pn2 exam 1
18. A nurse is caring for a client whose arterial blood gas (ABG) results show a pH of 7.36, HCO3: 30 mEq/L. PaCO2: 50 mm Hg. The nurse correctly interprets these results as which of the following? A. Fully compensated metabolic acidosis B. Fully compensated respiratory acidosis C. Normal ABG result D. Uncompensated respiratory acidosis
B. Fully compensated respiratory acidosis
8. Immediately after having surgery to create an ileostomy. Which goal has the highest priority? A. Maintaining odor formation B. Maintaining fluid and electrolyte balance C. Assisting the client with self-care activities D. Providing relief from constipation
B. Maintaining fluid and electrolyte balance
30. The nurse obtains all of the following assessment data about a client with deficient fluid volume caused by dehydration. Which of the following assessment data will be of greatest concern? A. Urine output is 30ml over the last hour B. Oral fluid intake is 100ml for the last 8 hours C. There is prolonged skin tenting over the sternum D. The blood pressure is 88/40 mmHg
D. The blood pressure is 88/40 mmHg
5. when teaching the client with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the client to report which symptoms to the health care provider (HCP)? Select all that apply. A. Cloudy urine for the first few days B. New onset of blood in the urine C. urinating every 3 to 4 hours D. Mild nausea E. Rash F. fever above 100° F
B. New onset of blood in the urine E. Rash .F. fever above 100° F
17.The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea that has lasted a week. For which complication will the nurse assess? (Select all that apply) A. Deep vein thrombus B. Skin breakdown C. Hyperkalemia D. Dehydration E. hypokalemia
B. Skin breakdown D. Dehydration E. hypokalemia
24. The nurse is assessing an elderly client receiving IV fluids. Which of the following would not indicate fluid volume overload? A. Distended neck veins when positioned at 4 degrees B. Weak and thready pulses C. Course crackles in the lungs field D. Pitting edema of the lower extremities
B. Weak and thready pulses
7.A nurse is reviewing the blood urea nitrogen (BUN) and creatinine levels of an older client admitted for acute renal failure as a result of obstructive renal calculi. The nurse should expect which of the following laboratory findings? BUN 12 mg/dL and creatinine 0.6 mg/dL BUN 9 mg/dL and creatinine 0.7 mg/dL BUN 34 mg/dL and creatinine 5.2mg/dL BUN 21 mg/dL and creatinine 1.0 mg/dL
BUN 34 mg/dL and creatinine 5.2mg/dL
33. The nurse is caring for a client a with a bleeding duodenal ulcer who was admitted to the hospital after vomiting bright red blood. Which condition does the nurse anticipate when the client develops a sudden, sharp pain in the mid-epigastric region and a rigid, board-like abdomen? A. Pancreatitis B. Development of ad C. Small bowel obstruction D. Ulcer perforation
D. Ulcer perforation
10. The nurse is evaluating the fluid volume status of a client after ileostomy surgery. Which finding indicates that adequate fluid replacement has been achieved in the client? A. Fluid intakes less than urinary output B. An increase in body weight C. Blood pressure of 90/40 mm Hg D. Urine output greater than 30 mL/Hr.
D. Urine output greater than 30 mL/Hr.
22.The nurse will anticipate preparing an older client who is vomiting coffee-ground emesis which of the following? a. angiography b. endoscopy. c. barium studies. d. gastric analysis.
b. endoscopy.
