Nur 134 Final Exam

The nurse should instruct a young female adult with sickle cell anemia to do which of the following? Select all that apply. A. Drink plenty of fluids when outside in hot weather B.Avoid travel to cities where the oxygen level is lower C.Be aware that since she is homozygous for HbS, she carries the sickle cell trait D.Know that pregnancy with sickle cell disease increases risk of crisis E.Avoid flying on commercial airlines

Rationale A, B, D People with homozygous for HbS have sickle cell anemia, the heterozygous form is the sickle cell carrier trait. Crises can be caused by dehydration, decreased oxygenation and stress. Talk about use of preventative health measures such as vaccinations.

The client performs self -peritoneal dialysis. What should the nurse teach the client about preventing peritonitis? Select all that apply? A.Broad spectrum antibiotics may be administered to prevent infection B.Antibiotics may be added to the dialysate to treat peritonitis C.Clean technique is permissible for prevention of peritonitis D.Peritonitis is characterized by cloudy dialysate drainage and abdominal discomfort E.Peritonitis is the most common and serious complication of peritoneal dialysis

Rationale A, B, D, E Clean technique is not permissible.

A nurse receives the change of shift report assigned clients and prioritizes client rounds. In what order should the nurse assess these clients? A.A client with an endotracheal tube transferred out of intensive care today B.A client with type 2 diabetes who had a cerebral vascular accident 4 days ago C.A client with cellulitis of the left lower extremity with a fever of 100.8F D.A client receiving D5W IV at 125 mL with 75 mL remaining.

Rationale A, C, D, B

The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to: A.Obtain adequate bed rest B.Increase fluid intake C.Take antibiotic therapy as prescribed D.Drink 8 ox of an electrolyte solution every day

Rationale A- Bedrest decreases metabolic demands allowing liver to regenerate. Fluids are important but no need to force.

A client with cirrhosis is receiving lactulose (Cephulac). During the assessment, the nurse notes increased confusion and asterixis. The nurse should: A.Assess for gastrointestinal bleeding B.Hold the lactulose (Cephulac) C.Increase protein in the diet D.Monitor serum bilirubin levels

Rationale A- GI bleeding and protein consumed in the diet increase protein in the intestine and can elevate the ammonia level. Bilirubin is elevated with gallbladder duct obstruction

Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline ash diet was prescribed. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications? A.Milk, apples, tomatoes, and corn B.Eggs, spinach, dried peas, and gravy C.Salmon, chicken, caviar, and asparagus D.Grapes, corn, cereals, and liver

Rationale A- low purine foods include milk, all fruits, tomatoes, cereals and corn. Organ meats, gravy are high purine. Alkaline ash diet includes milk, fruits except cranberry, plumes and prunes) and vegetables

An adult with type II diabetes is taking metformin (Glucophage) 1,000 mg two times every day. After the nurse provides instructions regarding the interaction of alcohol and metformin, the nurse evaluates that the client understands the instructions when the client says: A."If I know I'll be having alcohol, I must not take metformin, I could develop lactic acidosis." B."If my physician approves, I may drink alcohol with my metformin." C."Adverse effects I should watch for are feeling excessively energetic, unusual muscle stiffness, low back pain, and a rapid heartbeat." D."If I feel bloated, I should call my physician."

Rationale A. A rare but serious adverse effect of metformin (Glucophage) is lactic acidosis; half the cases are fatal. Ideally metformin should be held 2 days before and after alcohol. S/S of lactic acidosis are weakness, fatigue, unusual muscle pain, dyspnea, unusual stomach discomfort, dizziness or light headedness, bradycardia and cardiac arrhythmia. Bloating is NOT an adverse effect but a side effect.

The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that: A.There is a strong link between alcohol use and acute pancreatitis B.Alcohol intake can interfere with the tests used to diagnose pancreatitis C.Alcoholism is a major health problem and all clients are questioned about alcohol intake D.The physician must obtain all the pertinent facts, regardless of religious beliefs.

Rationale A. There is a known link between alcohol use and acute pancreatitis. Alcohol will also increase amylase levels.

