RNSG 2404 COMMONS FINAL REVIEW

A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect? A. Confusion B. Friction Rub C. Hypertension D. Dry Skin

A. Confusion R: it can cause decreased tissue perfusion, which can lead to confusion. monitor the clients mental status

A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include? (Select all that apply.) A. Limited alcohol intake B. Regular exercise program C. Decreased magnesium intake D. Reduced potassium intake E. Smoking cessation

A, B, E. Limited alcohol intake, Regular exercise program, Smoking cessation

A nurse is assessing a client who has pulmonary edema related to hear failure. Which of the following findings indicates effective treatment of the client's condition? A. Absence of adventitious breath sounds B. Presence of a nonproductive cough C. Decrease in respiratory rate at rest D. Sao2 86% on room air

A. Absence of adventitious breath sounds

Which precaution is most important for the nurse to teach a 62-year-old client newly diagnosed with early-stage dry age-related macular degeneration? A. Quit smoking B. Quit drinking alcoholic beverages C. Eat more dark green, red, and yellow vegetables D. Wear dark glasses whenever he or she is outside or in bright interior lighting environments

Answer: A Rationale: Dry AMD is more common and progresses at a faster rate among smokers than among nonsmokers. Thus, quitting smoking can slow the rate of AMD progression. Avoiding alcohol and bright light (even ultraviolet light) is not related to AMD development or progression. Although increasing long-term dietary intake of antioxidants, vitamin B12, and the carotenoids lutein and zeaxanthin that are found in green, red, and yellow vegetables is thought to help slow the progression of AMD, the effects are not as profound as quitting smoking.

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds

Answer: A, D, E Rationale: Any action that would increase pressure in the eye should be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects. Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.

What is the action of miotics in the client with glaucoma? A. Decrease the inflammatory process B. Enhance aqueous outflow C. Increase the production of vitreous humor D. Vasoconstrict the blood vessels in the eye

Answer: B Rationale: Miotics are used to improve the flow of fluid (aqueous humor) and decrease intraocular pressure in clients with glaucoma. Steroid drops, not miotics, decrease the inflammatory process. Vitreous humor fills the space between the lens and the retina, is stagnant, and is not replenished as the aqueous humor is. Miotics make the pupil smaller, which creates more room between the iris and the lens.

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply.) A. "You will need to wear a patch on your eye for several weeks after the surgery." B. "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." C. "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." D. "Bring sunglasses with you on the day of your procedure." E. "You might experience a lot of bruising and swelling around the eye."

Answer: B, C, D Rationale: The client will have multiple eyedrops to use after surgery and should be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eyedrops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure. A patch is required after surgery only if a risk for injury is present. Cataract surgery does not cause bruising and swelling post-surgery.

A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? A. Increased tearing B. Itching of the eye C. Reduction in vision D. Swollen eyelid

Answer: C Rationale: A reduction in vision after cataract surgery indicates a problem, and the client should notify the provider immediately. Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.

During patient teaching regarding self-administration of ophthalmic drops, with statement by the nurse is correct? A. "Hold the eyedrops over the cornea, and squeeze out the drop." B. "Apply pressure to the lacrimal duct area for 5 minutes after administration." C. "Be sure to place the drop in the conjuctival sac of the lower lid." D. "Squeeze your eyelid closed tightly after placing the drop into your eye."

Answer: C Rationale: Because the cornea is sensitive, most eye medications are placed inside the lower lid. For systemic osmotic drugs, pressure only needs to be applied to lacrimal duct for 60 seconds.

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? A. Burning in the eye B. Inability to differentiate colors C. Increased sensitivity to light D. Gradual vision changes

Answer: D Rationale: Gradual vision changes are an indication of increased intraocular pressure. A burning sensation in the eye usually indicates inflammation and/or infection. An inability to differentiate colors is an early sign of cataracts. An increased sensitivity to light might be a sign of a corneal abrasion.

