NUR 155 Final Review
which of the following symptoms would you assess in a patient experiencing hypervolemia? a. BP 88/56 b. BP 146/92 c. jugular vein distension d. weak pulses e. weight loss f. crackles upon ling auscultation
b. BP 146/92 c. jugular vein distension f. crackles upon ling auscultation
a 23 year old patient states that she has been having anxiety and insomnia after being assaulted at a local bar. which of the following medications would be most beneficial in treating her anxiety and insomnia? a. lithium b. paroxetine c. alprazolam d. buproprion
c. alprazolam
the capsule endoscopy results show a picture of the following. which inflammatory disease process is depicted? (picture of narrow tube with polyps on the inside) a. ulcerative colitis b. irritable bowel syndrome c. crohn's disease d. peptic ulcer disease
c. chron's disease
patient is one day post right hip replacement. you assess and review her plan of care. which assessment finding should be reported immediately to the HCP? a. bloody wound drainage b. a temp of 100 c. numbness in the operative leg d. pedal pulses equal in strength bilaterally
c. numbness in the operative leg
58 year old hispanic male passed out at home while working in his garden. his wife took him to the er. his labs are as follows: skin is hot and flushed, mucous membranes dry T- 99.3 HR- 108 B/P- 92/60 RR- 22 which data would be most helpful at this time? a. intake and output b. hematocrit c. time of last meal d. pain level
hematocrit
The nurse is providing discharge education to a patient following gastric bypass surgery. Which of the following statements made by the patient indicates that teaching was successful? A. "I will drink at least 30 mL of water with meals" B. "I will lay down after I eat my meals" C. "I will eat until I feel nauseous" D. "I will be able to resume a regular diet on post-op day 3 "
B. "I will lay down after I eat my meals"
A nurse at the clinic speaks to a diabetic patient on the phone who reports symptoms of nausea and vomiting. What priority instruction should the nurse tell this patient? A. "You should continue with your normal diet" B. "Try to eat or drink small amounts of carbohydrates every 1-2 hours if possible to keep your BGL in the target range" C. "Make sure you check your blood sugar levels AC and HS during this time of day" D. "Let your digestive system rest and only consume sips of water for the next eight hours"
B. "Try to eat or drink small amounts of carbohydrates every 1-2 hours if possible to keep your BGL in the target range"
Which of the following nursing actions would be most important in the prevention of post-operative complications in the patient who has undergone a Roux-en-Y? A. Assessing the patients NG tube output for blood B. Assisting the patient to ambulate following surgery C. Giving bolus feedings using a PEG tube D. Initiating a PCA pump per MD orders
B. Assisting the patient to ambulate following surgery
Which of the following dietary choices would best indicate that a patient understands the lifestyle management of hypertension? A. Fried fish, coleslaw and baked potato with butter and sour cream B. Broiled shrimp, Caesar salad and garlic roasted potatoes C. Grilled sirloin steak, garden salad and garlic cheese bread D. Chicken Alfredo, green beans and apple pie
B. Broiled shrimp, Caesar salad and garlic roasted potatoes
Which interventions would be performed for a client that has undergone an outpatient arthroscopic procedure on the left knee? Select all that apply. A. Prepare the client to transfer to orthopedic flood B. Educate the client on recognizing signs and symptoms of infection C. Apply band-aid over incision site D. Apply compression dressing to left knee E. Inform client to resume exercise regimen F. Assess neuromuscular status of the left lower extremity
B. Educate the client on recognizing signs and symptoms of infection D. Apply compression dressing to left knee F. Assess neuromuscular status of the left lower extremity
The nurse is educating a postoperative client about prevention of DVT. Which of the following statements made by the client indicates that teaching was effective? A. "I will begin ambulating on post-operative day two" B. "I will maintain bedrest" C. "I will perform leg exercises every half hour while I am awake" D. "I will wear my SCD's at least once a day"
