Random MC questions I found online - test 1
If one of your parents has CF does that mean you have a chance of getting the infection? A. True B. False
B. False Both your parents must have the gene in order for you to get Cystic Fibrosis
Which nursing intervention takes priority for the client having a tonic-clonic seizure? 1 - maintaining patient airway 2 - timing the duration of the seizure 3 - noting the origin of seizure activity 4 - inserting a padded tongue blade to prevent the client from biting his tongue
1 - maintaining patient airway
A nurse is assessing a 3-week-old infant admitted to the pediatric unit with hydrocephalus. What finding identifies a complication requiring immediate attention? 1. Tense anterior fontanel 2. Uncoordinated eye/muscle movement 3. Larger head circumference than chest circumference 4. Inability to support the head while in the prone position
1. Tense anterior fontanel
When giving IV phenytoin (Dilantin), which method should be used? 1 - administering rapidly 2 - withholding other anticonvulsants 3 - mixing the drug with saline solution only 4 - flushing the IV catheter with dextrose solution
3 - mixing the drug with saline solution only
Which nursing diagnosis would a circulating nurse use on her intraoperative patients who have a general anesthetic? (Mark all that apply.) A. A) Disturbed sensory perception B. B) Risk for hypovolemia C. C) Risk of latex allergy response D. D) Disturbed body image E. E) Anxiety
A. A) Disturbed sensory perception C. C) Risk of latex allergy response E. E) Anxiety
What's the most important concern for clients who drink alcohol while taking phenytoin? 1 - alcohol increases phenytoin activity 2 - alcohol raises the seizure threshold 3 - alcohol impairs judgement and coordination 4 - alcohol decreases the effectiveness of phenytoin
4 - alcohol decreases the effectiveness of phenytoin
You are the PACU nurse caring for a 45-year-old male patient who had a left lobectomy. You assess your patient frequently for airway patency and cardiovascular status. You know that the most common cardiovascular complications seen in the PACU include what? (Mark all that apply.) A. A) Hypotension B. B) Hypervolemia C. C) Heart murmurs D. D) Dysrhythmias E. E) Hypertension
A. A) Hypotension D. D) Dysrhythmias E. E) Hypertension
You are the circulating nurse. Which task are you solely responsible for? A. A) Monitoring the patient and documents B. B) Estimating the patient's blood loss C. C) Setting up the sterile tables D. D) Keeping track of drains and sponges
A. A) Monitoring the patient and documents
You are performing your shift assessment of your patient. You find his mental status, level of consciousness, speech, and orientation are intact and at baseline. Your patient tells you he is very anxious. What would you do next? A. A) Assess oxygen levels B. B) Give anti-anxiety medications C. C) Notify the physician D. D) Make a social services consult
A. A) Assess oxygen levels
You are the circulating nurse in an outpatient surgery center. Your patient is scheduled to receive moderate sedation. You know that a patient receiving this form of anesthesia should what? A. A) Never be left unattended by the nurse B. B) Receive an anti-emetic C. C) Remember most of the procedure D. D) Be able to maintain his or her own airway
A. A) Never be left unattended by the nurse
You are discharging a patient home from a same-day surgery center. You have gone over all of the discharge instructions with the patient and her caregiver. What else should you do before letting the patient leave the facility? (Mark all that apply.) A. A) Provide all discharge instructions in writing B. B) Provide the nurse's or surgeon's telephone number C. C) Give prescriptions to the patient D. D) Give advice on nutrition to the caregiver E. E) Provide dates and times of new appointments
A. A) Provide all discharge instructions in writing B. B) Provide the nurse's or surgeon's telephone number C. C) Give prescriptions to the patient
As an intraoperative nurse, what is your responsibility to your patient in relation to malignant hyperthermia? (Mark all that apply.) A. A) Recognize the signs and symptoms B. B) Be knowledgeable about the protocol C. C) Know how to call a code in the OR D. D) Have the appropriate medication available E. E) Direct the surgeon and anesthesiologist through the protocol
A. A) Recognize the signs and symptoms B. B) Be knowledgeable about the protocol D. D) Have the appropriate medication available
As an OR nurse, you have an increased awareness regarding asepsis. You know that a basic guideline for maintaining surgical asepsis is what? A. A) Sterile surfaces or articles may touch other sterile surfaces. ' B. B) Sterile supplies can be used on another patient if the packages are intact. C. C) The outer lip of a sterile solution is considered sterile. D. D) The scrub nurse may pour a sterile solution from a nonsterile bottle.
