PREBOARDS NP3

67. Nurse Teresa has also a client 54-year-old woman has recently been diagnosed with type 2 diabetes. She has a history of A. Weight reduction B. Blood pressure control C. Foot care D. Self-injection technique

A. Weight reduction

Situation: Sarah a Medical Nurse is reviewing the condition of clients in the ward for further evaluation and referral to the Physician. 81. Which clinical manifestation noted by nurse Sarah during the assessment of a client with a urinary tract infection (UTI) will be of most concern? A. Temperature of 102.8 degrees F B. Pain with voiding rated at 8 on a scale of 10 C. Cloudy-appearing urine D. Urge incontinence

A. Temperature of 102.8 degrees F

Situation: Management of Diabetes Mellitus requires a balance of multitude factors and an active participation of the clients. Nurse Teresa is attending to a 25-year-old man was recently diagnosed with Type 1 Diabetes. She is preparing an educational teaching plan for the client. 66. What statement by the client validates the need for additional education? A. "I can take ibuprofen routinely as long as I don't take it with caffeine." B. "I will reduce the amount of nicotine in my system daily until there is none." C. "I need to learn how to read labels to calculate carbohydrates and fat." D. "I need to go shopping for shoes with a closed toe to protect my feet."

A. "I can take ibuprofen routinely as long as I don't take it with caffeine."

88. Nurse Goldie attends to the different needs and concerns of the clients in the ward. One of her major roles as a nurse is to conduct health teaching related to their illness. Which statement by a client who has received teaching about oral herpes simplex lesions indicates that more teaching is necessary? A. "I will take all of the antibiotics that the doctor ordered for me." B. "I can make a salt-water solution to rinse my mouth." C. "I will avoid sharing my dishes with family members." D. "I can use an over-the-counter medication to numb the sores."

A. "I will take all of the antibiotics that the doctor ordered for me."

65. Another client with elevated Cholesterol and Low density levels of cholesterol for 6 months seeks consultation to Cardiologist. The physician prescribes Cholestyramine (Questran) for a client with Hyperlipidemia. Which instructions should Nurse Sarah include in the client's teaching plan? A. "Increase your intake of fiber and fluid" B. "Take the medication before you go to bed" C. "Check your pulse before taking the medication" D. "Contact your doctor if your skin or sclera turn yellow"

A. "Increase your intake of fiber and fluid"

32. Kris, further being treated for hypertension, reports having a persistent hacking cough. The nurse explains that this may be a side effect associated with: A. ACE inhibitors B. thiazide diuretics C. calcium channel blockers D. Angiotensin receptor blockers

A. ACE inhibitors

89. A 37-year-old female client is admitted in the ward with complaints of unilateral anterior neck pain and fever. During the assessment, Nurse Goldie learns that she has recently recovered from a bacterial respiratory infection. The nurse anticipates that the Physician will diagnose her with which type of Thyroiditis? A. Acute thyroiditis B. Subacute granulomatous thyroiditis C. Subacute lymphocytic thyroiditis D. Chronic thyroiditis

A. Acute thyroiditis

79. Nurse Antonio admitted another client who has a renal laceration and hematuria for observation. Which intervention will be included in the initial plan of care? A. Bed rest B. Private room C. Fluid restriction D. Oxygen administration

A. Bed rest

57. Nurse Kim must be alert for signs of respiratory acidosis in the client with Emphysema. In addition to a long-term problem with O2 maintenance, what problem does this client have? A. CO2 retention B. localized tissue necrosis C. increased respiratory rate D. saturated haemoglobin molecules

A. CO2 retention

62. Which is one of the more common complications of Myocardial Infarction identified by the nurse in the coronary care unit? A. Dysrhythmia B. hypokalemia C. anaphylactic shock D. cardiac enlargement

A. Dysrhythmia

55. Another client is admitted to the unit with acute Pulmonary Edema. Which rapidly acting diuretic that can be administered intravenously should the nurse anticipate that the physician will order? A. Furosemide (Lasix) B. Chlorothiazide (Diuril) C. Chlorthalidone (Hygroton) D. Spironolactone (Aldactone)

A. Furosemide (Lasix)

87. The family of the client is asking what is the earliest symptom of chronic renal failure? A. Increased BUN B. Oliguria C. Polyuria D. Pruritus

A. Increased BUN

74. An individual was recently diagnosed with type 1 diabetes. Nurse Roxas is providing education on what is termed "survival skills." Which of the following skills should the nurse make a priority when teaching the client? A. Insulin self-injection technique B. Treatment of hypoglycemia C. Sick day management D. Basic dietary information

A. Insulin self-injection technique

4. On the first postoperative day after an open Billroth II procedure a client develops hiccups, 6 on a scale of 10 epigastric pain, and a drop in blood pressure. The nurse's initial actions should be to: A. assess the amount of drainage from the nasogastric (NG) tube. B. notify the client's physician. C. assess the abdominal dressing. D. administer the ordered Morphine Sulfate 4 mg IV.

