MS Exam 2 Q's
A nurse is administering a potassium supplement to a patient. What will the nurse do to disguise the taste and decrease gastric irritation? A) dilute it B) give it after meals C) mix it with food D) freeze it
A
A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) full-thickness skin loss B) skin pallor C) blister formation D) eschar formation
A
A nurse monitoring the intake and output of fluids for a patient with severe diarrhea knows that normally how many mL of body fluids is lost via the gastrointestinal tract? A) 300 mL B) 1,000 mL C) 1,300 mL D) 2,600 mL
A
A nurse teaches a young couple to put their newborn on his back to sleep. What is the rationale for this information? A) prone position increases the risk for sudden infant death syndrome B) prone position decreases the risk for sudden infant death syndrome C) supine position may alter the size and shape of the infants head D) supine position makes changing diapers and feeding difficult
A
A nurse working the night shift assesses a patients vital signs at 4 a.m. (0340). What would be the expected findings, based on knowledge of NREM sleep? A) decreased TPR and BP B) increased TPR and BP C) no change from daytime readings D) highly individualized, cannot predict
A
A patient tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition? A) sensory deficit B) sensory deprivation C) sensory overload D) sensory stimulation
A
A patient who has a sleep disorder is trying stimulus control to improve amount and quality of sleep. What is recommended in this type of therapy? A) use the bedroom for sleep and sex only B) use the bedroom for reading and eating C) go to bed at the same time every night D) sleep alone with minimal coverings
A
A physician writes an order to force fluids. What will be the first action the nurse will take in implementing this order? A) Explain to the patient why this is needed. B) Tell the patient and family to increase oral intake. C) Decide how much fluid to increase each 8 hours. D) Divide the intake so the largest amount is at night.
A
An individual awakens from a sound sleep in the middle of the night because of abdominal pain. Why does this happen? A) stimuli from peripheral organs to the RAS B) stimuli to the wake center in the cerebral cortex C) messages from chemoreceptors to the brain D) messages from baroreceptors to the spinal cord
A
Cross-matching of blood is ordered for a patient before major surgery. What does this process do? A) determines compatibility between blood specimens B) determines a persons blood type C) predicts the amount of needed blood replacement D) specifies the donor and the recipient of the blood
A
Heat applications are often used to promote tissue healing. What is the rationale for this type of treatment? A) Physiologic effects of heat accelerate the inflammatory response. B) Local heat increases cardiac output and pulse rate. C) Heat reduces blood flow to tissues resulting in decreased edema. D) Heat reduces muscle tension to promote relaxation.
A
What is the most accurate definition of a wound? A) a disruption in normal skin and tissue integrity B) a change in the function of internal organs C) any injury that results in changes in nervous tissue D) any trauma resulting in serious damage and pain
A
Which of the following descriptions best summarizes fluid homeostasis? A) Almost every body organ and system helps maintain homeostasis. B) The cardiovascular and renal systems primarily maintain homeostasis. C) Homeostasis is maintained through intra- and extracellular exchange. D) Homeostasis is maintained by the arterioles, capillaries, and venules.
A
Which of the following patients would be the most likely candidate for the administration of total parenteral nutrition? A) a patient with severe pancreatitis B) a patient with a myocardial infarction C) a patient with hepatitis B D) a patient with mild malnutrition
A
Which of the following questions about fluid balance would be appropriate when conducting a health history for a patient? A) Describe your usual urination habits. B) Describe your problems with constipation. C) How did you feel when your calcium was low? D) Do you eat fruits and vegetables each day?
A
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which of the following statements accurately describe this process? Select all that apply. A) The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the bodys needs. B) The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. C) The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. D) The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acidbase balance. E) Thyroxine, released by the adrenal glands, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. F) The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
A, B, D, F
Which of the following are functions of the skin? Select all that apply. A) protection B) temperature regulation C) psychosocial, sensation D) vitamin C production E) immunological F) lipid reduction
ABCE
A nurse assessing the skin of patients knows that the following are health states that may predispose patients to skin alterations. Select all that apply. A) obesity B) excessive perspiration C) cataracts D) hypertension E) low BMI F) Jaundice
ABEF
A nurse is applying cold therapy to a patient with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply. A) constricts peripheral blood vessels B) reduces muscle spasms C) increases blood flow to tissues D) increases the local release of pain-producing substances E) reduces the formation of edema and inflammation. F) alters tissue sensitivity (producing numbness)
ABEF
Which of the following patients would be considered at risk for skin alterations? Select all that apply. A) a teenager with multiple body piercings B) a homosexual in a monogamous relationship C) a patient receiving radiation therapy D) a patient undergoing cardiac monitoring E) a patient with diabetes mellitus F) a patient with a respiratory disorder
ACE
A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? A) evisceration B) infection C) dehiscence D) fistula
B
A home care patient is complaining of weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request? A) The nurse is concerned that the patients diet has caused sodium loss. B) The nurse recognizes these symptoms of hypokalemia. C) The patient is actively seeking increased attention. D) The patient had bananas and orange juice for breakfast.
