310 practice questions exam 2

A patient has just returned to the floor following a transurethral resection of the prostate (TURP). A triple lumen indwelling urinary catheter has been inserted for continuous bladder irrigation. What, in addition to balloon inflation, are the functions of the three lumens? A. Continuous inflow and outflow of irrigation solution B. Intermittent inflow and continuous outflow or irrigation solution C. Continuous inflow and intermittent outflow of irrigation solution D. Intermittent flow of irrigation solution and prevention of hemorrhage

A. Continuous inflow and outflow of irrigation solution

A patient with cancer of the prostate has just returned to the unit from the PACU after a complicated surgery. The nurse is monitoring the patient's urine output hourly and notifies the physician when the hourly output is less than what? A. 30 ml B. 50 ml C. 100 ml D. 125 ml

A. 30 ml

The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula? A. A vein and an artery in your arm will be attached surgically. B. The arm should be immobilized for 4 to 6 days. C. One needle will be inserted into the fistula for each dialysis treatment. D. The fistula can be used 2 days after the surgery for dialysis treatment.

A. A vein and an artery in your arm will be attached surgically.

A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A. Assess pulse of affected extremity every 15 minutes at first. B. Palpate the affected leg for pain during every assessment. C. Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D. Perform Doppler evaluation once daily.

A. Assess pulse of affected extremity every 15 minutes at first.

A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A. Avoiding tight-fitting socks. B. Limit activity whenever possible. C. Sleep with legs in a dependent position. D. Avoid the use of pressure stockings.

A. Avoiding tight-fitting socks.

A patient presents to the ED in distress and complaining of "crushing" chest pain. What is the nurse's priority for assessment? A. Prompt initiation of an ECG B. Auscultation of the patient's point of maximal impulse (PMI) C. Rapid assessment of the patient's peripheral pulses D. Palpation of the patient's cardiac apex

A. Prompt initiation of an ECG

A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications? Select all that apply. A. Decreased protein intake B. Decreased sodium intake C. Increased potassium intake D. Fluid restriction E. Vitamin D Supplementation

A. Decreased protein intake B. Decreased sodium intake D. Fluid restriction

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention? A. Defibrillation B. ECG monitoring C. Implantation of a cardioverter defibrillator D. Angioplasty

A. Defibrillation

During the admission assessment of a patient with renal stones, was parameters would be priorities for the nurse to address? Select all that apply. A. Dietary history B. Family history of renal stones C. Medication history D. Surgical history E. Vaccination history

A. Dietary history B. Family history of renal stones C. Medication history

The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A. Dyspnea B. Unusual fatigue C. Hypotension D. Syncope E. Peripheral cyanosis

A. Dyspnea B. Unusual fatigue D. Syncope

The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards, the nurse should anticipate the administration of what medication? A. Epinephrine 1 mg IV push B. Lidocaine 100 mg IV push C. Amiodarone 300 mg IV push D. Sodium bicarbonate 1 amp IV push

A. Epinephrine 1 mg IV push

A nurse is teaching a 53 year old man about prostate cancer. What information should the nurse provide to best facilitate the early identification of prostate cancer? A. Have a digital rectal examination and prostate specific antigen (PSA) test done yearly B. Have a transrectal ultrasound every 5 years C. Perform monthly testicular self-examinations, especially after age 60 D. Have a complete blood count (CBC), blood urea nitrogen (BUN) and creatinine assessment performed annually

A. Have a digital rectal examination and prostate specific antigen (PSA) test done yearly

Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it? A. Heart failure B. Glomerulonephritis C. Ureterolithiasis D. Aminoglycoside toxicity

A. Heart failure

A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? A. Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B. Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C. A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D. There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.

A. Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.

A 43 years old man is diagnosed with renal calculi that is causing bladder outlet obstruction. This condition can cause what? A. Hydronephrosis B. Nephritic syndrome C. Pylonephritis D. Nephrotoxicity

A. Hydronephrosis

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A. Hypotension B. Hypervolemia C. Heart murmurs D. Dysrhythmias E. Hypertension

A. Hypotension D. Dysrhythmias E. Hypertension

A patient who is post-op day 10 reported occasional "dribbling" of urine. How should the nurse best respond to this patient's concern? A. Inform the patient that urinary control is likely to return gradually B. Arrange for the patient to be assessed by his urologist. C. Facilitate the insertion of an indwelling urinary catheter by the home care nurse. D. Teach the patient to perform intermittent self-catheterization

A. Inform the patient that urinary control is likely to return gradually

The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patient's symptoms are due to an MI, what will have happened to the myocardium? A. It may have developed an increased area of infarction during the time without treatment. B. It will probably not have more damage than if he came in immediately. C. It may be responsive to restoration of the area of dead cells with proper treatment. D. It has been irreparably damaged, so immediate treatment is no longer necessary.

