NSG 123 Exam 4
A nurse is assessing an infant who has been vomiting & experiencing diarrhea. Which findings would indicate to the nurse that the infant is experiencing severe dehydration? SATA A. slightly decreased urine output B. sunken fontanels C. pink moist oral mucosa D. bradycardia E. cool mottled extremities
B, D, E
A nurse is caring for an infant who has manifestations of acute otitis media. Which of the following places the infant at risk for otitis media? SATA A. breastfeeds w/o formula supplementation B. attends day care 4x/week C. immunizations are up to date D. hx of cleft palate repair E. parents smoke cigs outside
B, D, E
The client has been vomiting for several days. The nurse knows that the client is at risk for metabolic alkalosis because gastric secretions have which of the following characteristics? A. gastric secretions are green in color B. gastric secretions are alkaline C. gastric secretions are acidic D. gastric secretions have a foul smell
C
A nurse is preparing an 18 mo old for discharge after tx for dehydration following diarrhea. What instruction would the nurse most likely include in the discharge teaching? A. offer her flavored gelatin if she is hungry B. make sure she gets lots of clear liquids C. give her plenty of fruit juice or soda D. encourage bananas, applesauce, and crackers
D
A nurse is teaching a group of family members about communicable diseases. The nurse should include that which of the following is the BEST method to prevent a communicable disease? A. hand washing B. avoiding persons who have active disease C. covering your cough D. obtaining immunizations
D
The nurse is teaching a 60 y/o woman with type 2 DM how to prevent diabetic neuropathy. Which statement made by the patient indicates that the teaching has been successful? A. smokeless tobacco products decrease the risk of kidney damage B. I can help control my BP by avoiding foods high in salt C. I should have yearly dilated eye exams by an ophthalmologist D. I will avoid hypoglycemia by keeping my blood sugar above 180
B
A nurse is teaching a client who is scheduled for nuclear imaging for suspected cancer. Which of the following statements should the nurse give? A. the presence of a liver enzyme will be identified B. you will be given an injection of a radioactive substance C. an endoscope will be inserted through mouth D. the tumor will be aspirated
B
A nurse working in the NB obs unit is assigned 4 NBs closely being monitored. Which NB is at greatest risk for developing RDS? A. term male born vaginally with a positive Babinski reflex B. male preterm infant born by C/S with cold stress C. term female whose mother has HTN D. preterm female born vaginally whose mother has asthma
B
Based on the following lab results, which intervention should the nurse teach the client? RBC 2.1 Na 139 K 3.8 Platelets 22 WBC 4.3 A. encourage client to eat foods high in iron B. instruct client to use electric razor when shaving C. discuss importance of limiting sodium in the diet D. instruct the family to limit visits to once a week
B
The nurse has admitted a client who was brought to hospital after a morphine overdose. What acid/base imbalance does the nurse expect to observe in this client? A. resp alkalosis B. resp acidosis C. metabolic alkalosis D. metabolic acidosis
B
The nurse is reviewing lab results of a client who has HHS. Which of the following findings should the nurse expect? A. blood pH 7.2 B. blood osmolarity 350 C. blood K 3.8 D. blood Cr 0.8
B
The RN is teaching a student about importance of observing for bone marrow suppression during chemo. Select the person who displays bone marrow suppression. A. Hgb 7.4 and Hct 21.8 B. diarrhea & potassium 2.9 C. platelets 250,000 D. WBC 5,000
A
A nurse is obtaining ABGs for a client who has vomited for 24hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hrs? A. resp acidosis B. resp alkalosis C. metabolic acidosis D. metabolic alkalosis
D
The client dx with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the nurse implement? A. discuss implementing an advanced directive B. explain the use of chemo for brain involvement C. teach the client to discontinue driving D. have the significant other make decisions for the client
A
A new parent expresses concern to the nurse regarding SIDS. She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? A. side or prone B. back of prone C. stomach with the face turned D. back rather than on the stomach
D
A nurse is caring for a client who has been taking acarbose for type 2 DM. Which of the following lab tests should the nurse plan to monitor? A. WBC B. Amylase C. platelet count D. liver function tests
