Medical Surgical Questions for Exam 3

The nurse recognizes that genetic counseling is appropriate for which patient? A. Child with frequent urinary tract infections B. Adult with frequent urinary tract infection C. Adult with autosomal dominant polycystic kidney disease D. Adult with metastatic renal cancer

C. Adult with autosomal dominant polycystic kidney disease

The nurse correlates which clinical manifestation to superficial partial-thickness burns? A. Eschar B. Dry, leathery appearance C. Blisters D. Waxy appearance

C. Blisters

A nurse is caring for a client who has blood glucose 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 min. B. Provide a carbohydrate and protein food. C. Provide 15 g of simple carbohydrates D. Report findings to the provider

C. Provide 15 g of simple carbohydrates

Elevated ammonia levels can lead to hepatic encephalopathy. Which provider order best reduces this risk in patients with cirrhosis? A. Administer furosemide and spironolactone. B. Administer antibiotics. C. Restrict protein intake. D. Restrict caloric intake.

C. Restrict protein intake.

Which activity should be avoided in a patient with sickle cell anemia? A. Driving to the beach 3 hours away B. Going to a concert C. Running in 5k race D. Carpentry work

C. Running in 5k race

Which factor places the patient at a higher risk for developing secondary polycythemia? A. Type 2 diabetes mellitus B. History of alcohol abuse C. Smoking D. Hypertension

C. Smoking

The nurse should intervene immediately if a patient has which blood glucose level? A. 200 mg/dL B. 152 mg/dL C. 80 mg/dL D. 40 mg/dL

D. 40 mg/dL

What are the three classic clinical findings of cardiac tamponade known as BECKS triad?

Hypotension Jugular vein distention Muffled heart sounds

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change central lines once a week. 5. Administer antibiotics as prescribed.

1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 5. Administer antibiotics as prescribed.

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.

1. Replace fluids and electrolytes.

The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.

2. Deep partial thickness.

The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.

2. Notify the dietitian about the client's request.

Which assessment data indicates the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time and place. 3. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEqL.

2. The client is alert and oriented to date, time and place.

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Ensure adequate peripheral circulation to both feet.

4. Ensure adequate peripheral circulation to both feet.

Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, Pao2 99, Paco2 48, HCO3 24. 2. pH 7.38, Pao2 95, Paco2 40, HCO3 22. 3. pH 7.46, Pao2 85, Paco2 30, HCO3 26. 4. pH 7.30, Pao2 90, Paco2 30, HCO3 18.

4. pH 7.30, Pao2 90, Paco2 30, HCO3 18.

The nurse is caring for a client bitten by a rattle snake three hours prior to admission to the ED, the nurse correlates which of the following clinical manifestations with a venomous snake bite? (Select all that apply). A. Edema at the site B. Bleeding at the site C. Excessive diuresis D. Dysrhythmias E. Numbness at the site

A. Edema at the site B. Bleeding at the site

The nurse recognizes which of the following statements as correct in relation to the pathophysiology of type 2 DM? A. It is due to a relative lack of insulin. B. It is due to insulin resistance. C. It is due to an absolute lack of insulin. D. It remains stable over time. E. It is due to an autoimmune process that destroys the beta cells of the pancreas.

A. It is due to a relative lack of insulin. B. It is due to insulin resistance.

The nurse understands that it is essential for the patient to have which blood test before initiating folic acid supplementation? A. Vitamin B12 level B. Pregnancy test C. CBC D. Liver enzymes

A. Vitamin B12 level

What are considered clinical manifestations of type 2 diabetes? A. Decreased appetite B. Poor wound healing C. Fatigue D. Hyperactivity E. Visual disturbances

B. Poor wound healing C. Fatigue E. Visual disturbances

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes

3. "Have you had some type of infection lately?"

The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.

3. The client with DKA who has multifocal premature ventricular contractions.

Which of the following foods are most commonly causes of life threatening anaphylaxis? A. Peanuts B. Tree nuts C. Shellfish D. Milk E. Flour F. Sesame seeds

A. Peanuts B. Tree nuts C. Shellfish D. Milk

The nurse monitors for which clinical manifestations in the patient newly diagnosed with type 1 DM? A. Polyuria B. Fatigue C. Weight loss D. Polyphagia E. Decreased appetite

A. Polyuria B. Fatigue C. Weight loss D. Polyphagia

A nurse caring for a patient receiving chemotherapy receives a laboratory result of WBC 1.1 103/mm3. What is the primary goal for the nurse? A. Protect the patient from infection B. Institute isolation precautions C. Have the patient wear a face mask D. Restrict the number of visitors the patient receives

A. Protect the patient from infection

The nurse prioritizes which nursing diagnosis in the plan of care for the patient with type 2 DM? A. Risk for infection B. Risk for falls C. Risk for impaired gas exchange D. Risk for injury: hyperkalemia

A. Risk for infection

DURING A ROUTINE PHYSICAL EXAMINATION TO ASSESS A MALE CLIENT'S DEEP TENDON REFLEXES, THE NURSE SHOULD MAKE SURE TO: A)USE THE POINTED END OF THE REFLEX HAMMER WHEN STRIKING THE ACHILLES TENDON. B)SUPPORT THE JOINT WHERE THE TENDON IS BEING TESTED. C) TAP THE TENDON SLOWLY AND SOFTLY. D)HOLD THE REFLEX HAMMER TIGHTLY.

