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Nurselab 5

RN

QuestionAnswer
Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30? A. Septic arthritis B. Traumatic arthritis C. Intermittent arthritis D. Gouty arthritis
A heparin infusion at 1,500 units/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given? A. 15 ml/hour B. 30 ml/hour C. 45 ml/hour D. 50 ml/hour
A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke? A. Elbow contracture secondary to spasticity. B. Loss of muscle contraction decreasing venous return. C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side. D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus.
Heberden’s nodes are a common sign of osteoarthritis. Which of the following statements is correct about this deformity? A. It appears only in men. B. It appears on the distal interphalangeal joint. C. It appears on the proximal interphalangeal joint. D. It appears on the dorsolateral aspect of the interphalangeal joint. Correct An
Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis? A. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t. B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic. C. Osteoarthritis is a systemic disease, rheumatoid arthritis is
is localized. D. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t.
Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices? A. A walker is a better choice than a cane. B. The cane should be used on the affected side. C. The cane should be used on the unaffected side. D. A client with osteoarthritis should be encouraged to ambulate without the cane.
A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client: A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). B. 21 U regular insulin and 9 U NPH. C. 10 U regular insulin and 20 U NPH. D. 20 U regular insulin and 10 U NPH.
Nurse Len should expect to administer which medication to a client with gout? A. Aspirin B. Furosemide (Lasix) C. Colchicines D. Calcium gluconate (Kalcinate)
Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following ? A. Adrenal cortex B. Pancreas C. Adrenal medulla D. Parathyroid
For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet to- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client? A. They contain exudate and provide a moist wound environment. B. They protect the wound from mechanical trauma and promote healing. C. They debride the wound and promote healing by secondary intention.
D. They prevent the entrance of microorganisms and minimize wound discomfort.
Nurse Zeny is caring for a client in an acute Addisonian crisis. Which laboratory data would the nurse expect to find? A. Hyperkalemia B. Reduced blood urea nitrogen (BUN) C. Hypernatremia D. Hyperglycemia
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? A. Infusing I.V. fluids rapidly as ordered. B. Encouraging increased oral intake. C. Restricting fluids. D. Administering glucose-containing I.V. fluids as ordered.
A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check: A. Urine glucose level. B. Fasting blood glucose level. C. Serum fructosamine level. D. Glycosylated hemoglobin level.
Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction? A. 10:00 am B. Noon C. 4:00 pm D. 10:00 pm
The adrenal cortex is responsible for producing which substances? A. Glucocorticoids and androgens B. Catecholamines and epinephrine C. Mineralocorticoids and catecholamines D. Norepinephrine and epinephrine
On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. A. Hypocalcemia B. Hyponatremia C. Hyperkalemia D. Hypermagnesemia
Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer? A. Acid phosphatase level B. Serum calcitonin level C. Alkaline phosphatase level D. Carcinoembryonic antigen level
Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia? A. Nights sweats, weight loss, and diarrhea B. Dyspnea, tachycardia, and pallor C. Nausea, vomiting, and anorexia D. Itching, rash, and jaundice
In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says: A. The baby can get the virus from my placenta.” B. “I’m planning on starting on birth control pills.” C. “Not everyone who has the virus gives birth to a baby who has the virus.” D. “I’ll need to have a C-section if I become pregnant and av baby
When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction? A. “Put on disposable gloves before bathing.” B. “Sterilize all plates and utensils in boiling water. C. “Avoid sharing such articles as toothbrushes and razors.” D. “Avoid eating foods from serving dishes shared by other family members.”
Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? A. Pallor, bradycardia, and reduced pulse pressure B. Pallor, tachycardia, and a sore tongue C. Sore tongue, dyspnea, and weight gain D. Angina, double vision, and anorexia
After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first? A. Page an anesthesiologist immediately and prepare to intubate the client. B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. C. Administer the antidote for penicillin, as prescribed, and continue
to monitor the client’s vital signs. D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include: A. Weight gain. B. Fine motor tremors. C. Respiratory acidosis. D. Bilateral hearing loss.
immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). A. Neutrophil B. Basophil C. Monocyte D. Lymphocyte
When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?
In an individual with Sjögren’s syndrome, nursing care should focus on: A. Moisture replacement. B. Electrolyte balance. C. Nutritional supplementation. D. Arrhythmia management.
During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order: A. Enzyme-linked immunosuppressant assay (ELISA) test. B. Electrolyte panel and hemogram. C. Stool for Clostridium difficile test. D. Flat plate X-ray of the abdomen.
