Nursing Final Exam Questions with Answers, Exams of Nursing

Download Nursing Final Exam Questions with Answers and more Exams Nursing in PDF only on Docsity! NURSING FINAL EXAM#1 QUESTIONS WITH ANSWERS TESTED AND SOLVED COMPLETE UPDATED SOLUTIONS The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with itching Client with flushing Client with pruritus Client with wheezing The nurse observes that a client with sickle cell anemia and on a blood transfusion regimen has cardiac dysrhythmias due to iron overdose toxicity. Which medication is most beneficial to this client? Deferasirox Deferiprone Deferoxamine Ferrous gluconate Which type of immune preparation, made from donated blood, contains antibodies that provide passive immunity? Toxoid Killed vaccine Live attenuated vaccine Specific immune globin Arrange the sequence of steps required to stimulate antibody-mediated immunity in its correct sequence. 1. Exposure of antigen 2. Antigen recognition 3. Sensitization 4. Antibody production 5. Antigen elimination Good pasture syndrome A client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client? Type I Type II Type III Type IV The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with itching Client with flushing Client with pruritus Client with wheezing While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? Report to the primary healthcare provider Stop the blood transfusion immediately Recheck identifying tags and numbers on the client Maintain a patent intravenous (IV) line with saline solution The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? Increase in blood pressure Decrease in erythropoietin Increase in serum phosphate levels Decrease in serum sodium concentration An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? The nurse should wait for the court’s order to give blood to the client. The nurse should proceed with the transfusion in order to save the client’s life. The nurse should inform the primary healthcare provider and not give blood to the client. The nurse should explain to the family member that the client needs this transfusion. Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? Obtain the vital signs. Stop the transfusion. Assess the pain further Increase the flow of normal saline. While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? Panic Hemolytic Anaphylact ic Pyrogenic During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions 1. Elevate the head of the bed to 45 degrees 2. Apply oxygen via nasal cannula 3. Reduce the flow rate of the transfusion 4. Administer furosemide (Lasix) per provider prescription 5. Document findings in the client record A prescribed blood transfusion of packed red blood cells was started five minutes ago. Now the client is complaining of chest pain, flank pain, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 100.8° F (38.2° C), and the client seems less alert. What should the nurse suspect? Urticarial reaction Hemolytic reaction Circulatory overload Anaphylactic reaction A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted thru food?" The nurse should respond, "The type of hepatitis associated with food is hepatitis: A B C D The nurse is teaching a client who is prescribed iron supplements for iron-deficiency anemia. Which food should the nurse encourage the patient to take to enhance absorption of iron? Cereal Spinach Whole milk Orange Juice A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? A client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. Which statement/intervention is most accurate when administering potassium chloride intravenously to this client with hypokalemia? Rapid infusion of potassium prevents burning at the IV site. Oliguria is an indication for withholding intravenous (IV) potassium Clients with severe deficits should be given IV push potassium. Average IV dosage of potassium should not exceed 60 mEq in one hour. A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? Furosemide (Lasix) Propranolol (Inderal) Digoxin (Lanoxin) Spironolactone (Aldactone) Which assessment finding in a client signifies a mild form of hypocalcemia? Seizures Hand spasms Numbness around the mouth Severe muscle cramps A registered nurse is teaching a student nurse regarding the interventions for a client with human immunodeficiency virus (HIV) infection. Which statement by the student nurse indicates the nurse needs to follow up? “I will ask the client to avoid exposure to new infectious agents." "I will ask the client about intake of vitamins and micronutrients." "I will ask the client to avoid involvement in community activities." "I will ask the client if he or she is up to date with recommended vaccines." The laboratory report of a client reveals the presence of 350 cells/mm3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? STAGE 1 STAGE 2 STAGE 3 STAGE 4 The nurse is taking care of four clients with human immunodeficiency virus (HIV) infections. Which client’s condition should the nurse report to the primary healthcare provider within 24 hours after observation? Client A Client B Client C Client D A nurse is educating a client with human immunodeficiency virus (HIV) about self-management. Which suggestion by the nurse benefits the client? "Limit your daily fluid intake "Rinse your mouth with normal saline after every meal." "Eat more roughage." "Maintain a 4-to-5-hour gap in between meals." The registered nurse instructs the nursing student about caring for a hospitalized client with a human immunodeficiency (HIV) infection. Which action made by the nursing