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Test 3
| Question | Answer |
|---|---|
| 1)Teaching for the client with rheumatoid arthritis who is taking methotrexate (Rheumatrex) includes: | a.Never stop methotrexate abruptly. b.Have eye exams every 6-12 months. c.Monitor liver function tests every 6 months. d.Monitor blood sugars on a regular basis. |
| 2)On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take? | a.Explain the reasons for the phantom limb pain. b.Administer prescribed analgesics to relieve the pain. c.Loosen the compression bandage to decrease incisional pressure. d.Remind the patient that this phantom pain will diminish over time. |
| 3)The nurse is caring for a patient who has received an overdose of heparin. The nurse is prepared to administer: | a.Vitamin K b.Protamine sulfate c.2 units of packed red blood cells d.Lactated ringers |
| 4)When caring for a patient with an indwelling catheter, the nurse should: | a.Irrigate the catheter every shift to ensure patency b.Label the catheter with the date it was inserted. c.Ensure the tubing is secured to the patient d.Hang the collection bag on the side rail of the bed |
| 5)A client in diabetic ketoacidosis (DKA) is receiving an IV continuous insulin infusion (insulin drip). Which of the following orders would the nurse anticipate when the blood glucose levels drops to 250 mg/dl? | a.Glargine (Lantus) insulin b.5% dextrose 0.45% normal saline c.Injection of glucagon d.Diet order for clear liquids |
| 6)Prior to performing an electrocardiogram (ECG), which direction is important for the nurse to give the client? | a.You cannot eat or drink before the procedure. b.You must lie as still as possible during the procedure. c.You are likely to feel warmth as the dye enters the heart. d.Increase you fluid intake to at least 3L on the day of the test. |
| 7)The home care nurse teaches a client with autonomic Gastroparesis, that this condition increases risk for: | a.Hypoproteinemia b.Hyperglycemia c.Hyperosmolarity d.Hypoglycemia |
| 8)The nurse is teaching a client with rheumatoid arthritis who will be taking 20 mg of prednisone daily. Which following statement made by the client indicates the need for further teaching? | a.My blood sugar will need to be monitored while I am taking prednisone. b.Susceptible to infections while I am taking this drug. c.Take prednisone on an empty stomach: increase absorption. d.Never stop the drug abruptly; must be gradually tapered down |
| 9)The nurse is teaching the client newly diagnosed with type 1 diabetes about sick day rules. The nurse instructs the client: | a.To increase the frequency of blood glucose testing. b.To reduce his carbohydrate intake to diminish nausea. c.To hold his insulin dose if he cannot eat his usual foods. d.To take half his scheduled insulin dose when ill. |
| 10) To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What should the nurse do next? | a.Clamp the tube to create a fixed sample section for retrieval. b.Insert a 5 mL syringe into the injection port; aspirate the amount of urine required. c.Clean injection port cap with antiseptic solution. d.Request assistance from the heal care provid |
| 11)The client who has experienced a stroke has impairment of the cranial nerve IX. What nursing intervention should you implement to prevent complications from this problem? | a.Turn the client’s plate around halfway through the meal. b.Position the client in the high Fowler’s position during meals. c.Order a clear liquid diet for the client. d.Weigh the client twice weekly. |
| 12)The nurse knows that teaching for ibandronate sodium (Boniva) has been effective when the client states, “I will take this medication…. | a.at the same time every week.” b.30 minutes before I eat or drink.” c.60 minutes before I eat or drink.” d.right before I go to sleep.” |
| 13)The client who has had a stroke combs her hair only on the right side of her head and washes only the right side of her face. What is the nurse’s interpretation of these actions? | a.The client has poor left-sided motor control. b.The client has paralysis or contractures on the left side. c.The client’s visual perception of the left field is limited. d.The client is unaware of the existence of her left side. |
| 14)The client’s chest tube is accidentally dislodged. What should the nurse do? | a.No action is necessary since the area will reseal itself. b.Cover the insertion site with sterile occlusive gauze. c.Obtain a suture kit and prepare for the physician to suture the site. d.Reinsert the chest tube, using sterile technique. |
| 15)Which of the following clients with an extremity fracture should the nurse see first? A client: | a.who is complaining of extremity pain of 6 on a 1-10 scale. b.who complains of numbness in the affected extremity. c.whose affected extremity is red. d.who has +1 edema of the affected extremity. |
| 16)The nurse monitors for which clinical manifestation in the client who has experienced a stroke resulting in damage in Wernicke’s area? | a.Inability to comprehend spoken or written words b.Communication with repetitive speech only c.Slurred speech d.Inability to make sounds |
