Test 4

A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? a. Induce vomiting. b. Instill activated charcoal. c. Perform a gastric lavage with aspiration. d. Administer syrup specac. e. Infuse IV fluids.

b. Instill activated charcoal. c. Perform a gastric lavage with aspiration. e. Infuse IV fluids.

A nurse is discussing disaster planning with the board members of a hospital. Which of the following individuals should the nurse expect to request extra supplies and staffing for the facility? A) Incident commander B) Medical command physician C) Triage officer D) Media liaison

B) Medical command physician

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? " You can resume playing golf in two days." " You need to tell your head back when washing your hair." " You can get water in your eyes the first day." " You need to limit your housekeeping activities."

" You need to limit your housekeeping activities."

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? "I should restrict rapid movements and avoid bending at the waist for several weeks" "I should wait until the day after surgery to wash my hair" "I will remove the dressing behind my ear in 7 days" "My hearing should be back to normal right after surgery"

"I should restrict rapid movements and avoid bending at the waist for several weeks"

A nurse is interviewing a group of people several weeks after a community tornado. Which of the following statements by a group member should the nurse identify as the emotional reaction of reconstruction? (Select all that apply) "I am tired, and I do not think I will ever be able to fix everything" "I can't believe we survived I keep telling everyone what happened" "Things will never be the same, but we will find a way to go on" "Our neighborhood is working together to make good changes"

"Things will never be the same, but we will find a way to go on" "Our neighborhood is working together to make good changes"

A nurse is preparing a presentation on bioterrorism. Which of the following findings should the nurse include as an indication of potential bioterrorism? Nationwide incidence of pneumonia is higher than the prior year. A large number of otherwise healthy adults are dying from sepsis A health department reports cases of influenza in October Most of the clients' diagnoses with pneumonia have elevated white blood cell count

A large number of otherwise healthy adults are dying from sepsis

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptoms is associated with this eye problem? total loss of vision Pain in the affected eye a yellow discoloration of the sclera A sense of a curtain falling across the field of vision

A sense of a curtain falling across the field of vision

A patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? (Select all that apply). A) Alanine aminotransferase (ALT) B) C-reactive protein (CRP) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST) E) B-type natriuretic peptide (BNP)

A) Alanine aminotransferase (ALT) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST)

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema

A) Asterixis

A patient who is a victim of a terrorist attack involving a chemical agent presents to the emergency department with visual disturbances, nausea, vomiting, forgetfulness, and irritability. The nurse suspects this patient has been exposed to which of the following chemical agents? A) Nerve B) Pulmonary C) Vesicants D) Blood

A) Nerve

A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient? A) Packed red blood cells (PRBCs) B) Vitamin K C) Oral anticoagulants D) Heparin infusion

A) Packed red blood cells (PRBCs)

A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A) Position the patient on the right side with a pillow under the costal margin after the procedure. B) Administer 1 unit of albumin 90 minutes before the procedure as ordered. C) Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure. D) Confirm that the patient's electrolyte levels have been assessed prior to the procedure.

A) Position the patient on the right side with a pillow under the costal margin after the procedure.

Which of the following precautions must be put in place for a patient who has been exposed to anthrax by inhalation? A) Standard B) Airborne C) Droplet D) Contact

A) Standard

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A) Two to 3 soft bowel movements daily B) Significant increase in appetite and food intake C) Absence of nausea and vomiting D) Absence of blood or mucus in stool

A) Two to 3 soft bowel movements daily

The nurse manager is discussing with the staff the facility's protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion? Select all that apply. A) Open doors to client rooms B) Move beds away from windows C) Close window shades and curtains D) Place blankets over clients who are confined to bed E) Relocate ambulatory clients from the hallways back into their rooms

B) Move beds away from windows C) Close window shades and curtains D) Place blankets over clients who are confined to bed

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A) Measurement of abdominal girth and body weight B) Assessment for esophageal variceal bleeding C) Assessment for signs and symptoms of jaundice D) Monitoring of results of liver function testing

B) Assessment for esophageal variceal bleeding

A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A) Watery, blood-streaked diarrhea B) Orange and foamy urine C) Increased abdominal girth D) Decreased cognition

B) Orange and foamy urine

A nurse caring for patients exposed to a terrorist attack involving chemicals has been advised that personal protective equipment must be worn to give the highest level of respiratory protection with a lesser level of skin and eye protection. This is considered: A) Level A B) Level B C) Level C D) Level D

B) Level B

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention would be initiated immediately? Apply ice to the affected eye. Irrigate the eye with cool water. Notify the primary Health care provider Accompany the client to the emergency department.

