301 Final Post and Pre Lecture Questions
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? a) Obtain ECG b) Assess all pulses c) Auscultate lung fields d) Obtain family history
a
A client is admitted to the emergency room with a respiratory rate of seven per min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm HG Saturation 80% Bicarbonate 28 mEq/L a)Respiratory acidosis b)Metabolic acidosis c)Metabolic alkalosis d)Respiratory alkalosis
a
A client is admitted to the unit with diabetic keto acidosis (DKA). Which insulin would the nurse expect to administer intravenously? a)Regular b)Lente c)Glargine d)NPH
a
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a)Yellow Sclera b)Black, tarry stools c)Light amber urine d)Circumoral Pallor
a
A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the patient? a)Infection typically occurs due to ingestion of contaminated food and water b)Most affected patients acquired the infection during international travel. c)Many people possess genetic factors causing a predisposition to H. pylori infection. d)The H. pylori microorganism is endemic in warm, moist climates.
a
A nurse is instructing a client newly diagnosed with Raynaud's disease about the prevention of the onset of symptoms. Which of the following client statements should indicate to the nurse the need for additional teaching? a) "I will take my medications at the first sign of an attack." b) "I will wear gloves when removing food from the freezer." c)"I will try to anticipate and avoid stressful situations when possible." d) "I will complete the smoking cessation program I started."
a
A nurse is suctioning a client's airway. Which nursing action will limit hypoxia? a)Apply suction only after catheter is inserted b)Lubricate the catheter with saline before insertion c)Use a sterile suction catheter for each suctioning episode d)Limit suctioning with catheter to half a minute
a
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? a)Throbbing headache or dizziness b) Paresthesia c) Blurred vision d) Tinnitus
a
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias? a)Serum potassium level b)Serum Calcium c)Serum Sodium d)Serum Chloride
a
An older male patient visits his primary care provider because of burning on urination and production of urine that he describes as "foul smelling." The health care provider should assess the patient for what factor that may put him at risk for a urinary tract infection (UTI)? a)BPH b)Sedentary Lifestyle c)High Purine Diet d)Recent use of broad spectrum antibiotics
a
Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a)140, 90 b)110, 60 c)130, 80 d)120, 70
a
The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine? a)Increases ability for glucose to get into the cell and lowers blood sugar b)Creates an overall feeling of well-being and lowers risk of depression c)Decreases risk of developing insulin resistance and hyperglycemia d)Decreases need for pancreas to produce more cells
a
The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications? a)Bleeding and perforation b)Gallbladder gangrene and hyperglycemia c)Acidosis and hypoglycemia d)Pain and peritonitis
a
The nurse is caring for a patient who is having chest pain associated with a myocardial infarction (MI). What medication should the nurse administer intravenously to reduce pain and anxiety? a)Morphine sulfate b)Meperidine hydrochloride c)Codeine Sulfate d)Hydromorphone hydrochloride
a
The patient has scleroderma and is experiencing hypertension. The nurse should know that this could be related to which renal problem? a)Chronic Glomerulonephrtits b)Good pasture syndrome c)calcium oxalate urinary calculi d)Obstructive uropathy
a
Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? a)Monitor the site for bleeding or hematoma. b)Normal activities of daily living can be resumed the first day post op c)Cleanse the site with disinfectants and dress the wound appropriately d)Refrain from sexual activity for one month
a
A nurse is obtaining informed consent for a client who is having a paracentesis. Which of the following are appropriate nursing actions? (Select all that apply.) a) Ensure the client understood the information about the procedure. b) Determine if the client is mentally capable of understanding the reason for the procedure c) Witness the client signing the informed consent form d) Explain to the client the purpose of having the procedure e) Inform the client of risks to having the procedure.