The nurse is teaching a postmenopausal client about the use of calcium to prevent the effects of osteoporosis. The client asks "Why do I have to take vitamin D with my calcium?" Which of the following is the nurse's best response? A."Vitamin D prevents osteoporosis." B."Vitamin D increases intestinal absorption of calcium." C."You are most likely to be deficient in vitamin D." D."Calcium and vitamin D supplementation is the only way to prevent osteoporosis."

Rationale B

A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted below. Which action would be most appropriate for the nurse to implement? Hemoglobin 12.0 mg/dL Platelet count 108,000/mm3 White blood cell (WC) count 1,600/mm3 Absolute neutrophil count (ANC) <1,000/mm3 A.Wearing a protective gown and particulate respiratory mask when completing treatments. B.Washing hands before and after entering the room C.Restricting visitors D.Contacting the physician for a prescription for hematopoietic factors such as erythropoietin (Epogen, Procrit).

Rationale B ANC of 500-1000 indicates a moderate risk of infection, less than 500/mm3 indicates severe neutropenia and a high risk infection. Granulocyte stimulating factors are needed (Neupogen) for WBC not RBC.

The nurse is completing a health assessment of a 42 year old female with suspected Grave's disease. The nurse should assess this client for: A.Anorexia B.Tachycardia C.Weight gain D.Cold skin

Rationale B Graves disease is a hyperthyroid state, the others are s/s hypothyroid

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as prescribed. Which of the following statements is true concerning oxygen administration to a client with COPD? A.High oxygen concentration will cause coughing and dyspnea B.High oxygen concentrations may inhibit the hypoxic stimulus to breathe C.Increased oxygen use will cause the client to become dependent on the oxygen D.Administration of oxygen is contraindicated in clients who are using bronchodilators

Rationale B Hypoxic drive

A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis. Which medical facts about RA are essential in developing a plan of care. Select all that apply. A.Onset is acute and usually occurs between 20 and 40 B.The client experiences stiff, swollen joints bilaterally C.The client may no exercise once the disease is diagnosed. D.Erythrocyte sedimentation rate (ESR) is elevated, and xrays show erosions and decalcification of involved joints E.Inflamed cartilage triggers compliment activation, which stimulates the release of additional inflammatory mediators F.The first line treatment is gold salts and methotrexate

Rationale B, D, E starts insidiously between 35-50, maintaining ROM is essential, NSAIDS and salicylates are first line. Many drug that decrease immune system (methotrexate) cause flu like s/s and are not well tolerated.

The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide patient care? Select all that apply. A.A client with Crohn's disease who is receiving TPN B.A client who underwent inguinal hernia repair surgery 3 hours ago C.A client with an intestinal obstruction who needs a Cantor (NG) tube inserted D.A client with diverticulitis who needs teaching about home medications E.A client who is experiencing an exacerbation of his ulcerative colitis.

Rationale B, E It is not within scope of LPN to administer TPN, teach about home medications or insert an NG

Which of the following diets would be most appropriate for the client with ulcerative colitis? A.High caloric, low protein B.High protein, low residue C.Low fat, high fiber D.Low sodium carbohydrate

Rationale B- low residue. High residue items such as whole grains, nuts, raw fruit and vegetables should be avoided as they are irritating. Increase protein is necessary for nutrition due to malabsorption.

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? A.Limit caffeine intake to 2 cups of coffee per day B.Do not lie down for 2 hours after eating C.Follow a low-protein diet D.Take medications with milk to decrease irritation

Rationale B. no caffeine-decreases sphincter tone, milk increases acid production

Captopril (Capoten), furosemide (Lasix) and metoprolol (Toprol XL) are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 am the nurse reviews the following lab tests (below). Which of the following should the nurse do first? Sodium 140 meq Potassium 6.8 meq Chloride 101 BUN 18 mg/dL Creatinine 1.0 mg/dL Hemoglobin 12 g/dL Hematocrit 37% A.Administer the medications B.Call the physician C.Withhold the captopril D.Question the metoprolol dose

Rationale C The nurse should withhold the captopril and call the physician that the dose was held.

Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? A.Coma B.Apathy C.Irritability D.Depression

Rationale C as hypoxia worsens, confusion, coma

At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis to minimize gastric mucosal irritation? A.At bedtime B.On arising C.Immediately after a meal D.On an empty stomach

Rationale C ibuprofen decreases prostaglandin which is a gastric mucosal protectant, leading to irritation and sometimes GI bleeding if taken without food

The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, the nurse assess that the client is irritable and anxious and has moist skin. The nurse should do the following in which order? A.Obtain a history of which drugs the client has used recently B.Administer the prescribed dose of morphine C.Position electrodes on the chest D.Take vital signs

Rationale C, D, B ,A EKG will help determine if cardiac in nature, then baseline vitals before giving med that will affect VS, then morphine. Cause of MI at this time is least important (drug history). Assessing character of pain first is important as CP may be more GI or respiratory, can do this while putting electrodes on

The client has been recently diagnosed with type 2 diabetes and is taking metformin (Glucophage) two times per day, 1,000 mg before breakfast and 1,000 mg before dinner. The client is experiencing diarrhea, nausea, vomiting, abdominal bloating, and anorexia on admission to the hospital. The admission prescriptions include metformin (Glucophage). The nurse should do which of the following? (Select all that apply) A.Discontinue the metformin (Glucophage) B.Administer glargine (Lantus) insulin rather than the metformin (Glucophage) C.Inform the client that the adverse effects of diarrhea, nausea, and upset stomach gradually subside over time. D.Assess the client's renal function E.Monitor the client's glucose value prior to each meal.

Rationale C,D,E cannot change rx. Review sick day rules.

When a client and family receive the initial diagnosis of colon cancer, the nurse can act as an advocate by: A.Helping them maintain a sense of optimism and hopefulness B.Determining their understanding of the results of the diagnostic testing C.Listening carefully to their perceptions of what their needs are D.Providing them with written materials about the cancer site and its treatment

Rationale C- Listening carefully. Studies have demonstrated that needs are not necessarily what the nurse thinks they are. Helping maintain optimism and hopefulness is appropriate but not necessarily advocacy. Nurse role as educator is to provide written materials and understanding of diagnostic tests.

The nurse is unable to palpate the client's left pedal pulses after femoral popliteal surgery. Which of the following actions should the nurse perform next? A.Auscultate the pulses with a stethoscope B.Call the physician C.Use a Doppler ultrasound device D.Inspect the lower extremity

Rationale C. Auscultation and inspection cannot give same information as palpation. May need to call MD next.

A patient recently diagnosed with hypothyroidism demonstrates understanding of prescribed levothyroxine (Synthroid) medication when she makes which of the following statements. A."I should be able to become pregnant in a couple of months." B."This medication will help me lose all this excess weight." C."I should notify the physician for nervousness, diarrhea or increased pulse." D."This medication should be taken with food, preferably dairy products."

Rationale C. Side effects of thyroid hormone replacement medication may mimic symptoms of hyperthyroidism. After the client has reached normal serum T4 levels, the normal metabolic rate may help the client lose the weight gained during the hypothyroid state, but this is not the purpose of replacement. Take medication on empty stomach 1 hour before or 2 after a meal.

The client with type I diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 pm each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time? A.11 am, shortly before lunch B.1 pm, shortly after lunch C.6 pm, shortly after dinner D.1 am, while sleeping

Rationale D The client with diabetes who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent hypoglycemia while sleeping.

A nurse is preparing discharge instructions for an above the knee amputation client. Which instructions would be a priority? Select all that apply. A.Massage the residual limb in a motion away from the suture line. B.Avoid using heat application to ease pain C.Immediately report twitching, spasms, or phantom limb pain D.Avoid exposing the skin around the residual limb to excessive perspiration E.Be sure to perform the prescribed exercises. F.Rub the residual limb with a dry washcloth for 4 minutes three times daily if the limb is sensitive to touch.

Rationale D, E, F Perspiration may cause irritation, Rubbing the limb helps desensitize the limp and helps prepare for prosthesis. Massage toward not away. Twitching, etc is normal and may be relieved with heat

A priority goal for the hospitalized client who had a total laryngectomy with creation of a tracheostomy 2 days ago is to: A.Decrease secretions B.Instruct the client in caring for the tracheostomy C.Relieve anxiety related to the tracheostomy D.Maintain a patent airway

Rationale D, new trach will have a lot of secretions.