A. assess the amount of drainage from the nasogastric (NG) tube.

Situation: The patient's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the patient for surgery, interventions needed and responding to potential anxiety. 11. The nurse in the ambulatory Preoperative unit identifies that a client is more anxious than most clients. The nurse's best intervention is to: A. attempt to identify the client's concerns B. report the client's anxiety to the surgeon C. reassure the client that the surgery is routine D. provide privacy by pulling the curtain around the client

A. attempt to identify the client's concerns

Situation: Manny a Senior Nurse in a medical ward is assessing patients, mostly those with Cardiovascular Disease. He is reviewing and analyzing the diagnostic results of clients for further evaluation and referral. 36. Immediately after receiving spinal anesthesia a client experiences hypotension as a result of postural changes. To what physiologic change does the nurse attribute the change in BP? A. dilation of blood vessels B. decreased response of chemoreceptors C. decreased strength of cardiac contractions D. interruption of cardiac accelerator pathways

A. dilation of blood vessels

Situation: Edwin 36 year old seeks consultation in an Out-Patient Clinic with complaints of productive cough for 2 weeks and with difficulty of breathing. 51. The nurse is teaching Edwin deep-breathing exercises. The nurse understands that air rushes into the alveoli as a result of which change in pressure? A. increasing alveolar pressure B. elevated diaphragmatic pressure C. rising pressure in the pleural space D. lowered pressure within the chest activity

A. increasing alveolar pressure

47. Nurse Benjie admitted another client with an arterial blood gas report indicates the client's pH is 7.25, Pco2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance does the nurse identify based on these results? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

A. metabolic acidosis

78. Another client is admitted with dehydration as a result of prolonged water diarrhea. Which intervention ordered by the Physician should Nurse Antonio question? A. parenteral albumin B. psyllium (Metamucil) C. potassium supplements D. half normal saline

A. parenteral albumin

Situation: The postoperative care continues after the patient's condition stabilized as well as after the patient is discharged from surgery facility. It is necessary for recovery room nurses to continue evaluating the patient's condition to anticipate and treat complications. 6. On the first postoperative day after an abdomino-perineal resection, the surgical nurse notes that there is a large quantity of serous drainage on the client's perineal dressing. The nurse will: A. reinforce or change the dressing. B. notify the physician immediately. C. irrigate the wound drain. D. culture the drainage.

A. reinforce or change the dressing.

29. A client with intractable pain in the upper torso is admitted to the hospital. The nurse understands that the client may be candidate for surgery to control the pain. Which surgery should the nurse expect to schedule? A. rhizotomy B. rhinotomy C. cordotomy D. chonderectomy

A. rhizotomy

52. Edwin is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What is being measuring when the client follows these directions? A. tidal volume B. vital capacity C. expiratory reserve D. inspiratory reserve

A. tidal volume

15. A client has corrective surgery for a bladder laceration. Which nursing intervention takes priority during this client's postoperative period? A. turning frequently B. raising side rails on the bed C. providing range-of-motion exercises D. massaging the back three times a day

A. turning frequently

1. When Nurse Jane is admitting a client for surgery, which question is most useful in determining the client's current nutritional status? A. "How is your appetite usually?" B. "What did you eat and drink yesterday?" C. "Have you noticed any weight loss recently?" D. "Who does most of your shopping and cooking?"

B. "What did you eat and drink yesterday?"

Situation: Inadequate pain management can lead to many consequences affecting the patient and family members. 26. A male client is brought to the emergency department with complaints of pain around his right scapula. The pain seems to occur shortly after eating. This is not the first time the client has experienced this type of pain but the pain is worse now than ever before. What question should the nurse ask to obtain additional information to develop a plan of care? A. "Have you had nausea or vomiting recently?" B. "What type of food did you have within the last 24 hours?" C. "Have you noticed a significant weight gain or loss recently?" D. "Are you urinating less frequently than you were before?"

B. "What type of food did you have within the last 24 hours?"

97. The physician prescribed Heparin Sodium 18,000 units subcutaneously. The available vial is that is labelled Heparin sodium 20,000 units =1ml. Using a tuberculin syringe how much would the nurse administer? A. 1 ml B. 0.9 ml C. 2 ml D. 2.9 ml

B. 0.9 ml

99. The patient is receiving a Total Parenteral Nutrition (TPN) at a rate of 65ml / hour via an electronic infusion device. The drop factor of the infusion set is 60 drops per ml. What is the total amount of the TPN solution that the patient will receive in 24 hours? A. 1,500 ml B. 1,560 ml C. 1.600 ml D. 1,660 ml