A. It may have developed an increased area of infarction during the time without treatment.

A patient has experience occasional urinary incontinence in the last 5 weeks since his prostatectomy. In order to promote continence, the nurse should encourage which of the following? A. Pelvic floor exercises B. Intermittent urinary catheterization C. Reduced physical activity D. Active range of motion exercises

A. Pelvic floor exercises

The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A. Provide a high-calorie, high-protein diet. B. Apply a clean occlusive dressing once daily and whenever soiled. C. Irrigate the wound with hydrogen peroxide once daily. D. Apply an antibiotic ointment on the surrounding skin with each dressing change.

A. Provide a high-calorie, high-protein diet.

A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post procedure care? A. Strain the patient's urine following the procedure B. Administer a bolus of 500 ml normal saline following the procedure C. Monitor the patient for fluid overload following the procedure D. Insert a urinary catheter for 24-48 hours after the procedure

A. Strain the patient's urine following the procedure

The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what? A. Wash hands carefully and frequently. B. Ensure immediate function of the donated kidney C. Instruct the patient to wear a face mask. D. Bar visitors from the patient's room.

A. Wash hands carefully and frequently.

A patient was diagnosed with oxalate renal calculi. When planning this patient's health education, what nutritional guidelines should the nurse provide? A. restrict protein intake as ordered B. increase intake of potassium rich foods C. follow a low calcium diet D. encourage intake of food containing oxalates

A. restrict protein intake as ordered

The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day? A. 1250 ml B. 2000 ml C. 2750 ml D. 3500 ml

B. 2000 ml

The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? A. A patient with a history of polycystic kidney disease B. A patient with diabetes mellitus and poorly controlled hypertension C. A patient who is morbidly obese with a history of vascular disorders D. A patient with severe chronic obstructive pulmonary disease

B. A patient with diabetes mellitus and poorly controlled hypertension

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of heart failure and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A. Aoritis B. Deep vein thrombosis C. Thoracic aortic aneurysm D. Raynaud's disease

B. Deep vein thrombosis

A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? A. Imbalanced nutrition: More than body requirements B. Excess fluid volume C. Sedentary lifestyle D. Adult failure to thrive

B. Excess fluid volume

While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A. Assess the patient's use of over-the-counter dietary supplements. B. Implement interventions relevant to arterial narrowing. C. Encourage the patient to increase intake of foods high in vitamin K. D. Adjust the patient's activity level to accommodate decreased coronary output.

B. Implement interventions relevant to arterial narrowing.

A nurses preparing a patient for discharge after a successful treatment for kidney stones. The nurse knowns that there is a 50% chance of recurrence of kidney stones. What preventative measure should the nurse encourage the patient to adopt? A. Increasing intake of protein from plant sources B. Increasing fluid intake C. Adopting a high calcium diet D. Eating several small meals each day

B. Increasing fluid intake

A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse realizes significant urine leakage round the suprapubic tube. What is the nurse's most appropriate action? A. Cleanse the skin surrounding the suprapubic tube B. Inform the urologist of this finding C. Remove the suprapubic tube and apply a wet to dry dressing D. Administer antispasmodic drugs as ordered

B. Inform the urologist of this finding

A 56 years old man reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. His left lower leg is slightly edematous and is hairless. When planning this patient's care, the nurse should address what problem? A. Coronary artery disease (CAD) B. Intermittent claudication C. Arterial embolus D. Raynaud's disease

B. Intermittent claudication

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? A. Leg exercises increase the patient's muscle mass postoperatively. B. Leg exercises improve circulation and prevent venous thrombosis. C. Leg exercises help to prevent pressure sores to the sacrum and heels. D. Leg exercise help increase the patient's level of consciousness after surgery

B. Leg exercises improve circulation and prevent venous thrombosis.

A nurse in the ED receives a patient with a recent diagnosis of nephrolithiasis. The patient has no previous history of cardiopulmonary disorders. What aspect of care should the nurse prioritize? A. 1000 L of IV fluid administration B. Insertion of an indwelling urinary catheter C. Pain management C. Assisting with aspiration of the stone

C. Pain management

An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A. Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories B. Morphine sulphate, oxygen, and bed rest C. Oxygen and beta-adrenergic blockers D. Bed rest, albuterol nebulizer treatments, and oxygen

B. Morphine sulphate, oxygen, and bed rest

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum? A. Skin turgor B. Potassium level C. White blood cell count D. Peripheral pulses