The client who had cataract surgery with a lens implant 1 week ago remarks to the home care nurse that after his daughter left to go to her home in another state yesterday, he combined all of his prescribed eyedrops together in one container so he had fewer drops to administer. What is the nurse's best response? A. "This is not a good idea because not all of the drugs are on the same schedule." B. "That is a good idea; just remember to not touch the dropper to your eye when giving yourself the drops." C. "Call your surgeon immediately and get new prescriptions because together these drugs can lower your blood pressure." D. "Call your surgeon immediately and get new prescriptions to use one at a time because these drugs cannot be mixed together."

Answer: D Rationale: These drugs are not to be mixed together. Not only is the chance for contamination high, but the drug concentrations and effectiveness are also reduced when mixed together. Even when the drugs are administered separately, they should be given 5 to 10 minutes apart.

A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? A. A client who has hypothyroidism b. A client who has DM c. A client whose daily caloric intake consists of 25% fat d. A client who consumes two bottles of beer a day

B. A client who has DM DM places the client at risk for microvascular damage and progressive PAD

A nurse is caring for a client who is being treated for HF and has prescriptions for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication? A. SOB b. Lightheadedness c. Dry cough d. Metallic taste

B. Lightheadedness Furosemide can cause a substantial drop in BP resulting in lightheadedness

A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following? A. Tendon pain b. Persistent cough c. Frequent urination d. Constipation

B. Persistent cough is an adverse effect of ACE inhibitors

A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? A. Apply the new patch to the same site as the previous patch. B. Place the patch on an area of skin away from skin folds and joints. C. Keep the patch on 24 hr per day. D. Replace the patch at the onset of angina.

B. Place the patch on an area of skin away from skin folds and joints. R: it should be applied to an area of skin that is not prone to movement or wrinkling

A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? A. Obtain clients current weight B. Review serum electrolyte values C. Determine the time of the last digoxin dose D. Check the clients urine output

B. Review serum electrolyte values

A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find? A. Inc abdominal girth b. Weak peripheral pulses c. Jugular vein distention d. Dependent edema

B. Weak peripheral pulses related to decreased CO

Which of the following drugs should a primary care provider prescribe to induce labor in a woman who is at 42 weeks of gestation? A.) Methylergonovine (Methergine) B.) Oxytocine (Pitocin) C.) Leuprolide (Lupron) D.) Terbutaline (Brethine)

B.) Oxytocine (Pitocin)

A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the clients family history of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection

C. Inquire about the presence or absence of claudication Experiencing claudication helps differentiate venous from arterial ulcers. (arterial ulcers experience claudication)

A nurse is caring for a client who presents to the ER with a BP of 254/138 mmhg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Obtain blood samples for laboratory testing B. Tell the client to report vision changes C. Place the head of the bed at 45 degrees D. Initiate an IV

C. Place the head of the bed at 45 degrees this improves respiratory status and promotes venous return to reduce workload on the hear

A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? A. Hemoglobin 14.4 g/dl b. History of peripheral arterial disease c. Urine output 200 ml/4 hr d. Previous allergic reaction to shellfish

D. Previous allergic reaction to shellfish Contrast medium use is iodine-based

A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? A. Hemoglobin 14 g/dl B. Minimal bruising of extremities C. Reduced circumference of affected extremity D. INR 2.0

INR 2.0 R: within the desired therapeutic range

A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse.

Mitral - Left fifth intercostal space Midclavicular

A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Identify the area of the strip the nurse should examine to observe for atrial depolarization.

