Exam 1

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? "You could have gotten it by using I.V. drugs." "You must have received an infected blood transfusion." "You probably got it by engaging in unprotected sex." "You may have eaten contaminated restaurant food."

"You may have eaten contaminated restaurant food."

The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client? Signs of oxygen toxicity Chronic chest pain A barrel chest Long, thin fingers

A barrel chest

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A resident with mid-stage Alzheimer disease A 92-year-old resident who needs extensive help with ADLs A resident with severe and deforming rheumatoid arthritis A resident who suffered a severe stroke several weeks ago

A resident who suffered a severe stroke several weeks ago

The nurse is caring for a patient who is scheduled to have a liver biopsy. Before the procedure, it is most important for the nurse to assess the patient's: Tolerance for pain Allergy to iodine or shellfish History of nausea and vomiting Ability to lie still and hold breath

Ability to lie still and hold breath

On auscultation, which finding suggests a right pneumothorax? Bilateral inspiratory and expiratory crackles Absence of breath sounds in the right thorax Inspiratory wheezes in the right thorax Bilateral pleural friction rub

Absence of breath sounds in the right thorax

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? Ammonia Calcium Bicarbonate Alcohol

Ammonia

Which of the following are actions in verifying the "right patient" before medication administration? Select all that apply. Ask the client to state his or her name and date of birth. Scan the bar code on the client's armband. Compare the client's name with the eMAR. Skip this step if the patient is asleep.

Ask the client to state his or her name and date of birth. Scan the bar code on the client's armband. Compare the client's name with the eMAR.

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? Shallow respirations Bilateral wheezes Increased anterior-posterior (AP) diameter Bradypnea

Bilateral wheezes

A nurse checking a client's medication record notices a change in the dose and route for a medication given earlier in the day. What would be the appropriate action by the nurse? Check for new orders by the provider. Administer the medication as it appears on the medication record. Change the medication record back to the dose and route that was administered with the morning dose. Ask the client to verify the order.

Check for new orders by the provider.

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? Pleural friction rub Sibilant wheezes Low-pitched rhonchi during expiration Crackles in the lung bases

Crackles in the lung bases

Which nursing assessment is most important in a patient diagnosed with ascites? Daily measurement of weight and abdominal girth Auscultation of abdomen Palpation of abdomen for a fluid shift Assessment of the oral cavity for foul-smelling breath

Daily measurement of weight and abdominal girth

Which of the following are examples of using technology for safe medication administration? Select all that apply. Electronic medication administration record (eMAR). Scanning procedures of the medication package and patient armband. Safeguard parameters on the IV pump. Automated medication dispensing machines.

Electronic medication administration record (eMAR). Scanning procedures of the medication package and patient armband. Safeguard parameters on the IV pump. Automated medication dispensing machines.

A patient admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the patient with breathing? Repositions side to side every 2 hours Elevates the head of the bed to 60 degrees Auscultate the lung fields every 4 hours Encourages deep breathing exercises hourly

Elevates the head of the bed to 60 degrees

Which of the following is an example of an appropriate order? Furosemide 40 mg by mouth qd Furosemide 40 mg by mouth Q.D. Furosemide 40 mg by mouth daily Furosemide 40 mg by mouth QD

Furosemide 40 mg by mouth daily

A patient has been scheduled for an Endoscopic Retrograde Cholangiopancreatography (ERCP) the following morning. What should the nurse do in preparation for this diagnostic study? Administer the contrast agent orally 10 to 12 hours before the study. Encourage the intake of 64 ounces of water 8 hours before the study. Administer the radioactive agent intravenously the evening before the study. Have the patient refrain from food and fluids after midnight.

Have the patient refrain from food and fluids after midnight.