a, b, c,
The nurse is working on a busy respiratory unit. In caring for a variety of clients, the nurse must be knowledgeable of diagnostic studies. With which diagnostic studies would the nurse screen the client for an allergy to iodine? Select all that apply. a)Lung Scan b)Bronchoscopy c)CXR d)Pulmonary Angiography e)Pulmonary Function Test f)Fluroscopy
a, d, f
The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply. a)Swollen lymphoid follicles b)A temperature >100.4°F c)Red pharyngeal membranes d)White-purple exudates on the back of the throat e) A dry, nonproductive cough
a,b,c,d
The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply. a)Arterial occlusion b)Bleeding at the insertion site c) Abrupt closure of the coronary artery d)Retroperitoneal bleeding e)Venous insufficiency
a,b,c,d
The primary healthcare provider is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracentesis? Select all that apply. a)Encourage deep breaths b)Ensure a chest x-ray is performed after the procedure. c)Instruct the client to cough during the procedure. d)Observe for signs of pneumonia. e) Verify breath sounds.
a,b,e
A nurse is creating a plan of care for a client who has a tonic-clonic seizures disorder. Which of the following seizure precautions should the nurse implement? (Select all that apply.) a)Place the bed in the lowest position. b)Furnish restraints at the bedside. c)Keep an oxygen setup at the bedside. d)Elevate the side rails when in bed. e)Provide a suction setup at the bedside.
a,c,d,e
A 52-year-old female patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? a)Cough, diarrhea, headaches, blurred vision, muscle fatigue b)Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea c)Night sweats, fatigue, fever, and persistent generalized lymphadenopathy d)Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes
b
A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA? a)Administer prescribed dose of insulin b)Begin fluid replacements c)Give prescribed antiemetics d)Administer bicarbonate to correct acidosis.
b
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? a)Keeping the door to the client's room open to observe the client b)Putting on an individually fitted mask when entering the client's room c)Instructing the client to wear a mask at all times d)Wearing a gown and gloves when providing direct care
b
A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately? a)Hematocrit 42% b)White blood cell (WBC) count 22.8/mm3 c)Serum sodium 135 mEq/L d)Serum potassium 4.2 mEq/L
b
A nurse is caring for a client admitted to the hospital with a diagnosis of myasthenia gravis. The nurse should observe the client for a) Increased intracranial pressure b)Respiratory Difficulty c)Confusion and disorientation d)Increased urine output
b
A nurse is caring for a client who has just undergone insertion of chest tubes. Which of the following is an appropriate nursing action? a)Coil the tubes carefully to prevent kinking. b)Keep the collection device below chest level. c)Keep the client flat to avoid leaks in the tubing. d)Clamp the tube when the client is ambulating.
b
A nurse is caring for a client who is hospitalized with deep vein thrombosis and has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate nursing response? a)"The IV heparin increases the effects of the Coumadin and decreases the length of your hospital stay." b) "The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therapeutic level." c) "I will call the provider to get a prescription for discontinuing the IV heparin today." d) "Both heparin and Coumadin work together to dissolve the clots."
b
A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's procedural consent forms. By signing as a witness, the nurse is verifying that a) the provider informed the client about the risks and benefits of the procedure. b) it was the client who signed the consent form. c) the client understands the risks and benefits of the procedure. d) the client has no unanswered questions about the procedure.
b
A nurse is caring for a client who was admitted to the hospital after having two seizures at work. The client suddenly gives a short cry and stiffens. Which of the following should be the initial nursing action? a)Administer an IV anticonvulsant. b)Make a mental notation of the time after looking at a watch. c)Turn the client's head to the side. d)Loosen the clothing around the client's neck.
b
A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following symptoms is typically the initial reason clients with PAD seek medical attention? Rubor Intermittent claudication Foot ulcers Rest pain
b
A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patient's diet? a)Carbohydrates b)Protein c)Calories d)Fat
b
An older adult client with a history of myocardial infarction (MI) comes to the emergency department reporting bilateral calf pain. He states that it started 2 weeks ago when he began a more advanced stretching and exercise regimen. The client also states that he has been having indigestion for the past 24 hr. Which of the following is the nurse's priority action? a)Checking the client's calves for redness and warmth b)Obtaining an ECG for the client c)Applying warm, moist wraps to the client's lower legs d)Further questioning the client about his indigestion
b
Perforation of the appendix generally occurs within which timeframe of the onset of pain if no intervention is done? a) 12 hours b)24 hours c)48 hours d)36 hours
b
The nurse is caring for a 73-year-old man patient with a history of benign prostatic hyperplasia and symptoms of a possible urinary tract infection. Which diagnostic finding would support this diagnosis? a)Glucose, protein, and ketones are present in the urine. b)Nitrites and leukocyte esterase are present in the urine. c)Antistreptolysin-O (ASO) titer is 106 Todd units/mL. d)White blood cell count is 7500 cells/µL.