B)SUPPORT THE JOINT WHERE THE TENDON IS BEING TESTED. TO PREVENT THE MUSCLE FROM CONTRACTING, SUPPORT THE JOINT WHERE THE TENDON IS BEING TESTED. USE THE FLAT END OF THE HAMMER WHEN STRIKING THE TENDON. TAPPING SOFTLY WON'T PROVOKE A DEEP TENDON REFLEX. HOLD THE HAMMER LOOSELY, SO IT CAN SWING IN AN ARC.

Which statement by a patient diagnosed with liver trauma indicates understanding of the prescribed plan of care? A. "I will need a liver transplant." B. "I will need a blood transfusion." C. "I am at increased risk for infection." D. "I will never be able to drink alcohol again."

B. "I will need a blood transfusion."

Using the Parkland formula, the nurse determines that a patient requires a total of 12 L of fluid in the first 24 hours post injury. How much of the total volume needs to be given within the first 8 hours? A. 4,000 mL lactated Ringer's B. 6,000 mL lactated Ringer's C. 8,000 mL lactated Ringer's D. 10,000 mL lactated Ringer's

B. 6,000 mL lactated Ringer's

Which patient is at greatest risk for developing IDA? A. A 6-year-old African American boy with no health problems B. A 15-year-old African American pregnant female C. A 52-year-old Mexican American female with hypertension D. A 72-year-old Caucasian male with cardiac problems

B. A 15-year-old African American pregnant female

The nurse understands that type 1 DM is caused by which of the following conditions? A. Gestational diabetes B. A history of mumps or rubella C. Family history of autoimmune disorders D. Autoimmune destruction of the beta cells of the pancreas E. Obesity

B. A history of mumps or rubella D. Autoimmune destruction of the beta cells of the pancreas

The nurse understands CRRT is indicated for which of the following patients? A. A hospitalized but hemodynamically stable patient B. A hospitalized, hemodynamically unstable patient C. A hospitalized ESRD patient being discharged home soon D. A hospitalized ESRD patient who is stable but in an intensive care setting

B. A hospitalized, hemodynamically unstable patient

The nurse correlates which diagnostic result as increasing the risk for infection in the patient with leukemia? A. WBC 110,000 mm3 B. ANC 500 mm3 C. Hb 8.6 g/dL D. Platelets 112,000 mm3

B. ANC 500 mm3

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? A. Check blood glucose immediately after breakfast. B. Administer insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time.

B. Administer insulin when breakfast arrives.

A patient with liver disease is being evaluated for varices. The nurse prepares the patient for which procedure? A. Liver biopsy B. EGD C. ERCP D. TIPS

B. EGD

The nurse recognizes which etiology as consistent with a thermal burn? A. Direct current B. Scalding C. Exposure to organic compounds D. Ionizing radiation

B. Scalding

A NURSE IS PERFORMING A NEUROLOGIC ASSESSMENT ON A CLIENT. THE NURSE OBSERVES THE CLIENT'S TONGUE FOR SYMMETRY, TREMORS, AND STRENGTH, AND ASSESSES THE CLIENT'S SPEECH. WHICH CRANIAL NERVE IS THE NURSE ASSESSING? A) IV B) IX C) XII D) VI

C) XII HYPOGLOSSAL

The nurse recognizes which patient is at greatest risk for death secondary to stroke? A. A 36-year-old Caucasian male B. A 45-year-old Asian male C. A 56-year-old African American female D. A 62-year-old Hispanic female

C. A 56-year-old African American female

The principal assessment of a patient with an injured extremity includes which of the following? A. History of the injury B. Past medical history C. The 6 Ps D. Extremity movement

C. The 6 Ps

Which of the following risk factors has been associated with renal cancer? A. Aspirin use B. Alcohol abuse C. Use of artificial sweeteners D. Cigarette smoking

D. Cigarette smoking

Please explain the three phases of Acute Respiratory Distress syndrome (ARDS).

Exudative Proliferative Fibrotic

_________ is a multi-drug resistant organism that has clinical manifestations of back pain, pain on urination, sensation of needing to urinate, and fever.

VRE

The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter (OTC) medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Explain the need to get the annual flu and pneumonia vaccines.

3. Take the prescribed insulin even when unable to eat because of illness.

A elderly adult presents to the Emergency Department at 1700 with deep partial thickness burns on the right arm, right anterior chest, and groin. The client weights 165 pounds. History reveals the burn occurred at approximately 1530. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be provided in 24 hours from the time of the burn. Determine how much fluid will be administered at 2330. ____________ mL within 24 hours of burn ____________ mL at 2330

5,700 mL within 24 hours of burn 2,850 mL at 2330

THE NURSE IS ASSESSING THE CLIENT'S PUPILS FOLLOWING A SPORTS INJURY. WHICH OF THE FOLLOWING ASSESSMENT FINDINGS INDICATES A NEUROLOGIC CONCERN? SELECT ALL THAT APPLY. A) UNEQUAL PUPILS B) PUPIL REACTS TO LIGHT C) PINPOINT PUPILS D) PUPIL REACTION QUICK E) ABSENCE OF PUPILLARY RESPONSE