A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order: A. E-rosette immunofluorescence. B. Quantification of T-lymphocytes. C. Enzyme-linked immunosorbent assay (ELISA). D. Western blot test with ELISA.
A complete blood count is commonly performed before Joe goes into surgery. What does this test seek to identify? A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels. B. Low levels of urine constituents normally excreted in the urine. C. Abnormally low hematocrit (HCT) and hemoglobin (Hb)
hemoglobin (Hb) levels. D. Electrolyte imbalance that could affect the blood’s ability to coagulate properly.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters? A. Platelet count, prothrombin time, and partial thromboplastin time B. Platelet count, blood glucose levels, and white blood cell (WBC) count C. Thrombin time, calcium levels, and potassium levels D. Fibrinogen level, WBC, and platelet count
When taking a dietary history from a newly admitted female client, Nurse Len should remember which of the following foods is a common allergen? A. Bread B. Carrots C. Orange D. Strawberries
Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first? A. A client with hepatitis A who states, “My arms and legs are itching.” B. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.
C. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.” D. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”
Nurse Sarah is caring for clients on the surgical floor and has just received a report from the previous shift. Which of the following clients should the nurse see first? A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing. B. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours. D. A 62-year-old who had an abdominal-perineal resection three days ago; client complains of chills.
Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed? A. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit. B. The client supports his head and neck when turning his head to the right.
C. The client spontaneously flexes his wrist when the blood pressure is obtained. D. The client is drowsy and complains of sore throat.
Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions? A. Encourage the client to change positions frequently in bed. B. Administer Demerol 50 mg IM q 4 hours and PRN.
C. Apply warmth to the abdomen with a heating pad. D. Use comfort measures and pillows to position the client.
Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first? A. Assess for a bruit and a thrill. B. Warm the dialysate solution. C. Position the client on the left side. D. Insert a Foley catheter
Nurse Jannah teaches an elderly client with right-sided weakness how to use a cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective? A. The client holds the cane with his right hand, moves the cane forward followed by the right leg, and then moves the left leg. B. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the
Right Ieg C. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. D. The client holds the cane with his left hand, moves the
the cane forward followed by his left leg, and then moves the right leg.
An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate? A. Ask the woman’s family to provide personal items such as photos or mementos. B. Select a room with a bed by the door so the woman can look down the hall.
C. Suggest the woman eat her meals in the room with her roommate. D. Encourage the woman to ambulate in the halls twice a day.
Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective? A. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker. B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
C. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker. D. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.
Nurse Derek is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason? A. Increased sensitivity to the side effects of medications. B. Decreased visual, auditory, and gustatory abilities. C. Isolation from their families and familiar surroundings. D. Decrease musculoskeletal function and mobility.
A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next? A. Encourage the client to perform pursed-lip breathing. B. Check the client’s temperature. C. Assess the client’s potassium level. D. Increase the client’s oxygen flow rate.
Randy has undergone a kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection? A. Sudden weight loss B. Polyuria C. Hypertension D. Shock
The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease: A. Pain B. Weight C. Hematuria D. Hypertension
Matilda, with hyperthyroidism, is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to: A. Decrease the total basal metabolic rate. B. Maintain the function of the parathyroid glands. C. Block the formation of thyroxine by the thyroid gland. D. Decrease the size and vascularity of the thyroid gland.
Ricardo was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with: A. Liver disease B. Hypertension C. Type 2 diabetes D. Hyperthyroidism
Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of: A. Ascites B. Nystagmu C. Leukopenia D. Polycythemia
Norma, with recent colostomy, expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to: A. Eliminate foods high in cellulose. B. Decrease fluid intake at mealtimes. C. Avoid foods that in the past caused flatus. D. Adhere to a bland diet prior to social events.
Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should: A. Lie on my left side while instilling the irrigating solution.” B. Keep the irrigating container less than 18 inches above the stoma.”
C. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.” D. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”
atrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. A. Administer Kayexalate B. Restrict foods high in protein C. Increase oral intake of cheese and milk. D. Administer large amounts of normal saline via I.V.
As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:
Mario has a burn injury. After 48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide: A. 18 gtt/min B. 28 gtt/min C. 32 gtt/min D. 36 gtt/min
Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns? A. Face and neck B. Right upper arm and penis C. Right thigh and penis D. Upper trunk
Herbert, a 45-year-old construction engineer, is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed: A. Reactive pupils B. A depressed fontanel C. Bleeding from ears D. An elevated temperature
Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? A. Take the pulse rate once a day, in the morning upon awakening. B. May be allowed to use electrical appliances. C. Have regular follow up care. D. May engage in contact sports.
