Semester 1 Final

Which of the following is not a symptom of hyperkalemia? 1. Positive Chvostek's sign 2. Decreased blood pressure 3. Muscle twitches/cramps 4. Weak and slow heart rate

1. Positive Chvostek's sign This is a sign of hypocalcemia or hypomagnesemia

Which assessment question is most appropriate when the nurse is assessing a patient who is receiving care for suspected obstructive sleep apnea (OSA)? "Do you smoke?" "Do you tend to awaken early in the morning?" "Are you under a lot of stress at work or at home right now?" "Do you have a history of chronic obstructive pulmonary disease?"

"Do you smoke?" Smoking is a major etiologic factor in OSA.

The volume of blood in the left ventricle at the end of diastole is best described as :A) afterload .B) stroke volume .C) preload .D) contractility.

.C) preload Preload is the volume of blood in the left ventricle at the end of diastole. Contractility refers to the heart's contractile force. Afterload can be defined as the ventricular wall tension or stress during systolic ejection

A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? 1) U waves 2) Absent P waves 3) Elevated T waves 4) Elevated ST segment

1) U waves

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply 1. Contact the surgeon 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and icepacks over the wound 6. Place the client in a supine position without a pillow under the head.

1, 2, 3 ,4 Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowlers position and the client is kept quite and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway 2. Check tubes or drains for patency 3. Check the dressing to assess for bleeding 4. Assess the vital signs to compare with preoperative measurements

1. Assess the patency of the airway

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? 1. Frequent swallowing 2. A decreased pulse rate 3. Complaints of discomfort 4. An elevation in blood pressure

1. Frequent swallowing This could be a sign of hemorrhaging

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell's sign. The nurse determines this sign indicates: 1.A softening of the cervix 2.A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus. 3.The presence of hCG in the urine 4.The presence of fetal movement

1.A softening of the cervix

Which nursing diagnosis would be the priority for the client experiencing acute delirium? 1.Risk for injury related to confusion and cognitive deficits 2.Fall precautions related to acute confusion 3.Risk for self-mutilation related to confusion and cognitive deficits 4.Acute confusion related to delirium of known/unknown etiology

1.Risk for injury related to confusion and cognitive deficits

A patient's potassium level is 3.0. Which foods would you encourage the patient to consume? 1. Cheese, collard greens, and fish 2. Avocados, strawberries, and potatoes 3. Tofu, oatmeal, and peas 4. Peanuts, bread, and corn

2. Avocados, strawberries, and potatoes

The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm tender skin

2. Serous drainage The other options are signs of infection

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? 1. Supine 2. Side-lying 3. High Fowler's 4. Trendelenburg's

2. Side-lying The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage.

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? 1. Maintain NPO status. 2. Turn the child to the side. 3. Administer the prescribed antiemetic. 4. Notify the health care provider (HCP).

2. Turn the child to the side.

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn't have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as: 1.G = 3, T = 2, P = 0, A = 0, L =1 2.G = 2, T = 0, P = 1, A = 0, L =1 3.G = 1, T = 1. P = 1, A = 0, L = 1 4.G = 2, T = 0, P = 0, A = 0, L = 1

2.G = 2, T = 0, P = 1, A = 0, L =1

Which patient should the nurse perform a focused assessment on first? 1. A patient with obstructive pulmonary disease who is using pursed lip breathing 2. A patient returning from a walk down the hall who is exhibiting nasal flaring 3. A patient with dyspnea who abruptly assumes the orthopneic position 4. A patient with asthma who is wheezing

3

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery. "2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery."

3. "I need to continue to take the aspirin until the day of surgery."

A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was September 19th, 2005. Using Nagele's rule, the nurse determines the estimated date of confinement as: 1.July 26, 2006 2.June 12, 2007 3.June 26, 2006 4.July 12, 2007

3.June 26, 2006

A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? 1) ST depression 2) Inverted T wave 3) Prominent U wave 4) Tall peaked T wave

4) Tall peaked T wave

Tall peaked T-waves, flat P-waves, prolonged PR intervals and widened QRS complexes can present in which of the following conditions? 1. Hypocalcemia 2. Hypercalcemia 3. Hypokalemia 4. Hyperkalemia

4. Hyperkalemia

A client with a perforated gastric ulcer is scheduled for surgery. The client 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 client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy

