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WorksheetsPNE 162 Mock Final
Total questions: 135
Worksheet time: 2hrs 38mins
Name
Class
Date
1.
What are the effects of aging on the nervous system?
a)
Accelerated loss of neurons in the brain
b)
Gradually declining loss of intellectual capability
c)
Decreased conduction speed of neurons
d)
Loss of long-term memory
2.
Which facts are generally accepted for most older adults?
a)
Intellectual capabilities are impaired.
b)
Functional brain activities decrease.
c)
Functional intellectual capability is maintained.
d)
Creativity and judgment are severely impaired.
3.
What factor increases the risk of respiratory infection for older adults?
a)
Decreased ciliary action
b)
Decreased physical activity
c)
Inadequate hydration
d)
Poor personal hygiene
4.
A nurse is caring for an older person whose renal changes make it impossible to concentrate or dilute urine. For what is this patient at the greatest risk?
a)
Urinary infection
b)
Dehydration
c)
Incontinence
d)
Renal failure
5.
A nurse explains to family members that the final developmental stage is ego integrity. What should occur in the older adult, according to Erikson, if this stage is not mastered?
a)
Needs to repeat a previous stage
b)
Experiences despair
c)
Inability to advance past the present stage
d)
Experiences disappointment
6.
When the water absorption in the renal tubules becomes greater than normal, what assessment finding should a nurse anticipate?
a)
More concentrated urine
b)
Less concentrated urine
c)
More alkaline urine
d)
Less alkaline urine
7.
What process occurs when oxygen is directed out of the arteries and into the capillaries?
a)
Active transport
b)
Diffusion
c)
Filtration
d)
Osmosis
8.
A patient’s intravenous (IV) injection has been infusing at a very high rate. What assessment indicates fluid volume overload in this patient?
a)
Hypotension
b)
Tachycardia
c)
Pulmonary edema
d)
Kidney failure
9.
What is primarily responsible for carrying fluids with nutrients and wastes on a random basis throughout the body?
a)
Filtrates
b)
Extracellular fluid
c)
Intracellular fluid
d)
Osmolytes
10.
A nurse clarifies that electrolytes, such as sodium and potassium (K+), break down into smaller particles when dissolved. What are these smaller particles?
a)
Cells
b)
Elements
c)
Ions
d)
Molecules
11.
A nurse assists a patient with dyspnea to sit in a high Fowler position. What process allows gravity to help move oxygen from the pulmonary capillaries into the blood when the patient is in this position?
a)
Active transport
b)
Diffusion
c)
Filtration
d)
Osmosis
12.
What is being administered when a nurse hangs an IV bag with Na+, K+, and Cl-?
a)
Nutrients
b)
Electrolytes
c)
Enzymes
d)
Vitamins
13.
Each compartment of the body has a water-fluid distribution movement of its own. What is the process allowing these fluids to move and distribute themselves among compartments?
a)
Active transport
b)
Diffusion
c)
Filtration
d)
Osmosis
14.
Both the intracellular and extracellular fluids are made up of many different electrolytes. What is the most abundant intracellular positively charged electrolyte?
a)
Calcium
b)
Chloride
c)
Potassium
d)
Sodium
15.
For what compensatory condition should the nurse carefully assess when the patient with metabolic acidosis is hyperventilating?
a)
Metabolic alkalosis
b)
Respiratory acidosis
c)
Respiratory alkalosis
d)
Thyroid imbalances
16.
The K+ laboratory report shows a level of 5.2 mEq/L. What is the most important assessment for the nurse to make?
a)
Excessive thirst
b)
Irregular heartbeat
c)
Swelling of ankles
d)
Frightening hallucinations
17.
A patient has renal damage because of diabetes. What is the highest risk for this patient?
a)
Hypercalcemia
b)
Hypocalcemia
c)
Hyperkalemia
d)
Hypokalemia
18.
Older adults are at risk for dehydration because of reduced thirst and aging kidneys. What should the nurse assess as an early indicator of dehydration?
a)
Reduced skin turgor
b)
Constipation
c)
Concentrated urine
d)
Disorientation
19.
A nurse understands that fluid balance is mainly monitored in the body by which two systems?
a)
Circulatory and renal
b)
Respiratory and circulatory
c)
Renal and gastrointestinal
d)
Hepatic and lymphatic
20.
What primarily maintains extracellular fluid osmolarity?
a)
Chloride
b)
Magnesium
c)
Potassium
d)
Sodium
21.
How does the healthy kidney adjust the volume and composition of filtrate that prevents excessive fluid loss?
a)
Active transport
b)
Filtration in the lymphatic system
c)
Secretion of adrenalin
d)
Tubular reabsorption
22.