The nurse is aware that the most relevant knowledge about oxygen administration to a male client with COPD is: A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breathe.
C. Oxygen is administered best using a non-rebreathing mask. D. Blood gases are monitored using a pulse oximeter.
Tonny has undergone a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit, Tonny is placed in Fowler’s position on either A. Reduce incisional pain. B. Facilitate ventilation of the left lung. C. Equalize pressure in the pleural space. D. Increase venous return.
his right side or on his back. The nurse is aware that this position:
Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse’s highest priority of information would be: A. Food and fluids will be withheld for at least 2 hours. B. Warm saline gargles will be done q 2h. C. Coughing and deep-breathing exercises will be done q2h. D. Only ice chips and cold liquids will be allowed initially.
Nurse Tristan is caring for a male client with acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: A. Hypernatremia. B. Hypokalemia. C. Hyperkalemia. D. Hypercalcemia
Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. D. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.
Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating her kidneys, the nurse should keep which anatomical fact in mind? A. The left kidney usually is slightly higher than the right one. B. The kidneys are situated just above the adrenal glands. C. The average kidney is approximately 5 cm (2 inches) long and 2 to 3 cm (¾ inch to 1 ⅛ inches) wide
D. The kidneys lie between the 10th and 12th thoracic vertebrae.
Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test is consistent with CRF if the result is: A. Increased pH with decreased hydrogen ions. B. Increased serum levels of potassium, magnesium, and calcium. C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.
Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide? A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin. B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found. D. Alteration in the size, shape, and organization of differentiated cells.
During a routine checkup, Nurse Marianne assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer? A. Squamous cell carcinoma B. Multiple myeloma C. Leukemia D. Kaposi’s sarcoma
Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client A. To prevent confusion. B. To prevent seizures. C. To prevent cerebrospinal fluid (CSF) leakage. D. To prevent cardiac arrhythmias.
client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia? A. Auscultate bowel sounds. B. Palpate the abdomen. C. Change the client’s position. D. Insert a rectal tube.
A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially? A. Lying on the right side with legs straight. B. Lying on the left side with knees bent. C. Prone with the torso elevated. D. Bent over with hands touching the floor.
A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding? A. Blood supply to the stoma has been interrupted. B. This is a normal finding 1 day after surgery. C. The ostomy bag should be adjusted. D. An intestinal obstruction has occurred.
Anthony suffers burns on the legs, which nursing intervention helps prevent contractures? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg. B. Urine output of 20 ml/hour. C. White pulmonary secretions. D. Rectal temperature of 100.6° F (38° C).
Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should: A. Turn him frequently. B. Perform passive range-of-motion (ROM) exercises. C. Reduce the client’s fluid intake. D. Encourage the client to use a footboard.
Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent? A. With a circular motion, to enhance absorption. B. With an upward motion, to increase blood supply to the affected area. C. In long, even, outward, and downward strokes in the direction of hair growth.
D. In long, even, outward, and upward strokes in the direction opposite hair growth.
Nurse Kate is aware that one of the following classes of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is: A. Beta-adrenergic blockers B. Calcium channel blocker C. Narcotics D. Nitrates
A male client has jugular distention. In what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention? A. High Fowler’s B. Raised 10 degrees C. Raised 30 degrees D. Supine position
The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility? A. Beta-adrenergic blockers B. Calcium channel blocker C. Diuretics D. Inotropic agents
A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client ? A. Fiber intake of 25 to 30 g daily. B. Less than 30% of calories from fat. C. Cholesterol intake of less than 300 mg daily. D. Less than 10% of calories from saturated fat.
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with acute myocardial infarction. Which of the following actions would breach the client’s confidentiality? A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit. B. The CCU nurse notifies the on-call physician about a change in the client’s condition.
C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress. D. At the client’s request, the CCU nurse updates the client’s wife on his condition.
A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilation through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, A. Start an L.V. line and administer amiodarone (Cordarone), 300 mg L.V. over 10 minutes. B. Check endotracheal tube placement. C. Obtain an arterial blood gas (ABG) sample. D. Administer atropine, 1 mg L.V.
compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?
Created by: Faith111
 

 



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