PN 140 Final Exam
You're developing a nursing care plan for a pt with a kidney stone. Which of the following nursing interventions will you include in the pt's plan of care? A Restrict calcium intake B Strain urine with every void C Keep pt in a supine position to alleviate pain D Maintain fluid restriction on 1-2 L per day
B Strain urine with every void
The nurse is assessing several clients. Which clients does the nurse identify as being at high risk for falls? Select all that apply A With visual impairments such as presbyopia B Who is reluctant to use a cane while walking C Who performs Tai Chi exercise daily D Who wears hearing aids and glasses E Who has difficulty arising from a sitting position F Who is male and over 55 years of age
A,B,E
A client is being admitted with a spinal cord transection at c7. Which of the following assessments take priority upon the client's arrival? Select all that apply A Reflexes B Bladder function C Blood pressure D Temperature E Respirations
A,C,D,E
The nurse is reviewing the clients record and notes that the health care provider has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply A Elevated serum creatinine B Elevated thrombocyte cell count C Decreased RBC count D Decreased WBC count E Decreased GFR
A,C,E
A patient with myocardial infarction is receiving tissue plasminogen activator (TPA). While on the therapy, the nurse plans to prioritize which of the following? A Observe for neurological changes B Monitor for any signs or renal failure C Check the food diary D Observe for signs of bleeding
D Observe for signs of bleeding
A pt is suspected of having MS. The neurologist orders various tests. The pt's MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms would correlate with this MRI finding in a pt with MS? Select all that apply A Blurry vision B Pain when moving eyes C Dysarthria D Balance and coordination issues E "Pill rolling" of fingers and hands F Heat Intolerance G Dark spots in vision H Ptosis
A,B,D,G
An older client is agitated and develops new-onset confusion on admission to the long term care unit. What is the best action for the nurse to take to minimize relocation stress syndrome for this client? A Provide reorientation during hourly rounding B Obtain a certified sitter to remain with this client C Speak to the client as little as possible to avoid overstimulation D Provide adequate sedation to lessen fear-provoking situations
A Provide reorientation during hourly rounding
A patient arrives in the ER with complaints of chest pain, and is diagnosed with acute MI. A morphine 4 mg IV was given 5 minutes ago. Which of the following assessments made by the nurse indicates a further immediate action? A Respiratory rate from 20 BPM to 12 BPM B Blood pressure from 120/70 to 100/60 mmHg C The patient still complains of chest pain with a pain scale of 2/10 D Cardiac rate of 103 BPM and a normal sinus rhythm of the ECG
A Respiratory rate from 20 BPM to 12 BPM
Which of the following blood tests is most indicative of cardiac damage? A Troponin B Myoglobin C BNP D CK
A Troponin
A nurse is assessing the neurovascular status of a patient who returned to the surgical nursing unit 4 hours ago after undergoing aortoilliacbypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: A Normal because of the increased blood flow through the leg B Slightly deteriorating and should be monitored for another hour C Moderately impaired and the surgeon should be called D Adequate from the arterial approach, but venous complications are arising
A Normal because of the increased blood flow through the leg
When planning care for the patient with acute pancreatitis, the LPN knows that which intervention is a priority of care? A Pain control B Nutritional supplementation C Observation for mental changes D Observation for intestinal obstruction
A Pain control
The patient diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of discharge instructions? A "His emotions will slow down now just like his movements." B "My spouse may experience hallucinations until the medication starts working." C "I will schedule appointments late in the morning after his morning bath." D "It is fine if we don't follow a strict medication schedule on weekends."
A "His emotions will slow down now just like his movements."
A client admitted with angina complains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which of the following actions should the nurse take first? A Activate the resuscitation team B Open the client's airway C Check for breathing D Check for signs of circulation
A Activate the resuscitation team
The healthcare provider is assisting a patient with severe anemia with ambulation. The patient suddenly experiences dyspnea. What should the healthcare provider do first? A Ask a colleague to get a wheelchair for the patient. B Administer oxygen to the patient. C Quickly assist the patient back to their bed. D Ease the patient to the floor to prevent injury.
