Renal/Urinary
Endocrine
Cardiac
Neuro
Pharmacology
100
The client with continuous ambulatory peritoneal dialysis (CAPD) has cloudy dialysate. Which of the following is the best initial nursing action?
a) send fluid to the laboratory for culture
b) administer antibiotic
c) do nothing, this is expected
d) stop drainage of fluid
What is a) send fluid to the laboratory for culture
-Cloudy dialysate indicates infection (peritonitis). A culture of the fluid must be taken prior to initiating antibiotic treatments in order to determine the microorganism present to guide treatment.
100
A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect?
a. Dysuria
b. Leg cramps
c. Tachycardia
d. Blurred vision
What is c) tachycardia.
-Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine.
100
A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?
a. Heart rate that speeds up and slows down
b. Friction rub at the left lower sternal border
c. Presence of a regular gallop rhythm
d. Coarse crackles in bilateral lung bases
What is b) Friction rub at the left lower sternal border.
-The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.
100
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?
a. Electrocardiogram (ECG)
b. Complete blood count (CBC)
c. Chest radiograph (Chest x-ray)
d. Noncontrast computed tomography (CT) scan
What is d) Noncontrast computed tomography (CT) scan
-Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
100
A new order for IV gentamicin 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient's
a. blood glucose.
b. serum potassium.
c. BUN and creatinine.
d. urine osmolality.
What is c) BUN and creatinine.
-When a patient at risk for CKD receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin.
200
A nurse is developing a plan of care for a client with nephrotic syndrome. The nurse documents that which important parameter needs to be assessed on a daily basis?
a) total protein levels
b) weight
c) blood urea nitrogen (BUN)
d) activity tolerance
What is b) weight
-The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels and BUN/Creatinine are monitored, but not necessarily daily. Additionally, the client's activity level is adjusted according to the amount of edema and water retention.
200
Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
a. Diabetic ketoacidosis
b. Thyroid crisis
c. Hypoglycemia
d. Tetany
What is b) thyroid crisis.
-Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.
200
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond?
a. The prosthetic valve places you at greater risk for a heart attack.
b. Blood clots form more easily in artificial replacement valves.
c. The vein taken from your leg reduces circulation in the leg.
d. The surgery left a lot of small clots in your heart and lungs.
What is b) Blood clots form more easily in artificial replacement valves.
-Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.
200
The nurse provides dietary instructions to the in-home caregiver of a 45-year-old man who has Huntington's disease. The nurse is most concerned if the caregiver makes which statement?
A. "Depression is common and may cause a decrease in appetite."
B. "If swallowing becomes difficult, a feeding tube may be needed."
C. "Calories should be restricted to prevent unnecessary weight gain."
D. "Muscles in the face are affected, and chewing may become impossible."
What is c) "Calories should be restricted to prevent unnecessary weight gain."
-Patients with Huntington's disease may require 4000 to 5000 calories per day to maintain body weight. Weight loss occurs in patients with Huntington's disease because of choreic movements, difficulty swallowing, depression, and mental deterioration.
200
A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
A. Treat thyroid storm.
B. Prevent cardiac irritability.
C. Treat hypocalcemic tetany.
D. Stimulate the release of parathyroid hormone.
What is C) Treat hypocalcemic tetany
-Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes or muscle spasms or twitching, the health care provider is notified immediately. Calcium gluconate should be kept at the bedside.
300
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?
a) Dehydration
b) Crackles
c) Hypertension
d) Hyperkalemia
What is a) dehydration.
-The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.
300
A client presents with hypocalcemia, hyperphosphatemia, muscle cramps, and positive Trosseau's sign. What diagnosis does this support?
Answers:
A. Diabetes insipidus
B. Conn's syndrome
C. Hypoparathyroidism
D. Acromegaly
What is c) hypoparathyroidism.
- Hypoparathyroidism often leads to low calcium levels and high phosphorous levels. Muscle cramps and Trousseau's sign are indicative of hypocalcemia.
300
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Fatigue
c. Speech alterations
d. Dyspnea with activity
What is c) Speech alterations.
-Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
300
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided reflexes
d. Difficulty in understanding commands
What is d) Difficulty in understanding commands
-Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
300
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
a. Initiate oxygen therapy.
b. Hold the next dose of Imdur.
c. Instruct the client to drink water.
d. Administer PRN acetaminophen.