student indicates effective learning? Keeping fresh flowers in the client’s room Encouraging the client to eat fresh fruits and vegetables Keeping a dedicated disposable glove box in the client’s room Changing gauze-containing wound dressings every other day Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? Pneumocystis jiroveci pneumonia Oropharyngeal candidiasis Cryptosporidiosis Toxoplasmosis encephalitis A circulating nurse in the operating room learns of being HIV positive. What should this nurse do regarding participation in exposure-prone procedures? Adhere to standard precautions at all times Avoid handling equipment used in direct client care Discuss procedures that can be performed with a review panel A nurse has received a report on a client being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment findings? Select all that apply. Tachycardia Hypertension Headache Diaphoresis Bounding Peripheral pulses QUIZ#1 What is a nursing priority to prevent complications in clients with respiratory acidosis? Assessing the nail beds Listening to breath sounds Monitoring breathing status Checking muscle contractions The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? PO2 value is 80 mm Hg PCO2 value is 60 mm Hg HCO3 value is 50 mEq/L (50 mmol/L) Serum potassium level is 4 mEq/L A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. Headache Irritability Restlessness Hypertension Lightheadedness A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? Question the client about the confusion Change the method of oxygen therapy Percuss and vibrate the client’s chest wall Discontinue or decrease the oxygen flow rate To determine the presence of respiratory alkalosis in a client, what should the nurse evaluate for? A change in the respiratory A tingling sensation in the hands Periodic changes in heart rate A pulse oximetry reading of less than 98% A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? An elevated pH, elevated PCO2 A decreased pH, elevated PCO2 An elevated pH, decreased PCO2 A decreased pH, decreased PCO2 A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? Skeletal and nervous Circulatory and urinary Respiratory and urinary Muscular and endocrine A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste products On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias Which type of immune preparation, made from donated blood, contains antibodies that provide passive immunity? Primary immunodeficiency Acute hypersensitivity reaction Major histoincompatibility When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)? Grapes Oranges Bananas Potatoes Tomatoes A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first? Dyspnea Dilated pupils Itching and edema Wheal-and-flare reaction You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Phosphorus falling to 2.1 mg/dL Magnesium rising to 2.9 mg/d While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? Weakness Paresthesias Facial spasms Muscle tremors You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? The potassium level may be increased if the patient has renal nephropathy. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. The patient may be excreting extra sodium and retaining potassium because of malnutrition. You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician? Loop diuretics Bronchodilators Antibiotics Antihypertensives The patient has chronic kidney disease and is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? IV Furosemide (Lasix) Renal dialysis IV potassium chloride IV normal saline at 250 mL per hour You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. In how many hours should the nurse anticipate hanging the next bag of D5W? hours 4 You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon Listen to the patient’s lung sounds and assess respiratory status Obtain a new bag of IV solution to maintain patency of the site Notify the physician and complete an incident report OUIZ #2 A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nursemake it a priority to use? Select all that apply. Goggles Surgical Mask Gown Shoes covers N95 mask Gloves The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? Class III Class II A client is hospitalized with pneumococcal pneumonia. Which drug will the nurse most likely administer? Penicillin G Vancomycin Meropenem Ceftriaxone The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? Maintaining fluid balance in the client Encouraging the client to perform breathing exercises Providing adequate oxygenation for the client Assisting the client in eating and drinking The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction? Inhaling air fully before inserting the mouthpiece Performing 10 breaths per session every hour Taking a long slow, deep breath keeping the mouthpiece in place Recording the volume of the air inspired Levofloxacin 750 mg intravenous piggyback (IVPB) is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? Record your answer using a whole number. gtt/minute 25 A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? Active range-of-motion exercises at least every four hours Isometric exercises every two hours while awake Gait training in the physical therapy department daily Passive range-of motion exercises at least every eight hours When caring for a client with pneumonia, which nursing intervention is the highest priority? Employ breathing exercises and controlled coughing increase fluid intake maintain a NPO status Ambulate as much as possible A client with a history of coronary artery