A. A) Sterile surfaces or articles may touch other sterile surfaces. '
What position used for surgery can cause irreparable nerve damage? A. A) Trendelenburg B. B) Prone C. C) Dorsal recumbent D. D) Lithotomy
A. A) Trendelenburg
Matilda, with hyperthyroidism is to receive Lugol's iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to: A. Decrease the size and vascularity of the thyroid gland. B. Block the formation of thyroxine by the thyroid gland. C. Maintain the function of the parathyroid glands. D. Decrease the total basal metabolic rate.
A. Decrease the size and vascularity of the thyroid gland.
Which surgical classification would be the most appropriate for a cardiac catheterization scheduled on a 44-year-old male client who is in the hospital with chest pain? A. Major B. Minor C. Ablative D. Elective
A. Major
Gingival hyperplasia is associated with use of A. Phenytoin B. Carbamazepine C. Topiramate D. Lamotrigine E. Ethosuximide
A. Phenytoin
The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse's best action? A. Place the sponge in the circulating area to include in the final count before incision closure. B. Hand the sponge back to the scrub nurse. C. Pick up the sponge and throw it out so no one slips on it. D. Obtain an additional sterile sponge to replace the contaminated one and place it on the instrument table.
A. Place the sponge in the circulating area to include in the final count before incision closure.
Which of the following is the most priority nursing diagnosis in a patient with seizure disorders? A. Risk for injury related to seizure activity B. Fear related to the possibility of seizures C. Ineffective individual coping related to stresses imposed by epilepsy D. Deficient knowledge related to epilepsy and its control
A. Risk for injury related to seizure activity
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A. Should be taken in the morning B. May decrease the client's energy level C. Must be stored in a dark container D. Will decrease the client's heart rate
A. Should be taken in the morning Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia
Which of the following assessment data is most important to determine when caring for a patient who has received spinal anesthesia? A. The time of return of motion and sensation in the patient's legs and toes B. The character if the patient's respiration C. The patient's level of consciousness D. The amount of wound drainage
A. The time of return of motion and sensation in the patient's legs and toes
The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to: A. Use cupped hands during percussion B. Do percussion after the child eats and at bedtime C. Change the child's position every 20 minutes D. Use the heel of her hand during percussion
A. Use cupped hands during percussion
Temporal lobe is the most common site for this seizure followed by the frontal lobe A. Simple B. Complex C. Secondarily generalized
B. Complex
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she: A. Uses an electric blanket at night B. Dresses in extra layers of clothing C. Applies a heating pad to her feet D. Takes a hot bath morning and evening
B. Dresses in extra layers of clothing
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? A Therapeutic drug levels should be maintained between 20 to 30 mg/ml. B Rapid dilantin administration can cause cardiac arrhythmias. C Dilantin should be mixed in dextrose in water before administration. D Dilantin should be administered through an IV catheter in the client's hand.
B Rapid dilantin administration can cause cardiac arrhythmias.