Apply ice to the affected eye.

A client is scheduled for an electronystagmography as part of a diagnostic work up for Meniere's disease. What is the most important question for the nurse to ask in preparation for this test? Have you ever experienced any anxiety in enclosed spaces Are you currently taking any stimulants or antivertigo medications Do you have a history of balance issues Do you have a history of high blood pressure

Are you currently taking any stimulants or antivertigo medications

A 78 year old client reports decreased hearing in right ear. The physician orders an irrigation of the right ear to remove cerumen. What is the priority action by the nurse? Protect the client's clothing from getting wet Use gentle pressure behind the cerumen impaction Ensure that warm water is used for irrigation Assess for a ruptured tympanic membrane

Assess for a ruptured tympanic membrane

The client is scheduled for right eye cataract removal surgery in five days. Which Preoperative instructions should be discussed with the client? Administer dilating drops to both eyes for 72 hours prior to surgery Prior to surgery do not lift or push any objects heavier than 15 pounds Make arrangements for being in the hospital for at least three days Avoid taking any type of medication which may cause bleeding, such as aspirin

Avoid taking any type of medication which may cause bleeding, such as aspirin

A community experiences an outbreak of meningitis and hospital beds are urgently needed. Which of the following clients should the nurse recommend for discharge? A) A client newly admitted with angina and a history of myocardial infarction 1 year ago B) A client who was preadmitted for rotator cuff surgery and has diabetes mellitus type 2 C) A client admitted the day before with pneumonia and dehydration D) A client who has a fractured hip and is scheduled for a total hip replacement the next day

B) A client who was preadmitted for rotator cuff surgery and has diabetes mellitus type 2

A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A) Finish all prescribed courses of antibiotics, regardless of symptom resolution. B) Adhere to dosing recommendations of OTC analgesics. C) Ensure that expired medications are disposed of safely. D) Ensure that pharmacists regularly review drug regimens for potential interactions.

B) Adhere to dosing recommendations of OTC analgesics.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A) Ensure that the patient's sodium intake does not exceed recommended levels. B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. C) Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D) Implement interventions aimed at ensuring a calm and therapeutic care environment.

B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages if cataract formation? Diplopia Eye pain Floating spots Blurred vision

Blurred vision

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply) Eye pain Floating spots Blurred vision White pupils Bilateral red reflexes

Blurred vision White pupils

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A) Assessment of blood pressure and assessment for headaches and visual changes B) Assessments for signs and symptoms of venous thromboembolism C) Daily weights and abdominal girth measurement D) Blood glucose monitoring q4h

C) Daily weights and abdominal girth measurement

Diagnostic testing has revealed that a patient's hepatocellular damage is restricted to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A) Cryosurgery B) Liver transplantation C) Lobectomy D) Laser hyperthermia

C) Lobectomy

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A) Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B) Place the left hand over the abdomen and behind the left side at the 11th rib. C) Place hand under right lower rib cage and press down lightly with the other hand. D) Hold hand 90 degrees to right side of the abdomen and push down firmly.

C) Place hand under right lower rib cage and press down lightly with the other hand.

A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A) Increased potassium intake B) Fluid restriction to 2 L per day C) Reduction in sodium intake D) High-protein, low-fat diet

C) Reduction in sodium intake

A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

C) Stage 3

A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A) The patient will obtain measurement of drainage from the T-tube. B) The patient will exercise three times a week. C) The patient will take immunosuppressive agents as required. D) The patient will monitor for signs of liver dysfunction.

C) The patient will take immunosuppressive agents as required.

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and sever eye pain over the operative sit. What would be the initial nursing action? Call the surgeon Reassure the client that this is normal Turn the client onto their operative side. Administer the prescribed pain medication and antiemetic.