D
A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A. provide emotional support to the family B. educate family on care of the child C. provide diversional activity D. admin analgesics
D
Normal HCO3-
22-26
Normal PaCO2
35-45
Normal pH values
7.35-7.45
Normal PaO2
80-100
A 4 mo old is brought to ED with severe dehydration. HR 198, BP 68/38, anterior fontanel is sunken. The nurse notes the infant does not cry when IV line inserted and the parent states she has not held anything down in 18 hrs. The nurse obtains a finger stick BG of 94. Which would the nurse expect to do immediately? A. admin bolus of NS B. admin bolus of D10W C. admin bolus of NS with 5% dextrose added to the solution D. offer child an oral rehydrating solution such as pedialyte
A
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? A. metabolic acidosis can occur due to DKA B. metabolic acidosis can occur in a client who has myasthenia gravis C. metabolic acidosis can occur in a client who has asthma D. metabolic acidosis can occur due to cancer
A
A client dx with cancer is receiving chemo. The nurse should assess which dx value while the client is receiving chemo? A. bone marrow cells B. liver tissues C. heart tissues D. pancreatic enzymes
A
A nurse is caring for a NB who is preterm and has RDS. Which of the following should the nurse monitor to evaluate the NB's condition following admin of synthetic surfactant? A. oxygen saturation B. body temp C. serum bilirubin D. HR
A
A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take? A. perform a tape test B. collect stool specimen for culture C. test stool for occult blood D. initiate IV fluids
A
A nurse is caring for a newborn who is preterm & has RDS. Which of the following should the nurse monitor to evaluate the newborn's condition following admin of synthetic surfactant? A. oxygen saturation B. body temp C. serum bilirubin D. HR
A
A nurse is reviewing the medical record of a client who had surgery to stage ovarian cancer. The nurse reviews the dx notation on the pathology report: T2-N3-MX. Which of the following findings should the nurse identify as supporting diagnosis? A. tumor is moderate in size B. no lymph nodes contain cancer cells C. the tumor is receptive to current medication therapy D. the cancer has metastasized to other areas in body
A
The female client dx with bladder cancer has a cutaneous urinary diversion and states, "Will I be able to have children now?". Which statement is the nurse's best response? A. cancer does not make you sterile, but sometimes the therapy can B. are you concerned you can't have children? C. you will be able to have as many children as you want D. let me have the chaplain come to talk with you about this
A
The nurse is caring for an 11 y/o w/ otalgia and fever. When reviewing the medical record, which would the nurse identify as a risk factor for acute otitis media? A. parent has had recurrent otitis media B. child had a first episode of acute otitis media 3 mo ago C. child lives with parents & older sister D. child was breastfed, not bottle fed
A
The nurse is caring for an older patient with Type 1 diabetes & diabetic retinopathy. What is the nurse's priority concern for assessing this patient? A. assess ability to measure & inject insulin and to monitor BG levels B. assess for damage to motor fibers, which can result in muscle weakness C. assess which modifiable risk factors can be reduced D. assess for albuminuria, which may indicate kidney disease
A
The nurse is discussing oral glyburide with the client dx with type 2 diabetes. Which info should the nurse discuss with the client? A. instruct client to take oral hypoglycemic meds with food B. explain that hypoglycemia will not occur with oral meds C. tell the client to notify HCP if HA, nervousness, or sweating occurs D. recommend the client check ketones in the urine every morning
A
The nurse is providing care for several clients who are at risk for acid/base imbalance. Which client is most at risk for respiratory acidosis? A. 68 y/o client w/ chronic emphysema B. 58 y/o who uses antacids every day C. 48 y/o with anxiety disorder D. 28 y/o with salicylate intoxication
A
The nurse is teaching a 47 y/o female about recommended screening practices for breast cancer. Which statement by client indicates understanding of the nurse's instructions? A. my mother & grandmother had breast cancer so I am at risk B. I get a mammography every 2 years since age 30 C. a clinical breast exam is performed every month since age 40 D. a CT scan will be done every year after age 50
A
