Exam 2 Practice Questions

A nurse is caring for a patient who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache? a. As soon as the patient senses the onset of symptoms b. As soon as the patient's pain becomes unbearable c. When the patient senses his or her symptoms peaking d. Twenty to 30 minutes after the onset of symptoms

As soon as the patient senses the onset of symptoms

What underlying conditions put people at higher risk of developing pulmonary hypertension? a. COPD, lymphedema b. avoiding alcohol and smoking c. CAD, congenital heart disease, exercising 30 minutes 3 times per week d. COPD, congenital heart disease, PE

COPD, congenital heart disease, PE

The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: a. Empty and measure the drainage and compress the Hemovac. b. Remove the Hemovac because it is expanded. c. Notify the surgeon that the Hemovac is not functioning. d. Assess the client's wound and apply a pressure dressing.

Empty and measure the drainage and compress the Hemovac.

The pain management nurse speaks with the patient about how to avoid constipation after starting their prescribed opioid. The nurse knows the patient understands when he states which response? a. I will start using bulk enemas b. I will start on a stool softener c. I will decrease my fluid intake d. I will decrease my exercising

I will start on a stool softener

A patient was recently diagnosed with myasthenia gravis (MG). Which is indicative of a person diagnosed with myasthenia gravis? a. Defects in the expression of acetylcholine receptors b. Decreased dopamine activity in the brain c. Impairment of acetylcholine binding to muscle cells d. Excessive serotonin activity in the brain

Impairment of acetylcholine binding to muscle cells

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? a. Inability to recognize his family members b. difficulty reading c. right hemiparesis d. aphasia

Inability to recognize his family members

An 80-year old patient is brought to the emergency room for a suspected hip fracture. In order for the nurse to get an accurate pain assessment, which tool will the nurse use? a. FLACC Scale b. CPOT Scale c. Wong Baker Faces Scale d. Numeric 1-10 Scale

Numeric 1-10 Scale

A patient with an infected appendix is scheduled for an appendectomy. However, the patient cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this patient? a. Obtain a telephone consent from a family member, following agency policy. b. Obtain a court order for the surgery. c. Have the charge nurse sign the informed consent immediately. d. Send the client to surgery without the consent form being signed.

Obtain a telephone consent from a family member, following agency policy.

A nurse is planning discharge teaching for the family of an older adult patient who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? a. Remind the client to scan their complete range of vision during ambulation. b. Keep the client's personal care items in the bathroom c. Keep the overhead lights on in the client's bedroom while the client is sleeping. d. Secure the client's extension cords under carpeting.

Remind the client to scan their complete range of vision during ambulation.

The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education should the nurse provide with regard to this medication? a. Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician. b. Aspirin should be increased until 3 days before surgery, then it should be discontinued until 3 days after surgery. c. Take half doses of the aspirin until 1 week after surgery. d. Continue to take the aspirin as ordered.

Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician

A nurse is assessing the postoperative patient on the second postoperative day. What assessment finding does the nurse realize needs to be immediately reported to the health care provider? a. absence of bowel sounds b. rales heard in the base of the lungs c. moderate amount of pain at incision site d. serous drainage noted on the post op dressing

absence of bowel sounds

What is a sign of hypoxemia? a. blue colored lips b. cap refill <3 seconds c. pink mucous membranes d. a respiratory rate of 15

blue colored lips

What is not a symptom of status asthmaticus? a. crackles b. wheezing c. shortness of breath d. anxiety

crackles

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound ____ . a. dehisced b. eviscerated c. pustulated d. hemorrhaged

dehisced

What lung sounds do you expect to hear in someone who has atelectasis? ' a. diminished with wheezes b. resonant c. diminished with crackles d.. absent

diminished with crackles

A nurse is assessing a patient who has a suspected stroke. The nurse should place priority on which of the following findings? a. dysphagia b. aphasia c. ataxia d. hemianopsia

dysphagia

A patient is diagnosed with opioid tolerance, what does this mean for the patient? a. smaller doses of opioids are needed than they needed two months ago b. larger doses of opioids are needed to control their pain than they needed a month ago c. the patient has signs and symptoms of respiratory depression, hypotension and diaphoresis

larger doses of opioids are needed to control their pain than they needed a month ago