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

Which of the following is indicative of an EKG change in a case of hypokalemia? 1. Widened QRS complex and prolonged PR interval 2. Prolonged ST interval and Widened T-wave 3. Tall T-waves and depressed ST segment 4. ST depression and inverted T-wave

4. ST depression and inverted T-wave

A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what? 1.Akinesia 2.Apraxia 3.Agnosia 4.Aphasia

4.Aphasia

Which patient is at highest risk for obstructive sleep apnea? 82-year-old male with Parkinson's disease who has dysphagia 68-year-old obese male who smokes one pack of cigarettes per day 18-year-old female with cystic fibrosis who has recurrent pneumonia 35-year-old female with a BMI of 22 kg/m2 who has seasonal allergies to pollen

68-year-old obese male who smokes one pack of cigarettes per day

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors says to the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the MOST APPROPRIATE nursing response? A "I can not discuss any patient situation with you." B "If you want to know about Mary, you need t ask her yourself." C "Only because you're worried about a friend, I'll tell you that she is improving." D "Being her friend, you know she is having a difficult time and deserves her privacy."

A "I can not discuss any patient situation with you."

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? A Hypersensitivity to eggs B Age greater than 80 years C History of upper respiratory infections D Chronic obstructive pulmonary disease (COPD)

A Hypersensitivity to eggs

A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for clients with brain damage? a) Biot's b) Cheyne-Stokes c) Kussmaul's d) Retractive

A)Biot's

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. A. The RR intervals are relatively consistent. B. One P wave precedes each QRS complex. C. Four to eight complexes occur in a 6-second strip. D. The ST segment is higher than the PR interval. E. The QRS complex ranges from 0.12 to 0.20 second.

A, B

When selecting a high-flow oxygen delivery system for a patient experiencing respiratory distress which of the following would be an option when looking for high-flow systems? SATA a) Face tent b) Nasal cannula c) Tracheostomy collar d) Simple face mask e) Venturi mask

A, c, e

Select the patient below who is at MOST risk for pernicious anemia:* A. A 75 year old male who recently had surgery on the ileum. B. A 25 year old female who reports craving ice and clay .C. A 66 year old male whose peripheral blood smear showed hypochromic red blood cells. D. All the patients above are at risk for pernicious anemia.

A. A 75 year old male who recently had surgery on the ileum.

The nurse is conducting a community education program. When explaining different medication regimens to treat hypertension, it would be accurate to state that African Americans probably respond best to which combination of medications? A. Diuretics and calcium channel blockers B. ACE inhibitors and diuretics C. Diuretics and beta blockers D. ACE inhibitors and beta blockers

A. Diuretics and calcium channel blockers

The nurse understands a patient who is treated for hypertension may be switched to an angiotensin receptor blocker (ARB) because of which angiotensin-converting enzyme (ACE) inhibitor adverse effect? A. Dry, nonproductive cough B. Hypokalemia C. Fatigue D. Orthostatic hypotension

A. Dry, nonproductive cough

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? A. Heart rate B. Blood pressure (BP) C. Increases in edema D. Sodium level

A. Heart rate

On admission, a patient blood alcohol limit is greater than 400 mg/dL. The patient reports drinking a 12 pack of beer on a daily basis. Which of the following conditions is this patient MOST at risk for? A. Hypomagnesemia B. Hypermagnesemia C. Hyponatremia D. Hypernatremia

A. Hypomagnesemia

The nurse is assessing a client with fluid volume deficit. Which finding should the nurse identify that supports fluid volume​ deficit? A. Increased hematocrit B. Wheezes upon auscultation C. Edema D. Weight gain

A. Increased hematocrit

The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? A. Respiratory status B. Level of consciousness C. Level of pain D. Reflexes and movement of extremities

A. Respiratory status AIRWAY FIRST!!

The nurse is evaluating the laboratory work of a client who is receiving replacement therapy for hypokalemia. Which value should the nurse identify that evaluates the effectiveness of the replacement​ therapy? A. Serum potassium 4.2​ mEq/L B. Serum chloride 100​ mEq/L C. Serum potassium 2.3​ mEq/L D. Serum calcium 9.2​ mEq/L

A. Serum potassium 4.2​ mEq/L

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? A. Suggest that the patient's oxygen be humidified. B. Suggest that a simple face mask be used instead of a nasal cannula. C. Suggest that the patient be provided with an extra pillow. D. Suggest that the patient sit up in a chair at the bedside.

