Competency 10
A patient with asthma is experiencing respiratory difficulty, expiratory wheezing, coughing, and diaphoresis. The Nurse Practitioner orders a nebulization treatment with albuterol. Which of the following best describes the purpose of giving this medication?
A. To increase muscle tone in the bronchial passages
B. To provide long-acting relief of symptoms
C. To decrease the bronchial inflammation
D. To relax the bronchial smooth muscles
ANSWER
D:
After completing the physical assessment of a patient with heart failure, the nurse concludes that the client has progressed into right-sided failure based on which of the following findings?
A. Consistent weight loss on a daily basis
B. Jugular vein distention
C. Weak peripheral pulses
D. Oliguria during the day
B. Jugular vein distention
The nurse is providing disease management education to a patient with Raynaud’s disease. What should be included in the health teaching regarding this disease?
a. “Apply cold compress when you have symptoms.”
b. “Wear warm clothing when exposed to cool temperatures.”
c. “Avoid placing alcohol-based lotion on affected extremities.”
d. “Check the strength of pulses in your arms and legs daily.”
b. “Wear warm clothing when exposed to cool temperatures.”
Answer
The nurse reviews the following lab results in the client's chart. Which of the following are out of normal range, and need to be reported to the health care provider? (Select all that apply)
A. Phosphorus 3.2 md/dl
B. Magnesium 3.8 mEq/L
C. Calcium 9.5 mg/dl
D. Potassium 6.2 mEq/L
E. Sodium 136 mEq/L
B. Magnesium 3.8 mEq/LD.
D. Potassium 6.2 mEq/L
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, “The stool in my pouch is still liquid.” How would the nurse respond?
A. “The stool will always be liquid with this type of colostomy.”
B. “Eating additional fiber will bulk up your stool and decrease diarrhea.”
C. “Your stool will become firmer over the next couple of weeks.”
D. “This is abnormal. I will contact your health care provider.”
A. “The stool will always be liquid with this type of colostomy.”
A nurse assesses a client with irritable bowel syndrome (IBS). Which question would the nurse include in this client’s assessment?
A. “Which food types cause an exacerbation of symptoms?”
B.“Have you lost a significant amount of weight lately?”
C. “Are your stools soft, watery, and black in color?”
D. “Do you feel hungry all the time?”
A. “Which food types cause an exacerbation of B. symptoms?”
The nurse is caring for a client with heart failure. Which of the following statements made by the client with heart failure most clearly represents a key feature in the progression of that disease?
A. " I have a hard time getting ready in the morning, I get short of breath so quickly "
B. "The upper number in my blood pressure ranges between 110 to 130."
C. " I don't have much of an appetite recently, I think I have lost about 2 pounds "
D. " I can walk up to three blocks every morning without feeling weak or tired."
A. " I have a hard time getting ready in the morning, I get short of breath so quickly "
The nurse administers pentoxifylline(Trental) to a patient with peripheral arterial disease. Which of the following is a therapeutic effect that the nurse would expect from this drug therapy?
A. Decreased edema and inflammation in the affected extremity
B. Decreased pain and improved walking endurance
C. Improvement in ankle discoloration and decreased swelling of veins
C. Reduced inflammation and improved venous return
B. Decreased pain and improved walking endurance
Answer
The nurse is assessing a client with a stage 2 pressure ulcer. Which assessment finding(s) would be important for the nurse to report? Select all that apply.
A. WBC 6000 mm3
B. Temperature 102 F
C. purulent drainage
D. pain unrelieved by analgesic
E. hemoglobin 15 grams/dl
B. Temperature 102 F
C. purulent drainage
D. pain unrelieved by analgesic
Recognizing the risk for urolithiasis in the immobilized client, the nurse appropriately plans to include which of the following in the plan of care?
A. Increase fluid intake to 3000mL per day.
B. Administer a daily calcium supplement.
C. Maintain an indwelling urinary catheter.
D. Regularly monitor the urine pH.
A. Increase fluid intake to 3000mL per day.
Answer
A 74-year-old client admitted with COPD has daily labs drawn each morning. Her most recent ABG results are pH 7.20, paCO2 59, paHC03 24, paO2 85. The nurse knows that this probably resulted from which of the following?
A. Increased excretion of bicarbonate
B. Increased retention of bicarbonate
C. Increased retention of carbon dioxide
D. Increased excretion of carbon dioxide
C.Increased retention of carbon dioxide
When caring for a patient with heart failure, the nurse expects manifestations of which early compensatory mechanism to improve cardiac output?
A. Urine specific gravity would decrease
B. Arterial pressure would decrease
C. Heart rate would increase
D. Cardiac enzymes would decrease
C. Heart rate would increase
The nurse is providing care for a patient with venous insufficiency. Which medical-surgical concept has priority with this patient?