What would the nurse advise the parent of a child with a barky cough that gets worse at night? A. take child outside into the more humid night air for 15 min B. take the child to the ED immediately C. give OTC cough suppressant D. give child warm liquids to soothe the throat
A
When assessing a newborn, the nurse determines that the newborn is most likely experiencing RDS based on which finding? A. see-saw respirations B. slightly diminished breath sounds C. peripheral cyanosis D. respiratory distress occurring by 6 hrs of age
A
Which child is at highest risk for requiring hospitalization to treat RSV? A. 2 mo old born at 32 weeks B. 16 mo old with tracheostomy C. 3/o with congenital heart defect D. 4 y/o who was born at 30 weeks
A
Which is the recommendation for early detection of cancer of the prostate? A. a yearly PSA level and digital rectal exam beginning at age 50 B. a biannual rectal exam beginning at age 40 C. a semiannual alkaline phosphatase level beginning at age 45 D. a yearly urinalysis to determine the presence of prostatic fluid
A
Which statement indicates the parent needs further teaching on how to prevent his other children from contracting RSV? A. I should make sure that both my children receive Synagis injections for the remainder of this year B. I should be sure to keep my infected child away from his brother until he has recovered C. I should insist that all people who come in contact with my children thoroughly wash their hands before playing with them D. I should insist that anyone w/ a respiratory illness avoid contact with my children until well
A
A nurse is assessing a child who has a rotavirus infection. Which of the following are expected findings? SATA A. fever B. vomiting C. watery stools D. bloody stools E. confusion
A, B, C
A nurse is reviewing the health history of a client who has DM type 2. Which of the following are risk factors for HHS? SATA A. evidence of recent myocardial infarction B. BUN 35 C. takes calcium channel blocker D. age 77 years E. daily insulin injections
A, B, C, D
The nurse is caring for client dx with type 2 DM. The client is reporting a HA, jitteriness, and nervousness. Which interventions should the nurse implement? SATA A. check client's serum BG level B. give client glass of OJ C. determine when last antidiabetic med was administered D. assess client's BP and apical pulse E. admin prescribed insulin via sliding scale
A, B, C, D
Which of the following are common causes of bacterial conjunctivitis? SATA A. chlamydia trachomatis B. neisseria gonorrhoeae C. haemophilus influnzae D. staphylococcus aureus E. streptococcus pneumoniae
A, B, C, D, E
A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? SATA A. advise to client to keep food diary B. encourage client to brush teeth before & after meals C. assess the lab report of ferritin D. eat nutrient dense foods last at meal time E. encourage client to limit drinking fluids during meals
A, B, C, E
A nurse is providing discharge teaching to a client who had DKA. Which of the following info should the nurse include about preventing DKA? SATA A. drink 2 L fluids daily B. monitor blood glucose every 4 hr when ill C. admin insulin as prescribed when ill D. notify provider when blood glucose is 200 E. report ketones in the urine after 24 hr of illness
A, B, C, E
A nurse is providing discharge teaching to a client who has DKA. Which of the following info should the nurse include about preventing DKA? SATA A. drink 2 L fluids daily B. monitor BG every 4 hr when ill C. admin insulin as prescribed when ill D. notify provider when BG is 200 E. report ketones in urine after 24hr of illness
A, B, C, E
The client dx with cancer of the uterus is scheduled to have radiation brachytherapy. Which precautions should the nurse implement? SATA A. place client in private room B. wear a dosimeter when entering the room C. encourage visitors to come & stay with client D. plan to spend extended time with the client E. notify the nuclear medicine technician
A, B, E
A pt with newly dx diabetes has peripheral neuropathy. Which key points should the nurse include in the teaching plan for this patient? SATA A. clean & inspect feet daily B. be sure shoes fit properly C. nylon socks are best to prevent friction on toes from shoes D. only a podiatrist should trim toenails E. report any non-healing skin breaks to your HCP F. use a thermometer to check the temp of water before taking a bath
A, B, E, F