A. Suggest that the patient's oxygen be humidified. When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. It is reasonable to use humidified oxygen for patients who require high-flow oxygen systems for more than 24 hours or who report upper airway discomfort due to dryness. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

A. The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? a. Decongestants can be used to relieve swelling. b. Blowing the nose should be avoided to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position

ANS: A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

Which assessment finding for a patient who is receiving furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 180 mg/dL b. Blood potassium level of 3.0 mEq/L c. Early morning BP reading of 164/96 mm Hg d. Orthostatic systolic BP decrease of 12 mm Hg

ANS: B

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Obtain a BP reading in each arm and average the results. b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. c. Have the patient sit in a chair with the feet flat on the floor. d. Assist the patient to the supine position for BP measurements.

ANS: C The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position.

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? A Patient comfort B Airway patency C Incisional drainage D Blood pressure and heart rate

B Airway patency Remember the ABCs of prioritization. AIRWAY FIRST

Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following? A) Anemia. B) Hypertension. C) Dysmenorrhea. D) Acne vulgaris.

B) Hypertension. Before advising a client about oral contraceptives, the nurse needs to assess the client for of hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method.

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what? a) Tachypnea b) Bradypnea c) Hypoventilation d) Hyperventilation

B)Bradypnea

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a) Ask the client how long they have to rest between activities b) Observe the client's respiratory rate and pattern c) Assess for symmetry of chest expansion d) Report this to the health care provider immediately

B)Observe the client's respiratory rate and pattern

An immobile client has developed an area of skin breakdown on his hip. The nurse recognizes that there are several factors that potentially contributed to this skin breakdown. Select all of the following extrinsic factors that would have contributed to skin breakdown in a patient. A. Nutrition B. Moisture C. Friction D. Shear E. Tissue Perfusion

B, c, d Moisture, friction, and shear

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response? A. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." C. "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction." D. "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."

B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."

A patient's magnesium level is 0.9. The doctor orders Magnesium Sulfate IV. Which nursing intervention takes PRIORITY? A. Assessing for hypertension B. Monitoring deep tendon reflexes C. Monitoring potassium levels D. Monitoring skin turgor.

B. Monitoring deep tendon reflexes

Which ability should Nurse Rebecca expect from a client in the mild stage of dementia of the Alzheimer's type? A. Remembering the daily schedule. B. Recalling past events. C. Coping the anxiety. D. Solving problems of daily living.

B. Recalling past events

You're educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury? A. There is full loss of skin tissue that can extend to the muscle, bone, or tendon. B. A hallmark of a stage 3 pressure injury is that the skin will be intact but it not blanch. C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue. D. The wound edges will never roll away (epibole) as with a stage 2 pressure injury.

C

he charge nurse observes a new RN doing discharge teaching for a hypertensive patient who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. check the BP with a home BP monitor every day. b. move slowly when moving from lying to standing. c. increase the dietary intake of high-potassium foods .d. make an appointment with the dietitian for teaching.

C The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB). B. A 68-year old just returned from bronchoscopy and biopsy. C. A 72-year old who needs teaching about the use of incentive spirometry. D. A 69-year old with COPD who is ventilator dependent.

C. A 72-year old who needs teaching about the use of incentive spirometry. Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care.

Which medication should the nurse question if prescribed together with ACE inhibitors? A. Docusate sodium (Colace) B. Furosemide (Lasix) C. Potassium chloride (K-Dur) D. Morphine

C. Potassium chloride (K-Dur)

Mrs. Jordan is an elderly client diagnosed with Alzheimer's disease. She becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: A. Tell the client firmly that it is time to get dressed. B. Obtain assistance to restrain the client for safety. C. Remain calm and talk quietly to the client. D. Call the doctor and request an order for sedation.

C. Remain calm and talk quietly to the client.

The nurse teaches a 66-year-old man with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? A. "I should avoid using ibuprofen (Motrin) for pain and discomfort." B. "It is important for me to take my blood pressure medication every day." C. "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." D. "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

D Rationale: A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure would be to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin or nonsteroidal antiinflammatory drugs such as ibuprofen increase the bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed.

A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? A. "Take the medication with an antacid." B. "Take the medication with a glass of milk." C. "Take the medication with cereal." D. "Take the medication on an empty stomach."

D. "Take the medication on an empty stomach."

A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? A "You have everything to live for." B"Why do you see yourself as a failure?" C "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?"

