NARSING PRAKTIS 3
9. During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome? A. Able to perform self-care activities without pain B. Severe chest pain C. Can recognize the risk factors of Myocardial Infarction D. Can Participate in cardiac rehabilitation walking program
A. Able to perform self-care activities without pain
42. Which of the following parameters should be checked before administering digoxin? A. Apical pulse B. Blood pressure C. Radial pulse D. Respiratory rate
A. Apical pulse
27. Which of the following conditions most commonly results in CAD? A. Atherosclerosis B. DM C. MI D. Renal failure
A. Atherosclerosis
38. Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation? A. Beta-adrenergic blockers B. Calcium channel blockers C. Narcotics D. Nitrates
A. Beta-adrenergic blockers
18. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function. A. Blood pressure B. Consciousness C. Distension of the bladder D. Pulse rate
A. Blood pressure
44. Which of the following symptoms is most commonly associated with left-sided hear failure? A. Crackles B. Arrhythmias C. Hepatic engorgement D. Hypotension
A. Crackles
86. A nurse is caring for client with pheochromocytoma. The client asks for a snack and something warm to drink. The most appropriate choice for this client to meet nutritional needs would be which of the following? A. Crackers with cheese and tea B. Graham crackers and warm milk C. Toast with peanut butter and cocoa D. Vanilla wafers and coffee with cream and Sugar
B. Graham crackers and warm milk
7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication: A. GI bleeding B. Peptic ulcer disease C. Abdominal cramps D. Partial bowel obstruction
C. Abdominal cramps
39. What is the most common complication of a myocardial infarction? A. Cardiogenic shock B. Heart failure C. Arrhythmias D. Pericarditis
C. Arrhythmias
2. A client comes to the ER complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior wall myocardial infarction (MI). Which ECG characteristics indicates myocardial ischemia? A. Prolonged PR interval B. Absent Q wave C. Elevated ST segment D. Widened QRS complex
C. Elevated ST segment
11. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing? A. Upper extremity flexion with lower extremity flexion B. Upper extremity flexion with lower extremity extension C. Extension of the extremities after a stimulus D. Flexion of the extremities after stimulus
C. Extension of the extremities after a stimulus
49. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? A. Taking hourly blood pressures with mechanical cuff B. Encouraging fluid intake of at least 200mL per hour C. Position in high fowlers with knee gatch raised D. Administering Tylenol as ordered
B. Encouraging fluid intake of at least 200mL per hour
31. Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease? A. Decrease anxiety B. Enhance myocardial oxygenation C. Administer sublingual nitroglycerin D. Educate the client about his symptoms
B. Enhance myocardial oxygenation
16. Among the following signs and symptoms, which would most likely be present in a client with mitral regurgitation? A. Altered level of consciousness B. Exceptional Dyspnea C. Increase creatine phospholinase concentration D. Chest pain
B. Exceptional Dyspnea
13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to... A. Elevate client's bed at 45° B. Instruct the client to cough and deep breathe every 2 hours C. Frequently monitor client's apical pulse and blood pressure D. Monitor client's temperature every hour
C. Frequently monitor client's apical pulse and blood pressure
29. Which of the following risk factors for coronary artery disease cannot be corrected? A. Cigarette smoking B. DM C. Heredity D. HPN
C. Heredity
95. A nurse caring for a client with Addison's disease would expect to note which of the following on assessment of the client? A. Obesity B. Edema C. Hypotension D. Hirsutism
C. Hypotension
33. Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of the heart? A. Anterior B. Apical C. Inferior D. Lateral
C. Inferior
24. Which of the following arteries primarily feeds the anterior wall of the heart? A. Circumflex artery B. Internal mammary artery C. Left anterior descending artery D. Right coronary artery
C. Left anterior descending artery
15. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of... A. Dental floss B. Electric toothbrush C. Manual toothbrush D. Irrigation device
C. Manual toothbrush
19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure? A. Tonic seizure B. Absence seizure C. Myoclonic seizure D. Clonic seizure
C. Myoclonic seizure
88. A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse knows that which of the following diets most likely would be prescribed for this client? A. High fat intake B. Low protein intake C. Normal sodium intake D. Low carbohydrate intake
C. Normal sodium intake
46. Which of the following symptoms might a client with right-sided heart failure exhibit? A. Adequate urine output B. Polyuria C. Oliguria D. Polydipsia
C. Oliguria
32. Medical treatment of coronary artery disease includes which of the following procedures? A. Cardiac catheterization B. Coronary artery bypass surgery C. Oral medication administration D. Percutaneous transluminal coronary angioplasty are invasive, surgical treatments.
