Exam 3

4. The nurse is preparing to administer a unit of packed red blood cells to an elderly client who is one day post-op after having a repair of an abdominal aortic aneurysm. Which interventions should the nurse implement? List in order of performance. 1. Obtain the unit of blood from the blood bank 2. Start an IV access with normal saline at a keep-open rate. 3. Make sure the physician has the client sign the consent to receive blood products 4. Check the unit of blood with another nurse at the bedside 5. Initiate the transfusion at a slow rate for 15 minutes.

3. Make sure the physician has the client sign the consent to receive blood products 2. Start an IV access with normal saline at a keep-open rate. 1. Obtain the unit of blood from the blood bank 4. Check the unit of blood with another nurse at the bedside 5. Initiate the transfusion at a slow rate for 15 minutes.

13. The nurse is assessing a client with a history of multiple sclerosis (MS). Impaired immobility now prevents the client from living independently. Which of the following statements by the nurse demonstrates an understanding of the client's impaired physical mobility? A. "Do you have any pain or ulcers on your legs, ankles, or hips?" b. "Maybe we can look into getting you a motorized wheelchair." c. "How often do you have episodes of diarrhea?" d. "What meals would you prefer while your in the hospital?"

A. "Do you have any pain or ulcers on your legs, ankles, or hips?"

36. The client diagnosed with Buerger's disease (thromboangitis obliterans) asks the nurse "what is the worst thing that could happen if I don't quit smoking? I love my cigarettes." Which statement is the nurse's best response? A. "You are concerned about quitting smoking. Let's sit down and talk about it." B. "Many clients end up having to have an amputation, especially the leg." C. "You should consider attending a smoking cessation program." D. "Your coronary arteries could block and cause a heart attack."

B. "Many clients end up having to have an amputation, especially the leg."

21. The nurse is assessing a client with multiple sclerosis and notes the client is experiencing tremors and muscle weakness. The client is scheduled for several tests that require transport off the floor, as well as a physical therapy session during the shift. Which of the following nursing actions would be most helpful for this client? A. Administer analgesics as ordered to provide comfort for the day's activities B. Coordinate with various disciplines to perform tests back-to-back C. Encourage activity independence for ADLs prior to going for tests D. Contact physical therapy to delay the session until the client is finished with the tests

B. Coordinate with various disciplines to perform tests back-to-back Rationale: You want to cluster the care as much as possible together to conserve the clients energy

39. The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further education if the client makes which statement? A. "I will wash my face with cotton pads" B. "I'll have to start chewing on my unaffected side" C. "I'll try to eat my food either very warm or very cold" D. "I should rinse my mouth if tooth brushing is painful"

C. "I'll try to eat my food either very warm or very cold"

38. The nurse has given instructions to a client with Parkinson's disease about maintaining mobility. Which action demonstrates that the client understands the directions? A. Sits in soft, deep chairs to promote comfort B. Exercises in the evening to combat fatigue C. Rocks back and forth to start movement with bradykinesia (slow movements) D. Buys clothes with many buttons to maintain finger dexterity

C. Rocks back and forth to start movement with bradykinesia (slow movements)

37. The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? A. Gets angry with family if interrupt a task B. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. Consistently uses adaptive equipment in dressing self

D. Consistently uses adaptive equipment in dressing self

41. The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the clients room? A. Nebulizer and pulse oximeter B. Blood pressure cuff and flashlight C. Flashlight and incentive spirometer D. Electrocardiographic monitoring electrodes and intubation tray

D. Electrocardiographic monitoring electrodes and intubation tray

40. The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? A. Meningitis or encephalitis during the last 5 years B. Seizures or trauma to the brain within the last year C. Back injury or trauma to the spinal cord during the last 2 years D. Respiratory of gastrointestinal infection during the previous month

D. Respiratory of gastrointestinal infection during the previous month Rationale: Can be caused by a viral illness or by influenza vaccine

42. Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side/adverse effects to the medication. Which finding indicates that the client is experiencing an adverse effect? A. Pruritus B. Tachycardia C. Hypertension D. Impaired voluntary movements