disease is admitted with pneumonia. The healthcare provider prescribes atenolol. What should the nurse monitor to determine the therapeutic effect of atenolol? Temperature Respirations Heart rate Pulse oximetry A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? to accomplish? Permit the development of positive pressure between the layers of the pleura Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Provide access for the installation of medication into the pleural space Nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? Stop giving the medication Elevate the head of the client’s bed Measure the other vital signs Report to the primary healthcare provider A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. mL/hr 35 A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? Discuss with spouse the risk for morphine addiction Add a placebo to the morphine to appease the spouse Assess the client’s pain before increasing the dose of morphine Check the client’s heart rate before increasing the morphine to the next level POP QUIZ #2 A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? Cleanse the site with the new product first and then follow the agency’s protocol Use the new product sample when changing the dressing Follow the agency’s policy unless it is contraindicated by a primary healthcare provider’s prescription Cleanse the site with alcohol first and the with povidone-iodine A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? There is less chance of this infusion infiltrating It is more convenient so clients can use their hands It prevents the development of infection The large amount of blood helps dilute the unconcentrated solution Request an oral supplement from the primary healthcare provider A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first? Healthcare provider UAP LPN RN A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply. Deep tendon reflexes Urinary output ABG results Last bowel movement Patency of the IV access Last serum potassium level A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply. Administering 100% oxygen manually to the client Administering IV fluids to the client Reporting to the primary healthcare provider Stopping the suctioning procedure immediately A nurse is providing tracheostomy care. Which action is priority? Monitor body temperature after the procedure is completed Maintain sterile technique during the procedure Clean the inner cannula with sterile water when it is removed Place the client in the semi-Fowler position Surgical incision in the chest to gain access to the internal organs is THORACOTOMY VATS=Video assisted thoracoscopic surgery The valve used to evacuate air from the pleural space is called Flutter valve of Heimlich valve Give the patient pain medication 30-60 minutes before chest tube removal TRUE QUIZ#3 A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? Barium enema Colonoscopy Gastroscopy CT scan An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow? High fiber Low fat Low carb 9:00AM, 12:00PM, and 3:00PM Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of Nasogastric suctioning Impaired peristalsis Irritation of the bowel Inflammation of the incision site The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? A decrease in appetite by 50% over 24 HRs Muscle tremors and other signs of hypomagnesemia Abdominal pain and bloating No bowel movement for 3 days The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? Delay the patient’s signature on the consent and notify the physician about the conversation with the patient Ask the family members whether they have discussed the surgical procedure with the physician. Explain the planned surgical procedure as well as possible and have the patient sign the consent form Have the patient sign the consent form and state the physician will visit to explain the procedure before surgery The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? The tube will push past the area that is blocked and thus help to stop the vomiting The tube will help to drain the stomach and prevent further vomiting The tube is just a standard procedure before many types of surgery to the abdomen The tube will let us measure your stomach contents so that we can plan what type of IV fluid replacement would be best A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess first? Fecal impaction Antidiarrheal agent use Dietary fiber intake Perineal hygiene What information would have the highest priority to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy? Which medications will be used during surgery The location and care of drains after surgery How to care for the wound How to deep breathe and cough The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? Increases peristalsis by stimulating nerves in the colon wall Increases fluid by retention in the intestinal tract Increases bulk in the stool Lubricates the intestinal tract to soften feces The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Maintain a high intake of fluid and fiber in the diet Eat several small meals per day to maintain bowel motility Reduce intake of medications causing constipation very well The drainage from the stoma can damage my skin I will be able to wear the pouch until it leaks I will be able to regulate when I have stools The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? High-pitched and hyperactive above the area of obstruction Low-pitched and rumbling above the area of obstruction Low-pitched and hyperactive below the area of obstruction High-pitched