.
B. Requirements for intensive therapy with small, frequent insulin doses.
Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: A. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. B. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. C. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. D. At birth, the neonate of a diabetic mother is no longer in any greater risk.
B. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations.
Which of the following statements regarding burn injuries in children is correct? A. Burns are the most frequent cause of accidental death during childhood. B. The prognosis for a burned child is directly related to the amount of tissue destroyed. C. The standard "rule of nines" chart is typically used for assessing the size of a burn in small children. D. Children younger than age 2 years have significantly lower mortality rates than older children with similar burns.
B. The prognosis for a burned child is directly related to the amount of tissue destroyed.
The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? A. 8:40 PM to 9:00 PM B. 9:00 PM to 11:30 PM C. 10:30 PM to 1:30 AM D. 12:30 AM to 8:30 AM
C. 10:30 PM to 1:30 AM
The nurse is explaining to a parent how to care for a child with vomiting associated with a viral illness. Which of the following should the nurse include? A. Give nothing by mouth for 24 hours. B. Avoid carbohydrate-containing liquids. C. Brush teeth or rinse mouth after vomiting. D. Give plain water until vomiting ceases for at least 24 hours.
C. Brush teeth or rinse mouth after vomiting.
A 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? A. Routine insulin therapy and exercise B. Administer a different antibiotic for the UTI. C. Cardiac monitoring to detect potassium changes D. Administer IV fluids rapidly to correct dehydration.
C. Cardiac monitoring to detect potassium changes
7. When planning care for a diabetic patient with microalbuminura, it is important to include which goal to reduce the progression to renal failure? A. Decrease the total percentage of calories from carbohydrates. B. Decrease the total percentage of calories from fruits. C. Decrease the total percentage of calories from proteins. D. Decrease the total percentage of daily caloric intake.
C. Decrease the total percentage of calories from proteins.
Several types of long-term central venous access devices are used. Which of the following is a benefit of using an implanted port (e.g., Port-a-Cath)? A. Accessed without piercing skin B. Easy to use for self-administered infusions C. Easy access for blood work D. Catheter unable to dislodge from port even if the child "plays" with the port site
C. Easy access for blood work
A college student is newly diagnosed with type 1 diabetes. She now has a headache, changes in her vision, and is anxious, but does not have her portable blood glucose monitor with her. Which action should the campus nurse advise her to take? A. Eat a piece of pizza. B. Drink some diet pop. C. Eat 15 g of simple carbohydrates. D. Take an extra dose of rapid-acting insulin.
C. Eat 15 g of simple carbohydrates.
5. What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? A. Dyspnea B. Precordial pain C. Increased pulse rate D. Elevated blood pressure
C. Increased pulse rate
A patient, who is admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? A. Central apnea B. Hypoventilation C. Kussmaul respirations D. Cheyne-Stokes respirations
C. Kussmaul respirations
Which of the following is a major complication of total parenteral nutrition in children? A. Anemia B. Asthma C. Liver disease D. Renal impairment
C. Liver disease
Depression of the central nervous system (CNS), manifested by lethargy, delirium, stupor, and coma, is observed in which of the following? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic and respiratory acidosis D. Metabolic and respiratory alkalosis
C. Metabolic and respiratory acidosis
When caring for a child with an intravenous infusion, the nurse should do which of the following? A. Change the insertion site every 24 hours. B. Use a macrodropper to facilitate the prescribed flow rate. C. Observe the insertion site frequently for signs of infiltration. D. Avoid restraining the child to prevent undue emotional stress.
C. Observe the insertion site frequently for signs of infiltration.
Therapeutic management of the child with acute diarrhea and dehydration usually begins with which of the following? A. Clear liquids such as fruit juice and soft drinks B. Adsorbents, such as kaolin and pectin C. Oral rehydration solution D. Antidiarrheal medications such as paregoric
C. Oral rehydration solution
8. The nurse should institute which precaution for the hypoglycemic patient receiving intramuscular glucagon due to an inability to swallow the oral form? A. Elevate the head of the bed. B. Have a padded tongue blade at the bedside. C. Position the client face down or in a side-lying position. D. Apply pressure and massage the injection site for 5 minutes.