The patient's surgery is nearly finished. The surgeon has decided to use tissue adhesives to close the surgical wound. As the nurse, you know that this puts the patient at increased risk for what? A. A) Hypothermia B. B) Anaphylaxis C. C) Infection D. D) Malignant hyperthermia
B. B) Anaphylaxis
Your postoperative patient suddenly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. You suspect hemorrhage. What would be your first nursing action? A. A) Notify the physician B. B) Determine the cause of hemorrhage C. C) Order blood work D. D) Put the patient in Trendelenberg position
B. B) Determine the cause of hemorrhage
Wound assessment is an important part of the nursing care of the postoperative patient. What does ongoing assessment of the surgical site involve? A. A) Adherence of the dressing to the wound B. B) Discoloration C. C) Blanching D. D) Granulation of the wound
B. B) Discoloration
You are preparing to take your patient into the operating room. As the circulating nurse, one of your responsibilities is to review the patient's record. What are you reviewing the record for? A. A) Progress notes B. B) History and physical C. C) Admission papers signed by patient D. D) Intake and output record
B. B) History and physical
You admit a patient to the postanesthesia care unit with a blood pressure of 130/90 and a pulse of 68 beats per minute. After 30 minutes, the patient's blood pressure is 120/65, and the pulse is 100. You document the patient's skin as cold, moist, and pale. What is the patient showing signs of? A. A) Hypothermia B. B) Hypovolemic shock C. C) Neurogenic shock D. D) Malignant hypothermia
B. B) Hypovolemic shock
You are the nurse writing a plan of care for a patient who is status postsurgery for a broken femur. What is the most important goal for this patient? A. A) Relief of pain B. B) Optimal respiratory function C. C) Optimal cardiovascular function D. D) Unimpaired wound healing
B. B) Optimal respiratory function
What are the determining factors for a patient to be discharged from the PACU? (Mark all that apply.) A. A) Temperature within normal limits B. B) Stable blood pressure C. C) Ability to respond to voice commands D. D) Adequate oxygen saturation E. E) Adequate respiratory function
B. B) Stable blood pressure D. D) Adequate oxygen saturation E. E) Adequate respiratory function
The PACU nurse is caring for a patient who has arrived from the operating room who is still unconscious. During the initial assessment, the nurse notices that the patient's skin is blue and dusky. She looks, listens, and feels for breathing, and determines the patient is not breathing. The priority intervention is to A. A) check an oxygen saturation rate, continue to monitor for apnea, and perform a focused assessment. B. B) treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. C. C) check the arterial pulses, and place the patient in the Trendelenburg position. D. D) call a code blue, and then get an rapid intubation kit and prepare to reintubate
B. B) treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.
The nurse is evaluating the client in the hospital's postanesthesia care unit (PACU) and determines that the Aldrete score is 8. Based on this assessment, the nurse anticipates that the client will: A. Be sent to the intensive care unit B. Be discharged back to his or her room on the nursing unit C. Remain in the PACU until the score improves D. Return to the operating room for surgical evaluation
B. Be discharged back to his or her room on the nursing unit
A 36-year-old female diabetic client is having an elective breast augmentation procedure done. Which of the following tests must be done on the day of surgery? A. Complete blood count (CBC) B. Blood glucose C. Serum electrolytes D. Coagulation studies
B. Blood glucose
Which of the following goals is most appropriate for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information? A. Client will understand the need for scheduled surgery before leaving the provider's office. B. Client will understand the preoperative routines of surgical care before leaving provider's office. C. Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery. D. Client will be able to successfully accomplish the preoperative bowel preparation by morning of scheduled surgery
B. Client will understand the preoperative routines of surgical care before leaving provider's office.
Which of the following client evaluations is most reflective of compliance for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information? A. Client will present for scheduled blood laboratory work 48 hours before surgery. B. Client's preoperative blood laboratory work results are present on preoperative chart. C. Client will share the preoperative routines of surgical care with family to facilitate compliance. D. Client will understand the preoperative routines of surgical care before leaving provider's office.