Which cancer is the leading cancer killer in the US? a. bladder b. brain c. breast d. lung

lung

It is important for the nurse to assist a postsurgical patient to sit up and turn the head to one side when vomiting in order to a. minimize risk of aspiration b. avoid dizziness c. maximize comfort d. help eliminate inhaled anesthetics

minimize risk of aspiration

Which opioid analgesic is the most appropriate to give for an opioid-naive patient in severe pain from a hip fracture? a. oxycodone b. hydromorphone c. morphine sulfate d. fentanty

morphine sulfate

A patient with acute on chronic pain will be managed using what type of analgesic regimen? a. a non-opioid analgesic b. an opioid analgesic c. multimodal therapy d. monotherapy

multimodal therapy

A patient with multiple sclerosis asks the nurse how they can reduce their level of fatigue. The nurse responds should tell the patient: a. rest in an air conditioned room as needed b. take a hot bath c. avoid taking naps during the day d. remember to increase the dose of the muscle relaxants

rest in an air conditioned room as needed

A patient has been taking ibuprofen for the last several days but states that every time they take it, their stomach has gotten upset. What advice can the nurse give to help with the gastric irritation? a. take with grapefruit juice b. make sure to have on empty stomach c. take with milk d. take with coffee

take with milk

Is the function of the fluid in the pleural space to act as a lubricate to allow the pleura to move smoothly within the chest cavity? True or False True or False

True

The target oxygen saturation for a patient with COPD is different than that of a patient with community-acquired pneumonia. True or False

True

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? a. "The MRI contrast dye contains iodine and can cause your skin to itch." b. "An MRI scan is not distorted by movement, so you do not have to lie still." c. "An MRI scan is a short procedure and should take no longer than 30 minutes." d. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

The nurse is teaching a male patient with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the patient that this can be prevented most effectively by: a. Taking medications on time to maintain therapeutic blood levels b. Eating large, well-balanced meals c. Doing muscle-strengthening exercises d. Doing all chores early in the day while less fatigued

. Taking medications on time to maintain therapeutic blood levels

A nurse comes to reassess a patient after administering oxycodone. The nurse is concerned that the patient's respiratory rate is abnormal. Which respiratory rate would the nurse be most concerned with? a. 15 b. 8 c. 20 d. 13

8

How does a nonrebreathing mask work? a. A one-way valve located between the reservoir bag and the base of the mask allows gas from the reservoir bag to enter the mask on inhalation but prevents gas in the mask from flowing back into the reservoir bag during exhalation. b. It has a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. c. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Excess gas leaves the mask through the two exhalation ports, carrying with it the exhaled carbon dioxide.

A one-way valve located between the reservoir bag and the base of the mask allows gas from the reservoir bag to enter the mask on inhalation but prevents gas in the mask from flowing back into the reservoir bag during exhalation.

Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client: a. States that he will use oxygen via a nasal cannula at 3 L/minute. b. States actions to reduce pain c. Promises to do pursed lip breathing at home. d. Agrees to call the physician if dyspnea on exertion increases.

Agrees to call the physician if dyspnea on exertion increases.

A clinic nurse is providing education for a patient diagnosed with migraine headaches. During the teaching session, the patient asks the nurse about alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? a. Alcohol has an excitatory effect on the CNS. b. Alcohol causes hormone fluctuations. c. Alcohol diminishes endorphins in the brain. d. Alcohol causes vasodilation of the blood vessels.

Alcohol causes vasodilation of the blood vessels.