P wave

Fire Safety (RACE)

R: Rescue patients in danger A: Activate the fire alarm C: Confine the fire E: Extinguish the fire

After having a transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

The client reports bladder spasms and the urge to void

A nurse working in the ED is caring for a client who reports costovertebral angle tenderness, nausea, and vomiting. For which of the following laboratory values should the nurse notify the provider? a. WBC 15,000 mm3 b. BUN 15 mg/dL c. urine specific gravity 1.020 d. urine pH 5.5

a. WBC 15,000 mm3

A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to monitor for signs of nephrotoxicity? a. a client who is receiving gentamicin for treatment of a wound infection. b. a client who is receiving digoxin for treatment of heart failure c. a client who is receiving methylprednisolone for treatment of hypertension d. a client who is receiving propranolol for treatment of hypertension

a. a client who is receiving Gentamicin for treatment of a wound infection. Aminoglycoside antibiotics can injure cells of the proximal renal tubules, causing acute tubular necrosis. The nurse should plan to monitor this client for nephrotoxicity and acute kidney injury.

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify what groups are most at risk for developing hep A? a. children b. older adults c. women who are pregnant d. middle-aged men

a. children

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. What lab findings should the nurse monitor prior to the procedure? a. prothrombin time b. serum lipase c. bilirubin d. calcium

a. prothrombin time

A nurse is preparing a community education program about hep B. What statement should the nurse include in the teaching? a. a Hep B immunization is recommended for those who travel, especially military personnel b. a Hep B immunization is given to infants and children c. Hep B is acquired by eating foods that are contaminated during handling d. Hep B can be prevented by using good personal hygiene habits and proper sanitation

b. a Hep B immunization is given to infants and children

A nurse is assessing a client who is in the early stages of hepatitis A. What manifestations should the nurse expect? a. jaundice b. anorexia c. dark urine d. pale feces

b. anorexia

A nurse is teaching a client who has a new diagnosis of acute pyelonephritis. Which of the following instructions should the nurse include in the teaching? a. Drink up to 1,500 mL of fluid per day b. avoid the use of NSAIDs for pain c. Monitor peripheral blood glucose level twice per day d. increase dietary protein intake

b. avoid the use of NSAIDs for pain the nurse should instruct the client to avoid the use of NSAIDs for pain, which can further damage the kidney

A nurse is reviewing the medical records of four clients. Which of the following conditions is a risk factor for chronic pyelonephritis? a. parkinson's disease b. diabetes mellitus c. peptic ulcer disease d. gallbladder disease

b. diabetes mellitus A client who has a history of diabetes mellitus is at risk for the development of chronic pyelonephritis due to reduced bladder tone.

A nurse is obtaining a voided urine culture and sensitivity for a client who has manifestations of urinary tract infection. Which of the following actions should the nurse take? a. collect the client's urine in a clean specimen container b. instruct the client to initiate the flow of urine before collecting the specimen c. obtain the client's first morning voiding on the following day d. place the client's urine specimen in a container with a preservative

b. instruct the client to initiate the flow of urine before collecting the specimen

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy tube and is receiving intermittent feedings. Prior to initiating the feeding, what following actions should the nurse take first? a. flush the tube with water b. place the client in semi-fowlers postion c. cleanse the skin around the tube site d. aspirate the tube for residual contents

b. place the client in semi-fowlers postion

A nurse working in a women's health clinic is caring for a client who reports urinary and dysuria. Which of the following additional findings should the nurse identify as an indication of a urinary tract infection (UTI)? a. vaginal discharge b. pyuria c. glucosuria d. elevated creatine kinase-MB

b. pyuria The nurse should identify pyuria, which is white blood cells in the urine, as a common manifestation of UTI

A nurse is providing teaching for a client who has urge urinary incontinence. The nurse should include which of the following instructions? a. sit on the toilet with water running every 4hr. b. set an interval for toileting based on previous voiding pattern c. respond immediately to the urge to void d. self-catheterize daily following a regular voiding

b. set an interval for toileting based on previous voiding pattern

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? a. to visualize polyps in the colon b. to detect an ulceration in the stomach c. to identify an obstruction in the biliary tract d. to determine the presence of free air in the abdomen

b. to detect an ulceration in the stomach

A nurse is providing teaching to a client who has diverticulitis about preventing acute attacks. What foods should the nurse recommend? a. foods high in vit c b. foods low in fat c. foods high in fiber d. foods low in calories