Call the surgeon

A client asks the nurse, "how does glaucoma damage my eyesight?" The nurse should explain to the client that chronic open angle glaucoma? Leads to detachment of the retina Results from chronic eye inflammation Causes increased intraocular pressure Is caused by decreased blood flow to the retina

Causes increased intraocular pressure

A community health nurse is determining available and needed supplies in the event of a bioterrorism attack. The nurse should be aware that community members exposed to anthrax will need access to which of the following medications? Metronidazole Ciprofloxacin Zanamivir Fluconazole

Ciprofloxacin

Following a motorcycle accident, a 17 year old male is brought into the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? The tympanic membrane is pearly grey Tenderness reported when mastoid area is palpated Clear watery fluid draining from client's ear Malleus is visualized upon examination

Clear watery fluid draining from client's ear

Nerve deafness would most likely result from an injury or infection that damaged what nerve? Vagus nerve Cochlear nerve Vestibular nerve Trigeminal nerve

Cochlear nerve

The nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first? A) A postoperative client preparing for discharge with a new medication B) A client requiring daily dressing changes of a recent surgical incision C) A client scheduled for a chest x-ray after insertion of a nasogastric tube D) A client with asthma who requested a breathing treatment during the previous shift

D) A client with asthma who requested a breathing treatment during the previous shift

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse would assign priority to which client? A) A client complaining of muscle aches, a headache, and history of seizures B) A client who twisted their ankle when rollerblading and is requesting medication for pain C) A client with a minor laceration on the index finger sustained while cutting an eggplant D) A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

D) A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

The nurse expects the patient who has been admitted after exposure to a nerve agent to be treated with which of the following? A) Nitrate B) Dimercaprol C) Erythromycin D) Atropine

D) Atropine

A 40-year-old male patient who was at the site of a workplace explosion that is considered a disaster area has suffered second- and third-degree burns to 65% of his body, but he is conscious. This person would be triaged as: A) Green B) Yellow C) Red D) Black

D) Black

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A) Infusion of intravenous heparin B) IV administration of albumin C) STAT administration of vitamin K by the intramuscular route D) IV administration of octreotide (Sandostatin)

D) IV administration of octreotide (Sandostatin)

The home health nurse is assessing a patient who is immunosuppressed following a liver transplant. What is the most essential teaching for this patient and the family? A) How to promote immune function through nutrition B) The importance of maintaining the patient's vaccination status C) How to choose antibiotics based on the patient's symptoms D) The need to report any slight changes in the patient's health status

D) The need to report any slight changes in the patient's health status

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? Diuretic Beta-blocking agent Opioid analgesic Lactulose Sedative

Diuretic Beta-blocking agent Lactulose

Which action by the nurse has the highest priority when caring for a client diagnosed with vertigo? Administer antivertiginous medication as ordered Educate client on using the call light for ambulation Encourage client to keep their eyes open Encourage client to look straight ahead focusing on one object

Educate client on using the call light for ambulation

A nurse is reviewing the health records of a client with severe otitis media. Which of the following is a expected finding? (Select all that apply) Enlarged adenoids Report of recent upper respiratory infection Prescription for daily furosemide Light reflex visible upon exam of affected ear Ear pain relieved by meclizine

Enlarged adenoids Report of recent upper respiratory infection

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care? Avoid overuse of the eyes Decrease the amount of salkt in the diet Eye medications will need to be administered for life describe fluid intake to control the intraocular pressure.

Eye medications will need to be administered for life

A nurse should instruct a client who had cataract surgery to contact the physician if which of the following conditions develops? Glare Itching Eye pain Blurred vision

Eye pain

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? Increase intake of deep yellow and orange vegetables Administer eyedrops twice daily Avoid bending at the waist Wear an eyepatch at night

Increase intake of deep yellow and orange vegetables

A nurse is performing an otoscopic examination of a client. Patient which of the following is an expected finding? Pearly grey tympanic membrane Malleus visible behind the tympanic membrane Presence of soft cerumen in the external ear canal Fluid of bubble seen behind the tympanic membrane

Fluid of bubble seen behind the tympanic membrane

A nurse is caring for an older male client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with the disease? (Select all that apply) Gender Genetic predisposition Hypertension Age Diabetes Mellitus

Genetic predisposition Hypertension Age Diabetes Mellitus

A newly hired public health nurse is reviewing the disaster management cycle. Which of the following actions is a component of disaster prevention? Outlining specific roles of community agencies Identifying community vulnerabilities Prioritizing care of individuals Providing stress counseling

