NURSING 3312 TEST BANK

NURSING 3312 TEST BANK 1-A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation as a- dyspnea. b- weight loss. c- dysphagia. d- hoarseness. 2-A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? a- Allergic b- Acute pain c- Hemolytic d- Febrile 3-A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions? a- Gingivitis b- Candidiasis c- Xerostomia d- Halitosis 4-A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the health care provider? a. White lochia on postpartum day 11 b. Pink lochia on postpartum day 4 c. Bloody lochia on postpartum day 2 d. Reddish lochia on postpartum day 8 5- Fluticasone propionate and albuterol, administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the: a. Fluticasone propionate immediately after inhaling the albuterol b. Albuterol a few minuts before inhaling the fluticasone propionate c. Fluticasone propionate several minutes before inhaling the albuterol d. Albuterol immediately after inhaling the fluticasone propionate 6- Lab results for a client with liver cirrhosis who has developed portal hypertension show low level of serum albumen Base on this information, the nurse knows that he has a high chance of developing which of the following? Select one: a. Albuminuria b. Ascites c. Esophageal ulceration d. Hypoglycemia 7-A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the clientť's postoperative plan of care? SELECT MULTIPLE ANSWERS a. Place sequential compression devices on the bilateral lower extremities. b. Discontinue suction when assessing for peristalsis c Reposition the client from side to side every 2 hr. A d. Irrigate the NG tube with 0.9 % sodium chloride irrigation solution. V e. Encourage the use of an incentive spirometer every 2 hr while the client is awake. 8-A nurse is monitoring a pregnant client with placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note as an emergency and should call the physician? a. Soft, relaxed, nontender uterus b. Sustained tetanic contractions c. Painful vaginal bleeding d. Complaints of abdominal pain 9-A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? SELECT MULTIPLE ANSWERS Select one or more: * a. Moist, clammy skin b. Tachycardia c. Polydipsia d. Polyuria e. Blurred vision 10-A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored? a. Visual acuity b. Skin color c. Cardiac rhythm d. Urine output 11-A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? a Respiratory rate 18/min b. Straw-colored urine from an indwelling urinary catheter C. yellow- green drainage on the surgical incision D. Blood pressure 120/66 mm Hg 12- The client has just had emergency intubation for respiratory distress. Immediately after endotracheal tube insertion, which of the following actions by the nurse is most appropriate? a. Assure the client that alternative communication means will be provided. b. Assess for bilateral breath sounds c. Tape the tube securely in place. d. Call for a chest X-ray to determine placement. 13- The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first? a. A victim with an open fracture of the arm that is bleeding profusely b. A victim who is unresponsive, with severe swelling and bruising around the eyes, and is not breathing C. A victim with a twisted ankle and leg bruises d. A victim who is anxiously moving among the victims, searching for her husband 14- A client who is prescribed chlorpromazine HCI (Thorazine) for schizophrenia develops rigidity, a shufflin and tremors. Which action by the nurse is most important? 1. Determine if the client has increased photosensitivity. 2. Provide comfort measures for sore muscles. 3. Assess the client for visual and auditory hallucinations. 4. Administer a dose of benztropine mesylate (Cogentin) PRN. 15-A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? a. Abnormally prominent U wave b. Wide QRS c. Elevated ST segment d. Inverted P wave 16- The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST? a. A client who receives hydrochlorothiazide and states that she is dizzy when she gets up in the morning. b. A client with AIDS who had a thoracentesis yesterday and is complaining of crackling under the skin of his chest. C. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision. d. A primigravida client, 10-days postpartum, who is anxious about caring for her newborn. 17- The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left- sided heart failure? Select one. a. "I have to stop halfway up the stairs to catch my breath. b. I have experienced blurred vision on several occasions c. "I have been drinking more water than usual." d. T have been awakened by the need to urinate at night. 18- The highest-priority nursing intervention for a child hospitalized with a bacterial respiratory infection and cystic fibrosis would be: a. Administering pancreatic enzymes. b. Recording vital signs every four hours. C. Arranging for sweat chloride testing d. Administering intravenous antibiotics. 19- A nurse caring for a woman in labor places client on the side, reading the fetal monitor tracing (see figure determines late decelerations. How does the nurse interpret this finding? a. Inadequate pacemaker activity of the fetal heart b. Umbilical cord compression c. Uteroplacental insufficiency during a contraction d. Pressure on the fetal head during a contraction 20-A patient's intracranial pressure (ICP) is 34 mm Hg, and his cerebral perfusion pressure is 55 mm Hg. Wi the following is the most appropriate intervention? a. Administer mannitol 1 to 2 g/kg IV. b. These are normal values, and no interventions are required. c. Have the patient lie flat in bed. d. Suction the patient to see if improving his airway will help his ICP.