NUR 233 Exam #3 Practice Questions

The nurse is providing care to a patient who is diagnosed with terminal lung cancer. Which clinical manifestations indicate imminent death? Select all that apply. Diaphoresis Increased cardiac output Decreased blood pressure Tachycardia followed by bradycardia An increase in urine output Loss of gag reflex Difficulty speaking

Diaphoresis Decreased blood pressure Tachycardia followed by bradycardia Loss of gag reflex Difficulty speaking

During morning rounds, the nurse notes that the unlicensed assistive personnel is assisting a patient with Parkinson's disease with breakfast. Which observation requires an immediate intervention? Patient sitting out of bed in a chair Head of the bed raised to 30 degree Thickener added to liquid menu items Oral suction catheter equipment turned on

Head of the bed raised to 30 degree

In providing care to the patient admitted for gastritis, which clinical manifestation requires immediate notification of the healthcare provider? Nausea Anorexia Hematemesis Epigastric pain

Hematemesis

Which diagnostic test should the nurse anticipate when providing care to a patient who is suspected of having a hiatal hernia?

Ileostomy - liquid to semi liquid Ascending - semiliquid Transverse - semiliquid to semiformal stool Descending - semiformal stool Sigmoid - formed stool

Which intervention would help to prevent or relieve persistent nausea? Assess for signs of dehydration. Provide dietary supplements. Have the patient sit in an upright position for 30 minutes after eating. Immediately remove any food that the patient cannot eat.

Immediately remove any food that the patient cannot eat.

The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask?

"What have you done to alleviate the heartburn?"

The patient asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in most instances, in females, it is usually caused by: Congenital strictures in the urethra. An infection elsewhere in the body. Urine stasis in the bladder An ascending infection from the urethra

An ascending infection from the urethra

For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment? It is a good tool to determine the etiology of dementia It is a good tool to evaluate mood and thought processes It can help to document the degree of cognitive impairment It is a definitive test for Alzheimer's

It can help to document the degree of cognitive impairment

The nurse is assessing the patient for palliative care. When assessing the psychosocial and psychiatric domain, which should the nurse include? Financial concerns Pain Depression Spiritual concerns

Pain

The nurse is providing care for a patient receiving curative care who is experiencing chronic pain as a result of cancer. Which type of care should the nurse plan for on discharge for this patient? Home healthcare Palliative care Hospice care Rehabilitative care

Palliative care

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

Place the patient in a room close to the nurses' station.

Which task can the nurse safely delegate to the nursing assistive personnel? Palpate the bladder of a patient who is unable to void Administering a continuous bladder irrigation Providing indwelling urinary catheter care Obtaining the patient's history and physical assessment

Providing indwelling urinary catheter care

A patient returns to the community clinic after being diagnosed with Parkinson's disease. What should the nurse expect to see documented in the patient's medical record to support this diagnosis? Rigidity with ambulation Unremarkable electroencephalogram Results of basic metabolic panel and CBC Integrity of cerebral vessels after a cerebral angiogram

Rigidity with ambulation

Which problem is most appropriate for the nurse to identify for the client with diarrhea?

Alteration in skin integrity.

The nurse is examining a 18-year-old female who is complaining of pain, frequency, and urgency when urinating. Which question should the nurse ask the client first?

"Are you sexually active?"

Which statements by the patient diagnosed with celiac disease indicate the need for further teaching? Select all that apply. "I am glad this can be cured with surgery" "I cannot have any gluten in my diet" "I wash all my dishes with water only" "I may become anemic because of this disease" "I am at risk for osteoporosis"

"I am glad this can be cured with surgery" "I wash all my dishes with water only"

The nurse is educating the family of a patient in hospice care who is receiving morphine for pain because of a terminal illness. Which statement by the family member indicates the need for further teaching? "I can only give the pain medications when requested." "I can give the pain medications if the patient is groaning and restless." "It is important to try to give these medications to manage the pain." "The morphine may also help the breathing difficulties."

"I can only give the pain medications when requested."

Which response by the nurse indicates the use of reflective listening when communicating with the family of a patient who is in the process of dying? "I can see this is difficult for you." "Thank you for taking such good care of your mother." "Your mother is experiencing quite a bit of pain at the moment." "A social worker will be able to answer all the questions that you have."

"I can see this is difficult for you."

Which patient statement indicates the need for additional teaching for the patient being discharged after total knee placement (TKR)? "Narcotics may cause constipation, so I will increase my water intake." "I will use an electric razor while I am on the blood thinners after surgery." "I will report pain, tenderness, or warmth in my calf to my doctor immediately." "I need to increase my intake of green, leafy vegetables to aid healing."