A Ask a colleague to get a wheelchair for the patient.
Which of the following is the most important data to collect from the patient who has fallen and bumped their head? A Assess the patient's LOC B Ask if they are taking any anticoagulants C Assess their pupillary reaction D Listen to their breath sounds
A Assess the patient's LOC
The nurse is caring for a pt who has long standing COPD and is recovering from a stroke. Which intervention is a priority when activity tolerance is assessed during rehabilitation? A Assess vital signs before, during, and after activity B Perform a daily cognitive assessment C Consult physical therapy to ambulate the pt D Monitor the pt's progress in self-care ability
A Assess vital signs before, during, and after activity
Which behavior exhibited by an older adult client alerts the nurse to the possibility that the client is experiencing delirium? A Becoming confused within 24 hours after hospital admission B Displaying a cheerful attitude despite poor prognosis C Becoming withdrawn and sleeping most of the day D Beginning to use slurred speech and losing coordination
A Becoming confused within 24 hours after hospital admission
A Pt with multiple sclerosis has issues with emptying the bladder completely. Which medication will the nurse expect to note as a new order to assist with this problem? A Bethanechol B Oxybutynin C Avonex D Amantidine
A Bethanechol
A nurse is instructing a client regarding carbidopa/levodopa. The expected outcome to be monitoring for is? A Ease of performing a voluntary movement B Increased blood pressure C Decreased heart rate D Clearnace of infection
A Ease of performing a voluntary movement
A 24 year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the patient for: A Familial tendency toward peripheral vascular disease B Smoking hx C Recent exposures to allergies D Hx of insect bites
A Familial tendency toward peripheral vascular disease
The nurse and the UAP are caring for patients on a medical-surgical unit. Which task should not be assigned to the UAP? A Feed the 69 year old with Parkinson's disease who is having difficulty swallowing B Turn and position the 89 year old diagnosed with a pressure ulcer secondary to Parkinson's disease C Assist the 54 year old diagnosed with Parkinson's disease with toilet training activities D Obtain vital signs on a 72 year old diagnosed with pneumonia secondary to Parkinson's disease
A Feed the 69 year old with Parkinson's disease who is having difficulty swallowing
Hyperthyroidism is caused by increased levels of thyroxine in the plasma blood. A client with this endocrine dysfunction experiences: A Heat intolerance and systolic hypertension B Weight gain and a goiter C Diastolic hypertension and widened pulse pressure D Anorexia and hyper-excitability
A Heat intolerance and systolic hypertension
A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patients blood pressure because of which change that is associated with liver failure? A Hypo-albuminemia B Increased capillary permeability C Abnormal peripheral vasodilation D Excess rennin release from the kidneys
A Hypo-albuminemia
A client is diagnosed with left sided HF. The nurse should monitor the client for which manifestation characteristic of this disorder? A Lung congestion B Dependent edema C Jugular vein distention D Abdominal distention and weight gain
A Lung congestion
The nurse is caring for a patient following removal of the thyroid. Immediately post-op, the nurse should: A Maintain the pt in a semi-fowler's position with the head and neck supported by pillows B Encourage the pt to turn her head side to side, to promote drainage of oral secretions C Maintain the pt is a supine position with sandbags placed on either side of the head and neck D Encourage the pt to cough and deep breathe every 2 hours, with the neck in a flexed position
A Maintain the pt in a semi-fowler's position with the head and neck supported by pillows
A patient is admitted with chest pain to the ER. The patient has been in the ER for 5 hours and is being admitted to your unit for overnight observation. From the options below, what is the most important information to know about this patient at this time? A Troponin result and when the next troponin level is due to be collected B Diet status C Last consumption of caffeine D CK result and when the next CK level is due to be collected
A Troponin result and when the next troponin level is due to be collected
Which nursing action is most appropriate for a client with acute pancreatitis? A Withholding all oral intake as ordered to decrease pancreatic secretions B Administering pancrealipase as ordered to relieve pain C Limiting IV fluids as ordered to reduce cardiac workload D Keep the client supine to increase comfort
A Withholding all oral intake as ordered to decrease pancreatic secretions
A pt has a hx of HF. Which of the following statements by the pt indicates the pt may be experiencing HF exacerbation?Select all that apply A "I've noticed that I've gained 6 lbs in one week." B "While I sleep I have to prop myself up with a pillow so I can breathe" C "I haven't noticed any swelling in my feet or hands lately." D "I have such an increased appetite."