What is d) Administer PRN acetaminophen.
-The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The clients headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.
400
A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous (AV) fistula. Which assessment finding would indicate to the nurse that the fistula is patent?
a) white fibrin specks noted in the fistula
b) lack of bruit over the site of the fistula
c) palpation of a thrill over the site of the fistula
d) a feeling of warmth at the site of the fistula
What is c) palpation of a thrill over the site of the fistula
-An internal AV fistula is created through a surgical procedure in which an artery in the arm is anastomosed to a vein. To assess patency, the nurse palpates over the fistula and auscultates for a bruit.
400
A 58 yo with type 2 diabetes was admitted to your unit with a dX of COPD exacerbation. When you prepare a plan of care for this pt, what would you be sure to include? Select all that apply.
a) fingerstick blood glucose checks before meals and at bedtime
b) sliding-scale insulin dosing as ordered
c) bed rest until the COPD exacerbation is resolved
d) demonstration of the components of foot care
What are A, B, and D.
-When a diabetic patient is ill, glucose levels become elevated, and administration of insulin may be necessary. Teaching or reviewing the components of proper foot care is always a good idea with a diabetic pt. Bed rest is not necessary, and glucose level may be better controlled when a patient is more active.
400
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability
What is c) Level of consciousness
-A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.
400
A client has dysfunction of cranial nerve VIII. The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?
a.) Hot pack for facial pain
b.) Eyeglasses
c.) A hearing aid
d.) A bath thermometer
What is c) A hearing aid.
-Cranial nerve VIII is the vestibulocochlear nerve. Dysfunction of this nerve could result in hearing difficulties.
400
The nurse giving discharge teaching for a client receiving carbamazepine (Tegretol) should include:
a.) Monitor blood glucose, and report decreased levels.
b.) Expect a discoloration of the contact lenses.
c.) Report unusual bleeding or bruises to the health care provider immediately.
d.) Expect an orange discoloration of urine.
What is c) Report unusual bleeding or bruises to the health care provider immediately.
-Carbamazepine affects vitamin K metabolism, and can lead to blood dyscraisias and bleeding. It does not significantly lower blood sugar or change the color of body fluids.
500
A client with nephrolithiasis arrives at a clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. The nurse tells the client to avoid consuming which food item?
a) lentils
b) strawberries
c) lettuce
d) pasta
What is b) strawberries
-Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea.
500
A client with Addison's disease makes all of the following statements. Which one does the nurse analyze as requiring further discussion?
a) "I wear a Medic-Alert bracelet at all times"
b) "I need to weigh myself daily and record it"
c) "It is important that I drink enough fluids and increase my salt intake"
d) "My medication doses will not need to be adjusted for any reason"
What is D) "My medication doses will not need to be adjusted for any reason"
-The client with Addison's disease is experiencing deficits of mineralocorticoids, glucocorticoids, and androgens. Aldosterone deficiency affects the ability of the nephrons to conserve sodium, so the client experiences sodium and fluid volume deficit. The client needs to manage this problem with daily hormone replacement and increased fluid and sodium intake. Clients are instructed to weigh themselves daily as a means of monitoring fluid volume balance. Additional doses of hormone replacement therapy are needed with any type of physical or psychological stressor. This information needs to be conveyed to the client and requires that the client wear a Medic-Alert bracelet so that health care professionals are aware of this problem if the client were to experience a medical emergency.
500
What condition would lead to the following ECG reading?
What is Hyperkalemia.
-Hyperkalemia can result in peaked T-waves due to the excess potassium affecting the ability of the ventricles to relax.
500
The post-head injury client opens eyes to sound, has no verbal response and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score?
A. GCS= 3
B. GCS= 6
C. GCS= 9
D. GCS= 11
What is c) GCS = 9
-Score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response the score is a 1. The total score is then equal to 9.
500
Cyclobenzaprine (Flexeril) is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which of the following disorders, if noted in the client's record, would indicate a need to contact the health care provider regarding the administration of this medication?
A. Glaucoma
B. Emphysema
C. Hyperthyroidism
D. Diabetes mellitus
What is A) Glaucoma.
-Because this medication has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. Cyclobenzaprine hydrochloride should be used only for short-term 2- to 3-week therapy.