Nursing 123 Exam 1 Questions & Answers

Nursing 123 Exam Questions & Answers A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing actions should have the highest priority? Select one: a. Call the lab for a stat glucose level. b. Administer 50% Dextrose via IV push. c. Assess the client's blood glucose level. Check the patient’s blood glucose. Although it is most likely that this patient is experiencing hypoglycemia, the blood glucose must be checked to confirm the problem and also to document HOW LOW the blood glucose is, which further helps determine the best treatment. Most facilities have protocols to treat hypoglycemia based on the blood glucose results. In addition, we can better evaluate how our interventions work when we compare later blood glucoses with the first blood glucose taken while the patient had symptoms. d. Give the client 4 ounces of orange juice. Feedback The correct answer is: Assess the client's blood glucose level. A client is admitted to the surgical unit after sustaining a compound fracture of the left femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure dressing on the left lower extremity. The client is receiving intravenous fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused and combative. Which of the following is the most likely cause of the change in the client’s condition? Select one: a. Fluid overload related to aggressive isotonic volume replacement b. Hypoxia related to fat embolism from the fractured bone. Although the mechanism is not really clear, it is thought that in compound long bone fractures the internal pressure in the fracture forces fat globules from the marrow into the systemic circulation, where they act as emboli. Initial symptoms within 24-48 hours post-fracture include confusion and combativeness secondary to hypoxemia. c. Hypovolemic shock related to hemorrhage from the open wound d. Infectious process related to contamination of the open wound. Feedback The correct answer is: Hypoxia related to fat embolism from the fractured bone. A nurse is caring for a client on the telemetry unit who is two days post coronary artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. Which of the following should be completed first? Select one: a. Prepare the client for cardioversion. b. Notify the health care provider. c. Assess the client’s blood pressure. Atrial fibrillation frequently occurs after CABG. In A-Fib the atrial kick is lost and cardiac output (C.O.) is decreased by 30%. Clients react differently to A-Fib and the decreased C.O. Some clients become hypotensive and develop shock-like symptoms: changes in LOC; cool, clammy skin; dyspnea; and chest pain. While other clients are normotensive despite the decrease in C.O., they are asymptomatic or considered stable. Treatment for A-Fib depends on the status of the client. The first action the nurse should take with a client who has converted from NSR to A-Fib is to assess the clients BP. d. Prepare a diltizem drip. Feedback The correct answer is: Assess the client’s blood pressure. The nurse is planning care for a client who is prescribed antiembolic stocking following abdominal surgery. Which of the following interventions should the nurse include? Select one: a. Remove stocking every 2 hours then reapply after 1 hour off. b. Remove stockings one to three times per day for skin care and inspection. Antiembolic stockings should be removed one to three times per day to allow for skin care and assessment. The client’s extremities should be monitored for calf pain, warmth, erythema and edema. c. Ensure stockings are loose fitting over client’s calves. d. Encourage client to only wear stockings when out of bed. Feedback The correct answer is: Remove stockings one to three times per day for skin care and inspection. A nurse is teaching lifestyle modifications to a client diagnosed with hypertension. Which of the following statements made by the client indicates a need for further teaching? Select one: a. “I will substitute mushrooms for the bacon in my daily omelets.” b. “I don’t like to walk, but I do aerobics and work out at the gym during the week.” c. “We have a glass of wine a couple of times a week with dinner.” d. “Losing weight is so hard, but so far I am losing 2 pounds a week.” A weight loss of 2 pounds per week is within the recommended lifestyle recommendations for management of hypertension. Feedback The correct answer is: “I will substitute mushrooms for the bacon in my daily omelets.” A nurse is caring for a client with Addison's disease. Which of the following diets should the nurse teach the client to follow? Select one: a. Low Sodium, high potassium and decreased fluids. b. Low Sodium, high calcium and decreased fluids. c. High Sodium, low potassium and increased fluids. The client with Addison's disease should have a diet high in sodium, low in potassium and increased fluids. In addition, these clients should be encouraged to consume small frequent meals to prevent hypoglycemia. d. High Sodium, low calcium and increased fluids. Feedback The correct answer is: High