Practice Exam #2

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply a. Cold exposure b. Sexual intercourse c. Amphetamine use d. Cigarette smoking e. Deep sleep

a. Cold exposure b. Sexual intercourse c. Amphetamine use d. Cigarette smoking

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of BPH. a. Decreased force in the stream of urine b. Occasional constipation c. Nocturia d. Scrotal edema

a. Decreased force in the stream of urine

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) a. Extreme fatigue b. Sharp inspiratory chest pain c. Dyspnea d. Anorexia e. Dizziness

a. Extreme fatigue c. Dyspnea e. Dizziness

.A 27-year-old male patient was admitted with severe left flank pain. After a confirmation of a renal calculi, what would be the most appropriate nursing interventions. Select all that apply. a. Strain all urine output b. Administer a low-fat diet. c. Promote increased fluid intake d. Administer prescribed analgesics e. Position patient in Trendelenburg position.

a. Strain all urine output c. Promote increased fluid intake d. Administer prescribed analgesics

A nurse is completing the admission assessment of a client who has a kidney stone. Select all that the nurse would expect to find. a. Tachycardia b. CVA tenderness/pain c. Bradypnea d. Hematuria e. Polyuria

a. Tachycardia b. CVA tenderness/pain d. Hematuria

An 82-year-old male patient is receiving continuous bladder irrigation with 0.45% NaCl. 1200ml have been instilled, a total output of 1500ml is collected in the Foley catheter collection bag. What would be the true urine output? a. 2700 ml b. 300 ml c. 1500 ml d. 1200 ml

b. 300 ml

The client is one day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? a. Medicate the client with intravenous morphine b. Assess the client chest dressing and vital signs c. Encourage the client to turn from side to side d. Check the client's telemetry monitor.

b. Assess the client chest dressing and vital signs

A patient is hospitalized with ureter renal calculi. What is the intervention the nurse should provide first? a. Start straining their urine b. Assess their pain level and administer pain medication as ordered c. Encourage fluid intake and provide them with a full pitcher of water d. Collect a urine sample for analysis

b. Assess their pain level and administer pain medication as ordered

A client had a transurethral prostatectomy for benign prostatic hypertrophy. He's currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the interventions should be done first? a. Stop the irrigation and call the physician b. Check for the presence of clots, and make sure the catheter is draining properly c. Administer an oral analgesic d. Administer a belladonna and opium suppository as ordered by the physician.

b. Check for the presence of clots, and make sure the catheter is draining properly

The nurse is reviewing a client's record and notes that the HCP has documented an onset of acute kidney injury. On review the nurse would most likely to note which findings. Select all that apply. a. Decreased red blood cell count b. Elevated Creatinine c. Elevated BUN d. Decreased specific gravity e. Decreased hemoglobin level

b. Elevated Creatinine c. Elevated BUN d. Decreased specific gravity

After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output? a. It's a normal finding associated with the client's nothing-by-mouth status. b. It's an abnormal finding that requires further assessment. c. It's a normal finding caused by blood loss during surgery. d. It's an abnormal finding that will correct itself when the client ambulates.

b. It's an abnormal finding that requires further assessment.

Which of the following are NOT typical signs/symptoms of right-sided heart failure? Select all that apply. a. Jugular venous distention b. Persistent cough c. Weight gain d. Crackles e. Nocturia f. Orthopnea

b. Persistent cough d. Crackles f. Orthopnea

After teaching a patient with chronic angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? a."I will take acetaminophen(Tylenol) to treat the headache caused by nitroglycerine". b. "I will take nitroglycerin 10 minutes before planned activities that usually causes chest pain". c. "I can take up to five tablets every 3 minutes for relief of my chest pain". d. "I will replace my nitroglycerin supply every six months."

c. "I can take up to five tablets every 3 minutes for relief of my chest pain".

Which assessment data would the nurse recognize to support the diagnoses of abdominal aortic aneurysm (AAA)? a. Shortness of breath b. Ripping abdominal pain c. Abdominal bruit d. Decreased urinary output

c. Abdominal bruit

Which ECG finding is most indicative of severe myocardial infarction? a. peaked P wave b. long QT interval c. ST segment elevation d. PR interval elevation

c. ST segment elevation

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding? a. Sinus tachycardia b. Normal sinus rhythm c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus bradycardia with premature ventricular contractions (PVCs)

c. Sinus rhythm with premature atrial contractions (PACs)

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is MOST important at this time? a. Administer meperidine every 3 hours b. Apply warm compress to the flank area c. Strain the urine carefully d. Report hematuria to the healthcare provider

c. Strain the urine carefully

Which of the following nursing actions is most important in caring for the client following lithotripsy? a. Administer allopurinol (Zyloprim). b. Monitor the continuous bladder irrigation. c. Strain the urine carefully for stone fragments. d. Notify the physician of hematuria.

c. Strain the urine carefully for stone fragments.

After receiving change of shift report in the coronary care unit, which client should you assess first? a. A client who has first degree heart block, rate 68, after having an inferior myocardial infarction. b. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 c. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled. d. The client with acute coronary syndrome who has a 3 pounds weight gain and dyspnea

d. The client with acute coronary syndrome who has a 3 pounds weight gain and dyspnea