C. Position the client face down or in a side-lying position.
A patient who is pregnant already has Type 2 diabetes with a hemoglobin A1c value of 7. The nurse would categorize this patient as having: A. Gestational diabetes. B. Insulin-dependent diabetes complicated by pregnancy. C. Pregestational diabetes mellitus. D. Non-insulin-dependent diabetes with complications.
C. Pregestational diabetes mellitus.
The newly diagnosed patient with type 2 diabetes has been prescribed metformin (Glucophage). What should the nurse tell the patient to bestexplain how this medication works? A. Increases insulin production from the pancreas. B. Slows the absorption of carbohydrate in the small intestine. C. Reduces glucose production by the liver and enhances insulin sensitivity. D. Increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying.
C. Reduces glucose production by the liver and enhances insulin sensitivity.
A pregnant woman at 14 weeks of gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. The primary goal of her treatment at this time is to: A. Rest the gastrointestinal (GI) tract by restricting all oral intake for 48 hours. B. Reduce emotional distress by encouraging the woman to discuss her feelings. C. Reverse fluid, electrolyte, and acid-base imbalances. D. Restore the woman's ability to take and retain oral fluid and foods.
C. Reverse fluid, electrolyte, and acid-base imbalances.
Which of the following is the viral pathogen that frequently causes acute diarrhea in young children? A. Giardia organisms B. Shigella organisms C. Rotavirus D. Salmonella organisms
C. Rotavirus
A pregnant woman has maternal phenylketonuria (PKU) and is interested in whether or not she will be able to breastfeed her baby. Which reaction by the nurse indicates accurate information? A. The patient can breastfeed the baby as long as she continues to maintain a PKU-restricted diet. B. The patient should alternate breastfeeding with bottle feeding in order to reduce PKU levels provided to the baby. C. The patient should be advised to not breastfeed the infant because her breast milk will contain large amounts of phenylalanine. D. The patient can breastfeed for the first 3 months without any untoward effects on the infant.
C. The patient should be advised to not breastfeed the infant because her breast milk will contain large amounts of phenylalanine.
Enteral feedings are ordered for a young child with burns covering 40% of total body surface area. The nurse should know that A. oral feedings are contraindicated. B. enteral feedings must be stopped during painful procedures. C. presence of a paralytic ileus does not preclude use of enteral feedings. D. the feedings will be high carbohydrate and low protein.
C. presence of a paralytic ileus does not preclude use of enteral feedings.
The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control his blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? A. "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." B. "I will go running each day when my blood sugar is too high to bring it back to normal." C. "I will plan to keep my job as a teacher because I get a lot of exercise every school day." D. "I will take a brisk 30-minute walk 5 days per week and do resistance training 3 times a week."
D. "I will take a brisk 30-minute walk 5 days per week and do resistance training 3 times a week."
3. A diabetic patient has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this patient about exercise? A. "Jogging for 20 minutes 5 to 7 days a week would most efficiently help you to lose weight." B. "One hour of vigorous exercise daily is needed to prevent progression of disease." C. "Avoid all forms of exercise because of your diabetic complications." D. "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you."
D. "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you."
4. Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis? A. Administration of oxygen by nasal cannula at 15 L/min. B. Intravenous infusion of 10% glucose. C. Implementation of seizure precautions. D. Administration of intravenous insulin.
D. Administration of intravenous insulin. Rationale: The Kussmaul's respirations pattern is the body's attempt to reduce the acids produced by utilization of fat for fuel. Administration of insulin will reduce this respiration pattern by assisting glucose transport back into cells to be used for fuel instead of fat. Nasal cannula oxygen is given at 1 to 6 L per minute; intravenous glucose administration will not have the desired effect of treatment; and although seizure precautions may be implemented, they will not have any effect on glucose transport into cells.
1. The nurse teaches which action to the diabetic client who self-injects insulin to prevent local irritation at the injection site? A. Be sure to aspirate prior to injecting insulin. B. Massage the site after injecting insulin. C. Use a 1-inch needle for the injection. D. Allow the insulin to warm to room temperature before injecting it.
D. Allow the insulin to warm to room temperature before injecting it.
Which of the following should the nurse recognize as an early clinical sign of compensated shock in a child? A. Confusion B. Sleepiness C. Hypotension D. Apprehension
D. Apprehension
A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which of the following conditions? A. Parasitic infection B. Fat malabsorption C. Protein intolerance D. Bacterial gastroenteritis
D. Bacterial gastroenteritis
In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: A. Mother's age. B. Number of years since diabetes was diagnosed. C. Amount of insulin required prenatally. D. Degree of glycemic control during pregnancy.