A,B
The patient with acute exacerbation of chronic pancreatitis has an NG tube and is NPO. Which interventions should the nurse implement? Select all that apply A Monitor bowel sounds B Assess IV site C Provide oral and nasal care D Monitor the blood glucose E Assure NG is to high continuous suction F Test the pH of the gastric contents every hour
A,B,C,D
An older adult client has been admitted to a skilled nursing facility after surgery. What interventions should the nurse add to this client's care plan to assist with adjusting to this situation? Select all that apply A Make sure the client has hearing aids and glasses if applicable B Offer the anxiolytic that the physician has prescribed C Encourage the family to bring in favorite pictures D Ask where the client wants the room furnishings placed E Encourage the client to eat meals alone in his or her room F Offer socialization for the client that includes group activites
A,B,C,D,F
Which ability should the nurse expect from a client in the mild/early stage of dementia of the Alzheimer's type? A Remembering the daily schedule B Recalling past events C Coping with the anxiety of the disease D Solving prolems of daily living
B Recalling past events
The nurse is assessing the dying client. Which manifestations of a dying client should the nurse assess to determine whether the client is near death? A LOC B Respiratory rate C Bowel sounds D Pain level on a 0 to 10 scale
B Respiratory rate
A pt with Alzheimer's disease is going to live with his daughter who does not work outside the home. The nurse determines that the daughter needs further instructions when she makes which of the following statements? A "I've put special locks on all the doors that Dad won't be able to unlock." B "Dad said what he missed most while he was here was using his aftershave so I put a bottle in his bathroom to make him happy." C "Dad will be in a bedroom that has nothing for him to trip over getting to the bathroom." D "I've taken the knobs off the stove so he won't be able to turn it on."
B "Dad said what he missed most while he was here was using his aftershave so I put a bottle in his bathroom to make him happy."
During the assessment of a patient suspected of anemia secondary to a nutritional deficiency, which question is important for the healthcare provider to ask the patient? A "Have you noticed if your stools have changed color?" B "Do you ever experience numbness or tingling of your extremities?" C "Have you noticed if your gums bleed when you brush your teeth?" D "What over-the counter medications do you take regularly?"
B "Do you ever experience numbness or tingling of your extremities?"
A nurse is providing instructions to a patient who is receiving warfarin sodium (Coumadin). Which statement made by the patient indicates the need for further instructions? A "I will observe the color of my urine and stool." B " I will take the Ecotrin (Enteric coated aspirin) for my headache." C "I will avoid drinking alcohol." D "I will take the medication daily at the same time."
B "I will take the Ecotrin (Enteric coated aspirin) for my headache."
