PN2 FINAL EXAM VERSION 2

A client asks the nurse why it is important to be weighed every day of he has right-sided heart failure. What is the nurse's best response?

"Weight is one of the best indicators that you are gaining or losing fluid"

The nurse is caring for four clients with asthma. Which client does the nurse assess first?

A client whose heart rate is 120 beats/min

Which teaching intervention is most appropriate for the client with Parkinson's disease?

Fall precautions

**The nurse assesses for which clinical manifestation in a client with suspected diabetic ketoacidosis?**

Increased rate and depth of respirations Previous exam ans **Oral temp 102F**

Which medication will the nurse prepare to administer to the client who is experiencing status epilepticus?

Lorazepam

A client is experiencing a loss of central vision nut not a loss of peripheral vision. The nurse realizes the client should be evaluated for which condition?

Macular degeneration

The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which action is part of the plan or preparation and administration of the potassium?

Prepare the medication for bolus administration

A client brought to the emergency department states that he has accidentally been taking two times has prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Prepare to draw a sample for an activated partial thromboplastin time(aPTT) level **Prepare to draw a sample for of PT/INR*

A client is admitted with a possible deep vein thrombosis (DVT). Nursing interventions should be implemented to prevent which complication?

Pulmonary Embolism

A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?

Red meat

A client receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider?

Sodium 154

The nurse is changing the central line of a client receiving TPN and notes that the catheter insertion site appears reddened. The nurse should next assess what item?

Temperature

A client is admitted with a diagnosis of diabetic ketoacidosis. Which ABG lab value would the nurse expect to see in this client?

pH 7.29; PACO2 35; HCO3 18

Which arterial blood gas value are expected with hyperventilation?

pH 7.55; PaCO2 32 mmHg; HCO3 25 mEq/L

A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause?

"Do you use diuretics or laxatives?"

**A client diagnosed with heart failure is prescribed furosemide. Which of the following should this client be monitored for because of this medication? SATA

**Hypokalemia, ** Hyponatremia, Dehydration

***A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?**

**Placing the client in at least Semi-Fowler's position during meals**

The nurse is assessing a client with anemia. Which clinical manifestations does the nurse expect to see in this client?

Dyspnea with activity

Which action should the nurse take when caring for a newly admitted client receiving a blood transfusion?

Instruct the client to report any itching, chest pain, or dyspnea

The nurse is discussing an elderly client's diet and nutritional status with the hospital dietician. The nurse knows this client is at risk for which complication?

Malnutrition

A nurse is caring for a client with a bowel obstruction with a Nasogastric tube (NG) in place to low intermittent suction. The nurse would assess for which of the following conditions?

Metabolic Alkalosis

A client diagnosed with type 1 diabetes mellitus administers a dose of NPH insulin at 7:00 am. At which of the following times would this client most likely exhibit hypoglycemia?

1400

The provider ordered normal saline with 20mEq of KCL to infuse at 50ml/hr. A 500ml bag was hung at 0900. What time does the nurse anticipate needing to hang the second bag of IV fluids

1900

The nurse is notifying the health care provider via telephone of a change in the condition of a client diagnosis with an exacerbation of asthma. Arrange in the nursing statements in order as they would be communicated using the SBAR method: 1 Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 L nasal cannula. 2 I am notifying you because Bob Smith has become increasingly short of breath with audible- wheezing this afternoon 3 I recommend that we increase his oxygen dose and prescribe and extra albuterol inhaler 4 Hello. My name is Nurse Jones from Unit D 5 Respirations are now 32 breaths/ minute. The pulse oximeter is 89% on 2 L nasal cannula. Lungs reveal wheezing in all lung fields

4,1,2,5,3

**Which client is at greatest risk for atherosclerosis?**

A 65-year-old client who is obese with LDL of 188 ***A 43-year-old male with a family history of heart disease and a cholesterol level of 158mg/dL ***(I think this one is wrong)

Phenazopyridine is prescribed for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with information regarding this medication.

A reddish orange discoloration of the urine may occur

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations specific to hypoglycemia (SATA)

A. Polydipsia B. Polyuria

The nurse is concerned that a client with a gastrostomy feeding tube is developing a complication. Which of the following are considered complications associated with this type of feeding tube? (SATA)

Abdominal distention Nausea Vomiting Aspiration

The home care nurse is about to administer intravenous medication to the client and reads in the chart that the peripherally inserted central catheter (PICC) line in the client's arm has been in place for four weeks. The PICC line is patent with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. What is the nurses best action?