| 17)A client with a chest tube is being transported for a chest x-ray. Which of the following nursing is most appropriate for this time? | a.Clamp the chest tube. b.Keep the drainage system below the insertion site. c.Provide mechanical ventilation during transport. d.Attach a portable suction machine to the chest tube. |
| 18)A nurse caring for a trauma client has expressed to the physician “I am concerned about the client’s blood pressure.” Following the TEAM STEPPS principles, the nurse will follow this statement with: | a.“You ordered a diuretic and the BP is low.” b.“I am uncomfortable administering the diuretic with a low BP.” c.“This is a safety issue, the diuretic order is dangerous.” d.“I disagree with the order and am going to ask someone else.” |
| 19)A client awakens in the middle of the night feeling cool, shaking and perspiring. His morning glucose reading is elevated, the nurse understands this client is experiencing which of the following reactions? | a.Insulin waning b.Dawn phenomemon c.Somogyi phenomemon d.Disulfiram |
| 20)A client is about to have blood tests to diagnosis suspected rheumatoid arthritis (RA). Which of the following statements is true regarding blood tests for RA? | a.A + RF test is considered a definite diagnosis for RA. b.An elevated ESR indicates presence of inflammation in the body. c.Pts with RA may have a decreased WBC count. d.Since blood tests are often unreliable for diagnosing RA, their use had decreased |
| 21)Which of the following statements indicates that an elderly client has been affected by polypharmacy? | a.Rx that are contraindicated are not prescribed. b.Rx are used to counteract the side effects of other prescribed Rx. c.No improvement in a condition even after the discontinuation of a Rx. d.Rx that might prove to be beneficial are not prescribed. |
| 22)The client presenting with late signs of increased intercranial pressure (ICP) would most likely exhibit which of the following vital signs? | a.BP 80/50; HR 50 b.BP 80/50; HR 120 c.BP 190/74; HR 50 d.BP 190/74; HR 120 |
| 23)A client who has sustained a crush injury to the right lower leg complains of numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse’s first intervention? | a.Assess pedal pulses. b.Elevate the right leg on a pillow. c.Notify the physician immediately. d.Document the finding as the only action. |
| 24)A client who had a wrist cast applied 3 days ago calls from home, reporting that the case is loose enough to slide off. How will the nurse respond? | a.“Keep your arm above the level of your heart.” b.“As your muscles atrophy, the cast is expected to loosen.” c.“Wrap an elastic bandage around the cast to prevent it from slipping.” d.“You need a new cast now that the swelling is decreased.” |
| 25)The nurse is teaching a client with ostearthritis about acetaminophen (Tylenol). The nurse knows that the client need further teaching if the client states: | a.“Tyl relieves OA pain but will not prevent further joint damage.” b.“I should take 650 mg Tyl every 4 hours to achieve maximum pain relief.” c.“Tyl has a low risk of GI bleeding.” d.“I should avoid excessive alcohol use when on Tyl therapy for pain.” |
| 26)The nurse is caring for a client 3 days after an above the knee amputation. Which is a priority intervention? | a.Lying client in the prone position every 3-4 hours. b.Use of a soft bed mattress to prevent contracture. c.Placing a pillow under the residual limb. d.Placing the client in a high Fowler’s position. |
| 27)Which neurological deficit will the nurse assess for in the client who has had a stroke in the right cerebral hemisphere? | a.Impaired proprioception b.Progressive aphasia c.Agraphia d.Dysarthria |
| 28)A patient’s wife asks the nurse why her husband did not receive tissue plasminogen activator (tPA). Her husband is diagnosis with a hemorrhagic stroke. The nurse’s best response is: | a.“Not everyone is eligible for this drug. Had surgery lately?” b.“You should discuss the Tx of your husband with his doctor.” c.“He didn’t arrive within the time frame for that therapy.” d.“This Rx could cause more bleeding in your husband’s head.” |
| 29)Which of the following assessment findings are typical for later stage rheumatoid arthritis? | a.Affected joints: reddened, hot, tender, swollen b.Joint pain: intensifies on activity c.Sudden pain (starts in the big toe); tophi d.Morning stiffness lasting several hours; joint deformities such as ulnar deviation; joints look soft and puffy. |
| 30)After returning from an early morning procedure, a client with diabetes mellitus has missed his breakfast. He is irritable, has moist hands and a headache. The nurse should do which of the following as the priority intervention? | a.Administer medication for the headache promptly. b.Order a breakfast tray and acknowledge his dissatisfaction. c.Review the day’s lab results and notify the physician. d.Check his blood glucose level, prepare to administer a carbohydrate. |