A client had a resection of the terminal ileum 3 years ago. While obtaining a health history and physical assessment, the nurse finds that the client has weakness, shortness of breath, and a sore tongue. Which additional information from the client indicates a need for intervention and client teaching? A."I have been drinking plenty of fluids." B."I have been gargling with warm salt water for my tongue." C."I have three to four loose stools per day." D."I take a vitamin B 12 tablet every day."

Rationale D- B12 needs to be taken IM due to lack of intrinsic factor with GI resection

The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). What is the action of this drug? A.Increase potassium excretion from the colon B.Release hydrogen ions for sodium ions C.Increase calcium absorption in the colon D.Exchange sodium for potassium ions in the colon

Rationale D- Kayexelate causes the body to excrete potassium through the GI tract. The sodium of the resin is particularly replaced by potassium. The potassium is then eliminated when the resin is eliminated with feces.

Which of the following findings should the nurse report to the client's physician for a client with unstable type 1 diabetes mellitus? (Select all that apply) A.Systolic B/P 145 mm HG B.Diastolic B/P 87 mm HG C.High-density lipoprotein (HDL) 30 mg/dL D.Glycosylated hemoglobin (HBA1c) 10.2% E.Triglycerides 425 mg/dL F.Urine ketones, negative

Rationale a, b, c, d, e The client with unstable diabetes mellitus is at risk for many microvascular and macrovascular complications. Goal B/P for someone with diabetes is 130/80. Goal HbA1c is less then 7%. HDL should be greater then 40 and triglycerides less than 150

A client has a wound on the ankle that is not healing. The nurse should assess the client for which of the following risk factors for delayed wound healing. Select all that apply. A.Atrial fibrillation B.Advancing age C.Type 2 diabetes mellitus D.Hypertension E.Smoking

Rationale b, c, e This is a venous ulcer not affected by arterial blood flow. Advancing age decreases venous return, diabetes increases risk infection decrease healing due to sugar content and smoking destroys fine capillaries.

A 34 year old female is diagnosed with hypothyroidism. The nurse should assesses the client for which of the following? (Select all that apply) A.Rapid pulse B.Decreased energy and fatigue C.Weight gain of 10 pounds D.Fine, thin hair with hair loss E.Constipation F.Menorrhagia

Rationale b, c, e, f Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair (not fine), constipation and menorrhagia are common signs and symptoms of hypothyroidism.

A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? Select all that apply. A.Suggest that the client use ginger when taking the medication B.Ask the client what is causing the nausea C.Tell the client to use stool softeners to minimize constipation D.Offer to administer the medication by an IM injection E.Suggest that the client take the iron with orange juice

Rationale-A, B, E-ginger may help decrease nausea, iron should be taken on empty stomach but can be taken with OJ, stool softeners should not be used in patients with iron deficiency?? Instead high fiber diet can prevent.

Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension initially treated with furosemide (Lasix) and Ramipril (Altace). An expected therapeutic effect is: A.Decrease in heart rate B.Lessening of fatigue C.Improvement in blood sugar levels D.Increase in urine output

Rationale: A beta blockers decrease HR and thus decrease B/P (CO X SVR=B/P) (CO=HR X SV)

A client is experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33, PCO2 48, PO2 58 and HCO3 26. Which of the following prescriptions should the nurse perform first? A.Albuterol (Proventil) nebulizer B.Chest X-Ray C.Ipratropium (Atrovent) inhaler D.Sputum culture

Rationale: A need to dilate bronchioles first as o2 is low

A client's stools are light gray in color. The nurse should assess the client further for which of the following? (Select all that apply) A.Intolerance to fatty foods B.Fever C.Jaundice D.Respiratory distress E.Pain at McBurney's point F.Peptic ulcer disease

Rationale: A, B, C Bile duct obstruction will cause gray colored stools as bile is unable to get through to give color to stool. Other symptoms are RUQ pain, jaundice from elevated serum bilirubin, fever from inflammation or infection of gallbladder. McBurney's point is lower abdomen and associated with appendicitis. Bleeding ulcer produces black stool and respiratory distress is not a symptom of cholelithiasis.

