Exam 1 Questions

Calculate the client's intake for the following 12-hour shift: 6:00 IV of Normal Saline at 125mL/hr is started 8:00 client voided 275 mL urine 10:00 client drank 6 ounces of juice 11:00 client voided 250 mL urine 12:00 client drank 6 ounces of juice and 4 ounces of tea 2:00 client felt nauseated and had 200 mL clear emesis 4:00 client drank 3 ounces of water with medication 5:00 client received IV piggyback medication in 250 mL NS 6:00 client voided 300 mL urine

2320 mL intake

The prescription reads: 1 gram of Ampicillin in 3000 mL NS to infuse in 45 minutes. The nurse will adjust the flow rate to how many mL/hour?

4000 mL/hour

The prescription reads: 1 liter of D5 Normal Saline to infuse over 12 hours. The nurse will set the pump to what hourly rate?

83 mL per hour

Match the symptom with the most likely cause: Hyponatremia Metabolic acidosis Hyperkalemia Respiratory alkalosis a. Heart palpitations, chest pain b. Confusion, rapid, shallow breathing c. Nausea, vomiting, headache d. Hyperventilation and anxiety

Hyponatremia c. Nausea, vomiting, headache Metabolic acidosis b. Confusion, rapid, shallow breathing Hyperkalemia a. Heart palpitations, chest pain Respiratory alkalosis d. Hyperventilation and anxiety

A client is scheduled for a radiography procedure using intravenous contrast dye. The nurse performs which priority action? a. Ask about allergy to iodine or shellfish b. Obtain a set of vital signs c. Ensure that the client is well hydrated d. Measure accurate height and weight

a. Ask about allergy to iodine or shellfish

The nurse is caring for a client with wrist restraints. Which is the priority nursing intervention for this client? a. Assessing color, sensation, and pulses distal to the restraint b. Providing range-of-motion exercises to the wrists c. Removing wrist restraints periodically per facility guidelines d. Applying lotion to the skin underneath

a. Assessing color, sensation, and pulses distal to the restraint

Which factors influence the amount and distribution of body fluids? (select all that apply) a. Body fat % b. Race c. Weight d. Age e. Height

a. Body fat % c. Weight d. Age

Which is the priority nursing intervention during the pre-operative phase of client care? a. Client teaching b. Diagnostic testing c. Client safety d. Documentation of care

a. Client teaching

The nurse reviews the following diagnostic findings for a client with type 2 diabetes. Which finding indicates a need for further evaluation? A1C 4.6% Fasting Blood Glucose 150 mmol/L LDL cholesterol 100 mg/dL Random Blood Glucose 140 mmol/L a. Fasting blood glucose b. A1C c. Random blood glucose d. LDL cholesterol

a. Fasting blood glucose

A client who has undergone preadmission testing and assessment. Which results should be reported to the surgeon's office immediately by the nurse, knowing that it could cause surgery to be postponed? a. Hemoglobin 8.0 g/dL b. Temperature 99.0 F c. Serum potassium 4.1 mmol/L d. SaO2 93% on room air

a. Hemoglobin 8.0 g/dL

The nurse is assessing a 30-year-old African American client. The client has a blood pressure of 152/92 mm Hg, a total cholesterol level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. Which is the priority risk factor for heart disease in this client? a. Hypertension b. Hyperlipidemia c. Elevated glucose level d. Age

a. Hypertension

The nurse is interviewing a client with newly diagnosed type 2 diabetes. Which statement by the client indicates a need for further instruction? a. I will give all my injections in my abdomen, since it is easiest to reach b. I need to meet with the nutritionist to discuss my dietary preferences c. I know that I will need to wear shoes when I am outside d. I will be sure to report any temperature elevations to my primary provider

a. I will give all my injections in my abdomen, since it is easiest to reach

A client is experiencing prolonged vomiting. This puts them at increased risk for which acid-base imbalance? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic alkalosis

