acute final (quizzes)

a nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone. which of the following manifestations should the nurse anticipate? a. increased thirst b. weight loss c. oliguria d. hypernatremia

c. oliguria

true or false. in the care of a client following an acute CVA, a decreasing score on the Glasgow coma scale would be a concern.

true

6. What should be included in colostomy care for a client with a stoma?

A client with diverticulitis may have a colostomy. A stoma can be created for stool or to drain out an infection. Colostomy care includes changing the pouch regularly, monitoring for skin breakdown, cleaning and drying the skin around the stoma, and monitoring for any irritations. Having a colostomy may also increase a patient's risk for fluid and electrolyte imbalances so it is important to monitor and treat any imbalances.

1. What are some lifestyle/behavioral modifications that should be recommended to a client with gastroesophageal reflux disease (GERD)?

A low fat diet would be recommended because fat is hard to digest. Since fats stay in the stomach longer, more pressure is going to buildup and this pressure buildup could cause more pain. A patient with GERD should avoid caffeine, nicotine, beer, milk, peppermint and spearmint, and carbonated beverages which could all cause an increase in gastric acid secretion. Avoiding milk is also important because whole milk has a lot of fat. This patient should not eat or drink within 2 hours of bedtime or lying down because symptoms will increase. They should avoid things that increase weight on their abdomen by managing their weight and avoiding tight fitting clothes as this will increase acid reflux. The head of their bed can be elevated so their head will be above their stomach to help with GERD as well.

7. How might a client with a small bowel obstruction present differently than a client with a large bowel (colon) obstruction?

A patient with a small bowel obstruction will have intermittent pain and when pressure builds up they will vomit. Vomiting is the biggest symptom with a small bowel obstruction. A patient with a large bowel obstruction will have a cramping pain that is vague, diffuse, and constant. They will also have significant abdominal distention.

a client is admitted for an aortic valve replacement. which of the following is considered an advantage of a prosthetic heart valve? a. no need for long term anticoagulation b. surgery is less invasive c. long term durability d. quietness of the valve

c. long term durability

3. What is peritonitis? What are the symptoms, and what should the nurse do if she suspects this complication?

In a patient with diverticulitis, there are pockets in their intestines called diverticula. Bacteria can get trapped in these causing irritation, infection, and perforation of the diverticula which can lead to peritonitis. Peritonitis is an infection of the peritoneal cavity. Symptoms of peritonitis include a rigid board like abdomen, guarding, extreme pain, and signs of infection such as tachycardia, a drop in blood pressure, and a fever. If a nurse suspects peritonitis they should place the patient in a semi-fowler's position to decrease the pressure on the abdomen and give the patient oxygen as the patient's oxygen demand will increase. A patient with peritonitis will have a nasogastric tube because you do not want anything to move through the gastrointestinal system as this could cause further infection. The patient should also be NPO. The nurse should monitor the patient for fluid and electrolyte imbalances, give IV antibiotics, and prepare the patient for surgery if it is needed to repair the perforation.

5. What is included in nursing care for a client with Crohn's Disease and Ulcerative Colitis?

Nursing care for a patient with Crohn's Disease or Ulcerative Colitis includes eating a diet high in protein and calories and low in fiber. This is because you do not want anything to bulk up the patient's stool and put pressure on the walls of the intestines. Caffeine and alcohol should be avoided because these can irritate the GI system. They should eat small, frequent meals throughout the day. The nurse should monitor for fluid and electrolyte imbalances, especially potassium. When a patient experiences fluid loss they can develop hypokalemia. Patient education is also important, specifically being able to identify trigger foods and know the signs and symptoms of a bowel obstruction or perforation.

2. What are the differences in symptoms for duodenal and gastric ulcers?

When a patient has a gastric ulcer, they experience weight loss. Eating makes the pain worse for a patient with a gastric ulcer so they choose to not eat. When a patient eats it triggers more hydrochloric acid secretion which causes the pain in their stomach to get worse as it is exposed to more stomach acid. Pain develops about 30 minutes after the patient eats. This patient may also experience vomiting which can cause further weight loss. When a patient has a duodenal ulcer, eating makes the pain feel better. The location of a duodenal ulcer is in the small intestine which is a very alkaline environment. Eating triggers the release of pancreatic enzymes into the duodenum. Pancreatic enzymes neutralize stomach acid making it safe to move through to the intestines without causing damage. Eating makes duodenal ulcers feel better because when a patient eats, the pancreatic enzymes enter the duodenum causing the environment to become alkaline and in turn making the ulcer feel better. Pain occurs when the patient has digested their food, about 2-3 hours after eating. Patients with duodenal ulcers also may wake up at night with pain because of this.