C. Oral medication administration
74 A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest A. Cyanosis B. Hypotension C. Paradoxical chest movement D. Dyspnea, especially on exhalation
C. Paradoxical chest movement
9. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help... A. Retard rapid drug absorption B. Excrete excessive fluids accumulated at night C. Prevents sleep disturbances during night D. Prevention of electrolyte imbalance
C. Prevents sleep disturbances during night
41. What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention? A. High-Fowler's B. Raised 10 degrees C. Raised 30 degrees D. Supine position
C. Raised 30 degrees
60. A community health nurse is conducting an educational session With community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: A. Dyspnea B. Chest pain C. A bloody, productive cough D. A cough with the expectoration Of mucoid sputum
D. A cough with the expectoration Of mucoid sputum
87. A nurse is performing an assessment on a client with pheochromocytoma. Which of the following assessment data would indicate a potential complication associated with this disorder? A. A coagulation time of 5 minutes B. A blood urea nitrogen level of 20 mg/dl C. A urinary output of 50 ml per hour D. A heart rate that is 90 beats/min and irregular
D. A heart rate that is 90 beats/min and irregular
80. Which instruction should be included in the teaching plan for a client requiring insulin? A. Administer insulin B. Administer insulin at a 45 degree angle into a deltoid muscle C. Shake the vial of insulin vigorously before withdrawing the medication D. Draw up clear insulin first when mixing two types of insulin in one syringe
D. Draw up clear insulin first when mixing two types of insulin in one syringe
35. Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? A. Cardiac catheterization B. Cardiac enzymes C. Echocardiogram D. Electrocardiogram
D. Electrocardiogram
72. A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which Of the following nursing interventions for this client? A. Administering atropine intravenously B. Administering small doses of midazolam (Versed) C. Encouraging additional fluids for the next 24 hours D. Ensuring the return of the gag reflex before offering food or fluids
D. Ensuring the return of the gag reflex before offering food or fluids
47. Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility? A. Beta-adrenergic blockers B. Calcium channel blockers C. Diuretics D. Inotropic agents
D. Inotropic agents
20. Smoking cessation is critical strategy for the client with Burgher's disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication? A. Paracetamol B. Ibuprofen C. Nitroglycerin D. Nicotine (Nicotrol)
D. Nicotine (Nicotrol)
8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action? A. Monitoring urine output frequently B. Monitoring blood pressure every 4 hours C. Obtaining serum potassium levels daily D. Obtaining infusion pump for the medication
D. Obtaining infusion pump for the medication
25. When do coronary arteries primarily receive blood flow? A. During inspiration B. During diastole C. During expiration D. During systole
B. During diastole
85. What laboratory finding is the primary diagnostic indicator for pancreatitis? A. Elevated blood urea nitrogen (BUN) B. Elevated serum lipase C. Elevated aspartate aminotransferase (AST) D. Increased lactate dehydrogenase (LD)
B. Elevated serum lipase
67. A nurse is suctioning fluids from a male client via a tracheostomy tube When suctioning, the nurse must limit the suctioning time to a maximum of: A. 1 minute B. 5 seconds C. 10 seconds D. 30 seconds
C. 10 seconds
84. The nurse is assigned to a 40-yr old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory results, anticipating a laboratory report that indicates a serum amylase level of: A. 45 units/L B. 100 units/L C. 300 units/L D. 500 units/L
C. 300 units/L
75 A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has an absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of: A Right pneumothorax B Pulmonary embolism C Displaced endotracheal tube D Acute respiratory distress syndrome
A Right pneumothorax
90. A nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? A. "I can eat foods that have a lot of potassium in them." B. "I will need to limit the amount of protein in my diet." C. "I am fortunate that I can eat all the salty foods I enjoy." D. "I am fortunate that I do not need to follow any special diet."
A. "I can eat foods that have a lot of potassium in them."
76. A client has just been diagnosed with type 1 diabetes mellitus. Which comment by the client correlates best with this disorder? A. "I was thirsty all the time. I just couldn't get enough to drink." B. "It seemed like I had no appetite. I had to make myself eat." C. "I had a cough and cold that just didn't seem to go away.' D. "I noticed I had pain when I went to the bathroom.
