Rasmussen PN2 Exam 1

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. "You can beat this disease if you just put your mind to it" D. "Is there someone you would like us to call for you?" E. "Let me sit with you for a while, and we can discuss how you're feeling about this."

"It sounds like death frightens you" "Let me sit with you for a while, and we can discuss how you're feeling about this"

The provider ordered a continuous IV of normal sailing with 20 MEQ of potassium chloride to infuse at 50 mL an hour. The first one liter bag was hung at 0100. What time does the nurse anticipate needing to hang the second bag of IV fluids?

0800

A nurse is reviewing the blood urea nitrogen (BUN) and creatinine levels of an older adult client admitted for acute renal failure because of obstructive renal calculi. The nurse should expect which of the following laboratory findings? A. BUN 34 mg/dL and creatinine 5.2 mg/dL B. BUN 9 mg/dL and creatinine 0.7 mg/dL C. BUN 12 mg/dL and creatinine 0.6 mg/dL D. BUN 21 mg/dL and creatinine 1.0 mg/dL

BUN 34 mg/dL and creatinine 5.2 mg/dL

The primary goal of nursing care for a client with stress incontinence as which of the following? a. Eliminate all episodes of incontinence B. Decrease the number of incontinence episodes C. Help the client adjust to the frequent episodes of incontinence D. Prevent the development of urinary tract infections

Decrease the number of incontinence episodes

A nurse is caring for a client who has a postoperative ileus in a nasogastric tube that has drained 2500 mL in the past six hours. Which of the following electrolyte imbalances should the nurse expect a monitor for in this client? a. elevated sodium level B. Decreased potassium level C. Elevated potassium level D. Elevated magnesium level

Decreased potassium level

The nurse is assessing an elderly client receiving IV fluids. Which of th following would not indicate fluid volume overload? A. Distended neck veins when positioned at 45 degrees B. Pitting edema of the lower extremities C. Dry mucous membranes D. Course crackles in the lung field

Dry mucous membranes

The nurse will anticipate preparing an older client who is vomiting "coffee-ground" emesis for which of the following? A. Gastric analysis B. Endoscopy C. Barium studies D. Angiography

Endoscopy

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which the priority when working as a professional nurse? A. Not making medication errors B. Providing client-focused care C. Attending to holistic client needs D. Ensuing client safety

Ensuring client safety

Before the nurse administers IV replacement of 5% dextrose in water with potassium chloride, what action is appropriate for the nurse to take? A. Evaluating laboratory results for electrolytes B. Adding potassium chloride to the bag at the bedside C. Checking the rate for IV push administration D. Priming tubing using sterile technique

Evaluating laboratory results for electrolytes

When teaching a client with a urinary tract infection about taking a prescribed antibiotic for seven days, the nurse should tell the client to report which symptom to the healthcare provider? Select all that apply. A. Mild nausea B. Cloudy urine during first few days of treatment C. Fever above 100 F D. Rash E. New onset of blood in the urine F. Urinating every 3 to 4 hours

Fever above 100 F Rash New onset of blood in the urine

A nurse is caring for a client who's arterial blood gas (ABG) results show a pH of 7.36, HCO3: 30 mEq/L, PaCO2: 50 mmHg. The nurse correctly interprets these results as which of the following? A. Fully compensated metabolic acidosis B. Fully compensated respiratory acidosis C. Uncompensated respiratory acidosis D. Normal ABG results

Fully compensated respiratory acidosis

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. HCO3 B. Lactic acid C. PH D. Potassium

HCO3

A 10 year old with a history of recent respiratory indirection has swelling around the eyes in the morning and dark urine. What question should the nurse ask first? A. Has the child had a rash or fever B. Has the child had a sore throat C. Does the child have an allergies D. Does the child drink a lot of liquids

Has the child had a sore throat

The nurse is assessing the client who has started to complain of muscle cramps and parenthesis 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. Hypercalcemia B. Hyperkalemia C. Hypophosphatemia D. Hypocalcemia