B. 1,560 ml

Situation: Problems in Oxygenation involves patients with disturbances in lower and upper airways. Nurse Benjie a Pulmonary Nurse is attending to clients with respiratory diseases. 46. Nurse Benjie observes an anxious client hyperventilating after learning that his wife met an accident and intervenes to prevent: A. cardiac arrest B. carbonic acid deficit C. reduction in serum pH D. excess oxygen saturation

B. carbonic acid deficit

73. A novice nurse is preparing to administer insulin to a client with a blood sugar level of 124 mg/dL. The student compares the result to the medication record and physician's order and notes that the client is ordered NovoLog insulin. The novice nurse draws the appropriate amount of insulin and then goes to the client's room to administer the injection. The meal tray is due in 30 minutes. What should the novice nurse do next? A. Administer the insulin immediately to coincide the onset with the time of the meal. B. Hold the medication until the tray is in front of the client, because onset is 5 minutes. C. Give the insulin immediately after the client has finished the entire meal. D. Administer the insulin because the blood glucose is high enough to prevent hypoglycemia.

B. Hold the medication until the tray is in front of the client, because onset is 5 minutes.

84. Karen a staff nurse is assigned in Medical Ward, with Kidney problem. One of the client with chronic kidney disease (CKD) and hypertension is receiving the Angiotensin Converting Enzyme (ACE) inhibitor captopril (Capoten). Sarah is checking the medications of the clients. Which of the following medications ordered for a client with acute renal failure should the nurse question? A. Mannitol (Osmitrol) 12.5 mg IV B. Milk of Magnesia 30 mL PO C. Lorazepam (Ativan) 0.5 mg PO D. Calcium carbonate (Tums) 500 mg PO

B. Milk of Magnesia 30 mL PO

80. Which information about a client with renal insufficiency who is to have an intravenous pyelogram with contrast infusion is of most concern to Nurse Antonio? A. The client's serum potassium level is 5 mg/dL. B. The client has poor skin turgor and dry oral mucosa. C. The client has had insulin-dependent diabetes for 20 years. D. The client takes acetaminophen (Tylenol) for occasional headaches.

B. The client has poor skin turgor and dry oral mucosa.

Situation: Nurses should conduct health teaching and provide appropriate information to facilitate recovery of clients. One of the clients in the ward developed renal failure. The dialysis team is discussing whether peritoneal dialysis should be started for a client with chronic kidney disease. 86. Which information about the client indicates that hemodialysis may be a better option? A. The client has insulin-dependent diabetes. B. The client has severe rheumatoid arthritis. C. The client has a history of coronary artery disease. D. The client has poor compliance with dietary restrictions.

B. The client has severe rheumatoid arthritis.

94. Which of the following assessment data would most likely be related to a client's current complaint of stress incontinence? A. The client's intake of 2 to 3 L of fluid per day B. The client's history of three full-term pregnancies C. The client's age of 45 year D. The client's history of competitive swimming

B. The client's history of three full-term pregnancies

64. Which of the following client data indicate that Nurse Sarah should check with the Physician before giving the Capoten? A. The client's blood pressure is 128/82 mm Hg. B. The client's serum potassium level is 5.6 mg/dL. C. The client has an elevated blood urea nitrogen and creatinine. D. The client has lung crackles in both bases.

B. The client's serum potassium level is 5.6 mg/dL

23. Charge Nurse Jane observes a new graduate RN taking all of the following actions when assessing a client who was admitted with abdominal pain. Which action indicates that the new RN needs more instruction? A. The new RN listens for bowel sounds only at the right lower quadrant. B. The new RN performs abdominal palpation before auscultating the abdomen. C. The new RN checks for rebound tenderness at the end of the examination. D. The new RN asks the client to bend the knees during the examination.

B. The new RN performs abdominal palpation before auscultating the abdomen.

70. Another 65-year-old man is being tested for Diabetes Mellitus. Today the client is to have a 2-hour postprandial glucose test. The client was given a regular meal and 2 hours later the result was 210 mg/dL. According to the result what should the nurse expect? A. The result is above the standard cut off for diabetes diagnosis; therefore the client is considered diabetic and will need follow-up care. B. The result is normal for the age of the client, so the client is not diagnosed with diabetes but will need follow-up care. C. Because the result is only slightly higher than normal, a retest maybe ordered with attention paid to the lunch to make sure that no caffeine is on the tray. D. Because the result was lower than what is expected for his age, the client is questioned regarding participation in a strenuous activity before the test.

B. The result is normal for the age of the client, so the client is not diagnosed with diabetes but will need follow-up care.

