1- What acid-base imbalance would a nurse expect to find in a patient with Myastenia Gravis
crisis and decreased pulmonary forced vital capacity?
Select
... [Show More] one:
a. pH 7.26, pO2 86 mmHg, p CO2 44 mmHg, HCO3 10 mEq/L
b. pH 7.31, pO2 97 mmHg, p CO2 30 mmHg, HCO3 19 mEq/L
d. pH 7.47, pO2 96 mmHg, p CO2 33 mmHg, HCO3 22 mEq/L
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Acute respiratory acidosis
The correct answer is: pH 7.32, pO2 80 mmHg, p CO2 60 mmHg, HCO3 24 mEq/L
2- A previously healthy older client's morning urine is amber, with strong odor, and specific
gravity 1.040. Which action by the nurse is best?
Select one:
a. Place the client on restricted dietary proteins.
b. Review the client's creatinine level.
c. Obtain an order for urine culture and sensitivity.
Feedback
Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with
dehydration, decreased kidney blood flow (often because of dehydration), and the presence of
antidiuretic hormone (ADH). Increasing the client's fluid intake would be a beneficial
intervention. The other interventions are not warranted.
The correct answer is: Increase the client's fluid intake.
3- The nurse working in an endocrinology service has assigned four clients. Which client should
the nurse see first?c. Type 1 diabetic client who has positive ++ ketones in urine
a. Enforce standard precautions and updated vaccinations.
Select one:
a. Type 1diabetic client who is noncompliant with her diet and has proteinuria
b. Type 2 diabetic client who presents with a hemoglobin A1c 12.8 %
d. Type 2 diabetic client whose capillary glucose immediately after lunch is 65 mg/dL
Feedback
Presence of ketone bodies in urine in type 1 diabetes means the client is developing a diabetic
ketoacidosis and is the absolute priority of these four clients.
The correct answer is: Type 1 diabetic client who has positive ++ ketones in urine
4- Which of the following measures is most important for the nurse to institute for a client who
has Cushing's disease?
Select one:
b. Assist the client to stand up changing positions slowly.
c. Pad the siderails of the client's bed with pillows.
d. Keep suctioning equipment at the client's bedside.
Feedback
Cushing's syndrome or disease greatly increases the serum levels of cortisol, which contributes
to immune suppression, hyperglycemia, hypertension, fluid retention, and excessive bone
demineralization and increases the risk for pathologic bone fracture. The client should not
require suctioning, padding the siderails or assisting the client to change position because
orthostatic hypotension. Risk for infection and its prevention is a priority.
The correct answer is: Enforce standard precautions and updated vaccinations.
5- A male client with Parkinson's disease is newly diagnosed with benign prostatic hypertrophy.
When reviewing the client's medication history, which medication is most likely to exacerbate
his urologic symptoms?
Select one:
a. Bromocriptine, a dopamine receptor agonist.a. Increased urination at night
b. Encourage 3000 to 4000 mL of oral fluids daily.
c. Levodopa, an antiparkinsonian agent.
d. Selegiline, a mono amino oxidase B inhibitor.
Feedback
ANS: A
Cogentin (A) is an anticholinergic drug. One of its side effects is urinary retention which could
be problematic for a client with benign prostatic hypertrophy. (B, C, and D) are all
appropriate drugs for the treatment of Parkinson's disease.
The correct answer is: Benztropine, an anticholinergic.
6- A client with a 16-year history of hypertension is having renal function tests because of
recent fatigue, weakness, lightly elevated blood urea nitrogen and serum creatinine levels.
Which finding should the nurse conclude as an early symptom of renal insufficiency?
Select one:
b. Uremic frost
c. Confusion and disorientation
d. Edema and lung crackles
Feedback
The capacity of concentration of urine is one of the first renal functions to be lost in the development of
renal insufficiency. Normally the urine is concentrated during the sleep hours, being nocturia an early
manifestation of the loss of this function.
The correct answer is: Increased urination at night
7- A patient with primary hyperparathyroidism has a serum calcium level of 14 mg/dL and a
phosphorus of 1.7 mg/dL. Which nursing action should be included in the plan of care?