4. What are the dietary recommendations for diverticulosis?

When a patient has active diverticulitis, they should be NPO or only consuming clear liquids. Once the diverticulitis has been treated and the patient goes back to having only diverticulosis, they should consume a diet high in fiber. Fiber bulks stool, allowing it to move through the gastrointestinal system easier and avoid getting caught in diverticula.

a client scheduled to start IV chemotherapy asks about hair loss. which statement made by the nurse is appropriate? a. "you will lose your hair during treatments, but lets talk about options to help with this side effect." b. "hair loss tends to happen more with radiation treatments" c. "you may not lose any hair - lets just wait and see, and we can address it if it becomes a problem." d. "hair loss should be the least of your concerns"

a. "you will lose your hair during treatments, but lets talk about options to help with this side effect."

a client with cancer of the bladder just returned to the unit from the PACU after surgery to create an ileal conduit. the nurse is monitoring the client's urine output hourly and notifies the physician when the hourly output is less than what? a. 30 mL b. 120 mL c. 90 mL d. 60 mL

a. 30 mL

which of the following lab values should the nurse look for prior to a client having a kidney biopsy? select all that apply. a. CBC b. urinalysis c. renal function d. coagulation studies e. chemistry panel

a. CBC b. urinalysis c. renal function d. coagulation studies e. chemistry panel

a client has an arterial blood gas sample drawn from her radial artery and reports sudden shortness of breath, chest pain, and anxiety. the nurse notes a decrease on oxygen saturation. which of the following complications does the nurse suspect? a. air embolism b. perforation c. infection d. hematoma

a. air embolism

when caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately? a. change in mental status b. fatigue and weight loss c. anorexia and dyspepsia d. diarrhea and constipation

a. change in mental status

which of the following interventions are appropriate to include when preparing to feed a client for the first time following a stroke? select all that apply a. evaluate for the presence of a gag reflex b. have suction equipment at the bedside c. start the client with solid foods first d. have the client sit upright for feedings e. have an unlicensed assistive personnel feed the client

a. evaluate for the presence of a gag reflex b. have suction equipment at the bedside d. have the client sit upright for feedings

which of the following symptoms is most associated with the diagnosis of anemia? a. fatigue b. hypertension c. weight gain d. bradycardia

a. fatigue

a patient has been admitted to the medical unit with a diagnosis of ureteral colic, or pain related to urolithiasis (stones). when planning the patient's admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis. select all that apply. a. hematuria b. diarrhea c. acute pain d. urinary frequency e. high fever

a. hematuria c. acute pain d. urinary frequency

the provider prescribed knee-high sequential compression devices. the client reports new pain localized in the right calf area. what should the nurse do first? a. leave the compression devices off, and contact the provider to report the findings b. offer analgesics as prescribed, and apply the compression devices c. leave the compression devices off, and report assessment findings to the oncoming shift d. massage the area before applying the compression devices

a. leave the compression devices off, and contact the provider to report the findings

determine if the following assessment findings or symptoms develop as a result of right sided or left sided HF a. orthopnea b. SOB c. paroxysmal nocturnal dyspnea (PND) d. crackles in lungs e. jugular venous distension (JVD) f. peripheral edema g. hepatomegaly

a. left sided b. left sided c. left sided d. left sided e. right sided f. right sided g. right sided

which of the following would be expected findings for someone who presents with peripheral venous disease? select all that apply. a. presents with large, irregular ulcers b. presence of edema c. brown pigmented skin in lower extremity d. skin temperature is cool e. pulses are absent

a. presents with large, irregular ulcers b. presence of edema c. brown pigmented skin in lower extremity

a nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on his breath. diabetic ketoacidosis is suspected. the nurse should anticipate using which of the following types of insulin to treat this patient? a. regular insulin b. glargine insulin c. lantus insulin d. NPH insulin

a. regular insulin

the nurse is caring for a client with a diagnosis of COPD exacerbation. upon assessment, which of the following findings would require immediate intervention? a. the client has an oxygen saturation of 98% on 3L nasal cannula b. the client has a productive cough c. the client is pursed lip breathing d. the client has a barrel shaped chest

