N3134 + FINAL EXAM PRACTICE QUESTIONS
A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment
A. Airborne Airborne precautions are required for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. B. Droplet precautions are required for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and Streptococcal pharyngitis. C. Contact precautions are required for clients who have infections that spread via direct contact or contact with the environment, including vancomycin-resistant Enterococci, methicillin-resistant Staphylococcus aureus, and scabies. D. Clients who have a compromised immune-system (e.g. after an allogenic hematopoietic stem cell transplant) require a protective environment.
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following disorders should the nurse identify as increasing the client's metabolic needs (Select all that apply). A. COPD B. Hypothyroidism C. Cancer D. Parkinson's disease E. Major burns
A. COPD B. Cancer C. Parkinson's disease E. Major burns Clients who have COPD develop hypermetabolism as a result of the increased amount of energy used to breathe. Cancer can cause a number of metabolic changes, including hypermetabolism as a result of tumor growth. Clients who have Parkinson's disease develop hypermetabolism because they burn calories due to muscular rigidity. Finally, clients who have major burns develop severe metabolic stress, which includes hypermetabolism and hypercatabolism. B. Insufficient thyroid hormone results in decreased metabolism.
A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorus D. Eat a diet high in protein
A. Limit fluid intake A client who has CKD should limit fluid intake to prevent hypervolemia (excessive fluid overload). B. A client who has CKD should increase caloric intake so that the body can use protein for protein synthesis instead of energy consumption. Using protein for energy can lead to a negative nitrogen balance and malnutrition. C. A client who has CKD should limit phosphorus intake because the kidneys are unable to excrete it. D. A client who has CKD should not eat excessive protein to prevent the build-up of protein waste products and uremia.
A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Provide oral care to a client who cannot take oral fluids. B. Check a client's IV insertion site for manifestations of infiltration. C. Assess a client's ability to ambulate. D. Demonstrate the use of a glucometer to a client who has diabetes mellitus
A. Provide oral care to a client who cannot take oral fluids. Providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP. B. Checking a client's IV insertion site for manifestations of infiltration is not within the range of function for an AP. C. Assessing a client's ability to ambulate is not within the range of function for an AP. Therefore, the nurse should not assign this task to the AP. D. Demonstrating the use of a glucometer to a client who has diabetes mellitus (DM) is not within the range of function for an AP. Therefore, the nurse should not assign this task to the AP.
A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax. (Select all that apply). A. Tracheal deviation to the left B. Temperature of 38.8 C (102 F) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea
A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficult breathing increases, the blood flow return compresses, causing the neck veins to distend. B. An elevated temperature is a sign of an infection and can be associated with the purulent drainage obtained. However, this is not a manifestation of a pneumothorax. E. Clients who experience a tension pneumothorax exhibit respiratory distress and tachypnea until a chest tube is inserted to re-inflate the lung.
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection? A. WBC 15,000 mm^3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specificity gravity 1.0063
A. WBC 15,000 mm^3 This finding is above the expected reference range and is an indication of infection. B. Although an elevated ESR can indicate an infection, this finding is within the expected reference range. C. A urine pH of 7.2 is within the expected reference range. D. A urine specific gravity of 1/0063 is within the expected reference range.
A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet? A. White bread and plain yogurt B. Shredded wheat cereal and blueberries C. Broccoli and kidney beans D. Oatmeal and fresh pears
A. White bread and plain yogurt Because of the acute inflammation of diverticulitis, the client should maintain a diet very low in fiber foods like white bread, low-fat milk, yogurt with active cultures, poached eggs, and canned soft fruit. B. Foods like shredded wheat cereal and blueberries can worsen the inflammation of acute diverticulitis. C. Foods like broccoli and kidney beans can worsen the inflammation of acute diverticulitis. D. Foods like oatmeal and fresh pears can worsen the inflammation of acute diverticulitis.
A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast. B. Cleanse the skin around the stoma with warm water. C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor
B. Cleanse the skin around the stoma with warm water The nurse should instruct the client to cleanse the skin around the stoma with warm water, as using soap can leave a residue on the skin and cause poor adherence of the pouch. A. The nurse should instruct the client to change the colostomy bag before a meal because drainage from the ostomy is less likely to occur. C. The nurse should instruct the client to change the pouch every 3 to 7 days to avoid skin breakdown around the stoma. D. Place aspirin in the ostomy pouch to decrease odor.