A) UNEQUAL PUPILS C) PINPOINT PUPILS E) ABSENCE OF PUPILLARY RESPONSE

A PATIENT COMES TO THE EMERGENCY DEPARTMENT WITH SEVERE PAIN IN THE FACE THAT WAS STIMULATED BY BRUSHING THE TEETH. WHAT CRANIAL NERVE DOES THE NURSE UNDERSTAND CAN CAUSE THIS TYPE OF PAIN? A) V B) IV C) III D) VI

A) V TRIGEMINAL

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (Select all that apply). A. "I will clean the pins more often if drainage from the pins increases" B. " I will use a separate cotton swab for each pin" C. I will report loosening of the pins to my doctor" D. "I will move my leg by lifting the device in the middle" E. "I will report increased redness at the pin sites"

A. "I will clean the pins more often if drainage from the pins increases" B. " I will use a separate cotton swab for each pin" C. I will report loosening of the pins to my doctor" E. "I will report increased redness at the pin sites"

When hemodynamic status is monitored in a patient with a burn injury, what amount of urine output indicates adequate fluid resuscitation? A. 0.5 mL/kg/hr B. 1 mL/kg/hr C. 2 mL/kg/hr D. 3 mL/kg/hr

A. 0.5 mL/kg/hr

The nursing diagnosis "ineffective peripheral tissue perfusion related to deficient knowledge of aggravating factors" applies to which fracture patient with the highest risk of developing VTE? A. A 30-year-old female on oral contraceptives who smokes one pack of cigarettes per day B. A 40-year-old male who ambulates four times a day with a walker C. A 70-year-old diabetic female who attends rehab once a day D. A 20-year-old male who smokes 10 cigarettes per day and ambulates with crutches

A. A 30-year-old female on oral contraceptives who smokes one pack of cigarettes per day

The nurse anticipates which burn patients will require higher fluid volumes during resuscitation? (Select all that apply.) A. A 45-year-old female who sustained an inhalation injury B. A 65-year-old male with an extensive alcohol history C. A 22-year-old male who sustained an electrical D. A 32-year-old healthy female with a thermal burn

A. A 45-year-old female who sustained an inhalation injury B. A 65-year-old male with an extensive alcohol history C. A 22-year-old male who sustained an electrical

The nurse should inform the physician if, when assessing the patient with an AV fistula, they note which of the following? A. A loud, turbulent bruit B. A quiet swooshing bruit C. A low-pitched thrill D. A continuous thrill

A. A loud, turbulent bruit

Which nursing action is the top priority when admitting a victim of drowning? A. Administer 100% non-rebreather B. Begin CPR C. Insert 18G IV

A. Administer 100% non-rebreather

What would the nurse working in emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? (Select all that apply). A. Airway management B. Obtain medication history C. Ventilation assistance D. Hemorrhage E. Hypothermia

A. Airway management C. Ventilation assistance D. Hemorrhage E. Hypothermia

A nurse if assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus? A. Altered mental status B. Reduced bowel sounds C. Swelling of the toes distal to the injury D. Pain with passive movement of the foot distal to the injury

A. Altered mental status

A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? A. Antibiotic therapy should continue for 3 months B. Relief of pain indicates the infection is eradicated C. Airborne precautions are used during wound care D. Expect paresthesia distal to the wound

A. Antibiotic therapy should continue for 3 months

Which nursing action is indicated for the patient with thrombocytopenia? A. Avoid intramuscular injections. B. Encourage the patient to drink plenty of fluids. C. Place the patient on isolation precautions. D. Encourage frequent rest periods.

A. Avoid intramuscular injections.

What is the most likely cause of the Somogyi effect? A. Basal insulin injections before bed without a small snack B. Naturally occurring release of hormones during the night C. Increased consumption of complex carbohydrates throughout the day D. Glucagon administration before breakfast

A. Basal insulin injections before bed without a small snack

A patient arrives in the ICU with the diagnosis of cervical spine fracture at the C6 level after a car crash. The patient has no motor movement below the shoulders, is intubated on mechanical ventilation, and is receiving a continuous infusion of an alpha-receptor agonist and a fluid bolus of 1 liter normal saline. In planning care for this patient during the next 12 hours, the nurse should anticipate and prepare for: A. Bradycardia B. Hypervolemia C. Pulmonary edema D. Renal failure

A. Bradycardia

A patient has returned from the PACU after having surgery to have an external fixator placed for an open tibia fracture with extensive soft tissue damage. What should the nurse do immediately? A. Conduct a neurovascular assessment B. Elevate the extremity C. Perform pin site care D. Remove the dressing and assess the wound

A. Conduct a neurovascular assessment

The nurse correlates which diagnostic result for an elderly patient with a suspected pathologic fracture? A. Decreased bone density B. Increased osteocytes C. Hypertension D. Coagulopathy

A. Decreased bone density

SLOW SPEECH WITH POOR ARTICULATION AND THE INABILITY TO INITIATE SOUNDS WITH INTACT COMPREHENSION ARE CHARACTERISTICS OF WHICH OF THE FOLLOWING? A. EXPRESSIVE (BROCA) APHASIA B. GLOBAL DYSPHASIA C. DYSARTHRIA D. RECEPTIVE (WERNICKE) APHASIA

A. EXPRESSIVE (BROCA) APHASIA RATIONALE: EXPRESSIVE (BROCA) APHASIA IS CHARACTERIZED BY SLOW SPEECH WITH POOR ARTICULATION AND THE INABILITY TO INITIATE SOUNDS WITH INTACT COMPREHENSION.

