term 2 final
A nurse should anticipate that a patient taking Vasotec, an angiotensin-converting enzyme (ACE) inhibitor, should have which positive outcome to this drug?
Decreased blood pressure
.A nurse is preparing to administer eardrops to a 2-year-old child. The nurse should pull the auricle in which of the following directions when instilling the medication?
Down and backward
.What are functional causes of hypoglycemia?
Dumping syndrome Addison disease Prolonged muscular exercise
.A patient asks what a transesophageal echocardiogram (TEE) is and what it is expected to do? What is the best explanation by the nurse?
Evaluates the efficiency of the valves
The nurse has a prescription to give a patient two puffs of albuterol (Proventil HFA) [a bronchodilator] and two puffs of the beclomethasone dipropionate (Qvar) [a glucocorticoid], by metered-dose inhaler. How should the nurse administer these medications?
Give albuterol first and then the beclomethasone dipropionate
A patient who has sustained a hemorrhagic stroke is placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The patient's pulse is 82 beats/min before the administration of the prescribed dose. Which action should the nurse implement?
Give the full dose as prescribed without further assessment.
An obese African American man reports that he smokes. How should the nurse stage this patient's hypertension?
Grade B
Which of the following are major complications of bone marrow and peripheral blood stem cell transplants? (Select all that apply)
Graft-versus-host disease Thrombocytopenia Infection
Which adrenergic symptoms of hypoglycemia might the nurse assess?
Headache and tachycardia
.Which action of ACE inhibitors results in effective treatment of heart failure?
Increased cardiac output
What should a nurse expect when assessing the CBC results of a patient with chronic bronchitis?
Increased red blood cells (RBCs)
.A nurse is caring for a patient with HIV infection taking Retrovir, a nucleoside antiviral that is a reverse transcriptase inhibitor. For what should the nurse be especially observant?
Jaundice
An LPN is assisting a patient being treated for PVD (peripheral vascular disease). The physician has prescribed Buerger-Allen exercises for him. What should the LPN tell the patient to do FIRST?
Lie flat on his back and raise his legs above the level of his heart for 2 minutes or until they become very pale.
A teaching plan for a patient with diabetes is focused on smoking cessation and the control of hypertension for the avoidance of microvascular complications. What are examples of microvascular complications?
Macular degeneration End-stage renal disease
Which signs and symptoms are indicative of fat embolism?
Measles-like rash over the neck, upper arms, chest, or abdomen
8.A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are: pH: 7.6, PaCO2: 40 mm Hg, HCO3: 32 mEq/L. Which of the following acid base conditions should the nurse identify the client is experiencing?
Metabolic alkalosis
.In relation to risk for transmission of HIV, how is anal or vaginal sex with a condom classified?
Moderate risk behavior
Which action will the nurse take when a patient receiving morphine sulfate via percutaneous coronary angioplasty (PCA) has a shallow, irregular respiratory rate of 6 breaths/min?
Notify the health care provider and prepare to administer naloxone (Narcan)
.The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?
Paralytic ileus
.A nurse is collecting data from a 65 year old client who is postoperative from a below-the-knee amputation and whose residual limb is wrapped with an elastic bandage to shrink the stump. Which of the following findings should alert the nurse to a possible complication?
Pitting edema above the bandage
.A nurse is reviewing the lab results of a patient who is taking warfarin to reduce the risk of stroke. The PT is 12, and the INR is 1. What is the nurse's BEST action? A
Place the results in the chart.
A blood pressure of 135/87 mm Hg is considered to be?
Prehypertension
.A nurse records the finding of a normal sinus rhythm (NSR) when the P, Q, R, S, and T are all present in the electrocardiographic complex. What additional information should the nurse document?
Rate of 82 seconds
A nurse recognizes that a patient diagnosed with COPD has a rising level of partial pressure of carbon dioxide (CO2) in arterial blood (PaCO2). How should the nurse interpret this assessment?
Respiratory acidosis has begun.
.On what is the selection of an antimicrobial agent based?
Sensitivity of the microorganism to the drug
1.What should a nurse expect of a patient's respirations caused by the falling blood pressure and impaired blood circulation during the refractory stage of shock?
Slow and shallow
The nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse should review the results of which diagnostic test to confirm this diagnosis?
Sputum culture
A patient has a diagnosis of type 1 diabetes mellitus. What is the main characterization of type 1 diabetes mellitus?
There is an absence of endogenous insulin
.What medication obtained in a patient's history will lessen the effects of warfarin (Coumadin)?
Yaz (drospirenone/estradiol) as an oral contraceptive
The following antiviral agents in combination of other antiretroviral agents are used to treat HIV-1 infections?
atazanavir (Reyataz) fosamprenavir (Lexiva)
.A nurse is preparing to administer gr 1/4 of a medication to a client. Available is 50 mg/mL. How many mL should the nurse administer per dose? (do not round)
gr 1/4 = 0.25 mg / 50 mg X 1mL = 0.3 mL
The nurse administers atropine ordered pre-op for surgery. Thirty minutes after administration, the client complains of a very dry mouth and has flushed, dry skin with an oral temperature of 101.5° F and an apical heart rate of 113. The most appropriate nursing action is for the nurse to:
notify the physician.