A. "I was thirsty all the time. I just couldn't get enough to drink."
37. What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying? A. "Tell me about your feeling right now." B. "When the doctor arrives, everything will be fine." C. "This is a bad situation, but you'll feel better soon." D. "Please be assured we're doing everything we can to make you feel better."
A. "Tell me about your feeling right now."
51. A male client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy If the client's baseline theophylline level was. A. 10 mcg/ml B. 12 mcg/ml C. 15 mcg/ml D. 18 mcg/ml
A. 10 mcg/mL
1.The nurse suspects that her client is in cardiac arrest. According to the American Heart Association, the nurse should perform the actions listed below. Order these actions in the sequence that the nurse should perform them. I. Activate the emergency medical system. II. Assess responsiveness. III. Call for a defibrillator. IV. Provide two slow breaths. V. Assess pulse. VI. Assess breathing. A. 2.1.3.6.4.5 B. 132456 C. 1,2,3,6,5,4 D. 2,3.1,5,6,4
A. 2.1.3.6.4.5
79. A nurse administered NPH insulin to a client with Diabetes mellitus at 7 am. At what time would the nurse expect the client to be at greatest risk for a hypoglycemic reaction? A. 10 am B Noon C. 4 pm D. 10 pm
C. 4 pm
81. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented; has hot, dry skin; and has the following vital signs: temperature 38.1 degrees Celsius, heart rate of 116 beats/min and blood pressure of 108/70 mmHg. Based on these assessment findings, which nursing diagnosis takes highest priority? A. Deficient fluid volume related to osmotic diuresis B. Decreased cardiac output related to osmotic diuresis C. Imbalanced Nutrition: less than body requirements related to insulin deficiency D. Ineffective thermoregulation related to dehydration
A. Deficient fluid volume related to osmotic diuresis
43. Toxicity from which of the following medications may cause a client to see a green halo around lights? A. Digoxin B. Furosemide C. Metoprolol D. Enalapril
A. Digoxin
52. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? A. Do nothing, because this is an expected finding. B. Immediately clamp the chest tube and notify the physician C. Check for an air leak because the bubbling should be intermittent D. Increase the suction pressure so that bubbling becomes vigorous
A. Do nothing, because this is an expected finding.
70 A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation Of pulmonary embolism? A. Dyspnea B Bradypnea C Bradycardia D Decreased respiratory
A. Dyspnea
77. Which outcome would indicate successful treatment of diabetes insipidus? A. Fluid intake of less than 2,500 ml in 24 hours B. Urine output of more than 200 ml/hr. C. Blood pressure of 90/50 D. pulse rate of 126 beats/minute
A. Fluid intake of less than 2,500 ml in 24 hours
11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza's highest priority would be... A. Hourly urine output B. Temperature C. Able to turn side to side D. Able to sips clear liquid
A. Hourly urine output
82. For the first 72 hours after thyroidectomy surgery, a nurse would assess a client for Chvostek's and Trousseau's signs because they indicate: A. Hypocalcemia B. Hypercalcemia C. Hypokalemia D. Hyperkalemia
A. Hypocalcemia
22. A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for: A. Increased blood pressure B. Decreased respirations C. Increased urinary output
A. Increased blood pressure
71. A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? A. Inhales the mist and quickly exhales B. Removes the cap and shakes the inhaler well before use C. Presses the canister down with the finer as he breathes in D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
A. Inhales the mist and quickly exhaleS
34. After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? A. Left-sided heart failure B. Pulmonic valve malfunction C. Right-sided heart failure D. Tricuspid valve malfunction
A. Left-sided heart failure
23. The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in vitamin B12? A. Meat, eggs, dairy products B. Peanut butter, raisins C. Broccoli, cauliflower, cabbage D. Shrimp, legumes, bran cereals
A. Meat, eggs, dairy products
69. An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: A. Metabolic acidosis B. Respiratory acidosis C. Overcompensated respiratory acidosis D. Combined respiratory and metabolic acidosis
A. Metabolic acidosis
5. A client who is awake and diaphoretic has a palpable pulse. The nurse runs an electrocardiogram (ECG) strip, which reveals the following pattern for the lead I. What does the pattern indicate? A. Normal sinus rhythm B. Atrial fibrillation C. Ventricular standstill D. Ventricular tachycardia
A. Normal sinus rhythm
14. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate? A. Protamine Sulfate B. Quinidine Sulfate C. Vitamin C D. Coumadin
A. Protamine Sulfate
21. Which of the following lab studies should be done periodically if the client is taking warfarin sodium (Coumadin)? A. Stool specimen for occult blood B. White blood cell count C. Blood glucose D. Erythrocyte count
A. Stool specimen for occult blood
57. A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? A. Stridor B. Occasional, pink-tinged sputum C. A few basilar lung crackles on the right D. Respiratory rate of 24 breaths/min
A. Stridor
58. An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. A low respiratory B. Diminished breathe sounds C. The presence of a barrel chest D. A sucking sound at the site of injury
B. Diminished breathe sounds
63. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that It does not exceed. A. 1 L/min B 2 L/min C 6 Limin D 10 L/min
B 2 L/min
61 A nurse performs an admission assessment on a female client With a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that Will confirm this diagnosis? A Bronchoscopy B Sputum culture C Chest x-ray D Tuberculin skin test
