Practice Exam Final questions 310 Adult Health/Med Surge

Clients with type I diabetes are following a routine dietary and insulin regimen. Which client does the nurse anticipate having the highest risk of developing hypoglycemia? a. A 20-year-old athlete who started daily Zumba classes b. A 35-year-old who has tonsillitis c. A 42-year old with asthma who is taking prednisone d. A 39-year-old with the new onset of COVID-19

20-year-old athlete who started daily Zumba classes

An 82-year-old male patient is receiving continuous bladder irrigation with 0.45% NaCl. 1200ml have been instilled, a total output of 1500ml is collected in the Foley catheter collection bag. What would be the true urine output? a. 1500 ml b. 300 ml c. 2700 ml d. 1200 ml

300 ml

A patient is prescribed medications to be taken before dinner. If dinner is at 7 pm. What time would the nurse advise the patient to take the medication? a. 8 pm b. 7 pm c. 6 pm d. 6:30 pm

6 pm

Which assessment data would the nurse recognize to support the diagnoses of abdominal aortic aneurysm (AAA)? a. Decreased urinary output b. Shortness of breath c. Ripping abdominal pain d. Abdominal bruit

Abdominal bruit

A patient underwent a bariatric surgery. What are the expected signs and symptoms that are expected 10 to 30 minutes after meals? Select all that apply. a. Lightheadedness b. Flushing c. Abdominal cramps d. Extreme alertness e. Rapid heart rate

Abdominal cramps Rapid heart rate Lightheadedness Flushing

A client with lung cancer presents with calcium 14.2 mg/dl. What related clinical manifestations should the nurse expect? Select all that apply Abdominal pain and discomfort Muscle and bone pain Confusion and lethargy Tachycardia Hyperactivity

Abdominal pain and discomfort Muscle and bone pain Confusion and lethargy Tachycardia

A client sustained a crush injury to the lower extremities while trying to do a car improvement project. The client was brought to the emergency room with blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status? a. Serum lactate level b. Hematocrit and hemoglobin levels c. Arterial blood gases d. Chest x-ray

Arterial blood gases

In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is most appropriate to maintain the safety of the client? Allow the client to rise from the bed to a standing position unassisted. Assess the client for dizziness and hypotension Elevate the head of the bed quickly to assist the client to a sitting position. Assist the client to move quickly from the lying position to the sitting position.

Assess the client for dizziness and hypotension

The client is one day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? a. Assess the client chest dressing and vital signs b. Check the client's telemetry monitor. c. Medicate the client with intravenous morphine d. Encourage the client to turn from side to side

Assess the clients chest dressing and vital signs

A patient is hospitalized with ureter renal calculi. What is the intervention the nurse should provide first? a. Collect a urine sample for analysis b. Encourage fluid intake and provide them with a full pitcher of water c. Assess their pain level and administer pain medication as ordered d. Start straining their urine

Assess their pain level and administer pain medication as ordered

A nurse is caring for a client who is post-operative day 2 after a large abdominal surgery. While assessing the client at the beginning of the shift, the nurse noted decreased breath sounds, crackles, and a mild cough. Most likely, what is the client experiencing? Acute Bronchitis Atelectasis Hypoxemia Pneumonia

Atelectasis

A client presented with Addison's disease. Which of the following assessment findings suggests an Addisonian crisis? a. Blood pressure decreases b. Respiratory rate unchanged c. Pulse decreases d. Temperature rise

Blood pressure decreases

The nurse is caring for a client who is postoperative day-5 after undergoing partial gastrectomy. The client's diet was changed from NPO status to clear liquids. The nurse should check which priority item before administering the diet? Bowel sounds Ability to ambulate Appetite and typical diet Urine specific gravity

Bowel sounds

The nurse is caring for a client who had a thyroidectomy. Which of these assessments or labs should the nurse check? a. Potassium b. Heart rate c. Sodium d. Calcium

Calcium

A client had a transurethral prostatectomy for benign prostatic hypertrophy. He's currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the interventions should be done first? a. Administer a belladonna and opium suppository as ordered by the physician. b. Check for the presence of clots, and make sure the catheter is draining properly c. Stop the irrigation and call the physician d. Administer an oral analgesic

Check for the presence of clots, and make sure the catheter is draining properly

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? Check the drainage system for an air leak. Increase the suction to the drainage system until the bubbling stops. Continue to monitor the drainage system. Reposition the patient because the tubing is kinked.