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves when collecting the specimen. B. Cleanse the wound with 0.9% sodium chloride irrigation. C. Allow the collection swab to absorb old exudate. D. Rotation the collection swab over the edges of the wound.
B. Cleanse the wound with 0.9% sodium chloride irrigation. The nurse should cleanse the wound with sterile water of 0.9% sodium chloride irrigation to remove any surface debris or old exudate. A. The nurse should wear clean gloves to collect a wound culture specimen. The nurse's hands will not touch the wound or the culture swab. C. Pooled drainage can collect microorganisms that are not the pathogens causing the wound infection. D. The nurse should rotate the swab back and forth over clean areas in the base of the wound that can harbor superficial microorganisms from the skin that are not infecting the wound.
A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist
B. Ensure an adequate airway The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to ensure the client's airway is adequate, as respiratory depression is a manifestation of opioid toxicity. A. The client might need fluid administration due to possible hypotension. However, there is another action the nurse should take first. C. The nurse should obtain an accurate medication history to provide care safely for the client. However, there is another action the nurse should take first. D. The nurse should prepare to administer an antagonist to reverse the action of the opioid. However, there is another action the nurse should take first.
A nurse is preparing an in-service program about the stages of acute kidney injury (AKI). Which of the following pieces of information should the nurse include about pre-renal azotemia? A. Pre-renal azotemia begins prior to the onset of symptoms. B. Interference with renal perfusion causes pre-renal azotemia. C. Pre-renal azotemia is irreversible, even in the early stages. D. Infections and tumors cause pre-renal azotemia.
B. Interference with renal perfusion causes pre-renal azotemia. Pre-renal azotemia results from interference with renal perfusion, such as from heart failure of hypovolemic shock. A. Clients who has pre-renal azostemia typically have tachycardia, lethargy, reduced urine output, and other manifestations. C. In early stages, reversal or pre-renal azotemia is possible with correction of hypovolemia and improvement in blood pressure and cardiac output. D. Infections and ingested toxins cause intrarenal AKI, not pre-renal azotemia.
A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? A. Bulging in the area over the surgical incision B. Shortening of the right leg C. Sensation of warmth over the surgical incision D. Pallor following elevation of the right leg
B. Shortening of the right leg The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip pain, an inability to move the extremity, and rotation of the hip internally or externally. A. The nurse should not expect visible bulging following dislocation of the prosthesis. C. The nurse should not expect a sensation of warmth over the surgical incision following dislocation of the prosthesis. A sensation of warmth or heat can indicate infection of the joint. D. The nurse should not expect pallor following the elevation of the right leg after dislocation of the prosthesis. The finding is expected for a client who has impaired arterial circulation.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should a nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL
B. Sodium 132 mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space. A. This laboratory value is below the expected reference range. The nurse should anticipate an elevated hemoglobin level during the resuscitation phase due to the loss of fluid volume. C. This laboratory finding is within the expected reference range. The nurse should anticipate a low albumin level during the resuscitation phase. D. This laboratory finding is within the expected reference range. The nurse should anticipate an elevated potassium level during the resuscitation phase.
A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my exposure to sunlight" B. "I should avoid drinking alcohol" C. "I should not smoke" D. "I should limit of intake of foods that are high in purine"
C. "I should not smoke" Raynaud's disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities to feel numb and cool in response to cold temperatures of stress. During a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white due to a lack of blood flow in the area. Affected areas then turn blue as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and later returns to normal color. This can cause tingling, swelling and painful throbbing. The attacks can last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased, causing the fingers to become thin and tapered, with smooth, shiny skin and slowly-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin can occur. Smoking cessation can prevent the onset of the manifestations of Raynaud's disease. A. Clients who have Raynaud's disease have poor blood circulation to the distal extremities. Exposure to sunlight increases warmth and blood flow to the extremities. B. Although drinking alcohol can interfere with some medications and illnesses, it does not relate to the progression of Raynaud's disease. D. Foods high in purine such as organ meats are contraindicated for clients who have gout, not Raynaud's disease.
A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? A. "Exertion often brings on pain" B. "Variant angina occurs randomly at various times" C. "Variant angina can cause changes on your electrocardiogram" D. "Reducing your cholesterol can help you experience less pain"
C. "Variant angina can cause changes on your electrocardiogram" Variant angina causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium. A. Variant angina typically occurs with rest. B. Variant angina pain tends to occur at the same tine of day. C. Vasospasm, not atherosclerosis, causes variant angina. If the client's cholesterol level is above the expected reference range, attempts should be made to lower it; however, this measure is unlikely to affect variant angina.