Which indicator of return to consciousness occurs first as client recovers form general anesthesia? a. Muscular irritability b. Restlessness c. Recognition of pain

a. Muscular irritability

After admitting a postoperative client to the medical-surgical unit, which assessment data require the most immediate attention? a. Oxygen saturation 85% b. Respiratory rate of 13 c. Temp 100.4 d. Blood pressure of 90/60

a. Oxygen saturation 85%

When is a client most susceptible to hypoglycemic symptoms after the administration of insulin? a. Peak b. Duration and peak c. Onset d. Duration

a. Peak

When assessing an older client for fluid balance, which is the best assessment technique for the nurse to use? a. Pinch the skin under the clavicle b. Auscultate the lungs c. Assess the skin for dryness d. Pinch the skin on the back of the hand

a. Pinch the skin under the clavicle

When providing care to an elderly client receiving IV fluids at 150 mL/hr, the nurse finds the client has developed shortness of breath, cough, puffiness around the eyes, and lung sounds with crackles. What is the nurse's first action? a. Place the client in an upright position, administer oxygen, slow the IV rate, and notify the provider b. Assess for patency of catheter, change the tubing, and resume the IV fluid administration c. Notify provider, remove IV, apply pressure, place client in semi-Fowler's position d. Notify provider, place client in Trendelenburg position, slow the infusion rate

a. Place the client in an upright position, administer oxygen, slow the IV rate, and notify the provider

The nurse assesses a client's surgical incision for signs of infection on the first post-operative day. Which findings by the nurse would be interpreted as normal findings? (select all that apply) a. Redness at the site b. Red streaks radiating from the site c. Serous drainage d. Sutures intact e. Warm, tender skin

a. Redness at the site c. Serous drainage d. Sutures intact

Which drug characteristics are appropriate to describe drugs used for moderate sedation? (select all that apply) a. Reduce sensory perception b. Require placement of an artificial airway c. Amnesia action is short d. Return to normal function is rapid e. Increase level of consciousness f. Must be administered by a physician

a. Reduce sensory perception c. Amnesia action is short d. Return to normal function is rapid

The nurse is caring for a client receiving regular enteral tube feedings. Which is the priority nursing diagnosis? a. Risk for aspiration b. Knowledge deficit c. Deficient fluid volume d. Imbalance nutrition, less than body requirements

a. Risk for aspiration

When providing client teaching regarding self-administration of insulin, the nurse includes which of the following pieces of information? (select all that apply) a. Rotation of injection sites is recommended to prevent tissue damage b. The medication is absorbed the fastest when injected into the abdomen c. Be sure to aspirate and check for blood before d. Do not use back of arm e. Hips, thighs easiest to reach

a. Rotation of injection sites is recommended to prevent tissue damage b. The medication is absorbed the fastest when injected into the abdomen e. Hips, thighs easiest to reach

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? a. Sit with the head of the bed at 45-90 degrees b. After expiration, hold your breath for 15 seconds c. Keep a loose seal between the lips and the mouthpiece d. Inhale as rapidly as possible

a. Sit with the head of the bed at 45-90 degrees

A nurse is explaining pain control methods to a patient undergoing a bowel surgery. The patient's interested in the patient-controlled analgesia (PCA) pump and asks the nurse to explain how it works. What would be the nurse's best response? a. The pump allows the patient to self-administer limited doses of pain medication b. The pump allows the patient to take unlimited amounts of medication as needed c. The pump allows the patient to be pain free during the post-operative period d. The pump allows the patient to choose the type of medication given post-operatively

a. The pump allows the patient to self-administer limited doses of pain medication

A client receives an injection of short-acting insulin and an intermediate acting insulin before at 800. Using the chart below, what time should the nurse expect the intermediate insulin to start to take effect? a. 0900 b. 1000 c. 1300 d. 1500

b. 1000

A client receives an injection of short-acting insulin and an intermediate-acting insulin before breakfast at 0800. Using the chart below, what time should the nurse expect the short-acting insulin to have its strongest effect? Insulin type Onset Peak Duration Short-acting / 15-30 minutes / 2-3 hours / 4-6 hours Intermediate-acting / 2-4 hours / 4-12 hours / 16-20 hours a. 0945 b. 1030 c. 1100 d. 0900

b. 1030

The nurse on a med surg unit is preparing to receive a client from the PACU. What should the nurse's initial action be upon the client's arrival on the inpatient care unit? a. Assess client's pain b. Assess vital signs c. IV infusion rate d. Check peripheral pulses

b. Assess vital signs

A 22-year-old client is diagnosed with type 1 diabetes. Which of the following will the nurse include in the discharge teaching? a. Taking your insulin as prescribed will also help control your blood pressure b. Be sure to drink alcohol only with meals and in moderation c. You are not at increased risk for sexually transmitted infections d. If you plan to exercise, be sure to eat a sugary snack before starting

b. Be sure to drink alcohol only with meals and in moderation

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to encourage further discussion between the client and the nurse? a. If it's any help, everyone is nervous before surgery b. Can you share with me what you've been told about your surgery? c. Let me describe the amount of pain you can anticipate d. I will be happy to explain the surgical procedure to you

b. Can you share with me what you've been told about your surgery?