"I need to increase my intake of green, leafy vegetables to aid healing."

The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective? "I will have 4 - 5 incisions" "I will be int he hospital for at least 1 week" "I will not experience nay pain because this is a laparoscopic surgery" "I will be returning to work the day after my surgery"

"I will have 4 - 5 incisions"

Which statement by the patient diagnosed with gastritis indicates the need for further teaching? "I will eat bland, non spicy foods." "I will eat smaller, more frequent meals." "I will take aspirin for headaches." "I will take an antacid if my symptoms continue."

"I will take aspirin for headaches."

The nurse instructs a woman about providing a clean-catch urine specimen. Which statement indicates that the patient correctly understands the procedure? "I will be sure to urinate into the 'hat' you placed on the toilet seat" "I will wipe my genital area from front to back with the wipes provided before I collect the specimen midstream" "I will need to lie still while you put in a urinary catheter to obtain the specimen" "I will collect my urine each time I urinate for the next 24 hours"

"I will wipe my genital area from front to back with the wipes provided before I collect the specimen midstream"

The nurse has implemented a care plan for an adult patient with gastroesophageal reflux disorder (GERD). On the next clinic visit, which statement by the patient indicates adherence to the plan of care? "I still like wearing my Spandex camisoles." "I have switched from margaritas to wine." "I've lost 6 pounds because I eat every 3 hours and never before bed." "I lay down flat after eating to promote digestion."

"I've lost 6 pounds because I eat every 3 hours and never before bed."

The nurse is assisting the client in caring for her ostomy. The client states, "Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's best response is... "I'm sure you will get used to taking care of it eventually." "Yes, it is pretty messy, so I'll take care of it for you today." "It sounds like you are really upset." "You sound very angry. Should I call the chaplain for you?"

"It sounds like you are really upset."

A patient returns to the clinic for an evaluation 2 weeks after total hip replacement. Which statement by the patient indicates the need for further teaching? "My daughter helps me put on my elastics stockings every morning." "Even though I use my walker, I still have a limp." "Now that I am stronger, I no longer need to use the raised toilet seat." "Each day I try to increase my walking time by 10 minutes."

"Now that I am stronger, I no longer need to use the raised toilet seat."

The client is being prescribed alendronate (Fosamax) to slow the progression of her osteoporosis. You know she will need more patient teaching when she says... "I should take this medication early in the morning." "I should not lie down for 1 hour after taking this medication." "I should drink a full glass of water after taking this medication." "Now that I am taking this medication, I will not need to take vitamin D with my calcium supplement."

"Now that I am taking this medication, I will not need to take vitamin D with my c"I should take this medication early in the morning."

An older patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate? "Depression is a common cause of confusion in older adults in the hospital." "It is normal for an older person to have cognitive problems while in the hospital." "The mental changes are most likely caused by the infection and most often reversible." "Drug therapy with antipsychotic agents is indicated to slow the progression of dementia."

"The mental changes are most likely caused by the infection and most often reversible."

Which statement by the patient taking proton pump inhibitors for peptic ulcer disease indicates understanding about the action of this medication? "This medication coats the lining of my stomach" "This medication suppresses secretion of acid in my stomach" "This medication decreases vomiting" "This medication neutralizes the acid in my stomach"

"This medication suppresses secretion of acid in my stomach"

Which diagnostic test should the nurse anticipate when providing care to a patient who is suspected of having a hiatal hernia? CBC Lower abdominal x-ray Barium enema Esophagogastroduodenoscopy (EGD)

Esophagogastroduodenoscopy (EGD)

The nurse correlates which data in a female patient's history to an increased risk of urinary tract infection (UTI)? Select all that apply. 25 year old who is sexually active Drinks 2L of water a day 28 weeks pregnant History of back strain History of renal calculi

25 year old who is sexually active 28 weeks pregnant History of renal calculi

A patient is admitted to the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10 pain scale and diagnosed with gastroesophageal reflux disorder (GERD) secondary to hiatal hernia. Based on this data, what is the priority nursing diagnosis? Fluid volume deficit Acute pain Ineffective health maintenance Dysfunctional gastrointestinal motility

Acute pain

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?

Administer an oil retention enema.

What does the nurse include in the education of a patient who is being discharged after a laparoscopic Nissen fundoplication? Select all that apply. Follow a soft diet for 1 month Avoid foods that are not easy to swallow Lie down immediately after eating Avoid carbonated beverages No heavy lifting until cleared by surgeon

Avoid foods that are not easy to swallow Avoid carbonated beverages No heavy lifting until cleared by surgeon

As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first?