2. The community nurse is talking with a group of individuals about colorectal cancer risk factors. Which community participant is at the highest risk for development of colorectal cancer? A. A 39-year-old with no family history of cancer B. A 23-year-old vegetarian C. A 46-year-old with a genetic predisposition to cancer D. A 30-year-old with Crohn's disease
D. A 30-year-old with Crohn's disease
27. A nurse is caring for a client who has a postoperative ileus and a nasogastric (NG) tube that has drained 2500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse expect and monitor for in this client? A. Elevated magnesium level B. Elevated sodium level C. Elevated potassium level D. Decreased potassium level
D. Decreased potassium level
31. A client with a calcium level of 14 mg/dL is being cared for on the medical unit. Nursing actions included in the care plan will include which of the following? A. Maintaining the client on bed rest B. Monitoring for bounding pulses C. Auscultating lung sounds every 4 hours D. Encouraging increased fluid intake daily
D. Encouraging increased fluid intake daily
32. A nurse is assessing a client who states she has leakage of small amounts of urine when attempting to get out of bed. The nurse should associate these findings with which of the following type of urinary incontinence? A. Reflex incontinence B. Urge incontinence C. Stress incontinence D. Functional incontinence
D. Functional incontinence
37. The nurse is evaluating the arterial blood gas (ABG) results of her clients. Which of the following ABG result exhibits partially compensated respiratory alkalosis? A. PH 7.50, PaCO2: 50mm Hg. HCO3: 38 mEq/L B. PH 7.24, PaCO2: 33 mm Hg. HCO3: 26 mEq/L C. PH 7.33, PaCO2: 55 mm Hg. HCO3: 30 mEq/L D. PH 7.55, PaCO2: 30 mm Hg. HCO3: 19mEq/L
D. PH 7.55, PaCO2: 30 mm Hg. HCO3: 19mEq/L
28. A nurse is admitting a client with suspected appendicitis. The nurse understands that this client will most likely identify pain at which of the following locations. A. Right upper quadrant (RUQ), Blarney's point B. Left lower quadrant (LLQ), Chvostek's point C. Left upper quadrant (LUQ), Trousseau's point D. Right lower quadrant (RLQ), McBurney's point
D. Right lower quadrant (RLQ), McBurney's point
21.A nurse is preparing to administer intravenous ciprofloxacin 400 mg IV to her client diagnosed with a urinary tract infection. The medication is available as 400 mg/100 mL normal saline solution. The order is to infuse the 100 mL bag in 30 minutes. What is the rate in mL/hr.) the nurse must infuse the medication at? (Round the answer to the nearest whole number. Do not use a trailing zero)
200
46. The provider ordered a continuous IV infusion of normal saline (NS) with 20 mEq of potassium chloride (KCI)/ liter to infuse at 50 mL/hr. The first 1-liter bag was hung at 0200. What time does the nurse anticipate needing to hang the second bag of IV fluids? (Record answer in military time)
2200
44. A nurse is preparing to infuse a 400 ML unit of packed red blood cells (PRBCs) over 4 hours. The drop factor of the manual IV tubing is 15 gtts/mL. what is the infusion rate in gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero)
25
36. which client is at greatest risk for development of hypercalcemia? A. A middle aged adult with a thyroid disorder B. An older adult with lactose intolerance C. An older adult taking a nonsteroidal anti-inflammatory D. A middle aged adult with chronic end stage kidney disease.
A. A middle aged adult with a thyroid disorder
48. A client has renal colic due to renal lithiasis. What is the nurse's priority in managing care for the client? A. Administer an opioid analgesic as prescribed. B. Encourage the client to drink at least 500 mL of water each hour. C. Do not allow the client to ingest fluids. D. Request the central supply department to send supplies for straining urine.
A. Administer an opioid analgesic as prescribed.
9. A client has the following arterial blood gas (ABG) results; pH 7.30, HCO3; 17 mEq/L, PaCO2; 25 mm Hg; PO2; 98 mm Hg. Which intervention by the nurse is most appropriate? A. Assess the client and notify the physician using SBAR communication. B. These are normal findings; document and continue to assess. C. Place the client on 2L oxygen via nasal cannula. D. Prepare to administer the ordered albuterol nebulizer treatment.
A. Assess the client and notify the physician using SBAR communication.
13. The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box, located inside the client's room. The medication dosage is not labeled, but the nurse recognizes the color and shape of the capsule. Which of the following should the nurse do next? A. Contact the pharmacy to bring a properly labeled medication B. Ask another registered nurse (RN) to verify that the capsule is ampicillin C. Notify the unit manager to report the problem D. Administer the medication to maintain blood levels of the drug
A. Contact the pharmacy to bring a properly labeled medication
41.The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply) A. Corticosteroids B. Caffeine C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Alcohol E. Fruit juice
A. Corticosteroids B. Caffeine C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Alcohol
6. A new nurse is working with a preceptor on an inpatient medical- surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse? A. Ensuring client safety B. Providing client-focused care C. Not making medication errors D. Attending to holistic client needs
A. Ensuring client safety
50. The nurse is assessing the client who has started to complain of muscle cramps and paresthesia in his hands and feet. The nurse notes a positive Chvostek sign upon assessment and knows this result is associated with which electrolyte disorder? A. Hypocalcemia B. Hyperkalemia C. Hypophosphatemia D. Hypercalcemia
A. Hypocalcemia
20.A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIS). Which of the following client statements indicates a need for further teaching? A. I will need to wipe my perineal area from back to front after urination B. I will need to drink apple cider vinegar each day C. I need to drink 8 cups of liquid each day D. I will need to empty my bladder regularly and completely.