Hypocalcemia

A nurse is providing teaching to a client about measures to prevent UTIs. Which of the following client statements indicates a need for further teaching? A. I will need to empty my bladder regularly and completely b. I will need to drink apple cider vinegar each day c. I will need to wipe my peroneal area from back to front after urination D. I need to drink 8 cups of liquid each day

I will need to wipe my peroneal area from back to front after urination

A nurse is teaching a client who is full overload about recognizing symptoms associated with his condition. Which of the following client statements indicates a Teaching was understood? A. If my legs have edema, this could mean I am retaining fluid B. If i have gained 1lb in a week, i need to call my doctor C. Increased blood pressure may indicate a worsening problem D. Heart rate is less than 75 E. If my respirations fall below 18 per minute, i need to call my doctor

If my legs have edema this could mean i am retaining fluid

Immediately after having surgery to create an ileostomy, which goal has the highest priority? A. Maintain fluid and electrolyte balance B. Providing relief from constipation C. Minimizing odor formation D. Assisting the client with self-care activities

Maintain fluid and electrolyte balance

A client is receiving 250mL of 3% sodium chloride solution intravenously for severe hyponatermia. 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. The client reports hand swelling D. Serum potassium level has decreased from 4.4 mEq/L to 4.2 mEq/L

Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg

A client has the following arterial blood gas (ABG) results: pH 7.30, HC03: 22 mEq/L, PaCO2: 67 mmHG, PaO2: 66 mmHg. Which intervention by the nurse takes priority? A. Administer mucolytic B. Provide oxygen via nasal cannula C. Administer bronchodilator D. Assess the client's airway

D. Assess the client's airway

A nurse is preparing to administer intravenous ibuprofen in 400mg IV to her client diagnosed with a urinary tract infection. The medication is available as 400mg/100mL normal saline solution. The order is to infuse the 50mL bag in 30 min. What is the rate in mL/hr the nurse must infuse the medication? (Round to the nearest whole number)

200

A nurse enters a clients semiprivate room and prepares to administer the 0900 medications. Place the steps in chronological sequence, indicating the measure to take to administer the medications safely. 1)open the unit dose package 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 medications A. 4,5,2,1,3 B. 5,1,4,2,3 C. 2,5,1,4,3 D. 5,4,3,2,1

4,5,2,1,3

A nurse is preparing to infuse a 400mL unit of packed red blood cells (PRBCs) over 4 hours. The drop factor of the manual IV tubing is 50 gtts/mL. What is the infusion rate in gtts/min? (Round the answer to the nearest whole number)

83

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 100.1F, and a WBC count of 13, 500 cells/mcL B. A 53 year old adult male admitted 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 hemodyalisis C. A 29-year-old client who has a colon resection yesterday. Foley catheter removed 12 hours ago, has been receiving morphine sulfate for pain, and has not voided for 14 hours D. A 57-year-old client admitted today with hematuria and possible bladder cancer. The client is scheduled for cystoscopy in two hours

A 23 year old adult male admitted with pyelonephritis, a temperature of 100.1F, and a WBC count of 13, 500 cells/mcL

The community nurse is talking with a group of individuals about colorectal cancer risk factors. Which community participant is at the highest risk for a development of colorectal cancer? A. A 23-year-old vegetarian B. A 46 year old with a genetic predisposition to cancer C. A 30 year old with ulcerative colitis D. A 39 year old with no family history of cancer

A 30 year old with ulcerative colitis

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? A. An 84- year-old with left-sided weakness who is slightly confused and has been awake most of the night. B. A 52 year old with pneumonia and chronic back pain who is requesting pain medication for severe pain C. A 35 year old admitted after motor vehicle accident whose urine output has totaled 30 mL 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