B
A nurse assesses an area of pale white skin over a patients coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments? A) Immediately report to the physician that the patient has a pressure ulcer. B) Recognize that this is ischemia, followed by reactive hyperemia. C) Document the presence of a pressure ulcer and develop a care plan. D) Implement nursing interventions for Altered Skin Integrity.
B
A nurse documents a closed wound on a patient chart. Which of the following is an example of a closed wound? A) abrasion B) ecchymosis C) incision D) puncture wound
B
A nurse is assessing wound drainage during the immediate postoperative period for a patient who has had a breast removed. In addition to assessing the dressing, where would the nurse also check for drainage? A) under the skin B) under the patient C) on the output sheet D) in the axilla
B
A nurse is caring for a patient who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the patient that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement.
B
A nurse is initiating a peripheral venous access IV infusion ordered for a patient presurgically. In what position would the nurse place the patient to perform this skill? A) high Fowlers B) low Fowlers C) Sims D) dorsal recumbent
B
A nurse teaches the parents of a toddler about normal sleep patterns for this age group. How many hours of sleep per night is normal near the end of this stage? A) 7 8 hours B) 8 10 hours C) 10 12 hours D) 12 15 hours
B
A patient is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base a teaching plan? A) Impaired Skin Integrity B) Risk for Deficient Fluid Volume C) Impaired Urinary Elimination D) Urinary Retention
B
A patient scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this? A) The patients family members have been donors. B) The patient donates his or her own blood. C) The patients blood has been rendered sterile. D) The patient will only need fluids, not blood.
B
Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this? A) Infants have less total body fluid and ECF than adults. B) Infants have more total body fluid and ECF than adults. C) Infants drink less fluid than adults. D) Infants lose more fluids through output than adults.
B
What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings? A) Change position at least once each shift. B) Implement a turning schedule every 2 hours. C) Use ring cushions for heels and elbows. D) Do not turn, use pressure-relieving support surface.
B
What type of cognitive responses might a nurse assess in a patient with sensory deprivation? A) uncoordinated movements, altered sense of smell B) decreased attention span, difficulty problem solving C) apathy, depression D) rapid mood changes, anxiety
B
Which body fluid is the fluid within the cells, constituting about 70% of the total body water? A) extracellular fluid (ECF) B) intracellular fluid (ICF) C) intravascular fluid D) interstitial fluid
B
Which of the following best describes an unintentional wound? A) clean wound edges, controlled bleeding B) jagged wound edges, uncontrolled bleeding C) little risk for infection, shorter healing time D) the result of surgery, intravenous therapy
B
Which of the following groups of terms best describes sleep? A) decreased state of activity, refreshed B) altered consciousness, relative inactivity C) comatose, immobility D) alert, responsive
B
Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients? A) In children younger than 2 years, the skin is thicker and stronger than it is in adults. B) An infants skin and mucous membranes are injured easily and are subject to infection. C) A childs skin becomes increasingly at risk for injury and infection. D) In the older adult, circulation and collagen formation are increased.
B
The student nurse studying fluid and electrolyte balance learns that which of the following is a function of water? Select all that apply. A) provide a medium for transporting wastes to cells and nutrients from cells B) provide a medium for transporting substances throughout the body C) facilitate cellular metabolism and proper cellular chemical functioning D) act as a buffer for electrolytes and nonelectrolytes E) help maintain normal body temperature F) facilitate digestion and promote elimination
B, C, E, F
A nurse is caring for a patient who is sleeping for abnormally long periods of time. This condition may be caused by injury to which of the following body structures? A) spinal cord B) pancreas C) hypothalamus D) thyroid
C
A nurse is teaching a postoperative patient about essential nutrition for healing. What statement by the patient would indicate a need for more information? A) I will drink a lot of orange juice and drink milk too. B) I will take the zinc supplement the doctor recommended. C) I will restrict my diet to fats and carbohydrates. D) I will drink 8 to 10 glasses of water every day.
C
A nurse measures a patients 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? A) Compare the patients intake with the normal range of adult fluid intake. B) Report the exact milliliter of intake to the physicians office nurse. C) Compare the total intake and output of fluids for the 24 hours. D) Ensure that the information is included in the verbal end-of-shift report.
C
A nurse reads a complete blood count report for a patient who has been admitted to the hospital with fluid overload from late-stage kidney disease. What abnormal result would the nurse expect to find? A) increased white blood cells B) increased platelets C) decreased hematocrit D) increased hematocrit
C
A patient has metabolic (nonrespiratory) acidosis. What type of respirations would be assessed? A) periods of apnea B) decreased depth and rate C) increased depth and rate D) alternating fast and slow
C
A patients PaCO2 is abnormal on an ABG report. Which of the following illnesses would most likely be the medical diagnosis? A) rheumatoid arthritis B) sexually transmitted infection C) chronic obstructive pulmonary disease D) infection of the bladder and ureters
C
A woman has had her left breast removed for cancer. She also had an axillary node dissection on the left during surgery. How would this affect placement of an intravenous line? A) Either arm may be used. B) Neither arm should be used. C) The left arm should not be used. D) The right arm should not be used.
