PCC final practice EAQ quizzes

Which rational guides the nurse when managing the dietary needs of a client with gastroenteritis? 1. Provides optimal amounts of all important nutrients 2. Increases amount of bulk and roughage in the diet 3. Eliminate chemical, mechanical, and thermal irritation 4. Promote psychological support by offering a wide variety of foods

3

Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a NG tube set to low intermittent suction? 1. Prevent constipation 2. Prevent dehydration 3. Prevent vomiting 4. Prevent electrolyte imbalance

4

Which action would the nurse first take after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis? 1. place the client on airborne precautions 2. notify the clients health care provider 3. auscultate the client's breath sounds 4. notify the public health department

1

Which nursing intervention would the nurse classify as the highest priority for a client with delirium? 1. providing a body massage 2. arranging for music therapy 3. teaching relaxation techniques 4. creating a calm and safe environment

4

Which priority nursing intervention would the nurse include in the plan of care for an older adult who sustained a right hip fracture? 1. oxygen therapy 2. cardiac monitoring 3. nutrition supplements 4. venous thromboembolism (VTE) prevention

4

Which of these actions would the nurse perform to provide preventive and primary care to adults during a health camp? Select all that apply. 1. discussing vaccinations 2. discussing family planning 3. mentioning adult daycare services 4. instructing the health camp about self-care at home 5. instructing the health camp about road safety measures

1,2,5

Which descriptions explain why medications behave differently in toddlers versus adults? Select all that apply. 1. gastric emptying is slowed in children 2.medications are more likely to enter the brains of children 3. the gastric pH is more acidic in children 4. first-pass elimination in the liver is increased 5. glomerular filtration rate is lower in younger clients

1,2,5

The nurse documents that a child lacks physical readiness for toilet training. Which assessment finding supports the nurse's conclusions. 1. The child wets 2 diapers a day 2. The child stays dry for 1 hour during the day 3. The child behaves impatiently with soiled diapers 4. The child sits on the toilet for 6 minutes without fussing

2

Which disease increases the risk of hyperkalemia?

end-stage renal disease

Which action is the nurse's priority when caring for a client admitted for dehydration on an IV infusion of normal saline at 125 mL/h who begins screaming "I can't breathe!" one hour after the IV is initiated? 1. elevate the head of the bed and obtain vital signs 2. discontinue the IV and contact the primary care provider 3. change the IV to an intermittent infusion device 4. contact the primary health care provider to obtain a prescription for a sedative

1

Which action would the RN assign to an LPN caring for the client with a cast or traction? Select all that apply. 1. monitoring skin integrity around the cast 2. marking circumference of any drainage on the cast 3. teaching the client and caregiver ROM exercises 4. instructing family members on assisting the client with cast care 5. checking color, temperature, capillary refill, and pulses distal to the cast

1,2,5

For which clinical manifestations would the nurse assess the client diagnosed with Alzhiemer's disease? 1. loss of recent memory 2. focused attention span 3. perceptual disturbances 4. willingness to accept change 5. difficulty learning something new

1,3,5

Which principle explains how loop diuretics promote diuresis?

osmosis

Which is an important topic to include in teaching to promote the comfort of a client with a pruritic skin disease?

sleep

For which voluntary physiologic response would the nurse monitor development in a client experiencing pain? 1. crying 2. splinting 3. perspiring 4. grimacing

3

Which medication would the nurse anticipate developing a teaching plan for when a client reports becoming panicked and having an irrational fear of talking in public? 1. buspirone 2. alprazolam 3. diazepam 4. lorazepam

2

Which component of skin maintains optimal barrier function? 1. keratin 2. melanin 3. collagen 4. adipose tissue

1

Which condition is likely in a client who has an interruption of venous return? 1. tenting 2. varicosity 3. petechiae 4. ecchymosis

2

Which condition would the nurse suspect if a client's laboratory reports show WBC in the urine? 1. pyelonephritis 2. kidney trauma 3. kidney infection 4. acute tubular necrosis

3

which assessment would the nurse complete after a client has a open reduction internal fixation of a fractured hip? 1. assess femoral pulse 2. assess toes for mobility 3. check condition of pain 4. monitor range of motion of the knee

2

The nurse plans to help a client get out of bed for the first time after surgery. Which assessment would the nurse complete before having the client sit on the side of the bed? Select all that apply. 1. presence of safe footwear 2. status of comfort and pain 3. appearance of wound and skin 4. patency of urinary catheter 5. observation of walking gait

1,2,3,4

Which clinical manifestation is expected for a client with moderate dementia? Select all that apply. 1. restlessness 2. pessimism 3. short attention span 4. disordered reasoning 5. impaired motor activities

1,2,3,4,5

Which data collection assessment would be performed to evaluate the effectiveness of furosemide administered to a client with congestive heart failure? Select all that apply. 1. daily weight 2. intake and output 3. monitor for edema 4. daily pulse ox 5. auscultate breath sounds

1,2,3,4,5

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. 1. mold 2. cold air 3. pet dander 4. air pollution 5. cigarette smoke

1,2,3,4,5

Which IV solution would a nurse anticipate administering when caring for a client with a history of severe diarrhea for the past 3 days who is admitted for dehydration?