C. "I will perform leg exercises every half hour while I am awake"
A nurse is preparing discharge instructions for an AKA client. Which instructions would be included in discharge instructions for home care? A. Massage the residual limb in a motion away from the suture line B. Immediately report twitching, spams, or phantom limb pain C. Be sure to perform the prescribed exercises D. Elevate the limb above the heart
C. Be sure to perform the prescribed exercises
A patient with peptic ulcer disease (PUD) is suddenly complaining of sharp, upper abdominal pain referring back to their shoulder. The patients abdomen is distended and board-like. Vital signs are as follows: T: 99.3, HR: 142, RR: 22, BP: 122/78. Which of the following should the nurse do next? A. Administer prescribed Oxycodone/Acetaminophen (Percocet) 5/325 mg PO B. Assess the patients bowel sounds C. Contact the MD with findings D. Prepare the patient for a blood transfusion
C. Contact the MD with findings
As the nurse is ambulating a patient diagnosed with vascular insufficiency, the patient complains of pain in the lower extremities. The nurse would document this finding as: A. Deep vein thrombosis B. Vasculitis obliterans C. Intermittent claudication D. Varicosities
C. Intermittent claudication
The nurse identifies which of the following clients to be at greatest risk for gallbladder disease? A. 19-year-old Hispanic women B. 35-year-old African American male with sickle cell disease C. 55-year-old African American male with chronic alcoholism D. 42-year-old Caucasian female who has two children
D. 42-year-old Caucasian female who has two children
What is the most important intervention when performing a bone scan? A. Drink a calcium solution 2 hours before the test B. NPO for 2 hours before and 3 hours after the test C. No screening is needed before the test D. Drink plenty of fluids after the test is completed
D. Drink plenty of fluids after the test is completed
A patient has been admitted with peptic ulcer disease (PUD) and subsequent Upper GI bleed. Which of the following physician orders would the nurse question? A. Administer IV Pantoprazole (Protonix) B. Check hemoglobin and hematocrit levels every 6 hours C. Keep patient NPO D. Every 8 hour intake/output documentation
D. Every 8 hour intake/output documentation
The home health nurse is visiting a patient diagnosed with peripheral arterial disease. Upon entering the patients home, the nurse finds the patient sitting upright in a chair (picture). What action is best for the nurse at this time? A. Assess the vital signs and begin assessment B. Assist the patient to elevate her legs C. Ask the patient is she is experiencing pain D. Emphasize the patient should be on bedrest
A. Assess the vital signs and begin assessment
Mrs. Adams asks if there are things that she can do to help Mr. Adams once he is discharged. The nurse teaches her that to support Mr. Adams nutrition, while also promoting respiratory function, she should offer him which of the following foods? Select all that apply. A. Chocolate pudding B. A sirloin steak C. A fresh, whole apple D. Mashed potatoes and gravy E. Corn on the cob F. Ice cream
A. Chocolate pudding D. Mashed potatoes and gravy F. Ice cream
The goal of insulin therapy is to regulate insulin and blood sugar as would the normal pancreas. This goal is best achieved by: A. Giving regular insulin whenever BGL is above 200 B. Using a combination of Aspart or Lispro insulin with Glargine insulin C. Administering NPH insulin twice daily D. Using a sliding scalee to manage basal and bolus dosing
B. Using a combination of Aspart or Lispro insulin with Glargine insulin
A nurse is reviewing a clients activities of daily living prior to discharge from total hip replacement. What would be a priority to include in the care of this client prevent complications? A. Adding a stool softener to the clients daily medications B. Using a grabber to help put socks on C. Limit lifting items weighing less than 10 pounds D. Manually lifting leg to cross over the other
B. Using a grabber to help put socks on