a. the client has an oxygen saturation of 98% on 3L nasal cannula

what is afterload? a. the force needed to eject blood into circulation b. the relaxation of ventricles in between heart beats c. the volume of blood ejected with each heart beat d. the force needed to eject blood to the atria to the ventricles

a. the force needed to eject blood into circulation

which is the rationale for checking residual prior to administering an enteral tube feeding? a. to prevent vomiting and aspiration b. to prevent hypoglycemia c. to flush the feeding tube d. to ensure placement of the tube

a. to prevent vomiting and aspiration

a client who has been diagnosed with hepatitis A asks "How did I get this disease?" what is the nurses best response? a. you may have eaten contaminated food at a restaurant b. you could have gotten it from using IV drugs c. you must have received an infected blood transfusion d. you may have gotten this from prolonged alcohol abuse

a. you may have eaten contaminated food at a restaurant

which medication is commonly used to improve cardiac contractility in a client who has HF? a. Lopressor b. Digoxin c. Lasix d. Amiodarone

b. Digoxin

which of the following assessment findings following a bronchoscopy should be reported to the provider immediately? a. intermittent cough b. bronchospasms and hypoxemia c. blood tinged sputum d. a sore throat

b. bronchospasms and hypoxemia

a nurse is caring for a patient who was just admitted 24 hours ago with diabetic ketoacidosis. upon entry to the patient's room, the nurse notes the patient appears confused. what action should the nurse take first? a. check the client's pupillary reaction b. check the client's vital signs c. obtain a blood draw for a serum glucose level d. call the physician

b. check the client's vital signs

the nurse is discussing the findings of a urinary tract infection (UTI) with a newly licensed nurse. which of the following should the nurse identify as a finding specifically associated with a UTI of an older adult client? a. low back pain b. confusion c. urinary retention d. incontinence

b. confusion

a geriatric nurse is performing an assessment of body systems on an 85 year old client. the nurse should be aware of what age related change affecting the renal or urinary system? a. urinary incontinence b. decreased glomerular filtration rate c. increased bladder capacity d. increased ability to concentrate urine

b. decreased glomerular filtration rate

select all of the following which could be seen in a client with peripheral arterial disease. a. ulcers with irregular borders b. decreased or absent peripheral pulses c. cool extremity d. pain is alleviated when leg is in dependent position e. peripheral edema

b. decreased or absent peripheral pulses c. cool extremity d. pain is alleviated when leg is in dependent position

a client is admitted to an emergency department and a diagnosis of myxedema coma is made. which action would the nurse prepare to carry out initially? a. warm the client b. maintain a patent airway c. administer thyroid hormone d. administer fluid replacement

b. maintain a patent airway

the nurse is caring for a client with end stage liver disease. which of the following menu choices made by the client would require further teaching? a. rice and steamed green beans b. steak, baked potato, and broccoli c. garden salad and dinner roll d. pasta and tomato sauce

b. steak, baked potato, and broccoli

the nurse suspects aspiration of tube feeding, which of the following actions should the nurse do first? a. place the client on oxygen b. stop the feeding c. notify the provider d. obtain a chest x-ray

b. stop the feeding

which of the following is the first step if extravasation is suspected in a client receiving intravenous chemotherapy? a. notify the provider b. stop the infusion c. obtain an accurate peripheral pulse d. gently massage the tissue around the insertion site

b. stop the infusion

a patient with an elevated BUN and creatinine values has been referred by her primary physician for further evaluation. the nurse should anticipate the use of what initial diagnostic test? a. angiogram b. ultrasound c. CT with contrast d. nuclear scan

b. ultrasound

a nursing student asks her preceptor why the provider wants to maintain the client's O2 saturation between 88 and 92%. which of the following answers is the most appropriate? a. "because COPD is a progressive disease, and clients can become dependent on oxygen if we use it too early in the disease process" b. "because too much oxygen for someone with COPD can cause a decrease in CO2 levels, leading to alkalosis" c. "because increasing his saturation with supplemental oxygen will inhibit his respiratory drive, causing a decrease in breathing"

c. "because increasing his saturation with supplemental oxygen will inhibit his respiratory drive, causing a decrease in breathing"

you are educating your newly diagnosed type 2 diabetic patient about what to do when they are sick and not eating much due to the illness. which of the following statements by the patient demonstrates further education is necessary? a. I'll make sure to test my urine for ketones b. I'll make sure I keep taking my metformin even though I'm sick c. I'll double my insulin dose when sick d. I'll drink a glass of water every hour if possible