Check the drainage system for an air leak.

A client presents to the clinic with dull abdominal pain that comes and goes. The pain is felt mostly when the stomach is empty. Diagnostic tests performed showed that the client has H-pylori. What treatment interventions should the nurse expect to educate the client on? Select all that apply. a. Checking stools b. Smoking cessation c. Medications such as amoxocillin, clarithromyci, metronidazole d. H2 blockers such as cimetidine e. Spicy foods

Checking stools Smoking cessation Medications such as amoxocillin, clarithromyci, metronidazole H2 blockers such as cimetidine

The nurse should teach the patient who is being radiated about protecting their skin and oral mucosa. An important teaching point would be to tell the patient to: Cleanse the skin with a mild soap, using fingertips, not a rough cloth Use approved emollient 2 hours before radiation to give skin time to absorb the medication and provide a shield for damage Apply a small ice compress to treat area afterward to decease localized redness, post radiation Use an ointment, after treatment, to decrease the feeling of burning, which may last for several hours

Cleanse the skin with a mild soap, using fingertips, not a rough cloth

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of BPH. a. Scrotal edema b. Decreased force in the stream of urine c. Nocturia d. Occasional constipation

Decreased force in the stream of urine

A patient with emphysema receives discharge instructions regarding home oxygen use via nasal cannula. Which of the following statements should the nurse include? Do not smoke or be around others who do smoke Adjust the flow rate to comfort during meals Replace nasal cannula weekly Inhale through the mouth, exhale through the nose

Do not smoke or be around others who do smoke

You are assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? Document as normal finding Assess for an air leak due to bubbling noted in the suction chamber. Notify the physician about the drainage. Milk the tubing to ensure patency of the tubes.

Document as normal finding

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) a. Anorexia b. Dyspnea c. Sharp inspiratory chest pain d. Extreme fatigue e. Dizziness

Dyspnea Dizziness Extreme fatigue

A nurse is providing patient teaching to a client who underwent bariatric weight loss surgery. What points should the nurse include? Select all that apply. a. Rest or lie down for 15 minutes after a meal b. Eat six small meals daily to avoid overloading the stomach. c. Limit fluids to 4 oz (1/2 cup) during mealtimes. d. Chew well before swallowing. e. Eat sweets and sugars as advised

Eat six small meals daily to avoid overloading the stomach. Limit fluids to 4 oz (1/2 cup) during mealtimes. Chew well before swallowing.

The nurse is reviewing a client's record and notes that the HCP has documented an onset of acute kidney injury. On review the nurse would most likely to note which findings. Select all that apply a. Decreased red blood cell count b. Elevated Creatinine c. Elevated BUN d. Decreased specific gravity e. Decreased hemoglobin level

Elevated Creatinine Elevated BUN Decreased specific gravity

What clinical findings do you expect in a patient with liver cirrhosis? Select all that apply. a. High bilirubin b. Low Albumin c. Decreased potassium d. Decreased liver enzymes e. Increased Prothrombin Time (PT)

High bilirubin Low Albumin Increased Prothrombin Time

client is diagnosed with hypothyroidism. What clinical manifestations should the nurse expect? Select all that apply. a. Extreme fatigue b. Hair loss c. Hoarseness of voice d. High libido e. High cholesterol levels

High cholesterol levels Extreme fatigue Hair loss Hoarseness of voice

A client is suspected to have Cushing Syndrome. What clinical manifestations are consistent with the disease? a. Increase urine output b. High glucose c. Obesity d. High potassium e. High sodium

High glucose Obesity High sodium

A client presents with Addison's disease. Which clinical manifestations are consistent with the disease? a. High potassium b. High Blood pressure c. Low Sodium d. High calcium e. Low cortisol

High potassium High calcium Low Cortisol Low Sodium

A nurse is teaching a client about the risks for cancer. Which of the following client statements indicates the need for further teaching? I will use sunscreen when laying out in the sun? I take Milk of Magnesia for occasional constipation? I see a dermatologist regularly for the mole on my thigh? I used to smoke but switched to chewing tobacco 3 years ago?

I used to smoke but switched to chewing tobacco 3 years ago?