77. An older female client is being seen for recent history of diarrhea and vomiting. The client states that she has had at least two episodes of vomiting with more episodes of diarrhea within the last few days. Nurse Antonio suspects dehydration. Where should the nurse test skin turgor on this client? A. Lower forearm B. Top of the sternum C. Forehead D. Abdomen

B. Top of the sternum

75. Larger than normal amounts of acetoacetic acid have been entering the blood as one of the indirect results of a client's insulin deficiency. The nurse understands the chemical mainly responsible for buffering acetoacetic acid is: A. potassium B. bicarbonate C. carbon dioxide D. sodium chloride

B. bicarbonate

Situation: A Tertiary Hospital has a special health program on how to control smoking and improve lifestyle. The nurse is teaching a group of clients with peripheral vascular disease to stop smoking. 41. Which physiologic effect of nicotine should the nurse explain to the group? A. constriction of the superficial vessels, dilating the deep vessels B. constriction of the peripheral vessels, increasing the force of flow C. dilation of the superficial vessels with constriction of the collateral circulation D. dilation of the peripheral vessels, causing a reflex dilation of visceral vessels

B. constriction of the peripheral vessels, increasing the force of flow

60. Another client in the recovery room is suspected with Atelectasis. Which clinical indicator does the nurse expect to identify when assessing the client? A. slow, deep respirations B. diminished breath sounds C. a dry, unproductive cough D. a normal oral temperature

B. diminished breath sounds

50. The client stated that the Physician said the tidal volume is slightly diminished and asks the nurse what this means. What explanation should the nurse give the client? Tidal volume is the amount of air: A. exhaled forcibly after a normal expiration B. exhaled after there is a normal inspiration C. inspired forcibly above a normal inspiration D. trapped in the alveoli that cannot be exhaled

B. exhaled after there is a normal inspiration

38. A 35-year-old executive secretary is hospitalized for treatment of severe hypertension. The physician orders captopril (Capoten) and alprazolam (Xanax). The client quickly finds fault with the therapeutic regimen and nursing care. The nurse identifies that this behavior is probably a manifestation of the client's: A. denial of illness B. fear of the health problem C. response to cerebral anorexia D. reaction to hypertensive medications

B. fear of the health problem

43. A client is admitted with chest pain unrelieved by Nitroglycerin, an elevated temperature, decreased blood, and diaphoresis. A Myocardial Infarction is diagnosed. Which is the most accurate explanation for one of these clinical indicators based on the nurse's understanding of the disease process? A. parasympathetic reflexes from the infracted myocardium cause diaphoresis B. inflammation in the myocardium causes a rise in the systemic body temperature C. catecholamines released at the site of the infarction cause intermittent localized pain D. constriction of central and peripheral blood vessels causes a decreased in blood pressure

B. inflammation in the myocardium causes a rise in the systemic body temperature

19. After abdominal surgery another client suddenly complains of numbness in the right leg and "funny feeling" in the toes. What should the nurse do first? A. elevate the legs and tell the client to drink more fluids B. instruct the client to remain in bed and notify the physician C. rub the client's legs to stimulate circulation and cover the client with blanket D. tell the client about the dangers of prolonged bed rest and encourage ambulation

B. instruct the client to remain in bed and notify the physician

13. What is the priority nursing intervention for a client during the immediate postoperative period? A. observe for hemorrhage B. maintaining a patent airway C. recording the intake and output D. checking the vital signs every 15 minutes

B. maintaining a patent airway

Situation: A male 72 year old client is admitted with severe difficulty of breathing and with a history of smoking for 15 years. The Physician diagnosed Emphysema and prescribed an oxygen inhalation at 2-3 liters per minute. 56. Nurse Kim repositions a client to which of the following position who is diagnosed with emphysema to facilitate maximum air exchange? A. supine B. orthopneic C. Low-Fowler's D. Semi-Fowler's

B. orthopneic

17. A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching the client to avoid pressure on the popliteal space? A. cerebral embolism B. pulmonary embolism C. dry gangrene of a limb D. coronary vessel occlusion

B. pulmonary embolism

14. The nurse in the postanesthesia care unit identifies that after an abdominal cholecystectomy a client has sero-sanguineous drainage on the abdominal dressing. What should the nurse do? A. change the dressing B. reinforce the dressing C. apply an abdominal binder D. replace the tape with Montgemery traps

B. reinforce the dressing

92. Nurse Ashley uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts (Heimlich maneuver) to expel a foreign object in the larynx? A. tidal B. residual C. vital capacity D. inspiratory reserve

B. residual

2. A client complains of severe pain 2 days after surgery. Which initial action should Nurse Jane take after assessing the character of the pain? A. have the client rest B. take the client's vital signs C. administer the prn analgesic D. document the client's complaint

B. take the client's vital signs

63. Nurse Sarah is documenting a 2-g sodium diet prescribed for a male client with severe Hypertension. The client does not like the diet, and the nurse hears him requesting to the spouse to "Bring in some good home-cooked food." What is the most effective nursing intervention? A. call in the dietitian for client teaching B. wait for the client's family and discuss the diet with the client and family C. tell the client what the use of salt is forbidden, because it will raise the BP D. catch the family members before they go into the client's room and tell them about the diet