Select one:
a. Monitor for positive Chvostek's sign.
c. Have a tracheostomy kit available.
d. Encourage the patient to remain on bed rest.
b. Benztropine, an anticholinergic.b. Dizziness when rising from a sitting position.
a. head of bed elevated 30 degrees; head and neck in midline position
Feedback
The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high
fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are
appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to
decrease calcium loss from bone.
The correct answer is: Encourage 3000 to 4000 mL of oral fluids daily.
8- Which assessment finding has the highest priority when assessing and planning nursing care
for a client recently admitted with a peptic ulcer disease (PUD) with risk of bleeding?
Select one:
a. Very dark color stools.
c. Hemoglobin 10 g/dL, hematocrit 29%.
d. Epigastric pain two hours after eating.
Feedback
Active bleeding and hypovolemia are priorities in patients with PUD. The presence of dizziness with
changes of position suggests orthostatic hypotension and hypovolemia secondary to actual bleeding.
Dark tarry stools mean the presence of digested blood in the stools, but not necessarily implies present
active bleeding or hypovolemia.
The correct answer is: Dizziness when rising from a sitting position.
9- The nurse is caring for a patient who has returned from the operating room having
undergone a supratentorial craniotomy. The nurse, knowing that brain surgery produces brain
swelling, should position the patient in which of the following positions?
Select one:
b. supine with bed flat; head and neck in neutral midline position
c. head of bed elevated 45 degrees; legs elevated to prevent DVT
d. head of bed elevated 30 degrees; head turned toward non-operative sideb. Prolonged prothrombin time and INR
d. Hyperammonemia
e. Hypoglycemia
f. Hyperbilirubinemia
a. Corn flakes
Feedback
Head of bed elevated with neck in neutral position to facilitate venous drainage
The correct answer is: head of bed elevated 30 degrees; head and neck in midline position
10- A client is diagnosed with liver cirrhosis. Which laboratory alterations does the nurse expect
to find? Select all that apply
Select one or more:
a. Elevated blood urea nitrogen and creatinine
c. Hyperalbuminemia
Feedback
Liver detoxificates ammonia and bilirubin, store glucose as glycogen, and synthetize prothrombin and
albumin. Hyperammonemia, hypoalbuminemia, hyperbilirubinemia, hypoglycemia and prolonged
coagulation times are expected findings in cirrhosis
The correct answers are: Hyperammonemia, Hyperbilirubinemia, Prolonged prothrombin time
and INR, Hypoglycemia
11- A nurse provides dietary instructions to the mother of a child with celiac disease. Which of
the following foods does the nurse tell the mother to include in the child's breakfast?
Select one:
b. Oatmeal biscuits
c. Rye crackers
d. Wheat cereald. Twelve bloody liquid stools a day.
d. Ensure that all enrolled children have been immunized for hepatitis A
Feedback
Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, and
oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements,
especially fat-soluble vitamins and folate may be needed in the early period of treatment to
correct deficiencies. Dietary restrictions are likely to be lifelong, although small amounts of
grains may be tolerated after the ulcerations have healed.
The correct answer is: Corn flakes
12- The client is diagnosed with ulcerative colitis. When assessing this client, which
sign/symptom would the nurse expect to find?
Select one:
a. Hard, rigid abdomen.
b. Oral temperature of 102 F.
c. Urinary stress incontinence.
Feedback
The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea.
Ten (10) to twenty bloody diarrhea stools is the most common symptom of ulcerative
colitis.
The correct answer is: Twelve bloody liquid stools a day.
13- Which is the most important intervention should the school nurse implement to decrease
the incidence of hepatitis A in a preschool setting?
Select one:
a. Teach children the correct handwashing technique to use after toileting
b. Promote hygiene by ensuring that children's faces and hair are kept clean.
c. Put a strip bandage on bleeding injuries to prevent contamination of othersd. Determine the capillary blood glucose level.
c. Grapes and peaches
Feedback
The CDC recommended immunization schedule for children includes the hepatitis A vaccine
(HAV), so follow-up of enrolled children's immunization status with HAV or human-immune
gamma globulin should be implemented (B). Preschoolers should be taught the importance of
hygiene practices, such as (A and D), but hepatitis A is transmitted via the fecal-oral route and
immunization provides the best universal protection. Hepatitis A is not transmitted through
blood contact (C).