B. Client's preoperative blood laboratory work results are present on preoperative chart.
The patient had undergone spinal anesthesia for appendectomy. To prevent spinal headache, the nurse should place the patient in which of the following positions? A. Semi-Fowler's B. Flat on bed for 6 to 8 hours C. Prone position D. Modified Trendelenburg position
B. Flat on bed for 6 to 8 hours
Myoclonic seizures are charecterised by A. Focal electrical hyperactivity in the brain B. Generalized EEG abnormalities with gerks C. A form of partial seizures D. Secondary generalized seizures
B. Generalized EEG abnormalities with gerks
Which of the following is most dangerous complication during induction of spinal anesthesia? A. Cardiac arrest B. Hypotension C. Hyperthermia D. Respiratory paralysis
B. Hypotension Hypotension is the most dangerous complication of induction of spinal anesthesia. This is due to paralysis of vasomotor nerves
The mother of a child with cystic fibrosis tells the nurse that her child makes "snoring" sounds when breathing. The nurse is aware that many children with cystic fibrosis have: A. Enlarged adenoids B. Nasal polyps C. Choanal atresia D. Septal deviations
B. Nasal polyps Children with cystic fibrosis are susceptible to chronic sinusitis and nasal polyps, which might require surgical removal.
Nursing Care During a Seizure include all, except A. Ease the patient to the floor, if possible. B. Restrain the patient during the seizure to prevent from falling C. Protect the head with a pad to prevent injury. D. Loosen constrictive clothing. E. If the patient is in bed, remove pillows and raise side rails
B. Restrain the patient during the seizure to prevent from falling
In the postoperative period, the nurse recognizes that an early sign of malignant hyperthermia is: A. Fever B. Tachycardia C. Muscle relaxtion D. Skin pallor
B. Tachycardia
Seizures that show with automatisms such as lip smacking, chewing, and picking A. Secondarily generalized seizures B. Temporal lobe complex partial seizures C. Frontal lobe complex partial seizures D. Complex partial seizures
B. Temporal lobe complex partial seizure
The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the preoperative teachings? A. Before administration of preoperative medications B. The afternoon or evening prior to surgery C. Several days prior to surgery D. Upon admission of the client in the recovery room
B. The afternoon or evening prior to surgery Explanation The best time to provide preoperative teaching is the afternoon or evening prior to surgery. This time, the patient had finished undergoing different laboratory and diagnostic procedures. Therefore, he/she can now concentrate on the teachings. Teachings given days before surgery may tend to be forgotten. Teachings given before administration of preoperative medications may not be understood anymore because the anxiety level more likely is high during this time
You are the intraoperative nurse transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old female. You know that special attention must be paid to what? A. A) Cardiovascular status B. B) Positioning C. C) Keeping the patient warm D. D) Keeping the patient hydrated
C. C) Keeping the patient warm
What precaution must be taken when giving phenytoin (Dilantin) to a client with an NG tube for feeding? A - check phenytoin level after giving drug to check for toxicity B - elevate the HOB before giving phenytoin through NG tube C - give phenytoin 1 hour before or 2 hours after NG tube feedings to ensure absorption D - verify proper placement of NG tube by placing end of tube in glass of water and observing for bubbles
C - give phenytoin 1 hour before or 2 hours after NG tube feedings to ensure absorption
Which adverse effect may occur during phenytoin (Dilantin) therapy? A - dry mouth B - furry tongue C - somnolence D - tachycardia
C - somnolence
Your patient is a 78-year-old male who has had outpatient surgery. You are getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension, what should you plan to have the patient do? A. A) Sit in a chair for 10 minutes prior to ambulating B. B) Drink plenty of fluids to increase circulating blood volume C. C) Stand upright for 2 to 3 minutes prior to ambulating D. D) Sit upright on the side of the bed for 15 minutes prior to ambulating
C) Stand upright for 2 to 3 minutes prior to ambulating D.