B. wait for the client's family and discuss the diet with the client and family

Situation: Based on evidenced studies a lot of people are now affected of Diabetes Mellitus. This is usually caused by lack of discipline in health promotion and lifestyle modifications. Nurse Roxas, a Nurse Educator is gathering data to validate the occurrence of diabetes in their hospital, through responding to their nursing care and health teaching. 71. A middle-age male client has recently been diagnosed with diabetes mellitus. He has been started on insulin and has been attending diabetes education classes. During the class, the client asks whether drinking alcohol would be possible "with the new diabetes stuff" because he has heard there is sugar in alcoholic drinks. What is the nurse's best response? A. "Alcohol is a fast-acting sugar that will increase your blood sugar rapidly." B. "The calories from alcohol must be figured into the daily plan to prevent weight gain." C. "Alcohol does not require insulin fo

C. "Alcohol does not require insulin for absorption so hypoglycemia may be a problem."

83. Sarah is preparing the client for possible discharge. Which statement by a client after receiving teaching about prevention of urinary tract infections (UTIs) indicates that the teaching has been effective? A. "I will drink at least a quart of water or other fluids every day." B. "I will plan to take a quick bath after sexual intercourse." C. "I will have cranberry juice every morning for breakfast." D. "I will need to give up drinking coffee or cola beverages."

C. "I will have cranberry juice every morning for breakfast."

3. A client who is scheduled for a Billroth II procedure asks the nurse to explain what will be done during the surgery. Which response should the nurse make? A. "The surgeon will explain the procedure to you since the doctor is responsible for obtaining consent." B. "Your stomach is completely removed and the esophagus is connected to the small intestine." C. "The bottom part of the stomach is removed and the remainder is attached to the small intestine." D. "The nerves that go to your stomach are cut and a larger opening is made for stomach emptying."

C. "The bottom part of the stomach is removed and the remainder is attached to the small intestine."

98. The client develops Cardiac Arrhythmias and the Physician prescribed Atropine 0.3mg to be administered by IV bolus. The vial of Atropine is labelled 600mcg=1ml. How many ml should the nurse draw into the syringe? A. 1 ml B. 2 ml C. 0.5 ml D. 1.5 ml

C. 0.5 ml

100. The Nurse is caring for a patient who's IV has been regulated to deliver 35 drops per minute of D5NSS. The drop factor of the infusion set is 15 drops / ml. The nurse recognizes that the amount absorbed in one hour will be how many ml? A. 120 ml B. 130 ml C. 140 ml D. 150 ml.

C. 140 ml

10. On the first postoperative day after Mrs. Cambay has had an open cholecystectomy, the nurse notes crackles at both lung bases, a temperature of 100" F, and complains of severe abdominal pain. Which action should the nurse take first? A. Have the patient ambulate in the room. B. Ask the client to deep breathe and cough. C. Administer the ordered morphine sulfate D. Give the prn acetaminophen (Tylenol).

C. Administer the ordered morphine sulfate

9. Mrs. Cambay 47 year old is being admitted for elective surgery. The client has a history of diabetes and hypertension. She uses alternative therapies to assist in keeping her diabetes and hypertension under control like taking black tea as an adjunct therapy. The Physician is requesting her to stop ingesting black tea in preparation for surgery. What should the nurse expect to see with the discontinuation of the black tea? A. Increased blood pressure B. Increased urine output C. Increased blood sugar D. Increased heart rate

C. Increased blood sugar

7. When developing the postoperative plan of care for a client who has had a Cystectomy and creation of a neobladder, which action is appropriate to include? A. Assess the stoma every hour for the first 24 hours after surgery. B. Call the surgeon if the urine appears cloudy or has clots. C. Irrigate the urethral catheter with saline every 2 to 4 hours. D. Change the ostomy bag when it is one-half full of urine.

C. Irrigate the urethral catheter with saline every 2 to 4 hours.

28. The nurse is working with an elderly female with complaints of abdominal pain and nausea and vomiting. While assessing the abdomen, the nurse notes the shape is round and the abdomen sags. From analyzing these data, what condition should the nurse expect? A. Possible small bowel obstruction B. Constipation C. Nothing, normal aging process D. Peptic ulcer

C. Nothing, normal aging process

85. Sarah is completing her charting with a client with acute renal failure (ARF) has a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements related to anorexia. Which of the following interventions will be included in the plan of care? A. Keep fresh water at the bedside. B. Administer prn antiemetics before meals. C. Offer high-calorie snacks at frequent intervals. D. Have family members bring food from home.