A nurse is presenting information to a group of clients about nutrition habits to prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? A. Eat at regular intervals B. Decrease intake of saturated fats C. Increase daily fiber intake D. Limit saturated fat intake to 15% of daily caloric intake E. Include omega-3 fatty acids in the diet

A. Eat at regular intervals B. Decrease intake of saturated fats C. Increase daily fiber intake E. Include omega-3 fatty acids in the diet

Which of the following medications would most likely be utilized in the treatment of neurogenic shock emergency situation? A. Epinephrine B. Vasopressin C. Dopamine D. Furosemide E. Norepinephrine

A. Epinephrine B. Vasopressin C. Dopamine E. Norepinephrine

The nurse is caring for a patient who is being transported to the emergency department with clinical manifestations of stroke. Which is the priority action upon arrival to the hospital? A. Establish the time that the patient was last known to be without symptoms. B. Draw blood for coagulation studies. C. Perform an electrocardiogram. D. Perform an EEG.

A. Establish the time that the patient was last known to be without symptoms.

The nurse has received the following provider orders for a patient who was recently admitted to the emergency department with acute stroke symptoms and time of symptom onset of 70 minutes prior to presentation. Which actions are of highest priority in evaluating this patient and preparing to administer IV rt-PA? (Select all that apply.) A. Establish two peripheral intravenous catheters B. Check blood glucose C. Perform bedside swallow screen D. Check temperature E. Assist with transport of the patient to CT scan

A. Establish two peripheral intravenous catheters B. Check blood glucose E. Assist with transport of the patient to CT scan

The nurse correlates which clinical manifestations to the possibility of an inhalation injury? (Select all that apply.) A. Facial burns B. Singed nasal hairs C. Soot in the sputum D. Hoarseness E. Eschar

A. Facial burns B. Singed nasal hairs C. Soot in the sputum D. Hoarseness

A nurse correlates which laboratory value with the diagnosis of DM? A. Fasting blood glucose greater than 140 mg/dL B. Hemoglobin A1c, 5.8% C. Random blood glucose, 150 mg/dL D. OGTT, 155 mg/dL

A. Fasting blood glucose greater than 140 mg/dL

The nurse correlates which of the following critically low laboratory results with a traumatic amputation? A. Hemoglobin (Hgb): 7.0 g/dL B. Glucose: 60 mg/dL C. BUN: 10 mg/dL D. WBC: 4,000 103 /mm3

A. Hemoglobin (Hgb): 7.0 g/dL

The nurse prioritizes which nursing diagnosis in the patient immediately after arthroscopic surgical repair of the medial meniscus injury? A. High risk for ineffective airway clearance related to general anesthesia B. High risk for ineffective breathing related to intubation C. Self-care deficit related to pain, edema, and immobility D. Pain related to inflammation

A. High risk for ineffective airway clearance related to general anesthesia

The nurse anticipates supplementary feeding via a nasogastric tube in a patient for which reasons? (Select all that apply.) A. Hypermetabolic state B. Multiple open wounds C. Increased heat loss D. Increased caloric needs E. Burn greater than 20% TBSA

A. Hypermetabolic state B. Multiple open wounds D. Increased caloric needs E. Burn greater than 20% TBSA

The risk factor or factors most often associated with CKD include which of the following? (Select all that apply.) A. Hypertension B. Diabetes mellitus C. Malnutrition D. Peripheral vascular disease E. Smoking

A. Hypertension B. Diabetes mellitus

A client being treated for septic shock, can expect to receive which of the following treatment? (Select all that apply). A. IV fluids B. Ampicillin C. Amlodipine D. Levophed E. Propranolol

A. IV fluids B. Ampicillin D. Levophed

A nurse is assessing a client who had an external fixation device applied 2 hours ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? (Select all that apply). A. Intense pain when the client's left toes B. Capillary refill of 3 second on the client's left toes C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication

A. Intense pain when the client's left toes C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply). A. Limit visitors in the client's room B. Encourage fresh vegetables C. Increase protein intake D. Instruct the client to consume 2,000 calories/day E. Restrict fresh flowers in the room

A. Limit visitors in the client's room C. Increase protein intake E. Restrict fresh flowers in the room

WHEN TESTING THE OCULOCEPHALIC REFLEX, THE HEAD IS TURNED RAPIDLY FROM SIDE TO SIDE. A NORMAL REFLEX IS A. MOVEMENT OF THE EYES IN THE OPPOSITE DIRECTION B. MIDLINE POSITIONING OF BOTH EYES C. DISCONJUGATE DEVIATION OF THE EYES D. MOVEMENT OF THE EYES IN THE SAME DIRECTION

A. MOVEMENT OF THE EYES IN THE OPPOSITE DIRECTION RATIONALE: A NORMAL RESPONSE CONSISTS OF MOVEMENT OF THE EYES IN THE OPPOSITE DIRECTION, AND THEN, WITHIN A FEW SECONDS, SMOOTH AND SIMULTANEOUS MOVEMENT OF BOTH EYES BACK TO MIDLINE.