and hypoactive below the area of obstruction What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? Ensure dietary intake of 10g of fiber each day Take a dose of mineral oil at the same time Add extra salt to food on at least one meal tray Take each dose with a full glass of water or other liquid A client with a diagnosis of gastric cancer has a gastric resection with a vagotomy. Which clinical response should alert the nurse that the client is experiencing dumping syndrome? Constipation Clay-colored stools Reactive hypoglycemia Sensations of hunger A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? Low-protein, high-carb diet Fluid intake below 500mL Small, frequent feeding schedule Low-residue, bland diet Palpitations CRANIAL NERVES QUIZ Glossopharyngeal Nerve: innervates the pharynx Optic Nerve: vision Facial Nerve: control of facial muscles Vestibulocochlear: equilibrium and hearing Hypoglossal: innervates the tongue muscles Vagus: controls visceral and cardiac muscles; cranial nerve that innervates smooth muscle and glands of the heart, lungs, larynx, trachea, and most abdominal organs Trigeminal: controls muscles of mastication Cerebellum: controls posture, balance, and the coordination of body movements Medulla oblongata: the respiratory, cardiac, and vasomotor control centers are located here After a major head trauma, the patient's respiratory and cardiac functions are affected. Which area of the brain is damaged? Temporal lobe of the cerebrum Brainstem Cerebellum Spinal Nerves What is the purpose of the blood-brain barrier? To protect the brain by cushioning To inhibit damage from external trauma To keep harmful agents away from brain tissue To provide the blood supply to brain tissue When assessing a patient with a traumatic brain injury, you notice uncoordinated movement of the extremities. How would you document this? Ataxia How do you assess the accessory nerve? Assess the gag reflex by stoking the posterior pharynx Ask the patient to shrug their shoulders against resistance Ask the patient to push the tongue to either side against resistance Have the client say “ah” while visualizing elevation of the soft palate When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity. How would you accurately document this finding? Athetosis Hypotonia Hemiparesi s Pronator drift DIABETES QUIZ A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician's prescriptions? Endotracheal intubation 100 units of NPH insulin IV infusion of normal saline IV infusion of sodium bicarbonate "A client is taking Humulin NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: Which disease process should the nurse suspect the client is developing? Type 1 diabetes Type 2 diabetes Gestational diabetes Acanthosis nigricans An external insulin pump is prescribed for a client with DM. The client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: Gives small continuous dose of regular insulin subcutaneously and the client can self-administer a bolus with an additional dosage from the pump before each meal Is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? BP 126/80 A1C 9% FBG 130 mg/dL LDL cholesterol 100 mg/dL One of the benefits of glargine (Lantus) insulin is its ability to: Release insulin during the day to help control the basal glucose Release insulin evenly throughout the day to control basal glucose levels Simplify the dosing and better control blood glucose levels during the day Cause hypoglycemia with other manifestation of other adverse reactions The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement? Ensure the client eats the bedtime snack Determine how much food the client ate at lunch Perform a glucometer reading at 0700 Offer the client protein after administering insulin A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply. Hypotension Muscle twitching Polyuria Respiratory acidosis Lethargy A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Impaired GFR, causing retention of sodium and metabolic waste products Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion It decreases the need for immobility because it clears toxins in short and intermittent periods It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? Protei n Fluid Sodiu m Potassium A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client? Increases urinary output Prevent respiratory acidosis Correct Hyperkalemia Increases serum calcium levels A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client’s blood level of calcium, potassium, and creatinine? Select all that apply. Creatinine 1.1 mg/dL Calcium 7.6 mg/dL Creatinine 3.2 mg/dL Potassium 3.5 mEq/L Calcium 10.5 mg/dL Potassium 6.0 mEq/L A client with acute kidney injury states, "Why am I twitching and my fingers and toes tingling?" Which process should the nurse consider when formulating a response to this client? Sodium chloride depletion Calcium depletion Acidosis Potassium depletion A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first? Obtain an ECG strip and obtain an antiarrhythmic medication Take vital signs and notify the HCP Call RRT Call the lab to repeat the test A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client’s spouse asks the nurse about the anticipated plan of care. Which is an appropriate nursing response? The staff will provide total care, because the infection causes severe fatigue Mood elevators will be prescribed to improve depressions and irritability Vitamin B12 will be prescribed for the anemia and the stools will be dark The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products