b
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes a) Vasodilation b)Vasospasm c) Slowed Heart Rate d)Diuresis
b
When assessing a client with pleural effusion, what does the nurse expect to identify? a)Moist crackles at the posterior of the lungs b)Reduced or absent breath sounds at the base of the lung c)Increased resonance with percussion of the involved area d)Deviation of the trachea toward the involved side
b
Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk? a)Paralysis of both lower extremities b)Pain radiating to the hip and leg c)Stiffness in shoulders d)Overgrowth of tissue on the lower back
b
Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a)Bladder Distention b)CVA Tenderness c)Suprapubic discomfort d)Foul Smelling Urine
b
A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and lab values are used to confirm HIV infection? Select all that apply. a)Cerebrospinal fluid analysis b)Western Blot c)Indirect Immunofluorescence Assay d)CD4 + T-lymphocyte count e)HIV RNA test
b,c
A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. a)Headaches b)Scanning speech c)Nystagmus d)Skin infections e)Intention tremors
b,c,e
The nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions will be appropriate for this client? Select all that apply. a)Offer a high-potassium diet b) Encourage turning, coughing, and deep breathing exercises c)Decrease by mouth fluid intake d)Perform frequent breath sounds assessment e) Obtain a chest x-ray
b,d
Which interventions should the nurse perform while collecting subjective data from a client during a focused respiratory assessment? Select all that apply. a)Check the hematocrit and hemoglobin values b)Question the client about shortness of breath c)Palpate the chest and back for masses d)Inspect the skin and nails for integrity and color e)Ask the client about color and quantity of sputum
b,d
*A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find? a)Hypernatremia b)Proteinuria c)Hypokalemia d)Urine specific gravity of 1.010
c
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? a) Cool, moist skin b)Arm and leg trembling c)Rapid, thready pulse d)Slow, shallow respirations
c
A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information should the nurse provide about the purpose of the chest tube? a)It drains fluid from the pleural space. b)It monitors the function of the lung. c)It removes air from the pleural space. d)It checks for bleeding in the lung.
c
A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of: a)short- and long-acting insulins. b) short- and intermediate-acting insulins. c)rapid-acting insulin only d)intermediate- and long-acting insulins.
c
A nurse in an intensive care unit is caring for a client who had an acute myocardial infarction (MI) and had cardiac enzymes drawn. The nurse should know that the results of the cardiac enzyme studies help determine the a)Size of infarction b)Location of pulmonary congestion c)Degree of myocardium damage d)Location of infarction
c
A nurse is caring for a client admitted to the hospital with a diagnosis of myasthenia gravis. The nurse should observe the client for a)Wear an eye patch on the right eye at all times b)Plan to relax in a hot tub spa each day c)Plan to alternate activity with periods of rest d)Engage in a vigorous exercise program
c
A nurse is caring for a client with the following arterial blood gases: HCO3 of 18 mEq (22-26), CO2 of 28 mmHg (35-45). What pH value and acid base imbalance would accompany these values? a)Elevated pH and respiratory alkalosis. b)Decreased pH and respiratory acidosis. c)Decreased pH and metabolic acidosis. d)Elevated pH and metabolic alkalosis.
c
It is most important that the nurse ask a patient admitted with acute glomerulonephritis about a)history of kidney stones b)frequency of bladder infections c)recent sore throat and fever. d)history of high blood pressure
c
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment? a)Pulmonary Function Testing b)Thoracic Palpation c)Chest Auscultation d)Chest Percussion
c
The nurse identifies that the patient with the greatest risk for a urinary tract infection is: a)A 69-year-old man who has urinary retention caused by benign prostatic hyperplasia. b)A 37-year-old man with renal colic associated with kidney stones. c)A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence. d)A 26-year-old pregnant woman who has a history of urinary tract infections.
