CoursePoint Cumulative Review
A nurse obtains a fingerstick glucose level of 45 mg/dl on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene? A. Obtain a serum glucose level. B. Obtain a repeat fingerstick glucose level. C. Notify the physician. D. Give the client 4 oz of milk and a graham cracker with peanut butter.
B. Obtain a repeat fingerstick glucose level.
A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the nurse specify about this client's target blood pressure?
140/90 or lower
The nurse is meeting a client, Cindy Smith, for the first time. Which introduction by the nurse promotes ethical nursing care?
"Hello, I am the nurse working with you today, what name do you prefer to be called?"
During a client health history the nurse is assessing a female client's gender identity and sexual orientation. Which question demonstrates the nurse's ability to safely ask this question?
"How would you define your sexual identity of orientation?"
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?
International normalized ratio (INR) is 2.5.
A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?
7:45 AM
The nurse is caring for a patient with dementia in the long-term care facility when the patient has a change in cognitive function. What should the nurse suspect this patient may be experiencing? A. A UTI B. A stroke C. A aneurysm D. Fecal Impaction
A. A UTI
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what actions should the nurse perform? Select all that apply. A. Administer oxygen B. Place the client in an upright position C. Have the client take deep breaths D. Perform chest physiotherapy E. Instruct the client to cough
A. Administer oxygen B. Place the client in an upright position
A nurse is teaching a client about bronchodilators. What bronchodilator actions that relieve bronchospasm should the nurse include in the client teaching? Select all that apply. A. Alter smooth muscle tone B. Reduce airway obstruction C. Decrease alveolar ventilation D. Increase oxygen distribution E. Reduce inflammation
A. Alter smooth muscle tone B. Reduce airway obstruction D. Increase oxygen distribution
A client has been diagnosed with diabetes and discusses treatment strategies with the nurse. What consequences of untreated diabetes should the nurse include with client teaching? Select all that apply. A. Blindness B. Limb Amputation C. Cardiovascular disease D. Liver failure E. Kidney disease
A. Blindness B. Limb Amputation C. Cardiovascular disease E. Kidney disease
Which nursing intervention(s) are related to a client with breast cancer? Select all that apply. A. Client education and preparation for treatment B. Promotion of positive body image C. Relieving fear D. Prevention of social isolation E. Management of complications
A. Client education and preparation for treatment B. Promotion of positive body image C. Relieving fear E. Management of complications
A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? A. Do not eliminate insulin when nauseated and vomiting. B. Report elevated glucose levels greater than 150 mg/dL. C. Eat three substantial meals a day, if possible. D. Reduce food intake and insulin doses in times of illness.
A. Do not eliminate insulin when nauseated and vomiting.
Lately, a 75-year-old man is having difficulty emptying his bladder. He is unable to empty it completely and yet it feels full, causing discomfort. The physician suspects prostate cancer. Which question(s) would you expect the physician to ask the client? Select all that apply. A. Do you pass blood in your urine? B. Do you feel thirsty often? C. Do you have difficulty urinating? D. Dd you leak urine involuntarily? E. Do you have a family history of prostate cancer?
A. Do you pass blood in your urine? C. Do you have difficulty urinating? E. Do you have a family history of prostate cancer?
The nurse is assessing a client 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 is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. A. Encouraging a liberal fluid intake B. Instructing the client to move the legs in a "pumping exercise" C. instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day D. Using elastic stockings, especially when decreased mobility would promote venous stasis E. Applying a sequential compression device
A. Encouraging a liberal fluid intake B. Instructing the client to move the legs in a "pumping exercise" D. Using elastic stockings, especially when decreased mobility would promote venous stasis E. Applying a sequential compression device
The nurse is caring for a client receiving continuous tube feedings. The nurse knows that flushing the tube to maintain patency will be done at certain times. Which of the following times would the nurse check for patency? Select all that apply. A. Every 4 hours B. After checking for gastric residual C. When refilling the formula container D. Before and after medication administration E. When the feeding is interrupted for any reason
A. Every 4 hours B. After checking for gastric residual D. Before and after medication administration E. When the feeding is interrupted for any reason
Enlargement of the prostate causes which of the following to occur? Select all that apply. A. Frequency B. Oliguria C. Anuria D. Obstruction of urine flow E. Polyuria
A. Frequency B. Oliguria C. Anuria D. Obstruction of urine flow
The nurse is caring for a client who had transurethral resection of the prostate (TURP) 1 day ago. Which assessment finding(s) does the nurse expect? Select all that apply. A. Large amounts of amber-colored urine in the drainage bag B. Rounded swelling above the pubis C. Reports of the urge to void from the client D. Drainage tube secured to the inner thigh E. Increasing pulse rate and diaphoresis
A. Large amounts of amber-colored urine in the drainage bag C. Reports of the urge to void from the client D. Drainage tube secured to the inner thigh
A nurse is providing education to a client with GERD. The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend? Select all that apply. A. Maintaining an upright position following meals B. Avoid foods that intensify symptoms C. Sleeping in a supine position D. Ensuring intake of food and fluids 2-3 hours before bedtime
A. Maintaining an upright position following meals B. Avoid foods that intensify symptoms
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. A. Post thoracotomy B. Spontaneous pneumothorax C. Need for postural drainage D. Chest trauma resulting in pneumothorax E. Pleurisy
A. Post thoracotomy B. Spontaneous pneumothorax D. Chest trauma resulting in pneumothorax
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the patient speak to loved ones on the phone daily. C. Help the patient complete his or her sentences. D. Speak in a loud and deliberate voice to the patient.