The correct answer is: Ensure that all enrolled children have been immunized for hepatitis A
14- The 56-year-old male client received 10 units of Humulin R, a fast-acting insulin, at 0700. At
1030 the unlicensed nursing assistant tells the nurse the client has a headache, the skin is wet
and cold, and is acting "funny." Which action should the nurse implement first?
Select one:
a. Practice a dipstick for ketones in urine.
b. Administer a glass of orange juice and reevaluate in 15 minutes.
c. Prepare to administer one amp 50% Dextrose intravenously.
Feedback
Regular insulin peaks in 2-4 hours. Therefore, the nurse should think about the
possibility that the client is having a hypoglycemic reaction and should assess the
client. The nurse should not delegate nursing tasks to an assistant if the client is unstable.
The correct answer is: Determine the capillary blood glucose level.
15- A client has end-stage kidney disease (ESKD). Which food selection by the client
demonstrates understanding of a low-sodium, low-potassium diet?
Select one:
a. Baked potatoes without salt
b. Vegetable soup
d. Organic sliced turkey cold cutd. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 99 mm Hg
c. No symptoms exist
Feedback
Some fruits like apples and pears have low potassium content. Potatoes are high in potassium.
Soups are high in sodium. Many salt substitutes contain potassium chloride and should not be
used.
The correct answer is: Grapes and peaches
16- A nurse assesses a client who has type 1 diabetes mellitus. Wh
67- A client with type 2 diabetes has a serum creatinine of 2.9 mg/dL. The nurse correlates
which urinalysis finding with the diagnosis of diabetic nephropathy in this client?
Select one:
a. White blood cells in the urine during a random urinalysis
b. Increased leukocytes and presence of bacteriab. "I should increase my intake of proteins and eliminate carbohydrates from my diet."
b. Difficulty in handwriting.
d. Ketone bodies in the urine during ketoacidosis
Feedback
Urine should not contain protein. The presence of proteinuria in a diabetic client marks the
beginning of kidney problems known as diabetic nephropathy, which progresses eventually to
end-stage kidney disease. Decline in kidney function is assessed with serum creatinine. This
client's creatinine level is high. The other findings would not be correlated with declining kidney
function.
The correct answer is: Albumin in the urine during a random urinalysis
68- After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse
assesses the client's understanding. Which statement made by the client indicates a need for
additional teaching?
Select one:
a. "My intake of saturated fats should be no more than 10% of my total calorie intake."
c. "I should increase my intake of vegetables with higher amounts of dietary fiber."
d. "My intake of water is not restricted by my treatment plan or medication regimen."
Feedback
The client should not completely eliminate carbohydrates from the diet and should reduce
protein if microalbuminuria is present. The client should increase dietary intake of complex
carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be
restricted unless kidney failure is present.
The correct answer is: "I should increase my intake of proteins and eliminate carbohydrates from
my diet."
69- The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic
encephalopathy. Which finding should the nurse consider an indication of progressive hepatic
encephalopathy?
Select one:
a. Increased level of blood urea nitrogen (BUN).b. Administer a tissue plasmin activator ( r-TPA) drug, like alteplase.
c. An increase in abdominal girth.
d. Hypertension and a bounding pulse.
Feedback
In advanced cirrhosis the liver is unable to metabolize the blood ammonia into urea (BUN). The
elevation of the ammonia is associated with hepatic encephalopathy. An early sign of this condition is a
characteristic tremor called asterixis or flapping tremor. This alteration of the fine movement translates
in difficulty in handwriting, easy to demonstrate comparing the patient's writing before and after the
development of the hepatic encephalopathy. The increase in abdominal girth is related to portal
hypertension. Systemic hypertension is not a direct consequence of hepatic cirrhosis.
The correct answer is: Difficulty in handwriting.