Ask if the decision has been discussed with the patients health care provider

The nurse monitors for which clinical manifestations in the patient diagnosed with Parkinson's disease? Photophobia Nuchal rigidity Bradykinesia Decreased level of consciousness

Bradykinesia

The nurse is caring for a patient admitted with severe dehydration secondary to gastroenteritis. Which item on the patient's meal tray does the nurse question? Apple juice Coffee Broth Caffeine-free soda

Coffee

In providing care to a patient who underwent a colostomy 2 days ago for the treatment of colon cancer, which finding requires an immediate intervention? Serosanguineous drainage from the stoma Dark red, purplish color of the stoma Slight edema of the stoma Reddish-pink, moist stoma

Dark red, purplish color of the stoma

Which of the following are physical changes seen at the end-of-life? (Select all that apply) Decreased urination Mottling of the hands and feet loss of gag reflex increased blood pressure Difficulty speaking

Decreased urination Mottling of the hands and feet loss of gag reflex Difficulty speaking

What finding should the nurse expect when assessing a patient with osteoarthritis of the knee? Bouchard's nodes A fever Discomfort with joint movement Redness and swelling of the joint

Discomfort with joint movement

Which finding should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?

Discomfort with joint movement

One month after discharge, a client who had a left total hip replacement calls a clinic reporting acute constant pain in the left groin and hip area and feeling like the left leg is shorter than the right. A nurse advises the client to come to the clinic immediately suspecting:

Dislocation of the prosthesis

A nurse is caring for a client who had a bowel resection and formation of a colostomy for colon cancer. The client is 24 hours post-surgery. During an assessment of the client, the nurse notes no stool in the colostomy bag. A review of the client's medical record indicates that, since surgery, there has not been stool in the bag. Considering this information, the nurse should... Call the doctor immediately to report this. Reposition the client to the left side. Administer pain medication. Document the finding.

Document the finding.

The nurse monitors for which clinical manifestations in the patient diagnosed with acute gastritis? Eructation Epigastric pain Constipation Peripheral edema

Epigastric pain

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? Place the client prone in bed and administer nonsteroidal anti-inflammatory medications Have the client remain upright at all times and walk for 30 minutes three (3) times a week Instruct the client to maintain a right lateral side-lying position and take antacids before meals. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?

Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing.

In assessing pain in the patient with a urinary tract infection, which clinical manifestation does the nurse correlate to progression of the infection to pyelonephritis? Dysuria Flank pain Hematuria Urinary frequency

Flank pain

Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning?

Fluid volume deficit (hypovolemia)

The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she wishes her husband were eligible for hospice care, but she thinks that hospice is only available for cancer patients and would require a change in healthcare providers. Which responses by the nurse are appropriate? Select all that apply. Inform her that hospice care is very expensive Inform her that a diagnosis of cancer is not required for hospice care Inform her that all hospice programs provide care 24 hours per day, 7 days per week Inform her that her husband can retain his provider when transitioning to hospice care. Inform her that her husband is not eligible for hospice care with the current diagnosis of COPD.

Inform her that a diagnosis of cancer is not required for hospice care Inform her that her husband can retain his provider when transitioning to hospice care.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

Leaning over to pull on shoes and socks

The client diagnosed with AIDS is experiencing diarrhea. Which interventions should the nurse implement? Select all that apply.

Monitor diarrhea charting amount character and consistency, Weigh the client daily in the same clothes and at the same time, Assist the client with a warm sitz bath PRN.

Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply.

Monitor the client for orthostatic hypotension, Use Standard Precautions when caring for the client, Institute safety precautions when ambulating the client.

Which of the following procedures is an anti-reflux surgery performed to treat GERD? Nissen fundoplication Endoscopic balloon dilation Gastropexy Pyloroplasty

Nissen fundoplication

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next?

Notify the health care provider

A patient who had total knee replacement continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. What action should the nurse take next? Notify the healthcare provider Assess the incision for redness Request an alternative PRN pain medication from the healthcare provider Check the patient's HR and BP

Notify the healthcare provider

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective?

Oatmeal with skim milk and fruit yogurt

Which intervention is an example of secondary prevention when discussing osteoporosis? Obtain a bone density evaluation test Perform non-weight-bearing exercises regularly Increase intake of dietary calcium Refer clients to a smoking cessation program

Obtain a bone density evaluation test

Which action should the nurse take when beginning bladder training using scheduled voiding? Offer the patient a bedpan every 2 hours while awake Increase the voiding interval by 30-60 minutes each week Frequently ask the patient whether they have the urge to void Increase the frequency between voiding even if urine leakage occurs

Offer the patient a bedpan every 2 hours while awake

The nurse explains to the patient with gastroesophageal reflux disease (GERD) that this disorder: Results in acid erosion of the esophagus from frequent vomiting. Will require surgical wrapping or repair of the pyloric sphincter to control the symptoms. Is the protrusion of a portion of the stomach into the esophagus through an opening in the diaphragm. Often involves relaxation of the lower esophageal sphincter (LES), allowing stomach contents to back up into the esophagus.