A patient who has a diagnosis of chronic bronchitis is experiencing an acute exacerbation and is progressing to respiratory failure. When assessing the patient, which of these will be expected? A Bradycardia B Altered level of consciousness C Weak, thready pulse D Hypotension
B Altered level of consciousness
An older adult client has become agitated and combative toward health care personnel on the unit. What is the first action that the nurse will take? A Obtain an order for a sedative-hypnotic medication to reduce combative behavior B Attempt to soothe the client's fears and reorient the client to surroundings C Obtain an order to place the client's arms in restraints to protect personnel D Arrange for the client to be transferred for a mental health facility
B Attempt to soothe the client's fears and reorient the client to surroundings
A 74 year old female presents to the ER with complaints of dyspnea, persistant cough, and unable to sleep at night due to difficulty breathing. On assessment you note crackles throughout the lungs, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following labs confirm your suspicions of HF? A K+ 5.6 B BNP 920 C BUN 9 D Troponin <0.02
B BNP 920
A patient who has a diagnosis of chronic bronchitis is experiencing an acute exacerbation. Assessments include increasing dyspnea and a cough producing thick, purulent mucus. Which class of medications should the healthcare provider to administer first? A Leukotriene inhibitor B Beta-2 agonist C Non-steroidal anti-inflammatory agent D Mucolytic
B Beta-2 agonist
A patient who has a history of chronic bronchitis is admitted to the medical unit. The healthcare provider notes the red blood cell count is elevated. Which of these is the likely contributing factor to this lab result in this patient? A Hypercapnia B Chronic hypoxia C Insensible water loss D Decreased fluid intake
B Chronic hypoxia
A healthcare provider orders lactulose for a pt with hepatic encephalopathy. The nurse will monitor for effects of this medication for this pt by assessing what? A Relief of constipation B Decreased ammonia levels C Relief of abdominal pain D Increased potassium levels
B Decreased ammonia levels
During a routine prenatal visit by a woman at 24weeks' gestation, the healthcare provider notes the woman's pre-pregnancy hematocrit was 42%, but today the hematocrit is 34%. Which of the following provides the best explanation of the change in hematocrit for this patient? : A The woman is anemic because more of her blood is being diverted to the placenta and fetus. B During pregnancy the increase in plasma volume exceeds the increase in erythrocyte production. C Because she has been experiencing pregnancy-related nausea, the woman's diet has been poor. D Because of pregnancy-related immune suppression, the woman is not making enough erythrocytes.
B During pregnancy the increase in plasma volume exceeds the increase in erythrocyte production.
Which intervention would best support a client who relates a feeling of "loss of control" after having a mild stroke? A Explain that such feelings are normal, but that expectations for rehabilitation must be realistic. B Encourage the client to perform as many tasks as possible and to participate in decision making C Further assess the client's mental status for other signs of denial or psychopathology D Obtain an order for physical and occupational therapy evaluations
B Encourage the client to perform as many tasks as possible and to participate in decision making
For a patient who is in the late stages of chronic bronchitis, which of the following would indicate the patient has developed cor pulmonale? A Night sweats B Hepatomegaly C Hypocapnia D Venous stasis ulcers
B Hepatomegaly
Spironolactone is prescribed for a patient with chronic cirrhosis and ascites. The nurse should monitor the patient for which of the following medication-related side effects? A Jaundice B Hyperkalemia C Tachycardia D Constipation
B Hyperkalemia
A client was admitted to the hospital with ascites and jaundice to rule out cirrhosis of the liver. The biopsy confirms the diagnosis of advanced cirrhosis. Which intervention is of highest priority to be implemented into his care plan? A Administer pain medication as ordered B Monitor PT/PTT trends C Record daily I/O D Manage TPN infusion every 12 hours as ordered
B Monitor PT/PTT trends
A client with Alzheimer's disease has been hospitalized for dehydration. In making an assessment, the nurse notes the presence of a cluster of bruises on the client's buttocks. What is the nurse's priority action? A Call the local police to report a crime B Notify the client's physician and social worker C Confront the client's caregiver with the suspicions D Alert security to prevent visits by the client's caregiver
B Notify the client's physician and social worker
A client is to receive 6 weeks of antibiotic therapy. The nurse expects to use which type of IV catheter? A Hickman B PICC C Nontunneled central D Short peripheral
B PICC
When a pt is taking hydroxychloriquine what is the most important thing to educate this pt about? A Always take on an empty stomach B Schedule an appointment with an optometrist every 6 months C This medication is going to depress the immune system D Always pair with a steroid
B Schedule an appointment with an optometrist every 6 months
A pt who has tested positive for the human immunodeficiency virus (HIV) arrives at the clinic with a report of fever, nonproductive cough, and fatigue. The pt's CD4 count is 345 cells/mcl. How should the nurse interpret these findings? A The pt is diagnosed with AIDS B The pt has a compromised immune system C These findings provide evidence that the pt has seroconverted D This is an expected finding because the pt has tested positive for HIV
B The pt has a compromised immune system
When planning home care for a pt with hepatitis A, which preventative measure should be emphasized to protect the pt's family? A Keeping the pt in complete isolation B Using good sanitation with dishes and shared bathrooms C Avoiding contact with blood soiled clothing or dressing D Forbidding the sharing of needles or syringes
B Using good sanitation with dishes and shared bathrooms
A client is being discharged after undergoing a thyroidectomy. Which discharge instructions are appropriate for this client? Select all that apply A "Report signs and symptoms" B "Take thyroid replacement medication as ordered" C "Watch for changed in body such as lethargy, restlessness, sensitivity to cold, and dry skin, and report changes to the physician" D "Recognize the signs of dehydration" E "Carry injectable dexamethasone at all times"
B,C
A patient who has chronic bronchitis will be receiving oxygen therapy at home. The teaching plan for this patient should include which of these instructions? Select all that apply: A "Be careful around open flames because liquefied oxygen is highly flammable." B "Do not allow smoking in your home while you are receiving oxygen therapy." C "Your body may forget to breathe if you turn the oxygen up too high." D "Oxygen can be addictive so it should be used only when needed." E "Be sure to wash the nasal cannula prongs twice each week to decrease infection risk."