A. Tissue perfusion
B. Body image
C. fluid and electrolyte imbalance
D. knowledge deficit
A. Tissue perfusion
The nurse in the intensive care unit receives arterial blood gases (ABG) of a client complaining of shortness of breath. The ABG has the following values:
pH = 7.30, PaCO2 = 58 mm Hg, HCO3 = 23 mm Hg. What do these values reflect?
A. respiratory alkalosis
B. respiratory acidosis
C. metabolic acidosis
D. metabolic alkalosis
B. respiratory acidosis
AnsweA client with a kidney stone reported severe cramping pain on the left side that radiates to the groin after being admitted to the ER four hours ago. What is the priority nursing action?
A. Administer the prescribed narcotic analgesic.
B. Strain all urine for stone analysis.
C. Notify the health care provider immediately.
D. Obtain a bladder scan to check for residual urine.
A. Administer the prescribed narcotic analgesic.
The patient is taking fluticasone/salmeterol (Advair Diskus) 250/50. Which of the following would the nurse teach the patient about this medication?
a. Is a combination of steroid and long-acting beta 2 adrenergic agonist medication
b. Is a short-acting beta 2 adrenergic agonist medication
c. Used for emergency treatment for asthma
d. May lower the heart rate and blood pressure
a. Is a combination of steroid and long-acting beta 2 adrenergic agonist medication
Answer
The nurse is taking the history of a patient who is displaying signs and symptoms of early heart failure. Which illness in the patient's history would alert the nurse to the possibility of damaged heart valves as the possible cause of the heart failure?
A. Recent asthma episode
B. Emphysema relate to smoking
C. Rheumatic fever in childhood
D.Recurrent viral pneumonia
C. Rheumatic fever in childhood
The nurse is assessing the effects of patient teaching with a patient who has peripheral arterial disease (PAD). Which statement suggests that the patient needs additional education about self-care related to PAD?
A. It's fine to sleep with my affected leg hanging from the bed.
B. I should keep my legs elevated above the level of my heart.
C. It's fine to sit up in a recliner with my legs extended straight out.
D. I should avoid crossing my legs and standing up for long period.
B. I should keep my legs elevated above the level of my heart.
Answer
The client who is having a second unit of blood transfusion verbalized difficulty in breathing. The client's blood pressure has increased from 120/80 to 160/100 and respiratory rate increased from 14 to 25. What will be the priority nursing actions?
A. Stop the infusion and change the unit of blood.
B. Stop the infusion and place the patient in upright position with feet dependent.
C. Stop the infusion and administer prescribed antihistamine.
D. Stop the infusion and collect urine and blood specimen for culture.
B. Stop the infusion and place the patient in an upright position with feet dependent.
A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking, it is most important for the nurse to ask the client which the following question?
A. " Do you have a gastric ulcer. "
B. "Have you been told you are at risk for blood clots."
C. " Do you suffer from left-sided heart failure."
D. "Did you have a sore throat recently. "
D. "Did you have a sore throat recently. "
The nurse is receiving a report on a client who had a stroke. The outgoing nurse states, “Keep your eye on them, they keep trying to get up out of the bed and making really poor, impulsive decisions.” The receiving nurse recognizes this as what kind of stroke?
A. Right hemisphere
B. Left hemisphere
C. Frontal lobe
D. Occipital lobe
The answer A
Right hemisphere: This client had a stroke in the right hemisphere of the brain because impulsivity, poor safety awareness, and impaired judgment are conducive to right-sided injury. Left-sided injury tends to have more language comprehension, facts, and logical reasoning deficits.
The nurse is caring for a client with congestive heart failure. Which of the following interventions will help reduce afterload?
A. Administer medication to increase vasoconstriction
B. Decrease supplemental oxygen delivery.
C. Restrict client's activity while in the hospital.
D. Administer prescribed Enalapril.
D. Administer prescribed Enalapril.
A patient is diagnosed with a peripheral arterial ulcer on the right big toe. What other characteristics and clinical manifestations should the nurse observe on the client with peripheral arterial ulcer? Select all that apply.
A. cold foot
B. decreased or absent pulses
C. possible gangrene
D. ankle discoloration and edema
E. claudication and rest pain are usually present
A. cold foot
B. decreased or absent pulses
C. possible gangrene
E. claudication and rest pain are usually present
The client's ABG results are
pH 7.30
PaCO2 44
HCO3 18
PaO2 81
The nurse accurately interprets these values as what?
A. Respiratory acidosis
B. Respiratory alkalosis
C.Metabolic acidosis
D. Metabolic alkalosis
C.Metabolic acidosis
A. nurse assesses a patient who presents with renal calculi. Which question would the nurse ask?
A. “Do any of your family members have this problem?”
B. “Do you drink any cranberry juice?”
C. “Do you urinate after sexual intercourse?”
D. “Do you experience burning with urination?”
A. nurse assesses a patient who presents with renal calculi. Which question would the nurse ask?