B Sputum culture
91. A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: A. 2 to 4 hours after administration B. 4 to 12 hours after administration C. 16 to 18 hours after administration D. 18 to 24 hours after administration
B. 4 to 12 hours after administration
59. A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease Which of the following would the nurse expect to note on assessment of this client? A. Hypocapnia B. A hyperinflated chest noted on the chest ray C. Increase oxygen saturation With exercise D. A widened diaphragm noted on the chest xray
B. A hyperinflated chest noted on the chest ray
36. What is the first intervention for a client experiencing myocardial infarction? A. Administer morphine B. Administer oxygen C. Administer sublingual nitroglycerin D. Obtain an electrocardiogram
B. Administer oxygen
53. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on the assessment, which action would be appropriate? A. Inform the physician B. Continue to monitor the client C. Reinforce the occlusice dressing. D. Encourage the client to deep-breathe
B. Continue to monitor the client
26. Which of the following illnesses is the leading cause of death in the US? A. Cancer B. Coronary artery disease C. Liver failure D. Renal failure
B. Coronary artery disease
6. Mrs. Chua a 78-year-old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client's lungs indicative of chronic heart failure would be: A. Stridor B. Crackles C. Wheezes D. Friction rubs
B. Crackles
56. While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing acting is to: A. Call the physician to reinsert the tube B. Grasp the retention sutures to spread the opening C. Call the respiratory therapy department to reinsert the tracheostomy D. Cover the tracheostomy wite with sterile dressing to prevent infection.
B. Grasp the retention sutures to spread the opening
65. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? A. Limiting fluids B. Having the clients take three deep breaths C. Asking the client to split into the collection container D. Asking the client to obtain the specimen after eating
B. Having the clients take three deep breaths
40. With which of the following disorders is jugular vein distention most prominent? A. Abdominal aortic aneurysm B. Heart failure C. Myocardial infarction D. Pneumothorax
B. Heart failure
10. What would be the primary goal of therapy for a client with pulmonary edema and heart failure? A. Enhance comfort B. Increase cardiac output C. Improve respiratory status D. Peripheral edema decreased
B. Increase cardiac output
54. The nurse is caring for a male client with a chest tube, turns the client to the side and the chest tube accidentally disconnects. The initial nursing action is to: A. Call the physician B. Place the tube in a bottle of sterile water C. Immediately replace the chest tube system D. Place the sterile dressing ove the disconnection site.
B. Place the tube in a bottle of sterile water
28. Atherosclerosis impedes coronary blood flow by which of the following mechanisms? A. Plaques obstruct the vein B. Plaques obstruct the artery C. Blood clots form outside the vessel wall D. Hardened vessels dilate to allow the blood
B. Plaques obstruct the artery
7. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine A. Decrease anxiety and restlessness B. Prevents shock and relieves pain C. Dilates coronary blood vessels D. Helps prevent fibrillation of the heart
B. Prevents shock and relieves pain
3. Nyosh admits himself on the ER following an intense chest pain and the doctor orders an ECG. The result below will be interpreted as A. AV bundle block B. Sinus rhythm C. Atrial flutter D. Sinus arrhythmia
B. Sinus rhythm
48. Stimulation of the sympathetic nervous system produces which of the following responses? A. Bradycardia B. Tachycardia C. Hypotension D. Decreased myocardial contractility
B. Tachycardia
62 The nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this Information if the student states that the tuberculosis is transmitted by: A. Hand and mouth B. The airborne route C. The fecal-oral route D. Blood and body fluids
B. The airborne route
12. A 64-year-old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is... A. To determine the existence of CHD B. To visualize the disease process in the coronary arteries C. To obtain the heart chambers pressure D. To measure oxygen content of different heart chambers
B. To visualize the disease process in the coronary arteries
10. A 68-year-old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to: A. Application of elastic stockings to prevent flaccid by muscle B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions C. Use a bed cradle to prevent dorsiflexion if feet D. Do passive range of motion exercise
B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
93. A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should assess the client for a hypoglycemic reaction at: A. 10:00 am B. 11:00 am C. 5:00 pm D. 11:00 pm
C 5:00 pm
96. A nurse is assessing a client with a diagnosis of goiter. Which of the following would the nurse expect to note during the assessment of the client? A Client complains of slow wound healing B. Client complains of chronic fatigue C. An enlarged thyroid gland D. The presence of heart damage
C An enlarged thyroid gland
66 A nurse is caring for a female client after a bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians? A. Dry cough B Hematuria C Bronchospasm D Blood-streaked sputum
C Bronchospasm
94. The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which most important statement? A. *Your hair will need to be shaved." B. Deep breathing and coughing will be needed after surgery.' C. Brushing your teeth will not be permitted for at least 2 weeks following surgery. D. You will receive spinal anesthesia.