A. I will need to wipe my perineal area from back to front after urination
16. The nurse is caring for a client who has been diagnosed with esophageal cancer. The client appears anxious and asks the nurse, does this mean I'm going to die? Which nursing response is appropriate? (Select all that apply) A. It sounds like death frightens you. B. No, surgery can cure you C. Let me sit with you for a while, and we can discuss how you are feeling about this D. Let me call the hospital chaplain to talk to you E. You can beat this disease if you just put your mind to it
A. It sounds like death frightens you. C. Let me sit with you for a while, and we can discuss how you are feeling about this
3. Which blood laboratory value does the nurse need to evaluate to determine whether the client's acidosis has a respiratory origin or metabolic origin? A. PaCO2 B. Potassium C. Lactic acid D. p
A. PaCO2
25. The nurse writes the nursing problem of fluid volume excess (FVE). Which intervention should be included in the plan of care? A. Restrict the client's sodium in the diet B. Change the IV fluid from 0.9% normal saline to D5W C. Prepare the client for hemodialysis D. Monitor blood glucose levels
A. Restrict the client's sodium in the diet
40.A client is admitted to the emergency room with a respiratory rate of 6 breaths/min. Arterial blood gas (ABG's) have been drawn and reveal the following values: pH 7.22, PaCO2;68 mmHg, HCO3; 25 mEq/L. which of the following is an appropriate analysis of these ABG'S? A. Uncompensated respiratory acidosis B. Partially compensated metabolic alkalosis C. Uncompensated metabolic acidosis D. Partially compensated respiratory alkalosis
A. Uncompensated respiratory acidosis
23. A nurse is teaching a client who has fluid overload about recognizing symptoms associated with his condition. Which of the following client statements indicates the teaching was understood? (Select all that apply) A. if my resting heart rate is elevated, that means the condition may be worsening B. if I have gained 1 pound in a week, I need to call my doctor C. increased blood pressure may indicate a worsening problem D. if my legs have edema, this could mean I am retaining fluid E. if my respirations fall below 18 per minute, I need to call my docto
A. if my resting heart rate is elevated, that means the condition may be worsening C. increased blood pressure may indicate a worsening problem D. if my legs have edema, this could mean I am retaining fluid
11.Before the nurse administer IV replacement of 5% dextrose in water with potassium chloride. What action is appropriate for the nurse to take? A. Adding potassium chloride to the bag at the bedside B. Evaluating laboratory results for electrolytes C. Checking the rate for IV push administration D. Priming tubing using sterile technique
B. Evaluating laboratory results for electrolytes
42. A 10-year-old with a history of recent respiratory infection has swelling around the eyes in the morning and dark urine, what question should the nurse ask first? select all that apply A. "Does the child have any allergies?" B. "Does the child drink a lot of liquids?" C. "Has the child had a sore throat?" D. "Has the child had a rash and a fever?"
B. "Does the child drink a lot of liquids?" C. "Has the child had a sore throat?"
14. A nurse enters a client's semiprivate room and prepares to administer the 0900 medication. Place the steps in chronological sequence, indicating the measures to take to administer the medication safely. 1) Open the unit dose packages. 2) Confirm the client's identity. 3) Administer the medication. 4) Check the clients' medication administration record (MAR) for the 0900 medications. 5) Obtain the correct unit dose medication. A. 5,4,3,2,1 B. 4,5,2,1,3 C. 5,1,4,2,3 D. 2,5,1,4,3
B. 4,5,2,1,3
39.The nurse just received change of shift report on all the following clients. Which one should the nurse assess first? A. A 23-year-old adult male admitted with pyelonephritis, a temperature of 100.1 F, and white blood cell (WBC) count of 13,500 cells/mcL B. A 29-year-old client who had a colon resection yesterday, Foley catheter removed 12 hours ago, has been receiving morphine sulfate for pain, and has not voided for 14 hours. C. A 57-year-old client admitted today with hematuria and possible bladder cancer. The client is scheduled for cystoscopy in 2 hours. D. A 53-year-old client with chronic renal failure. The client has a blood pressure of 104/61 mm Hg a serum creatinine level of 5.6 mg/dL and is scheduled for hemodialysis today
B. A 29-year-old client who had a colon resection yesterday, Foley catheter removed 12 hours ago, has been receiving morphine sulfate for pain, and has not voided for 14 hours.
