Final exam test questions

A client is brought to the emergencydepartment with suspected bleeding esophageal varices. Which hemoglobin level would the nurse immediately report to the physician?

5.0 g/dL

Which is the best thing a nurse can do to provide culturally sensitive care?

Accept each client as a unique individual

In addition to teaching a client with constipation to increase dietary fiber intake to 25 g/day, which of the following would the nurse include as important?

Adding fiber rich foods to the diet gradually

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of CVA, the nurse anticipates the medical treatment to include which of the following?

Anticoagulant therapy

A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?

Assess for elevated blood urea nitrogen and creatinine levels

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

Assist the client to increase dietary fiber

A client is experiencing an irregular heart beat. The client asks the nurse how a heartbeat occurs. The nurse explains the conduction system of the heart starting with the sinoatrial node. Place the conduction sequence in order beginning with the SA node.

Atrial cell stimulation-->AV node-->Bundle of His-->Bundle branches-->Purkinje fibers

A 76 y/o male client is brought to the clinic. The daughter states that her father has had two TIAs in the past week. The physician ordered a carotid angiography and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply

Balloon angiplasty of the carotid artery followed by stent placement Carotid endarterectomy

A client is brought to the ER with symptoms of a CVA. The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Brain CT scan or MRI

The physicians office is caring for a client with a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

Cerebral angiography

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Cerebrospinal fluid is cloudy

When examining the skin of a client who is dehydrated due to fluid losses from the GI tract, which of the following would be most important?

Checking if the mucous membranes are dry

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to have?

Clay colored stool

You are caring for three clients who have the following blood count values: Client A has 24,500/mm3 WBC, Client B has 13.4 g/dL hemoglobin, and Client C has a 250,000/mm3 platelet count. Which statement correctly describes the condition of each client?

Client A has a higher than normal WBC count, Client B has a normal hemoglobin count, Client C has a normal platelet count

A nurse is obtaining information from a client with Crohns disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?

Corticosteroids

A client with a fib is placed on warfarin to reduce the potential of developing a CVA. The INR is 1.5. What does this finding indicate?

Coumadin will be increased

The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?

Crackles

Which of the following is a process by which the nurse consistently works in the cultural context of the client, family, and community?

Cultural competence

The nurse is caring for a geriatric client. The client is ordered Lanoxin(digoxin) tablets 0.125 mg daily for cardiac dysrhythmias. Which of the following assessments is essential when caring for this age group?

Digoxin level

The nurse is providing health ed on the body's ability to exchange oxygen and carbon dioxide through the alveolar capillary membrane. Which statement is most correct when asked about diffusion during inspiration?

During inspiration, oxygen is greater in the alveoli than in the capillaries

A nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart?

Echocardiogram

The nurse is assessing the client newly prescribed Lasix for 3+ pitting edema. To evaluate the effectiveness of diuretic therapy, which of the following would be documented?

Edema

A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells?

Epoetin alfa(Epogen)

The nurse is instructing a senior health class on the function of the kidney. The nurse is correct to highlight which of the following? Select all that apply

Excretes waste products Controls blood pressure Regulates sodium and potassium Regulates RBC production

You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure might experience?

Gradual unexplained weight gain

When obtaining vital signs from a client who has reduced erythrocyte production and a hemoglobin level of 8.2 g/dL, what results would be indicative of these lab studies?

Heart rate of 120 bpm

A client is suspected of sepsis from a postsurgical incision infection. What characteristics of sepsis would the nurse recognize?

Heart rate of 120 bpm Temperature of 102 degrees F Respiratory rate of 24 breaths per minute

A diabetic client maintains glucose control with the use of long acting and short acting insulin. Which nursing instruction would be considered a priority?

If using Lantus or Levimir, give in separate syringe

You are caring for a client with breast cancer who has been receiving chemotherapy. The client was admitted with an infected lesion on her leg. The physician has ordered Neupogen. What will Neupogen do for this client? Select all that apply

Increase WBC production Boost the immune system

When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first?

Inspection

A client is being treated for anemia and has a hemoglobin of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?

Iron

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?