Which statement from the client shows understanding of their diagnosis of ulcerative colitis? A. "Ulcerative colitis can be scattered throughout the GI tract in patches with some areas appearing healthy while others are diseased" B. "Ulcerative colitis usually occurs in the small intestine" C. "Strictures are a common complication with ulcerative colitis" D. "I may see blood in my stool"
D. "I may see blood in my stool"
The nurse is caring for a client undergoing chemotherapy. CBC results from this morning include: WBC: 1000 mm2; HGB: 7.6 g/dL; HCT: 22.7%; PLT: 150,000 mm2. The nurse develops a plan of care for the client. The nurse plans to: A. Provide the client a mask to wear while they are inside their private room B. Restrict fluid intake C. Insert an indwelling urinary catheter to prevent skin breakdown D. Provide education on food hygiene and safe food handling
D. Provide education on food hygiene and safe food handling
For Mrs. Waters, which assessment finding should the nurse report immediately to the health care provider? A. Client complains of pain 5/10 three hours after administering pain medication B. The client reports last BM was 2 days ago C. There is a large area of bruising noted on the clients right side D. The right leg is tender, swollen and warm to the touch
D. The right leg is tender, swollen and warm to the touch
which characteristics are associated with LFSH? peripheral edema SOB on exertion orthopnea lung crackles adventitious breath sounds hypertension positive JVD
SOB on exertion orthopnea lung crackles adventitious breath sounds
a patient has a serum sodium level of 110 mEq/L. the nurse would anticipate an order for which of the following IV fluids? a. 3% sodium chloride b. 0.45% sodium chloride c. D5 0.4% sodium chloride d. D5W
a. 3% sodium chloride
for which of the following patients would the nurse question the following order? "propranolol 10mg PO twice daily" a. 56 year old caucasian male diagnosed w diabetes being treated for essential hypertension b. 72 female w a history of chronic hypertension c. 47 hispanic male diagnosed w hypertension, hyperlipidemia, and obesity d. 83 female diagnosed w renal failure and hypertension e. 62 african american male diagnosed w primary hypertension
a. 56 year old caucasian male diagnosed w diabetes being treated for essential hypertension e. 62 african american male diagnosed w primary hypertension
a patient presents with diarrhea x3 days. the nurse understanding acid/base imbalance the patient would be at risk for, anticipates administering which of the following medications? a. IV sodium bicarbonate b. IV albumin c. IV 3% sodium chloride d. IV lactated ringers
a. IV sodium bicarbonate
ALT 25 U/mL a. LFT normal b. LFT abnormal c. CBC normal d. CBC abnormal
a. LFT normal
ammonia 65 mcg/dL a. LFT normal b. LFT abnormal c. CBC normal d. CBC abnormal
a. LFT normal
the nurse is caring for a patient admitted with peptic ulcer disease (PUD). which of the following assessment findings should be reported to the physician immediately? a. VS- HR: 120, RR: 24, BP: 118/72 b. patient complains of gnawing pain in the mid epigastric area c. patient complains of being awakened in the middle of the night with pain d. vomiting
a. VS- HR: 120, RR: 24, BP: 118/72
which of the following risk factors are associated with the development of diabetes? a. having a first degree relative (parent/sibling) with diabetes b. being obese c. delivering an infant weighing more than 9 pounds d. having a history of insulin resistance during pregnancy e. being underweight and malnourished for 1 year
a. having a first degree relative (parent/sibling) with diabetes b. being obese c. delivering an infant weighing more than 9 pounds d. having a history of insulin resistance during pregnancy
a patient is diagnosed w hypertension. when looking at the patients history the healthcare provider anticipates the patient will report which of the following? a. i have not notices any significant changes in my health b. every once in a while i wake up at night covered in sweat c. sometimes i get pain in my lower legs when i take my daily walk d. im starting to get out of breath when i go up a flight of stairs
a. i have not notices any significant changes in my health
a patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. which menu selection is most likely the best choice for this patient? a. scrambled eggs, white toast with jelly and apple juice b. raisin bran with whole milk c. yogurt with granola and orange juice d. cereal bar with sweet tea