The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury? a. Avoid rubbing the eye on the affected side of the face. b. Use over-the-counter antibiotic eye drops for at least 14 days. c. Avoid watching television or using a computer for more than 1 hour at a time. d. Rinse the eye on the affected side with normal saline daily for 1 week.

Avoid rubbing the eye on the affected side of the face.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? a. Testing visual acuity b. Observing for facial symmetry c. Checking the pupillary response to light d. Eliciting the gag reflex

Checking the pupillary response to light

Which factors predispose patients to hospital-acquired pneumonia (HAP)? a. chronic illnesses b. intubation c. risk for aspiration d. prolonged hospitalization e. deep breathing and coughing f. malnutrition

Chronic Illnesses intubation risk for aspiration prolonged hospitalization

The term "blue bloater" refers to which of the following conditions? a. Chronic obstructive bronchitis b. Emphysema c. Asthma d. Acute Respiratory Distress Syndrome (ARDS)

Chronic obstructive bronchiti

And older adult patient has an open reduction and internal fixation of the left femoral head after a fracture. Which action by the nurse is best? a. Encourage the client to cough and deep breath every 2 hours b. Instruct the client to exercise their arms c. Keep the patient turned to the non operative side d. Offer the patient a clear liquid diet

Encourage the client to cough and deep breath every 2 hours

A patient is exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head. A nurse is assessing the patient in the emergency department (ED). The nurse should first gauge the patient's LOC on the results of what assessment tool? a. Glasgow Coma Scale b. Cranial nerve functions c. Monro-Kellie hypothesis d. Mental status examination

Glasgow Coma Scale

Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics? a. How to recognize the signs of an impending respiratory infection b. How to treat respiratory infections without going to the physician. c. How to increase his oxygen therapy d. How to have his wife learn to listen to his lungs with a stethoscope from Wal-Mart

How to recognize the signs of an impending respiratory infection

How does smoking cigarettes affect the anatomy of the lungs? a. It disrupts mucociliary and macrophage activity. b. It increases the body's immune response to pathogens. c. It increases the surface area available for gas exchange. d. It causes increased permeability of the alveolar tissue.

It disrupts mucociliary and macrophage activity.

A nurse is assessing an unconscious patient and observes that the patient's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? a. It suggests an onset of a metabolic abnormality. b. It indicates paralysis at cranial nerve X. c. It indicates paralysis on the right side of the body. d. It indicates an injury at the midbrain level.

It indicates an injury at the midbrain level.

A client asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate? a. It prevents aspiration and respiratory complications. b. It decreases the risk of elevated blood sugar and slow wound healing. c. It decreases urine output so that a catheter will not be needed. d. It prevents overhydration and hypertension

It prevents aspiration and respiratory complications.

A patient with a history of a seizure disorder experiences a generalized seizure. What nursing action is the most appropriate? a. Loosen the patient's restrictive clothing. b. Apply restraints to the patient to prevent injury. c. Open the patient's jaw to insert an oral airway. d. Position the patient in high-Fowler.

Loosen the patient's restrictive clothing.

In a hospital, a patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety? a. Place the patient in a side-lying position b. Reassure the patient and family members. c. Administer antianxiety medications as prescribed. d. Pad the patient's bed rails.

Place the patient in a side-lying position

During a nurses assessment of a patient's abdominal pain, the nurse asks where the pain is located. Which part of the PQRST assessment is the nurse asking about? a. S b. P c. Q d. T e. R

R

The nurse is caring for a female patient who begins to experience a seizure while laying in bed. Which of the following actions by the nurse would be contraindicated? a. Restraining the client's limbs b. Loosening restrictive clothing c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward

Restraining the client's limbs

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the client is taken to the preoperative holding area? a. That preoperative teaching was performed b. That the family is aware of the length of the surgery c. That follow-up home care is not necessary d. That the family understands the client will be discharged immediately after surgery.

