NUR 114 Evolve Questions
Seeing halos around lights & the inability to see objects in the periphery:
glaucoma
A client is newly diagnosed with hypertension. The primary healthcare provider prescribes an antihypertensive medication to be taken once in the morning and a 2 gram sodium diet. What is most important for the nurse to teach the client about lowering the blood pressure?
"Take your medicine exactly as prescribed."
A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test?
Assess if the client is allergic to shellfish.
A client is prescribed ranitidine 150 mg daily to treat peptic ulcer disease (PUD). Which instruction would the nurse give to the client about when to take this medication?
At bedtime
How can the nurse best assist a client with an obsessive-compulsive disorder to decrease the use of ritualistic behavior?
By attempting to limit situations that will worsen the anxiety
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic?
Continues after rest and nitroglycerin
A client on bupropion therapy for depression experiences seizures. Which actions of the primary healthcare provider are used to reduce the risk for seizures? Select all that apply.
Discouraging rapid dose titration Avoiding administration of the medication with paroxetine Avoiding concomitant use of fluoxetine with the medication
Sildenafil is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug, which include what? Select all that apply.
Flushing Headache Dyspepsia
A client with dementia and chronic confusion is suspected to have Alzheimer disease. Which imaging technique is specific for Alzheimer disease?
Magnetic resonance spectroscopy (MRS)
A client has a tonic-clonic seizure caused by an overdose of aspirin. What is an appropriate nursing action?
Monitor vital signs every 15 minutes
Who are the members of the panel that identifies new National Patient Safety Goals? Select all that apply.
Nurses Pharmacists Risk managers
Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply.
Prayer Hypnosis Aromatherapy Guided imagery
The nurse is caring for a client with complete partial seizures. Put in priority order the care activities performed by the nurse
1.Maintaining airway 2.Recording the time and duration of seizure 3.Assessing vital signs 4.Performing neurologic checks
An adolescent child with a seizure disorder is to be discharged with a prescription for phenytoin 140 mg/day, to be divided into two doses. The hospital pharmacy prepares an oral suspension in a concentration of 125 mg/5 mL. What amount of solution will the nurse teach the parents to give for each dose? Record your answer using one decimal place. _____mL
2.8 mL
While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?
Stop the blood transfusion immediately.
A client with glaucoma is receiving a carbonic anhydrase inhibitor. Which statement made by the client will require the nurse to notify the primary healthcare provider?
"I am allergic to sulfonamides."
What is the priority nursing care for a client with delirium?
Creating a calm and safe environment
An intravenous piggyback (IVPB) of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record your answer using a whole number. Do not include units in your answer. ______ gtt/min
ANS: 38-39 gtt/min Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 minutes = 750 / 20 = 37.5. Round the answer to 38 drops per minute
Evaluation of clients with anorexia nervosa requires reassessment of behaviors after admission. Which finding indicates that the therapy is beginning to be effective?
The client has gained 6 lb (2.7 kg) since admission 3 weeks ago.
A client with schizophrenia is observed sitting alone quietly talking. The client appears sad and is tearful. Place the following nursing assessment questions in the appropriate order to best ensure client safety.
"Are you hearing voices?" "What are the voices telling you?" "Are you thinking about hurting yourself or someone else?" "What do you usually do to make the voices stop?"
A nurse provides dietary instructions to a client with calcium oxalate kidney stones. Which instruction should the nurse give to the client?
"You should limit your sodium intake."
A healthcare provider prescribes cefazolin sodium 375 mg intravenous piggyback (IVPB) every 8 hours. The vial of powder contains 500 mg of the medication. This must be reconstituted with 2 mL of 0.9% sodium chloride. In the resulting solution 1 mL contains 225 mg of cefazolin. How many mL of cefazolin solution should the nurse administer? Record your answer using one decimal place. ____mL
ANS: 1.7 mL 375 mg divided by 225 = 1.67 mL round to 1.7 mL
A client with an obsessive-compulsive disorder continually walks up and down the hall, touching every other chair. When unable to do this, the client becomes upset. What should the nurse do?
Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed
A male client diagnosed with bipolar disorder is prescribed medication that has caused a decreased libido. Which drugs would be appropriate to be prescribed by the primary healthcare provider to treat this condition? Select all that apply.
Asenapine Quetiapine Aripiprazole
An ambulatory client with benign prostatic hyperplasia tells the nurse on morning rounds that he has not been able to void. The nurse assesses the client and determines that the bladder is distended. What should the nurse do?
Assist him into a warm shower.
Which alternative therapy may be beneficial for the nurse to discuss with a client who has terminal bone cancer?
Biofeedback
A client is scheduled to begin chemotherapy 2 weeks after surgery for colon cancer. What explanation does the nurse give to explain the delay following surgery?
Chemotherapy interferes with cell growth and delays wound healing.
A self-help group of clients with irritable bowel syndrome have invited a nurse to present a program on nutrition. Which substance should the nurse teach the clients to minimize in the diet to decrease gastrointestinal (GI) irritability?