A. Provide a board of commonly used needs and phrases
The nurse reviews data collected during a client assessment. Which lifestyle modifications will the nurse discuss with the client to prevent the development of gastroesophageal reflux disease (GERD)? Select all that apply. A. Smoking cessation B. Limit the intake of alcohol C. Avoid eating before bedtime D. Engage in intermittent fasting E. Achieve a BMI of 22
A. Smoking cessation B. Limit the intake of alcohol C. Avoid eating before bedtime E. Achieve a BMI of 22
A nurse is responsible for monitoring indicators of potential complications after laryngectomy. Which indicators would be priority concerns? Select all that apply. A. Somnolence and hypotension B. Rapid capillary refill C. Tachycardia and tachypnea D. Impaired swallowing E. Persistent high tracheostomy cuff pressure
A. Somnolence and hypotension C. Tachycardia and tachypnea D. Impaired swallowing E. Persistent high tracheostomy cuff pressure
The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply. A. Stoma is pink and shiny B. Stoma is edematous and bleeding C. Formed stool in collection pouch D. Continuous liquid flows from the stoma E. Slight skin excoriation around the stoma
A. Stoma is pink and shiny D. Continuous liquid flows from the stoma
What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply. A. Sudden, sustained abdominal pain B. Abdominal distention C. Sudden drop in body temperature D. Intermittent, severe pain
A. Sudden, sustained abdominal pain B. Abdominal distention
A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply. A. Tachycardia B. Hypotension C. Mild epigastric pain D. A rigid, board-like abdomen E. Diarrhea
A. Tachycardia B. Hypotension D. A rigid, board-like abdomen
Which of the following is a strategy to promote urinary continence? A. Void regularly, 5-5 times a day B. Take diuretics after 4 PM C. Use caffeine in moderation D. Implement a low fiber diet
A. Void regularly, 5-8 times a day
A client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6 °F (37.6 °C); a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. What assessment is the nurse's highest priority? A. acute pain B. anxiety C. risk for imbalanced body temperature D. decreased cardiac output
A. acute pain
Which priority issue should the nurse choose when caring for a client with long-standing hypertension?
Altered tissue perfusion
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial Fibrillation
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply. A. A decreases respiratory rate B. ABG reporting a PaCO2 of 48 and PaO2 of 84 C. Nasal flaring with abdominal retractions D. Administration of corticosteroid inhaler for quick relief E. Lung sounds of wheezing F. Increased respiratory effort
B. ABG reporting a PaCO2 of 48 and PaO2 of 84 C. Nasal flaring with abdominal retractions E. Lung sounds of wheezing F. Increased respiratory effort
The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which measures should the nurse complete to prevent the development of deep venous thrombosis (DVT) and possible pulmonary embolism (PE)? Select all that apply. A. Place pillows in the popliteal space B. Apply antiembolism stockings C. Encourage the client to cross their legs D. Avoid elevating the knees on the bed E. Initiate passive exercised
B. Apply antiembolism stockings D. Avoid elevating the knees on the bed E. Initiate passive exercised
The nurse is reviewing the medication administration record of a client who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply. A. Increased venous return B. Decreased peripheral resistance C. Decreased blood volume D. Decreased strength and rate of myocardial contractions E. Decreased blood viscosity
B. Decreased peripheral resistance C. Decreased blood volume D. Decreased strength and rate of myocardial contractions
When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck
B. Elevation of the head of the bed
A client is brought to the emergency department. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply. A. Leukocytosis B. Glycosuria C. Dehydration D. Hypernatremia E. Hyperglycemia
B. Glycosuria C. Dehydration E. Hyperglycemia
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 an abnormal finding that will correct itself when the client ambulates. B. It's an abnormal finding that requires further assessment. C. It's a normal finding associated with the client's nothing-by-mouth status. D. It's a normal finding caused by blood loss during surgery.