A nurse is reviewing orders for patients newly diagnosed with type 2 DM. What initial medication orders should be anticipated? A. Metformin PO twice a day B. Nutritional insulin subcutaneously prior to meals. C. Basal insulin subcutaneously before bed D. Correctional insulin subcutaneously after meals

A. Metformin PO twice a day

The nurse correlates which clinical manifestation with the pathophysiology of acute pyelonephritis? (Select all that apply.) A. Nausea and vomiting B. Hematuria C. Flank pain D. Fever E. Abdominal pain

A. Nausea and vomiting B. Hematuria C. Flank pain D. Fever

The nurse is caring for a patient status post craniotomy for resection of a right frontal tumor. Upon admission, the patient was alert and oriented X 3, moving all extremities symmetrically, and the cranial nerves were intact. Three hours after admission, the nurse notes that the patient is slower to awaken than during previous assessments, requiring vigorous shaking, and cannot recall location. The patient also exhibits a left pronator drift. What are the nurse's next actions? A. Notify the patient's provider and prepare the patient for a computed tomography (CT) scan. B. Record vital signs and prepare to draw blood for serum osmolality. C. Notify the patient's provider and prepare the patient for a magnetic resonance imaging (MRI) scan. D. Prepare to hang a fluid bolus and notify the patient's provider.

A. Notify the patient's provider and prepare the patient for a computed tomography (CT) scan.

A patient is admitted to the emergency room after sustaining a flash burn to his face. He presents with facial burns and singed nasal hair but is reporting no difficulty breathing. The nurse places the patient on 100% oxygen via face mask. Upon reassessment, the nurse notes that his voice has changed and the patient is reporting difficulty swallowing. What is the most appropriate nursing action? A. Notify the physician and anticipate endotracheal intubation. B. Obtain a chest radiograph. C. Administer a bronchodilator. D. Lower the rate of the patient's intravenous fluids.

A. Notify the physician and anticipate endotracheal intubation.

The charge nurse is reviewing orders for a newly admitted patient with type 1 DM. It is a priority for the charge nurse to follow up with the provider about which order? A. NovoLog insulin subcutaneous at bedtime B. NovoLog insulin subcutaneous 15 minutes prior to meals C. Basal insulin subcutaneous at bedtime D. Correctional and nutritional insulin administered immediately after the meal

A. NovoLog insulin subcutaneous at bedtime

The nurse correlates which laboratory values as a diagnostic for DKA? A. Serum bicarbonate of 15 mEq/L B. Negative anion gap C. Serum glucose of 350 mg/dL D. Positive anion gap E. Arterial pH of 7.36

A. Serum bicarbonate of 15 mEq/L C. Serum glucose of 350 mg/dL D. Positive anion gap

The nurse recognizes that the stretching or tearing of a muscle or tendon occurs in which condition? A. Strains B. Dislocations C. Fractures D. Sprains

A. Strains

A nurse in a providers office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness

A. Superficial thickness

A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hour. Which of the following findings are common during this phase? Select all that apply. A. Temperature 36.1 (97) B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

A. Temperature 36.1 (97) C. Hyperkalemia D. Hyponatremia

The nurse is screening patients for the risk of developing type 2 DM. The nurse should consider which patients at risk? A. Women with a history of gestational diabetes B. Women with a history of multiple births C. Men with a history of pancreatic cancer D. Men who are overweight or obese E. Men and women with cardiovascular disease

A. Women with a history of gestational diabetes D. Men who are overweight or obese E. Men and women with cardiovascular disease

The nurse correlates which zone of burn injury as the most susceptible to sustained injury because of insufficient fluid resuscitation? A. Zone of stasis B. Zone of conversion C. Zone of hyperemia D. Zone of coagulation

A. Zone of stasis

Which pathophysiological mechanism is involved in a tension pneumothorax?

AIR enters the thoracic cavity but cannot escape

The nurse assesses for which clinical manifestations in the patient diagnosed with liver cancer? (Select all that apply.) A. Periumbilical pain B. Anorexia C. Hemoptysis D. Fatigue E. Jaundice

B. Anorexia D. Fatigue E. Jaundice

A patient is admitted to a unit with a diagnosis of left middle cerebral artery acute ischemic stroke and is not eligible for thrombolytic therapy. The nurse recognizes that this patient is at a high risk for which complication? A. Delirium B. Aspiration C. Bronchospasm D. Palpitations

B. Aspiration

A client in an assisted living facility ignites a dish rag on the stove. You respond to the situation and extinguish the fire. The next nursing priority is to? A. Offer the client oral fluids to begin replacement. B. Assess for singed hairs on the face. C. Wrap the client in a blanket for warmth. D. Determine the percentage of burned area.

B. Assess for singed hairs on the face.

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? A. Skeletal traction B. Buck's traction C. Halo traction D. Bryant's traction

B. Buck's traction

The nurse recognizes which diagnostic test as most sensitive in a patient with a suspected electrical burn injury? A. Arterial blood gas B. CK-MB levels C. Echocardiogram D. Serum carboxyhemoglobin

B. CK-MB levels

The nurse understands which of the following statements are correct concerning carpal tunnel syndrome (CTS)? A. CTS is a complication of a wrist fracture. B. CTS is due to repetitive motion of the wrist. C. CTS is treated with immobilization in a cast. D. CTS cannot be corrected by surgery.