C. Offer high-calorie snacks at frequent intervals.

5. As a Surgical Nurse management of Peri-operative clients demand the use of knowledge, judgement and skills based on the principles of surgical nursing practice. Which information obtained in the postoperative assessment of a 32-year-old client with Peritonitis will be of most concern to the nurse? A. Bowel sounds are decreased in all four quadrants. B. Drainage from wound drains is purulent. C. Oxygen saturation is 90%. D. Pain level is 6 on a scale of 10.

C. Oxygen saturation is 90%.

Situation: Pain is a subjective symptom often experienced by clients. Therefore, nurses must individually assess clients when they express and complain about pain. Charge Nurse Jane is a Medical Nurse attending to the needs of clients with pain. 21. A 45-year-old male client with a history of blood clots and degenerative joint disease in his bilateral knees is taking over-the-counter glucosamine and chondroitin along with his prescribed warfarin. What potential nursing diagnosis should be a priority? A. Risk for Impaired Circulation: arterial B. Risk for Alteration in Comfort C. Risk for Imbalanced Nutrition D. Risk for Ineffective Breathing Pattern

C. Risk for Imbalanced Nutrition

40. Ms. Gil electrocardiogram has a 12 lead electrocardiogram taken during an episode of chest pain. A Nurse examines the tracing for which electrocardiogram change caused by myocardial ischemia? A. Prolonged PR interval B. Widened QRS complex C. ST segment elevation with depression D. Tall peaked T -waves

C. ST segment elevation with depression

72. A female client with diabetes mellitus begins a discussion with the diabetes nurse Roxas regarding sugar substitutes. The client is overweight and knows that she needs to reduce her calorie intake to reduce the weight and help prevent complications associated with diabetes. The client asks which sugar substitute would assist in meeting her goal. What sugar substitute should the nurse suggest? A. Fructose B. Sucrose C. Sucralose D. Sorbitol

C. Sucralose

8. Which information about a client on the first postoperative day after a total vaginal hysterectomy is most important to communicate to the physician? A. The client has hypotonic bowel sounds. B. The client complains of incisional pain with coughing rated at 8 on a scale of 10. C. The client's sanitary pad needs to be changed every hour. D. The client's temperature is 100.3 degrees F.

C. The client's sanitary pad needs to be changed every hour.

82. Which of the following Physician's orders should nurse Sarah implement first for the client admitted with a urinary tract infection, flank pain, and fever? A. Gentamicin (Garamycin) 80 mg IV B. Acetaminophen (Tylenol) 600 mg PO C. Urine for culture and sensitivity D. Flat plate x-ray study of the abdomen

C. Urine for culture and sensitivity

68. The nurse notes all of the following laboratory values when reviewing the chart for a client with a 20-year history of diabetes. Which one is of most concern? A. Hemoglobin A1C 6.9% B. Hemoglobin 11.0 g/dL C. Urine protein level 3+ D. Urine specific gravity 1.005

C. Urine protein level 3+

30. A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? A. maintain the same dial settings every day B. turn the machine on several times a day for 10 to 20 minutes C. adjust the TENS dial until the client experiences relief of pain D. apply the color-coded electrodes anywhere it is comfortable for the client

C. adjust the TENS dial until the client experiences relief of pain

54. What nursing action will limit hypoxia when suctioning a client's airway? A. lubricate the catheter with saline B. use a sterile suction catheter each time C. apply suction only after catheter is inserted D. limit suctioning with catheter to 30 seconds

C. apply suction only after catheter is inserted

58. Nurse Romeo a recovery room nurse is attending the client on his first 24 hours after insertion of chest tubes, and assessing the function of a three chamber, closed-chest drainage system. He notes that the water in the underwater seal tube is not fluctuating. What initial action should the Nurse Romeo take? A. inform the physician B. take the client's vital signs C. check whether the tube is kinked D. turn the client to the unaffected side

C. check whether the tube is kinked

90. What clinical indicator is important for Nurse Goldie to assess when a client undergoes a submucosal resection (SMR) for a deviated septum? A. occipital headache B. periorbital crepitus C. expectoration of blood D. changes in vocalization

C. expectoration of blood

42. A Nurse in a Special Health program department is assessing the skin of a client with a history of chronic venous insufficiency. The nurse understands that the darkening of tissue results from the breakdown of Hemoglobin with subsequent formation of: A. heme B. ferric chloride C. ferrous sulphide D. insoluble amino acids

C. ferrous sulphide

69. A nursing student is shadowing a nurse who is providing education to a client with atherosclerosis and recently diagnosed type1 diabetes and with no significant cardiovascular history. After the nurse is finished providing the education, the nursing student requests from the nurse a rationale for why this particular client received education on Atherosclerosis without indication of the condition. What statement by the nurse best fits the rationale for the education? A. In type 1 diabetes, ketones are a by-product of fat metabolism that increases the osmotic pressure, leading to increase in fluid loss. B. In type 1 diabetes, stress is the major cause of the body switching to fat metabolism that leads to plaque build-up in the vascular system. C. in type 1 diabetes, when fat is used as the primary source of energy, the body lipid level can increase greatly, leading to plaque buildup. D. In type 1 diabetes, the lac

C. in type 1 diabetes, when fat is used as the primary source of energy, the body lipid level can increase greatly, leading to plaque buildup.