A nurse is caring for client who has cervical cancer and is scheduled for brachytherapy. Which of the following actions should the nurse take? SATA A. permit visitors to stay with client for 30 min at a time B. warn pregnant indiv ti visit room only once daily C. wear dosimeter when in client's room D. place soiled dressings in biohazard bag before discarding in regular trash E. dispose soiled linens in the hamper outside client's room
A, C
A child is hospitalized with dehydration as a result of rotavirus. When reviewing the tx plan, what can the nurse anticipate will be included? SATA A. monitor I&O B. antibiotic therapy C. daily weight D. IV fluid admin E. antidiarrheal agents
A, C, D
A nurse is teaching a group of caregivers about E. coli. Which of the following info should the nurse include? SATA A. severe abd cramping occurs B. watery diarrhea is present for more than 5 days C. it can lead to hemolytic uremic syndrome D. it is a foodborne pathogen E. antibiotics are given for tx
A, C, D
The nurse identifies which condition(s) will place the client at risk for metabolic alkalosis? SATA A. peptic ulcers B. chronic diarrhea C. excess diuretic therapy D. gastric suctioning
A, C, D
A nurse is caring for an 81 y/o with type 2 DM, HTN, and PVD. Which admission assessment findings increase the patient's risk for development of HHS? SATA A. hydrochlorothiazide prescribed to control BP B. weight gain of 6 lb over past month C. avoids consuming liquids in evening D. BP of 168/94 E. urine output of 50-75 mL/hr F. glucose greater than 600
A, C, F
A nurse is preparing a teaching plan for a client with DM regarding proper foot care. Which instruction is included in the plan? A. soak feet in hot water B. apply moisturizing lotion to dry feet but not between the toes C. always have podiatrist cut your toenails, never cut yourself D. avoid using mild soap on the feet
B
A client who is receiving chemo develops stomatitis. What should the nurse instruct the client to do? A. rinse mouth with full strength hydrogen peroxide every 4 hrs B. use a soft-bristled toothbrush after each meal C. drink hot tea w honey to soothe the painful oral mucosa D. avoid using dental floss until the stomatitis is resolved
B
A client with metabolic acidosis has been admitted to the unit from the ED and is experiencing confusion & weakness. Which of the following does the nurse implement as a priority of care for this client? A. place client in high fowler's B. protect client from injury C. admin sodium bicarb D. give the client skin care
B
A nurse caring for a toddler who has rhinitis, cough, and diarrhea for 2 days. Upon assessment, it is noted that the tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse make? A. your child has an ear infection that requires antibiotics B. your child could experience transient hearing loss C. your child will need to be on a decongestant until this clears D. your child will need to have a myringotomy
B
A 5 y/o is brought to ED with temp of 99.5, a barky cough, stridor, and hoarseness. Which nursing intervention should the nurse prepare for? A. immediate IV placement B. respiratory treatment of racemic epinephrine C. a tracheostomy set at bedside D. inform the parents about the vital signs
B
A client is struggling with the decision whether or not to continue therapy. They tell the nurse, "It's making me so sick and ruining whatever time I have with my family". What is the nurse's role when caring for this client? A. share stories about how others made this decision B. listen to the client's concerns C. advocate for the client with the HCP D. teach the client how to logically approach the situation
B
A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take? A. offer chicken broth B. initiate oral rehydration therapy C. start hypertonic IV solution D. keep NPO until diarrhea subsides
B
The nurse is teaching the family of a 6 y/o with allergic conjunctivitis how to minimize the exposure to allergens. What action would the nurse anticipate as being most difficult for the family to implement? A. washing the child's hands & face when returning from outdoors B. encouraging child to keep hands away from eyes C. rinsing the child's eyelids with clean washcloth & cool water D. making sure child showers & shampoos before bedtime
B
The parent of a child with frequent ear infections asks the nurse if there is anything that can be done to prevent future ones. Which is the nurse's best response? A. your child should be put on a daily dose of monotelukast (Singulair) B. your child should be kept away from tobacco smoke C. your child should be kept away from other children with otitis media D. your child should always wear a hat when outside in the cold
B
The parent of a toddler calls the nurse asking about croup. What is a distinguishing manifestation of spasmodic croup? A. wheezing is heard audibly B. harsh, barky cough C. bacterial in nature D. child has a high fever
