Unit I
The patient who continues to take opioids despite harmful effects is considered what?
What is an Addict
A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload?
A. Flushing
B. Bradycardia
C. Vomiting
D. Dyspnea
What is Dyspnea - Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention.
A nurse is collecting data from an adult client who has meningococcal meningitis. Which of the following findings should the nurse expect?
A. Petechial rash on the chest and extremities
B. Negative Kernig's sign
C. Mild Headache
D. Stiff Lower Extremities
What is Petechial rash on the chest and extremities
Which outcome is realistic for a patient with stage 1 Alzheimer’s disease?
A. Caregiver will assume role of decision maker for patient to reduce stress
B. The patient will maintain the highest possible functional level to preserve autonomy
C. Arrangements will be made for appropriate long-term placement to minimize risk of injury
D. The patient will retain full physical functioning through cognitive and occupational therapies
What is B - The patient will maintain the highest possible functional level to preserve autonomy
Which statement best exemplifies the client’s understanding of rehabilitation after a full-thickness burn injury?
A. “I am fully recovered when all the wounds are closed.”
B. “I will eventually be able to perform all my former activities.”
C. “My goal is to achieve the highest level of functioning that I can.”
D. “There is never full recovery from a major burn injury.”
What is C. “My goal is to achieve the highest level of functioning that I can"
A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. What is the Nurses Priority Action?
1. Give EpiPen
2. Document Antibiotic name in chart as allergy
3. Assess Airway
4. Call 911
What is Assess Airway
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following actions should the nurse take?
a. Maintain continuous IV of 0.9% sodium chloride.
B. Request provider order for Low Sodium Diet
c. Continue administration of Antidiuretic Medication, desmopressin
d. Implement oral fluid restrictions.
What is Implement Oral fluid restrictions
A nurse is reviewing the prescriptions for a client who had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?
A. Administer Enoxaparin injection every 12 hours
B. Encourage the client to perform foot and calf exercises every 2 hr
C. Place a wedge or pillow between the client's legs when turning
D. Instruct the client to restrict flexion of the hip past 120°
What is Instruct the client to restrict flexion of the hip past 120° - Do not want it to go past 90
An elderly patient was well until 12 hours ago, when she reported to her family that in the middle of the night she awakened to see a man standing at the foot of her bed. There is no evidence that this situation ever happened. This series of events supports which possible diagnosis?
a. Delirium
b. Anxiety
c. Paranoia
d. Dementia
What is A - Delirium
Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous and without pain?
A. Decreased Tissue Perfusion
B. Disturbed Body Image
C. Risk for Disuse Syndrome
D. Risk for Ineffective Breathing Pattern
What is A - Decreased Tissue Perfusion
A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?
A. Change disposable mask immediately after use
B. Minimize Patient Contact
C. Change gloves immediately after use
D. Minimize conversation with the client
C - Change gloves immediately after use
A nurse is assisting with the plan of care for a client who has leukemia and whose platelet count is 50,000 mm3. Which of the following interventions should the nurse include in the plan of care?
a. Administer Antibiotics
b. Delegate aide to assist with shaving
c. Instruct patient on limiting visitors
d. Administer stool softener
What is D - Administer Stool Softener
What are the findings in a patient with Decorticate Posturing ?
A. External rotation of the lower extremities
B. Extension of upper extremities
C. Arms bent towards body
D. Legs bent towards body
What is C. What are Arms bent towards body
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?
A. Control Impulsive Behavior
B. Assist with left sided deficits
C. Re-establish Communication
D. Teach techniques to compensate for left sided vision loss
What is C. Re-establish Communication
The primary problem in cataract is:
A. Blurring of vision
B. Loss of peripheral vision
C. Presence of floaters
D. Halos around light
What is A - Blurring of vision - Clouded, blurred or dim vision. Increasing difficulty with vision at night. Sensitivity to light and glare - Colors are muted not as sharp
A client newly diagnosed with gout ask what it is. Your response would be?
Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues, leading to inflammation and pain.
A nurse is monitoring a client who is receiving chemotherapy and has a platelet count of 22,000 mm3. Which of the following findings should the nurse identify as the priority?
a. Loss of appetite for past 3 days
b. Current fever of 99.0* F
c. Ecchymosis of the chest
d. Mild edema to the right lower extremity
What is Ecchymosis of the chest
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?
A. Blood Pressure
B. Oxygen Saturation
C. Level of consciousness
D. Intercranial Pressure
What is D. Intercranial pressure
A patient is admitted with uncontrolled atrial fibrillation. The patient’s medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?
A. Ischemic Thrombosis Stroke
B. Ischemic Embolism Stroke
C. Hemorrhagic Stroke
D.Ischemic Stenosis
What is B - Ischemic Embolism Stroke
The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis?
A. "I have been seeing small flashes of light."
B. "I have trouble threading my sewing needle. I have to hold it far away to see it."
C. "I notice that my peripheral vision is becoming worse."
D. "I see a blurry spot in the middle of the page when I read."
What is D - I see a blurry spot in the middle of the page when I read
A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs additional education?
A. We will bring in books and magazines for entertainment
B. We can bring in fresh flowers to brighten their room
C. We will bring in personal care items for comfort
D. We will distance ourselves from him when visiting
C. We will bring in fresh flowers to brighten their room
A nurse is reinforcing teaching with a client who is to begin external radiation treatment for a lower leg tumor. The nurse should instruct the client to monitor for which of the following adverse effects?
A. Cystitis
B. Alopecia
C. Mucositis
D. Shedding of the Skin
What is shedding of the skin - monitor the skin at the radiation site for sloughing, blanching, or redness following radiation treatment. The client should report these findings to the provider
The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?
A. Emphasize the importance of hand washing before meals.
B. Tell adolescents and young adults to avoid crowds in the winter.
C. Support serving healthy nutritional options in the college cafeteria.
D. Encourage immunization for adolescents and college freshmen
What is D. Encourage immunization for adolescents and college freshmen
The wife of a patient who is recovering from a cerebral vascular accident (CVA) tells the healthcare provider, “My husband acts as though I’m talking to him in a foreign language.” The healthcare provider will correctly document this communication disorder as which of the following?
A. Receptive Aphasia
B. Expressive Aphasia
C. Dysphasia
D. Dysarthria
What is A- Receptive Aphasia
Patients diagnosed with sickle cell disease (SCD). tissue damage results from which of the following?
A. Air hunger and respiratory alkalosis due to deoxygenated red blood cells.
B. Hypersensitivity of the central nervous system (CNS) due to elevated serum bilirubin levels
C. A general inflammatory response due to an autoimmune reaction from hypoxia
D. Local tissue damage with ischemia and necrosis due to obstructed circulation
What is D. Local tissue damage with ischemia and necrosis due to obstructed circulation