59. Romeo is a Recovery room nurse preparing to endorse his clients to the next incoming shift. A client diagnosed with a spontaneous Pneumothorax. Which physiologic effect of a spontaneous Pneumothorax should the nurse include in a teaching plan for the client? A. the heart and great vessels shift to the affected side B. there is greater negative pressure within the chest cavity C. inspired air will move from the lung into the pleural space D. the other lung will collapse if not treated immediately

C. inspired air will move from the lung into the pleural space

39. The Physician scheduled for an exercise electrocardiogram (stress test). What information should the nurse include when explaining the value of this test? Exercise stress testing is a: A. definitive method to diagnose the cause of chest pain B. diagnostic modality of minimal value in planning treatment of angina C. noninvasive means of assessing cardiovascular conduction and function D. minimally invasive manner of assessing a body's reaction to increase in exercise

C. noninvasive means of assessing cardiovascular conduction and function

Situation: Kris a 48 year old Bank manager is receiving an antihypertensive drug intravenously for control of severe hypertension. The client's blood pressure is unstable and is 160/94 mm Hg before the infusion. Fifteen minutes after the infusion is started, the blood pressure rises to 180/100 mm Hg. 31. The response to the drug is described as a (n): A. allergic response B. synergistic response C. paradoxical response D. hypersusceptibility response

C. paradoxical response

53. Edwin is admitted for further management and treatment .The nurse notes that Edwin's Hemoglobin level is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test result indicates acceleration in O2 dissociation from haemoglobin? A. pH B. po2 C. pco2 D. HCO3

C. pco2

Situation: Sarah an Intensive Care Unit Nurse attends a 55 year old executive vice president of a bank admitted to the hospital with severe chest pain, difficulty of breathing and weakness of upper extremities. The Physician diagnosed Myocardial Infarction. 61. She is being instructed on the use of antiembolism stockings. The nurse should teach the client that the stockings should be: A. alternately kept on 2 hours and off 2 hours B. worn only at night when activity is lessened C. put on before getting out of bed in the morning D. left in place until the physician advises otherwise

C. put on before getting out of bed in the morning

22. Another female client with multiple lumbar muscle strains is looking at using alternative therapies to reduce the pain. The client seeks advice from Nurse Jane as to what type of alterative therapy would provide the best pain relief. How should the nurse respond? A. "I have seen many individuals with your type of pain be relieved of pain through the use of acupuncture." B. "These types of therapies are more than just therapies; they are really a mind over matter type of event or game." C. "Some of my other clients swear by magnet therapy to reduce pain as it is very small and very easy to use." D. "You need to choose the alternative therapy that is right for you based on research that supports the intervention."

D. "You need to choose the alternative therapy that is right for you based on research that supports the intervention."

Situation: Accurate computation prior to drug administration is an important nursing intervention to assist clients during their treatment phase. The following are common medications given in the ward. 96. The Physician has prescribed Lente Human Insulin ( Humulin L ) 36 units subcutaneously once a day. The available s in a vial labelled Humulin L -100 units per ml. Using a tuberculin syringe the nurse should administer how many ml? A. 1 ml B. 2 ml C. 0.26 ml D. 0.36 ml

D. 0.36 ml

95. The primary goal of nursing care for a client with stress incontinence is to: A. Help the client adjust to the frequent episodes of incontinence B. Eliminate all episodes of incontinence C. Prevent the development of urinary tract infections D. Decrease the number of incontinence episodes

D. Decrease the number of incontinence episodes

25. Nurse Jane admitted a 22-year-old client is with right lower quadrant abdominal pain of unknown etiology rated at 7 on a scale of 10. Which action will be included in the initial plan of care? A. Have client cough and deep-breathe q4h. B. Apply heating pad to abdomen prn for pain. C. Teach client about a high-fiber diet. D. Place client on NPO (nothing by mouth) status.

D. Place client on NPO (nothing by mouth) status.

18. A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery. In formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a post-op client can lead to: A. Fluid imbalance B. Carbon dioxide retention C. Pulmonary edema D. Pneumonia

D. Pneumonia

Situation: Nurse Antonio a medical nurse is preparing to review the Nurse's notes of clients to continue the nursing management. One of the clients is a 72-year-old client with a 3-day history of nausea, vomiting and diarrhea. Vital signs are blood pressure 88/46, pulse 114 beats per minute, respirations 18 breaths per minute, temperature 100.1 degrees F. 76. Which of the following Physician's orders should the Nurse Antonio implement first? A. Obtain a chest x-ray study. B. Insert a retention catheter. C. Measure blood urea nitrogen and creatinine. D. Start a normal saline infusion at 200 mL/hr.