Ischemic

The nurse notes that the client has had a change in mental status. Why would it be important for the nurse to report extremes in the thought process of a client with cardiovascular disorder to the physician?

It may indicate a problem with oxygenation

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory process and compensation?

Lungs and kidneys

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a NG tube to low continuous suction. Which acid base imbalance is most likely to occur?

Metabolic alkalosis

A client with diabetes is receiving oral antidiabetic medication that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin

The LPN is performing the physical examination of a client with a suspected neurological disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurses assess neck rigidity?

Moving the head and chin toward the chest

A nurse is completing an assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neuro deficit?

Occipital lobe

The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake?

Offer small, frequent feedings

The nurse is caring for a client with intusseption of the bowel. What does the nurse understand occurs with this disorder?

One part of the intestine telescopes into another portion of the intestine

A client with a diagnosis of acute appendicitis is awaiting surgery. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and firm. What complication may be occurring at this time?

Peritonitis

The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot?

Platelets

A patient was found unresponsive at home for an undetermined amount of time. A CVA is suspected. The family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply

Presence of an ischemic stroke Administer within 3 hours of onset of symptoms

A client is asked to collect a 24 hour urine specimen for culture. Which of the following measures can the nurse suggest to the client that may help prevent the entire urine specimen from being contaminated?

Refrigerate the specimen until it is taken to the lab

A client is admitted to the unit with DKA. Which insulin would the nurse expect to give intravenously

Regular (Humulin R)

You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin aldosterone system. What does this system do?

Restores blood pressure

The nurse is assessing the cardiovascular status of a client who was found unresponsive in a lobby area. The family asks how blood circulates through the body. The nurse is most correct to state the proper circulation as which? Place the pattern of circulation in the correct order beginning in the right atrium.

Right Ventricle-->Pulmonary artery-->Pulmonary vein-->Left atrium-->Left ventricle-->Aorta

A student asks the consequences of uncorrected left-sided heart failure. What would be your best response?

Right sided heart failure

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?

Second Lumbar Vertebrae

The nurse is providing care to a patient who had a percutaneous liver biopsy. The nurse would monitor the client for which of the following?

Signs of bleeding

Undifferentiated cells that migrate to the thymus gland develop into which of the following?

T lymphocytes

A client who has experienced a TIA says "I'm glad it wasnt anything serious" Which is the best nursing response?

TIA is a warning sign. Lets talk about lowering your risks

The nurse is caring for a client newly diagnosed with MS. The client indicates that there is so much to understand at one time. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. Which nursing action is correct?

Tell the client the covering is called myelin

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are difficult to remove

You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician immediately?

The client's heart rate is greater than 90 bpm

The nurse is caring for a client diagnosed with COPD and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH?

The lungs are not able to blow off carbon dioxide

A client has been involved in an automobile accident and is found to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen?

The spleen is a lymphatic structure and assists with phagocytosis

A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse "What are tonsils good for anyway?" What is the best response by the nurse?

These tissues filter bacteria from tissue fluid

The nurse is observing the skin of a client who is taking meds that depress the hematopoietic system and notices multiple areas of ecchymosis on the arms, bleeding for a prolonged period after IV access was started, and reports of black tarry stool. What does the nurse understand may be a side effect of this medication that the client is displaying?

Thrombocytopenia

The nursing instructor is teaching her students about lab test results. What is the major function of erythrocytes?

Transportation of O2 to the tissues and removal of CO2 from the tissues

You are caring for a client with right-sided heart failure. When assessing the respiratory rate of this client what is an indication that the client is having difficulty breathing?

Using accessory muscles during respiration

What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract

A Swedish client with the diagnosis of ovarian cancer confides in the nurse that she practices holistic medicine. The client believes a cure exists through a macrobiotic diet rather than what surgery or medical treatment can achieve. Which statement by the nurse is most appropriate?

We can talk to your doctor about adding this diet as a complementary therapy

A client with a cerebral aneurysm asks the nurse "Whats the big fuss over a headache?" Which is the nurses best response?

Your physician wants to evaluate the location and condition of the aneurysm

The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. Which medication will the nurse give to detoxify ammonium and act as an osmotic agent?

lactulose

The emergency department nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an ABG. What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

pH