B,C,E
The healthcare provider is caring for a patient experiencing an acute exacerbation of chronic bronchitis. The patient is coughing uncontrollably and is using accessory muscles to breathe. Which of these interventions will support the patient's respiratory status? Select all that apply: A Administer cough suppressant B Administer a corticosteroid C Provide humidified oxygen via face mask D Assist the patient to a side-lying position. E Administer a short acting beta-2 agonist
B,C,E
The healthcare provider is teaching a patient strategies to manage chronic bronchitis. Which of these will be included in the teaching? Select all that apply: A "You should decrease fluid intake to control the amount of edema." B "Here's the address of a nearby smoking cessation support group." C "It's important for you to avoid being around people who are sick." D "Limiting your physical activity is very important." E "I'll show you how to use a spacer when you take your medication."
B,C,E
You're developing a plan of care for a pt who is at risk for pressure injury development. The pt is 75 years old and weighs 95 lbs. The pt is confused and has right and left leg contractures. In addition, the pt has a urinary tract infection and is incontinent of urine. The pt is on aspiration precautions and is ordered a honey thick liquid diet with pureed foods. Select all interventions that would be included in the plan of care for pressure injury: A When feeding the pt keep the head of the bed elevated at 45 degrees and avoid elevating the foot of the bed B Apply barrier cream as needed to the skin daily C Turn the pt every 4 hours D Keep linens and gowns dry and wrinkle free E Use a wedge pillow for the right and left legs daily
B,D,E
You are providing care for a patient with acute hemorrhagic stroke. The patient's husband has been reading a lot about strokes and asks shy his wife did not receive alteplase. What is your best response? A "Your wife was not admitted within the time frame that alteplase is usually given." B "This drug is used primarily for patients who experience an acute heart attack." C "Alteplase dissolves clots and may cause more bleeding into your wife's brain." D "Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase."
C "Alteplase dissolves clots and may cause more bleeding into your wife's brain."
Which instructions will the nurse include when teaching a patient about the proper use of metered dose inhalers? A "After you inhale the medication once, repeat until you obtain relief." B "Make sure that you puff out air repeatedly after you inhale the medication." C "Hold your breath for 10 seconds if you can after you inhale the medication." D "Hold the inhaler in your mouth, take a deep breath, and then compress the inhaler."
C "Hold your breath for 10 seconds if you can after you inhale the medication."
The nurse delegates the unlicensed nursing assistant to ambulate an older adult client. What information must the nurse communicate to the UAP when delegating this task? A "The client has skid-proof socks, so there is no need to use your gait belt." B "Teach the client how to use her walker while you are ambulating up the hall." C "Sit the client on the edge of the bed with legs dangling before ambulating." D "Ask the client if she needs pain medication before you walk her in the hall."
C "Sit the client on the edge of the bed with legs dangling before ambulating."