Breast milk should be discontinued for how long prior to surgery? A. 8 hours B. 6 hours C. 4 hours D. 2 hours
C. 4 hours
An appendectomy is appropriately documented by the nurse as: A. Diagnostic surgery B. Palliative surgery C. Ablative surgery D. Reconstructive surgery
C. Ablative surgery
The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function? A. Cyanosis, lethargy B. Fast, thready pulse, bradypnea C. Apprehension and restlessness D. Faintness, pallor
C. Apprehension and restlessness The earliest signs of poor tissue perfusion and poor respiratory function are apprehension and restlessness. The brain is the first organ affected by poor tissue perfusion and oxygenation. This also results from stimulation of the sympathetic nervous system
Untreated hyperthyroidism during pregnancy may result in all of the following except: A. Preeclampsia B. Low birthweight C. Autism D. Premature birth and miscarriage
C. Autism In addition to the above-mentioned complications of uncontrolled hyperthyroidism in pregnancy, expectant mothers may suffer congestive heart failure and thyroid storm, which is life-threatening thyrotoxicosis with symptoms that include agitation, confusion, tachycardia, shaking, sweating, diarrhea, fever, and restlessness.
An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: A. After meals B. Around the child's play schedule C. Between meals D. After medication
C. Between meals Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process
As an intraoperative nurse, you know that maintaining an aseptic environment in the operating room is essential. When moving around surgical areas, what distance must be kept from the sterile field? A. A) 2 feet B. B) 18 inches C. C) 1 foot D. D) 6 inches
C. C) 1 foot
You are caring for a male patient who has had spinal anesthesia. The patient is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to comply with the physician's order. What is the rationale for complying with this order? A. A) Hypotension B. B) Respiratory depression C. C) A headache D. D) Pain at the lumbar injection site
C. C) A headache
Your patient is a 25-year-old obstetric patient. You know that she is at increased risk for what? A. A) Infection B. B) Hypothermia C. C) Anesthesia awareness D. D) Moderate sedation
C. C) Anesthesia awareness
As an intraoperative nurse, you know that the patient's emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patient's ability to influence their outcome? A. A) Teach the patient guided imagery B. B) Assess the patient's coping strategies C. C) Incorporate cultural, ethnic, and religious considerations as appropriate D. D) Give him or her anti-anxiety medication
C. C) Incorporate cultural, ethnic, and religious considerations as appropriate
In portable wound suction, the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps against the underlying tissue, thus removing "dead space." Which of the following is a portable suction device? A. A) Penrose B. B) Chest tube C. C) Jackson-Pratt D. D) Hemodynavac
C. C) Jackson-Pratt
You are the nurse in the emergency department (ED). You are caring for a man who has returned to the ED after receiving ten stitches for a knife wound while cleaning fish. The wound is now infected, the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what? A. A) Late intention B. B) Second intention C. C) Third intention D. D) First intention
C. C) Third intention
The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given highest priority by the nurse? A. Assessing the patient's level of consciousness B. Checking the patient's vital signs C. Checking the patient's identification and correct operative permit D. Positioning and performing skin preparation to the patient
C. Checking the patient's identification and correct operative permit
The perioperative nurse realizes that the most effective means of evaluating the client's understanding of previous teaching is to: A. Provide written material on the subject to be reviewed after discharge B. Reinforce the material with family as the procedure is being performed C. Discuss it with the client and family in the immediate preoperative period D. Offer to answer any questions that the client or family have just before discharge
C. Discuss it with the client and family in the immediate preoperative period
The client undergoing induction of anesthesia with succinylcholine, a depolarizing blocker agent, begins to experience generalized muscle twitching. What the circulating nurse's best response? A. Ensure the client is secured to the table. B. Cover the client with a warm blanket. C. Document this expected response. D. Call the anesthesia provider's attention to this response.
C. Document this expected response. Rationale: Depolarizing blocker agents depolarize the motor end plates of nerves innervating skeletal muscles, causing a brief period of fasciculations or muscle twitching. This response is considered normal.