70- While assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis
today, the nurse notes the absence of a thrill and bruit at the shunt site, suspecting thrombosis
of the fistula. What action should the nurse anticipate the provider would take to reestablish
the fistula patency?
Select one:
a. Advise the client that the pressure of the dialysis will reopen the fistula.
c. Flush the fistula with a heparinized saline solution.
d. Order a daily dose of warfarin until bruit and thrill reappear.
Feedback
Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify
the health care provider so that intervention can be initiated to restore function of the shunt.
An AV shunt is internal and cannot be flushed and heparin doesn't dissolve already formed
clots. The thrombolytic therapy can reestablish patency of the obstructed fistula.
The correct answer is: Administer a tissue plasmin activator ( r-TPA) drug, like alteplase.
71- The client has been diagnosed with Cushing's syndrome. The nurse would monitor this
client for which of the following expected signs of this disorder? Select all that apply.
Select one or more:
a. Anorexiad. Truncal obesity
f. Moon face
c. Leave the room and re-approach the client in about 30 minutes.
c. Weight loss
e. Hyperkalemia
Feedback
Rationale: The client with Cushing's syndrome may exhibit a number of different manifestations.
These could include moon facies, truncal obesity, and a "buffalo hump" fat pad. Other signs
include hypokalemia, peripheral edema, hypertension, increased appetite, and weight gain.
Dizziness is not part of the clinical picture for this disorder.
The correct answers are: Hypertension, Moon face, Truncal obesity
72- A male client with moderate Alzheimer's disease had abdominal surgery yesterday. Today,
when the nurse begins to perform a dressing change, the client states, "I don't want you to
change my dressing." What is the best initial action for the nurse to take?
Select one:
a. Do not change the dressing and note "refused" in the client's medical record.
b. Explain the importance of dressing change and proceed with the procedure.
d. Ask another nurse, who had the client before, to do the dressing change.
Feedback
The nurse shouldn't pass the assignment to another nurse. It is probable that the client forgets the initial
refusal and allows the care after a while
The correct answer is: Leave the room and re-approach the client in about 30 minutes.
73- A nurse assesses a male client with a spinal cord injury at level T5 because the client is not
feeling well while he was transferred in wheelchair for a chest x-ray. The client's blood pressure
is 194/95 mm Hg, heart rate 59 beats/min, and the client presents with a headache, nasal
congestion, flushed face and blurred vision. Which action should the nurse take first?
Select one:
b. Hypertensiond. Palpate the bladder for distention.
a. Apical pulse regular at 70 beats/minute.
c. Vitamin B12, intramuscular
a. Administer a dose of atropine IV.
b. Initiate oxygen via a nasal cannula.
c. Place the client in left lateral and Trendelenburg position.
Feedback
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder
distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the
client could experience neurologic injury. Precipitating conditions should be eliminated, and the
physician notified. The other actions would not be appropriate.
The correct answer is: Palpate the bladder for distention.
74- A client is receiving the medication propylthiouracil (PTU). Which assessment finding
indicates to the nurse that the medication is effective?
Select one:
b. The blood level of TSH has decreased
c. Client improves cold tolerance.
d. White blood cell count is 4,500 cells/mm3.
Feedback
The medication is effective when an euthyroid state is achieved, which includes a return of
vital signs to within normal parameters.
The correct answer is: Apical pulse regular at 70 beats/minute.
75- A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has
normal hematologic parameters. Which supplement should the nurse explain to the client is
indicated for lifetime to prevent complications?
Select one:
a. Vitamin B6, intramuscular
b. Intrinsic factor, oral with each meald. Vitamin B12, oral
Feedback
The gastric mucosa secretes the intrinsic factor which is required for the absorption of the
extrinsic factor (Vitamin B12) that is used in the maturation and release of erythrocytes from
the bone marrow. Following gastrectomy, a client should be prepared to take a maintenance
dose of an injectable Vitamin B12 (D) for the rest of his life to prevent pernicious anemia. The
intrinsic factor is not available to prevent iatrogenic-induced complications related to surgery.
The correct answer is: Vitamin B12, intramuscular [Show Less]