Exam 1
A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action?
A) Ask the nurse manager to provide an in-service program about confidentiality to the staff on the unit.
B) Quietly tell the AP's that this is not appropriate.
C) Complete an incident report.
D) Document this occurrence in a personal log.
B) Quietly tell the AP's that this is not appropriate.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in prevention of pulmonary complications?
A) Encourage use of incentive spirometer
B) Perform ROM exercises
C) Place suction equipment at bedside
D) Administer an expectorant
A) Encourage use of incentive spirometer
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
A) Urine output of 2,200 mL in the past 24 hr
B) First-voided urine in the morning has a strong odor
C) Urine is cloudy after sitting in the urinal for 6 hr
D) Urine output of 175 mL in the past 8 hr
D) Urine output of 175 mL in the past 8 hr
A nurse is caring for a client with pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?
A) Encourage increased fluid intake
B) Encourage early ambulation
C) Encourage coughing and deep breathing
D) Encourage use of incentive spirometer
A) Encourage increased fluid intake
A nurse is assessing an adolescent who has an exacerbation of Graves' disease. Which of the following findings should the nurse expect?
A) Bradycardia
B) Heat Intolerance
C) Weight Gain
D) Lethargy
B) Heat Intolerance
The nurse is teaching the class about professionalism. The nurse should include that joining a professional organization is an example of which of the following?
A) Professional commitment
B) Quality improvement
C) Professional identity
D) Risk management
A) Professional commitment
A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition?
A) Dysphagia
B) Pleural effusion
C) Apnea
D) Hypoxemia
D) Hypoxemia
A postoperative client has been placed on a clear liquid diet. The nurse understands that all of the following items are allowed to be consumed except for
A) Gelatin
B) Vegetable Juice
C) Broth
D Coffee
B) Vegetable Juice
Status Asthmaticus is best described as:
A) An asthma attack requiring high dose steroids
B) An asthma attack lasting longer than 1 hour
C) An asthma attack which does not respond to typical treatment
D) An asthma attack precipitated by an allergen
C) An asthma attack which does not respond to typical treatment
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
A) Hypotension
B) Diaphoresis
C) Hyperpigmentation
D) Weight loss
C) Hyperpigmentation
When performing a physical assessment, what approach is the most important for the nurse to use?
A) An approach that allows time to collect the nursing history data while performing the assessment data
B) A head-to-toe approach to avoid missing an important area
C) The same systematic, efficient sequence for all assessments
D) A sequence that is least revealing and embarrassing for the patient.
C) The same systematic, efficient sequence for all assessments
The nurse understands that which of the following is true when caring for a client who has shingles?
A) Two clients with shingles can be placed in the same room
B) Open lesions are not considered contagious
C) The client should be put on airborne and contact precautions
D) Shingles are a widespread rash that affects both sides of the body
C) The client should be put on airborne and contact precautions
A nurse is teaching a client who has a new prescription for ciprofloxacin to treat an uncomplicated UTI. Which of the following instructions should the nurse include?
A) "Monitor for tendon pain."
B) "Take this medication with an antacid."
C) "Drink 1,000 milliliters of fluid daily."
D) "Expect urine to turn dark orange."
A) "Monitor for tendon pain."
A nurse is caring for a client who has an opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer?
Narcan (Naloxone)
Adrenaline ( Epinephrine)
Protamine (Protamines)
Romazicon ( Flumazenil)
Narcan (Naloxone)
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client’s blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?
A) 1 tsp sugar Distractor
B) 4 oz diet soda
C) 4 oz skim milk
D) Graham crackers
D) Graham crackers
In what order would you complete a 5 step abdominal assessment?
1) Gather History by Asking Questions
2) Inspect
3) Auscultate
4) Percuss
5) Palpate
A nurse is reviewing the diagnostic test results of an older adult female who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results?
A) Hematocrit 40%
B) Creatinine 0.9 mg/dL
C) WBC count 20,000/mm3
D) Potassium 3.8 mEq/L
C) WBC count 20,000/mm3
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?
A) Uremia
B) Nephrosclerosis
C) Cystitis
D) Diverticulitis
C) Cystitis
The definition of primary hypertension is:
A) Elevated blood pressure associated primarily with renal failure.
B) Elevated blood pressure without identifiable causes.
C) Elevated blood pressure associated with identifiable causes.
D) Elevated blood pressure not connected with genetic traits.
B) Elevated blood pressure without identifiable causes.
A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include?
A) Perform vigorous exercise when blood glucose is less than 100 mg/dL.
B) Do not exercise if ketones are present in your urine
C) Avoid eating for 2 hr before exercise.
D) Examine your feet weekly.
B) Do not exercise if ketones are present in your urine
Which patient characteristic enhances learning outcomes?
A) Laughing about current health problems
B) Feeling moderate anxiety
C) Being in the precontemplation stage of change
D) Developing high self-efficacy
D) Developing high self-efficacy
Changing behaviors to make changes long term
The nurse is caring for a client diagnosed with acute otitis media. Which sign/symptoms MOST supports this medical diagnosis?
A) Green, foul smelling drainage
B) Otalgia to left ear
C) Sensations of congestion in ear
D) Reports to hearing loss
B) Otalgia to left ear
A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching?
A) "Pyelonephritis increases a pregnant woman’s risk for preterm labor."
B) "Pyelonephritis is most often caused by Staphylococcus saprophyticus."
C) "Pyelonephritis is an infection of the lower urinary tract."
D) "Pyelonephritis often causes no symptoms in affected clients."
A) "Pyelonephritis increases a pregnant woman’s risk for preterm labor."
A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?
A) Obstructive Sleep Apnea (OSA)
B) Elevated High-Density lipoprotein (HDL) levels
C) Taking lisinopril
D) A diet high in potassium
A) Obstructive Sleep Apnea (OSA)
Hypoxemia causes systemic inflammation and stress on the body which overtime, will elevate blood pressure.
A client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates adequate understanding of the peak action of NPH insulin and exercise?
A) "The best time for me to exercise is after breakfast"
B) "I should not exercise since I am taking insulin"
C) "The best time for me to exercise is mid- to late afternoon"
D) "NPH is a basal insulin, so I should exercise in the evening"
A) "The best time for me to exercise is after breakfast"