When providing patient teaching, the nurse emphasizes which priority complication related to chronic hyperglycemia? a. Uncontrolled weight gain and self-shame b. Chronic damage to blood vessels causing tissue hypoxia c. Increased risk for respiratory complications d. Vitamin and mineral deficiencies

b. Chronic damage to blood vessels causing tissue hypoxia

The nurse is caring for a client with type 2 diabetes. Which client symptom would alert the nurse to the presence of a possible hypoglycemic reaction? a. Muscle cramps b. Confusion c. Hot, dry skin d. Anorexia

b. Confusion

A client is admitted to the hospital with gross abdominal swelling and difficulty breathing. What is the priority nursing action? a. Auscultate lung sounds every 4 hours b. Elevate the head of the bed 75 degrees c. Reposition the patient every 2 hours d. Get an accurate height and weight

b. Elevate the head of the bed 75 degrees

When providing care to a client receiving IV fluids at a rate of 150mL/hr, the nurse finds that the client has developed shortness of breath, wet cough, and crackles in the lungs on auscultation. What do these clinical findings suggest? a. Allergic reaction to IV fluid b. Fluid volume overload c. Developing thrombophlebitis d. IV catheter related infection

b. Fluid volume overload

When assessing a client with hyperglycemia, the nurse would evaluate the client for which symptoms? a. Confusion and tremors b. Increased thirst, frequent urination c. Low urine output, itchy skin d. Sweating and hunger

b. Increased thirst, frequent urination

Which are common causes of hypoglycemia? (select all that apply) a. Increased food intake after missed or delayed meals b. Insulin injected at the wrong time relative to food intake c. Too much insulin compared to food intake and physical activity d. Medication taken orally instead of by injection e. Decreased insulin sensitivity as a result of regular exercise and weight control

b. Insulin injected at the wrong time relative to food intake c. Too much insulin compared to food intake and physical activity

A 25-year-old with type 1 diabetes says, "I have 2 kidneys and I'm young. I expect to be around for a long time, so I don't need to worry about my blood sugar." What is the nurse's best reply? a. You have little to worry about as long as your kidneys keep making urine b. Keeping your blood sugar under control can help prevent damage to both kidneys c. You would be right, as long as you remember to take your prescribed insulin d. You should discuss this with your provider because you are being unrealistic

b. Keeping your blood sugar under control can help prevent damage to both kidneys

The nurse would be alerted to the occurrence of possible malignant hyperthermia when the client demonstrates which manifestations? a. Hypocapnia b. Muscle rigidity c. Decreased body temperature d. Confusion on arousal from anesthesia

b. Muscle rigidity

A nurse has been asked to witness a patient signature on an informed consent form for surgery. What information should be included on the form? (select all that apply) a. Explanation of the guaranteed outcome of the procedure b. Name of the provider who will perform the surgery c. The option of non-treatment d. Details about the underlying disease process and its natural course e. A description of the specific procedure to be performed

b. Name of the provider who will perform the surgery c. The option of non-treatment e. A description of the specific procedure to be performed

A client arrives in the emergency room in moderate distress and vomiting bright red emesis. What is the priority nursing action? a. Ask the client about precipitating events b. Obtain a set of vital signs c. Complete an abdominal assessment d. Call the provider

b. Obtain a set of vital signs

Which of the following techniques will the nurse when administering insulin to a very thin client? a. Spread the skin and massage the area after injection b. Pinch the skin up and insert the needle at a 45-degree angle c. Pinch the skin up and insert the needle at a 90-degree angle d. Warm the skin prior to injection, to increase circulation

b. Pinch the skin up and insert the needle at a 45-degree angle

A post-operative client asks why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? a. Fluid imbalance b. Pneumonia c. Pulmonary embolism d. Hypoxemia

b. Pneumonia

The nurse is teaching incisional care to a client who is being discharged after abdominal surgery. Which priority instruction must the nurse include? a. Do not rub or touch incision site b. Practice proper handwashing c. Clean incision site twice a day with soap and water d. Splint the incision site as often as needed for comfort

b. Practice proper handwashing

When caring for an elderly, confused client which of the following is the nurse's primary concern regarding fluid and electrolyte imbalances? a. Risk of kidney failure b. Risk of dehydration c. Risk of fluid shift d. Risk of stroke