After discharge from the postanesthesia care unit (PACU), the client returned to the surgical nursing unit at 10:00 AM. It is now 11:30 AM, and the client is not experiencing any complications or difficulties. The nurse will plan to measure the client's vital signs: A. Every 15 minutes B. Every 30 minutes C. Every 1 hour D. Every 4 hours
C. Every 1 hour
A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his right shoulder at an ambulatory surgery unit. The nursing diagnosis the client is at greatest risk for postoperatively is: A. Risk for injury B. Risk for infection C. Impaired wound healing D. Imbalanced nutrition: less than body requirements
C. Impaired wound healing
Preferred drug in status epilepticus is A. Carbamazepine B. Valproate C. Lorazepam D. Clonazepam E. Phenobarbitone
C. Lorazepam
The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? A. A decreased TSH level B. An increase in the TSH level after 30 minutes during the TSH stimulation test C. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay
C. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.
Which of the following AEDs is available in intravenous preparation? A. Phenobarbitone B. Carbamazepine C. Phenetoin D. Ethosuximide
C. Phenetoin
Which medication will the nurse have available for emergency treatment of tetany in the client who has had thyroidectomy? A. Magnesium chloride B. Calcium chloride C. Potassium chloride D. Sodium bicarbonate
C. Potassium chloride
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is: A. Brittle nails B. Hair loss C. Sore throat D. Weight gain
C. Sore throat Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Answers A, B, and C are not associated with Pulmozyme; therefore, they are incorrect.
A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect? A. Dysuria B. Leg cramps C. Tachycardia D. Blurred vision
C. Tachycardia
A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication? A. The client complains of blurred vision. B. The client complains of increased weight gain over the past year. C. The client complains of increased thirst and increased urination. D. The client complains of ringing in the ears.
C. The client complains of increased thirst and increased urination. Increased thirst and increased urination are signs of lithium toxicity.
The postanesthesia recovery unit nurse is receiving a hand-off report from the nurse anesthetist and the circulating nurse for an 82-year-old client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details? A. The client reported an allergy to codeine. B. The client is Jewish. C. The total intraoperative urine output is 25 mL. D. The estimated blood loss is 150 mL.
C. The total intraoperative urine output is 25 mL.
A client with new-onse seizures of unknown cause is started on phenytoin (Dilantin), 750 mg IV now and 100 mg PO TID. Which statement best describes the purpose of the loading dose? A - to ensure the drug reaches the CSF B - to prevent the need for surgical excision of the epileptic focus C - to reduce secretions in case of another seizure D - to more quickly attain therapeutic levels
D - to more quickly attain therapeutic levels
The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child? A. "I'll give the enzyme capsule before every snack" B. "My child might need an extra capsule if the meal is high in fat" C. "I'll give the enzyme capsule before every meal" D. "My child hates to take pills, so I'll mix the capsule into a cup of hot chocolate
D. "My child hates to take pills, so I'll mix the capsule into a cup of hot chocolate The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication's integrity.
The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 am, and the client's regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] 300 mg, and ferrous fumarate [Feostat] 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse's best action? A. Hold all medications. B. Administer all medications parenterally. C. Administer all medications orally. D. Administer digoxin with minimal water and hold the other drugs
D. Administer digoxin with minimal water and hold the other drugs Rationale: Regularly scheduled cardiac medications should be administered on schedule. If taken with only a few small sips of water at least 2 hours before surgery, the amount of water should not increase the risk of intraoperative or postoperative aspiration. However, not administering this drug could result in cardiac complications during surgery.
A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? A. When bronchospasms occur B. When secretions have mobilized C. Immediately before a meal D. At least 2 hours after a meal
D. At least 2 hours after a meal The nurse should perform chest physiotherapy at least 2 hours after a meal to reduce the risk of vomiting and aspiration. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication for postural drainage, another component of chest physiotherapy.