A client presents to the Emergency Department with potassium 6.5. What will the nurse anticipate the patient to be prescribed to lower potassium? a. IV insulin and glucose b. Lactulose c. Levothyroxin d. Calcium gluconate

IV insulin and glucose The rationale is based on the theory that exogenous glucose stimulates insulin secretion which shifts potassium into the cell.

A patient is admitted back to the floor following surgery. The student nurse working on the unit knows that which of the following interventions should be implemented to prevent atelectasis? Select all that apply. Range of Motion (ROM) exercises in bed Around-the-clock spO2 monitoring Incentive Spirometry hourly Administering an inhaled corticosteroid Ambulating the patient within 24 hours after surgery

Incentive Spirometry hourly Ambulating the patient within 24 hours after surgery

The nurse is preparing a 65 years old woman with body mass index (BMI) of 38.5 for knee surgery. The nurse knows that based on the patient's age and BMI that the patient is at a high risk for what complication postop? a. Hyperglycemia b. Infection c. Azotemia d. Falls

Infection

A client is experiencing hyperkalemia due to Addison's Disease. What clinical manifestations should the nurse expect? Select all that apply Irregular heartbeat Shortness of breath Muscle weakness Increased appetite

Irregular heartbeat Shortness of breath Muscle weakness

After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output? a. It's a normal finding associated with the client's nothing-by-mouth status. b. It's a normal finding caused by blood loss during surgery. c. It's an abnormal finding that will correct itself when the client ambulates. d. It's an abnormal finding that requires further assessment.

It's an abnormal finding that requires further assessment.

The nurse is giving patient education to clients with GERD. What points should the nurse include in the teaching? Select all that apply. a. Eat large meals at lunch b. Low fat diet c. Avoid eating 2 hours before bed time d. Start esomeprazole as prescribed e. Smoking cessation

Low fat diet Avoid eating 2 hours before bed time Start esomeprazole as prescribed Smoking cessation

A nurse is caring for a client with hypothyroidism. What assessment findings will the nurse expect? Select all that apply. a. Low heart rate b. Low body temperature c. Hyperactivity d. Increase in weight e. Feelings of cold

Low heart rate Low body temperature Increase in weight Feelings of cold

A client was diagnosed with primary Aldosteronism CONN'S. What clinical manifestations are consistent with the disease? Select all that apply. a. Low potassium b. Hyperglycemia c. Low sodium d. Increase activity tolerance e. High blood pressure

Low potassium Hyperglycemia High blood pressure

A nurse administers oxygen at 6 L/min via face mask to a client with COPD. Which clinical indicators should the nurse closely observe in the client? Increased respirations Hypertension Cyanosis Mental confusion

Mental confusion

A nurse is teaching nursing students about hyperthyroidism. What clinical manifestations should the nurse emphasize? Select all that apply. a. Nervousness b. Increase heart rate c. Decrease appetite d. Exophthalmos e. Poor heat tolerance

Nervousness Increase heart rate Exophthalmos Poor heat tolerance

A college athlete comes to the emergency room after having an acute asthma attack during a game. The nurse conducts an assessment and finds the respiratory rate is 38 breaths /minute, bilateral wheezes heard on auscultation, and the athlete appears to be having difficulty breathing. Which of the actions should be done first by the nurse? a. Obtain an order for a bronchodilator to be given by nebulizer b. Apply a cardiac monitor to the patient c. Provide emotional support to the patient d. Take a complete health history

Obtain an order for a bronchodilator to be given by nebulizer

A 76 years old client presented with difficulty breathing. The nurse assesses the client and findings show that the client has a temperature of 102.2 F (39 C), blood pressure 98/66 mm Hg, pulse 115/min, and respirations 30/min. Assessment also reveals crackles in the right lower lobe, dusky nail beds, and dry mucus membranes. The client is suspected to have pneumonia. What should the nurse do first? a. Teaching incentive spirometer use b. Normal saline (NS) solution at 125 mL/hr. c. Blood cultures x2 for temperature > 102F (38.9C) d. Oxygen per nasal cannula 4L/min

Oxygen per nasal cannula 4L/min

Which of the following are NOT typical signs/symptoms of right-sided heart failure? Select all that apply. a. Persistent cough b. Orthopnea c. Weight gain d. Nocturia e. Jugular venous distention f. Crackles