B
The physician orders fluorescent antibody testing for a child with suspected RSV. The nurse would obtain the specimen for testing from: A. sweat B. nasopharyngeal secretions C. arterial blood D. sputum
B
The unlicensed assistive personnel reports to the nurse that a client seems very anxious, and vital sign measurement included a RR of 38. Which acid/base imbalance should the nurse suspect? A. resp acidosis B. resp alkalosis C. metabolic acidosis D. metabolic alkalosis
B
Which activity performed by the community health nurse best reflects primary prevention of cancer? A. assisting women obtain free mammograms B. teaching a class on cancer prevention C. encourage long-term smokers to get a chest xray D. encouraging sexually active women to get annual pap smears
B
Which of the following findings in a newly admitted patient with diabetes should be reports to HCP immediately? A. hammer toe of the left second metatarsophalangeal joint B. rapid RR with deep inspirations C. numbness & tingling bilaterally in the feet & hands D. decreased sensitivity & swelling of the abd
B
Which of these does the nurse recognize as the goal of palliative surgery for the client with cancer? A. cure of cancer B. relief of sx or improved quality of life C. allowing other therapies to be more effective D. prolonging client's survival time
B
The nurse is caring for a client with metabolic acidosis. Which of the following are appropriate goals for this client? SATA A. client will maintain a RR of 30 or more B. client will describe preventative measures for the underlying chronic illness C. client will maintain baseline cardiac rhythm D. pH will range from 7.25-7.35 E. client will take K supplements to increase K levels
B, C
A nurse is teaching a group of parents about Salmonella. Which of the following info should the nurse include? SATA A. incubation period is nonspecific B. it is a bacterial infection C. bloody diarrhea is common D. transmission can be from house pets E. antibiotics are used for tx
B, C, D
A nurse is assessing a client who has DKA & ketones in the urine. The nurse should expect which of the following findings? SATA A. weight gain B. fruity odor of breath C. abd pain D. Kussmaul respirations E. metabolic acidosis
B, C, D, E
A nurse is assessing a client who has DKA & ketones in the urine. The nurse should suspect which of the following findings? SATA A. weight gain B. fruity odor of breath C. abd pain D. Kussmaul respirations E. metabolic acidosis
B, C, D, E
A nurse is collecting info from a client in a provider's office. Which of the following should the nurse identify as an indication of possible cancer? SATA A. temp. 102 for more than 48 hr B. sore that does not heal C. difficulty swallowing D. unusual discharge E. weight gain 4 lb in 2 weeks
B, C, D, E
A nurse is planning care for a client who is undergoing chemo & is on neutropenic precautions. Which of the following interventions should be included in plan of care? A. encourage high fiber diet B. remove plants from room C. have client wear mask when leaving room D. have client-specific equipment remain in room E. eliminate raw foods from diet
B, C, D, E
A nurse is planning care for a client who is undergoing chemo and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? SATA A. encourage high fiber diet B. eliminate standing water in the room C. have the client wear mask when leaving room D. have client-specific equipment remain in the room E. eliminate raw foods from diet
B, C, D, E
A nurse is assessing an infant. Which of the findings are clinical manifestations of acute otitis media? SATA A. decreased pain in the supine position B. rolling head side to side C. loss of appetite D. increased sensitivity to sound E. crying
B, C, E
Pts receiving chemo are at risk for thrombocytopenia related to chemo or disease processes. Which actions are needed for pts who must be placed on bleeding precautions? SATA A. provide mouthwash w/ alc for oral rinsing B. use paper tape on fragile skin C. provide soft toothbrush or oral sponge D. gently insert rectal suppositories E. avoid aspirin or aspirin-containing products F. avoid over inflation of BP cuffs
B, C, E, F
A child has been admitted to the acute care facility for management of dehydration. Which IV fluids are suitable for fluid replacement? SATA A. 10% dextrose in water B. lactated ringer C. 0.45% NS D. normal saline E. 5% dextrose in water
B, D