Seizure where pt falls limply to the ground A. Absence B. Tonic-clonic C. Myoclonic D. Atonic
D. Atonic
Which of the following client outcomes is most therapeutic for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information? A. Client will share the preoperative routines of surgical care with family to facilitate compliance. B. Client will understand the preoperative routines of surgical care before leaving provider's office. C. Client will call laboratory to schedule appointment for preoperative blood draw for required testing. D. Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery
D. Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery
You are a nurse in the PACU caring for a 56-year-old male patient who had a hernia repair. The patient's blood pressure is now 164/92, he has no history of hypertension prior to surgery, and his preoperative blood pressure was 112/68. You know that hypertension following surgery is often related to what? A. A) Dysrhythmias, blood loss, and hyperthermia B. B) Electrolyte imbalances and neurologic changes C. C) A parasympathetic reaction and low blood volumes D. D) Pain, hypoxia, or bladder distention, which all cause sympathetic stimulation
D. D) Pain, hypoxia, or bladder distention, which all cause sympathetic stimulation
You are the nurse in a same-day surgery center. What can you do to ensure patient safety and recovery? A. A) Record vital signs and intake and output B. B) Document all your assessment findings C. C) Report to the home health nurse all of the pertinent details D. D) Provide expert teaching
D. D) Provide expert teaching
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? A. Impaired physical mobility related to decreased endurance B. Hypothermia r/t decreased metabolic rate C. Disturbed thought processes r/t interstitial edema D. Decreased cardiac output r/t bradycardia
D. Decreased cardiac output r/t bradycardia The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices
The nurse is evaluating the outcome "Client describes surgical procedures and postoperative treatment" and determines that the client has not achieved this outcome. The nurse should: A. Obtain the consent, because this is expected with preoperative anxiety B. Teach the client all about the procedure C. Ask the unit manager to assist with a teaching plan D. Inform the surgeon so that information can be provided
D. Inform the surgeon so that information can be provided
The best position for kidney, chest, or hip surgery is: A. Supine B. Trendelenburg C. Lithotomy D. Lateral
D. Lateral
Auras are typical of A. Primary GTCS B. Absence seizures C. Myoclonic seizures D. Partial seizures
D. Partial seizures
A 92-year-old client is scheduled for a colectomy. Which normal physiological change that accompanies the aging process increases this client's risk for surgery? A. An increased tactile sensation B. An increased metabolic rate C. A relaxation of arterial walls D. Reduced glomerular filtration rate
D. Reduced glomerular filtration rate
Which of the following best describes the primary nursing role regarding a client's consent to surgery immediately before surgery? A. Explaining the procedure to the client in a fashion that is easily understood B. Placing the signed consent in the client's medical record C. Ensuring that the client understands the possible risks of the procedure before signing the consent D. Reviewing the client's surgical consent as a part of the routine preoperative checklist
D. Reviewing the client's surgical consent as a part of the routine preoperative checklist
The charecteristic EEG findings in seizure disorders is A. Alpha rhythm B. Asynchronous EEg rhythm C. Slow waves D. Spikes, sharp waves
D. Spikes, sharp waves
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? Widening pulse pressure Decrease in the pulse rate Dilated, fixed pupil Decrease in LOC
Decrease in LOC
Which is a specific investigation of diagnosing seizure disorder? A. EMG B. EOG C. ECT D. ERP E. EEG
E. EEG
Nurse Wayne is aware that a positive Chvostek's sign indicate? Hypocalcemia Hyponatremia Hypokalemia
Hypocalcemia
Which of the following respiratory patterns indicate increasing ICP in the brain stem? Slow, irregular respirations Rapid, shallow respirations Asymmetric chest expansion Nasal flaring
Slow, irregular respirations
A female client has a serum calcium level of 7.2 mg/dl. During the physical examination, nurse Noah expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sing
Trousseau's sign.
1. The client is prescribed carbamazepine (Tegretol) for a seizure disorder. The nurse cautions the client to avoid taking which of the following types of medications that could cause a fatal reaction with this medication? a. Nonsteroidal anti-inflammatory drugs (NSAIDs) b. Opioid analgesics c. Skeletal muscle relaxants d. Monoamine oxidase inhibitors (MAOIs)
d. Monoamine oxidase inhibitors (MAOIs)