A pt who has been receiving antiretroviral therapy (ART) to manage infection with HIV has an undetectable viral load. How would the healthcare provider interpret this information? A More tests are needed to determine the effectiveness of ART B HIV has been eliminated from the client's blood C ART has been effective in reducing viral load D ART can be discontinued in 3 months
C ART has been effective in reducing viral load
Which of the following actions is the first priority of care for a patient exhibiting signs and symptoms of coronary artery disease? A Decrease anxiety B Enhance myocardial oxygenation C Administer sublingual nitroglycerin D Educate the patient about his symptoms
C Administer sublingual nitroglycerin
A patient is undergoing peritoneal dialysis. The dialysate dwell time is completed and the dwell clamp is opened to allow dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount instilled was 1500 ml. Which of the following interventions would be done first? A Continue with the next bag early to instill into peritoneum B Call the physician C Check the catheter for kinks or obstruction D Clamp the catheter and instill more dialysate at the next exchange time
C Check the catheter for kinks or obstruction
The nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mmHg. What should the nurse do first? A Position the client on the left side B Control the environment by turning lights off and decreasing stimulation C Check the client's bladder for distention D Administer pain medication
C Check the client's bladder for distention
A 58 year old client with a 40 year hx of smoking one to two packs of cigarettes a day has chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this info, he most likely has which of the following conditions? A Adult respiratory distress syndrome (ARDS) B Asthma C Chronic obstructive bronchitis D Emphysema
C Chronic obstructive bronchitis
The healthcare provider is reviewing a patient's laboratory results and notes the hemoglobin is 9 and the hematocrit is 28%. Which of the following orders will the healthcare provider expect to implement first? A Administer PO ferrous sulfate (iron). B Administer cyanocobalamin (vitamin B12) IM. C Draw blood for red blood cell indices. D Type and cross for a blood transfusion.
C Draw blood for red blood cell indices.
The patient diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the patient to assume to help decrease the pain? A Recommend lying in the prone position with legs extended B Maintain a tripod position over the bedside table C Place the patient in a side-lying position with knees flexed D Encourage a supine position with a pillow under the knees
C Place the patient in a side-lying position with knees flexed
Which of the following is not included in a care plan of a patient with moderate cognitive impairment involving dementia of the alzheimer's type? A Daily structured schedule B Positive reinforcement for ADLs C Stimulating environment D Use of validating techniques
C Stimulating environment
A patient who has a diagnosis of chronic bronchitis is receiving albuterol (Proventil) via nebulizer to treat an acute exacerbation. Which assessment noted by the healthcare provider is an indication the patient is experiencing an side effect of this medication? A Urinary incontinence B Sedation C Tachycardia D Hypoglycemia
C Tachycardia
The client is diagnosed with peritonitis. Which assessment data indicates to the nurse that the client's condition is improving? A The client is using more pain medication on a daily basis B The client's NG tube is draining coffee-ground material C The client has a decrease in temperature and a soft abdomen D The client has had two soft, formed bowel movements
C The client has a decrease in temperature and a soft abdomen
The rehabilitation nurse is caring for an obese pt with new bilateral leg amputations. The nurse is planning to move the client from the bed to the chair. What is the best approach? A Use the bear hug method to transfer the pt safely B Ask several members of the health care team to assist C Utilize the facility's mechanical lift to move the pt D Consult physical therapy before performing all transfers
C Utilize the facility's mechanical lift to move the pt
The healthcare provider is assessing a patient with a 20 year history of smoking and a chronic cough. Which description of the patient's cough best supports a diagnosis of chronic bronchitis? A "Usually my cough occurs in the evening." B "My cough is brassy and hoarse." C "I sound like a barking seal when I cough." D "I cough up a lot of thick mucus."
D "I cough up a lot of thick mucus."
The spouse of a dying client states that she is concerned that her husband is choking to death. What is the nurse's best response? A "Do not worry. The choking sound is normal during the dying process." B "I will administer more morphine to keep your husband comfortable." C "I can ask the respiratory therapist to suction secretions out through his nose." D "I will have another nurse assist me to turn your husband on his side."
D "I will have another nurse assist me to turn your husband on his side."