A client is admitted to the hospital with a diagnosis of severe chronic kidney disease. Which assessment findings should the nurse expect the client to exhibit? Select all that apply. Paresthesias Widening pulse pressure HTN Polyuria Metabolic alkalosis EXAM #2 When a nurse brings a dinner tray to a 44 year old patient hospitalized with pneumonia, the patient says, "I'm too sick to feed myself." What is the best response by the nurse? You can eat later when you feel better." You're really not that sick, and I'm sure you can feed yourself. Try to eat as much as you can. Wait a few minutes, and I will be back to help you. An 50-year-old patient with viral pneumonia is admitted to the telemetry unit. The admitting nurse reviews the instructions from the healthcare provider. Which prescription should the nurse question? Start IV fluids D5% 0.45% NS at 80 mL/hr Aspirin 325 mg every 4 hours prn for fever higher than 101.4° F (38.6° C) physiotherapy twice a day Encourage oral fluids A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C & S) are prescribed. Place these interventions in the order in which they should be implemented. 1. Promote bed rest with raised head of bed 2. Provide oxygen via nasal cannula 3. Obtain blood specimens for C&S 4. Administer prescribed antibiotic A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished. 1. Obtain data about the client’s history and physical status 2. Insert an IV catheter to establish venous access 3. Collect sputum sample for culture and sensitivity 4. Administer prescribed antibiotic IVPB 5. Check peak and trough levels of the antibiotic What early clinical findings does the nurse expect to identify? Nosebleeds and papilledema Enlargement of the axillary and groin lymph nodes Abdominal pain and reddened complexion Fatigue and ecchymotic areas A patient who has acute lymphoblastic leukemia is scheduled to receive cranial radiation. What should the nurse explain to the patient and family about radiation? It reduces the risk for systemic infection. It prevents central nervous system involvement. It limits metastasis to the lymphatic system. It avoids the need for chemotherapy. A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? Conjunctiva Mucous membrane Sclera Lips A nurse is assessing four different clients. Which findings depict that the client is at risk for heart disease? Client 1 Client 2 Client 3 Client 4 A nurse is assessing four clients. Which client is at the highest medical risk of coronary heart disease and hypertension? Client A A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that apply. Olive oil Enriched whole milk Chicken broth Liver and other glandular organ meats Red meats such as beef Vegetables and whole grains A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply Diabetes insipidus African-American ancestry Obesity Increased high-density lipoprotein (HDL) HTN What are the clinical manifestations of myocardial infarction in women? Select all that apply. Tightness of the chest Indigestion Sleep disturbances Unusual fatigue Anoxia The nurse is examining the nails of four different clients. Which client does the nurse anticipate having a myocardial infarction? Client A Client B Client C Client D A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? Sodium bicarbonate Atropine Amiodarone Epinephrine A client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The healthcare provider prescribes 500 mL of D5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which most common side effect of this medication? HTN Nausea Bradycard ia Syncope Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. Which statement by the client indicates the teaching was effective? I should take the medicine three times a day." "I will be sure to take my pulse after I have exercised." "I should take one tablet before attempting to climb two flights of stairs." "It will be important to avoid activities that are too strenuous." A client is admitted for chest pain and a myocardial infarction. The nurse caring for the client is preparing to apply nitroglycerin ointment. Before applying the ointment, what action will the nurse take? Assess the client's pulse rate. Shave the client’s chest in the area for application. Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount. Prepare the site with an alcohol swab. A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of what drug? Digoxin Furosemide Captopril A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse? "This test will detect your heart sounds." The ECG will tell us how much stress your heart can tolerate." "This test will reflect any heart damage." "This procedure helps us change your heart’s rhythm." The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Warm, flushed skin Decreased urinary output Rapid pulse Increased BP Deep respirations A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply. Restlessnes s Bradypnea Decreased urinary output Tachypnea Warm, moist skin A woman comes to the emergency department reporting signs and symptoms that are determined by the primary healthcare provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? Select all that apply. Severe fatigue Pain radiating down the left arm Choking sensation Sense of unease Chest pain relieved by rest A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. How would the nurse expect the client to describe the chest pain? Mild, radiating toward the abdomen Burning and of short duration Severe, intense Squeezing, relieved by nit A client who recently had a myocardial infarction