D. Degree of glycemic control during pregnancy.
A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: A. Oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin. B. Dietary modifications and insulin are both required for adequate treatment. C. Glucose levels are monitored by testing urine four times a day and at bedtime. D. Dietary management involves distributing nutrient requirements over three meals and two or three snacks.
D. Dietary management involves distributing nutrient requirements over three meals and two or three snacks.
The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control? A. Prealbumin level B. Urine ketone level C. Fasting glucose level D. Glycosylated hemoglobin level
D. Glycosylated hemoglobin level
The school nurse is called to the cafeteria because a child "has eaten something he is allergic to." The child is in severe respiratory distress. The nurse should do which of the following first? A. Determine what the child has eaten. B. Administer diphenhydramine (Benadryl). C. Move the child to the nurse's office or hallway. D. Have someone call for an ambulance or paramedic rescue squad.
D. Have someone call for an ambulance or paramedic rescue squad.
2. A priority nursing intervention for a patient with hyperthermia would be A. Initiating seizure precautions B. Limiting oral intake C. Providing a blanket D. Removing excess clothing
D. Removing excess clothing
9. A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem? A. Serum chloride level of 90 mmol/L. B. Serum calcium level of 8 mg/dL. C. Serum sodium level of 132 mmol/L. D. Serum potassium level of 2.5 mmol/L.
D. Serum potassium level of 2.5 mmol/L.
1. The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. Increased Respirations B. Rapid pulse rate C. Red, sweaty skin D. Slow capillary refill
D. Slow capillary refill
6. Which clinical manifestation of decreased renal function in the diabetic clinic should the nurse anticipate as a potential problem? A. Elevated specific gravity. B. Ketone bodies in the urine. C. Glucose in the urine. D. Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg.
D. Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg. Rationale: Hypertension is both a cause and a result of renal dysfunction in the diabetic client. Although ketones and glucose in the urine are findings in diabetes mellitus, they are not specific for renal function. Specific gravity is elevated with dehydration.
3. the nurse is teaching a class of junior high school students abput infection control though effective hand washing. The nurse knows the students need further teaching when one states: a. hand sanitizer works just as well as washing with soap and water b. if I sing happy birthday twice through, that should be long enough c. I need to read the label on the hand sanitizer to be sure that it is at least 60% alcohol d. We should all wash our hands before eating lunch
a. hand sanitizer works just as well as washing with soap and water
6. an 82 year old woman is brought to her physician by her daughter with complaints of some confusion. What testing should the nurse suggest for this patient? a. urinalysis b. sputum culture c. red blood cell count d. white blood cell count
a. urinalysis
3. What should the nurse teach the patient in the assisted living facility to decrease risk for antibiotic resistant infection? Select all the apply a. wash hands frequently b. take antibiotics as prescribed c. take antibiotic until it is gone d. take antibiotics to prevent illness like colds e. save leftover antibiotics to take if needed later
a. wash hands frequently b. take antibiotics as prescribed c. take antibiotic until it is gone
4.Which statement by the patient with type 2 diabetes is accurate? a."I am supposed to have a meal or snack if I drink alcohol." b."I am not allowed to eat any sweets because of my diabetes." c."I do not need to watch what I eat because my diabetes is not the bad kind." d."The amount of fat in my diet is not important. Only carbohydrates raise my blood sugar."
a."I am supposed to have a meal or snack if I drink alcohol."