Identifying community vulnerabilities

A nurse is caring for a client who had a recent mastoidectomy. In an effort to prevent postoperative infection, what is the priority client education? Teach the client about ototoxic medications Instruct client to protect ear from water for several weeks Teach client to remove cerumen once per week Instruct client to protect ear from extreme temperatures

Instruct client to protect ear from water for several weeks

A client presents to the ED with a sudden onset of room spinning, nausea, vomiting, and tinnitus. The client mentions that she suddenly cannot hear. What would the nurse expect the clients diagnosis to be? Meniere's disease Ototoxicity Labyrinthitis Otosclerosis

Labyrinthitis

A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) Limit physical activity Avoid alcohol Take acetaminophen for comfort Wear a mask when in public places Eat small frequent meals

Limit physical activity Avoid alcohol Eat small frequent meals

The nurse is reviewing the physician's orders for a client with Meniere's disease. Which diet will most likely be prescribed? Low cholesterol diet Low sodium diet Low carbohydrate diet Low fat diet

Low sodium diet

The nurse manager is discussing with the staff the facilitys protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion? Select all that apply. a. Open the doors to the client rooms b. move the beds away from windows. c. Close windows shades and curtains. d. Place blankets over clients who are confined to bed. E Relocate ambulatory clients from the hallways back into their rooms.

b. move the beds away from windows. c. Close windows shades and curtains. d. Place blankets over clients who are confined to bed.

A client is admitted to the recovery area after cataract removal with an intraocular lens implant on his right eye. Which position would be the best for the client? Supine and flat High Fowlers On the left side On the right side

On the left side

An older adult client who has diabetes mellitus reports a gradual loss of peripheral vision. The nurse should recognize that this is a manifestation of which of the following diseases? Cataracts Open angle glaucoma Macular degeneration Angle closure glaucoma

Open angle glaucoma

A Community health nurse is educating the public on the agents of bioterrorism. Which of the following agents should the nurse include as Category A biological agents? (Select all that apply) Hantavirus Typhus Plague Tularemia Botulism

Plague Tularemia Botulism

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (Select all that apply) Reduce exposure to bright lighting Move head slowly when changing positions Do not eat fruit high in potassium Plan evenly-spaced daily fluid intake Avoid fluids containing caffeine

Reduce exposure to bright lighting Move head slowly when changing positions Plan evenly-spaced daily fluid intake

A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? Initiate contact precautions Weigh the client weekly Measure abdominal girth at the base of the ribcage Provide a high-calorie, high-carbohydrate diet

Provide a high-calorie, high-carbohydrate diet

The nurse has noted that the physician has a diagnosis of presbycusis on the client's chart. The nurse plans care knowing the condition is what? Sensorineural hearing loss that occurs with aging Conductive hearing loss that occurs with aging Tinnitus that occurs with aging Associated with deafness

Sensorineural hearing loss that occurs with aging

A client is being provided with discharge instructions after having a cataract extraction and intraocular lens implant. Which of the following activities should the nurse advise the client to avoid? Straining while having a bowel movement Eating a regular diet Reading or watching TV for at least 12 hours Keeping a patch over the affected eye for 24 hours

Straining while having a bowel movement

A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding? Presence of purulent lesion in external ear canal Feeling of pressure in ear Bulging, red bilateral tympanic membranes Unilateral hearing loss

Unilateral hearing loss

A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder in this part of the ear? Hearing loss Pruritus Tinnitus Burning of the ear

Tinnitus

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurses priority? a. A client who received crush injuries to the chest and abdomen and is expected to die b. A client who has 4-inch laceration to the head c. A client who has parial-thickness and full-thickness burns to his face, neck, and chest. d. A client who has a fractured fibula and tibia.

c. A client who has parial-thickness and full-thickness burns to his face, neck, and chest.

A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first? a. A post operative client preparing for discharge with a new medication b. A client requiring daily dressing changes of a recent surgical incision. c. A client scheduled for a chest xray after insertion of a nasogastric tube. d. A client with asthma who requested a breathing treatment during the previous shift.

d. A client with asthma who requested a breathing treatment during the previous shift.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse would assign priority to which client? a. A client complaining of muscle aches, a headacehm and history seizures b. A client who twisted their ankle when rollerblading and is requesting medication for pain. c. A client with a minor laceration on the index finger sustained while cutting and eggplant. d. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce.

d. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce.