A & P
Medications
S & S
Nursing Dx
Interventions
100
A client presents to the health care clinic after an episode of Raynaud’s phenomenon. The nurse asks the client about a history of which of the following that may be associated with this disorder?
What is: Microemboli due to atrial fibrillation/ Chronic peripheral venous insufficiency/ Collagen disorder such as lupus erythematosus/ Lung disorders such as chronic airflow limitation
100
A nurse is caring for the client with a history of mild heart failure who is receiving diltiazem hydrochloride (Cardizem) for hypertension. The nurse would assess the client for:
What is: Bradycardia / Wheezing / Peripheral edema and weight gain / Apical pulse rate lower than baseline
100
A client has been diagnosed with urolithiasis in the right ureter. The nurse would expect the client to describe the pain (renal colic) as:
What is: Located in the upper right epigastric area radiating to the right shoulder or back / Occurring two to three hours after a meal / Intermittent in the right upper abdominal quadrant radiating to the groin / Worsening with the ingestion of food
100
A 75 year old woman is admitted to the hospital c/o an aching pain and edema in her right calf. The nursing diagnosis most applicable to her care is:
What is: Altered nutrition: < body requirements / Social isolation / Impaired mobility / Ineffective tissue perfusion
100
The nurse is monitoring the fluid balance for a client who had arterial bypass surgery. The nurse assesses which of the following as the best indicator of fluid balance?
What is: Urine output / Intravenous fluid infusion / Weight / Nasogastric tube drainage
200
The renal pelvis has a capacity of how many mLs?
What is: 1-3 / 5-8 / 12-15 / 20-25
200
A nurse is assessing a client with an arm fracture for signs of arterial damage sustained at the time of the fracture. Which sign is inconsistent with arterial damage?
What is: Pallor or blotchy cyanosis / Reddish coloration to the skin / Weakened or absent distal pulse / Continued pain despite medication
200
A hospitalized client has developed thrombophlebitis in the right lower extremity. The nurse assesses the client for which manifestation of this disorder?
What is: Bilateral calf tenderness / Unilateral edema / Coolness and pallor of the affected limb / Diminished distal peripheral pulses
200
Your 92 year old male patient has recently begun experiencing incontinence at night. You know that this issue creates the risk for :
What is: Injury / Infection / Impaired mobility / Constipation
200
A nurse is caring for a hospitalized client with polycystic kidney disease who had an intravenous pyelography (IVP). The nurse monitors which specific item in the post-procedure period?
What is: Lung sounds / Groin area / Carotid pulse rate / Intake and output
300
In arteries, the innermost layer that provides a slick surface to facilitate blood flow is called:
What is: tunica adventitia / tunica intima / tunica media / tunica arteriolia
300
A client who has been taking lisinopril (Prinivil) for 3 months complains to the nurse of a persistent dry cough that began about 1 month ago. The nurse interprets that this is most likely:
What is: Caused by a concurrent upper respiratory infection / Due to neutropenia as a result of therapy / An expected, although bothersome, side effect of therapy / An indication that the client will show signs of heart failure
300
A nurse is assessing a client with a diagnosis of abdominal aortic aneurysm (AAA). Which assessment finding is most likely unrelated to the AAA?
What is: Pulsatile abdominal mass / Hyperactive bowel sounds / Systolic bruit over the area of the mass / Subjective sensation of the “heart beating” in the abdomen
300
A 45 year old female patient newly diagnosed with hypertension is 5' 3", weighs 198 pounds, and works as a secretary. She has three children ages 8 through 14 who are in many after school activities. they eat primarily at fast food restaurants. Select the most appropriate nursing diagnosis.
What is: Ineffective coping / Fatigue / Powerlessness / Imbalanced nutrition: > body requirements
300
A client is diagnosed with urolithiasis and laboratory analysis of the stone that the client passed indicates that it is of the uric acid type. The nurse gives the client dietary instructions and tells the client to avoid consuming:
What is: Sardines / Cheese / Tea / Milk
400
Peripheral vascular resistance and what other primary factor determine the mean arterial pressure?
What is: Cardiac output / Vasodilation / Vasoconstriction / Urine output
400
A nurse reinforces dietary instructions for the client receiving spironolactone (Aldactone). Which food would the nurse instruct the client to avoid while taking this medication?
What is: Crackers / Shrimp / Apricots / Popcorn
400
A client has been diagnosed with acute pyelonephritis. The nurse assesses the client for which manifestation of this disorder?
What is: Low grade fever / Flank pain on the unaffected side / Chills and nausea / Pale, dilute urine
400
A patient with lymphedema is likely to need nursing care for:
What is: Excess fluid volume / Altered urinary elimination / Risk for trauma / Acute confusion
400
A nurse is assessing the renal function of the client. The nurse checks which item as the best indirect indicator of renal status?
What is: Bladder distention / Level of consciousness / Pulse rate / Blood pressure
500
Blood return via the venous system is facilitated by what structures?
What is: Lymph nodes / Valves / Capillary beds / Bony prominences
500
A nurse is gathering data from a client about the client’s medication history and notes that the client is taking tolterodine tartrate (Detrol LA). The nurse determines that the client is taking the medication to treat which disorder?
What is: Glaucoma / Renal insufficiency / Pyloric stenosis / Urinary frequency and urgency
500
A client with renal malignancy is admitted to the hospital for a diagnostic workup and probable surgery. During the admission assessment, the nurse inquires about the presence of which common symptom related to this problem?
What is: Flank pain and intermittent hematuria / Suprapubic pain and constant slight hematuria / Flank pain and foul smelling urine / Abdominal pain and decreased urine output
500
A client diagnosed with cancer of the bladder has a nursing diagnosis of “Fear related to the uncertain outcome of upcoming cystectomy and urinary diversion." The nurse determines that this diagnosis is appropriate if the client makes which statement?
What is: “I’m so afraid I won’t live through all this.” / “What if I have no help at home after going through this awful surgery?” / “I’ll never feel like myself once I can’t go to the bathroom normally.” / “I wish I’d never gone to the doctor at all.”
500
A registered nurse is observing a nursing student prepare a client for a renal angiography. The registered nurse would intervene if the nursing student:
What is: Checked circulation to the client’s legs / Checked for client allergies / Ensured that an informed consent for the diagnostic procedure was signed / Ensured that an anesthesia consent was signed
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