A 35 year old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours

Which client is at greatest risk for the development of hyperkalemia? a. A female taking nonsteroidal anti-inflammatory drugs daily b. A female with hypertension using a salt substitute C. Emile with type two diabetes taking oral anti-diabetic agent d. Email taking a thiazide diuretic for heart failure

A female with hypertension using a salt substitute

Which client is at greatest risk for development of hypercalcemia? A. A middle age adults with chronic end stage kidney disease B. A middle-aged adults with a thyroid disorder C. An older adults with lactose intolerance D. An older adult taking a nonsteroidal anti-inflammatory drug

A middle-age at all with chronic end-stage kidney disease

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (SATA) A. Corticosteroids B. Alcohol C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Milk E. Caffeine

A. Corticosteroids B. Alcohol C. NSAIDs E. Caffeine

A client has renal colic due to renal lithium is. What is the nurse's priority in mana gaming care for this client? A. Administer an opioid analgesic as prescribed B. Do not allow the client to ingest fluids C. Request the control supply department to send supplies for straining urine D. Encourage the client to drink at least 500mL of water each hour

Administer an opioid analgesic as prescribed

Which client being managed for dehydration does the nurse consider it at great risk for possible reduce kidney function? A. A 62-year-old woman with unknown allergy to contrast media B. A 48-year-old woman with establish urinary incontinence C. A 45-year-old man receiving oral and IV fluid therapy D. An 80-year-old man who has benign prostatic hyperplasia

An 80-year-old man who has benign prostatic hyperplasia

A client with a serum sodium level of 113 mEq/L has been receiving 3% sodium chloride IV infusion at 50mL/hr for 16 hours. The client feels tired and short of breath. Which of the following is a priority? A. Notify the physician B. Obtain order to decrease infusion C. Assess for signs of fluid overload D. Check the latest sodium levels

Assess for signs of fluid overload

A client has the following ABG results: pH 7.30, HCO3 17 mEq/L, PaCO2 25 mm Hg, PO2 98 mm Hg. Which intervention by the nurse is not appropriate? A. Prepare to administer the ordered albuterol nebulizer treatment B. These are normal findings; document and continue to assess C. Place the client on 2L oxygen via nasal cannula D. Assess the client and notify the physician using SBAR communication

Assess the client and notify the physician using SBAR communication

A nurse assesses a client with a mechanical bowl obstruction who reports intermittent abdominal pain. An hour later, the client reports concert abdominal pain. Which action with the nurse take next? a. Position the client with knees to chest b. Administer Inttravenous opioid medication's C. Insert a nasogastric tube for decompression d. Assess the client bowel sounds

Assess the clients bowel sounds

A 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. Limit strenuous exercise C. Take NSAIDs for pain D. Avoid drinking caffeine

Avoid drinking caffeine

The nurse is to administer ampicillin 500mg 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. Administer the medication to maintain blood levels of the drug B. Contact the pharmacy to bring a properly labeled medication C. Ask another registered nurse (RN) to verify that the capsule is ampicillin D. Notify the unit manager to report the problem

B. Contact the pharmacy to bring a properly labeled medication

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. Notify the client's health care provider B. Check the chart for the most recent (blood urea nitrogen) BUN and creatinine levels C. Administer magnesium IV replacement as ordered D. Review the magnesium level on the client's chart

Check the chart for the most recent (blood urea nitrogen) BUN and creatinine levels

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. Baked chicken C. Chocolate D. Nonfat milk

Chocolate

A nurse is caring for a client who has been admitted for an exacerbation of Crohn's disease. An NG tube has been placed and is to suction, and the client is currently receiving an infusion of total Parenteral nutrition via a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse take? A. Remove unused Parenteral nutrition after 12 hours of use B.Place the Parenteral nutrition solution on a warming device during infusion C. Monitor the flow rate of the Parenteral nutrition carefully and increase the rate as needed if it falls behind D. Monitor laboratory values and assess for abnormal respiratory or cardiac functioning