0.9% sodium chloride

A primary care provider prescribes 0.25 mg of alprazolam by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. Which side effect of this medication will the nurse monitor for in this client? 1. drowsiness 2. bradycardia 3. agranulocytosis 4. tardive dyskinesia

1

Which is a primary contributing factor for the risk-taking behavior of school-aged children? 1. peer pressure 2. cognitive ability 3. chronological age 4. developmental age

1

Which situation would the nurse address first according to maslows hierarchy of needs? 1. has history of being injured from sudden falls 2. complains of sleeplessness due to pain postsurgery 3. reports they feel lonely and socially isolated 4. conveys to the nurse that they want to become manager of the company

2

Which purpose does confabulation serve for an older client with the diagnosis of early-onset dementia? 1. prevents regression 2. increases self-esteem 3. attracts attention of others 4. helps recall achievements

2

Which intervention would the nurse include in the plan of care for a client after total hip replacement? Select all that apply. 1. maintain the affected hip in the adduction position when moving the client 2. regularly scheduled analgesics and as needed medications for pain control 3. the client should sit in a chair at the height to encourage flexion of the hip joint 4. frequent neurovascular assessment should be done and compaired with affected side 5. when turning the client should be log rolled to prevent the leg from falling forward or backward

2,4,5

Which factor is a likely cause of hyponatremia? Select all that apply. 1. Diabetes insipidus 2. Profuse diaphoresis 3. Excess sodium intake 4. Removal of the parathyroid glands 5. Rapid IV infusion of 5% dextrose in water (D5W)

2,5

The RN is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? 1. "I will avoid pooling of urine in the tubing" 2. "I will avoid prolonged clamping of the tubing" 3. "I will avoid draining urine from the tubing before ambulation" 4. "I will avoid raising the drainage tube above the level of the bladder"

3

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early alzheimer dementia and lives alone, with adult children living nearby. According to the prescribed medication regimen, the client is to take medications 6 times throughout the day. Which nursing intervention is correct to assist the client with taking the medication? 1. contact the client's children and ask them to hire a private-duty aide who will provide round-the-clock care 2. develop a chart for the client, listing the times the medication should be taken 3. contact the primary care provider and discuss the possibility of simplifying the medication regimen 4. instruct the client and client's children to put medications in a weekly pill organizer

3

Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on NPO status is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take? 1. give the client orange juice by mouth 2. increase the IV flow rate 3. moisten the clients lips with a wet 4x4 gauze 4. offer the client 4oz of water by mouth

3

Which action would the nurse encourage the daughter of a client diagnosed with early Alzheimers disease to do to best address the functional and behavioral changes associated with this disease? 1. place the client in a long-term care facility 2. provide for the client's basic physical needs 3. post a schedule of the client's daily activities 4. preform care so the client does not need to make decisions

3

Which assessments are a priority for a disturbed client who is brought to the emergency room by the police? 1. recollection of past events and events preceding police involvement 2. previous history of incarceration or hospitalization for psychiatric disorders 3. current behavior, appearance, cognitive function, affect, and orientation 4. cultural background, family hx, developmental level, and verbal skills

3

Which cause would the nurse suspect when caring for a client who has an anaphylactic reaction after receiving intravenous penicillin? 1. an acquired atopic sensitization occurred 2. there was passive immunity to the penicillin allergen 3. antibodies to penicillin developed after a previous exposure 4. genes encoded for allergies cause a reaction on an initial penicillin exposure

3

Which factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment? 1. level of interest in unit activites 2. orientation to time, place, and person 3. ability to perform tasks without becoming frustrated 4. cognitive impairment, which will increase until adjustment to the home is accomplished

3

Which immune function change places older clients at risk for bacterial and fungal infections? 1. decline in natural antibodies 2. reduction of neutrophil function 3. decrease in circulating T lymphocytes 4. reduction of colony-forming B lymohocytes

3

Which would the nurse include in dietary teaching for a client with a colostomy? 1. liquids should be limited to 1L per day 2. non-digestible fiber and fruits should be limited 3. a formed stool is an indicator of constipation 4. the diet should be adjusted to result in manageable stools

