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Fund Test #3 Q's
Test on April 23, 2014
| Question | Answer |
|---|---|
| Which of these patients do you expect will need teaching regarding dietary sodium restriction? | A 65-year-old recently diagnosed with heart failure |
| You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? | Fluid that has sodium (salt) in it |
| You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? | 28-year-old who has acute pancreatitis |
| Which of the following activities can you delegate to nursing assistive personnel (NAP)? | Measuring oral intake and urine output and Reporting an IV container that is low in fluid |
| Assessment findings consistent with intravenous (IV) fluid infiltration include | Edema and pain; Pallor and coolness |
| Which of the following defi ning characteristics is consistent with fluid volume deficit? | Dry mucous membranes, thready pulse, tachycardia |
| Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? | Auscultate dependent portions of lungs |
| The health care provider’s order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid? | Oliguria |
| Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient’s breathing? | Provide frequent oral care to keep her mucous membranes moist |
| A new RN orientee asks the nurse preceptor about acid base imbalances. Which of the following responses by the preceptor best decribes respiratory acidosis? | This condition occurs when a client has inadequate ventilation, retains CO2, and the pH drops |
| The nurse would closely monitor a client with diabetic ketoacidosis (DKA) for which of the following acid base imbalances? | Metabolic acidosis |
| The client is admitted to a nursing unit from a long term care facility with a hematocrit of 56% and serum sodium level of 52 mEq/L. Which condition is a cause for these findings? | Dehydration |
| Rapid IV infusion of 750 mL, client coughs and asks for HOB to raise and has an increased respiratory rate. What is happening? | Hypervolemia is developing |
| Who is at a high risk for fluid volume deficit? | 76 year old who has an NG tube to w/ low suction following colon cancer surgery |
| Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? | Difficulty arousing the patient |
| The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? | The amount of daily acetaminophen |
| A patient with chronic low back pain who took an opioid (ATC) for the past year abruptly stopped the med for fear of addiction. He now has shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of | Physical dependence. |
| After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient’ s respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: | Assess patient’s vital signs every 15 minutes for 2 hours |
| Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? | Only the patient should push the button. |
| A pt w/ history of stroke that left her confused & unable to comm. returns from radiology after placement of gastrostomy tube. The health care provider’s order reads: “Vicodin 1 tab, per tube, q4 hours, prn.” Which action is most appropriate? | Request to have the ordered changed to ATC for the first 48 hours. (if you anticipate pain for most of the day, should consider ATC. Insertion of a gastrostomy tube is painful. This patient will most likely experience pain for at least the next 48 hours) |
| A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse’s first action is to: | Assess the characteristics of the pain. |
| The pt rates his pain as a 6 from 0 to 10, with 0 being no pain and 10 being the worst pain. The patient’s wife says that he can’t be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? | The patient’s report of pain is the best method for assessing the pain. |
| When using ice massage for pain relief, which of the following are correct? | Apply ice until numbness occurs and remove the ice for 5 to 10 minutes and apply ice using firm pressure over skin |
| A postoperative patient is currently asleep. Therefore the nurse knows that: | The sedative administered may have helped him sleep, but assessment of pain is still needed. |
| The nurse is gathering a sleep history from a patient who is being evaluated for obstructive sleep apnea. Which common symptoms does the patient most likely report? | Excessive daytime sleepiness, headache, snoring |
| Older adults are cautioned about the long-term use of sedatives and hypnotics because these medications can: | Lead to sleep disruption. |
| The nurse is providing health teaching for a patient using herbal compounds such as melatonin for sleep. Which points need to be included? | Should not be used indefinitely, may interfere with prescribed medications, are not regulated by the U.S. Food and Drug Administration (FDA) |
| The patient reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs during which sleep phase? | REM sleep |
| The nurse teaches a patient taking a benzodiazepine that this group of medications causes which symptom of a sleep problem? | Grogginess and feeling hungover |
| The nurse is developing a plan of care for a patient experiencing narcolepsy. Which intervention is appropriate to include on the plan? | Encourage patient to take one or two 20-minute naps during the day |
| Which nursing measure best promotes sleep in a school-age child? | Use quiet activities consistently before bedtime |
| Which statement made by an older adult best demonstrates understanding of taking a sleep medication? | “I’ll talk to my health care provider before I use an over the- counter sleep medication.” |
| The school nurse is teaching health-promoting behaviors that improve sleep to a group of high school students. Which points should be included in the education? | Do not study in your bed, turn off your cell phone at bedtime, avoid drinking coffee or soda before bedtime |
| The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? | I always feel tired when I wake up in the morning. |
| The nurse is providing education on sexually transmitted infections (STIs) to a group of adolescents. The nurse knows that further teaching is needed when one of the adolescents states: | “I know I’ m not infected if I don’t have any symptoms such as discharge or sores.” |
| A 25 yr old is in the emergency room & states she's had a cough & fever for past 3 days. The nurse finds several bruises that are in various stages of healing & suspects the patient possibly is a victim of sexual abuse. Which is the nurse’s first action? | Tell the patient about the safe house for women |
| 26 yr old pregnant woman. The nurse discovers she has purulent vaginal discharge. The pt states, “It burns when I urinate, and I seem to have to go to the bathroom frequently.” The nurse determines that further follow-up is needed because the patient: | May have a sexually transmitted infection (STI) such as chlamydia. |
| Certain cultural groups in the United States are disproportionately affected by diseases such as human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The nurse understands that this is most likely caused by: | Expectations about behavior by men or women in the culture, communication patterns and language practiced by the culture |
| A 15-year-old girl states that she is having unprotected intercourse with her boyfriend. She asks for more information about birth control methods. The nurse informs the patient that: | Barrier methods offer some protection against STIs, hormonal methods offer little protection against sexually transmitted infections (STIs). |
| Which of the following represents a nonjudgmental approach when gathering a sexual health history? | Do you have sex with men, women, or both? |
| The nurse notes that a woman who recently began cancer treatment appears quiet and withdrawn, states that she does not believe the treatments will make any difference, does not ask about her progress, and missed two chemotherapy sessions. Nsg. Diagnosis? | Hopelessness |
| Which of the following nursing actions best reflects sensitivity to cultural differences related to end-of-life care? | Ask family members if they prefer to help with the care of the body after death. |
| Regarding grief in older adults, which understanding helps guide your relationship with an elderly patient? | Older adults have usually sustained many losses in life, which influence the current loss. |
Created by:
heatherodom12