| 31)A client with continuous bladder irrigation complains he feels the need to urinate. Which intervention should the nurse implement first? | a.Call the physician to report the client’s complaint. b.Administer a narcotic analgesic to help the client urinate. c.Tell the client the sensation is expected. d.Assess the continuous irrigation catheter to determine if it is patent. |
| 32)The nurse is evaluating a client’s knowledge of hypoglycemic insulin reaction. Which of the following statements by the client indicates understanding of teaching? | a.“I should notify the physician.” b.“I should lie down until the reaction passes.” c.“I should skip the next dose of Aspart (Novolog).” d.“I should take an oral form of glucose.” |
| 33)The HCP recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? | a.“The carotid endarterectomy involves surgical removal of plague from an artery in the neck.” b.“The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.” c.“A wire is threaded through an artery in the left to the |
| 34)A client has a chest tube connected to a three-chamber chest drainage system. In which compartment of the chest tube drainage system will the nurse observe tidal movements as the client breathes? | a.Suction compartment b.Collection compartment c.Dry suction chamber d.Water seal compartment |
| 35)A client with type 2 diabetes is admitted in a coma to the intensive care unit with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which assessment data does the nurse expect the client to exhibit? | a.Kussmaul’s respirations b.Diarrhea and epigastric pain c.Dry mucous membranes d.Ketone odor on his breath |
| 36)What will the nurse do to ensure the validity of comparison electrocardiograms (ECGs) taken at different times? | a.Remove electrodes after each ECG is completed. b.Place new ECG chest leads on the client before each ECG is completed. c.Position the client supine prior to each ECG. d.Ensure that electrode placement is identical for each ECG. |
| 37)The nurse is teaching a class about non-pharmacologic arthritis treatments to clients with osteoarthritis (OA) and rheumatoid arthritis (RA). Which of the following information should be included? | a.Clients should place pillows under the knees when in bed to take pressure off the lower back. b.Not necessary for pt with OA to have a home evaluation. d.Applying heat to affected joints will help lessen pain and stiffness associated with arthritis. |
| 38)A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? | a.“You will need to assess and clean the pin insertion sites daily.” b.“The external fixator can be removed during the bath or shower.” c.“You will need to remain on bed rest until bone healing is complete.” d.“Prophylactic antibiotics are used until t |
| 39)The client had a right sided chest tube inserted for a pneumothorax 3 days ago. If there is no fluctuation (tidaling) in the water seal chamber, which action should the nurse take first? | a.Obtain an order for a chest x-ray. b.Prepare for the removal of the chest tube. c.Pre-medicate the client with an analgesic. d.Assess the client’s right-sided lung sounds. |
| 40)A homecare nurse is visiting a DB pt with a new cast on the arm. On assessment, the nurse finds the client’s fingers to be pale, cool, and swollen with capillary refill greater than 4 seconds. Which of the following is the most important intervention? | a.Notify the physician. b.Encourage range of motion of the hand. c.Apply heat to the affected hand. d.Apply ice to the affected hand. |
| 41)When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? | a.Apply an eye patch to the left eye. b.Approach the patient from the left side. c.Place objects needed for activities of daily living on the patient’s right side. d.Reassure the patient that the visual deficit will resolve as the stroke progresses. |
| 42)When removing a Foley catheter from a patient, the most important thing for the nurse to do is: | a.Deflate the balloon. b.Wear sterile gloves. c.Clean the meatus with soap and water. d.Dispose of the equipment in an appropriate waste container. |
| 43)What is frequently a contributing factor to polypharmacy in the elderly? | a.Decreased frequency of side effects of most medications. b.Reluctance to make lifestyle changes. c.Increased challenges in compliance with medication regimens. d.Healthcare providers’ failure to coordinate medication regimens. |
| 44)A client who has just been diagnosed with gout asks the nurse, “Is there anything I can do to prevent gout attacks?” What is the nurse’s best response? | a.“To prevent gout attacks, take asprin for pain instead of acetaminophen (Tylenol).” b.“There is not much you can do to prevent gout attack except to take your allopurinol.” c.“Excessive alcohol can cause a gout attack so limit alcohol consumption.” d |
| Answer Key | 1)C; 2)B; 3)B; 4)C; 5)B; 6)B; 7)D; 8)C; 9)A; 10)C; 11)B; 12)C; 13)D; 14)B; 15)B; 16)A; 17)B; 18)B; 19)C; 20)B; 21)B; 22)C; 23)A; 24)D; 25)B; 26)A; 27)A; 28)D; 29)D; 30)D; 31)D; 32)D; 33)A; 34)D; 35)C; 36)D; 37)D; 38)A; 39)D; 40)A; 41)C; 42)A; 43)D; 44)C; |
Created by:
Slacker
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