A client is receiving monthly doses of chemo for tx of stage 3 colon cancer. Which lab results should the nurse report to the oncologist before the next dose of chemo is administered? SATA A. Hgb 14.5 B. Platelet 40 C. BUN 12 D. WBC 2.3 E. Temp 101.2 F. Urine specific gravity 1.020
B, D, E
A client is admitted with manifestations of metabolic alkalosis. Which dx test findings should the nurse suspect will confirm this dx? SATA A. serum glucose level 142 B. blood pH 7.47 & bicarb 34 C. IV pyelogram shows kidney stones D. bilateral lower lobe infiltrates on xray E. EKG changes consistent with hypokalemia
B, E
The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? SATA A. hold all venipuncture sites for at least 5 min B. limit fresh fruits & flowers C. place all clients in reverse isolation D. have clients use soft-bristle toothbrush E. screen visitors for infectious disease
B, E
The client dx with ovarian cancer is prescribed radiation therapy for regional control of the disease. Which statement indicates the client requires further teaching? A. I will not wash the marks off my abdomen B. I will have a tx every day for 6 weeks C. Nausea caused by radiation cannot be controlled D. I need to drink a nutritional shake if I don't feel like eating
C
The client dx with type 2 diabetes is receiving the combo oral meds glyburide/metformin. Which data suggests the med is effective? A. skin turgor is elastic B. urine ketones are negative C. serum BG level is 118 D. glucometer reads BG of 170
C
A 4 mo old has had vomiting & diarrhea for 24hrs. The infant is fussy, and the anterior fontanel is sunken. The nurse notes the infant does not produce tears when crying. Which task will help confirm the dx of dehydration? A. urinalysis obtained by bagged specimen B. urinalysis obtained by sterile cath C. analysis of serum electrolytes D. analysis of cerebrospinal fluid
C
A child with acute asthma has a PaCO2 of 48, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets this as which of the following? A. metabolic acidosis B. resp alkalosis C. resp acidosis D. metabolic alkalosis
C
A client is brought to the ED in an unresponsive state & a dx of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician prescriptions? A. endotracheal intubation B. 100 units of NPH insulin C. IV infusion of normal saline D. IV infusion of sodium bicarb
C
A client taking doxorubicin and is distressed about hair loss. What should the nurse do? A. have client wash & massage scalp daily to stimulate hair growth B. explain hair loss is temporary & will quickly grow back to original appearance C. provide resources for a wig selection before hair loss begins D. recommend client limit social contacts until hair regrows
C
A nurse is caring for a client admitted with confusion & lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying nect to the bed. Vital signs reveal BP 104/72, HR 116, RR 42 and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.68; PaO2 96, PaCO2 38; HCO3- 28 B. pH 7.48; PaO2 100, PaCO2 28; HCO3- 23 C. pH 6.98; PaO2 100; PaCO2 30; HCO3- 18 D. pH 7.58; PaO2 96; PaCO2 38; HCO3- 29
C
A nurse is caring for a client who is receiving chemo and has mucositis. Which of the following actions should the nurse take? A. use glycerin-soaked swab to clean client's teeth B. encourage increased intake of citrus fruit juices C. obtain a culture of the lesions D. provide alcohol-based mouthwash for oral hygiene
C
A nurse is caring for a client who is undergoing chemo and reports severe nausea. Which of the following statements should the nurse make? A. your nausea will lessen with each course of chemo B. hot food is better tolerated due to the aroma C. try eating several small meals throughout the day D. increase your intake of red meat as tolerated
C
A nurse is caring for a toddler who has had 3 ear infections in the past 5 months. Which of the following long-term complications is the child at risk for developing? A. balance difficulties B. rash C. speech delays D. mastoiditis
C
A nurse is reviewing the medical record for a client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? A. admin IV infusion of regular insulin at 0.3 unit/kg/hr B. admin slow IV infusion of 3% sodium chloride C. rapidly admin IV infusion of 0/9% sodium chloride D. add glucose to the IV infusion when blood glucose is 350
C
A nurse is teaching a client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the teaching? A. I will need to have a mammogram every 2 yrs beginning at 45 B. I should have colonoscopy every 15 yrs beginning at 60 C. I will need to have an annual breast exam every year after 40 D. I should have a fecal occult test done every 3 years
C