Which of the following is the priority nursing intervention in helping a patient expectorate thick lung secretions? Humidify the oxygen as able Administer cough suppressant q4hr Teach patient to splint the affected area Increase fluid intake to 3 L/day if tolerated

Increase fluid intake to 3 L/day if tolerated

To promote airway clearance in a patient with pneumonia and recent abdominal surgery, the nurse instructs the patient to do which of the following (select all that apply)? Maintain adequate fluid intake Splint the abdomen when coughing Maintain a high Fowler's position Maintain a Sim's position Cough at end of exhalation

Maintain adequate fluid intake Splint the abdomen when coughing Maintain a high Fowler's position Cough at end of exhalation

A nurse is administering medications to a client and accidentally drops a pill onto the floor. What is the most appropriate response by the nurse? Administer the medication after picking it up because getting a new pill would be wasteful. Do not administer the medication and document that the dose was skipped in the medication administration record (MAR). Ask the client if they are willing to take the pill that fell on the floor or if they would like a new one. Obtain a new pill from the medication dispensary and administer the new pill to the client.

Obtain a new pill from the medication dispensary and administer the new pill to the client.

Which term describes the passage of a hollow instrument into a cavity to withdraw fluid? Asterixis Ascites Paracentesis Dialysis

Paracentesis

After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should Put pressure on the biopsy site using a sandbag Elevate the head of the bed to facilitate breathing Place the patient on the right side with the bed flat Check the patient's post-biopsy coagulation studies

Place the patient on the right side with the bed flat

When caring for a patient with acute pancreatitis, the nurse should use which comfort measure? Administering frequent oral feedings Encouraging frequent visits from family and friends Positioning the patient sitting up and leaning forward Positioning the patient lying flat

Positioning the patient sitting up and leaning forward

During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? Receive vaccinations Exercise daily Drink six glasses of water daily Take all prescribed medications

Receive vaccinations

While the nurse is administering morning medications, the client asks, "What is the pill for?" When the nurse explains the pill is for high cholesterol, the client responds, "I have never had a problem with high cholesterol." What is the appropriate action by the nurse? Encourage the client to take the medication. Leave a note in the client's chart for the prescriber. Repeat the three checks for the medication. Review the original order for the medication.

Review the original order for the medication.

A charge nurse is observing a new nurse preparing medications for a patient. Which of the following would require the charge nurse to intervene? The new nurse pulls all the medications that are due for that patient. The new nurse crushes enteric coated aspirin to put in the client's applesauce. The new nurse verifies the order in the computer and on the medication packaging. The new nurse wipes down the work station in the med room before preparing medications.

The new nurse crushes enteric coated aspirin to put in the client's applesauce

A nurse is administering a new fentanyl patch to a client with chronic back pain. When removing and discarding the previous fentanyl patch, what is the proper disposal technique? The nurse should discard the removed patch in the locked sharps container and it must be witnessed by another RN. The nurse should discard the removed patch in the trash and it must be witnessed by another RN. The nurse should discard the removed patch by flushing it down the toilet and it must be witnessed by the charge nurse. The nurse should discard the removed patch in the trash and it must be witnessed by the nursing supervisor.

The nurse should discard the removed patch in the locked sharps container and it must be witnessed by another RN.

The nurse is preparing DULoxetine. How do the capital letters "DUL" assist the nurse in safe medication administration? They help in alphabetizing the medications in the automated medication dispensing machine. They alert the nurse of a sound-alike/look-alike medication. They are the initials for the medication classification. They are the letters that start both the generic and trade name for the medication.

They alert the nurse of a sound-alike/look-alike medication.

A client is ordered for 10 units of NPH insulin SC and 2 units of Regular insulin SC. After injecting air, the nurse should draw up the Regular insulin and then the NPH insulin. True False

True

A patient with suspected esophageal varices is scheduled for an upper endoscopy with moderate sedation. After the procedure is performed, how long should the nurse withhold food and fluids? For 2 hours after the last dose of medication is given Until the gag reflex returns Until the patient expresses thirst For 6 hours after the procedure

Until the gag reflex returns

When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows: redness and induration drainage tissue sloughing bruising

redness and induration

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because: the attack is over the airways are so swollen that no air can get through the swelling has decreased crackles have replaced wheezes

the airways are so swollen that no air can get through