Persistent cough Orthopnea Crackles

Which of the following signs and symptoms are suggestive of Diabetes Mellitus? Select all that apply. a. Polydipsia b. Polyuria c. Weighloss d. Loss of appetite e. Sudden vision loss

Polydipsia Polyuria Weighloss Sudden vision loss

A client was brought to the emergency room after sustaining a crushed injury. What electrolyte is most at risk to be abnormal as a result of the crush injury? Potassium Calcium Sodium Phosphorus

Potassium

A 27-year-old male patient was admitted with severe left flank pain. After a confirmation of a renal calculi, what would be the most appropriate nursing interventions. Select all that apply. a. Promote increased fluid intake b. Position patient in Trendelenburg position. c. Administer a low-fat diet. d. Strain all urine output e. Administer prescribed analgesics

Promote increased fluid intake Strain all urine output Administer prescribed analgesics

A 92 years old client underwent a major cardiac surgery. On the first day post surgery, what is an important nursing intervention to prevent a postoperative complication? a. Massage the client's legs. b. Assist the client to sit up in bed after surgery. c. Maintain the legs in a dependent position. d. Remind the client to exercise the legs and feet.

Remind the client to exercise the legs and feet.

A nurse is caring for a client diagnosed with breast cancer The client is scheduled for radiation therapy to the breast. Which of the following should the nurse teach the client to expected. Select all that apply a. Administer stool softeners and fluids b. Reporting of fatigue and nausea c. Breast tenderness and swelling d. Wash the area with soap and hot water e. Dry mouth and taste changes

Reporting of fatigue and nausea Breast tenderness and swelling

A patient presents with shortness of breath, non-pitting edema of lower extremities, and distended neck veins. Past medical history includes hyperlipidemia and asthma. What are appropriate nursing actions? Select all the apply. a. Assess medication regimen for asthma b. Restrict fluid and sodium c. Administer Oxygen d. Check peripheral pulses e. Administer Nitroglycerine

Restrict fluid and sodium Administer Oxygen Check peripheral pulses

Which ECG finding is most indicative of severe myocardial infarction? a. ST segment elevation b. Long QT interval c. PR interval elevation d. Peaked P wave

ST segment elevation

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply a. Deep sleep b. Sexual intercourse c. Cold exposure d. Cigarette smoking e. Amphetamine use

Sexual intercourse Cold exposure Cigarette smoking Amphetamine use

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding? a. Sinus bradycardia with premature ventricular contractions (PVCs) b. Sinus rhythm with premature atrial contractions (PACs) c. Normal sinus rhythm d. Sinus tachycardia

Sinus rhythm with premature atrial contractions (PACs)

The nurse recognizes the importance of "Time Out." What is the purpose of "Time Out" during surgery? As a signal for the scrub nurse or certified scrub technician to perform and instrument and sponge count So, all members of the OR team participate in the positive identification of the client, identify the correct site, and identify the planned procedure So, the anesthesiologist can wake up the client and confirm that the correct procedure is being done on the correct person To allow the operating room (OR) team time to scrub and gown

So, all members of the OR team participate in the positive identification of the client, identify the correct site, and identify the planned procedure

A patient with DM type 1 presents to the ER with lethargy. Upon assessment, glucose level is 650 mg/dl. What should the nurse expect to do? Select all that apply. a. Give Humilin N IV drip b. Start IV line c. Electrocardiogram d. Start IV hydration with 0.45%NS e. Give K 20 meq

Start IV line Electrocardiogram Start IV hydration with 0.45%NS Give K 20 meq A blood sugar level less than 140 mg/dL is normal. A reading of more than 200 after two hours indicates diabetes. A reading between 140 and 199 indicates prediabetes

A 45-years old man was diagnosed with Diabetes Mellitus type 2. He is also known to be obese and hypertensive and controlled on medication. What patient teaching should the nurse prioritize? a. Blood pressure control b. Foot care c. Self injection d. Weight management

Weight management

The nurse is teaching clients about decreasing the risks of COPD. What behaviors should the nurse emphasize? Abstain from cigarette smoking Avoid exposure to respiratory infections Participate regularly in aerobic exercises Maintain a high-protein diet

Abstain from cigarette smoking

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates Muscle rigidity Hypocapnia. Decreased body temperature. Confusion upon arousal from anesthesia.