D. "You've been feeling like a failure for a while?" Restating is the best form of therapeutic communication

Which of the following patients is MOST at risk for hypermagnesemia? A. A patient with alcoholism B. A patient taking a proton-pump inhibitor called Protonix C. A patient suffering from Crohn's Disease D. A patient with a magnesium level of 0.6 receiving IV magnesium sulfate

D. A patient with a magnesium level of 0.6 receiving IV magnesium sulfate Alcoholism would cause HYPOmagnesemia...not hypermagnesemia

A patient has a Magnesium level of 1.3. Which of the following is NOT a sign or symptom of this condition? A. Tall T-wave and depressed ST segment B. Torsades de pointes C. Positive Trouesseau's and Chvostek's D. Absent deep tendon reflexes

D. Absent deep tendon reflexes

Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated

D. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm.

The nurse would write which of the following outcome statements for a client starting an exercise program? A. Client will walk quickly three times a day B. Client will be able to walk a mile C. Client will have no alteration in breathing during the walk D. Client will progress to walking a 20-minute mile in one month

D. Client will progress to walking a 20-minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.

A patient with a magnesium level of 3.6 would exhibit which of the signs and symptoms EXCEPT?* A. Hypotension B. Profound Lethargy C. Respiratory failure D. Hyperreflexia of the deep tendons

D. Hyperreflexia of the deep tendons

The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals

D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings.

A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition? A. Memory loss occurring as part of the natural consequence of aging. B. Difficulty coping with physical and psychological change. C. Severe cognitive impairment that occurs rapidly. D. Loss of cognitive abilities, impairing ability to perform activities of daily living.

D. Loss of cognitive abilities, impairing ability to perform activities of daily living The impaired ability to perform self-care is an important measure of a client's dementia progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal activities of daily living, such as maintaining hygiene and grooming, toileting, making meals, and maintaining a household, are significant indications of dementia. Slowing of processes necessary for information retrieval is a normal consequence of aging. However, the global statement that memory loss occurs as part of natural aging is not true.

ACE inhibitors and ARBs both work to decrease blood pressure by which action? A. Enhance sodium and water resorption B. Increase the breakdown of bradykinin C. Prevent the formation of angiotensin II D. Prevent aldosterone secretion

D. Prevent aldosterone secretion

A patient reports cold, watery nasal discharge, sore throat, cough, and fever. The nurse suspects viral pharyngitis after receiving negative throat culture reports. Which regimen would ensure safe and effective care of the patient? Decreasing fluid uptake Prescribing an antibiotic Encouraging the use of lozenges Encouraging the use of saline gargles Administering acetaminophen (Tylenol)

Encouraging the use of lozenges Encouraging the use of saline gargles Administering acetaminophen (Tylenol)

A 35 year old female is currently pregnant with twins. She has 10 year old triplets who were born at 32 weeks gestation, and a 16 year old who was born at 41 week gestation. Twelve years ago she had a miscarriage at 19 weeks gestation. What is her GTPAL?* A. G=4, T=1, P=2, A=1, L=1 B. G=3, T=1, P=1, A=0, L=4 C. G=4, T=1, P=1, A=1, L=4 D. G=4, T=1, P=1, A=1, L=1

G=4, T=1, P=2, A=1, L=4

The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? A. Whole grains B. Green leafy vegetables C. Meats and dairy products D. Broccoli and Brussels sprouts

Meats and dairy products

A nurse is reviewing a basal body temperature chart with a couple. Which change would indicate probable ovulation? a) A decrease in temperature followed by an increase for several days b) An increase in temperature followed by a decrease for several days c) A decrease in temperature that remains until menses begins d) A steadily increasing temperature over seven daya

a) A decrease in temperature followed by an increase for several days

You are the nurse, and you go get your patient a partial rebreather mask. You pick up two masks that look similar and don't know which one is the partial rebreather mask and which is the nonrebreather mask. How do you distinguish between the two? a) The partial rebreather mask has a reservoir bag without a valve b) The partial rebreather mask has a reservoir bag with a one-way valve c) The partial rebreather mask does not have a reservoir bag attached to the mask d) The partial rebreather mask has a two-way valve

a) The partial rebreather mask has a reservoir bag without a valve

Your patient is complaining of a cough, itchy watery eyes, sneezing and a runny nose. On assessment you note that the patient has pale swollen nasal cavity. What would you suspect as the cause of these symptoms if the patient has been exposed to pollen and mold? a) allergic rhinitis b) sinusitis c) asthma d) common cold

a) allergic rhinitis

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a) Dyspnea b) Hypotension c) Small pulse pressure d) Decreased respiratory rate e) Pallor f) Increased pulse rate

a,c,e,f

The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report? a. Loss of peripheral vision b. Floating spots in the vision c. A yellow haze around everything d. A curtain coming across vision

a. Loss of peripheral vision

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: A. Normal sinus rhythm B. Sinus bradycardia C. Sick sinus syndrome D. First-degree heart block

a. Normal sinus rhythm measurements are normal, measuring 0.12 to 0.20 seconds and < .12 seconds, respectively.