B. CTS is due to repetitive motion of the wrist.

What is the etiological process in glomerulonephritis? A. Tubular necrosis caused by bacteria and antibody reactions B. Deposition of immunological complexes and complement along the GBM C. Deposition of bacteria and immunological components within the loop of Henle D. Destruction of proteolytic enzymes contained in the GBM

B. Deposition of immunological complexes and complement along the GBM

The nurse is providing care for a patient newly diagnosed with type 1 diabetes. Which lifestyle modifications need to be included into the plan of care? A. Limit exercise, carbohydrate counting, self-monitoring of blood glucose B. Distribute carbohydrate intake throughout the day, control weight, limit alcohol C. Carbohydrate counting, self-monitoring of blood glucose, physician visits as needed D. Limit protein intake, distribute carbohydrate intake throughout the day regular physician visits.

B. Distribute carbohydrate intake throughout the day, control weight, limit alcohol

The nurse correlates which laboratory data to decreased liver function secondary to liver cancer or cirrhosis? A. Elevated serum globulin level B. Elevated serum ammonia level C. Elevated serum protein level D. Elevated serum amylase

B. Elevated serum ammonia level

The nurse should intervene immediately if the patient post renal transplantation is noted to have which of the following symptoms? A. Weight loss, hypotension, reduced urine output B. Fever, reduced urine output, elevated blood pressure C. Weight gain, hypotension, increased urine output D. Increased urine output, hypertension, fever

B. Fever, reduced urine output, elevated blood pressure

A patient with epilepsy is being started on phenytoin (Dilantin). Which blood test does the nurse understand must be checked before administering the Dilantin? A. Dilantin level B. Folate level C. Serum ferritin level D. Cobalamin level

B. Folate level

The Nurse documents glucose in the urine as which finding? A. Polyuria B. Glucosuria C. Hyperglycemia D. Hyperosmolarity

B. Glucosuria

A nurse is preparing to assess a client experiencing neurogenic shock, which vitals signs should the nurse anticipate? A. BP 132/74 B. HR 53 C. RR 14 D. Temp 37.9

B. HR 53

The nurse understands basic treatment for a sprain or strain includes which of the following? (Select all that apply.) A. Keep extremity dependent to increase blood flow to the area B. Maintain rest of injured extremity C. Apply ice to injured extremity D. Maintain compression to injured extremity E. Keep extremity elevated to decrease swelling

B. Maintain rest of injured extremity C. Apply ice to injured extremity D. Maintain compression to injured extremity E. Keep extremity elevated to decrease swelling

A patient just returned from the procedure area after having a liver biopsy. The primary nursing intervention includes which action? A. Ambulation B. Monitor blood pressure and assess the site for bleeding C. Heparin drip D. Obtain a culture from the biopsy site

B. Monitor blood pressure and assess the site for bleeding

A patient is admitted to the emergency room after sustaining an electrical burn with contact points to his right hand and left foot. The patient is being resuscitated with lactated Ringer's solution using the consensus formula. A urinary catheter was placed, and the nurse observes myoglobin in the urine along with a decrease in urine output. What is the most appropriate nursing action? A. Give the patient a normal saline fluid bolus. B. Notify the physician and anticipate increasing the intravenous fluid rate. C. Administer a diuretic. D. Continue monitoring the patient.

B. Notify the physician and anticipate increasing

The nurse recognizes that burns to which body areas meet the criteria for referral to a burn center because of the increased risk of functional changes? (Select all that apply.) A. Chest B. Perineum C. Elbows D. Face E. Hand

B. Perineum C. Elbows D. Face E. Hand

The nurse understands that CKD is characterized by which of the following? A. Rapid decrease in urine output with a CKD-elevated BUN B. Progressive irreversible destruction to the kidneys C. Abrupt increasing creatinine clearance with a. decrease in urinary output D. Confusion and somnolence leading to coma and death

B. Progressive irreversible destruction to the kidneys

A diabetic patient who had an elective below-the-knee amputation returns to the unit for IV antibiotic care on postop day 3. Upon closer examination, the nurse notices the patient has a pillow under the residual limb. What should the nurse do in this situation? A. Leave the pillow in place to prevent dependent edema B. Remove the pillow to prevent contractures C. Remove the pillow to prevent VTE D. Leave the pillow to promote circulation

B. Remove the pillow to prevent contractures

The nurse providing care for the patient post motor vehicle accident with a suspected injury to the renal system anticipates which of the following orders? A. Perform an electrocardiogram (ECG). B. Send a urinalysis to the laboratory. C. Administer diuretics. D. Administer antihypertensives.

B. Send a urinalysis to the laboratory.

The nurse teaches a patient with polycythemia to immediately report which clinical manifestations to his or her health-care provider? (Select all that apply.) A. Temperature 100.4°F (38.0°C) B. Shortness of breath C. Headache D. Fatigue E. Pruritus

B. Shortness of breath C. Headache

The nurse correlates which rationale to the use of hyperventilation to decrease intracranial pressure in a patient after traumatic head injury? A. To maximize oxygenation B. To promote vasoconstriction C. To decrease cerebral perfusion D. To decrease ventilatory effort

B. To promote vasoconstriction

The nurse identifies which pathophysiological finding in a third-degree sprain? A. Stretched muscle or tendon fibers B. Torn/ruptured ligaments C. Torn/ruptured muscle or tendon fibers D. Stretched ligaments