After receiving a change of shift report at 0700, the RN and LPN are discussing the assignment. Which of these patients will the LPN assess first? A 28 year old with a migraine headache who is complaining of severe nausea associated with retching B 45 year old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching C 59 year old with Parkinson's disease who will need a swallowing assessment before breakfast D 63 year old with MS who has an oral temperature of 101.8 F and flank pain
D 63 year old with MS who has an oral temperature of 101.8 F and flank pain
A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000mls from the collection bag. One hour later the collection bag is full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of what substance is considered abnormal? A Creatinine B urobilinogen C Chloride D Albumin
D Albumin
A pt is wearing a continuous cardiac monitor which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: A Alert a code blue B Begin chest compression C Open the airway D Check pt status and lead placement
D Check pt status and lead placement
Which of the following indicates that the client with COPD who has been discharged to home understands the instructions? A Client promises to do pursed lip breathing at home B Client states actions to decrease pain C The client agrees to use an O2 cannula at 5 liters per min D Client agrees to call PCP as dyspnea upon exertion increases
D Client agrees to call PCP as dyspnea upon exertion increases
A patient with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for? A Stomatitis B Malaise C Hand tremors D Confusion
D Confusion
The nurse is performing passive range of motion exercises on a semiconscious pt and meets resistance while attempting to extend the right elbow more than 45 degrees. What action by the nurse is best? A Splint the joint and continue passive range of motion to the shoulder only B Progressively increase joint motion 5 degrees beyond resistance each day C Apply weights to the right distal extremity before initiating any joint exercise D Continue to move the joint only to the point at which resistance is met
D Continue to move the joint only to the point at which resistance is met
Which of the following classes of medications maximizes cardiac performance in patients with HF by increasing ventricular contractility? A Beta-adrenergic blockers B Calcium channel blockers C Diuretics D Inotropic agents
D Inotropic agents
A patient with a spinal cord injury at level C3-C4 is in the ER. What is the priority assessment? A Determine the level at which the patient has intact sensation B Assess the level at which the patient has retained mobility C Check blood pressure and pulse for signs of spinal shock D Monitor respiratory effort and oxygen saturation
D Monitor respiratory effort and oxygen saturation
The nurse caring for a patient diagnosed with parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? A Consult the occupational therapist the adaptive appliances for eating B Request a low-fat, low sodium diet from the dietary department C Provide three meals per day that include nuts and whole-grain breads D Offer six meals per day with a soft consistency
D Offer six meals per day with a soft consistency
What is the best way to check for patency of the AV fistula for hemodialysis? A Pinch the fistula and note the speed of filling on release B Use a needle and syringe to aspirate blood from the fistula C Check for capillary refill on the nail beds on that extremity D Palpate the fistula throughout its length to assess for a thrill
D Palpate the fistula throughout its length to assess for a thrill
The nurse assesses for which finding to indicate recovery is occurring in acute kidney injury? A Daily doubling of urine output (4 to 5 L/day) B Urine output less than 400 ml/day C Urine output less than 100 ml/day D Stabilization of renal function
D Stabilization of renal function
The LPN is preparing to perform oral care for an unconscious pt. Which of the following actions should the LPN do first? A Perform a swallowing test B Place the pt in the Sims position C Separate the teeth with a padded tongue blade D Suction secretions from oral cavity
D Suction secretions from oral cavity
Discharge teaching for a patient receiving beta-agonist bronchodilator should emphasize reporting which side effect? A Hypoglycemia B Nonproductive cough C Sedation D Tachycardia
D Tachycardia
The healthcare provider is assessing a patient with a diagnosis of chronic bronchitis. Which of these physical findings represents the effects of air trapping in this patient? A The sternum is prominently protruding from the chest. B There are indentations in the intercostal spaces during inspiration. C Asymmetrical expansion of the thorax is noted during inspiration. D The width of the chest is equal to the depth of the chest.
D The width of the chest is equal to the depth of the chest.
What is the primary reason for administering morphine to a pt with an MI? A To sedate the pt B To decrease the pt's pain C To decrease the pt's anxiety D To decrease oxygen demand on the pt's heart
D To decrease oxygen demand on the pt's heart