A nurse is teaching clients about the use of insulin to treat type 1 DM. For which of the following types of insulin should the nurse tell the clients to expect a peak effect 1-5 hr after admin? A. insulin glargine B. NPH insulin C. regular insulin D. insulin lispro
C
A parent asks the nurse how it will be determined whether their child has RSV. Which is the nurse's best response? A. we will do a simple blood test to determine whether your child has RSV B. there is no specific test for RSV, the dx is based on symptoms C. we will swab your child's nose & send that specimen for testing D. we will have to send a viral culture to an outside lab for testing
C
During a home visit, the nurse evaluates teaching provided to a client recently hospitalized for metabolic alkalosis. Which observation indicates that additional teaching is required? A. drinks 2 cups of black coffee per day B. consumes an orange each day with breakfast C. ingests bicarb of soda after each meal D. monitors & tracks daily weights
C
How will a child with resp. distress & stridor who is dx with RSV be treated? A. IV antibiotics B. IV steroids C. nebulized racemic epinephrine D. alternating doses of acetaminophen & ibuprofen
C
The client dx with bladder cancer states, "I have young children. I am too young to die". Which statement is the nurse's best response? A. this cancer is treatable, and you should not give up B. cancer occurs at any age, it is just one of those things C. you are afraid of dying and what will happen to your children D. have you talked to your children about your death?
C
The client has had an exploratory laparotomy to remove an ovarian tumor. The pathology report classifies the tumor as a "low malignancy potential" tumor. Which statement explain the scientific rationale for this pathology report? A. client does not have cancer but will need adjuvant therapy B. the client would have developed cancer if the tumor had not been removed C. these borderline tumors resemble ovarian cancer but have better outcomes D. the client has a very poor prognosis and has less than 6 months to live
C
The nurse is caring for a patient whose BG is 55. What is the likely nursing response? A. admin glucagon injection B. give small meal C. admin 15g of a carb D. give small snack of high protein food
C
The nurse will instruct the patient to treat hypoglycemia with which drug? A. acarbose (precose) B. Propranolol (inderal) C. glucagon (glucagen) D. bumetanide (bumex)
C
When preparing to admin a chemotherapeutic agent to a client, what should the nurse do? A. recap all needles used to prepare agents B. dispose of chemo wastes in the client's bedside trash C. use gloves & disposable long-sleeved gowns when handling agents D. admin only prepackaged agents from the manufacturer
C
Which intervention will be most helpful for a client with mucositis? A. admin biological response modifier B. encourage oral care w/ commercial mouthwash C. provide oral care with disposable mouth swab D. maintaining NPO until lesions have resolved
C
Which modifiable risk factor should the nurse identify for the development of cancer of the bladder in a client? A. previous exposure to chemicals B. pelvic radiation therapy C. cigarette smoking D. parasitic infections of the bladder
C
Which recommendation is the guideline for early detection of breast cancer? A. beginning at age 18, have a biannual clinical breast exam by an HCP B. beginning at age 30, perform monthly breast self-exams C. at age 40-55, receive a yearly mammogram D. beginning at age 50, have a breast sonogram every 5 years
C
Which statement best describes the scientific rationale for prescribing metformin? A. med decreases insulin resistance, improving BG control B. med allows carbs to pass slowly through large intestine C. med will decrease the hepatic production of glucose from stored glycogen D. med stimulates beta cells to release more insulin into bloodstream
C
Which statement by the parents of a toddler with repeated otitis media indicates they need additional teaching? A. if I quit smoking, my child may have decreased chance of getting an ear infection B. as my child gets older, he should have fewer ear infections, because his immune system will be more developed C. my child will have fewer ear infections if he has his tonsils removed D. my child may need a speech eval
C
A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? SATA A. admin oral prednisone B. initiate chest percussion & postural drainage C. admin humidified O2 D. suction nasopharynx as needed E. admin oral penicillin
C, D
A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? SATA A. admin oral prednisone B. initiate chest percussion and postural drainage C. admin humidified oxygen D. suction the nasopharynx as needed E. admin oral penicillin
