Concepts Exam 2
Which statement should the nurse include when providing anticipatory guidance to the patents of a 3 year old client? A) "It is important to set limits with your child." B) "Your child may begin to have more nightmares." C) "It is important to enroll your child in swimming lessons." D) "Your child mat begin to exhibit more aggressive behavior."
A) "It is important to set limits with your child."
What is contact precautions?
Prevents transmission of disease by direct or indirect contact. Ex: diarrhea, draining wound
What is droplet precautions?
Organisms that can be spread by large-particle droplets. Ex: Influenza
What is neutropenic precautions?
Used with patients who are immunocompromised. Ex: AIDS, chemotherapy
A pregnant woman was diagnosed with hypertension and was administered magnesium sulfate. What drug should be co-administered to prevent magnesium toxicity? A) Nifedipine B) Terbutaline C) Indomethacine D) Calcium gluconate
D) Calcium gluconate
The school nurse is assessing a 10-year-old boy with hemophilia who has fallen while playing in the schoolyard. At which site does the nurse expect to find internal bleeding? A) Joints B) Abdomen C) Cerebrum D) Epiphyses
A) Joints
The home health nurse is monitoring a client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classical signs of preeclampsia? Select all that apply: A) Proteinuria B) Hypertension C) Low-grade fever D) Generalized edema E) Increased pulse rate F) Increased respiratory rate
A) Proteinuria B) Hypertension D) Generalized edema
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea, the temperature is 100.6ºF. Which of the following would be a priority outcome for this client? A) Prevention of urinary tract outcomes B) Alleviation of nausea C) Alleviation of pain D) Maintenance of fluid and electrolyte balance
C) Alleviation of pain
The nurse is providing home care instructions to the parents of a 10 year old boy with hemophilia. Which sport activity should the nurse suggest? A) Soccer B) Baseball C) Football D) Swimming
D) Swimming
The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? A) Oxygen therapy B) Cardiac monitoring C) Nutrition supplements D) Venous thromboembolism (VTE) prevention
D) Venous thromboembolism (VTE) prevention
The nursing leader is teaching the newly hired nurse about the use of an electronic medication administration record. Which statement of the newly hired nurse indicates effective learning? A) "It will identify medication errors." B) "It will be accessible to a single user." C) It will decrease the accuracy of charge capture." D) "It will decrease the accuracy of pharmacokinetic monitoring."
A) "It will identify medication errors."
What advice is appropriate for a growing child to prevent obesity? Select all that apply: A) "You should eat small meals throughout the day." B) "You should put a video game system in your bedroom." C) "You should drink fewer sweetened beverages every day." D) "You should watch television for less than 2 hours every day." E) "You should skip breakfast and eat a healthy lunch and dinner."
A) "You should eat small meals throughout the day." C) "You should drink fewer sweetened beverages every day." D) "You should watch television for less than 2 hours every day."
When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain what? A) Abduction B) Adduction C) Traction D) Elevation
A) Abduction
A patient tells the healthcare provider, "I stopped taking my medication because it kept me up at night with a dry cough." When reviewing the patient's medical record, which of these antihypertensive medications will the healthcare provider identify as the likely cause of tis patient's report? A) Angiotensin converting enzyme inhibitor (ACE I) B) Calcium channel blocker C) Beta blocker D) Potassium sparing diuretic
A) Angiotensin converting enzyme inhibitor (ACE I)
Which of the following disorders may cause Congestive Heart Failure (CHF)? Select all that apply: A) Cardiomyopathy B) Coronary Artery Disease C) Hypertension D) Valvular Heart Disease E) Pneumonia
A) Cardiomyopathy B) Coronary Artery Disease C) Hypertension D) Valvular Heart Disease
Which intrinsic factors may contribute to falls in older adults? Select all that apply: A) Deconditioning B) Impaired vision C) Inappropriate foot wear D) Improper use of assistive devices E) Unfamiliar environment of hospital rooms
A) Deconditioning B) Impaired vision
During an outpatient visit you are assessing the patient's understanding about the signs and symptoms associated with osteoporosis. Select all of the sings and symptoms stated by the patient that are correct? A) Dowager's Hump B) Loss of 0.5 inches in hight compared to young adult height C) Swelling and warmth at the bone site D) Some patients are asymptomatic E) Fractures most commonly in the hips, wrist, and spine
A) Dowager's Hump D) Some patients are asymptomatic E) Fractures most commonly in the hips, wrist, and spine
Health promotion efforts for a chronically ill client should include interventions related to primary prevention. What should this include? A) Encouraging daily physical exercise B) Performing yearly physical examinations C) Providing hypertension screening programs D) Teaching a person with diabetes how to prevent complications
A) Encouraging daily physical exercise
A nurse is caring for an obese client with diabetes mellitus. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called teamwork and collaboration? Select all that apply: A) Engaging the physical therapist in managing the client's condition. B) Explaining the client's medication routine tot he next shift nurse. C) Consulting with the dietitian to help manage the client's condition. D) Consulting old records of similar client cases before preparing a care plan. E) Documenting in the electronic health recorder after administering every medication.