That preoperative teaching was performed

The nurse is assigned to care for a male patient with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The patient has weakness on the right side of the body, including the face and tongue. b. The patient has lost the ability to move the right arm but is able to walk independently c. The patient has lost the ability to move the right arm but is able to walk independently. d. The patient has complete bilateral paralysis of the arms and legs.

The patient has weakness on the right side of the body, including the face and tongue.

A nurse is caring for a patient who is withdrawing from heavy alcohol use. The nurse, and other members of the care team, are at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? a. The patient's activities immediately prior to the seizure. b. The patient's ability to describe the seizure in the postictal period. c. The success or failure of the care team to physically restrain the patient during the seizure. d. The patient's ability to follow instructions during the seizure.

The patient's activities immediately prior to the seizure.

What is the role of the alveolar macrophages and what happens if they do not function properly? a. They are type of phagocyte. If not functioning properly, the patient is at increased risk for pulmonary infection. b. They are type of eosinophil. If not functioning properly, the patient is at increased risk for an allergic reaction.. c. They are type of monocyte. If not functioning properly, the patient is at increased risk for tissue necrosis. d. They are type of monocyte. If not functioning properly, the patient is at increased risk for pulmonary infection.

They are type of phagocyte. If not functioning properly, the patient is at increased risk for pulmonary infection.

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a cholecystectomy. The patient has not started ambulating and states he needs to rest in bed. For what complication is the client most at risk? a. atelectasis b. shock c. anemia d. dehydration

atelectasis

A patient with metastatic osteosarcoma states that he all of a sudden has severe pain. The nurse notes that the patient has a fentanyl patch that was placed a couple of hours ago. What type of pain is this patient experiencing? a. breakthrough pain b. chronic pain c. referred pain d. neuropathic pain

breakthrough pain

Why are antihistamines usually not prescribed to patients who have a respiratory infection? a. can make it easier for secretions to be cleared b. can cause excessive fluid build up c. can cause excessive fluid build up and make secretions difficult to clear

can cause excessive fluid build up and make secretions difficult to clear

What should nurses expect to assess with a patient who is not getting enough oxygen? a. capillary refill b. deep tendon reflexes c. mucous membranes d. hepatosplenomegaly

capillary refill

A patient with chronic right shoulder pain has learned that the use of imagery and guided meditation has helped control his pain. A family member asks how these techniques can help with pain. The nurse replies that these therapies can _____ . a. change the cognitive and affective thoughts about the pain b. prevent transmission of nociceptive stimuli to the brain c. increase the modulating effect of the efferent pathways d. slow the release of transmitter chemicals in the dorsal horn

change the cognitive and affective thoughts about the pain

What are three nursing interventions for someone who has atelectasis? a. staying in bed b. educating about deep breathing exercises c. early mobilization d. educating how to use an incentive spirometer

educating about deep breathing exercises early mobilization educating how to use an incentive spirometer

A nurse is assessing a client with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitation? a. Bronchial asthma and bronchitis b. Bronchial asthma c. Chronic obstructive bronchitis d. emphysema

emphysema

A patient has residual dysphagia after suffering from a recent cerebrovascular accident. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the patient thin liquids b. Thickening liquids to the consistency of oatmeal c. Allowing plenty of time for chewing and swallowing d. Placing food on the unaffected side of the mouth

giving the patient thin liquids

In which position in the hospital bed improves oxygenation in patients with acute respiratory distress syndrome (ARDS)? a. supine b. side-lying on right c. side-lying on left d. prone

prone

What is not a non-pulmonary assessment findings of patients with cystic fibrosis? a. pulmonary hypertension b. depression c. pancreatic insufficiency d. anorexia

pulmonary hypertension

A nurse and a certified nurse assistant (CNA) are caring for a patient who has bacterial meningitis. The nurse should give the CNA which of the following instructions? a. wear a mask. b. wear a gown. c. keep the patient's room well-lit d. maintain the head of the bed at 45 degrees elevation

wear a mask.