. The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report?
pH 7.25, PCO2 50 mm Hg
A nurse in the outpatient clinic is collecting data from a client who has psoriasis. Which of the following findings should the nurse expect?
thick, erythematous plaques covered by silvery scales
A nurse is caring for multiple patients with above-the-knee amputations. Which patient would the nurse assess first?
A patient who complains of phantom limb pain
Which patient has most likely experienced cell-mediated immunity?
A patient who has rejected a transplanted kidney
Which is the best explanation of acquired immunity?
Activated only when needed
.A 29-year-old patient is to receive cardioversion for a dysrhythmia. What should the nurse instruct the patient to expect?
Administration of a short-acting sedative
Which of the following is an invasive diagnostic procedure used to assess the vascular system?
Angiography
.A nurse is caring for a client who is prone to post op nausea and vomiting. Which of the following drug classifications is commonly used preoperatively to decreases secretions and helps reduce the risk of emesis and aspiration during induction and maintenance of general anesthesia?
Anticholinergics
Which intervention is most appropriate for emergency care of a pneumothorax?
Apply a vented dressing, sealed on three sides.
The nurse notes that the result of the serum theophylline level of a client taking theophylline is 15 mcg/mL. How does the nurse interpret this result?
At the top of the therapeutic range
A nurse administers nalbuphine (Nubain), an opioid agonist-antagonist, to a 78-year-old patient. The family is worried about the patient and thinks that this drug is too strong and will cause harm. What should the nurse assure the family regarding this drug?
Blocks the side effects observed in opioid agonists
A nurse is providing education to a patient taking rifampin ( an antimycobacterial) as a result of an exposure to TB. What side effect of this drug should the nurse include?
Body fluids to become red-orange
A nurse records the assessment of stasis dermatitis on an intake assessment for a patient with peripheral vascular disease (PVD). What is the best way to describe this finding?
Brownish skin discoloration on the lower legs
A 78-year-old retired teacher with a history of osteoporosis has fallen in her bathroom and sustained a subcapital femoral fracture. She is scheduled for an open reduction and internal fixation (ORIF) procedure in the morning. Which type of traction will most likely be implemented?
Buck
.A nurse is reviewing a recent laboratory report for a client who has Human Immunodeficiency Virus (HIV). Which of the following laboratory values should the nurse report to the provider?
CD4-T-cell count 140/mm3
.What should a patient with HIV avoid to prevent bacillary angiomatosis (BA)?
Cats
.An LPN is drawing blood from a patient for a variety of blood tests. What should be the HIGHEST priority nursing action as part of the patient preparation?
Choose the correct blood tubes in which to collect the blood
A nurse is caring for a client who has a fractured tibia as a result of a fall. The x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should recognize this is a finding for which of the following types of fractures?
Comminuted fracture
Assistive devices such as canes, crutches, and walkers are used for people who need to limit weight-bearing activities on joints. Which statement by a nurse best illustrates an understanding of the appropriate use of these devices?
"Canes provide minimal support and balance and are carried on the unaffected side."
A nurse is caring for a client who states, "I am not going to take my medication anymore." Which of the following responses should the nurse make?
"Tell me more about this decision."
The nurse is providing teaching to a patient with heart failure who has been prescribed nifedipine, a calcium channel blocker. Which statement by the nurse is accurate?
"This medication reduces the resistance your heart has to pump against."
A patient with severe psoriasis who is to be treated with the systemic drug methotrexate sodium anxiously asks, "Is this cancer drug safe? Are there some side effects I need to know about?" What is the best response by the nurse?
"We use this drug to treat many kinds of patients, including patients with cancer. You will have periodic blood tests."
Before administering client medications, the nurse must identify the client. Which of the following methods of identification should the nurse use?
. Ask the client's full name and date of birth.
.A nurse is preparing to administer 3 mg of a medication. The amount available for injection is 5 mg/ 2 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)
1.2 mL
A nurse is preparing to administer a client's daily dose of NPH insulin at 0730. The nurse should expect this type of insulin to peak within which of the following timeframes after administration?
6 to 10 hr
The nurse is to administer 0.2 g of a medication. On hand is a 15 mg/ 0.5 mL vial. How many mL's should the nurse calculate? (round to the tenths)
: 0.2 g = 200 mg x5 = 100/15 = 6.666; rounded to tenths = 6.7
A nurse is preparing to administer 225 mg of a medication. Available is 250 mg/2.5 mL. How many mL should the nurse administer? (round to the nearest tenth)
: 225/2.5 = 562.5 divide by 250 = 2.25; round to tenth is 2.3