Clinical nursing Q3 Final
108.) What are the results of using glucocorticoid drugs to treat asthma? (Select all that apply.) a. Reduced bronchial hyperreactivity b. Reduced edema of the airway c. Reduced number of bronchial beta2 receptors d. Increased responsiveness to beta2-adrenergic agonists e. Increased synthesis of inflammatory mediators
abd
21.) A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort
abd
29.) Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications
abd
39.) a patient is being administered the first dose of adalimumab (humira). what actions by the nurse are most appropriate? a. Observe the patient for at least 2 hours afterward. b. Monitor the patient for rales and tachycardia. c. Inform the patient that she cannot breastfeed while on this drug. d. Ensure emergency equipment is working and nearby e. Make a follow up appointment for a lipid panel in 2 months
abd
140.) A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the clients bedside b. Ensure the client can communicate if awake c. Keep the television tuned to a favorite channel d. Provide back and hand massages when turning e. Turn the client every two hours or more
abde
17.) A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."
abde
22.) A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.
abde
111.) A home health nurse evaluates a patient who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this patient's evaluation? (Select all that apply.) A. Examination of mucous membranes and nail beds B. Measurement of rate, depth, and rhythm of respirations C. Auscultation of bowel sounds for abnormal sounds D. Check peripheral veins for distention while at rest E. Determine the patient's need and use of oxygen
abe
112.) A nurse plans care for a patient who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this patient's plan of care? (Select all that apply.) A. Ask the patient to drink 2 L of fluids daily. B. Add humidity to the prescribed oxygen. C. Suction the patient every 2 to 3 hours. D. Use a vibrating positive expiratory pressure device. E. Encourage diaphragmatic breathing.
abe
162.) A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night
abe
20.) The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis c. Excess uric acid excretion - Gout d. Footdrop and paresthesias - Osteoarthritis e. Vasculitis causing organ damage - Rheumatoid arthritis
abe
54.) A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a. Use a lift sheet when moving the client in bed. b. Avoid tape when applying dressings. c. Avoid whirlpool therapy. d. Use loose dressing on all wounds. e. Implement pressure-relieving devices.
abe
76.) A nurse assesses a patient who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. tachycardia b. new- onset cough c. purulent sputum d. bradypnea e. pain with respirations
abe
129.) The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. a. Activities should be resumed gradually. b. Avoid contact with other individuals, except family members, for at least 6 months. c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed. e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. f. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.
acd
18.) The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss
bce
53.) . A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take?(Select all that apply.) a. Prepare a room for reverse isolation. b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. d. Choose a roommate who also is immune suppressed. e. Ensure that gloves are available in the room.
bce
131.) A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur
bde
147.) A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.
bde
153.) A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor
bde
145.) A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement
be
102.) A patient with asthma is admitted to an emergency department with a respiratory rate of 22 breaths per minute, a prolonged expiratory phase, tight wheezes, and an oxygen saturation of 90% on room air. The patient reports using fluticasone [Flovent HFA] 110 mcg twice daily and has used 2 puffs of albuterol [Proventil HFA], 90 mcg/puff, every 4 hours for 2 days. The nurse will expect to administer which drug? a. Four puffs of albuterol, oxygen, and intravenous theophylline b. Intramuscular glucocorticoids and salmeterol by metered-dose inhaler c. Intravenous glucocorticoids, nebulized albuterol and ipratropium, and oxygen d. Intravenous theophylline, oxygen, and fluticasone (Flovent HFA) 220 mcg
c
123.) A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of coug
c
15.) A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. "Be sure you get enough sleep at night." b. "Eat plenty of high-protein, high-iron foods." c. "Notify your provider at once if you get a fever." d. "Weigh yourself every day on the same scale."
c
154.) The nurse is assessing the client's electrocardiography (ECG). What does the P wave on the ECG tracing represent? a. Contraction of the atria b. Contraction of the ventricles c. Depolarization of the atria d. Depolarization of the ventricles
c
158.) A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation
c
167.) A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention? a. Take the client's apical pulse for 1 full minute before drug administration. b. Place the client in Trendelenburg position to facilitate blood flow to the heart. c. Educate the client to sit on the side of the bed for a few minutes before rising. d. Instruct the client to drink 3 L of fluid daily when taking this medication.