Administer the prescribed medication

Which action by the nurse is most effective to prevent becoming exposed to the human immunodeficiency virus?

Always use Standard Precautions with all clients in the workplace

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a deep vein thrombosis (DVT)?

Apply sequential compression device; Assess legs for redness or swelling; Administer ordered subcutaneous heparin; **Turn patient every 2 hours** ( not sure)

A client appears dyspneic; nut the oxygen saturation is 97%. What action by the nurse is best?

Assess for other manifestations of hypoxia

The nurse is caring for a client who was started on TPN two days previously. The client reports increased thirst, dry mouth, and voiding frequently. Which is the nurses most appropriate action?

Assess the clients blood sugar

A nurse is assessing a client with mechanical bowel obstruction who reports intermittent abdominal pain. An hour later, the client reports constant abdominal pain. Which is the nurse's priority action?

Assess the clients bowel sounds

A client has the following arterial blood gases (ABGs): pH 7.30, HCO3 22mEq/L, PaCO2 55 mm Hg, PaO2 86mm Hg. Which intervention by the nurse takes priority?

Assessing the airway

A client being treated for a spinal cord injury needs immediate ventilator support. The nurse realizes that this client's level of injury is most likely at which level

C3

The nurse assesses a client with pneumonia and notes decreases lung sounds on the left side and decreased left side lung expansion. What is the nurse's best action?

Check O2 Stats and notify provider **another answer** Assess oxygen saturation and notify the health care provider.

A client receiving care for a spinal cord injury complains of pounding headache, flushed skin, cardiac dysrhythmias and has a blood pressure of 220/125. What is the first action the nurse should take?

Check bladder for distention

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs

The nurse has completed an assessment on a client with decreased cardiac output. Which findings should receive highest priority?

Confusion, urine output 15mL over the last 2 hours, orthopnea

The nurse conducts a physical assessment for a client with abdominal pain. Which findings leads the nurse to suspect appendicitis?

Constant right lower quadrant pain Severe, steady right lower quadrant pain(PositiveObturator)

To delay the onset of microvascular and macrovascular complications in the diabetic clinic. The nurse stress which action?

Controlling Hyperglycemia

A client who is experiencing an exacerbation of Chron's disease should be monitored for which complication?

Dehydration

A client is worried about contracting influenza. What is the nurses best response to the client?

Did you receive a flu vaccine this year?

Which of the following would the nurse most likely assess in a client diagnosed with right sided heart failure?

Distended neck veins

A client is suspected of having an abdominal aortic aneurysm. Which question is the highest priority for the nurse to ask first?

Do you have any abdominal or back pain?

The nurse suspects a client is experiencing an exacerbation of COPD when which of the following is assessed? (SATA)

Dyspnea on exertion cough peripheral edema Sputum production Decrease oxygen saturation

A client returned to the nursing unit after a prostatectomy. Which activities does the nurse delegate to the unlicensed assistive personnel? (SATA)

Encourage the client to get out of bed and use the chair Demonstrate how to use incentive spirometer Measuring and recording output from the indwelling catheter

A client with diabetes mellitus has hot dry skin; rapid and deep respirations; and a fruity odor to his breath. The charge nurse observes a newly graduated registered nurse performing all the following tasks. Which action requires that the charge nurse intervene immediately?

Encouraging the client to drink 4-6 oz of orange juice

A nurse is caring for a client post spinal cord injury. What interventions will the nurse provide to minimize the risk of autonomic dysreflexia?

Ensure strict adherence to a bowel retraining program **Usually caused by bowel or bladder issues or restrictive clothing**

** A nurse is caring for a client experiencing a seizure that has persisted for 5 minutes. What is the nurse's priority action?

Establish a large-bore catheter and start 0.9% sodium chloride.

A nurse is documenting the plan of care for a client who has type 1 diabetes mellitus that has remained unstable despite conventional insulin therapy. The provider has explained to the client that the new plan will incorporate a long-acting insulin preparation. The nurse anticipates seeing prescription for the addition of which of the following insulin preparations?

Glargine(Lantus)

A nurse is instructing a client diagnosed with type 2 diabetes mellitus on diagnostic tests used to evaluate how well the control disorders has been managed. The nurse should instruct the client on which of the following diagnostic tests that will provide this intervention?