43. A client with a serum sodium level of 113 mEq/L has been receiving 3% sodium chloride IV infusion at 50 mL/hr for 16 hours. The client feels tired and short of breath. Which of the following is a priority? A. Check the latest sodium level B. Assess for signs of fluid overload C. Notify the physician D. Obtain order to decrease infusion
B. Assess for signs of fluid overload
4. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later, the client reports constant abdominal pain. Which action would the nurse take next? A. Position the client with knees to chest B. Assess the client's bowel sounds C. insert a nasogastric tube for decompression D. Administer intravenous opioid medications
B. Assess the client's bowel sounds
49. A client is receiving 250 mL of a 3% sodium chloride solution intravenously for severe hyponatremia. Which signs or symptoms indicate to the nurse that this therapy is effective? A. Bowel sounds are present in all four abdominal quadrants. B. Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg. C. Serum potassium level has decreased from 4.4 mEq/L to 4.2 mEq/L. D. The client reports hand swelling.
B. Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg
1.The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? A. A 52-year-old with pneumonia and chronic back pain who is requesting pain medication for severe pain B. An 84-year-old with left sided weakness who is slightly confused and has been awake most of the night C. A 35-year-old admitted after motor vehicle accident whose urine output has totaled 30mL over the last 2 hours. D. A 38-year-old who is 2 days post-mastectomy due to breast cancer, having difficulty coping with the diagnosis.
C. A 35-year-old admitted after motor vehicle accident whose urine output has totaled 30mL over the last 2 hours
38. which client is at greatest risk for the development of hyperkalemia? A. A male with type 2 diabetes taking an oral antidiabetic agent B. A female taking nonsteroidal anti-inflammatory drugs daily C. A female with hypertension using a salt substitute D. A male taking a thiazide diuretic for heart failure
C. A female with hypertension using a salt substitute
12.A client has the following arterial blood gas (ABG) results; pH 7.30, HCO3; 22mEq/L PaCO2; 67mm Hg, PaO2; 66mm Hg. Which intervention by the nurse takes priority? A. Administer mucolytic B. Administer bronchodilator C. Assess the client's airway D. Provide oxygen via nasal cannula
C. Assess the client's airway
45. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on the list? A. Scrambled eggs B. Nonfat milk C. Chocolate D. Baked chicken
C. Chocolate
29. The primary goal of nursing care for a client with stress incontinence is which of the following? A. Help the client adjust to the frequent episodes of incontinence B. Prevent the development of urinary tract infections C. Decrease the number of incontinence episodes D. Eliminate all episodes of incontinence
C. Decrease the number of incontinence episodes
19. A nurse is caring for a client who has been admitted for an exacerbation of Crohn's disease. A nasogastric (NG) tube has been placed and is to suction, and the client is currently receiving an infusion of total parental nutrition via a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take? A. Remove unused parenteral nutrition after 12 hours of use B. Monitor the flow rate of the parenteral nutrition carefully and increase the rate as needed if it falls behind. C. Monitor laboratory values and assess for abnormal respiratory or cardiac functioning D. Place the parenteral nutrition solution on a warming device during infusio
C. Monitor laboratory values and assess for abnormal respiratory or cardiac functioning
26. A client with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension at home for indigestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first? A. Administer magnesium IV replacement as ordered B. Check the chart for the most recent (blood urea nitrogen) BUN and creatinine levels C. Review the magnesium level on the client's chart D. Notify the client's health care provider
C. Review the magnesium level on the client's chart
15. The client has the following arterial blood gas (ABG) results: pH 7.48, HCO3; 35mEq/L, PaCO2; 46mm Hg. The nurse correlates these values to which clinical situation in the client. A. 15 liquid stools daily for 7 days B. Anxiety induced hyperventilation C. Shallow respirations of 5/minute D. Tracheostomy suctioning every hour for thick copious secretions
C. Shallow respirations of 5/minute
47. which assessment findings would alert the nurse to a client's worsening hypernatremia? A. The client's deep tendon reflexes have increased from 1+ to 2+ B. The client has an irregular heart rhythm C. The client has an altered mental status D. The clients diastolic blood pressure has decreased by 8 mm Hg
C. The client has an altered mental status
35. which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? a. An 80-year-old man who has benign prostatic hyperplasia b. A 62-year-old woman with a known allergy to contrast media c. A 48-year-old woman with established urinary incontinence d. A 45-year-old man receiving oral and intravenous fluid therap
a. An 80-year-old man who has benign prostatic hyperplasia
34. The nurse is providing teaching for a client who has experienced an acute episode of gastritis. Which of the following instructions should the nurse include in the teaching? a. Limit drinking milk. b. Take nonsteroidal anti-inflammatory drugs (NSAIDS) for pain. c. Avoid drinking alcohol. d. Limit strenuous exercise.
c. Avoid drinking alcohol.