Rationale: Indicates low level of medication in the patient

11. A nurse reviews the plan of care for a client who has myasthenia gravis. Which of the following interventions would not be appropriate for the client? a. Monitor for sudden increases in weakness b. Refer to speech and occupational therapy for evaluation c. Assist with daily activities prior to medication administration d. Teaching patient stress reduction exercises

c. Assist with daily activities prior to medication administration

2. A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the client's fluid intake and output is approximately 1200 mL daily. What client teaching would the nurse provide? (Select all that apply) a. "Try to drink at least six-to-eight glasses of water each day." b. "Try to limit your fluid intake to one (1) quart of water daily." c. "Limit, sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase foods containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

a. "Try to drink at least six-to-eight glasses of water each day." c. "Limit, sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." f. "Weigh yourself daily and report any changes in your weight." Rationale: as a rule fluid intake and output should equal about 2600 mL per day. The client should be encourage to drink more water, maintain a normal body weight, avoid eating foods high in salt, sugar and caffeine, limit alcohol and monitor side effects of medication especially diarrhea.

35. The terminally ill client diagnosed with ALS has a DNRCC order in place and is currently complaining of "pain all over." The nurse notes the client has shallow breathing and a pulse of 67, RR 8, B/P 104/62. What intervention should the nurse implement? a. Administer the narcotic pain medication IVP b. Turn and reposition the client for comfort. c. Refuse to administer pain medication d. Notify the HCP of the client's vital signs

a. Administer the narcotic pain medication IVP

5. An obese client taking Warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? (Select all that apply) a. Apply lanolin or petroleum jelly to intact skin. b. Follow a reduced-calorie, reduced fat diet. c. Inspect the involved areas daily for new ulcerations. d. Limit activities of daily living (ADL's) e. Use an electric razor to shave.

a. Apply lanolin or petroleum jelly to intact skin. b. Follow a reduced-calorie, reduced fat diet. c. Inspect the involved areas daily for new ulcerations. e. Use an electric razor to shave. Rationale: maintaining skin integrity is important in preventing chronic ulcers and infection, they should be taught to check the skin daily, to reduce weight to promote circulation, and use an electric razor to decrease the chance of bleeding due to the Warfarin

32. The nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks should not be delegated to the unlicensed assistive personnel (UAP)? (Select all that apply) a. Check the client's skin under the restraints. b. Administer the client's antipsychotic medication c. Perform the client's morning hygiene care. d. Ambulate the client to the bathroom e. Obtain the client's routine vital signs

a. Check the client's skin under the restraints. c. Perform the client's morning hygiene care.

28. The nurse is caring for a client with Parkinson's disease. During the physical assessment, the nurse notes that which of the following signs and symptoms are consistent with this disease? (Select all that apply). a. Difficulty swallowing b. Shuffling gait c. Dropping of eyelids d. Pill rolling tremor e. Tardive dyskinesia

a. Difficulty swallowing b. Shuffling gait d. Pill rolling tremor

30. The client is diagnosed with ALS. Which client problem would be most appropriate for the client? a. Disuse syndrome b. Altered body image c. Fluid and electrolyte imbalance d. Alteration in pain

a. Disuse syndrome Rationale: disuse syndrome is associated with complications of bedrest. Clients with ALS cannot move or reposition themselves, and they frequently have altered nutritional and hydration status

8. The nurse is planning discharge teaching for a client with Parkinson's disease. To maintain safety, the nurse should make which of the following suggestions to the family? a. Install a raised toilet b. Obtain a hospital bed c. Instruct the client to hold their arms dependently during ambulation d. Participate in an exercise program during the late afternoon

a. Install a raised toilet

1. A client has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Keeping fluids readily available for the patient. b. Planning to offer most daily fluids in the evening. c. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. d. Emphasizing the long-term outcome of increasing fluids when the client returns home.

a. Keeping fluids readily available for the patient.

