UCONN CEIN NURS 4304 Practice
A 75-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. An emergency room nurse is obtaining assessment data from this patient. What assessment finding is characteristic of a small bowel obstruction?
- Nausea and vomiting
The nurse has paged a hospital patient's primary care provider because the patient's urine output over the past 12 hours is approximately 140 mL. The nurse would recognize that this patient is experiencing what health problem?
- Oliguria
A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mmHg, HCO3 = 24 mmHg. What does the ABG reflect?
- Respiratory acidosis
A client with a longstanding diagnosis of generalized anxiety disorders 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 assessing the client for the presence of Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate?
- hypocalcemia
You know your patient with heart failure understands how to weigh himself appropriately, when he states:
-- "I weigh myself every morning at the same time, wearing the same thing, after I use the bathroom."
A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching?
-- "I will keep the toilet paper in the specimen."
A 70-year-old woman with a complex medical history made an appointment with her primary care provider because she has recently been experiencing heartburn, abdominal pain, and nausea. The clinician has identified that the woman's symptoms are characteristic of acute gastritis. Which of the woman's following statements is suggestive of the etiology of her problem?
-- "I've changed from taking Tylenol for my arthritis pain to taking asprin."
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?
-- "It is inserted into the space between the lining of the lungs and the ribs."
A patient with a recent history of hematologic abnormalities has been scheduled for a bone marrow biopsy. The patient has expressed to the nurse, "That sounds like an incredibly painful experience." How should the nurse best respond to this patient's concern?
-- "There is some pressure and pain when the doctor removes the marrow, but this should only be short-lasting."
A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity tolerance?
-- "What daily activities were you able to do 6 months ago compared to the present?"
A nurse has provided education for a patient newly diagnosed with hypertension who is just beginning therapy with antihypertensive medications. Which statement by the patient indicates a need for further teaching?
-- "When my symptoms subside, I may discontinue the medications."
A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the need to tell the client?
-- "When you increase fiber in your diet, you also need to increase liquids."
Which of the following individuals would be likely to require administration of exogenous erythropoietin?
-- A man with a diagnosis of acute renal failure secondary to type 1 diabetes.
A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?
-- Anxiety
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal healthy stoma?
-- Dark pink/red and moist
A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?
-- Decreased bladder contractility may lead to urine retention and stasis, which increases the likelihood of urinary tract infection.
A 66-year-old man underwent a successful partial gastrectomy for the treatment for stomach cancer 3 years ago. At a follow-up appointment he complains of numbness in his lower extremities and his blood work indicated anemia. The nurse who is contributing to the patient's care should recognize that this patient's anemia may be attributed to what factor?
-- Decreased vitamin B-12 absorption
The client nurse is teaching a young woman about preventing recurrent urinary tract infections. What information should the nurse include?
-- Drink liberal amounts of fluid
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate?
-- Encourage the patient to sit up at the bedside in a chair and lean slightly forward.
Which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure?
-- How to take and record daily weight -- How to read dietary labels for sodium content -- Symptoms indicating worsening heart failure -- Actions and side effects of prescribed medications
The nurse is planning and providing the care of a patient with heart failure (HF). What will be the overall goals of management for this patient?
-- Improve functional status -- Relieve patient symptoms -- Extend Survival
A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach?
-- Increase oral intake of fluids to two to three quarts per day.
The nurse recognizes that an older adult patient with heart failure is experiencing the effects of inadequate cardiac output, a problem that affects many of the body systems. Inadequate perfusion of the patient's kidneys leads to which of the following pathophysiological effects?
-- Increased renin release
A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?
-- Initiate interventions to help relieve the symptoms.
A client with chronic obstructive pulmonary disease (COPD) on oxygen therapy is experiencing increased dyspnea which interferes with the resident's ability to eat, and the nurse recognizes the potential nursing diagnosis of altered nutrition: less than body requirements. How can the nurse best foster the resident's nutritional status?
-- Order small frequent meals and nutritional supplements for the residents.