Often involves relaxation of the lower esophageal sphincter (LES), allowing stomach contents to back up into the esophagus.

A competent older adult patient has an advance directive that expresses the patient's desire to avoid resuscitation and heroic life support measures. The patient's family, however, is not supportive of this directive and plans to contest the living will. Which nursing action is appropriate based on the current situation? Notify the hospital attorney Contact the social services department Place the document in the patient's medical record Explain to the patient that the conflict could invalidate the document

Place the document in the patient's medical record

The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor?

Potassium (K) levels

D.B. is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for him is to

Promote orientation t every encounter with the pt. by asking the day, time, and place

For a patient who has had right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Reposition the patient every 1 to 2 hours

The nurse is developing a plan of care for a client with late-stage Alzheimers disease. The nurse identifies which client problem as having the highest priority?

Risk for injury

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? Walking on the toes Unsteady and staggering Shuffling and propulsive Broad-based and waddling

Shuffling and propulsive

The nurse identifies the diagnosis Impaired Urinary Elimination in an older adult patient admitted after a stroke. Impaired Urinary Elimination places the patient at risk for which complication? Skin breakdown Urinary tract infection Bowel incontinence Renal calculi

Skin breakdown

In providing care to a patient who is experiencing urine leakage when coughing or laughing, the nurse includes management of which type of incontinence in the plan of care? Urge Stress Overflow Functional

Stress

A patient complains that urine is passed when coughing or sneezing. How should the nurse document this complaint in the patient's healthcare record? Transient incontinence Overflow incontinence Urge incontinence Stress incontinence

Stress incontinence

The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report? The 84-year-old female with a fractured right femoral neck in Buck's traction The 64-year-old female with a left total knee replacement who has confusion The 88-year-old male post-right total hip replacement with an abduction pillow. The 50-year-old postop client with a continuous passive motion (CPM) device.

The 64-year-old female with a left total knee replacement who has confusion

The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation?

The client has become confused and irritable.

Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective?

The client prepares a scheduled voiding plan.

The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client?

The client will be admitted to a long-term care facility to have activities of daily living (ADL) needs met.

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP? The client's Bernstein esophageal test was positive. The client's abdominal x-ray shows a hiatal hernia. The client's WBC count is 14,000/mm3 The client's hemoglobin is 13.8 g/dL.

The client's WBC count is 14,000/mm3

A client asks the nurse to take a laxative, as he or she has not had a bowel movement today. What is the first information the nurse should obtain prior to administering the laxative? The amount of fiber in daily diet The last dose of laxative received If the client has had any flatus The client's normal bowel elimination pattern

The client's normal bowel elimination pattern

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? The patient was alert and oriented when admitted The patient's speech is fragmented and incoherent The patient is oriented to person but disoriented to place and time The patient has a history of increasing confusion over several years

The patient was alert and oriented when admitted

The student nurse asks for an indwelling urinary catheter for a hospitalized patient who is incontinent. Which response should the nurse make about the use of catheters only being absolutely necessary? They are the leading cause of infection They are too expensive for routine use They contain latex, increasing the risk for allergies Insertion is painful for most patients

They are the leading cause of infection

Which diagnostic test does the nurse correlate to the diagnosis of an active infection with Helicobacter pylori for a patient diagnosed with gastritis? Guaiac Hematest Hemoccult Urea breathing test

Urea breathing test

The nurse correlates which physiological factor to the decreased risk of urinary tract infection in men compared with women? Increased urine flow Ureter length Prostate enlargement Urethral length

Urethral length

Frequent assessment of patients with urinary tract infections is important for the recognition and early treatment of what potentially lethal complication? Pyelonephritis Hydronephrosis Urosepsis Cystitis

Urosepsis

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? Move the client next to the nurses station Use an indirect light source and turn off the TV Keep the TV and a soft light on during the night Play soft music at night and maintain a well lit room

Use an indirect light source and turn off the TV

An older client is brought to the hospital ED by a neighbor who heard the client talking and found him wandering int he street at 3am. The nurse should first demonstrate which data about the clinet?

Whether this is a change in usual level of orientation

The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention?

place mattress sensor on bed/turn on bed alarm