Theory Final

A client is being discharged from the emergency department (ED) after being treated for an anaphylactic reaction to shrimp the client ate for dinner. The client asks the nurse to explain food reactions. Which would be correct responses? Select all that apply.

Anaphylactic reactions involve an antibody that causes the release of histamine. Histamines produce immediate reactions. Anaphylactic reactions can lead to respiratory distress and even respiratory arrest.

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What assessment is the best indicator of the client's oxygenation status

Arterial blood gasses (ABGs)

A client is hospitalized with sickle cell anemia and the nurse is preparing a teaching plan to review with the client and the client's family. Which interventions should be included? Select all that apply.

Dress warmly in cold temperatures. Never exceed the recommended dosages of analgesics. During a sickle cell crisis, fluids are to be restricted.

A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?

Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Hypocalcemia

An elderly patient has come in to the clinic for her twice-yearly physical. The patient tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest?

Increase daily intake of water.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling ad reporting that the crisis is over. The client says to the nurse, "I am finally cured. " How should the nurse interpret his behavior as a cue to modify the treatment plan?

Increasing the level of suicide precautions

The nurse cares for several clients with hematological conditions. Which assessment needs will the nurse prioritize for the client with aplastic anemia? Select all that apply.

Infection Bleeding

A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond?

Let's explore other options, because laxatives can have side effects and create dependency.

A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?

Nausea and vomiting

A patient's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation?

Neutrophils

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

Osmosis and osmolality

The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that which risk factors and cardiovascular problems are related to hypertension? Select all that apply.

Overweight/obesity Smoking Age greater than 65 in women

A 3-year-old client is admitted to the pediatric unit with pneumonia. The child has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the child has not been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should the nurse include in the care plan? Select all that apply.

Perform chest physiotherapy as ordered. Perform postural drainage. Maintain humidification with a cool mist humidifier. Encourage coughing and deep breathing.

A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function

Perfusion

A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem?

Renal failure

A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize?

Rising slowly from a lying or sitting position

The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply.

Safe exercise Assistive devices Medication dosages and side effects

The nurse's review of a patient's most recent blood work reveals a significant increase in the number of band cells (immature necrophils) . The nurse's subsequent assessment should focus on which of the following?

Signs and symptoms of infection

An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer?

Stage 4

You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patient's labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults?

Substantially reduced renal function

In children, high doses of nebulized albuterol have been associated with what conditions? (Select all that apply.)

Tachycardia Hypokalemia Hyperglycemia (In children, high doses of nebulized albuterol have been associated with tachycardia, hypokalemia, and hyperglycemia. Lowered or elevated blood pressure is not a usual issue with high doses of nebulized albuterol in children.)

A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patient's coping after discharge?

The family's ability to provide emotional support

Aerosols are often the drugs of choice to treat asthma because of what characteristics? (Select all that apply.)

They produce fewer adverse effects than oral or parenteral drugs. They act directly on the airways. They can usually be given in smaller doses. They relieve symptoms quickly.

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide?

To promote optimal lung expansion

Autism spectrum disorder is characterized by: Wide variation in behavior and sensory needs Different Social/Communication Skills Stereotyped Behavior

True

A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply.

administering diuretics enhancing patient positioning implementing fluid restrictions

A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?

tofu

A patient is receiving bumetanide (loop diuretic). The nurse would instruct the patient to be alert for what issues? (Select all that apply.)

weakness muscle cramps hypotension dizziness

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?

Baseline arterial blood gas (ABG) levels

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.

Destruction of normally formed red blood cells Abnormal erythrocyte production Blood loss

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health?

Fluid volume status

What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply.

abdominal distention sudden, sustained abdominal pain

The client has been diagnosied with Parkinson's disease and has been prescribed levodopa. What should the nurse include in the care plan? Select all that apply.

auscultate the client's bowel sounds once per shift monitor the client's urine output each shift monitor the client's vital signs each shift monitor the client's creatinine clearance whenever available

In anticipation of a patient's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient?

The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period.

The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?

The patient's airway patency

Naloxone 2 mg IM has been ordered for a post surgical client. The pharmacy has sent to the floor naloxone 1 mg/mL. How many mls of naloxone will the client receive?

2

Which disorder would alter the ability to move gases in and out of the lungs? (Select all that apply.)

Atelectasis Respiratory distress syndrome Bronchitis Cystic fibrosis

patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?

Avoid drinking alcohol while taking the drug.

A diabetes nurse educator is teaching a group of patients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic patient?

Do not eliminate insulin when nauseated and vomiting.

The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding?

This is an accurate indicator of myocardial injury

Risk of having a baby with Down syndrome increases as a woman ages

True

A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply.

Wheezing Chest tightness Cough

A depressed client on an inpatient unit says to the nurse: "My family would be better off without me." Which is the nurse's best response?

You sound very upset. Are you thinking of hurting yourself?

A 53-year-old man is receiving cyclosporine in order to prevent rejection of a transplanted kidney. The nurse should prioritize assessments related to:

infection

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?