Sodium, low potassium and increased fluids. A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which nursing action would be most appropriate at this time? Select one: a. Encourage water and other fluids. b. Provide oral hygiene and comfort measures. c. Monitor for diminished breath sounds. d. Administer 0.9% Normal Saline. Administering of isotonic IV therapy would be appropriate at this time for restoration of normal ECF volume. Feedback The correct answer is: Administer 0.9% Normal Saline. A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed aqueous vasopressin. Which of the following outcomes indicates that treatment has been effective? Select one: a. Urine output of 200mL per hour b. Fluid intake of 2,400mL in 24 hours DI is characterized by polyuria (up to 8L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with Lypressin should decrease the urine output and oral fluid intake. c. Blood pressure of 90/50 mm Hg d. Pulse rate of 126 beats/minute Feedback The correct answer is: Fluid intake of 2,400mL in 24 hours A nurse is reviewing a client’s lab results. Which finding would lead the nurse to suspect the client is experiencing dehydration? Select one: a. BUN 20mg/100mL b. Hematocrit 55% An increased hematocrit level (50%) is expected with dehydration. c. Urine specific gravity of 1.025 d. Serum sodium 130 mEq/L Feedback The correct answer is: Hematocrit 55% A nurse is caring for a toddler who is being treated for hypovolemia. Which of the following demonstrates to the nurse the desired response to fluid replacement? Select one: a. Apical heart rate 130 beats/min b. Central Venous Pressure 2 mm Hg c. Specific Gravity 1.025 d. Urine output 48 mL for the past 4 hours This urine output is insufficient for a toddler. Approximate weight for a toddler is 15kg (50% on CDC growth chart). Using 1mL/kg/hour, the urine output should have been at least 60mL for the 4 hours. Feedback The correct answer is: Specific Gravity 1.025 A nurse is caring of a client recently diagnosed with diabetes mellitus (DM). Which of the following is the physiologic basis for the polyuria manifested by individuals with untreated DM? Select one: a. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia Hyperosmolarity of the extracellular fluids secondary to hyperglycemia: The hyperosmolarity of the extracellular fluids causes fluid to leak out of the cells in order to return the body to an isotonic state; hence there is increased intravascular fluid the kidneys must excrete. b. Chronic stimulation of the detrusor muscle by the ketone bodies in the urine c. Inadequate secretion of antidiuretic hormone (ADH) d. Early-stage renal failure causes a loss of urine concentrating capacity Feedback The correct answer is: Hyperosmolarity of the extracellular fluids secondary to hyperglycemia A nurse is caring for a client who is intubated and receiving ventilatory assistance. The high pressure alarm is sounding on the ventilator. Which of the following would have the highest priority? Select one: a. Assess the clients need for suctioning. b. Administer sedation to calm the client’s fears. c. Check the endotracheal tube (ETT) to be sure there is no disconnection. Disconnection of the tubing from the endotracheal tube (ETT) would cause the low pressure alarm to sound. d. Assess the ETT cuff for proper inflation. Feedback The correct answer is: Assess the clients need for suctioning. A client is prescribed warfarin daily. Which of the following statement made by the client indicates to the nurse a need for further teaching? Select one: a. “I have two pairs of anti-embolic stockings so that one pair can be washed each day.” b. "Instead of a safety razor, I have been using an electric razor to shave.” c. “I will report any sign of Purple Syndrome to my physician.” d. “I have been eating more salads and other green, leafy vegetables to prevent constipation.” Warfarin inhibits the synthesis of vitamin K dependent clotting factors (factors II, VII, IX, and X). Green leafy vegetables contain vitamin K which is an antagonist to Coumadin. The patient can eat foods with vitamin K but the intake must remain consistent not “more” as stated in this answer. Foods low in vitamin K include roots, bulbs, fleshy parts of nuts, and fruit juices. Feedback The correct answer is: “I have been eating more salads and other green, leafy vegetables to prevent constipation.” A client is admitted to the emergency room after falling outside his home. The client is complaining of a severe headache with pain above his left eye. The client is restless and intermittently losses consciousness. Pupils are dilated; pulse 56 and BP 168/98. An x-ray of the head confirms a skull fracture. Which of the following is a priority assessment? Select one: a. Changes in level of consciousness b. Pupillary changes c. Respiratory Status Correct: Respiratory status is the priority assessment. The brain is dependent upon oxygen to maintain function and has little reserve available if oxygen is deprived. Brain function begins to diminish after 3 minutes of oxygen deprivation.