Muscle rigidity

After teaching a patient with chronic angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? a. "I can take up to five tablets every 3 minutes for relief of my chest pain" b. "I will take acetaminophen(Tylenol) to treat the headache caused by nitroglycerine" c. "I will take nitroglycerin 10 minutes before planned activities that usually causes chest pain" d. "I will replace my nitroglycerin supply every six months"

"I can take up to five tablets every 3 minutes for relief of my chest pain"

The nurse is teaching the client with type 1 diabetes to take NPH insulin at 9 p.m. each day. What time will he be at the greatest risk of developing hypoglycemia? a. 2 pm b. 12 am c. 2 am d. 9 pm

2 am

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is MOST important at this time? a. Apply warm compress to the flank area b. Administer meperidine every 3 hours c. Report hematuria to the healthcare provider d. Strain the urine carefully

Strain the urine carefully

Which of these assessment findings are suggestive of Diabetes Mellitus? Select all that apply. a. Fasting plasma glucose of 425 mg/dl b. Potassium of 6.0 c. A random plasma glucose of 178 mg/dl d. HbA1C of 9.7%

Fasting plasma glucose of 425 mg/dl HbA1C of 9.7%

Which of the following interventions are expected to be prescribed to a client with severe liver cirrhosis? Select all that apply. a. H2 antagonist b. Spirinolactone c. Vitamin K d. Acetaminophen e. Lactulose

H2 antagonist Spirinolactone Vitamin K Lactulose

A client known to have diabetes calls the clinic and talks to the nurse to share that the hemoglucotest taken at home measures 80 mg/dl. The client reports being lightheaded, sleepy, weak, and not feeling well. What should the nurse suggest to the client as the best plan of care? Select all that apply. a. 1/2 cup of fresh fruit juice b. 3 chocolate bars c. 1 cup nonfat milk d. Half banana

Half banana 1/2 cup of fresh fruit juice 1 cup nonfat milk

A nurse is completing the admission assessment of a client who has a kidney stone. Select all that the nurse would expect to find. a. Tachycardia b. CVA tenderness/pain c. Bradypnea d. Hematuria e. Polyuria

Hematuria CVA tenderness/pain Tachycardia

Which of the following nursing actions is most important in caring for the client following lithotripsy? a. Notify the physician of hematuria. b. Administer allopurinol (Zyloprim). c. Strain the urine carefully for stone fragments. d. Monitor the continuous bladder irrigation.

Strain the urine carefully for stone fragments.

Which nursing assessment data support that the client has experienced a pulmonary embolism? Calf pain with dorsiflexion of the foot. Sudden onset of chest pain and dyspnea Left-sided chest pain and diaphoresis Bilateral crackles and low-grade fever.

Sudden onset of chest pain and dyspnea

An older adult client has been diagnosed with chronic obstructive pulmonary disease (COPD). What characteristic of the client's current health status would prevent the safe and effective use of a metered-dose inhaler (MDI)? The client has cataracts The client has not yet quit smoking The client requires both corticosteroids and beta2-agonists The client has severe arthritis in her hands

The client has severe arthritis in her hands Safe and effective MDI use requires the patient to be able to manipulate the device independently, which may be difficult if the patient has arthritis. Smoking does not preclude MDI use. A modest loss of vision does not preclude the use of an MDI and a patient can safely use more than one MDI.

After receiving change of shift report in the coronary care unit, which client should you assess first? a. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 b. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled. c. The client with acute coronary syndrome who has a 3 pounds weight gain and dyspnea d. A client who has first degree heart block ,rate 68, after having an inferior myocardial infarction.

The client with acute coronary syndrome who has a 3 pounds weight gain and dyspnea

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? Urinary output of 20 mL/hour Temperature of 37.6 degrees Celsius (99.6° F) Blood pressure of 100/70 mm Hg Serous drainage on the dressing

Urinary output of 20 mL/hour

A client was diagnosed with diabetes insipidus after head injury. What clinical manifestations should the nurse expect? Select all that apply. a. Urine output 300 ml.hr b. dehydration c. High serum sodium levels d. Low serum sodium levels e. Low ADH

Urine output 300 ml.hr Dehydration High serum sodium levels Low ADH

What medication would you expect to be prescribed for a client with prolonged prothrombin time (PT) due to liver cirrhosis? a. Atenolol b. Vitamin K c. Kayexalate d. Insulin

Vitamin K