PN FINAL EXAM

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy

" I will irrigate my stoma every morning"

The nurse providers discharge teaching for a client newly diagnosis Crohn's disease about dietary measure to implement during exacerbation episodes. which statement made by the client need for further instruction?

"I should increase the fiber in the diet "

The PPD ( purified Protein derivative) test is performed to determine if the client has been exposed to tuberculosis bacillus (TB) Answer

(T) True

A group of students is studying together for their final exam. The thoughtful instructor prepared a pan of lasagna for them to eat while studying. The instructions on the lasagna. Practice your conversions. Bake at 182 degrees Celsius for 45 minutes. Eat well. Study hard. What Fahrenheit temperature will the lasagna cook at? ( Round to the nearest whole number?

360 degrees

33. Which statement about medical-surgical concept of immunity is accurate?

A) Artificial active immunity occurs via vaccination or immunization.

47. A client is having an operation. Which assessment findings concerns the nurse? SATA

A) Calcium level of 12mg/dl B) Heart rate of 110 beats/min E) Blood pressure of 90/40mmHg

33. Which of the following is not a consideration when planning care for the older preoperative client?

A) Decreased risk for dehydration.

A client with an intravenous line (IV) in place states having pain at the insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions should the nurse take? SATA

A) Document the assessment, nursing actions taken, and the client's response. B) Discontinue the infusion at the affected site. D) Remove the intravenous catheter from the affected site.

A diagnosed with lung cancer who is receiving morphine complains of constipation. Which instruction(s) by the nurse might help relieve the client's constipation? (Select all that apply) Answer

A) Drink at least eight 8-ounce glasses of water each day B) Be sure the amount of fruit, vegetables and fiber in your diet is adequate." D) Include psyllium supplements in your diet daily". E) Increase your exercise routine to include 1 hour of exercise every day."

A nurse is reviewing a metabolic panel laboratory report of a client on diuretic therapy for congestive heart failure. The report is as follows sodium 142 mEq/L calcium chloride, 98 mEq/L which of the following electrolyte disturbances should the nurse report to the physician? Answer

A) Hypokalemia

33. To assess the alleviating factors related to a client's pain, the nurse could ask the client to do which of the following?

A) Identify the methods the client uses to control the pain.

33. One week after a kidney transplant, the client develops a temperature of 101 degrees F, the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising, urine output is decreased. An x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates what treatment?

A) Increased immunosuppression therapy

33. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? SATA

A) Locking beds and wheelchairs during transfer B) Providing information about home safety checks. C) Placing a bedside table within the client's reach Teaching about balance and strengthening exercises

which one of the following statements by the parent of a child indicates that further teaching by the nurse is required?

A) Now that my child is 2 years old, I can let her sit in the front seat of the car with me."

The nurse is notifying the health care provider via telephone of a change in the condition of a client with an exacerbation of asthma. Which of the nurse's SBAR statement? Answer

A) Respiration are now 32 breaths/minute. The pulse oximeter is 89% on 2 L via nasal cannula. Lung have wheezing in all lung fields. Slight nasal flaring.

A volunteer at the senior center asked the visiting nurse why the senior citizen always seem to be complaining about the temperature. The nurse's nurse best response is that older people have a diminished ability to regulate body temperature because of what? Answer

A) Slower metabolic rates.

33. A client who was diagnosed with senile dementia has become incontinent of urine. The client's daughter asks the nurse why this is happening. What is the best response by the nurse?

A) The client is losing sphincter control due to dementia.

47. The nurse planning the care for a frail, malnourished, immobile client recognizes which of the following is the best treatment to protect the client's integument?

A) Turning the client at least every 2hours.

The nurse is caring for a client who is at for impaired tissue integrity. Which intervention will prevent impaired tissue integrity (select all that apply)? Answer

A) keep the client's skin clean and dry C) Place a gel pad on the chair before getting the client out bed E) Provide a healthy diet, including protein. F) Moisture skin when needed to prevent excessively dry skin.

The nurse is caring for a client in a long-term care facility. Which action contributes to encouraging autonomy in the client:

Allowing the client to choose social activities.

A home health nurse is receiving the medication list of older adult client who reports falling a couple of times over the past week. Which of the following medications should the nurse suspect is causing the client to fall?