14. A clinically obese client with moderately painful varicose veins chooses self-care options for managing the varicosities. The nurse should encourage the client to follow which health care practices? Select all that apply a. Lose weight b. Wear compression stockings c. Apply lotion to the veins d. Elevate the legs e. Sleep with pillows under the knees.

a. Lose weight b. Wear compression stockings d. Elevate the legs Rationale: To manage varicose veins, the nurse should encourage the client to lose weight to relieve pressure on the veins, wear compression stockings to promote circulation, and elevate the legs when sitting or lying down. Lotion with keep the skin moist but will not promote circulation, pillows can obstruct circulation

26. The nurse in the neuro intensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? (Select all that apply) a. Monitor the pulse ox reading b. Provide pureed foods six (6) times a day c. Encourage coughing and deep breathing. d. Assess for autonomic dysreflexia e. Administer intravenous corticosteroids

a. Monitor the pulse ox reading c. Encourage coughing and deep breathing. e. Administer intravenous corticosteroids

23. A client who suffers from multiple sclerosis (MS) struggles with spasticity of the leg muscles and requires assistance with ambulation. Which ambulatory assistive device would be most appropriate for a client with muscle spasticity? (Select all that apply.) a. Standard walker b. Cane c. Crutches d. Front-wheeled walker e. Rollator

a. Standard walker b. Cane c. Crutches Rationale: Nothing with wheels as they are unstable for this patient

19. The nurse knows that which of the following clients is at risk for developing a sodium (Na) level of 130 mEq/L. a. The client who is taking diuretics. b. The client with hyperaldosteronism. c. The client that is taking potassium. d. The client who is taking corticosteroids.

a. The client who is taking diuretics.

29. A client with Parkinson's disease has tremors in the hands that make eating difficult. Which of the following adaptive devices could the nurse employ that would help this client eat? a. Weighted utensils b. A divided plate c. A bendable straw d. A flattened steak knife

a. Weighted utensils

6. A client weighs 300 lbs (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When teaching them about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client makes which statement. a. "I'll limit exercise that involves walking." b. "I'll try to lose weight by following a reduced-calorie, balanced diet." c. "I'll perform leg lifts every 4 hours to strengthen hamstring muscles." d. "I'll wear knee-high stockings, rolled up at the top to hold the stockings up."

b. "I'll try to lose weight by following a reduced-calorie, balanced diet." Rationale: the client is at risk for developing varicose veins, prevention is the goal of the treatment plan—maintaining ideal body weight is the goal.

34. The home health nurse is admitting a female client diagnosed with myasthenia gravis. The client tells the nurse, "Even with my medication I get exhausted when I do anything." Which intervention should the nurse implement? a. Talk the client's husband about helping around the house more. b. Contact the home health occupational therapist to discuss the client's concern. c. Allow the client to verbalize her feelings of being exhausted d. Recommend the client make an appointment with her primary care provider (PCP).

b. Contact the home health occupational therapist to discuss the client's concern. Rationale: the occupational therapist could help the client identify ways to save energy while performing activities of daily living. Myasthenia gravis causes skeletal muscle weakness

25. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the care plan? a. Potential for injury b. Powerlessness c. Disturbed thought processes d. Sexual dysfunction

b. Powerlessness

16. At which time of the day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia (slow or reduced muscle movement) a. Early in the morning when the client's energy level is high b. To coincide with the peak action of drug therapy c. Immediately after a rest period d. When family members will be available

b. To coincide with the peak action of drug therapy

31. The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? a. Discuss the need to be placed in a long-term care facility. b. Explain how to care for a sigmoid colostomy. c. Assist the client to prepare an advance directive. d. Teach the client how to use a motorized wheelchair.

c. Assist the client to prepare an advance directive. Rationale: the client with ALS usually dies within 5 yrs. The nurse should offer the client the opportunity to determine how they want to die

15. A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receive tissue plasminogen activator (t-Pa)? a. Ask what medication the client is taking b. Complete a history and health assessment c. Identify the time of the onset of the stroke d. Determine if the client is scheduled for any surgical procedures.

c. Identify the time of the onset of the stroke Rationale: studies show that clients who receive recombinant t-Pa treatment within 3 hours of a stroke have better outcomes. The time from the onset of a stroke to t-Pa treatment is critical

27. Which is a common cognitive problem associated with Parkinson's disease? a. Emotional lability b. Depression c. Memory deficits d. Paranoia

c. Memory deficits Rationale: All of these can be seen in Parkinson's but not with every client, for the most part all clients will have memory deficits and you need to plan for it