Glycosylated hemoglobin (Ab1C)

A client presented to the emergency department with decreased level of consciousness, polydipsia, hyperthermia, dry mucus membranes, and positive Babinski sign. Blood glucose result was 600 mg/dl and sodium (Na) = 155 mEq/L, potassium (K+) =6mmol/L, and no serum ketones. The nurse determines the physician will likely diagnose the client with which of the following conditions?

Hyperglycemic hyperosmolar nonketotic syndrome

The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen?

I can skip a couple of pills if they make me ill

A client is having a sudden and sever anaphylactic reaction to a medication. The nurse immediately stops the medication and calls a rapid response. The clients blood pressure is 80/52, HR 120 BPM and oxygen saturation 87%. Audible wheezing is noted, along with facial redness and swelling. Which initial treatment should be administered first?

IM epinephrine

A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen?

In the clients peripheral view

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between and arterial ulcer and a venous stasis ulcer?

Inquire about the presence or absence of claudication

A new nurse demonstrates their understanding of a proper physical assessment of an abdomen when the four techniques of examination are completed in which order?

Inspect, auscultate, percuss, palpate

A client with benign prostate hyperplasia asks why his enlarged prostate is causing difficulty with urination. Which is the nurses most accurate response?

It compresses the urethra, blocking the flow of urine

A nurse is teaching a group of nursing student about a dissecting abdominal aortic aneurysm.(AAA) Which of the following statements should the nurse include in the teaching?

It is a medical emergency requiring immediate treatment

A nurse suspects anaphylaxis when caring for a client following the initial administration of an intravenous infusion of an antibiotic. Which of the following would the nurse likely assess I this client? (SATA)

Itchiness, Hypotension, Tachycardia, Edema/swelling

A nurse is assessing a client who has systemic lupus systemic erythematosus. Which of the following should the nurse expect? ( SATA)

Joint inflammation, Elevated creatinine, Butterfly rash Elevated temperature during exacerbation

A client has metabolic alkalosis due to renal failure. Which laboratory results is the nurse most likely to assess as consistent with this condition?

K+ 3.0

A nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent aspiration-related respiratory complications in the client?

Maintain the head of the bed at least 30 degrees or greater

A client is receiving TPN. Which of the following routes is not appropriate for the type of nutrition administration?

Measuring and recording output from the indwelling catheter PEG tube

A client returned to the nursing unit after a proctectomy. Which activities does the nurse delegate to the unlicensed assistive personnel? (SATA)

Measuring and recording output from the indwelling catheter, Encouraging the client to get out of bed and into the chair. **Irrigating the catheter with normal saline for blood clots** (possible answer)

A 75-year-old diabetic client presents to the ER after collapsing in a local department store. The client has been fasting for days and testing had found ketones in the urine. Which acid base imbalance would the nurse expect assess in the client?

Metabolic acidosis

A client with heart failure has been prescribed intravenous nitroglycerin and furosemide for pulmonary edema. Which is the priority nursing intervention?

Monitor the client's blood pressure

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client?

Muscle weakness that worsens with use and improves with rest.

The nurse is assessing a client admitted to hr. cardiac unit. What statement made by the client alerts the nurse to the priority of right-sided heart failure?

My shoes fit tight lately

The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin sodium. What instruction does the nurse provide to this client?

Notify your healthcare provider if your stools appear tarry

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rates is 36 breaths per minute and he appears very restless. The nurse anticipates which of the following values to be outside the expected references range if the client is experiencing respiratory alkalosis?

PaCO2

A nurse is assessing a client diagnosed with peripheral arterial occlusion. Which of the following will the nurse assess in this client (SATA)

Pain, Pallor, Pulselessness, Parenthesis, Paralysis

The nurse assess a client who has Gullian - Barre syndrome. Which clinical manifestation does the nurse expect to find in this client?

Progressive ascending weakness and paresthesia

Intravenous heparin therapy is prescribed for a client. While implementing this prescription. The nurse ensures which medications is available on the nursing unit?

Protamine Sulfate

A client comes into the emergency department (ED) with acute shortness of breath and a cough that produces a pink, frothy sputum. Admission assessment reveals crackles and wheezing, a blood pressure of 85/46mm, a heart rate of 122 beast per minute and a respiratory rate of 38 breaths per minute. The client's medical history included diabetes mellitus (DM), Hypertension (HTN), and heart failure. Which of the following disorders should the nurse suspect?

Pulmonary Edema

A client with Alzheimer's disease is admitted to the hospital. Which psychosocial assessment is most important to the nurse to complete?