A 21 year old client undergoes bone marrow aspiration at the clinic to establish a diagnosis of possible lymphoma. Which statement made by the client demonstrates proper understanding of discharge teaching? Select all that apply. A."I will take Tylenol for pain." B."I do not need to inspect the puncture site." C."I will not be able to play basketball for the next 2 days. D."I will take aspirin if I have pain." E."I can apply an ice pack or a cold compress to the puncture site."

Rationale: A, C, E Aspirin can cause more bleeding and site should be assessed every 2 hours for bleeding. Contact sport may increase bleeding

The nurse should assess the client with left sided heart failure for which of the following? Select all that apply A.Dyspnea B.Jugular vein distention C.Crackles D.Right upper quadrant pain E.Oliguria F.Decreased oxygen saturation levels

Rationale: A, C, E, F Others are signs of right heart failure. A decrease CO will lead to decrease renal perfusion leading to oliguria

A client is to receive epoetin (Epogen, Procrit) injections. What laboratory value should the nurse assess before giving the injection? A.Hematocrit B.Partial thromboplastin time C.Hemoglobin concentration D.Prothrombin time

Rationale: A- increases RBC formation; hct is percentage of RBC in plasma. PT, PTT assess bleeding times.

The nurse is caring for a client newly diagnosed with osteoporosis. Which statements should the nurse include when teaching the client about the disease? Select all that apply. A.Osteoporosis is common in females after menopause. B.Osteoporosis is a degenerative disease characterized by a decrease in bone density. C.The disease is congenital, caused by poor dietary intake of milk products. D.Osteoporosis can cause pain and injury E.Passive ROM exercises can promote bone growth F.Weight bearing exercises should be avoided.

Rationale: A. B D degenerative disorder, occurs with menopause due to lack of estrogen. Low calcium can contribute but not congenital. Weight bearing exercises such as walking is helpful.

When administering a thrombolytic drug to the client who is experiencing infarction (MI) and a cardiac arrythmia what is the expected outcome? A.Promote hydration B.Dissolve clots C.Prevent kidney failure D.Treat dysrhythmias

Rationale: B Thrombolytics dissolve clots

The client with TB is to be discharged home with community health nursing follow up. Of the following nursing interventions, which should have the highest priority? A.Offering the client emotional support B.Teaching the client about the disease and its treatment C.Coordinating various agency services D.Assessing the clients environment for sanitation

Rationale: B- teaching importance of compliance with medication, long term medication use.

Which factor would the nurse assess to be a symptom of pulmonary embolism? A.Slow increase in heart rate and respiratory rate B.Cyanosis of the upper torso C.Abrupt onset of dyspnea and apprehension D.Significant bilateral wheezing

Rationale: C classic PE s/s is sudden onset SOB and anxiety. May have clear breath sounds, VS will change quickly.

The nurse is caring for an older adult male who had open reduction internal fixation (ORIF) of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having "tightness in chest." The nurse reviews the recent lab results. The nurse should report which of the following lab results to the physician? A.Hematocrit (Hct) 40% B.Serum glucose 120 mg/dL C.Troponin 1.4 mcg/L D.Erythrocyte sedimentation rate (ESR) 22 m/h

Rationale: C- Elevated troponin indicates some cardiac damage. Remember possible fat emboli from long bone fracture.

Which of the following statements by a female client would indicate that she is at high risk for a recurrence of cystitis? A."I can usually go 8 to 10 hours without needing to empty my bladder." B."I take a tub bath every evening." C."I wipe from front to back after voiding." D."I drink a lot of water during the day."

Rationale A Stagnant urine increases risk of infection

Following joint replacement, which of the following complications has the greatest likelihood of occurring? A.Deep vein thrombosis (DVT) B.Dysuria C.Paralytic ileus D.Wound evisceration

Rationale A- platelets aggregate around foreign substance. The others are risks that can occur more with abdominal surgeries but all are potential risk with any surgery.