4

Which characteristics are unique to vascular dementia? Select all that apply. 1. memory impairment 2. failure to identify objects 3. focal neurological signs 4. episodic progression of symptoms 5. inability to use words to communicate

3,4

Which clinical manifestation would the nurse identify as an indicator suggesting a client has urinary retention and overflow after sustaining a CVA? Select all that apply. 1. Edema 2. polyuria 3. frequent voiding 4. suprapubic distention 5. continual incontinence

3,4

Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing a client who experienced a recent cerebrovascular accident (CVA) and has residual right-sided hemiplegia? 1. shortening and eventual atrophy of the affected muscles will occur 2. hypertrophy of the muscles eventually will result from disuse 3. extension of rigidity can occur, making therapy painful and difficult 4. decreased movement on the affected side predisposes the client to infection

1

Which statement by the breast-feeding client indicates that the nurse's teaching about breast care has been effective? 1. I should air-dry my nipples after each feeding 2. I should use a mild soap when i wash my breasts 3. I'll place breast shells inside my bra to protect my nipples 4. I will use nipple shields to prevent sore nipples

1

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? Select all that apply. 1. pain history, including location, intensity, and quality of pain 2. clients purposeful movement in arranging the papers on the bedside table 3. pain pattern, including precipitating and alleviating factors 4. vital signs such as increased blood pressure and heart rate 5. the clients family statement about increases in pain with ambulation

1,3

Which clinical finding would the nurse expect to identify when caring for a client with left leg venous thrombosis? Select all that apply. 1. pain in the left calf 2. intermittent claudication 3. redness in the affected area 4. swelling of the lower left leg 5. ecchymotic areas at the left ankle 6. localized warmth in the lower left leg

1,3,4,6

Which approach would the nurse use for a client with alzheimers disease who expresses fear and anxiety upon admission to a long-term care facility? 1. exploring reasons for the concerns 2. reassuring the client with the presence of 1 or 2 staff members 3. providing the client with a written schedule of planned interactions 4. explaining to the client why the admission to the facility is necessary

2

Which nursing interventions are best for a client who states , "I get down on myself when I make a mistake." in a cognitive therapy approach? Select all that apply. 1. teaching the client relaxation exercises to diminish stress 2. exploring with the client past experiences that have caused distress 3. providing the client with mastery experiences designed to boost self-esteem 4. encouraging the client to replace these negative thoughts with positive thoughts 5. helping the client modify the belief that anything less than perfection is unacceptable

4,5

Which manifestations are seen in older adults with the diagnosis of dementia? Select all that apply. 1. resistance to change 2. inability to recognize familiar objects 3. preoccupation with personal appearance 4. inability to concentrate on new activities 5. tendency to dwell on the past

1,2,4,5

During administration of an enema, a client experiences intestinal cramps. Which action would the nurse take? 1. discontinue the procedure 2. instill the fluid at a slower rate 3. lower the height of the container 4. stop the fluid until the cramps subside

4

The nurse is caring for a client who has experienced a near-drowning. For which potential danger would the nurse assess the client? 1. alkalosis 2. Renal failure 3. hypervolemia 4. Pulmonary edema

4

Which action would the nurse take after identifying that a client's urinary output is less than 40 mL/h over the past 3 hours? 1. Assess breath sounds and obtain vital signs 2. Decrease the IV flow rate and increase oral fluids 3. Insert an indwelling catheter to facilitate emptying of the bladder 4. Check for dependent edema by assessing the lower extremities

1

Which client would the nurse see first among this group of patients? 1. A toddler with diarrhea 2. An adult who is nauseated 3. An older adult who has vomiting because of food poisoning 4. An older adult whose last bowel movement was 3 days ago

1

Which statement by the client indicates to the nurse a need for further teaching on rifampin therapy? 1. i can expect my skin to turn yellow 2. i can expect my sweat to change colors 3. i can expect my urine to turn red-orange 4. i can expect my contact lenses to stain orange

1

A client has been robed, beaten, and sexually assaulted. The primary care provider prescribes 0.25 mg of alprazolam for agitation. Which event would alert the nurse to administer this medication? 1. the client's crying increases 2. the client requests something to calm her 3. the nurse determines a need to reduce her anxiety 4. the primary health care provider is getting ready to perform a vaginal examination

2

For which therapeutic effect will the nurse monitor the client who is prescribed alprazolam? 1. pain relief 2. decreased anxiety 3. reduction in dysrhythmias 4. reduced blood pressure

2

The nurse is reviewing a plan of care for a client who is scheduled for a barium swallow test. Which will the plan include? 1. giving clear fluids the day of the test 2. asking the client about allergies to iodine 3. administering cleansing enemas before the test 4. administering a laxative after the procedure