12. The nurse is preparing to administer heparin sodium to a client diagnosed with thrombophlebitis. The nurse will ensure that which of the following is available if the client develops a significant bleeding problem? a. Phytonadione b. Fresh frozen plasma c. Protamine sulfate d. Reteplase

c. Protamine sulfate

7. The nurse cares for a client admitted for gastrointestinal (GI) bleed. The provider has ordered the client to receive 2 units of packed red blood cells (PRBCs). Fifteen minutes after the start of the transfusion, the client reports chills, shortness of breath, and lumbar pain. Which of these should be the nurse's first action? a. Obtain vital signs and notify the provider of potential reaction. b. Slow the transfusion and reassess the client in 15 minutes. c. Stop the blood transfusion and infuse normal saline (NS) to keep the vein open (KVO). d. Administer PRN analgesic, apply oxygen at 2L/minute, and provide an additional blanket.

c. Stop the blood transfusion and infuse normal saline (NS) to keep the vein open (KVO).

18. The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client? a. Joint pain of the neck and jaw b. Unconscious grinding of the teeth during sleep c. Sudden severe unilateral facial pain d. Progressive loss of calcium in the nasal septum

c. Sudden severe unilateral facial pain

24. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? a. The assistant places a gait belt around the client's waist prior to ambulating. b. The assistant places the client on the back with the client's head to the side. c. The assistant places a hand under the client's right axilla to move up in bed. d. The assistant praises the client for attempting to perform ADL's independently

c. The assistant places a hand under the client's right axilla to move up in bed. Rationale: moving the client in this manner can cause a shoulder dislocation, you should instruct the UAP to put her arm completely under the clients back or to use a lift sheet

9. The charge nurse of a long-term facility is making assignments. Which client should be assigned to the most experience unlicensed assistive personnel (UAP)? a. The client with arterial occlusive disease who must dangle their legs off the side of the bed. b. The client with congestive heart failure who is angry about the family not visiting. c. The client with an above the knee amputation who needs a full body lift to get in the wheelchair. d. The client with Buerger's disease who is particular about the way things are done.

c. The client with an above the knee amputation who needs a full body lift to get in the wheelchair.

17. The nurse is caring for several clients on a medical unit. Which client should the nurse assess first? a. The client with ALS who is refusing to turn every two (2) hours. b. The client with abdominal pain who is complaining of nausea. c. The client with pneumonia who has a pulse ox reading of 90%. d. The client complaining of not receiving any pain medication.

c. The client with pneumonia who has a pulse ox reading of 90%.

22. The nurse is caring for a client who is newly diagnosed with multiple sclerosis. Which of the following is appropriate teaching for this client? a. "Make sure you're getting good fluid intake, around 2L/day" b. "If you are compliant with your treatment regimen, there is a chance this will resolve completely" c. "Here is a list of foods containing rye, barley, and oats. You must not consume these if you want to avoid flare ups" d. "You may notice you start to walk by shuffling or move your hands like you're rolling a pill. That is normal"

d. "You may notice you start to walk by shuffling or move your hands like you're rolling a pill. That is normal"

3. The nurse is preparing an IV solution for a client who has hypernatremia. Which of the following solutions are the best choices for this condition? (Select all that apply) a. 5% dextrose in 0.9% NaCl (normal saline) b. 0.9% NaCl c. Lactated Ringers solution d. 0.33 NaCl (1/3 strength normal saline) e. 0.45 NaCl (1/2 strength normal saline) f. 5% Dextrose in Lactated Ringers Solution

d. 0.33 NaCl (1/3 strength normal saline) e. 0.45 NaCl (1/2 strength normal saline) Rationale: Patient has hypernatremia so you don't want to give more than 0.45 NaCl

10. What priority client problem should be included I the care plan for the client diagnosed with Guillain-Barre syndrome who is admitted to the critical care unit? a. Decreased cardiac output b. Fear and anxiety c. Complications of immobility d. Ineffective breathing pattern

d. Ineffective breathing pattern

33. Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barre syndrome who is admitted to the critical care unit? a. Decreased cardiac output b. Fear and anxiety c. Complications of immobility d. Ineffective breathing pattern

d. Ineffective breathing pattern Rationale: Guillain-Barre syndrome causes ascending paralysis and will cause respiratory failure, therefore breathing pattern is a priority

20. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH 7.53, Pco2 33mm/mg, HCO3 28mEq/L. What conclusion about the client should the nurse make? a. The client has acidotic blood. b. The client is probably overreacting c. The client is fluid volume overloaded d. The client is probably hyperventilating

d. The client is probably hyperventilating