b. Risk of dehydration

While assessing a client's peripheral IV site, the nurse notes that the surrounding skin appears pale, and is swollen and cool to the touch. How will the nurse interpret this assessment finding? a. Localized extravasation b. Signs and symptoms of infiltration c. Developing hematoma d. Minimal signs of thrombophlebitis

b. Signs and symptoms of infiltration

While assessing a client's peripheral IV site, the nurse notes that the surrounding skin appears red and inflamed, and the vein is hard and cordlike on palpation. How will the nurse interpret this assessment finding? a. Localized extravasation b. Signs of phlebitis c. Developing hematoma d. Early symptoms of infiltration

b. Signs of phlebitis

While assessing a client's IV site, the nurse notes signs and symptoms of infiltration. What is the priority nursing action? a. Remove the IV access b. Stop the IV infusion c. Elevate the extremity d. Apply a sterile dressing

b. Stop the IV infusion

The nurse is educating a client with a new diagnosis of diabetes mellitus. Which of the following should the nurse emphasize? (select all that apply) a. Weight gain of 10-15 pounds is not considered significant b. You will need to get your eyes checked annually c. Risk for stroke is 2-4 times higher in adults with diabetes d. Stress can cause changes in your blood glucose level e. Aerobic exercise is not advised for adults with diabetes

b. You will need to get your eyes checked annually c. Risk for stroke is 2-4 times higher in adults with diabetes d. Stress can cause changes in your blood glucose level

A client with a sprained ankle says "I have been waiting for 4 hours and other people who came in after me have already been seen by the provider. My ankle hurts!" What is the nurse's best response? a. "Other patients have problems that are more serious than yours" b. "Sir, I see that you are frustrated but please sit down and wait your turn" c. "We have to treat life-threatening and unstable conditions first" d. "This is a system problem. I can call the supervisor for you"

c. "We have to treat life-threatening and unstable conditions first"

The nurse is caring for a client 1 hour after abdominal surgery and notes considerate bleeding from the incision site. What is the nurse's first action? a. Request a complete blood count b. Notify the surgeon c. Apply pressure and additional layers to the dressing d. Remove the dressing and inspect the incision

c. Apply pressure and additional layers to the dressing

A client is admitted with shortness of breath and possible pneumonia. Which nursing activity is the priority to include in the client's care? a. Request a referral for respiratory therapy b. Restrict visitors to evening hours only c. Assess respirations and SpO2 every 4 hours d. Place the client on respiratory isolation

c. Assess respirations and SpO2 every 4 hours

Tanner's Clinical Judgement Model includes which part of the Nursing Process in the "noticing" phase? a. Planning b. Analysis c. Assessment d. Evaluation

c. Assessment

The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Check tubes or drains for patency b. Check the dressing to assess for bleeding c. Check airway patency d. Check the blood pressure

c. Check airway patency

Which is the best description of the 3-pronged approach to diabetes care? a. Involve the patient, spouse, and family in all aspects of patient teaching b. Consider family history, culture, and personal beliefs c. Consider the diet, exercise, and prescribed medications d. Encourage extra medication and food during illness and exercise

c. Consider the diet, exercise, and prescribed medications

A client who is admitted with dehydration due to nausea and vomiting. Which nursing assessment will be the best indicator that the dehydration is resolving? a. Lung sounds b. Serum sodium level c. Daily weights d. Skin turgor

c. Daily weights

While assessing a patient in the post-anesthesia care unit (PACU), the nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these findings as most likely indicating which complication? a. Infection b. Atelectasis c. Hemorrhage d. Thrombophlebitis

c. Hemorrhage

The most dangerous metabolic side effect of general anesthesia is which of these? a. Hypoglycemia b. Hypernatremia c. Hyperthermia d. Hypothermia

c. Hyperthermia

Which of the following is the appropriate initial action by the nurse when preparing insulin administration? a. Withdrawing the clear and cloudy insulin in separate syringes b. Withdrawing the cloudy insulin first before the clear insulin c. Injecting air into the cloudy insulin but withdrawing the clear insulin first d. Injecting air into the regular insulin first

c. Injecting air into the cloudy insulin but withdrawing the clear insulin first

Nurse is educating a client with new diagnosis of diabetes. Which of the following should the nurse emphasize about foot care? (select all that apply) a. Cut toenails with rounded corners b. Use heating pad c. Inspect feet daily d. Wear proper fitting shoes e. Don't walk barefoot