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient's temperature is 100.1° F (37.8° C). d. The patient complains of level 8 (0 to 10 scale) pain.

a. The oxygen saturation is 89%. Remember: Pain shouldnt be a priority!

The nurse is caring for a client diagnosed with acute otitis media. Which s/s support this medical diagnosis? a. Unilateral pain in the ear b. Green, foul-smelling drainage c. Sensation of congestion in the ear d. Reports of hearing loss

a. Unilateral pain in the ear Otalgia (ear pain) is experienced by clients with otitis media

A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data? a) Impaired Gas Exchange b) Ineffective Airway Clearance c) Ineffective Breathing Pattern d) Risk for Respiratory Infection

b) Ineffective Airway Clearance

The client diagnosed with glaucoma is prescribed a biotic cholinergic medication. Which data indicate the medication has been effective? a. No redness or irritation of the eyes b. A decrease in intraocular pressure c. The pupil reacts briskly to light d. The client denies any type of floaters

b. A decrease in intraocular pressure

Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives? a. Weight gain should be reported to the physician. b. An alternate method of birth control is needed when taking antibiotics. c. If the client misses one or more pills, two pills should be taken per day for 1 week. d. Changes in the menstrual flow should be reported to the physician.

b. An alternate method of birth control is needed when taking antibiotics.

The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? a.Schilling's test, elevated b.Intrinsic factor, absent. c.Sedimentation rate, 16 mm/hour d.RBCs 5.0 million

b.Intrinsic factor, absent.

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. "I can take acetaminophen (Tylenol) to treat my discomfort." b. "I will drink lots of juices and other fluids to stay well hydrated." c. "I can use my nasal decongestant spray until the congestion is all gone." d. "I will watch for changes in nasal secretions or the sputum that I cough up."

c. "I can use my nasal decongestant spray until the congestion is all gone." The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

The client requires oxygen using a face mask but wants to discontinue the face mask while watching tv. Which of the following statements provides understanding by the nurse about simple face masks? a) Arrange a consultation with a respiratory therapist before discontinuing the face mask b) Encourage the client to remove the mask occasionally to begin the weaning process c) Obtain a physician's order to discontinue the face mask d) Change the face mask to a nasal cannula occasionally, at mealtimes.

d) Change the face mask to a nasal cannula occasionally, at mealtimes.

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds? a) Sonorous wheezes b) Sibilant wheezes c) Pleural friction rubs d) Coarse crackles

d) Coarse crackles

Your patient is complaining of having a runny nose, nasal congestion, a cough, a sore throat, a low fever, headache, and tiredness. She states she has felt like this for the past week and she says, "I think I spread whatever I have to my boyfriend because he's coming down with the same symptoms." What would you expect is the cause? a) allergic rhinitis b) sinusitis c) asthma d) Viral rhinitis (common cold)

d) Viral rhinitis (common cold)

The 65 yr old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? a. Corneal dystrophy b. Conjunctivitis c. Diabetic retinopathy d. Cataracts

d. Cataracts

A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient? a. Check BP daily before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet. d. Change position slowly to help prevent dizziness and falls.

d. Change position slowly to help prevent dizziness and falls The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change.

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Hand washing is the primary way to prevent spreading the condition to others. b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.

d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.

The nurse is performing an assessment on a client with fluid volume excess. Which finding should the nurse identify that supports fluid volume​ excess? (Select all that​ apply.) A .Tenting of skin B. Pitting edema C. Weight gain D. Thirst E. Crackles on auscultation

pitting edema, weight gain, crackles on auscultation ​

A client is experiencing severe diarrhea. Which data should indicate to the nurse that the client is experiencing fluid volume​ deficit? (Select all that​ apply.) A. Weight gain B. Increased heart rate C. Poor skin turgo D. Orthostatic hypotension E. Increased urine output

​increased heart rate, poor skin turgor, orthostatic hypotension