Exam 1 Practice Questions
A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make? A. "Your body is destroying the cells that secrete insulin." B. "Your body has insulin resistance and decreased insulin secretion." C. "An infection in your pancreas destroyed the cells that make insulin." D. "Your kidneys are not able to reabsorb water which leads to Type 2 diabetes mellitus."
B.
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? A. Pitting edema B. Fatigue C. Dyspnea D. Oliguria
B.
A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? A. Attach defibrillator pads to the client. B. Check for a carotid pulse. C. Begin chest compressions. D. Deliver two breaths.
B.
A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Increased pulmonary artery wedge pressure (PAWP). D. Decreased specific gravity
B.
A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching? A. "I will feel shaky." B. "I will be more thirsty than usual." C. "My skin will be warm and moist." D. "My appetite will be decreased."
A.
A nurse observes mild hand tremors in a client who has diabetes mellitus. Which of the following actions should the nurse take after obtaining a glucose meter reading of 60 mg/dL? A. Administer 15 g of carbohydrates. B. Retest the blood glucose level. C. Administer 1 mg of glucagon IM. D. Administer IV dextrose.
A.
A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? A. Ventricular depolarization B. Slow repolarization of ventricular Purkinje fibers C. Atrial depolarization D. Early ventricular repolarization
C.
A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Confirming the gag reflex D. Measuring blood pressure
C.
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? A. Glucocorticoid medications B. Dextrose 5% in 0.45% sodium chloride C. Oral hypoglycemic medications D. 0.9% sodium chloride IV bolus
D.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? A. Initiating oxygen therapy B. Providing immediate rest for the client C. Positioning the client in high-Fowler's D. Administering a nebulized beta-adrenergic
D.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis 7.22 PaCO2 68 mm Hg Base
A.
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub
B.
A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider? A. Splinter hemorrhages to the nails B. Dyspnea C. Fever D. Clusters of petechiae in the mouth
B.
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect? A. Malignant hypertension B. Acetone odor to breath C. Cheyne-Stokes breathing D. Blood glucose level below 40 mg/dL
B.
A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching? A. "I will rest for at least 30 minutes before eating." B. "I will take my bronchodilators after meals." C. "I will eat five or six small meals each day." D. "I will choose foods that are not gas-forming."
B.
A nursing is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should nurse include in the teaching? A. Limit intake of potassium-rich foods. B. Restrict sodium intake. C. Increase carbohydrate intake. D. Decrease protein intake.
B.
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? A. "I am gaining weight." B. "I am constipated." C. "My vision seems yellow." D. "My tongue is red and beefy."
C.
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? A. Anorexia B. Weight gain C. Breathlessness D. Distended abdomen
C.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. Check the client's blood pressure. B. Auscultate heart tones. C. Perform a 12-lead ECG D. Determine if pain radiates to the left arm.
C.
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C.
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? A. 0720 B. 0730 C. 0745 D. 0815
C.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Jugular venous distention B. Abdominal distension C. Dependent edema D. Hacking cough
D.
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions
D.
A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client? A. High Fowler's with neck extended B. High Fowler's with neck in a neutral position. C. Semi-Fowler's with neck extended D. Semi-Fowler's with neck in a neutral position
D.
A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? A. Summon the code team. B. Begin chest compressions. C. Administer rescue breathing. D. Open the client's airway.
A.
A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe? A. Troponin B. Creatinine kinase (CK) C. Brain natriuretic peptide (BNP) D. C-reactive protein
A.
A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? A. Troponin I B. Lipase C. B-type natriuretic peptide (BNP) D. Aspartate aminotransferase (AST)
A.
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis? A. Provide a quiet, low-stimulus environment. B. Administer aspirin as prescribed for any sign of hyperthermia. C. Keep the client NPO. D. Observe the client carefully for signs of hypocalcemia.
A.
A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect? A. Tingling of the extremities B. Hypoactive deep tendon reflexes. C. Shortened QT intervals. D. Constipation
A.
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A. Frothy sputum B. Dependent edema C. Nocturnal polyuria D. Jugular distention
A.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? A. Suggest that the client use a salt substitute. B. Obtain a 12-lead ECG. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a blood sample for a serum sodium level.
B.
A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise
B.
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Different blood pressures in the upper limbs. B. Different apical and radial pulses. C. Differences between oral and axillary temperatures. D. Differences in upper and lower lung sounds.
B.
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? A. Give the client 15 to 20 g of carbohydrate. B. Monitor the client for hypoglycemia. C. Complete an incident report. D. Notify the nurse manager.
B.
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet
B.
A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? A. PR interval B. QT interval C. ST segment D. QRS complex
B.
A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? A. Apply a heating pad on a low setting to help relieve leg pain. B. Adjust the thermostat so that the environment is warm. C. Wear antiembolic stockings during the day. D. Rest with the legs above heart level.
B.
A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. HCO3- 30 mEq/L B. PaCO2 50 mm Hg C. pH 7.45 D. Potassium 3.3 mEq/L
B.