a. scrambled eggs, white toast with jelly and apple juice
a type 2 diabetic patient with a glycolsolated hemoglobin (HBG A1c) has a lab result of 9%. what is the best interpretation by the nurse for these results? a. the patient probably needs an adjustment in their medication b. the lab results indicate good glucose control c. this lab test needs to be repeated immediately d. the lab results indicate chronic hypoglycemia
a. the patient probably needs an adjustment in their medication
A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level (15g/dL) b. Elevated serum bilirubin level (3.2 mg/dL) c. Elevated blood urea nitrogen level (25 mg/dL) d. Decreased erythrocyte sedimentation rate (10 mm/hr)
b. Elevated serum bilirubin level (3.2 mg/dL)
Albumin 2g/dL a. LFT normal b. LFT abnormal c. CBC normal d. CBC abnormal
b. LFT abnormal
serum bilirubin 3.2 mg/dL a. LFT normal b. LFT abnormal c. CBC normal d. CBC abnormal
b. LFT abnormal
the nurse is evaluating a client who has been receiving medical intervention for a diagnosis of chrons disease. which expected outcome is most important for this client? a. performs skin care b. gains a half pound per week c. exercises 30 min 3x week d. tolerates oral fluids
b. gains a half pound per week
a patient has an order to receive D5% Lactated Ringers. once infused this solution will what? a. replenish hydration in the cells b. provide electrolytes in the blood c. maintain fluid in the vascular space d. supply energy for the cells e. dispense fluid in the interstitial tissues
b. provide electrolytes in the blood c. maintain fluid in the vascular space d. supply energy for the cells
for the client in the picture below, which of the following information should be included in the teaching? (picture is of leg flat in bed with velcro cast, foam boot, and traction device over the foot of the bed.) a. this type of traction will help prevent contractures b. this type of traction will help to relieve muscle spasms c. this type of traction will maintain alignment of the pins d. with this type of traction you will have to keep the pin sites clean
b. this type of traction will help to relieve muscle spasms
the nurse is caring for a patient with a potassium level of 5.8 mEq/L. which of the following medication orders would the nurse question at this time? a. kayexalate 15g PO QID b. 10 units regular insulin IV push and 25 grams Dextrose IV push c. 10 mEq potassium IV at 10 mEq/hr d. 20 mg Lasix IV push
c. 10 mEq potassium IV at 10 mEq/hr
Hgb 14.8 g/dL a. LFT normal b. LFT abnormal c. CBC normal d. CBC abnormal
c. CBC normal
PLT 200,000 a. LFT normal b. LFT abnormal c. CBC normal d. CBC abnormal
c. CBC normal
WBC 7800 mm a. LFT normal b. LFT abnormal c. CBC normal d. CBC abnormal
c. CBC normal
a patient has come to the clinic for a 6 month follow up after beginning treatment for hypertension, hyperlipidemia and atherosclerosis. which of the following would indicate that the patients health status has improved? a. trigylcerdies = 190 b. total cholesterol = 218 c. HDL = 65 d. LDL = 132
c. HDL = 65
the nurse is admitting a client with glaucoma. the client brings prescribed eyedrops from home and insists on using them in the hospital. the nurse should? a. allow the client to keep the eye drops at the bedside and use as prescribed on the bottle b. place the eyedrops in the hospital medication drawer and administer as labeled on the bottle c. explain to the client that the healthcare provider will write a prescription for the eyedrops to be used at the hospital d. ask the clients wife to assist the client in administering the eyedrops while the client is in the hospital
c. explain to the client that the healthcare provider will write a prescription for the eyedrops to be used at the hospital
what is a priority nursing intervention for a patient who has just begun antihypertensive treatment with lisinopril (Zestril)? a. review the patients labs for hypokalemia b. order a sodium restricted diet for the patient c. take the patients BP d. monitor the patient for headaches
c. take the patients BP