Help distinguish reduced renal blood flow from decreased renal function

Which symptoms are indicators that the client is having an anaphylactic reaction? (Select all that apply.)

Hives Panicked feeling Difficulty breathing

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

Hypovolemia

A client is admitted with a recent history of sever anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to he nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply:

I might have died over a few dollars in my pocket. I see his face everywhere I go. I keep reliving the robbery.

You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers?

Post a turning schedule at the patient's bedside and ensure staff adherence.

A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following?

Reducing the heart's workload by decreasing heart rate and myocardial contraction

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Respiratory alkalosis

The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best response?

"An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks."

A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?

"Eliminating bothersome foods will help."

An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinson's disease. Which of the wife's descriptions of her husband's health and function is most suggestive of Parkinson's disease?

"Lately he seems to move far more slowly than he ever has in the past."

A client tells the nurse that the client recently started on SSRIs for the treatment of depression. The client asks if there are any side effects to the SSRIs. The nurse should inform the client to watch for the following adverse effects:

A high incidence of nausea, diarrhea, and weight loss, as well as anxiety, nervousness, and insomnia.

The nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. The nurse is aware that afterload influences a patient's stroke volume. The nurse recognizes that afterload is increased when there is what?

Arterial vasoconstriction

Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patient's orders specify an initial bolus dose. What is your priority assessment?

Assessment for respiratory depression

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply.

Atelectasis Pneumonia Metabolic imbalances

A patient with hypertension is waking up several times a night to urinate. The nurse knows that what laboratory studies may indicate pathologic changes in the kidneys due to the hypertension? (Select all that apply.)

Blood urea nitrogen (BUN) Creatinine

The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?

Diffusion

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems?

Diminished deep tendon reflexes

A nurse is caring for a patient who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.)

Encouraging the patient to care for the residual limb. Introducing the patient to local amputee support groups. Allowing the expression of grief

A 27-year-old athlete with newly diagnosed asthma presents for patient education regarding situations that could precipitate an asthma attack. The nurse teaches that acute episodes of asthma may last minutes to hours. In this teaching, which precipitants would the nurse state may cause the asthma? (Select all that apply.)

Exercise Allergens Pollutants

The nurse is caring for a patient with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine." What principle should guide the nurse's response to the colleague

Immunodeficient patients will usually exhibit subtle and atypical signs of infection.

A nurse is caring for a client with COPD. The client's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. Therapeutic effects of this medication would include which of the following? Select all that apply.

Increased expiratory flow rate Relief of dyspnea

The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?

Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patient's medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?

Infection

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding?

Insulin levels are inadequate (Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the patient's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.)

A male client's physician orders levodopa for the treatment of the client's Parkinson's disease. The client asks the nurse whether the levodopa will cure his condition. Which is a correct statement about the effects of levodopa?

It does not alter the underlying disease process, but it may improve a client's quality of life.

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient?

MS is a progressive demyelinating disease of the nervous system.

The nurse is preparing to admit a 6 year old child diagnosed with autism spectrum disorder. Prior to meeting the patient, the nurse plans to incorporate which elements into the care of this child? Select all that apply.

Maintaining a quiet environment Adhering to the patient's familiar routines Placing the patient in a private room Asking the parents about the patient's preferences

The emergency-room nurse is caring for a trauma client with the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results?

Metabolic acidosis with a compensatory respiratory alkalosis

A client with asthma should always carry a rescue inhaler or quick-relief medication with them at all times. Which of the following are considered quick-relief medications? Select all that apply:

Metaproterenol Albuterol

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do first to assess her fluid balance in the home setting?

Monitor her weight daily

The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs

Nasal cannula

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?

Notify the physician and continue to monitor the hourly urine output closely.

A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?

Obstructive sleep apnea

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply.

Overinflated alveoli that impair gas exchange Inflamed airways that obstruct airflow Mucus secretions that block airways

The nurse is caring for a cognitively impaired child and is aware that children with impaired cognition are less capable of managing environmental challenges. What related risk does the nurse anticipate for this child?

Physical injuries

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?

Resting in an air-conditioned room whenever possible

A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, "A client in renal failure partially loses the ability to regulate changes in pH." What is the cause of this partial inability?

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

The nurse is caring for an acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?

The patient's average urine output has been 10 mL/hr for several hours.

A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what most potential adverse effects?

Throbbing headache or dizzines

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics?

Watery with blood and mucus

A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications? Select all that apply.

decreased protein intake fluid restriction vitamin D supplementation decreased sodium intake

A client comes to the clinic and informs the nurse that he believes he is suffering from Parkinson disease. What objective data assessed by the nurse would correlate with the client's concern? Select all that apply.

tremors bradykinesia rigidity

The nurse is caring for a client who has just returned to the postsurgical unit following renal surgery. When assessing the client's output from surgical drains, the nurse should assess what parameters? Select all that apply.

visible characteristics of the output color quantity odor

The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what?

wash hands carefully and requently

A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patient's medication regimen?

Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

A client's physician has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.

GGT AST ALT

A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply.

glucose metabolism ammonia conversion protein metabolism