B. Potassium level

The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A. P wave inversion B. T wave inversion C. Q wave changes with no change in ST or T wave D. P wave enlargement

B. T wave inversion

The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A. Numbness and tingling in the distal extremities B. Unequal peripheral pulses between extremities C. Visible clubbing of the fingers and toes D. Reddened extremities with muscle atrophy

B. Unequal peripheral pulses between extremities

A nurse is providing a health awareness session at a community center. The nurse was asked about the risk of varicose veins. What should the nurse suggest as a preventative measure for varicose veins? A. Sit with crossed legs for a few minutes each hour to promote relaxation. B. Walk for several minutes every hour to promote circulation. C. Elevate the legs when tired. D. Wear snug-fitting ankle socks to decrease edema.

B. Walk for several minutes every hour to promote circulation.

A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A. A patient who has peripheral edema secondary to chronic heart failure B. An older adult patient who has a diagnosis of unstable angina C. A patient with poorly controlled type 1 diabetes who is a smoker D. A patient who has community-acquired pneumonia and a history of COPD

C. A patient with poorly controlled type 1 diabetes who is a smoker

A nurse is providing an educational session to a group of men at a local community center. The nurse should cite an increased risk of prostate cancer in what ethnic group? A. Native Americans B. Caucasian Americans C. African Americans D. Asian Americans

C. African Americans

The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure? A. Jugular vein distention B. Right upper quadrant pain C. Bibasilar fine crackles D. Dependent edema

C. Bibasilar fine crackles

A nurse is admitting a 45-year-old man who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A. The lack of exercise, which is the main cause of PAD. B. The likelihood that heavy alcohol intake is a significant risk factor for PAD. C. Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D. Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.

C. Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.

A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase? A. Hypokalemia B. Hypocalcemia C. Dehydration D. Acute flank pain

C. Dehydration

How should the nurse best position a patient who has leg ulcers that are venous in origin? A. Keep the patient's legs flat and straight. B. Keep the patient's knees bent to 45-degree angle and supported with pillows. C. Elevate the patient's lower extremities. D. Dangle the patient's legs over the side of the bed.

C. Elevate the patient's lower extremities.

A nurse is caring for a 33 year old male who has come to the clinic for a physical examination. He reports that he has not had a routine physical in 5 years. The physician conducts a digital rectal examination (DRE). The findings of the DRE reveals a non-mobile, "stoney" hardening in the posterior lobe of the prostate gland. The nurse recognizes that the observation typically indicates what? A. A normal finding B. A sign of early prostate cancer C. Evidence of a more advanced lesion D. Metastatic disease

C. Evidence of a more advanced lesion

A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patient's admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply. A. Diarrhea B. High fever C. Hematuria D. Urinary frequency E. Acute pain

C. Hematuria D. Urinary frequency E. Acute pain

The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? A. Hypernatremia B. Hypomagnesemia C. Hyperkalemia D. Hypercalcemia

C. Hyperkalemia

The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? A.Partial thromboplastin time (PTT) within normal reference range B. Prothrombin time (PT) eight to ten times the control C. International normalized ratio (INR) between 2 and 3 D. Hematocrit of 32%

C. International normalized ratio (INR) between 2 and 3

The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient? A. Maintain a resting heart rate below 70 bpm. B. Maintain adequate control of chest pain. C. Maintain adequate cardiac output. D. Maintain normal cardiac structure.

C. Maintain adequate cardiac output.

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? A. Monitor her blood pressure daily B. Assess her radial pulses daily C. Monitor her weight daily D. Monitor her bowel movements

C. Monitor her weight daily

A nurse is assessing a 55 year old male patient who is complaining of perineal discomfort, burning, urgency, and frequency with urination. The patient reports that he has pain with ejaculation. The nurse knows that the patient is exhibiting symptoms of what? A. Varicocele B. Epididymitis C. Prostatitis D. Hydrocele

C. Prostatitis

The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A. P wave B. T wave C. QRS complex D. U wave

C. QRS complex

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? A. Sudden increase in blood pressure and a decrease in heart rate B. Cessation of pulsating in an aneurysm that has previously been pulsating visibly C. Sudden onset of severe back or abdominal pain D. New onset of hemoptysis

C. Sudden onset of severe back or abdominal pain

The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient? A. Using a stethoscope for auscultating the fistula is contraindicated. B. The patient feels best immediately after the dialysis treatment. C. Taking a BP reading on the affected arm can damage the fistula. D. The patient should not feel pain during initiation of dialysis.