B. Torn/ruptured ligaments

Which intervention is the priority for the patient during the emergent phase of burn management? A. Application of silver sulfadiazine cream B. Use of clean, dry sheets and warm blankets C. Initiation of wet normal saline dressings D. Maintaining the injured area open to air

B. Use of clean, dry sheets and warm blankets

In a patient with cirrhosis, the nursing diagnosis "risk for injury and bleeding related to prolonged clotting factors" is most appropriate related to which disorder? A. Pruritus B. Vitamin K deficiency C. Hyponatremia D. Ascites

B. Vitamin K deficiency

Which statement by the patient indicates effective patient teaching has been done regarding phantom limb pain after an amputation? A. "This pain means I may have intact nerves that are required for successful limb reattachment." B. "There is nothing that can be done for this pain—my foot is gone!" C. "So do you think gabapentin might help with this pain?" D. "I understand massage of the residual limb helps with this pain."

C. "So do you think gabapentin might help with this pain?"

A patient weighing 100 kg sustains a burn at 1400 covering approximately 50% TBSA. The patient is a young healthy male with no medical history. Using the Parkland formula, how much fluid should be infused by 1800? A. 20,000 ml lactated Ringer's B. 10,000 ml lactated Ringer's C. 5,000 ml lactated Ringer's D. 2,000 ml lactated Ringer's

C. 5,000 ml lactated Ringer's

The nurse recognizes which patient is at greatest risk for type 1 autoimmune hepatitis? A. A 45-year-old postmenopausal female B. A 30-year-old female with a history of hyperthyroidism C. A 16-year-old female with type 1 diabetes mellitus D. A 12-year-old female with autism

C. A 16-year-old female with type 1 diabetes mellitus

The nurses recognizes that the elderly patient may have a reduced ability to concentrate urine which is attributed to which of the following? A. A reduction in bladder receptors B. Thickening of the basement membrane of the Bowman's capsule C. A decrease in the number of functioning nephrons D. A thickening of the efferent arteriole

C. A decrease in the number of functioning nephrons

The family of a patient who sustained a left temporoparietal subdural hematoma and bilateral frontal contusions is visiting the patient for the first time and is asking repeatedly when the family member will awaken. What is the best method for the nurse to use for beginning education with this family? A. Providing a detailed diagram of the brain and pointing out the functions of each lobe in order to create a foundation from which the family can understand the patient's injury B. Providing a handout printed from the Internet on severe TBI C. Assessing the family's level of knowledge and information about the patient's brain injury and providing general information regarding the uncertainty of the outcome in the first several days after TBI D. Deferring any sharing of information until a formal family conference is held with the medical care team

C. Assessing the family's level of knowledge and information about the patient's brain injury and providing general information regarding the uncertainty of the outcome in the first several days after TBI

The nurse includes which dietary information in the teaching plan about the management of chronic kidney disease? A. Decrease fluid intake and protein intake, decrease carbohydrate intake B. Increase fluid intake, decrease carbohydrate intake and protein intake C. Decrease fluid intake and protein intake, increase carbohydrate intake D. Increase fluid intake, increase carbohydrate intake and protein intake

C. Decrease fluid intake and protein intake, increase carbohydrate intake

In a diabetic patient, numbness, tingling, and pain in the hands and feet are all symptoms of which complication? A. Autonomic neuropathy B. Hyperosmolar hyperglycemic syndrome C. Diabetic peripheral neuropathy D. Diabetic ketoacidosis

C. Diabetic peripheral neuropathy

A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose 278 mg/dL. Which of the following actions should the nurse take? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe . C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

C. Draw up and administer regular and glargine insulin in separate syringes.

A 17-year-old patient sustained blunt abdominal trauma (was hit in the abdomen with a baseball bat) and is being discharged home after 24 hours of observation. Discharge planning includes which teaching? A. Self-defense maneuvers B. Antibiotic teaching C. Education about abdominal signs and symptoms of increased pain, tenderness D. Limit solid food intake

C. Education about abdominal signs and symptoms of increased pain, tenderness

When the patient is in the diuretic phase of AKI, the nurse must monitor which serum electrolyte imbalance? A. Hypokalemia and hyponatremia B. Hypokalemia and hypernatremia C. Hyperkalemia and hyponatremia D. Hyperkalemia and hypernatremia

C. Hyperkalemia and hyponatremia

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The clients voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

C. Inhalation injury

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of the body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal

C. Intravenous

A patient is admitted to the neuroscience intensive care unit (NICU) after a TBI. If the goal of ICP monitor insertion is to measure ICP and drain CSF to control ICP, what device should the nurse anticipate being inserted? A. Intraparenchymal sensor B. Epidural sensor C. Intraventricular catheter D. Subarachnoid bolt

C. Intraventricular catheter

Prior to the patient's CT scan, which information should be obtained from the patient or family member? A. Family history of CT scans B. Time of patient's last meal C. List of patient's allergies D. Time of last pain medication

C. List of patient's allergies

In reviewing diagnostic results of a patient with suspected hepatitis, the nurse correlates which result as consistent with hepatitis A? A. Prolonged prothrombin time (PT) B. Decreased white blood cell count C. Presence of IgM anti-HAV D. Detectable serum HBV DNA

C. Presence of IgM anti-HAV

A 25-year-old male presents to the emergency room with a chemical burn to his hand. What is the nurse's first intervention? A. Delay treatment until the chemical is able to be identified. B. Elevate the extremity to promote circulation. C. Protect yourself, remove the patient's clothing, and begin irrigation with copious amounts of water. D. Contact The Poison Control Center to determine the most appropriate neutralizing agent.