Monitor laboratory values and assess for abnormal respiratory or cardiac functioning

The nurse is evaluating the ABGs results of her clients. Which of the following ABG results exhibits partially compensated metabolic alkalosis? A. pH 7.33, PaCO2 55 mmHG, HCO3 30 mEq/L B. pH 7.50, PaCO2 50 mmHg, HCO3 38 mEq/L C. pH 7.55, PaCO2 30 mmHg, HCO3 19 mEq/L D. pH 7.24, PaCO2 33 mmHg, HCO3 26 mEq/L

PH 7.55, PaCO2 30 mmHG, HCO3 19 mEq/L

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. Auscultating lung sounds every 4 hours B. Maintaining the client on bed rest C. Monitoring for bounding pulses D. Provide continuous IV fluid infusion as ordered

Provide continuous IV fluid infusion as ordered.

The nurse writes the nursing problem of fluid volume excess (FVE). Which intervention should be included in the plan of care? A. Monitor blood glucose levels B. Prepare the client for hemodialysis C. Change the IV fluid from 0.9% normal saline to D5W D. Restrict the client's sodium in the diet

Restrict the client's sodium in the diet

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. Left upper quadrant (LUQ), Trausseau's point B. Left lower quadrant (LLQ), Chvotek's point C. Right upper quadrant (RUQ), Blarney's point D. Right lower quadrant (RLQ), McBurney's point

Right Lower Quadrant (RLQ), McBurney's point

The client has the following ABG results: pH 7.48, HCO3 35 mEq/L, PaCO2 46 mm Hg. The nurse correlates these values to which critical situation in the client? A. Tracheostomy suctioning every hour for thick, copious secretions B. Anxiety induced hyperventilation C. 15 liquid stools daily for 7 days D. Shallow respirations of 5/min

Shallow respirations of 5/min

A nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea that has last and a week. For which complication will the nurse assess? (SATA) A. Deep vein thrombosis (DVT) B. Fluid overload C. Hyperkalemia D. Skin breakdown E. Hypokalemia

Skin breakdown Hypokalemia

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 types of urinary incontinence? A. Functional incontinence B. Urge incontinence C. Reflect incontinence D. Stress incontinence

Stress incontinence

The nurse obtains all the following assessment data about a client with deficient fluid volume caused by dehydration. Which of the following assessment data will be a greatest concern? a. The blood pressure is 88/40 MM Hg B. Oral fluids and take is 100 mL for the last eight hours c. Your an output is 30 ML over the last hour d. There's prolong skin tenting over the sternum

The blood pressure is 88/40 mm Hg

Which assessment finding would alert the nurse to a client's worsening hypernatermia? A. The clients diastolic blood pressure has decreased by 8 mm Hg B. The client's deep tendon reflexes have increased from 1+ to 2+ c. The client has an altered mental status D. The client has an irregular heart rhythm

The client has an altered mental status

The nurse is caring for a client with a bleeding duodenal ulcer who has 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 epi gastric region and a rigid, board-like abdomen? A. Small bowel obstruction B. Development of additional ulcers C. Pancreatitis D. Ulcer perforation

Ulcer perforation

A client is admitted to the emergency room with a respiratory rate of 6 breaths/min. ABGs have been drawn and reveal the following values: pH 7.22, PaCO2: 68a mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate analysis of these ABGs? A. Partially compensated metabolic alkalosis B. Partially compensated respiratory alkalosis c. Uncompensated respiratory alkalosis d. Uncompensated metabolic acidosis

Uncompensated metabolic acidosis

The nurses evaluating the food volume status of a client after ileostomy Surgery. Which finding indicates the adequate food replacement has been achieved in the client? A. Fluid intake less than urinary output B. Blood pressure of 90/40 mm Hg C. Urine output greater than 30 mL/hr D. An increase in body weight

Urine output greater than 30 mL/hr