You only have one docusate (Colace) tablet. Which patient needs it most?
-- Patient recovering from myocardial infarction.
A 44-year-old man with longstanding diagnosis of AIDS has been admitted to the hospital with an absolute neutrophil count (ANC) of 385/mm3. When planning the patient's care, what action should the nurse prioritize?
-- Placing the patient on protective isolation precautions
Clostridium difficile infection has been moving through an extended-care facility, and several of the elderly residents have been experiencing severe diarrhea. One particularly sick resident has told the nurse that he is now experiencing extreme fatigue and muscle cramps and that his heart feels like it occasionally "skips a beat." The nurse should facilitate a stat assessment of the resident's:
-- Potassium levels
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
-- Prolonged expiration to reduce airway resistance.
The nurse is working with a patient who has uncontrolled hypertension. The patient asks the nurse what can happen if his blood pressure is not brought under control. What are potential consequences of uncontrolled hypertension?
-- Retinal hemorrhage -- Renal failure -- Stroke
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with hypertensive emergency. Which finding is most important to report to the health care provider?
-- The patient cannot move the left arm and leg when asked to do so.
A patient's white blood cell (WBC) differential reveals a bandemia, which indicates a higher-than-normal proportion of band cells. What should the nurse infer from this assessment finding?
-- The patient is currently fighting an infection
Thrombolytic therapy is being prepared for administration to an older adult patient who has presented to the emergency department with ST-segment elevation MI (STEMI). The nurse recognizes that the primary goal of this intervention is:
-- To restore the flow of blood through the coronary arteries
A 60-year-old woman has been brought to the emergency department (ED) by ambulance after she experienced a sudden onset of dyspnea and phoned 911. The woman is obese but claims an unremarkable medical history and denies chest pain. When assessing this patient, the nurse in the ED should be aware that:
-- Women often present with an MI much differently than do men.
Which is the FIRST intervention for the nurse to implement for a client experiencing crushing substernal chest pain?
-- administer oxygen
A nurse is caring for a 73-year-old male patient with a urethral obstruction related to prostatic enlargement. The nurse is aware this may result in what?
--A urinary tract infection (UTI)
A patient with a new ileostomy is preparing to go home. What should the patient be taught about changing his ileostomy?
--Apply a skin barrier to the peristomal skin prior to applying the pouch.
A 69-year old man has been experiencing progressive dyspnea and activity intolerance in recent months and is currently undergoing a diagnostic workup for heart failure (HF). During echocardiography, systolic HF could be differentiated from diastolic HF by appraising the patient's:
--Ejection fraction (EF)
During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify?
--Perceived constipation
The nurse is planning the care of complex elderly patient who has been admitted to the medical ward for the treatment of an infection. The patient has a longstanding history of chronic obstructive pulmonary disease (COPD). What assessment finding would most clearly indicate the need for oxygen therapy?
--Sa02 of 86% on room air
The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (AHD)?
Answer = increased serum sodium
A child who ingested a handful of aspirin tablets from a medicine cabinet at home is brought to the ER. The nurse caring for the child notes a respiratory rate of 48 breaths per minute. The nurse understands that this child's respiratory rate is the result of the body's attempt to compensate for:
Answer = metabolic acidosis
A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the clients PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious when administering oxygen?
Answer = using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia
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:
Answer: - Alanine aminotransferase (ALT) - Gamma-glutamyl transferase (GGT) - Aspartate aminotransferase (AST)
During an assessment of a client's self-esteem, a man age 45 years tells the nurse that he lost his job due to downsizing and has been unemployed for six months. What would be the appropriate response from the nurse?
Answer: "How has losing your job affected your life and the lives of your significant others?"
What might a nurse ask during a health history to assess personal identity?
Answer: "How would you describe yourself to others?"
Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis?
Answer: Albumin level
To obtain subjective data about a burn client's self-concept, the nurse should do what?
Answer: Ask the client how she would describe herself.