A) Engaging the physical therapist in managing the client's condition. B) Explaining the client's medication routine tot he next shift nurse. C) Consulting with the dietitian to help manage the client's condition.
The nurse is providing care to a client with chronic pain. During assessment, what findings would the nurse expect? A) Heart rate, blood pressure, and pulse rate may be normal while the client is experiencing pain. B) Opioid-based analgesics may have little if any effect on reducing the quality of chronic pain. C) The client may have adapted so successfully to presence of chronic pain that measures for the relief are unnecessary. D) The actual intensity of chronic pain is difficult to assess because the client may complain constantly.
A) Heart rate, blood pressure, and pulse rate may be normal while the client is experiencing pain.
When discussing hypertension with a student, which of the following will the healthcare provider identify as a factor related to hypertension? A) Increased afterload B) Decreased peripheral resistance C) Decreased cardiac output D) Hypovolemia
A) Increased afterload
While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. The client also complains of urinary incontinence. Which nursing intervention is beneficial for the client? A) Providing thorough perineal care after each voiding B) Encouraging the client to use the toilet or bedpan every 2 hours C) Responding quickly to the client's indication of the need to void D) Providing privacy, assistance, and voiding stimulants over the perineum
A) Providing thorough perineal care after each voiding
The nurse is caring for a client with peripheral arterial disease (PAD) for which symptoms does the nurse assess? A) Reproducible leg pain with exercise B) Unilateral swelling of affected leg C) Decreased pain when legs are elevated D) Pulse oximetry reading of 90%
A) Reproducible leg pain with exercise
The nurse is reviewing a health care provider's order for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which orders should the nurse question? A) Restrict fluid intake B) Position for comfort C) Avoid strain on painful joints D) Apply nasal oxygen a 2L/minute
A) Restrict fluid intake
A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administration the furosemide to the patient, which laboratory result should the healthcare provider to review? A) Serum potassium B) Serum troponin C) Serum sodium D) Serum calcium
A) Serum potassium
The nursing student is teaching a client who has undergone hip replacement surgery. Which instructions from the nursing student indicate a need for correction? Select all that apply: A) Sit on chairs without arms B) Use an elevated toilet seat C) Cross legs at the knees or ankles D) Use a pillow between the legs for the first 6 weeks E) Keep hips in neutral, straight position when sitting
A) Sit on chairs without arms C) Cross legs at the knees or ankles
Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply: A) Slowed movement B) Cartilage degenerations C) Increased bone density D) Increased range of motion E) Increased bone prominence
A) Slowed movement B) Cartilage degenerations E) Increased bone prominence
The nurse is providing education for an individual receiving treatment with a transcutaneous electrical nerve stimulation (TENS) unit. What information should the nurse include in the teaching? A) The client can adjust both voltage and pulsation B) One electrode only is used over the painful site C) This therapy is useful for very few clients D) The electrode wires should be visible to detect early problems
A) The client can adjust both voltage and pulsation
When providing nutritional counseling for patients at risk for coronary artery disease, which foods would the nurse encourage patients to include in their diet? Select all that apply: A) Tofu B) Walnuts C) Tuna fish D) Whole milk E) Orange juice
A) Tofu B) Walnuts C) Tuna fish - All are rich in Omega-3 Fatty acids
Which instruction would be most beneficial for an aging African-American client with hypertension? A) "Check the pulse daily." B) "Have an annual urinalysis." C) "Record blood pressure weekly." D) "Visit an ophthalmologist monthly."
B) "Have an annual urinalysis."
When obtaining a health history of a patient admitted with a diagnosis of heart failure, which statement made by the patient supports the diagnosis of heart failure? A "I sweat during the night." B) "I get short of breath when walking." C) "I experience chest pain during exercise." D) "I feel pain in my lower legs when checking the mail."
B) "I get short of breath when walking."
A patient diagnosed with mild heart failure is prescribed hydrochlorothiazide. The healthcare provider should determine the teaching about the medication has been successful if the patient makes which of these statements? A) "I should not worry if I experience a dry cough when taking this medication." B) "It is important for me to change positions slowly because I might become dizzy." C) "This medication might cause me to have a decrease in my appetite." D) "I might experience swelling in my legs when taking this medication."
B) "It is important for me to change positions slowly because I might become dizzy." - Caused by the diuretic effect and decrease in fluid volume.
Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply: A) 55 year old make with hyperlipidemia and diabetes B) A 70 year old female with severe sepsis C) A 25 year old male who uses intravenous drugs D) A 65 year old female who is post-op day 1 after joint replacement surgery
B) A 70 year old female with severe sepsis C) A 25 year old male who uses intravenous drugs D) A 65 year old female who is post-op day 1 after joint replacement surgery
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? A) Constriction of the superficial vessels dilates the deep vessels B) Constriction of the peripheral vessels increases the force of flow C) Dilatation of the superficial vessels causes constriction of collateral circulation D) Dilation of the peripheral vessels causes reflex constriction of visceral vessels
B) Constriction of the peripheral vessels increases the force of flow
True or False: Assessment of Homan's Sign is the most reliable indicator of deep vein thrombosis. A) True B) False
B) False
When assessing a patient with chronic heart failure, the healthcare provider would expect to identify which of these clinical manifestations? A) Expiratory wheezing B) Inspiratory crackles C) Bradycardia D) Wight loss
B) Inspiratory crackles - When there is decreased pumping ability of the heart, fluid backs up into the pulmonary system.
After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next? A) Increase the IV rate of heparin B) Interrupt the infusion and notify the primary healthcare provided of the aPTT result C) Document the result on the medical record and recheck the aPTT in 4 hours D) Call the primary healthcare provided to obtain a prescription for a low-molecular-weight heparin
B) Interrupt the infusion and notify the primary healthcare provided of the aPTT result - Normal clotting time is 25 to 36 seconds.
Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures which medication is available on the unit? A) Vitamin K B) Protamine Sulfate C) Potassium Chloride D) Aminocaproic Acid (Amicar)
B) Protamine Sulfate
Cardiac cells differ from skeletal muscle cells in that: A) They contain actin and myosin B) They possess automaticity and conductivity C) Calcium must be present for muscle contraction D) They do not require oxygen to survive
B) They possess automaticity and conductivity
A patient who is newly diagnosed with stage 1 hypertension is being evaluated by a healthcare provider. Which of the following laboratory test would indicate organ damage that mat result from hypertension? A) Lipid panel B) Urinalysis C) Complete blood count (CBC) D) HbgA1C
B) Urinalysis
A client with coronary artery disease is scheduled for a cardiac catheterization. What should the client be able to describe if the nurse's preoperative teaching is considered effective? A) What will occur if there is an emergency B) What will be expected during the procedure C) The risks associated with this invasive procedure D) The importance of immediate postoperative exercises
B) What will be expected during the procedure
A patient is diagnosed with primary hypertension. When taking the patient's history, the healthcare provider anticipates the patient will report which of the following? A) "I wake up during the night with sweats." B) "I become short of breath walking up stairs." C) "I haven't noticed any changes in my health." D) "I sometimes have pain in my lower legs when walking."
C) "I haven't noticed any changes in my health."
The nurse educates an obese adolescent about healthy dietary habits and risk associated with obesity. Which statement by the adolescent indicates the need for further counseling? A) "I should do exercise." B) "I should plat more outdoor games." C) "I should watch more TV to reduce stress." D) "I should modify my diet and have lots of vegetables and water."
C) "I should watch more TV to reduce stress."
Which patient below is NOT at risk for osteoporosis? A) A 50 year old female whose last menstrual period was 7 years ago. B) A 45 year old male patient who has been taking glucocorticoids for the last 6 months. C) A 30 year old make who drinks alcohol occasionally and has a BMI of 28. D) A 35 year old female who has a history of seizures and takes Dilantin regularly.
C) A 30 year old make who drinks alcohol occasionally and has a BMI of 28.
A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? A) Maintain the settings programmed by the healthcare provider B) Turn the machine on several times a day for 10 to 20 minutes C) Adjust the dial on the unit until the client states the pain is relieved D) Apply the color-coded electrodes on the client where they are most comfortable
C) Adjust the dial on the unit until the client states the pain is relieved
The nurse is caring for a client who is three days post-operative repair of a hip fracture. The client reports shortness of breath and difficultly breathing. What should the nurse's first action be? A) Call the health care provider to report the change in condition. B) Give the client a paper bag to breathe into to decrease her anxiety. C) Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. D) Explain that this is normal after such trauma and administer the ordered medication.
C) Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? A) Thermography B) Plethysmography C) Duplex venous doppler D) Somatosensory evoked potential
C) Duplex venous doppler
Which are extrinsic factors responsible for falls in older adults? Select all that apply: A) Impaired vision B) Cognitive impairment C) Environmental hazards D) Inappropriate footwear E) Improper use of assistive devices
C) Environmental hazards D) Inappropriate footwear E) Improper use of assistive devices
What medication does a nurse expect to administer to control bleeding in a child with hemophilia A? A) Albumin B) Fresh frozen plasma C) Factor VIII concentrate D) Factors II, VII, IX, X complex
C) Factor VIII concentrate
A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid? A) Bananas B) Oranges C) Grapefruit D) Eggs
C) Grapefruit
The nurse is planning to administer hydrochlorothiazide. The nurse understands that which is a concern related to the administration of this medication? A) Hyperuricemia, hyperkalemia B) Increased risk of osteoporosis C) Hypokalemia, hyperglycemia, sulfa allergy D) Hyperkalemia, hypoglycemia, penicillin allergy
C) Hypokalemia, hyperglycemia, sulfa allergy
The nurse provides education related to the relationship between aerobic exercise and weight loss to an obese client. The nurse evaluates that teaching is effective when the client states which effect of exercise? A) Decreases my appetite B) Decreases my metabolic rate C) Increases my lean body mass D) Increases my resting heart rate
C) Increases my lean body mass
A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement? A) Turning on the television for diversion B) Calling the primary healthcare provider for another analgesic prescription C) Placing the prescribed as-needed warm, wet compress on the elbow D) Informing her gently that she must wait until the pump reactivates to get more medication
C) Placing the prescribed as-needed warm, wet compress on the elbow
A patient who has a history of pulmonary valve stenosis tells the healthcare provider, "I don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provided conclude is the likely cause of these clinical findings? A) Deep Vein Thrombosis B) Cellulitis C) Right side heart failure D) Peripheral artery disease
C) Right side heart failure - S/S of heart failure is bilateral peripheral edema and fatigue.
Bones play an important role in the body. Which of the following is NOT a function performed by the bones? A) Provide protection and support for the organs B) Give the body shape C) Secrete hormone calcitonin and store blood cells D) Stores calcium and phosphorus
C) Secrete hormone calcitonin and store blood cells
During a follow-up visit, a nurse finds that flexion contractures have developed in a client with osteoarthritis (OA). Which factor may have led to this condition? A) Wearing shoes without insoles B) Elevating the legs 8 to 12 inches C) Using large pillows under the knees or head D) Placing a small pillow under the head in the supine position
C) Using large pillows under the knees or head
The nurse provides discharge instructions to a client who is taking warfarin sodium (Coumadin). Which statement, by the client, reflects the need for further teaching? A) "I will avoid alcohol consumption." B) "I will take my pills everyday at the same time." C) "I have already ordered my Medic-Alert bracelet." D) "I will take enteric-coated aspirin for my headache because it is coated."
D) "I will take enteric-coated aspirin for my headache because it is coated."
Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the left femur? A) Assess for hip contractures B) Monitor for hip dislocation C) Check the peripheral pulses D) Ask about left hip pain level
D) Ask about left hip pain level
A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment findings indicates a worsening of the preeclampsia and the need to notify the health care provider? A) Urinary output has increased B) Dependent edema has resolved C) Blood pressure is at prenatal baseline D) Client complains of headache and blurred vision
D) Client complains of headache and blurred vision
After abdominal surgery a client reports pain. What action should the nurse take first? A) Reposition the client B) Obtain the client's vital signs C) Administer the prescribed analgesic D) Determine the characteristics of the pain
D) Determine the characteristics of the pain
A patient is being assessed for possible heart failure. Which of these laboratory results will provide support for this diagnosis? A) Decreased serum sodium B) Increased creatinine kinase C) Decreased c-reactive protein D) Increased brain natriuretic peptide (BNP)
D) Increased brain natriuretic peptide (BNP)
An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode? A) Mask B) Gown C) Face shield D) Pair of gloves
D) Pair of gloves
The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? A) Platelet count B) Hematocrit count C) Hemoglobin level D) Partial thromboplastin time
D) Partial thromboplastin time
A patient has been admitted to the cardiac unit with a diagnosis of right ventricular failure. Which of the following assessment findings would the healthcare provider expect to observe by the healthcare provider? A) Fatigue and hemoptysis B) Bradycardia C) Dyspnea, pulmonary crackles D) Peripheral edema and juglar vein distention
D) Peripheral edema and juglar vein distention
A client in sinus bradycardia with a heart rate of 45 beats/minutes, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? A) Administer digoxin B) Defibrillate the client C) Continue to monitor the client D) Prepare for transcutaneous pacing
D) Prepare for transcutaneous pacing
The nurse is caring for a client who had a laparoscopic cholecystectomy and is having right shoulder pain. The nurse documents this as what type of pain? A) Transient pain B) Superficial pain C) Phantom pain D) Referred pain
D) Referred pain
You're caring for a patient who has a health history of severe osteoporosis. On assessment you note the patient has severe kyphosis of the upper back. Which nursing diagnosis takes priority for the patient's care? A) Risk for skin breakdown B) Knowledge deficient regarding disease process C) Limited mobility D) Risk for falls
D) Risk for falls
A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? A) Reduces edema B) Increases cardiac conduction C) Increases rate of ventricular contractions D) Slows and strengthens cardiac contractions
D) Slows and strengthens cardiac contractions