C Brushing your teeth will not be permitted for at least 2 weeks following surgery.
50. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention: A. Adjust the room temperature B. Give a bolus of IV fluids C. Start Oxygen D Administer meperidine (Demerol) 75mg IV push
C. Start Oxygen
68. A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? A Continue to suction. B. Notify the physician immediately. C. Stop the procedure and reoxygenate the client. D. Ensure that the suction is limited to 15 seconds
C. Stop the procedure and reoxygenate the clienT
92. A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the Client, indicates a need for further teaching? A"I need to drink diet soft drinks B."I will eat a balanced meal plan. C."I need to purchase special diabetic foods D. "I'll snack on fruits instead of cake
C."I need to purchase special diabetic foods
89. A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder? A. "I take oral insulin instead of shots" B. "By taking these medications, I am able to eat more." C. "When I become ill, I need to increase the number of pills I take." D. "The medications I'm taking help release the insulin I already make.
D. "The medications I'm taking help release the insulin I already make.
30. Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary artery disease? A. 100 mg/dl B. 150 mg/dl C. 175 mg/dl D. 200 mg/dl
D. 200 mg/dl
83. On a medical-surgical floor, the nurse is caring for a cluster of clients who have been diagnosed with diabetes mellitus. Which client should the nurse assess first? A. An 80-year-old client with a blood glucose level of 350 mg/dl B. A 20-year-old client with a blood glucose level of 70 mg/dl C. A 60-year-old client experiencing nausea and vomiting D. A 55-year-old client complaining of chest pressure
D. A 55-year-old client complaining of chest pressure
4. The electrocardiogram (ECG) tracing shown below, excluding the seventh beat, has a normal QRS complex, one premature atrial contraction (PAC), and what other attributes? A. P wave is identifiable, PR is 0.16 second, and sinus rhythm is at 95 beats/minute. B. P wave and PR interval are unidentifiable and sinus arrhythmia is at 95 beats/minute. C. P wave is identifiable, PR interval is 0.16 second, and sinus rhythm is at 95 beats/minute. D. P wave is identifiable, PR interval is 0.16 second, and sinus arrhythmia is at 95 beats/minute.
D. P wave is identifiable, PR interval is 0.16 second, and sinus arrhythmia is at 95 beats/minute.
73. A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? A. Slow deep respirations B. Rapid deep respirations C. Paradoxical respirations D. Pain, especially With inspiration
D. Pain, especially With inspiration
55. Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A. Exhale slowly B. Stay very still C. Inhale and exhale quickly D. Perform the Valsalva maneuver
D. Perform the Valsalva maneuver
64. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of purSed-lip breathing is to: A Promote oxygen intake. B Strengthen the diaphragm. C Strengthen the intercostal muscles. D. Promote carbon dioxide elimination.
D. Promote carbon dioxide elimination.
17. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the... A. Urinary meatus B. Pain in the Labium C. Suprapubic area D. Right or left costovertebral angle
D. Right or left costovertebral angle
45. In which of the following disorders would the nurse expect to assess sacral edema in bedridden client? A. DM B. Pulmonary emboli C. Renal failure D. Right-sided heart failure
D. Right-sided heart failure
8. Which of the following should the nurse teach the client about the signs of digitalis toxicity? A. Increased appetite B. Elevated blood pressure C. Skin rash over the chest and back D. Visual disturbances such as seeing yellow spots
D. Visual disturbances such as seeing yellow spots