C. Taking a BP reading on the affected arm can damage the fistula.

A patient who has recently undergone ESWL for the treatment of renal calculi called the urology unit where he was treated. The patient told the nurse that he has a temperature of 101.1F (38.4C). How should the nurse best respond to the patient? A. Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence B. Remind the patient that occasional febrile episodes are expected following ESWL. C. Tell the patient to report to the ED for further assessment. D. Tell the patient to monitor his temperature for the next 24 hours and then contacts urologist's office.

C. Tell the patient to report to the ED for further assessment.

A nurse is performing an admission assessment on a 40 year old man who has been admitted for outpatient surgery on his right knee. The patient reports: "My father died of prostate cancer at age 48." The nurse should instruct him on which of the following health promotion activities? A. The patient will need PSA levels drawn starting at age 55. B. The patient should have testing for presence of the CDH1 and STK11 genes C. The patient should have PSA levels drawn regularly D. The patient should limit alcohol use due to the risk of malignancy

C. The patient should have PSA levels drawn regularly

The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)? A. The patient is complains of an inability to initiate voiding. B. The patient's urine is cloudy with a foul odor. C. The patient's average urine output has been 10 mL/hr for several hours. D. The patient complains of acute flank pain.

C. The patient's average urine output has been 10 mL/hr for several hours.

The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient? A. limit oral fluid to 1000ml intake for 1-2 days B. report the presence of fine, sand like particles through the nephrostomy tube C. notify the physician about cloudy or foul smelling urine D. report any pink tinged urine within 24 hours after the procedure

C. notify the physician about cloudy or foul smelling urine

A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? A. Ensure that the patient moves the extremity with the vascular access site as little as possible. B. Change the dressing over the vascular access site at least every 12 hours. C. Utilize the vascular access site for infusion of IV fluids. D. Assess for a thrill or bruit over the vascular access site each shift.

D. Assess for a thrill or bruit over the vascular access site each shift.

A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic? A. Typical diet B. Allergy status C. Psychosocial stressors D. Current medication use

D. Current medication use

A 43 years old man is admitted with kidney stones. During admission assessment, the patient tells the nurse that he has been drinking 2.5L to 3 L of fluids daily since his flank pain started. What would be the nurse's best response? A. Supplement the patient's fluid intake with a high-calorie diet B. Emphasize the need to limit intake to 2L of fluid daily C. Obtain an order for a high sodium diet to prevent dilution hyponatremia D. Encourage the patient to continue this pattern of fluid intake

D. Encourage the patient to continue this pattern of fluid intake

A patient has presented at the clinic with symptoms of benign prostatic hyperplasia (BPH). What diagnostic findings would suggest that this patient has chronic urinary retention? A. Hypertension B. Peripheral edema C. Tachycardia and other dysrhythmias D. Increased blood urea nitrogen (BUN)

D. Increased blood urea nitrogen (BUN)

A patient is 24 hours postoperative following prostatectomy. The urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag? A. Red wine colored B. Tea colored C. Amber D. Light pink

D. Light pink

A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments? A. They are the part of an ECG that reflects systole. B. They are the part of an ECG used to calculate ventricular rate and rhythm. C. They are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D. They are the part of an ECG that represents early ventricular repolarization.

D. They are the part of an ECG that represents early ventricular repolarization.

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider immediately? A. Drinks 6 cans of beers on the weekend B. Gets up 4 times during the night to void C. Smokes 1 pack of cigarettes daily D. Uses sildenafil (Viagra) occasionally

D. Uses sildenafil (Viagra) occasionally

The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time? A. Only when needed B. Daily at bedtime C. First thing in the morning D. With each meal

D. With each meal

A 27-year-old male patient was admitted with severe left flank pain. After a confirmation of a renal calculi, what would be the most appropriate nursing interventions. Select all that apply. a. Administer prescribed analgesics b. Strain all urine output c. Administer a low-fat diet. d. Promote increased fluid intake e. Position patient in Trendelenburg position.

a. Administer prescribed analgesics b. Strain all urine output d. Promote increased fluid intake

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply a. Cigarette smoking b. Sexual intercourse c. Deep sleep d. Amphetamine use e. Cold exposure

a. Cigarette smoking b. Sexual intercourse d. Amphetamine use e. Cold exposure

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is MOST important at this time? a. Strain the urine carefully b. Administer meperidine every 3 hours c. Apply warm compress to the flank area d. Report hematuria to the healthcare provider

a. Strain the urine carefully

Which of the following nursing actions is most important in caring for the client following lithotripsy? a. Strain the urine carefully for stone fragments. b. Notify the physician of hematuria. c. Administer allopurinol (Zyloprim). d. Monitor the continuous bladder irrigation.

a. Strain the urine carefully for stone fragments.