c
The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position? a)Right 3rd intercostal space at the midclavicular line b)Right 2nd intercostal space at the midclavicular line c)Left 5th intercostal space at the midclavicular line d)Left 2nd intercostal space at the midclavicular line
c
The nurse teaches a 21-year-old female patient who came to the clinic to discuss interventions to prevent a recurrence of urinary tract infections. Which statement, if made by the patient, indicates that teaching was effective? a)"I will use vinegar as a vaginal douche every week." b)"I can stop the antibiotics when symptoms disappear." c)"I will urinate before and after having intercourse." d)"I should drink three 8-ounce glasses of water daily."
c
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? a)"The pain lasted about 45 minutes." b)"The pain occurred while I was mowing the lawn." c) "The pain resolved after I ate a sandwich." d)"The pain occurred while I was mowing the lawn."
c
Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis? a)Hypernatremia and hypercalcemia b)Hyperkalemia and hyperglycemia c)Hypokalemia and hypoglycemia d)Hypocalcemia and hyperkalemia
c
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a)The patient denies pain with voiding. b)The urine dipstick is negative for nitrites. c)The periorbital and peripheral edema is resolved. d)The antistreptolysin-O (ASO) titer is decreased
c
Which of the following arterial blood gas results would be consistent with metabolic alkalosis? a)pH 7.30 b)Serum bicarbonate of 21 mEq/L c)Serum bicarbonate of 28 mEq/L d)pH 7.26
c
You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? a)The trachea and bronchi b)The pleural surfaces c)A puncture at the radial artery d)A catheter in the arm vein
c
A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply. a)Reducing the traction weight b)Loosening the client's bandage c)Elevating the extremity above heart level d)Applying cold compresses e)Splitting the cast in half
c,d
A patient is undergoing diagnostic testing for symptoms of polyarthralgia, fatigue, and hair loss. Laboratory results include the presence of anti-DNA, antinuclear antibodies, and anti-Smith in the blood. The nurse recognizes that these findings are most likely to be related to which diagnosis? a)Chronic Fatigue Syndrome b)Rheumatoid Arthritis c)Systemic Lupus d)Systemic sclerosis
c,d
A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? Select all that apply. a)Lower the casted arm when laying down b)Resume usual activities c)Report swelling of the fingers d)Elevate casted arm when standing
c,d
A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? a)Instruct the client to remove his or her dentures. b)Obtain informed consent from the client. c)Check the client's blood glucose levels. d)Assess if the client is allergic to shellfish.
d
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin? a)They have no effect. b)They cause wide fluctuations in the need for insulin c)They decrease the need for insulin. d)They increase the need for insulin.
d
A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? a)Hypertension and lack of fever b)Bradypnea and bradycardia c)Nonproductive cough and abdominal pain d)Chest pain and dyspnea
d
A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patient's pain, the nurse should anticipate that it may radiate to what region? a)Neck or Jaw b)Inguinal area c)Left Upper chest d)Right Shoulder
d
A nurse is caring for a client who is undergoing a diagnostic workup for a suspected GI problem. The client reports gnawing epigastric pain following meals and heartburn. The nurse suspects the client has a)Ulcerative colitis b)Diverticulitis c)Appendicitis d)Peptic ulcer disease
d
A patient in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? a)Ask about any skin color changes that occur in response to cold. b)Assess for unilateral swelling and tenderness of either leg. c)Check for the presence of tortuous veins bilaterally on the legs. d)Attempt to palpate the dorsalis pedis and posterior tibial pulses.
d
A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)? a)The patient has had angina longer than 3 years. b)The patient has an ejection fraction of 65%. c)The patient has compromised left ventricular function. d)The patient has at least a 70% occlusion of a major coronary artery
d
The nurse is educating the diabetic client on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include? a)Do not take insulin if not eating. b)Decrease food intake until nausea passes c)Take half the usual dose of insulin until symptoms resolve. d)Increase frequency of glucose self-monitoring.
d
Which of the following terms refers to chest pain brought on by physical or emotional stress and relieved by rest or medication? a)Athersclerosis b)Angioedema c)Ischemia d)Angina Pectoris
d
You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis? a)Caution against frequent coughing. b)Provide meticulous mouth care every 4 hours. c)Monitor for signs of dysphagia. d)Encourage deep breathing every 2 hours.
d