3.Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? a.A1C 9% b.BP 126/80 mm Hg c.FBG 130 mg/dL (7.2 mmol/L) d.LDL cholesterol 100 mg/dL (2.6 mmol/L)
a.A1C 9%
3.Effective interventions to decrease absorption or increase elimination of an ingested poison include which of the following (select all that apply)? a.Hemodialysis b.Milk dilution c.Eye irrigation d.Gastric lavage e.Activated charcoal
a.Hemodialysis d.Gastric lavage e.Activated charcoal
5.You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital (select all that apply)? a.Insulin administration b.Elimination of sugar from diet c.Need to reduce physical activity d.Use of a portable blood glucose monitor e.Hypoglycemia prevention, symptoms, and treatment
a.Insulin administration d.Use of a portable blood glucose monitor e.Hypoglycemia prevention, symptoms, and treatment
8.Which are appropriate therapies for patients with diabetes mellitus (select all that apply)? a.Use of statins to treat dyslipidemia b.Use of diuretics to treat nephropathy c.Use of ACE inhibitors to treat nephropathy d.Use of serotonin agonists to decrease appetite e.Use of laser photocoagulation to treat retinopathy
a.Use of statins to treat dyslipidemia c.Use of ACE inhibitors to treat nephropathy e.Use of laser photocoagulation to treat retinopathy
2.Which antibiotic-resistant organisms cannot be killed by normal hand soap? a.Vancomycin-resistant enterococci b.Methicillin-resistant Staphylococcus aureus c.Penicillin-resistant Streptococcus pneumoniae d.β-Lactamase-producing Klebsiella pneumonia
a.Vancomycin-resistant enterococci
1. Emerging infections can affect health care by (select all that apply) a.revealing antibiotic resistance. b.generating scientific discoveries. c.creating a strain on limited resources. d.challenging established medical traditions. e.limiting travel options for nursing personnel.
a.revealing antibiotic resistance. b.generating scientific discoveries. c.creating a strain on limited resources. d.challenging established medical traditions.
2. Which of the following patients is at great risk for contracting a primary bacterial infection> a. a patient newly diagnosed with diabetes b. a patient with leukopenia c. a patient receiving broad spectrum antibiotics d. a patient following laparoscopic cholecystectomy
b. a patient with leukopenia
7. the patient admitted to the ED with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, diarrhea. What nursing measures will help identify the need for further assessment of the cause of this patient's manifestations? select all that apply a. assessment of lung sounds b. assessment of sexual behavior c. assessment of living conditions d. assessment of drug and syringe use e. assessment of exposure to an ill person
b. assessment of sexual behavior d. assessment of drug and syringe use
4. the patient has vanomycin resistant enterococcci infection in the surgical wound. What infection precautions should the nurse use to best prevent transmission of infection to the hospital staff? a. droplet b. contact c. airborne d. standard
b. contact
1. A hospital has seen recent increase in the incidence of hospital care associated infections. Which measure should be prioritized in response to this trend? a. use of gloves during patient contact b. frequent and thorough hand washing c. prophylactic antibiotics d. fitting and apporpirae ise of N95 masks
b. frequent and thorough hand washing
5. The mother does not want her child to have any extra immunizations for diseases that no longer occur. What teaching about immunization should the nurse provide to the mother? a. there is currently no need for those older vaccines b. there is reemergence of some of the infections, such as pertussis c. there is no longer an immunization available for some of those diseases d. the only way to protect our child is to have federally required vaccines
b. there is reemergence of some of the infections, such as pertussis
3.A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature? a.Use a cooling blanket while the patient is febrile. b.Administer antipyretics on an around-the-clock schedule. c.Provide increased fluids and have the UAP give sponge baths. d.Give prescribed antibiotics and provide warm blankets for comfort.
b.Administer antipyretics on an around-the-clock schedule.
8.A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses is/are most appropriate (select all that apply)? a.Acute pain related to tissue damage and inflammation b.Impaired skin integrity related to immobility and decreased sensation c.Impaired tissue integrity related to inadequate circulation secondary to pressure d.Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke
b.Impaired skin integrity related to immobility and decreased sensation c.Impaired tissue integrity related to inadequate circulation secondary to pressure
5.A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 × 106/µL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a.Imbalanced nutrition: more than body requirements related to high-fat foods b.Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c.Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d.Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking
b.Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking
4.A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a.Tertiary intention b.Secondary intention c.Regeneration of cells d.Remodeling of tissues
b.Secondary intention
1.A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a.The abdominal incision shows signs of an infection. b.The patient is having a normal inflammatory response. c.The abdominal incision shows signs of impending dehiscence. d.The patient's physician needs to be notified about her condition.
b.The patient is having a normal inflammatory response.