the nurse is administering a TB skin test to a client who has possibly been exposed to another patient with active TB. which statement best describes the need for the client to receive a chest x-ray instead of skin testing? a. the clients first skin test indicates a purple flat area at the site of injection b. the clients second skin test indicates a red area measuring 4mm c. the clients previous skin test was read as positive d. the client has never shown a reaction to the TB skin test medication
c. the clients previous skin test was read as positive
monoamine oxidase inhibitors work in the CNS to a. block the GABA at the receptor sites b. provide replacement of neurotransmitters affecting mood c. block the action of epinephrine and norepinephrine in the synapses d. stop the removal of serotonin, dopamine, and other neurotransmitters in the brain
d. stop the removal of serotonin, dopamine, and other neurotransmitters in the brain
which characteristics are associated with RSHF? peripheral edema SOB on exertion orthopnea lung crackles adventitious breath sounds hypertension positive JVD
peripheral edema hypertension positive JVD
Your patient is admitted with peritonitis secondary to peritoneal dialysis. What order from the physical would you question? A. Place patient on a clear liquid diet B. Insert NG tube per MD order C. Administer IV antibiotics D. Administer IV fluids
A. Place patient on a clear liquid diet
A patina tis diagnosed with an iron-deficiency anemia and has a hemoglobin of 9.0 mg/dL. Which of the following foods would be most appropriate for this patient to consume? Select all that apply. A. Roast beef B. Liver with onions C. 1/2 cup vanilla ice cream D. Kale
A. Roast beef B. Liver with onions D. Kale
A nurse is providing education about hypertension to a community group. One client reports that his doctor has diagnosed him with hypertension, but he feels he is just fine. He asks, "What would happen if I did not treat my hypertension?" Which of the following are possible consequences of untreated hypertension? Select all that apply. A. Myocardial infarction B. Stroke C. Tension pneumothorax D. Pancreatitis E. Coronary artery disease
A. Myocardial infarction B. Stroke E. Coronary artery disease
For the past several months, 23 year old Bryan had been on a mission trip when he began to exhibit several symptoms. Among them we increasing fatigue, nausea with vomiting and increasing jaundice. Bryan also had intermittent periods of fever and chills. Additionally, he complained of abdominal pain. The nurse understands that this client is most likely experiencing what type of hepatitis? A. Hep A B. Hep B C. Hep C D. Hep D
A. Hep A
A nurse is evaluating a patients understanding of proper treatment of hypoglycemia. Which of the following measures indicates effective teaching? Select all that apply. A. "I will drink 120 mL of orange juice" B. "I could eat 2 soft boiled eggs with 2 saltine crackers" C. "I will take a 4 mg Glucose tablet" D. "I will drink a regular 150 mL of Coca Cola" E. "I should keep Lifesavers or other hard candies with me at all times"
A. I will drink 120 mL of orange juice D. I will drink a regular 150 mL of Coca Cola
When receiving a patients lab work, the nurse notes the following values. Which value would require immediate action by the nurse? A. Magnesium 1.2 mEq/L B. Calcium 8.5 mg/dL C. Phosphorous 2.6 mg/dL D. Chloride 98 mEq/L
A. Magnesium 1.2 mEq/L
A client has vertigo. Which goal would be most appropriate to prevent injury related to altered immobility and gait disturbances? Select all that apply. A. The client assume a safe position when dizzy B. The client experiences no falls C. The client performs vestibular/balance exercises D. The client demonstrates family involvement E. The client keep the head still when dizzy
A. The client assume a safe position when dizzy B. The client experiences no falls C. The client performs vestibular/balance exercises E. The client keep the head still when dizzy
The nurse is caring for a patient admitted with peptic ulcer disease (PUD). Which of the following assessment findings should be reported to the physician immediately? A. Vital signs as follows: HR: 120, RR: 24, BP: 118/72 B. Patient complains of gnawing pain in the mid epigastric area C. Patient complains of being awakened in the middle of the night with pain D. Vomiting
A. Vital signs as follows: HR: 120, RR: 24, BP: 118/72