A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
Answer: Asterixis
Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
Answer: Avoiding alcohol ingestion
A nurse caring for critically ill clients uses interventions to help clients maintain a sense of self. Which of the following are recommended interventions?
Answer: Converse with the client about his or her life experience.
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
Answer: Fewer episodes of bleeding varices
One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribed a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal?
Answer: Help distinguish reduced renal blood flow from decreased renal function
A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of the client's presentation?
Answer: How many alcoholic drinks do you typically consume in a week?
A nurse is caring for a client with liver failure and is performing an assessment in the knowledge of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor mist likely contributes to this loss of function?
Answer: Inability of the liver to use vitamin K.
For a patient with cirrhosis, which nursing action can the registered nurse delegate to unlicenesed assistive personnel (UAP)?
Answer: Providing oral hygiene after a meal.
The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
Answer: Shallow respirations
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices?
Answer: The medication will prevent irritation of the enlarged veins.
The nurse is caring for a man client, age 47 years, who suffers from myasthenia gravis. He has periods of great weakness and is unable to do the things for his family that he would like to. He tells the nurse that he is not worth much these days. Knowing that sometimes clients focus on things they cannot do, which of the following statements by the nurse might be helpful?
Answer: What are some of the things you do well?
To prepare a patient with ascites for paracentesis, the nurse:
Answer: asks the patient to empty the bladder
A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patients most recent blood work indicates a K+ level of 2.7 mEq/L. The potassium level should prompt the nurse to assess for which of the following physical manifestations?
Answer: fatigue, cramps, & weakness
A community health nurse is conducting a workshop for adults who have hypertension and is now teaching participants about reading food labels when they are shopping at the supermarket. What teaching point should this nurse prioritize?
-- "Take particular note of the amount of sodium that a serving contains."
The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She stats that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect?
- Hypocalcemia
The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance?
- Metabolic alkalosis
A specially trained nurse has inserted a PICC line. What would be done next?
- Send the client to the radiology department.
Of all factors, what is the most important risk factor in pulmonary disease?
-- Active and passive cigarette smoke
A 40-year-old man newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the rational behind that advice to the patient.
-- Smoking increases the risk of heart disease.
A 66 year-old male patient with high body mass index and a history of hypertension made an appointment with his primary care provider because of sudden, severe, and unprecedented fatigue over the past several days. The care provider referred the patient to the emergency department, where the patient underwent assessment for acute coronary syndrome. Assessment of the man's cardiac biomarkers revealed normal levels of myoglobin and CK-MB but elevated levels of troponin I. What conclusion is suggested by these data?
--The man had an MI in the recent past.
A 30-year-old woman has presented for care, stating " I'm pretty sure that I've got a UTI, so I think I'll need some antibiotics. " In the presence of a UTI, the nurse would expect the woman to have which of the following signs and symptoms?
--Urgency -- Urinary frequency --Pain on urination
A 45-year-old adult male patient is admitted to emergency after he developed unrelieved chest pain that was present for approximately 20 minutes before he presented to the emergency department. The patient has been subsequently diagnosed with a myocardial infarction (MI). To minimize cardiac damage, what health care provider's order will the nurse expect to see for this patient?
--Ya gurl MONA (Morphine, Oxygen, Nitro, and Aspirin)
A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding?
-Assist him to a standing position
A nurse measures a client's 24-hour fluid intake and documents the finding. To be an accurate indicator of fluid status, what must the nurse also do with the information?
Answer = compare the total intake and output of fluids for the 24 hours
You are working on a burn unit. One of your patients is exhibiting signs and symptoms of third spacing, which occurs when fluid moves out of the intravascular space but not into the intracellular space. Based upon this fluid shift, what would the nurse expect the patient to demonstrate?
Answer: hypovolemia
Which order for potassium (KCl) would the nurse question? [select all]
Answers: 1000 mL D5 0.9% NS with 80 mEq KCL IV @150 mL/hour potassium chloride 20 mEq, 5 tablets by mouth daily for a patient in diabetic ketoacidosis potassium chloride, 20 mEq rapid IV push