D. Start a normal saline infusion at 200 mL/hr.

33. What should the nurse assess to determine if Kris is experiencing the therapeutic effect of valsartan (Diovan), an Angiotensin II receptor blocking agent? A. pulse rate B. breath sounds C. cardiac output D. blood pressure

D. blood pressure

34. To assess the effectiveness of a vasodilator administered to a client, what should the nurse assess? A. pulse rate B. breath sounds C. cardiac output D. blood pressure

D. blood pressure

49. Nurse Benjie understands that in the absence of pathology, a client's respiratory center is stimulated by: A. oxygen B. lactic acid C. calcium ions D. carbon dioxide

D. carbon dioxide

35. Nifepidine (Procardia XL) 90 mg is prescribed for another client with Hypertension. The nurse should instruct the client to notify the Physician if the client experiences: A. blurred vision B. dizziness on rising C. excessive urination D. difficulty breathing

D. difficulty breathing

24. A client tells Nurse Jane that he has severe and continuous scrotal pain. The nurse anticipates testing for: A. testicular cancer. B. pyelonephritis. C. nephrolithiasis. D. epididymitis.

D. epididymitis.

48. A client arterial blood gas report indicates the pH is 7.52, Pco2 is 32 mm Hg, and HCO3 is 24 mEq/L. What imbalance does Nurse Benjie identify as a possible cause of these results? A. airway obstruction B. inadequate nutrition C. prolonged gastric suction D. excessive mechanical ventilation

D. excessive mechanical ventilation

93. When caring for a client with a portable wound drainage system, Nurse Ashley understands that the principle behind its functioning is: A. the lumen diameter will determine the rate fluid flow B. gravity causes liquids to flow down a pressure gradient C. siphonage causes fluids to flow from one level to a lower one D. fluids flow from an area of higher pressure to one of lower pressure

D. fluids flow from an area of higher pressure to one of lower pressure

12. Which is an independent nursing measure that would be helpful in preventing the accumulation of secretions in a client who had general anesthesia during surgery? A. postural drainage B. cupping the chest C. nasotracheal suctioning D. frequent changes of position

D. frequent changes of position

44. Which clinical indicator of this complication should the nurse expect to identify when assessing the client? A. pitting edema of the lower leg B. ecchymotic areas of the extremity C. intermittent claudication of the leg D. localized warmth of the lower extremity

D. localized warmth of the lower extremity

27. The nurse is managing acute pain complained by the older adult client during the first 24 hours after admission to the hospital. The nurse should ensure that: A. pain medication is ordered via the intramuscular route B. an order for meperidine (Demerol) is secured for pain relief C. patient-controlled analgesia is avoided in this population D. ordered PRN analgesics are administered on a scheduled basis

D. ordered PRN analgesics are administered on a scheduled basis

Situation: Nurse Ashley, an emergency room nurse is attending to clients with various conditions. 91. Nurse Ashley must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? A. alkalosis B. renal failure C. hypervolemia D. pulmonary edema

D. pulmonary edema

20. After a bilateral lumbar sympathectomy Mr. Harold 54-year-old has a sudden drop in blood pressure but there is no evidence of bleeding. What should the nurse recognize as the most likely cause of the change in pressure? A. inadequate fluid intake B. after effects of anesthesia C. increased level of epinephrine D. reallocation of the blood supply

D. reallocation of the blood supply

37. What should the nurse teach a client to do to minimize orthostatic hypotension? A. wear support hose continuously B. lie down for 30 minutes after taking medication C. avoid tasks that require high energy expenditures D. sit on the edge of the bed a short time before arising

D. sit on the edge of the bed a short time before arising

Situation: A Recovery room nurse is skilled in the care of patients with multiple -medical and surgical problems immediately after a surgical procedure. 16. The nurse in the postanesthesia care unit is caring for a client who has received a general anesthetic. The nurse should notify the Physician if the: A. client pushes the airway out B. client has snoring respirations C. respirations of 16 breaths/min are shallow D. systolic blood pressure drops from 130 to 90 mm Hg

D. systolic blood pressure drops from 130 to 90 mm Hg

45. When caring for a client with chronic occlusive arterial disease, what precipitating cause would the nurse most likely to identify for development of ulceration and gangrenous lesions? A. emotional stress, which is short-lived B. poor hygiene and limited protein intake C. stimulants such as coffee, tea, or cola drinks D. trauma from mechanical, chemical, or thermal sources

D. trauma from mechanical, chemical, or thermal sources