A nurse is completing the admission assessment of a client who has a kidney stone. Select all that the nurse would expect to find. a. Tachycardia b. CVA tenderness/pain c. Bradypnea d. Hematuria e. Polyuria

a. Tachycardia b. CVA tenderness/pain d. Hematuria

An 82-year-old male patient is receiving continuous bladder irrigation with 0.45% NaCl. 1200ml have been instilled, a total output of 1500ml is collected in the Foley catheter collection bag. What would be the true urine output? a.2700 ml b. 300 ml c. 1500 ml d. 1200 m

b. 300 ml

The client is one day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? a. Medicate the client with intravenous morphine b. Assess the client chest dressing and vital signs c. Encourage the client to turn from side to side d. check the client's telemetry monitor.

b. Assess the client chest dressing and vital signs

A patient is hospitalized with ureter renal calculi. What is the intervention the nurse should provide first? a. Start straining their urine b. Assess their pain level and administer pain medication as ordered c. Encourage fluid intake and provide them with a full pitcher of water d. Collect a urine sample for analysis

b. Assess their pain level and administer pain medication as ordered

A patient presents with shortness of breath, non-pitting edema of lower extremities, and distended neck veins. Past medical history includes hyperlipidemia and asthma. What are appropriate nursing actions? Select all the apply. a.Assess medication regimen for asthma b. Check peripheral pulses c. Administer Oxygen d. Administer Nitroglycerine e. Restrict fluid and sodium

b. Check peripheral pulses c. Administer Oxygen e. Restrict fluid and sodium

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) a. Anorexia b. Dizziness c. Extreme fatigue d. Sharp inspiratory chest pain e. Dyspnea

b. Dizziness c. Extreme fatigue e. Dyspnea

The nurse is reviewing a client's record and notes that the HCP has documented an onset of acute kidney injury. On review the nurse would most likely to note which findings. Select all that apply a. Decreased red blood cell count b. Elevated Creatinine c. Elevated BUN d. Decreased specific gravity e. Decreased hemoglobin level

b. Elevated Creatinine c. Elevated BUN d. Decreased specific gravity

Which of the following are NOT typical signs/symptoms of right-sided heart failure? Select all that apply. a. Jugular venous distention b. Persistent cough c. Weight gain d. Crackles e. Nocturia f. Orthopnea

b. Persistent cough d. Crackles f. Orthopnea

After teaching a patient with chronic angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? a. "I will replace my nitroglycerin supply every six months." b. "I will take acetaminophen(Tylenol) to treat the headache caused by nitroglycerine". c. "I can take up to five tablets every 3 minutes for relief of my chest pain". d. "I will take nitroglycerin 10 minutes before planned activities that usually causes chest pain".

c. "I can take up to five tablets every 3 minutes for relief of my chest pain".

Which assessment data would the nurse recognize to support the diagnoses of abdominal aortic aneurysm (AAA)? a. Shortness of breath b. Ripping abdominal pain c. Abdominal bruit d. Decreased urinary output

c. Abdominal bruit

A client had a transurethral prostatectomy for benign prostatic hypertrophy. He's currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the interventions should be done first? A. Stop the irrigation and call the physician b. Administer a belladonna and opium suppository as ordered by the physician. c. Check for the presence of clots, and make sure the catheter is draining properly d. Administer an oral analgesic

c. Check for the presence of clots, and make sure the catheter is draining properly

Which ECG finding is most indicative of severe myocardial infarction? a. peaked P wave b. long QT interval c. ST segment elevation d. PR interval elevation

c. ST segment elevation

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding? a. Sinus tachycardia b. Normal sinus rhythm c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus bradycardia with premature ventricular contractions (PVCs)

c. Sinus rhythm with premature atrial contractions (PACs)

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of BPH. a. Occasional constipation b. Nocturia c. Scrotal edema d. Decreased force in the stream of urine

d. Decreased force in the stream of urine

After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output? a. It's a normal finding caused by blood loss during surgery. b. It's an abnormal finding that will correct itself when the client ambulates. c. It's a normal finding associated with the client's nothing-by-mouth status. d. It's an abnormal finding that requires further assessment.

d. It's an abnormal finding that requires further assessment.

After receiving change of shift report in the coronary care unit, which client should you assess first? a. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled. b. A client who has first degree heart block ,rate 68, after having an inferior myocardial infarction. c. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 d. The client with acute coronary syndrome who has a 3 pounds weight gain and dyspnea

d. The client with acute coronary syndrome who has a 3 pounds weight gain and dyspnea