c
100.) What actions would the nurse take? a. administer prescribed salmeterol (serevent) inhaler. b. assess the patient for a tracheal deviation c. Administer oxygen to keep saturations greater than 94% d. perform peak expiratory flow rate e. administer prescribed albuterol (Proventil) inhaler
ce
75.) The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-streaked sputum
3
104.) A patient who has been newly diagnosed with asthma is referred to an asthma clinic. The patient reports daily symptoms requiring short-acting beta2-agonist treatments for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient's forced expiratory volume in 1 second (FEV1) is 75% of predicted values. The nurse will expect this patient to be started on which regimen? a. Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed b. Daily low-dose inhaled glucocorticoid and a SABA as needed c. Daily medium-dose inhaled glucocorticoid/LABA combination d. No daily medications; just a SABA as needed
a
115.) A client has acute rhinitis. What is the most important intervention for the nurse to perform? a. Assess for symptoms of infection. b. Ascertain whether the client has allergies. c. Question the client on the use of nasal sprays. d. Do blood and urine screenings for drug use.
a
124.) A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age, History of diabetes On insulin twice a day, Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs, Dullness to percussion LLL, Afebrile, Oriented to person only WBC: 5,200/mm3, PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.
a
14.) A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.
a
27.) A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.
a
70.) A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium
a
71.) A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.
a
7.) The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.
a. IgA is found in high concentrations in secretions from mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.
8.) The nurse is teaching an elderly patient on the risks of infection for older adults. Which of the following factors would the nurse include in the education? a. Older patient are at more risk for respiratory tract and genitourinary infections. b. Older adults may not have a fever with sever infections. c. Older adults show expected changes in white blood cell counts. d. Older adults should receive influenza, pneumococcal and shingles vaccine. e. Skin tests for tuberculosis may be falsely negative
a. Older patient are at more risk for respiratory tract and genitourinary infections. b. Older adults may not have a fever with sever infections. d. Older adults should receive influenza, pneumococcal and shingles vaccine. e. Skin tests for tuberculosis may be falsely negative
55.) A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a. Wash your hands before touching the client. b. Wear gloves when bathing the client. c. Assess skin for breakdown during the bath. d. Apply lotion to lesions while the skin is wet. e. Use a damp cloth to scrub the lesions.
ab
113.) A nurse teaches a patient who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this patient's teaching? (Select all that apply.) A. "Avoid drinking fluids just before and during meals." B. "Rest before meals if you have dyspnea." C. "Have about six small meals a day." D. "Eat high-fiber foods to promote gastric emptying." E. "Increase carbohydrate intake for energy."
abc
121.) The public health nurse is providing education to social service workers about the reasons to encourage their clients to get an annual influenza (flu) vaccine. What reasons should the nurse include in the education session? (Select all that apply) a. The predominant influenza virus strain changes from year to year b. The new vaccine has specific antigens predicted for that year c. infants, young children and people aged 50 or older are more likely to get the flu d. people without health insurance are at higher risk of getting the flu e. people living in buildings with small quarters are at higher risk for getting the flu
abc
130.) A client enters the clinic with an acute sore throat and a temperature of 101.5° F (38.5° C). What diagnostic testing does the nurse educate the client about? (Select all that apply.) a. Complete blood count (CBC) b. Throat culture c. Rapid Antigen Test (RAT) d. Arterial blood gas e. Biopsy
abc
137.) A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? Select all that apply. a. Oxygen administered at 100%, PaO2 60 b. Increasing dyspnea c. Anxiety d. chest pain e. pitting pedal edema
abc
139.) The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the patient on a regular schedule
abcd
28.) A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.
abcd
30.) A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes
abcd
95.) A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.