c. I'll double my insulin dose when sick

following a thoracentesis, a client is found to have a pneumothorax. which of the following is the best definition of this condition? a. an infection in the parietal layer of the pleural space, causing difficulty breathing b. a collapse of alveolar sacs in the pulmonary tree c. a collapsed lung from air or gas in the pleural space d. a popular band from the 80s

c. a collapsed lung from air or gas in the pleural space

a nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. which of the following actions should the nurse take? a. provide a low carb diet b. administer PO prednisone c. administer IV corticosteroids d. restrict fluid intake

c. administer IV corticosteroids

a nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. the client states "I don't need this medication. I am not constipated." the nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the blood stream? a. potassium b. glucose c. ammonia d. bicarbonate

c. ammonia

the nurse is caring for a client with a bowel obstruction. the client suddenly develops a rigid board like abdomen, abdominal distention and pain, and a fever. which of the following complications does the nurse suspect? a. hemorrhage and hypovolemia b. paralytic ileus c. bowel perforation and peritonitis d. septic shock

c. bowel perforation and peritonitis

when the nurse is assessing an individual with peripheral arterial disease, which clinical manifestation would indicate complete arterial occlusion in the leg? a. burning pain in the leg b. numbness and tingling in the leg c. coolness in the leg

c. coolness in the leg

a client with venous thrombosis reports having pain in the legs. what should the nurse do first? a. elevate the legs using a pillow under the knees b. massage the lower extremities c. elevate the foot of the bed d. encourage adequate fluid intake

c. elevate the foot of the bed

which of the following safety interventions is appropriate for a client receiving internal radiation for a diagnosis of cancer? a. ensure the client remains on strict bedrest b. do not allow any visitors c. ensure the client has a private room and bathroom d. avoid entering the client's room to provide care unless absolutely necessary

c. ensure the client has a private room and bathroom

a nurse is assessing a client who has hyperthyroidism. the nurse should expect the client to report which of the following manifestations? a. sensitivity to cold b. constipation c. frequent mood changes d. weight gain of 10 lbs in 3 weeks

c. frequent mood changes

which of the following electrolyte abnormalities is most closely associated with pancreatitis? a. hypermagnesemia b. hyperphosphatemia c. hypocalcemia d. hypernatremia

c. hypocalcemia

which of the following anatomical locations would most likely be used to obtain a bone marrow biopsy? a. trochanter b. rib c. iliac crest d. sternum

c. iliac crest

which of the following interventions would help prevent tumor lysis syndrome? a. monitor the client's cardiac rhythm b. ensure safety while ambulating c. increase fluid intake d. increasing potassium in the client's diet

c. increase fluid intake

which of the following interventions would be most appropriate to help promote dietary intake for a client receiving chemotherapy? a. encourage food choices that are heavily spiced and have strong odors b. encourage the client to drink plenty of water prior to eating c. medicate with anti-nausea medications prior to eating d. provide large meals 3x a day

c. medicate with anti-nausea medications prior to eating

a nurse is caring for a client who is receiving peritoneal dialysis. the nurse should monitor the client for which of the following manifestations of peritonitis? a. bradycardia b. increased urinary output c. nausea and vomiting d. hyperactive bowel sounds

c. nausea and vomiting

a nurse preparing to obtain an arterial blood gas sample completes an Allen test on the client. what does an Allen test assess for? a. sensation in the extremity b. pain in the extremity c. patency of the radial and ulnar circulation d. client's ability to follow simple instructions

c. patency of the radial and ulnar circulation

after several diagnostic tests a client is diagnosed with diabetes insipidus. the nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? a. fatigue b. diarrhea c. polydipsia d. weight gain

c. polydipsia

a nurse is reviewing a medication list for a client who has a new diagnosis of type 2 diabetes mellitus. the nurse should recognize which of the following medications can cause an elevated blood sugar or glucose intolerance? a. ranitidine b. guaifenesin c. prednisone d. atorvastatin

c. prednisone

a nurse is suctioning fluids from a female client through an endotracheal tube. during the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. which of the following is the appropriate nursing intervention? a. notify the provider immediately b. ensure the suctioning time is limited to 15 seconds c. stop the procedure and re-oxygenate the client d. continue to suction