4

The nurse is providing preoperative teaching to a client who is scheduled for abdominal surgery. The client is fidgeting, slightly diaphoretic, and asking simple questions about information that was already provided during the educational session. Which initial step would the nurse take? 1. repeat the information, speaking slowly and distinctly 2. reduce the client's level of anxiety 3. teach the client about measures to lessen preoperative anxiety 4. ask the client to verbalize concerns and questions

2

Which action would the nurse implement when providing care for a client with continuous bladder irrigations? 1. monitor urinary specific gravity to determine hydration 2. subtract irrigant from output to determine urine volume 3. record urinary output every hour to determine kidney function 4. obtain a 24 hour urine specimen to determine urine concentration

2

Which approach would the nurse use when managing the care of a client diagnosed with GAD? 1. creating an anxiety-free environment 2. assisting the client with the development of healthy, adaptive coping mechanisms 3. avoiding triggers that produce anxiety in the client 4. providing reinforcement that the client's anxiety issues can be eliminated

2

Which cause would a nurse suspect is responsible for warmth, redness, and tenderness identified at a client's IV site? 1. rapid fluid delivery 2. phlebitis 3. allergic response 4. infiltration

2

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? 1. Restrict the client's fluid intake 2. Regularly offer the client a urinal 3. Apply incontinence pants 4. Insert an indwelling urinary catheter

2

Which nursing intervention is most important for supporting the success of the bowel training program for a client who sustained a CVA and is incontinent of feces? 1. use prescribed medications to induce elimination 2. adhere to a definite time for attempted evacuations 3. consider previous habits associated with the client's defecation 4. time scheduled eliminations to take advantage of the gastrocolic reflex

2

Which statement about benzodiazepines requires correction? 1. they are indicated for ethanol withdrawal ] 2. these medications increase the activity of gamma-aminobutyric acid 3. benzos are the first-line medications used in chronic anxiety disorders 4. these medications depress activity in the brainstem

2

Which client is at an increased risk for hospital acquired pneumonia? 1. client who was admitted yesterday with hypoxia and fever 2. client who has been on mechanical ventilation for 5 days 3. client who reports being on an airplane with other sick individuals 4. client who was admitted to the hospital 5 days ago for abdominal pain

4

A client is prescribed alprazolam. Which action must the nurse include in the client assessment during the initiation of therapy? 1. measure the client's urine output 2. examine the client's pupils daily 3. check the client's blood pressure 4. assess the abdomen for distention

3

Which finding in the older adult client is associated with a UTI? Select all that apply. 1. dysuria 2. urgency 3. confusion 4. incontinence 5. slight rise in temperature

3,4,5

Which conscious, healthy, coping behaviors would the nurse recommend a client to use to reduce anxiety? Select all that apply. 1. eating 2. sublimation 3. exercise 4. suppression 5. rationalization 6. talking to friends

3,4,6

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. 1. diplopia 2.Skin rash 3. leg cramps 4. tachycardia 5. muscle weakness

3,5

In which time frame would the nurse advise a client with a long leg cast for a fractured bone to take the prescribed as-needed oxycodone? 1. just as a last resort 2. before going to sleep 3. as the pain becomes intense 4. when the discomfort begins

4

The newborn of a lactating woman taking fluoxetine developed tremors, seizures, and fever. Which medication-induced physiological alterations may be responsible for the central nervous system effects of the medication on the neonate? 1. Delayed first stooling 2. Increase in fat content 3. Increase in protein binding 4. Immature blood-brain barrier

4

Which client statement indicates that teaching about acetaminophen is effective? 1. "I can drink beer with this but not wine" 2. "I need to limit my intake of acetaminophen to 650 mg a day" 3. "I should take an emetic if I accidentally overdose on acetaminophen" 4. I have to be careful about which over-the-counter cold preparations I take"

4

Which identified clinical manifestation is a sign of allergic rhinitis? 1. presence of high-grade fever 2. reduced breathing through the mouth 3. presence of pinkish nasal discharge 4. reduced trans-illumination on the skin over the sinuses

4

Which benefit would be provided by administering a patient-controlled analgesia (PCA) to a client after surgery? select all that apply. 1. client is able to self-administer pain-relieving medications as necessary 2. amount of medication received is determined entirely by the client 3. decreases client dependency 4. relieves the nurse from monitoring the client 5. increases client sense of autonomy

1,3,5

Which physiological factor alters the psychokinetic properties of medication in the breastfeeding neonate? select all that apply. 1. decreased fat content 2. increased protein binding 3. immature blood-brain barrier 4. increased first pass elimination 5. decreased glomerular filtration rate

1,3,5