c. Inspect feet daily d. Wear proper fitting shoes e. Don't walk barefoot

The client has been receiving insulin injections in the abdomen for 3 days. On day 4, where is the best location for the nurse to administer the injection? a. In the deltoid b. Back of the lower arm c. Middle of the thigh d. Abdomen, in the same area as the previous injection

c. Middle of the thigh

When assessing a post op GI system, what is best indicator that peristalsis has returned? a. Presence of bowel sounds b. Client states he is hungry c. Passing of flatus or stool d. Presence of abdominal cramping

c. Passing of flatus or stool

When assessing a client with hyperglycemia, the nurse would evaluate the client for changes in which electrolyte? a. Sodium b. Chloride c. Potassium d. Magnesium

c. Potassium

Which signs/symptoms are considered post op complications? (select all that apply) a. Sedation b. Pain at surgical site c. Pulmonary embolism d. Hypothermia e. Wound evisceration f. Postoperative ileus

c. Pulmonary embolism d. Hypothermia e. Wound evisceration f. Postoperative ileus

The nurse performs an assessment on a client with type 2 diabetes. Findings include a fasting blood glucose of 120, temp of 101, pulse 88, respirations of 22, and blood pressure of 100/72. Which finding would be of most concern? a. Pulse b. Respiration c. Temperature d. Blood pressure

c. Temperature

An appendectomy is being performed on a client with appendicitis. What is the correct classification for this surgery? a. Curative b. Diagnostic c. Urgent d. Radical

c. Urgent

Which finding will the nurse most closely monitor for a client who was just admitted to the medical-surgical unit post-operatively? a. Temperature of 99.0 F b. Serous drainage on the surgical dressing c. Urine output of 20 mL/hr d. Blood pressure of 114/70

c. Urine output of 20 mL/hr

Which blood pH value does the nurse interpret as within normal limits? a. 7.47 b. 7.5 c. 7.27 d. 7.37

d. 7.37

When planning interventions for a post op client, the nurse focuses on promoting ambulation and the use of incentive spirometry. Which action will best help the client to achieve the desired outcomes? a. Educating the client about possible complications if the activities are not performed b. Giving positive feedback when activities are performed correctly c. Asking the client to demonstrate post op exercises once per shift d. Administering adequate analgesics to promote relief or control of pain

d. Administering adequate analgesics to promote relief or control of pain

When initiating a peripheral IV, the nurse follows which of these guidelines? a. Limit unsuccessful attempts to no more than 6 total b. Choose the patient's dominant arm when possible c. Choose a vein that feels hard or cordlike d. Avoid choosing a site at a point of flexion

d. Avoid choosing a site at a point of flexion

Which is the basic principle of meal planning for a client with type 1 diabetes? a. Five small meals per day plus a bedtime snack b. Take extra insulin when planning to eat sweet foods c. High protein, low carbohydrate, and low fiber foods d. Consider the effects and peak action times of the client's insulin

d. Consider the effects and peak action times of the client's insulin

A client who is experiencing fluid overload is likely to exhibit which of the following symptoms? a. Distended neck veins with lying flat b. Pale skin and mucous membranes c. Orthostatic hypotension d. Distended neck veins when sitting

d. Distended neck veins when sitting

A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action? a. Obtain a thorough health history b. Encourage the client to express their feelings c. Administer an anti-anxiety medication d. Examine and treat the wound sites

d. Examine and treat the wound sites

The priority nursing intervention to aid a preoperative client in coping with fear of postoperative pain would be which of the following? a. Assure client that pain medication will be available b. Teach client to use splinting to help manage pain c. Describe type of pain associated with client's scheduled surgery d. Explain the pain management plan, including the use of a pain scale

d. Explain the pain management plan, including the use of a pain scale

A client is transferred to the medical-surgical unit 6 hours after surgery. The nurse suspects the development of acidosis after assessing which symptom? a. Hyperactive muscle activity b. SaO2 93% c. Increased urine output d. Hypotension

d. Hypotension

When caring for an elderly client, the nurse carefully monitors for which early sign of fluid and electrolyte imbalance? a. Poor skin turgor b. Elevated blood pressure c. Elevated temperature d. Mental status change

d. Mental status change

A nurse is caring for a client with type I diabetes. Which client complaint would alert the nurse to the presence of a possible hypoglycemic reaction? a. Hot, dry skin b. Muscle cramps c. Anorexia d. Tremors

d. Tremors