abcd
120.) A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply. a. get plenty of rest b. increase intake of fluids c. take antipyretics for fever d. get a flu shot immediately e. eat fruits and veggies high in Vitamin C
abce
37.) The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I - Examples include hay fever and anaphylaxis b. Type II - Mediated by action of immunoglobulin M (IgM) c. Type III - Immune complex deposits in blood vessel walls d. Type IV - Examples are poison ivy and transplant rejection e. Type V - Examples include a positive tuberculosis test and sarcoidosis
acd
38.) A nurse has taught a patient about safety related to an automatic epinephrine injector and the indicators for obtaining replacements. Which statement by the patient indicate good understanding of this teaching? a. I need to go to the hospital after using it. b. I should get a new injector every 2 years. c. I will obtain a new pen if the cap comes off d. If the drug has expired, I will get a new pen e. I only need a new injector if I use the one I have
acd
The nurse is assessing a client with asthma. Scattered wheezes are noted, and the patients oxygen saturation is 88% on room air. 99.) What other assessments are essential for the nurse to perform? a. assess for accessory muscle use. b. assess a chest x-ray c. assess suprasternal retraction d. assess the mucous membrane e. perform a stress test
acd
125.) A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension
acde
151.) A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL
ace
152.) A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d.. Myocardial infarction e. Cardiac tamponade
ace
170.) An older adult client is prescribed furosemide (Lasix) for control of hypertension. What client education does the nurse provide? (Select all that apply.) a. "Confusion can occur when taking this medication." b. "Drink at least 3 liters of water every day." c. "Arise slowly from a chair or from your bed." d. "Persistent coughing is a side effect of this drug." e. "You should eat foods high in potassium."
ace
19.) An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.
ace
127.) A client started on therapy for tuberculosis infection is reporting nausea. What does the nurse teach this client? (Select all that apply.) a. Eat a diet rich in protein, iron, and vitamins. b. Do not drink fluids with medications. c. Take medications at bedtime. d. Space medications 12 hours apart. e. Take medications with milk. f. Take an antiemetic daily.
acf
168.) The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the health care provider? (Select all that apply.) a. Laboratory draw for activated partial thromboplastin time (aPTT) b. Administer vitamin K c. Laboratory draw for prothrombin time (PT)/international normalized ratio (INR) d. Administer protamine sulfate e. Administer enoxaparin (Lovenox)
ad
87.) A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy
ad
155.) A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output
ade
171.) A client is hospitalized after a myocardial infarction. Which hemodynamic parameters does the nurse correlate with cardiogenic shock? (Select all that apply.) a. Decreased cardiac output b. Increased cardiac output c. Increased mean arterial pressure (MAP) d. Decreased MAP e. Increased afterload f. Decreased afterload
ade
173.) The nurse is planning a community health promotion program for cardiovascular disease. Which risk factors of coronary artery disease (CAD) does the nurse include in the education? (Select all that apply.) a. Cigarette smoking b. Use of alcohol c. Insomnia d. Hypertension e. Obesity f. Depression
ade
80.) A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Find an activity that you enjoy and will keep your hands busy. b. Keep snacks like potato chips on hand to nibble on. c. Identify a punishment for yourself in case you backslide. d. Drink at least eight glasses of water each day. e. Make a list of reasons you want to stop smoking.
ade
86.) A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.
ade
90.) A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."
ade
52.) A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the clients heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.
adf
122.) An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."
b
13.) An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.
b
134.) A patient is on intravenous heparin to treat a pulmonary embolism. The patients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. decrease the heparin rate b. increase the heparin rate c. no change to the rate d. stop heparin, start warfarin (Coumadin)
b
136.) A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery
b
146.) The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected? a. Faint S1 and S2 sounds b. Decreased cardiac output c. Increased blood pressure d. Absent peripheral pulses
b
169.) The nurse assesses a client's legs. Which assessment finding indicates arterial insufficiency? a. Ankle discoloration and pitting edema b. Dependent mottling and absence of hair c. Pain with activity but not while resting d. Full veins present in dependent extremity
b
24.) 6. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.
b
34.) The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client
b
81.) A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the clients level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.
b
98.) A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. Cromone Disrupts the production of pathways of inflammatory mediators
b
5.) A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.
b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.
16.) The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.
b.c
128.) A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3
bc
143.) A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr
bc
172.) The nurse administers intravenous dobutamine (Dobutrex) to a client who has heart failure. Which clinical manifestations indicate that the client's status is improving? (Select all that apply.) a. Decreased heart rate b. Increased heart rate c. Increased contractility d. Decreased contractility e. Increased respiratory rat
bc
74.) a nurse prepares a patient who is scheduled for a bronchoscopy procedure at 9:00 AM. What actions would the nurse take? a. Provide a clear liquid breakfast b. verify that the informed consent was obtained c. document the patients allergies d. review the laboratory results e. hold the patients bronchodilator
bcd
92.) A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets
bcd
31.) client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the clients fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities
bcde
32.) A nurse is providing education about HIV risks at a health fair. what groups would the nurse include as needing to be tested for HIV? a. anyone who received a blood product in 1989 b. couples planning on getting married c. those who are sexually active with multiple partners d. injection drug users e. prostitutes and their customers
bcde
109.) A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.) a. What color is your sputum? b. Do you have any difficulty sleeping? c. How long does it take to perform your morning routine? d. Do you walk upstairs every day? e. Have you lost any weight lately?
bce
132.) Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema
bce
23.) A patient with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a cd4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first? a. Initiate droplet precautions for the patient b. Notify the provider about the cd4 results. c. Place the patient under airborne precautions. d. use standard precautions to provide care.
c
36.) A patient is in the hospital and receiving IV antibiotics. When the nurse answers the patients call light, the patient presents an appearance as shown below (lady with the side view of the swollen face) a. Administer epinephrine 1:1000, 0.3 mg IV push immediately b. apply oxygen by face mask at 100% and a pulse oximeter c. Ensure a patent airway while calling the rapid response team d. reassure the patient that these manifestations will go away
c
40.) The nurse provides discharge teaching for a client to prevent a new attack of gout. Which statement by the client indicates that additional teaching is required? a. "I will keep a food and symptom diary for a few weeks." b. "If I get a headache, I will take Tylenol instead of aspirin." c. "I hate to start limiting my fluid intake so much!" d. "Citrus juices and milk may keep me from having kidney stones."
c
65.) A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds
c
126.) The nurse is caring for a client who has inhalation anthrax. What nursing actions are of the highest priority? (Select all that apply.) a. Placing the client in an isolation room b. Teaching the client how to use a mask c. Teaching the client about long-term antibiotic therapy d. Using handwashing and other Standard Precautions e. Reporting suspected cases to the proper authorities
cde
141.) The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.) a. Change the settings in accordance with provider orders. b. Modify the settings for weaning the client. c. Assess the reasons for alarms. d. Compare the ventilator settings with ordered settings. e. Assess the water level in the humidifier. f. Change the ventilator tubing according to hospital policy.
cde
144.) The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. Excessive bubbling in the water seal chamber b. Vigorous bubbling in the suction control chamber c. Drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. Occlusive dressing in place over the chest tube insertion site f. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
cdef
114.) A patient with stable COPD receives prescriptions for an inhaled glucocorticoid and an inhaled beta2-adrenergic agonist. Which statement by the patient indicates understanding of this medication regimen? a. "I should use the glucocorticoid as needed when symptoms flare." b. "I will need to use the beta2-adrenergic agonist drug daily." c. "The beta2-adrenergic agonist suppresses the synthesis of inflammatory mediators." d. "The glucocorticoid is used as prophylaxis to prevent exacerbations.
d
135.) The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action? a. Increase the heparin dose and cancel discharge order. b. Increase the warfarin dose and continue discharge plan. c. Continue the current therapy and obtain order to discontinue discharge plan d. Discontinue the heparin and provide information about warfarin prior to discharge.
d
163.) After reviewing the client's chart upon admission to the unit, the nurse consults the health care provider about a new order for lovastatin (Mevacor). What triggered the nurse's action? a. Blood glucose of 182 mg/dL b. History of peptic ulcers c. History of high cholesterol d. Elevated liver enzymes
d
25.) An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.
d
57.) The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.
d
82.) A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention? a. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate. b. Crackles are heard in bases. The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
d
97.) A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.
d