Alprazolam

At last measurement, the client's vital signs were as follows: oral temperature 98 F(36.7 C), heart rate 76 beats /min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mmHg. Four hours later, the vital signs are as follows : oral temperature 103.2 F (38.5 C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mmHg. Which should be the nurse's first action at this time?

Ask the client if he has had a warm drink in the last 30 minutes

In which of the following answers in the answers is the hospital in compliance with the Consolidation Omnibus Budget Reconciliation Act and E Answer

B) A client chest pain is triaged directly to a room for evaluation and registration information is obtained after the....."

A client had a colon resection for the removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities postoperative complications? (Select all the apply) Answer

B) Assist the client to turn, breathe deeply and cough every 2 hours D) Monitor vital sign on a regular basis. E) Assess the drainage from the surgical site.

33. The nurse has telephone messages from four clients who requested information and assistance. Which one should the nurse refer to a social worker or communication?

B) I ran out of money and am cutting my insulin dose in half

A nurse instructs a group of nursing students about the responsibilities involved in organ donation and procurement. When the nurse explains that all the clients waiting for a kidney qualification the student should understand that this aspect of care delivery is an example of which of the following ethical principle? Answer

B) Justice.

A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety? Answer

B) My baby loved to play with his crib gym, but I took it away from him."

A 19-year-old male has sustained a transaction of C-7 in an MVA rendering him a quadriplegic. The client describes his pain as burning sharp, and shooting. These findings are characteristic of which of the following? Answer

B) Neuropathic pain

The preoperative nurse cares for the client until the client progresses into intraoperative phrase of care which event is the beginning of the intraoperative phrase? Answer

B) The client arrives the surgical suite doors.

pressure ulcer form primarily as a result of which of the following?

B) Tissue Ischemia

The client is admitted for treatment of various poorly healing. Infected leg ulcers. The nurse recognizes that the client's nutritional history is of important importance since. Answer

B) Wound healing and infection prevention are negatively impacted by poor nutrition.

A client is admitted to the hospital for diabetic ketoacidosis. Which arterial blood gas(ABG) results should the nurse expect? SATA

C) Bicarbonate (Bicarb) 18meq/L, E) pH7.32

What are physiologic responses that indicate a client is experiencing acute pain? SATA

C) Diaphoresis, E) Tachycardia

33. A client tells the nurse that she rarely experiences pain, but when she does, she seeks medical attention. The nurse realizes this client understands that pain....

C) It is a protective system

33. Which situation demonstrates the intraoperative circulating nurse acting's the client's advocate

C) Keep the operating room door closed at all times

To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following?

C) Let's discuss the routine to see if there are any changes we can make

A client hospitalized with urinary retention has an indwelling catheter. Intravenous fluids are infusing. Which priority intervention does the nurse add to the care plan for this client? Answer

C) Perform catheter care per policy every shift.

A group of nursing students is sitting in the hospital cafeteria eating lunch. One student tells the group that she thinks the nursing instructor has acquired immunocompromise states that she thinks this instructor is an IV drug abuser because she always wears long sleeves. Which legal tort has been violated by the student who made this abuse? Answer

C) Slander

A client is agitated and continued to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next?

C) provide comfort measure

) The nurse would suspect that client who frequently uses which medication is risk for developing metabolic alkalosis

Calcium carbonate

A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. Which of the following signs and symptoms should the nurse expect to find in this client? (SATA)

Cardiac arrhythmias Trousseau's sign Fractures

When turning a client, the nurse notices a reading area on the coccyx. What skin care interventions should the nurse use in this area?

Clean the area with mild soap, dry, and add a protective moisturizer

47. A client tells the nurse that e is allergic to diazepam because he experience nausea, vomiting, and dizziness after ingesting. How should the nurse document this?

Client experiences nausea, vomiting, and dizziness after ingesting diazepam

Which client does the nurse asses first at the start of a nursing shift?

Client who reports increased pain and swelling after an arthroscopy

Dinners calls the health care provider (HCP) Regarding a new medication prescription because they dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the health care provider and the medication is due to be administered. which action should the nurse take?

Contact the nursing supervisor

The nurse is preparing to administer medications to a client with rheumatoid arthritis (RA). What does the nurse explain to the client as the goal of medication treatments for RA?