Reaction to a change of environment

A client is admitted to the ER with a RR of 6 breaths per minute. ABG have need drawn and revealed the following values: pH 7.22...

Respiratory acidosis

** The nurse reviews the arterial blood gas (ABG) results of a client and notes the following: pH 7.45, PaCO2 30mm, and HCO3 20 mEq/L. The nurse analyzes these results as indicating which condition?**

Respiratory alkalosis, fully compensated (I GOT***RESPIRATORY ACIDOSIS, FULLY COMPENSATED)

The nurse writes the nursing problem of "fluid volume excess" Which intervention should the nurse include in the plan of care?

Restrict the clients sodium in the diet

A nurse is caring for a client who is admitted for an acute exacerbation of ulcerative colitis. Which of the following actions is the priority for the nurse to take?**

Review the client's electrolyte values.

A client with renal failure who has been taking aluminum hydroxide\/magnesium hydroxide suspension at home for indigestion is drowsy and has decreased deep tendon reflexes. Which action should the nurse take first?

Review the magnesium level on the client's chart

A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the client to improve gas exchange?

Sitting up at the bedside or in a chair and leaning slightly forward

A nurse is reviewing the labs for a newly admitted heart failure client and notes a serum potassium level of 5.8. Upon reviewing the clients' meds, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance?

Spironolactone

A nurse is caring for a client who is about to have immunotherapy initiated due to severe allergies. Knowing that this client is being exposed to a known allergen. What intervention does the nurse implement to provide for client safety with this allergy treatment?

Stay with the client and ensure that emergency equipment is in the room

A client receiving a unit of red blood cells begin to report chest and lower back pain. Which action does the nurse take first?

Stop the transfusion

An older adult client who has mature cataract in the right eye states "Now I have lost the sight in my right eye because I wanted too long for treatment". How does the nurse best respond to the client?

Surgery can still save the sight in your eye with removal of the cataract

Which assessment data obtained by the home care nursing suggests that an older adult client may be dehydrated?

The client states that he feels lightheaded when he gets out of bed or stands up

The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 196mg/dl and hemoglobin A1C of 6.8. What are the nurses' interpretations of these findings?

The client's glucose control for the past 24 hours has been good, but the overall condition is poor.

The laboratory vales of a client who has diabetes mellitus include a fasting blood glucose level of 196mg/dl and hemoglobin A1C of 6.8. What are the nurses' interpretation

The clients glucose control for the past 24hrsgoodbutoverallpoor

The nurse is performing an assessment on a client with a diagnosis of left- sided heart failure. Which assessment component would elicit specific information regarding the client's left left-sided heart failure?

The nurse is performing an assessment on a client with a diagnosis of left- sided heart failure. Which assessment component would elicit specific information regarding the client's left left-sided heart failure?

A client is diagnosed with glaucoma and is prescribed medications to treat it. The nurse knows that which of the following best explains the purpose of the medications?

This medication lowers intraocular pressure

Which of the following conditions should the nurse recognize as a type II hypersensitivity reaction?

Transfusion with the improper blood type

Which of the following assessment techniques can the nurse us to determine if a client is experiencing hypocalcemia. (SATA)

Trousseau's Chvostek's sign **Check the chart to evaluate recent lab values** (Possible answer >>check)

A nurse is caring for a client and observes that the client's urine is cloudy and has unpleasant color. The nurse should recognize that these findings are associated with which of the following?

Urinary tract infection

A client has notified the nurse that she has completely eliminated fats from her diet. The nurse recognizes this type of diet places the client at risk for a deficiency of which fat-soluble vitamins and/or minerals?

Vitamins A, D, E, and K

A nurse is caring for a client who has deep vein thrombosis ( DVT) an has been on continuous heparin infusion for five days. The prescriber prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

Warfarin takes several days to work so the IV heparin will be used until the warfarin reaches a therapeutic level.

The nurse is assigned to care for a group of clients. Upon reviewing the clients' medical records, the nurse determines which client is most likely at risk for a fluid volume deficit?

client with an ileostomy

A client with diabetes mellitus is prescribed to take insulin glargine once daily and regular insulin four times a day. How will the nurse teach the client to take these two medications when the first dose of regular insulin should be given at the same time of the day as the insulin glargine dose?

"Draw up and inject the insulin glargine first and then draw up and inject the dose of regular insulin in a separate syringe."