c. stop the procedure and re-oxygenate the client

a nurse with kidney stones is scheduled for extracorporeal shock lithotripsy (ESWL). what should the nurse include in the client's post-procedure care? a. administer a bolus of 500 mL normal saline following the procedure b. monitor the client for fluid overload following the procedure c. strain the client's urine following the procedure d. insert a urinary catheter for 24-48 hours after the procedure

c. strain the client's urine following the procedure

what is the rationale for withholding food and fluids prior to a bronchoscopy? a. food can obstruct the view of the bronchoscope b. in case the client needs surgery following the procedure c. to prevent aspiration d. to prevent hyperglycemia

c. to prevent aspiration

a client who has had a cholecystectomy asks why a T-tube has been inserted. the best response is: a. "T-tubes drain small gallstones." b. "T-tubes help us monitor infection." c. "T-tubes are always inserted following a gallbladder surgery." d. "T-tubes drain fluid and bile to keep the duct patent."

d. "T-tubes drain fluid and bile to keep the duct patent."

why might a provider order a schilling test for a client? a. thrombocytopenia b. iron deficiency anemia c. neutropenia d. B12 deficiency

d. B12 deficiency

the nurse is receiving report on a client admitted with a left hemispheric stroke. which of the following would the nurse anticipate including in the client's plan of care based on this diagnosis? a. assistance with activities of daily living related to loss of depth perception b. safety precautions because the client may be impulsive c. positioning the call bell on the right side of the client's body because they will have left sided weakness d. assisting the client with alternative forms of communication because they may have difficulty speaking or understanding

d. assisting the client with alternative forms of communication because they may have difficulty speaking or understanding

the client returning from a respiratory procedure reports increasing dyspnea. which of the following additional assessment findings would alert the nurse to a possibility of a pneumothorax? a. crackles in the lung fields b. increasing oxygen saturation c. tracheal deviation to the affected side d. asymmetrical chest wall movement

d. asymmetrical chest wall movement

a nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. which of the following techniques should the nurse use to assess the patency of this graft? a. measure the client's blood pressure to ensure it is higher in the left arm than the right b. check the brachial and radial pulses of the left arm simultaneously c. schedule the client for an ultrasound every day until discharge d. auscultate the site for a bruit and palpate for a thrill

d. auscultate the site for a bruit and palpate for a thrill

a nurse is planning care for a client who has a new diagnosis of diabetes insipidus. which of the following interventions should the nurse include in the plan of care? a. measure blood glucose levels every 4 hours b. administer a diuretic c. initiate fluid restriction d. check urine specific gravity

d. check urine specific gravity

a nurse is assessing a child who has nephrotic syndrome. which of the following findings should the nurse expect? a. polyuria b. decreased urine specific gravity c. light yellow urine d. facial edema

d. facial edema

a nurse is assisting with serving dinner trays on the unit. upon receiving the dinner tray for a patient with acute gallbladder inflammation, the nurse will question which of the following foods? a. fruit salad b. multigrain dinner roll c. baked potato and grilled chicken d. fried fish and chips

d. fried fish and chips

a client with a diagnosis of neutropenia is at risk for which of the following complications? a. hypertension b. dyspnea c. bleeding d. infection

d. infection

a nurse is preparing to administer morning medications when a client falls on the ground and begins to have a seizure. which of the following actions would be appropriate during the seizure? a. obtain a blood pressure b. restrain the client c. insert an oral airway d. move hazards away from the client

d. move hazards away from the client

a nurse working in an emergency department notes that a new client is demonstrating symptoms consistent with meningitis. which of the following is the priority action? a. decrease stimulation to the client, including lights and noise b. alert the public health department c. implement seizure precautions d. place the client in isolation and on droplet precautions

d. place the client in isolation and on droplet precautions

a client has the following ABG results: pH 7.30 PaCO2 55 HCO3 24 what is the interpretation of these values? a. metabolic acidosis b. metabolic alkalosis c. respiratory alkalosis d. respiratory acidosis

d. respiratory acidosis

which of the following would be a contraindication for a client with a diagnosis of thrombocytopenia? a. taking tylenol for pain management b. using a stool softener to avoid constipation c. using an electric razor to shave d. taking heparin to prevent clots

d. taking heparin to prevent clots

what is preload? a. the amount of blood in the atria prior to contraction b. the amount of blood left in the atria just after contraction c. the amount of blood left in the ventricle just after contraction d. the stretch of the ventricles filling with blood prior to contraction

d. the stretch of the ventricles filling with blood prior to contraction