Control

33. A client receiving around-the-clock medication for terminal cancer experiences additional pain when performing activities of daily living. The nurse realizes this client is experiencing what type of pain?

D) Breakthrough Pain

47. The nurse provides discharge teachings for a client with a compromised immune system and on neutropenic precautions. When discussing types of vegetables and fruits that the client..........SATA

D) Canned pears, E) Cooked corn

The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? Answer

D) Encourage the child to continue coughing.

A nurse is instructing a client with ulcerative colitis regarding the need to avoid enteric-coated medication. The nurse knows that the client understands the reason for this teaching when the client the following? Answer

D) Enteric-coated medication are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue."

33. The nurse is removing personal protective equipment(PPE). Which item should be removed first?

D) Gloves

The nurse notes the client's temperature over the past 24hours risen from 98.8 to 101.6 F the nurse completes a head-to-toe assessment. Based on the nurse's documentation what is the nurse next action? 14:00 temperature 101.6 F pulse 88 beat/minute. Respiration 24 breaths/minute. Blood pressure 132/78 mm Hg lung clear. Harsh cough noted. Sputum. Denies chest pain sounds in all 4 quadrants. Last bowel movement this morning. Voiding dark amber urine. Gait steady with ambulation. No lower extremity edema noted. R. Brown, RN Answer

D) Notify the health care provider

A student nurse is educating a client with newly diagnosed osteoporosis. Which statement nurse would not apply to diagnosis of osteoporosis? Answer

D) Osteoporosis is degeneration disease characterized by the decrease in bone density.

........ immunity occurs when antibodies are created in another person or animal. Answer

D) Passive

33. What type of immunity is provided by intravenous (IV) administration of immunoglobulin G?

D) Passive

A client has severe Paget's disease. Which factor has the highest priority when the nurse intervenes in the care of this client? Answer

D) Relief of pain

While sponging a client who has a high fever, the nurse observes the client shivering. Which is the nurse's priority action?

D) Stopping Sponging the client.

A client will be undergoing palliative surgery. The client's daughter asks what this meant. What is the nurse's best response? Answer

D) The surgery will relieve the symptoms but will not cure your father,"

The nurse is interviewing a client to help the health care provider determine the client's for osteomalacia. Which assessment is the nurse most likely to perform? Answer

D) Typical 24-hour dietary intakes

A nurse is caring for a client admitted for acute inflammation of the ankle. The provide diagnosis an acute of gout and orders colchicine 2 mg IV now, 0.5 mg every 6 hrs. the colchicine has what purpose?

Decrease joint inflammation.

A nurse suspect an incisional wound infection in a client who is 5 days postoperative following a colon resection. Which of the following findings are not indicative of this condition? Answer

Decreased thirst

The nurse is assessing a client who reports severe knee pain after a fall. which question does the nurse ask to determine the radiation of the pain?

Does the pain move to another area from your knee?

A nurse in a delivery room is assisting with the delivery of a newborn, after delivery the nurse prepares to prevent heat loss in the newborn result from convention by of the following interventions.

Drying the infant with a warm blanket

The nurse is caring for a client with fluid volume excess who has edematous skin. Which of the following is an appropriate nursing consideration for this client?

Elevate an edematous part to a position higher than the heart's leveL

A client arrives on the unit 40 minutes ago from the post-anesthesia care unit (PACU). Report stated that the client received morphine 2 mg Intravenously and hour ago. The client scales that the pain is again 8/10 and the respiratory rate is 18/minute, Blood pressure is 145/85 m Hg, and pulse is 90 beats/minute. What would the nurse's best option be?

Examine transfer order and select appropriate pain medication

A nurse is caring for a client with advance cancer. After reading the nurse's documentation (below), determine the nurse's next action. 1549 : Client states, " the doctor says my chemotherapy isn't working anymore. They can only treat my symptoms now. I don't want to die in the hospital. I want to be I my own bed." R.Brown,RN

Explain the use of an advance directive to express the client's wishes.

The Health Information Portability and Accountability Act (HIPAA), Implemented in 2003, may influence nursing research in which area?

How the data will be obtained and protected

The nurse is caring for a client with respiratory muscle weakness, which has resulted in shallow respirations. which electrolyte abnormality would next suspect?