After an above the knee amputation of the right leg, a client reports pain in the right foot. Which reason would the nurse explain to the client about phantom limb pain. A. Tactile illusions are associated with severed blood vessels B. Nerve endings in the limb are still intact and react to stimuli C. An unconscious phenomenon aids with grieving over the lost body part D. Hallucinations are secondary to the emotional distress of amputation
B. Nerve endings in the limb are still intact and react to stimuli
When considering patient teaching about glargine insulin (Lantus), the nurse should include which of the following information? A. Glargine peaks in 4-6 hours to control glucose levels in between meals B. This insulin is designed to provide a basal rate of insulin for 24 hours C. Glargine will treat acute spikes in your glucose levels D. Glargine may be given IV in an emergent situation to lower blood sugar rapidly
B. This insulin is designed to provide a basal rate of insulin for 24 hours
A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the clients nursing care with the understanding that acute angle-closure glaucoma: A. Frequently resolves without treatment B. Is typically treated with sustained bed rest C. Is a medical emergency that can rapidly lead to blindness D. Is the most commonly treated with steroid therapy
C. Is a medical emergency that can rapidly lead to blindness
The nurse is assessing a patient who is post-op day one from bariatric surgery. Which of the following assessment findings would require immediate action by the nurse? A. Patient complaining of pain 6/10 B. Patient complaining of diarrhea C. Patient vital signs as follows: T: 99.1, HR: 132, RR: 24, BP: 110/72 D. Patient vital signs as follows: T: 99.3, HR: 90, RR: 20, BP: 136/84
C. Patient vital signs as follows: T: 99.1, HR: 132, RR: 24, BP: 110/72
The nurse is caring for a patient post-op day 1 from laparoscopic cholecystectomy. The nurse understands the patient may be experiencing complications from the procedure if they assess which of the following? A. Pain in the chest and shoulders B. T-tube that has drained 200 mL of green drainage over the past 24 hours C. Right lower extremity that is red and swollen D. JP drain that is collecting serosanguineous fluid
C. Right lower extremity that is red and swollen
One day after cataract surgery, the client is having discomfort from bright light. The nurse would advise the client to: A. Dim lights in the house and stay inside for 1 week B. Attach sun shields to existing eyeglasses when in direct sunlight C. Use sunglasses that wrap around the side of the face when in bright light D. Patch the affected eye when in bright light
C. Use sunglasses that wrap around the side of the face when in bright light
23 year old brian has been on a mission trip when he began to exhibit several symptoms. among them were increasing fatigue, nausea with vomiting, and increasing jaundice. brian also had intermittent periods of fever and chills. additionally he complained of abdominal pain. based on the information provided, what are the priority interventions for Jon? select all that apply a. increase intake of fluids including juices b. eat less often, preferably only three large meals per day c. encourage bed rest d. encourage a diet high in calories including fried foods e. administer antiemetics
a. increase intake of fluids including juices c. encourage bed rest e. administer antiemetics
the patient is prescribed spironolactone 25 mg po daily and furosemide 20 mg po daily. the nurse realizes that these orders were given to benefit the patient how? a. reducing the vascular volume b. maintaining potassium levels c. decreasing SNS stimulation d. promoting bronchodilation e. increasing cardiac contractility
a. reducing the vascular volume b. maintaining potassium levels
the nurse is caring for a patient who had undergone an exploratory laparotomy. which of the following post-op findings should the nurse report to the physician immediately? a. the patient pushes out the oral airway with his tongue b. the patients BP is 104/70 and HR is 100bpm c. the patient has a scant amount of drainage on the dressing d. the patient has a urine output of 200ml for the past 8 hours.
d. the patient has a urine output of 200ml for the past 8 hours.