B. It's an abnormal finding that requires further assessment
A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what factor most likely caused for this short-term change in treatment? A. Alterations in bile metabolism and release have likely caused hyperglycemia. B. Stress has likely caused an increase in the client's blood sugar levels. C. The client has likely overestimated her ability to control her diabetes using nonpharmacologic measures. D. The client's volatile fluid balance surrounding surgery has likely caused unstable blood sugars.
B. Stress has likely caused an increase in the client's blood sugar levels.
A nurse is obtaining health histories from clients at a busy low-income clinic. Which clients should the nurse follow more closely as being at the highest risk for developing breast cancer? Select all that apply. A. The male client with a family history of prostate cancer B. The client who has relatives with the BRCA1 mutated gene C. The client with a mother who had breast cancer D. The client who is over 50 years of age E. The client who is African American
B. The client who has relatives with the BRCA1 mutated gene C. The client with a mother who had breast cancer
The nurse is obtaining a health history from a client with a blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering blood pressure. Which medication classification does the nurse anticipate first? A. ACE inhibitors B. Thiazide diuretic C. Beta-Blocker D. Calcium channel blocker
B. Thiazide diuretic
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Bleeding
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? A. 2 days B. 12 - 24 hours C. 1 hour D. 1 month
C. 1 hour
A nurse caring for a client with small-bowel obstruction should plan to implement which nursing intervention first? A. Preparing to insert a nasogastric (NG) tube B. Obtaining a blood sample for laboratory studies C. Administering I.V. fluids D. Administering pain medication
C. Administering I.V. fluids
The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find? A. Serum bicarbonate of 19 mEq/L B. Blood glucose level of 250 mg/dL C. Blood pH of 6.9 D. PaCO2 of 40 mm Hg
C. Blood pH of 6.9
A student with diabetes reports feeling nervous and hungry. The school nurse assesses the student and finds the child has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? A. A combination of protein and carbohydrates, such as a small cup of yogurt B. Two teaspoons of sugar dissolved in a cup of apple juice C. Half of a cup of juice, followed by cheese and crackers D. Half a sandwich with a protein-based filling
C. Half of a cup of juice, followed by cheese and crackers
Which diagnostic test would be used first to evaluate a client with upper GI bleeding? A. Endoscopy B. Upper GI series C. Hemoglobin (Hb) levels and hematocrit (HCT) D. Arteriography
C. Hemoglobin (Hb) levels and hematocrit (HCT)
A nurse is inspecting the feet of a client with diabetes and finds a tack sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding? A. In diabetes, the autonomic nerves are affected. B. Motor neuropathy causes muscles to weaken and atrophy. C. High blood sugar decreases blood circulation to nerves. D. Nephropathy is a common complication of diabetes mellitus.
C. High blood sugar decreases blood circulation to nerves.
The nurse teaches the client whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be A. Fluid B. Mushy C. Solid D. Clear
C. Solid
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? A. The patient has developed diabetes insipidus due to the location of the stroke. B. The patient has new onset diabetes. C. This is significant finding for poor neurologic outcomes D. The patient has liver failure.
C. This is a significant finding for poor neurologic outcomes
Which is the most common motor dysfunction seen in clients diagnosed with stroke?
Hemiplegia
A client's spouse states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. What findings would indicate a need for further interventions? A. BP 122/82, HR 102, R 24, noted barrel chest, temperature 98.4 °F (36.9 °C) B. Client states, "It always seems like I just can't catch my breath." C. Pale, paper-thin skin, O2 at 2L/min via nasal cannula D. BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C)
D. BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C)
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? A. Apply a compression dressing to the area. B. Report the finding to the physician immediately. C. Measure the patient's pulse oximetry. D. Record the observation.
D. Record the observation
When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?
Hypoglycemia
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. What is the priority nursing diagnosis for this client?
Impaired Swallowing
A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury?
Install a bed alarm to remind the client to ask for assistance and to alert the staff that the client is getting out of bed
A client with enteritis reports frequent diarrhea. What assessment should the nurse should anticipate?
Metabolic Acidosis
A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to
Report decreased congestion.
A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding?
Report this to the health care provider as a possible sign of clinical deterioration
A client has been classified as status asthmaticus. The nurse understands that this client will likely initially exhibit symptoms of:
Respiratory Alkalosis
It is important for the nurse to encourage the client to rise slowly from a sitting or lying position because gradual changes in position
provide time for the heart to increase the rate of contraction to resupply oxygen to the brain.