Hypocalcemia

The nurse is discussing interventions to decrease a client isolation while on airborne precautions. Which statement by the nurse Requires that the charge nurse intervene?

I will leave the door propped open to increase auditory and visual stimulation

The client is one day postoperative for sigmoid column resection. Why caring for the client, the nurse notes a moderate amount of dark reddish-brown drainage on the midline abdominal incision. Which intervention should the nurse implement first?

Mark the drainage on the dressing with time and date

The nurse educator is teaching a module on proper body mechanism during orientation. which of the following statements by a newly hired nurse indicates the need for further teaching?

My line of gravity should fall outside my base of support

A client develops a respiratory rate of 6 breath /minute after receiving hydromorphone 2 mg IV. Which medication should the nurse anticipate administering to the client after notifying the prescription effect?

Naloxone

The nursing student uses the wrong-Baker Faces pain rating scale to assess the pain of a 4-year-old child. The nurse will intervene if the student performs which action?

Observes the child's facial expression and matches it to a face on the scale

Which of the following interventions will be appropriate for a client who has a fever? (SATA)

Offer the client fluid to drink over 1 to 2 hrs Put an ice pack on the client's neck and axillae Ask the client about pain and other symptoms they are experiencing

The nurse is working on a plan of care with her client which includes turning and positioning and the adequate nutrition to help the client maintain intact skin integrity. The nurse helped the client to realize the chain of infection by eliminating which of the following?

Portal of entry

which pain management task can be safely delegated to a nursing assistive personnel?

Providing a therapeutic massage

To enhance meeting the psychological need of a client on transmission-based precaution, the nurse should place the highest priority on which of the following?

Providing the client with Diversional activities to enhance sensory input

What is the most appropriate measure for a nurse to use in assessing core body temperature when there I suspected problems with thermoregulation?

Rectal temperature

Which intervention would be the priority nursing intervention for a client suspected to be hypothermic

Remove wet clothes

A client who reports severe flank and abdominal pain is diagnosed with renal calculi. Which intervention does the nurse determine is appropriate?

Strain and urine

A male client with terminal illness is unconscious. His wife wants his status to be full code. His sister, who is the durable power of at least which person has legal precedence.

The Sister's The Sister's wishes are legally binding wishes are legally binding

The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely to be inadequately treated for this pain?

The client with expressive aphasia

The nurse is caring for an obese client with osteoarthritis (OA). What is the best rationale for encouraging this client to lose weight?

The extra weight of obesity increases the degeneration rate of hip and knee joints

The nurse is caring for a client who has undergone a kidney transplant. The client asks the nurse what will happen when his body realizes That the kidney is not "his". What is the nurses best response?

The immune system will try to destroy the kidney if we don't suppress it

The nurse preparing to perform a sterile procedure. After donning sterile gloves, which of the following objects can the nurse touch while maintaining sterile technique?

The inner wrapping of an item on the sterile field

A client who has been taking oxycodone for an extended period of time comes to the clinic reporting that the drug is no longer relieving his pain. Which category would be given to the client complaint?

Tolerance

A client is admitted to with severe diarrhea. Arterial blood gas (ABG) results are pH 7.33; PaCo 42 mmHg; HCO320 mEq/L. The nurse considers the nurse has which of the following acid base imbalance?

Uncompensated metabolic acidosis

A client is complaining of abdomen pain. The nurse realizes this client is experiencing which type of pain?

Visceral

A home health nurse is discussing the dangers of carbon monoxide poisoning with the client. which of the following information should the nurse include in the counseling?

carbon monoxide binds with the hemoglobin in the body

A 25- year -old client is admitted to healthcare facility with complaint of fever, vomiting and watery diarrhea for 2 days, on examination, the client has dry skin , delayed skin turgor and hypotension, what is the most likely nursing diagnosis?

deficient fluid volume

The client is a 70-year-old retired nurse who is interested in non-drug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. what options should be considered in the plan of care considering the client's expressed wishes?

music therapy, distraction techniques, meditation, Prayer, guided imagery, relaxation techniques, and pet therapy

During orientation to an emergency department the nurse educator will be concerned if the new nurse listed which of the following is a risk factor for impaired thermoregulation?

physical agility