is admitted to the cardiac care unit. How can the nurse best determine the effectiveness of the client’s ventricular contractions? Monitoring urinary output hourly Assessing breath sounds frequently Observing anxiety levels Evaluating cardiac enzyme results A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client’s temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what? Respiratory infection Venous thrombosis Tissue necrosis Pulmonary infarction A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? Are you feeling anxious?" "Do you have any palpitations?" "Do you have client first." "I recognize that you have been waiting for quite a while, but it now looks like you will have to wait even longer." A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Decrease the workload on the heart and promote maximum coronary artery filling Increase venous return to the right atrium and increase pulmonary arterial blood flow Increase left ventricular filling and improve cardiac output A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? Decreased catecholamine secretion Increased parasympathetic nervous system stimulation Myocardial hypoxia Metabolic alkalosis A nurse is developing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. Which statement from the client indicates the nurse needs to intervene? I will restrict my physical activity." I will take one baby aspirin every day." I will try to lose the extra weight I'm carrying around." I will continue my smoking cessation program." A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction? This prevents further fluid accumulation, which increases the workload of the heart. A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin? Chlorpromazine Ferrous sulfate Atenolol Acetylsalicylic acid A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A 76-year-old who has a history of thrombocytopenia A 68-year-old who had emergency dental surgery A 59-year-old who had a knee replacement A 60-year-old who has bacterial pneumonia After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? Pink Yello w Clear Gree n The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. Sudden chest pain Flushing of the face Abrupt onset of shortness of breath Elevation of temperature Pain rating increase from 2 to 8 in the hip The nurse provides care for a Chinese patient who is experiencing leg pain. The patient states, "I don’t want to take any medication that I may get addicted to." What is the best nursing intervention in this situation? Give morphine (Avinza) to the patient with hot teaphine (Avinza) to the patient with hot tea Give ibuprofen (Advil) to the patient with cold water Give ibuprofen (Advil) to the patient with hot tea Postpone medication administration to the patient A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? Turn the machine on several times a day for 10 to 20 minutes Apply the color-coded electrodes on the client where they are most comfortable. Maintain the settings programmed by the healthcare provider. Adjust the dial on the unit until the client states the pain is relieved. The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. Pruritus Constipati on Nausea and vomiting Respiratory rate Sedation The nurse is caring for victims of a bomb blast in the emergency department who are receiving different pain medications. Which client must be placed on electrocardiogram equipment? Client A Client B Client C Client D The registered nurse teaches the student nurse regarding the priority of care provided to clients with chest pain. Which activity performed by the student nurse indicates effective learning? Auscultating heart and breath sounds Placing the client in upright position Assessing airway, breathing, and circulation (ABC) Administering oxygen via nasal cannula A nurse is caring for a client with pain due to muscle spasm. Which nursing action is beneficial for the client? Providing heat compresses at the site Encouraging the client to perform isometric diseased pancreas." After surgery for cancer of the pancreas, the client's nutrition and fluid regimen are influenced by the remaining amount of functioning pancreatic tissue. The nurse considers both the exocrine and the endocrine functions of the pancreas and expects that, postoperatively, the client's dietary regimen will be focused on the management of what substances? Fats and carbohydrates Alcohol and caffeine Fluids and electrolytes Vitamins and minerals A nurse is caring for a client who had a pancreaticoduodenectomy for cancer of the pancreas. The nurse provides education about hypoinsulinism, a long- term complication related to this type of surgery. The nurse evaluates that the teaching is understood when the client states that he will seek medical supervision if he experiences which symptom? Oliguria Weight gain Anorexia Increased thirst A client with an inoperable cancer of the head of the pancreas involving the common bile duct has a T-tube inserted. During the first 48 hours after insertion of the tube, what should the nurse do? Ensure that the T-tube is connected to low intermittent suction Use normal saline to irrigate the T-tube every two hours Avoid positioning the client on the right side where the T-tube is located Maintain T-tube patency via gravity drain A client newly diagnosed with cancer of the pancreas is scheduled for surgery. The client says to the nurse, "Wouldn't I be better off with some other treatment instead of surgery?" What response by the nurse is the best? "Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?"