A nurse is caring for a client who is 2 days postoperative following gastric surgery and has an NG tube inserted. Which of the following findings should the nurse report to the provider? A. Dryness of the mucous membranes B. Hypoactive bowel sounds in all quadrants C. 200 mL of bright red drainage from the NG tube D. Suction set at continuous low suction
C. 200 mL of bright red drainage from the NG tube The nurse should notify the provider immediately if 200 mL of bright red drainage comes from the NG tube 2 days following gastric surgery. Drainage should be either a yellow-green color or clear. Bright red drainage indicates blood loss and can be the result of a disrupted suture line or other internal bleeding. Volume loss from blood is a medical emergency, and the provider should be immediately notified. A. The nurse should expect a client who has an NG tube following gastric surgery to have a dry mouth and nose, accompanied by thirst. The nurse can offer a lubricant for the nose and lips and provide ice chips, if they are approved by the provider. B. The nurse should expect bowel sounds to be hypoactive following gastric surgery. Resumption of bowel sounds occurs slowly and indicates a return pf peristalsis, which promotes healing. When peristalsis returns, the NG tube can be removed. D. The nurse should except the NG suction to be set at low continuous suction unless otherwise noted by the provider. The nurse can check the suction canister for drainage and the client's stomach for bloating and distention to determine if the decompression is effective.
A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? A. Pallor B. Jaundice C. Absence of hair on the legs D. Poor nailbed capillary refill
C. Absence of hair on the legs A progressive loss of hair is common with aging. However, thinning or absence of hair on extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider. A. Although pallor can indicate a hematologic disorder such as hyperbilirubinemia, yellowing of the skin is common with aging. Pallor is an unreliable indicator of anemia for an older adult. B. Although jaundice is an unreliable indicator of hyperbilirubinemia for an older adult. D. Although poor nailbed capillary refill can indicate a hematologic disorder such as an arterial insufficiency, thickening and discoloration of the nails are common with aging and are not a reliable indicator of arterial insufficiency for an older adult.
A nurse is caring for a client who has diabetes insipidus. Which of the following findings should the nurse monitor? A. Proteinuria B. Oliguria C. Polyuria D. Glycosuria
C. Polyuria Diabetes insipidus is characterized by increased thirst (polydipsia) and increased urination (polyuria). A client who has diabetes insipidus will excrete large quantities of urine with a very low specific gravity. A. Protein in the urine is a manifestation of kidney disease. B. Oliguria is a manifestation of kidney failure. C. Glucose in the urine is a manifestation of type 1 diabetes mellitus.
A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take? A. Suggest the client talk with someone who has survived breast cancer. B. Encourage the client not to give up. C. Support the client's decision. D. Refer the client to a counselor.
C. Support the client's decision. The nurse has the responsibility to support the client's decision and respect the client's right of refusal. The nurse should notify the provider of the client's decision and document the refusal in the client's medical record. A. By suggesting that the client talks with a cancer survivor, the nurse is challenging the client's decision, which indicates the nurse is not considering the client's feelings. B. By encouraging the client not to give up, the nurse is passing judgement on the client, which indicates that the nurse disapproves of the client's decision. D. By referring the client to a counselor, the nurse is challenging the client's decision, which will make the client feel defensive.
A nurse is preparing an in-service presentation about the basics of hematology. Which of the following factors provides a stimulus for the production of RBCs? A. Venous stasis B. Thrombocytopenia C. Inflammation D. Tissue hypoxia
D. Tissue hypoxia In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes (RBCs) in the bone marrow. A. Venous stasis activates platelets and stimulates blood clotting, it does not affect the production of RBCs. B. Platelets are essential for blood clotting. A platelet deficiency does not affect the production of RBCs. C. Inflammation and infection trigger the production of white blood cells.
A nurse is caring for a client who is receiving radiation therapy for a mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide? A. Offer graham crackers as a snack. B. Avoid foods containing citrus. C. Rinse the mouth with an alcohol-based mouthwash before eating. D. Use gravies or sauces to soften food.
D. Use gravies or sauces to soften food. The nurse should instruct the client to use gravies or sauces to soften foods and make them easier to eat. A. The client should avoid eating dry, coarse foods such as graham crackers. This type of food can make the client's mouth feel more dry and unpleasant. B. The client should consume foods containing citrus to stimulate saliva. C. The client should rinse the mouth with an alcohol-free mouthwash before eating. Alcohol-based mouthwash can make the client's mouth drier.