C
By what route do oxygen and carbon dioxide exchange in the lung? A) osmosis B) filtration C) diffusion D) active transport
C
Of the many topics that may be taught to patients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) taking medications as prescribed B) proper intake of food and fluids C) thorough hand hygiene D) adequate sleep and rest
C
What name is given to the rhythmic biologic clock that exists in humans? A) sleep-wake cycle B) alert-unaware process C) circadian rhythm D) yo-yo theory
C
Which of the following locations might the nurse use to assess the condition of an insertion site for a central venous access device? A) below the sternum B) over the fourth intercostal space C) over the jugular vein D) the back of the hand
C
A nurse is explaining the use of sleep hygiene to a patient experiencing insomnia. Which of the following statements accurately describe recommended guidelines for the use of this technique? Select all that apply. A) drink an alcoholic drink before bedtime B) take frequent naps during the day C) eat a light meal before bedtime D) sleep in a warm, dark room E) take a warm bath before bedtime F) eliminate the use of a clock in the bedroom
CEF
A home health nurse has a caseload of several postoperative patients. Which one would be most likely to require a longer period of care? A) an infant B) a young adult C) a middle adult D) an older adult
D
A nurse assessing a patients wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) clear, watery blood B) large numbers of red blood cells C) mixture of serum and red blood cells D) white blood cells, debris, bacteria
D
A nurse is discussing sleep problems with a patient. What type of foods would she recommend to promote sleep? A) one cup of hot chocolate B) three glasses of red wine C) a high-protein snack D) a carbohydrate snack
D
A nurse reads the laboratory report for a patient and notes that the patient has hyponatremia. What physical assessment would be made? A) Observe skin color and texture. B) Auscultate bowel sounds. C) Percuss lung density. D) Palpate skin of sternum.
D
A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? A) an 83-year-old who is mobile B) a 92-year-old who uses a walker C) a 75-year-old who uses a cane D) an 86-year-old who is bedfast
D
A patient asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond? A) There is only a very small chance; I know you will be safe. B) Although hepatitis is possible, AIDS is not. C) If I were you, I would request special handling of my blood. D) There is no way you can contract a disease by giving blood.
D
A patient has a decreased potassium level. What high-potassium foods would the nurse teach the patient to eat? A) lunch meat, salted nuts, whole milk B) buttermilk, hard candy, spinach C) carbonated beverages, beer, olives D) oranges, bananas, broccoli
D
A patient has an order to restrict fluids. What is one comfort measure nurses can implement for this patient to alleviate a common problem? A) back rubs B) chewing gum C) hair care D) oral hygiene
D
A patient is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than 4 hours. What should the nurse do next? A) Continue with the transfusion and document the drip rate. B) Report to the next shift the amount of blood left to infuse. C) Take and record vital signs more often. D) Discontinue the blood transfusion.
D
A specially trained nurse has inserted a PICC line. What would be done next? A) Start administration of prescribed fluids. B) Explain the procedure to the patient and family. C) Place the patient on restricted oral fluids. D) Send the patient to the radiology department.
D
A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the patient when accessing the vein? A) discomfort B) pain C) minor bleeding D) infection
D
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery.
D
The plan of care for a postoperative patient specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information? A) Question the physician about the accuracy of this agent. B) Refuse to use 0.9% normal saline on a wound. C) Document the rationale for not changing the dressing. D) Continue with the dressing change as planned.
D
What are the two major processes involved in the inflammatory phase of wound healing? A) bleeding is stimulated, epithelial cells are deposited B) granulation tissue is formed, collagen is deposited C) collagen is remodeled, avascular scar forms D) blood clotting is initiated, WBCs move into the wound
D
What independent nursing action can be used to facilitate sleep in hospitalized patients who are on bedrest? A) administering prescribed sleep medications B) changing the bed with fresh linens C) encouraging naps during the daytime D) giving a back massage
D
What is the average adult fluid intake and loss in each 24 hours? A) 500 to 1,000 mL B) 1,000 to 1,500 mL C) 1,500 to 2,000 mL D) 1,500 to 3500 mL
D
What nursing diagnosis would be a priority for a patient who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection
D
When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? A) friction B) necrosis of tissue C) ischemia D) shearing force
D
Which of the following considerations should be made when assessing a patient for the application of cold or heat therapy? A) prolonged exposure decreases tolerance B) the neck and perineum are less sensitive to thermal change C) open tissue or abraded skin is less sensitive to thermal changes D) applications of heat or cold to large areas of the body cause systemic responses
D
Which of the following is a recommended guideline nurses follow when using an electric heating pad on a patient? A) Secure the heating pad to the patients clothing with safety pins. B) Place a heavy towel or blanket over the heating pad to maximize heat effects. C) Use a heating pad with a selector switch that can be turned up by the patient if needed. D) Place a heating pad anteriorly or laterally to, not under, the body part.
D
Which of the following medications is least likely to affect sleep quality? A) diuretic B) steroid C) antidepressant D) Ambien
D
What term is used to describe the sense, usually at a subconscious level, of the movements and position of the body and especially its limbs, independent of vision? A) stereognosis B) visceral C) proprioception D) sensory perception
c