A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider? A. Sodium 136 mEq/L B. Potassium 2.3 mEq/L C. Chloride 99 mEq/L D. Calcium 10 mg/dL
B.
A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A. Attach the leads for a 12-lead ECG. B. Obtain a blood sample. C. Initiate oxygen therapy. D. Insert the IV catheter.
C.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension
C.
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding
C.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment B. A room with another nonsurgical client C. A room in the ICU D. A room that is within view of the nurses' station
A.
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? A. Propranolol B. Theophylline C. Montelukast D. Prednisone
A.
A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results? A. Decreased thyroid-stimulating hormone (TSH) level B. Decreased triiodothyronine (T3) level C. Decreased thyroxine (T4) level D. Decreased thyroid-stimulating immunoglobulins (TSI) percentage
A.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A. Dehydration B. Polyphagia C. Hyperglycemia D. Bradycardia
A.
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect? A. Hyperpigmentation B. Intention tremors C. Hirsutism D. Purple striations
A.
A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client? A. Chvostek's sign B. Babinski's sign C. Brudzinski's sign D. Kernig's sign
A.
A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? A. Withhold food and liquids until the client's gag reflex returns. B. Irrigate the client's throat every 4 hr. C. Have the client refrain from talking for 24 hr. D. Suction the client's oropharynx frequently.
A.
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following? A. Graham crackers B. 1 tsp sugar C. 4 oz diet soda D. 4 oz skim milk
A.
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The P wave falls before the QRS complex. B. The T wave is in the inverted position. C. The P-R interval measures 0.22 seconds. D. The QRS duration is 0.20 seconds.
A.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave
A.
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7.35 B. HCO3 above 26 mEq/L C. PaO2 below 70 mm Hg D. PaCO2 above 45 mm Hg
A.
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A.
A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? A. Obtain an EKG. B. Administer enteric-coated acetaminophen. C. Administer ibuprofen. D. Maintain oxygen saturations greater than or equal to 92%.
A.
A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? A. 6.3% B. 7.8% C. 8.5% D. 10%
A.
The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? A. Carvedilol B. Fluticasone C. Captopril D. Isosorbide dinitrate
A.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV. B. Administer oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.
B.
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-carbohydrate diet. B. Weigh the client daily. C. Administer oral corticosteroids. D. Restrict fluid intake.
B.
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Bumetanide 1 mg IV bolus every 12 hr
C.
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 4.5 kg (10 lb) in 3 weeks
C.
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a lipid whose levels reflect the risk for coronary artery disease. C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.
C.
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? A. Epinephrine B. Magnesium C. Atropine D. Sodium bicarbonate
C.
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine
C.
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? A. Pacemaker spikes after each QRS complex B. Pacemaker spikes before each P wave C. Pacemaker spikes before each QRS complex D. Pacemaker spikes with each T wave
C.
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? A. Maintenance of ideal weight B. Annual influenza immunization C. Smoking cessation D. Regular moderate exercise
C.
A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Applying cool compresses to her legs B. Wearing loose, non-constricting stockings C. Flexing her knees and feet frequently D. Taking an NSAID tablet daily
C.
A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus? A. HbA1c 5.5% B. 2 hr blood glucose 170 mg/dL C. Fasting blood glucose 155 mg/dL D. Casual blood glucose 180 mg/dL
C.
A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."
C.
A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll wear sandals in warm weather." B. "I'll put lotion between my toes after drying my feet." C. "I'll check my feet every day for sores and bruises." D. "I'll soak my feet in cool water every night before I go to bed."
C.
nurse is teaching a client who has a new diagnosis of Type 1 diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include? A. "Pull back on the plunger after injecting the insulin." B. "Massage the injection site after removing the needle." C. "Store the current bottle of insulin at room temperature." D. "Use each syringe up to six times."
C.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily
D.
A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take? A. Turn the client ever 4 hr. B. Check the client's blood pressure every 2 hr. C. Initiate measures to cool the client. D. Place the client on aspiration precautions.
D.
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 the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin B. Insulin glargine C. Insulin detemir D. Regular insulin
D.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. C. The client who has end-stage renal failure and is scheduled for dialysis today. D. The client who has gastroenteritis and is febrile.
D.
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.
D.
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? A. "A weight loss program can decrease my LDL cholesterol level." B. "Exercising regularly will increase HDL cholesterol levels." C. "Adding foods containing omega-3 fatty acids to my diet can lower my risk." D. "Increasing my intake of foods containing trans-fatty acids can lower my risk."
D.
A nurse is talking with a client whose thyroid-stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test? A. "This test measures the amount of thyroid hormone that attaches to a protein in your blood." B. "This test detects antithyroid antibodies in your blood." C. "This test measures the absorption of iodine and how it relates to the thyroid gland." D. "This test determines whether your thyroid gland is overactive, appropriately active, or underactive."
D.
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
D.
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include? A. "Have an eye examination once per year." B. "Examine your feet carefully every day." C. "Wear compression stockings daily." D. "Maintain stable blood glucose levels."
D.