c. foods high in fiber

A nurse is caring for a client who has chronic kidney failure and the following laboratory results: BUN 196 mg/dL, sodium 152 mEq/L, and potassium 7.3 mEq/L. Which of the following interventions should the nurse implement? a. initiate an IV infusion of 0.9% sodium chloride b. give oral spirolactone c. infuse regular insulin dextrose 10% in water d. administer furosemide

c. infuse regular insulin dextrose 10% in water The client has an elevated potassium level should receive regular insulin with dextrose 10% in water by continuous IV infusion to facilitate moving potassium out of the extracellular fluid into intracellular fluid.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. What finding should indicate to the nurse that a possible bowel perforation has occurred? a. elevated BP b. bowel sounds increased in frequency and pitch c. rigid abdomen d. emesis of undigested food

c. rigid abdomen

A nurse is completing a history and physical assessment for a client ho has chronic pancreatitis. What finding should the nurse identify as a likely cause of the client's condition? a. high-calorie diet b. prior gastrointestinal illness c. tobacco use d. alcohol use

d. alcohol use

A nurse is planning care for a client who is scheduled to undergo extracorporeal shock wave lithotripsy (ESWL) for urolithiasis. Which of the following actions should the nurse plan to take? a. place the client in a semi-Fowler's position b. assist with the client's intubation c. begin a 24-hr urine specimen collection after the procedure d. apply electrodes for cardiac monitoring

d. apply electrodes for cardiac monitoring The nurse should apply electrodes for continuous monitoring of the client's cardiac rhythm during ESWL. The monitoring allows the provider to deliver shock waves that are synchronized with the R wave.

A nurse is planning care for a client who is postoperative following a nephrectomy. Which of the following assessments is the priority for the nurse to evaluate? a. bowel sounds b. WBC count c. pain level d. blood pressure

d. blood pressure The greatest risk to the client is acute adrenal insufficiency. The adrenal gland can be removed or damaged during nephrectomy. The nurse should evaluate the client for hypotension, decreased urine output, and decreased level of consciousness.

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. What manifestations should the nurse expect? a. increased BP b. decreased heart rate c. yellowing of the skin d. boardlike abdomen

d. boardlike abdomen

A nurse is caring for a client who is 2 days postop following a gastric bypass. The nurse notes that bowel sounds are present. What foods should the nurse provide at the initial feeding? a. vanilla pudding b. apple juice c. diet ginger ale d. clear liquids

d. clear liquids

A nurse is caring for a client the night before a scheduled intravenous urography. Which of the following is the nurse's priority intervention? a. inform the client about dietary limitations b. place the informed consent document in the client's record c. administer a bowel preparation to the client d. determine if the client is allergic to iodine of shellfish

d. determine if the client is allergic to iodine of shellfish The greatest risk to the client is injury or death form an allergic reaction to radiopaque contrast media. The nurse should determine if the client has an allergy to iodine or shellfish, which indicates the client is at high risk of having an allergic reaction to the contrast media

A nurse is caring for a client who is receiving total parenteral nutrition therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? a. hypertension b. excessive thirst c. fever d. diaphoresis

d. diaphoresis

A nurse is caring for a client following extra corporeal shock wave lithotripsy (ESWL) for the treatment of calcium phosphate kidney stones. Which of the following actions is appropriate for the nurse to take? a. monitor for the client's urine for ketones b. provide the client with anincreased animal protein diet c. limit the client's fluid intake to 1.5L per day d. strain all of the client's urine

d. strain all of the client's urine The nurse should strain all of the client's urine following ESWL to monitor for stone fragments as they leave the body.

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? a. a full pitcher of water is sitting on the client's bedside table within the client's reach b. the disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding c. the client is lying on the right side with a visible dependent loop in the feeding tube d. the head of bed is elevated 20*

d. the head of bed is elevated 20*