Cola
Which theory of nursing leadership involves the traditional organizational hierarchy playing a less significant role as the "keeper of high-level knowledge?"
Complexity theory
A client with a history of occasional pain in the left foot when walking now has pain at rest. The left foot is cyanotic, numb, and painful. The suspected cause is arteriosclerosis. Which information will the nurse share with the client to help decrease the pain?
Comply with the prescribed exercise program
What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply.
Determining proper typing and crossmatching of blood
When admitting a client with benign prostatic hyperplasia, which assessment made by the nurse is most relevant?
Distention of the suprapubic area
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD?
Do not want to repeat the ritual but feel compelled to do so
A client with irritable bowel syndrome has instructions to take psyllium 2 rounded teaspoons full twice a day for constipation. What is most important for the nurse to include in the teaching plan?
Each dose should be taken with a full glass of water or juice.
The registered nurse is caring for a client with tonic-clonic seizures. Which action should the nurse perform immediately according to priority?
Ensuring patent airway
Which aspect relates to the quality of relationships while assessing the degree of conflict resolution in nursing leadership? Select all that apply.
Generation of empathy Understanding being created
A blood transfusion of packed cells has been prescribed for a client. The nursing unit is extremely busy. How should the nurse manager delegate for the task of blood administration?
Have all identification verified by registered nurses, then have the registered nurse hang the product and monitor the client, staying with the client during the initial 15 minutes.
A client is informed that he has benign prostatic hyperplasia (BPH), and the healthcare provider prescribes finasteride. The client would like to take saw palmetto instead of the finasteride. What does the nurse inform the client about this herbal supplement?
It may be taken after consultation with the healthcare provider.
A nurse is caring for a client with a diagnosis of benign prostatic hyperplasia (BPH). Which information about this condition is important for the nurse to consider when caring for this client?
It predisposes to hydronephrosis.
A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning, and the client no longer talks about suicide. What should the nurse do in response to this client's behavior?
Keep the client under close observation.
An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I'm sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do?
Maintain Independence
A client is receiving an antihypertensive drug intravenously for control of severe hypertension. The client's blood pressure is 160/94 mm Hg before the infusion. Fifteen minutes after the infusion is started, the blood pressure increases to 180/100 mm Hg. Which type of response is the client demonstrating?
Paradoxical
A client has an eye injury from exposure to a chemical blast. Which immediate nursing intervention is most appropriate for the client?
Performing ocular irrigation
A nurse is assessing the condition of a school-aged child with acute glomerulonephritis. What clinical finding does the nurse anticipate?
Periorbital edema
A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water?
Prevents reflux of air back into the chest
A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar disorder, manic phase. In which type of room should the nurse tell the admissions clerk to place this client?
Private
What could be the reason for cataracts in a 36-year-old client? Select all that apply.
Prolonged exposure to heat Prolonged exposure to metal powders
A nurse is caring for a client with a diagnosis of cancer of the prostate. The nurse should teach the client that which serum level will be monitored throughout the course of the disease?
Prostate-specific antigen (PSA)
A school-aged child is to receive a blood transfusion. What should the nurse do first if an allergic reaction to the blood occurs?
Shut off the infusion
The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis?
Spiral (helical) computed tomographic angiography (CTA)
A nurse is caring for a client who is a victim of trauma and is to receive a blood transfusion. How should the nurse respond when the client expresses fear that acquired immunodeficiency syndrome (AIDS) may be acquired as a result of the blood transfusion?
"Screening for the human immunodeficiency virus (HIV) antibodies has minimized this risk."
A nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result will the nurse check to confirm the diagnosis?
Biopsy of prostatic tissue
The nurse reviews the medical records of four male clients. Which client will the nurse assess most closely for developing prostate cancer?
Black 55-year-old
Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the client with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin?
Common side effects include headache and low blood pressure.
The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care?
Coughing and deep breathing every hour
What is the priority nursing action for a client with delirium?
Creating a calm and safe environment
To manage heart failure a client has been taking several medications, including furosemide 40 mg by mouth twice a day. The client develops severe muscle cramps and fatigue, and laboratory tests confirm the presence of hypokalemia. Potassium chloride intravenously (IV) and ECG monitoring have been prescribed. Which ECG change associated with hypokalemia should the nurse expect to observe?
Flattened T Waves
A school-aged child is admitted to the pediatric unit with hypertensive acute glomerulonephritis. In addition to hydralazine, what medication does the nurse anticipate will be prescribed initially?
Furosemide
A client has a prescription for an antibiotic in an intravenous piggyback (IVPB) of 50 mL of D5W to run for 30 minutes. The microdrip tubing has a drop factor of 60 gtt/mL. At what rate should the nurse set the IV infusion? Record your answer using a whole number. ___gtts/min
ANS: 100 gtt/min 60 gtt/mL x 50 mL divided by 30 minutes= 100 gtt/min
Famotidine 20 mg intravenous piggyback (IVPB) is prescribed for a client with a duodenal ulcer. The medication is diluted in 50 mL of 5% dextrose and is infused over 15 minutes. At what rate should the infusion control device (ICD) be set? Record your answer using a whole number. ___ mL/hr
ANS: 200 mL/hr 15 min x 1 hr/ 60 min = 0.25 hr rate = 50 mL/ 0.25 hr = 200 ml/ hr
The nurse taught a client with heart failure who is scheduled for discharge about how medications, diet, and exercise improve activity tolerance. During a follow-up visit, the nurse finds that the client has learned how to adapt his or her exercise prescription to compensate for an increased tolerance. Which theory did the nurse follow to achieve this positive outcome?
