The Final Exam Review
A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this client are what?
Inability to take in adequate oral food or fluids within 7 days
A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first
Check the client's indwelling urinary catheter for kinks to ensure patency
A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects?
Throbbing headache or dizziness
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified?
Cholesterol levels, hypertension, and smoking
A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond?
“Abdominal ultrasound poses no known safety risks of any kind.”
The school nurse is working with a female high school junior whose BMI is 31. When planning this girl's care, the nurse should identify what goal?
Increase in exercise and reduction in calorie intake
The nurse is caring for a client diagnosed with multiple myeloma who has just been told that his prognosis is poor. He is tearful and trying to express his feelings, but he is having difficulty. What should the nurse do first?
Ask if he would like you to sit with him while he collects his thoughts
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space
A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?
It will probably not have more damage than if the client came in immediately.
A clinic nurse is providing client education prior to a client's scheduled palliative radiotherapy to her spine. At the completion of the client teaching, the client continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from thiS?
The client has not achieved the desired learning outcomes.
A nurse who sits on the hospital's ethics committee is reviewing a complex case that has many of the characteristics of assisted suicide. Which of the following would be an example of assisted suicide
Administering a lethal dose of medication to a client whose death is imminent
imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should the nurse be aware of when assessing clients?
Prolonging confinement to bed
A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the client has a BMI of 45. What does this indicate?
The client is extremely obese.
A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize?
Rising slowly from a lying or sitting position
The nurse is creating a plan of care for a client with acute coronary syndrome. What nursing action should be included in the client's care plan?
Administer supplementary oxygen, as needed.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
Motor vehicle accidents
The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent?
Mottling of the lower limbs
The nurse is assessing a 73-year-old client who was diagnosed with metastatic prostate cancer. The nurse notes that the client is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the client is most likely in what stage of death and dying?
Depression
A diabetic educator is discussing “sick day rules” with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what?
“I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours.”
An oncology client will begin a course of chemotherapy and radiation therapy for the treatment of bone metastases. What is one means by which malignant disease processes transfer cells from one place to another?
Invading healthy host tissues
A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care?
Ability of technology to prolong life beyond meaningful quality of life
A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client?
In a high Fowler position
The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis?
Distended neck veins
A client's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this client's care, the nurse should identify what primary aim?
To prevent and relieve suffering
The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client?
Taking a BP reading on the affected arm can damage the fistula.