2.The nurse assessing a patient with a chronic leg wound finds local signs of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a.Serum protein analysis b.WBC count and differential c.Punch biopsy of center of wound d.Culture and sensitivity of the wound
b.WBC count and differential
2.A patient has a core temperature of 90° F (32.2° C). The most appropriate rewarming technique would be a.passive rewarming with warm blankets. b.active internal rewarming using warmed IV fluids. c.passive rewarming using air-filled warming blankets. d.active external rewarming by submersing in a warm bath.
b.active internal rewarming using warmed IV fluids.
1.An older man arrives in triage disoriented and tachypneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a.obtain a detailed medical history from his wife. b.assess his vital signs, including a rectal temperature. c.determine the kind of insurance he has before treating him. d.start supplemental oxygen and have the ED physician see him.
b.assess his vital signs, including a rectal temperature.
1.Polydipsia and polyuria related to diabetes mellitus are primarily due to a.the release of ketones from cells during fat metabolism. b.fluid shifts resulting from the osmotic effect of hyperglycemia. c.damage to the kidneys from exposure to high levels of glucose. d.changes in RBCs resulting from attachment of excessive glucose to hemoglobin.
b.fluid shifts resulting from the osmotic effect of hyperglycemia.
1. a patient is in contact isolation for bacterial infection. The nurse is going to implement which of the following interventions for the patient? a. prevent visitors from entering the room b. use personal protective equipment only when knowingly coming into contact with pathogens c. help to ensure adequate social interaction and support d. communicate with the patient over the cell light whenever possible.
c. help to ensure adequate social interaction and support
6. What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability? a.Call the physician. b.Administer insulin as ordered. c.Check the patient's blood glucose level. d.Assess for other neurologic symptoms.
c.Check the patient's blood glucose level.
6.Which one of the orders should a nurse question in the plan of care for a patient with a stage III pressure ulcer? a.Pack the ulcer with foam dressing. b.Turn and position the patient every 2 hours. c.Clean the ulcer every shift with Dakin's solution. d.Assess for pain and medicate before dressing change.
c.Clean the ulcer every shift with Dakin's solution.
4.An older woman arrives in the ED complaining of severe pain in her right shoulder. The nurse notes that her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a.Paranoia b.Possible cancer c.Family violence d.Orthostatic hypotension
c.Family violence
9.An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a.Stage I b.Stage II c.Stage III d.Stage IV
c.Stage III
7.A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of a.polyuria. b.severe dehydration. c.rapid, deep respirations. d.decreased serum potassium.
c.rapid, deep respirations.
The nurse identifies that the patient with the greatest risk for a urinary tract infection is a. A 37-year-old man with renal colic (the pain associated) associated with kidney stones. b. A 26-year-old pregnant woman who has a history of urinary tract infections. c. A 69-year-old man who has urinary retention caused by benign prostatic hyperplasia. d. A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence.
d. A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence.
4. After patient teaching, the patient is able to verbalize that _________ can delay wound healing after surgery. a. adequate arterial blood flow to the wound b. supplemental oxygen therapy c. a healthy diet d. an increased hospital stay
d. an increased hospital stay
5. A 5 year old boy with early flu s/s is at school working with some math blocks. He sneezes into his hand and then continues working with his blocks. An unvaccinated teacher's helper cleans up the blocks when the child leaves them on the table. After touching the blocks, she rubs her nose with her hand. The mode of transmission is represented by: a. the 5 year old boy b. the unvaccinated teacher's helper c. the hand to nose contact d. the unwashed math blocks
d. the unwashed math blocks
2.Which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia? a.The patient must receive insulin therapy to prevent ketoacidosis. b.The patient has islet cell antibodies that have destroyed the pancreas's ability to produce insulin. c.The patient has minimal or absent endogenous insulin secretion and requires daily insulin injections. d.The patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome.
d.The patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome.
5.A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of a.a code blue alert. b.a disaster medical assistance team. c.the local police and fire departments. d.the hospital's emergency response plan.
d.the hospital's emergency response plan.
"You are assessing a 12 month old infant for possible signs of dehydration. What are some things you might see? Select all that apply" o Sunken fontanels o Depressed, sunken eyes o Increased respirations o Elevated blood pressure o Weak, thready, rapid pulse o Decreased urine osmolality
o Sunken fontanels o Depressed, sunken eyes o Increased respirations o Weak, thready, rapid pulse o will also see increase in BUN, urine osmolality, hematocrit, creatinine, Hgb o hypotension