Roy's theory
A man with benign prostatic hyperplasia is scheduled for a transurethral incision of the prostate (TUIP). As he is being admitted to the surgical unit, he tells the nurse he is concerned that the operation will result in impotence. Which is the best response by the nurse?
"I can understand your concern, but this operation usually does not cause impotence."
An adolescent who had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions?
"I can't perform any weightlifting for at least 6 weeks."
A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask a nurse, "How much longer will my child need to take the medication?" What is the best response by the nurse?
"It is important that the medications be gradually decreased."
Which statements related to initial assessment of hypertension by the nurse requires correction? Select all that apply.
"The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure."
A client experiences elevated triglycerides and cholesterol. The client appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." Which is the nurse's most appropriate response?
"You need some fat to supply the necessary fatty acids, so it's mainly just a need to cut down on the amount of fat you consume."
A client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a screening session at a health fair asks the nurse what to do in light of this result. How should the nurse respond?
"Your cholesterol is elevated slightly. A diet low in saturated fats should be followed."
Which nursing interventions should the nurse provide to an older client with hypertension? Select all that apply.
Advise the client to limit salt intake Teach stress management Instruct the client to quit smoking
A client being treated for uncontrolled hypertension and chest pain calls out to the nurse and reports a nosebleed. Upon entry to the client's room, the nurse immediately applies pressure. Which action should the nurse take next?
Assess the client's blood pressure.
When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first?
Assess the client's heart and lung sounds.
A client is admitted to the hospital for surgery for rectosigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with rectosigmoid colon cancer does the nurse expect the client to report? Select all that apply.
Feeling tiredRectal bleedingChange in the shape of stoolsFeeling of abdominal bloating
A nurse is caring for a client who was recently admitted to the psychiatric unit with the diagnosis of bulimia nervosa. Which assessment findings support the diagnosis of bulimia nervosa?
Lack of control over binge-eating episodes
A client takes isosorbide dinitrate daily. The client states, "I would like to start taking sildenafil for erectile dysfunction." The nurse explains that taking both of these medications concurrently may result in which complication?
Severe hypotension
A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? Select all that apply.
Coughing or sneezing Straining when having a bowel movement
The laboratory report of a client reveals increased serum cholesterol levels. Which other finding indicates growth hormone deficiency in the client?
Pathological fractures
A nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, which action should the nurse take?
Place a support under the scrotum.
A client diagnosed with depression is prescribed phenelzine. Which foods, if consumed along with this drug, may cause a hypertensive crisis? Select all that apply.
Red wine Aged meat Aged Cheese
The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?
Inactivity
What instructions about the use of nitroglycerin should the nurse provide to a client with angina?
"Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs."
Severe hypertension develops in a child with acute glomerulonephritis. What medication does the nurse anticipate that the healthcare provider will prescribe?
Captopril
Ceftriaxone 2.5 grams intravenous piggyback (IVPB) every 8 hours is prescribed for a client with a severe infection. The pharmacy sends a vial labeled 5 grams per 10 mL. What volume of ceftriaxone should the nurse add to the IVPB solution? Record your answer using a whole number. ___mL
ANS: 5 mL 10 mL divided by 5 grams x 2.5 grams = 5 mL
The healthcare provider prescribes finasteride for a client with benign prostatic hyperplasia. What information does the nurse provide to the client?
Protection should be worn during intercourse with a pregnant female.
A client with a borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client?
Be firm, consistent, and understanding and focus on specific target behaviors.
An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis?
Cannot see objects in the center of the visual field
The nurse is caring for a 60-year-old client who is diagnosed with dementia. Which antipsychotic drugs would be contraindicated for the client? Select all that apply.
Haloperidol Chlorpromazine
A hospital organization plans to conduct a study on the effect of dried plums for lowering the risk of colon cancer. After selecting the subjects, a nurse researcher provides adequate information about the research and then inquires about the preference of the subjects to associate with the research. What does this procedure indicate?
Informed consent
A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply.
Promote dietary modifications by using varied techniquesAssess the client's current lifestyle and promote lifestyle changesMonitor the client's blood pressure and weight and establish blood pressure screening programs
A 9-year-old child is found to have acute glomerulonephritis after a recent infection. What microorganism should the nurse suspect as the cause of the child's current health problem?
Streptococcus
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?
Suspicious feelings
An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation?
The nurse should inform the primary healthcare provider and not give blood to the client.
Which action demonstrates the "analyticity" concept of a critical thinker? Select all that apply.
The nurse uses evidence-based knowledge for clinical decision-making. The nurse anticipates possible results or consequences in a given situation.