C, D
A nurse is assessing a toddler who is brought to the clinic by the parent. The parent states, "My toddler has been so irritable lately & I've noticed the toddler frequently pulling on the right ear". The nurse suspects acute otitis media based on which assessment findings? SATA A. mobile eardrum B. URI 3 mo ago C. loss of appetite D. low-grade fever E. red bulging tympanic membrane
C, D, E
A client with DKA is being treated in the ED. What would the nurse expect? A. comatose state B. decreased urine output C. increased respirations & increase in pH D. elevated BG level & low plasma bicarb level
D
A 32 y/o female is dx with gestational diabetes. As the nurse, you know that what test below is used to dx a patient with this condition? A. 1 hr glucose tolerance test B. 24 hr urine collection C. HbA1c D. 3 hr glucose tolerance test
D
A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned b/c the child is frightened, constantly crying and trying to climb out of the tent, Which is the most appropriate nursing action? A. tell the mother that the child must stay in the tent B. place a toy in the tent to make child feel more comfortabe C. call the HCP and obtain a script for a mild sedative D. let the mother hold the child and direct the cool mist over the child's face
D
The client with type 2 DM is admitted to hospital with wound on left leg that will not heal. The HCP prescribes sliding-scale insulin. The client tells the nurse, "I do not want to have to take shots, I take pills at home". Which statement is the nurse's best response? A. if you cannot keep your glucose under control with pills, you must take insulin B. you should discuss the insulin order with your HCP b/c you don't want to take it C. you are worried about having to take insulin. I will sit down & we can talk D. during illness you may need to take insulin to keep your BG level down
D
The nurse is admitting an older client to the acute medical unit. Which assessment factor alerts the nurse that this client has a risk for acid/base imbalances? A. hx of MI 1 year ago B. antacid use for occasional indigestion C. SOB with extreme exertion D. chronic renal insufficiency
D
The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures assoc with periods of apnea. The nurse be alert for which acid-base imbalance? A. resp alkalosis B. resp acidosis C. metabolic alkalosis D. metabolic acidosis
D
The nurse is preparing a patient for a CT scan using iodine contrast media. Which med should the nurse question if prescribed one day before scheduled procedure? A. acarbose B. pioglitazone C. repaglinide D. metformin
D
The nurse is taking the social history from a client dx with small cell carcinoma of the lung. Which info is significant for this disease? A. client worked with asbestos for a short time many years ago B. client has no family hx for this type of lung cancer C. client has numerous tattoos covering both upper and lower arms D. client has smoked 2 packs of cigarettes a day for 20 yrs
D
The nurse is teaching a class on breast health to a group of women at a senior citizens center. Which risk factor is the most important to emphasize to this age group? A. clients should find out about their family hx of breast cancer B. men at this age can get breast cancer also & should be screened C. monthly breast self-exams is the key to early detection D. the older a woman gets, the greater chance of developing breast cancer
D
What info should the nurse teach workers at a daycare center about RSV? A. RSV is transmitted through particles in air B. RSV can live on skin or paper for up to a few seconds after contact C. RSV can survive on nonporous surfaces for about 60 min D. frequent hand washing can decrease the spread of the virus
D
When a woman develops GDM, it is during a time in the pregnancy when insulin sensitivity is ____________. This is majorly influenced by hormones such as estrogen, progesterone, ___________, and ___________. A. High; prolactin and human chorionic gonadotropin B. low; estriol and human placental lactogen C. high; human chorionic gonadotropin and cortisol D. Low; human placental lactogen and cortisol
D
Which physical findings would be of most concern in an infant with respiratory distress? A. tachypnea B. mild retractions C. wheezing D. grunting
D
A nurse is assessing a client who has pancreatitis. The client's ABGs reveal metabolic acidosis. Which of the following are expected findings? SATA A. tachycardia B. HTN C. bounding pulses D. hyperreflexia E. dysrhythmia F. tachypnea
E, F