C. Protect yourself, remove the patient's clothing, and begin irrigation with copious amounts of water.

The nurse is monitoring a patient receiving rt-PA who develops a sudden headache. Which are the priority actions in evaluating this change in assessment? (Select all that apply.) A. Decrease the rate of the rt-PA infusion. B. Administer Tylenol for pain. C. Stop the rt-PA infusion. D. Notify the provider of the change. E. Perform a neurologic assessment.

C. Stop the rt-PA infusion. D. Notify the provider of the change. E. Perform a neurologic assessment.

The nurse explains external fixation is used to stabilize a fracture for which of the following reasons? A. The involved extremity is too large for a cast. B. The patient is not a safe candidate for ORIF surgical procedure. C. The extremity has significant soft tissue damage at the fracture site. D. The patient has a closed, nondisplaced fracture that does not require ORIF.

C. The extremity has significant soft tissue damage at the fracture site.

The nurse receives report on a patient in the ICU with an SAH and clarifies that the date of the patient's initial bleed was 4 days before. The nurse needs this information to gauge the patient's risk of which complication of SAH? A. Hydrocephalus B. Aspiration C. Vasospasm D. Myocardial ischemia

C. Vasospasm

A 72-year-old patient presents with complaints of fatigue, dyspnea on exertion, and numbness in her fingers and toes. The nurse correlates these findings to which condition? A. Thrombocytopenia B. Thrombocytosis C. Vitamin B12 deficiency anemia D. Iron-deficiency anemia

C. Vitamin B12 deficiency anemia

THE NURSE IS PREPARING A CLIENT FOR A NEUROLOGICAL EXAMINATION BY THE PHYSICIAN AND EXPLAINS TESTS THE PHYSICIAN WILL BE DOING, INCLUDING THE ROMBERG TEST. THE CLIENT ASKS THE PURPOSE OF THIS PARTICULAR TEST. THE CORRECT REPLY BY THE NURSE IS WHICH OF THE FOLLOWING? A) "IT IS A TEST FOR MOTOR ABILITY." B) "IT IS A TEST FOR MUSCLE STRENGTH." C) "IT IS A TEST FOR COORDINATION." D) "IT IS A TEST FOR BALANCE."

D) "IT IS A TEST FOR BALANCE."

When a patient with vitamin B12 deficiency is counseled about his diet, what statement by the patient indicates that he understands the cause of his anemia? A. "I know I need to eat more fruits and vegetables." B. "I have cut out all fried foods in my diet." C. "I have been eating more organic foods." D. "I have been having beef or fish at least once a day."

D. "I have been having beef or fish at least once a day."

The nurse is screening patient for their risk of developing renal cell cancer. The nurse should consider which patient at greatest risk? A. 76-year-old African American female B. 50-year-old Caucasian male C. 24-year-old male Caucasian male D. 50-year-old African American male

D. 50-year-old African American male

The nurse recognizes which patient has the greatest risk of renal cancer? A. A 76-year-old African American female B. A 50-year-old Caucasian male C. A 24-year-old Caucasian male D. A 50-year-old African American male

D. A 50-year-old African American male

What is measured by the HbgA1c test? A. Amount of glucagon stored in the liver. B. Specific insulin levels in the blood plasma C. Levels of hemoglobin after physical activity D. Average blood glucose concentration over time

D. Average blood glucose concentration over time

The nurse understands which diagnostic study is most specific in identifying PKD? A. Abdominal x-ray B. Serum creatinine level C. Urinalysis D. Computed tomography scan

D. Computed tomography scan

The nurse recognizes that the administration of cryoprecipitate is indicated in the treatment of which disorder? A. Thrombocytosis B. Iron-deficiency anemia C. Hodgkin's Disease D. Disseminated intravascular coagulation

D. Disseminated intravascular coagulation

Which assessment data indicates the client is experiencing a late symptom associated with chronic aspirin overdose? (Select all that apply). A. Emesis B. Nausea C. Tinnitus D. Ecchymosis E. Hyperthermia

D. Ecchymosis E. Hyperthermia

Which is a prerenal cause of AKI? A. Acute glomerulonephritis and neoplasms B. Septic shock and nephrotoxic injury from medications C. Pyelonephritis and calculi formation D. Hypovolemia and myocardial infarction

D. Hypovolemia and myocardial infarction

The nurse caring for a patient with liver failure notes a change in mental status and elevated ammonia level. Which ordered interventions are most directly related to treating these clinical manifestations? A. Diuretics B. High-protein diet C. Coumadin D. Lactulose and neomycin

D. Lactulose and neomycin

A patient with lymphoma is beginning the induction chemotherapy regimen. Which information is most essential for the nurse to include in the treatment plan? A. Advance directives B. Bleeding precautions C. Importance of frequent rest periods D. Neutropenic precautions

D. Neutropenic precautions

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? A. Remove calluses using over-the-counter remedies. B. Apply lotion between toes C. Test water temperature with the fingers before bathing D. Trim toenails straight across. E. Wear closed-toe shoes

D. Trim toenails straight across. E. Wear closed-toe shoes