What should treatment focus on when a patient is hypovolemic?
a)
Extracellular fluid deficit and limiting drinking water
b)
Hypertonic intracellular deficit and limiting water intake
c)
Extracellular fluid deficit and encouraging fluid intake
d)
Circulatory system hormone deficit and limiting water intake
23.
A patient is frequently thirsty. To what should the nurse attribute this symptom?
a)
Too much sodium and too much water in the body
b)
Too little sodium and too much water in the body
c)
Too much sodium and too little water in the body
d)
Too little sodium and too little water in the body
24.
A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours as needed (PRN). What should the nurse assess first?
a)
Assess for the presence of bowel sounds.
b)
Assess pupillary reaction.
c)
Ask the patient’s family if she is having pain.
d)
Determine when the patient last received pain medication.
25.
A nurse is caring for a postoperative patient. What should the nurse ask when assessing for the complication of malignant hyperthermia?
a)
“Do you think you might have a fever?”
b)
“Do you currently have an infection?”
c)
“Has anyone in your family ever had problems with general anesthesia?”
d)
“Have you ever had any type of malignancy?”
26.
A patient who had a hysterectomy yesterday has not been allowed food or drink by mouth (NPO). The physician has now ordered the patient’s diet to be clear liquids. What should the nurse assess prior to providing this patient with clear liquids?
a)
Feelings of hunger
b)
Bowel sounds
c)
Positive Homans sign
d)
Gag reflex
27.
Which technique should a nurse implement when changing a postoperative dressing?
a)
Enteric isolation
b)
Aseptic technique
c)
Clean technique
d)
Respiratory isolation
28.
What should a nurse ensure that a postoperative patient implement to best prevent deep vein thrombosis (DVT)?
a)
Splint the incision.
b)
Cough and deep breathe every 2 hours.
c)
Regularly remove antiembolism stockings.
d)
Ambulate frequently.
29.
A nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient’s blood pressure is 90/60 mm Hg, and the apical pulse is 108 beats/min. What should be the nurse’s first action?
a)
Check the dressing for bleeding.
b)
Notify the registered nurse (RN).
c)
Document the vital signs.
d)
Increase the rate of infusion of intravenous fluids.
30.
A nurse should include the proper use of an incentive spirometer in teaching a preoperative patient. What postoperative assessment of this patient would reveal that the incentive spirometry teaching has been effective?
a)
Adventitious breath sounds
b)
Expiratory wheezing
c)
Thick, green respiratory secretions
d)
Clear breath sounds
31.
When obtaining a patient’s signature on the surgical consent form, the patient seems confused about the procedure to be performed. What is the most appropriate response by the nurse?
a)
Tell the patient to talk to the physician after he or she gets to the surgical department.
b)
Ask the patient to go ahead and sign the consent.
c)
Ask the patient what the physician told him and then call the physician if necessary.
d)
Encourage the patient to ask his family what the physician told them.
32.
What is the goal of palliative surgery?
a)
Remove and study tissue to make a diagnosis.
b)
Relieve symptoms or improve function without correcting the basic problem.
c)
Remove diseased tissue or correct defects.
d)
Correct serious defects that only affect appearance.
33.
What information should a nurse ask a patient during the preoperative assessment?
a)
Current address and telephone number
b)
Food preferences
c)
Allergies, medications, and past medical conditions
d)
Bathing and sleep patterns
34.
A nurse is assisting in the transfer of a postoperative patient from the postanesthesia care unit to the surgical nursing unit. What action should the nurse implement to ensure the safety of the patient?
a)
Put the side rails up after moving the patient from the stretcher to the bed.
b)
Ask the patient to move from the stretcher to the bed.
c)
Move the patient rapidly from the stretcher to the bed.
d)
Uncover the patient before transferring from the stretcher to the bed.
35.
In an assessment of a patient who has been receiving intravenous (IV) fluids for the past 6 hours, a nurse finds that the pulse is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and pedal edema has developed. What should the nurse suspect?
a)
Infiltration of the IV site
b)
Vascular fluid volume excess
c)
Pulmonary air embolism
d)
Phlebitis of the leg veins
36.
A physician prescribes a hypertonic intravenous line for an extremely edematous patient. What solution should the nurse anticipate to be prescribed?
a)
D5W in NS
b)
Lactated Ringer solution
c)
D5W in 0.25 NS
d)
10% glucose in water
37.
What signs of infiltration should be assessed by a nurse?
a)
Burning sensation, pain, and puffy
b)
Pain, heat, and puffy
c)
Burning sensation and no feeling at the site
d)
Red streak up the arm
38.
A nurse assesses for signs of infected phlebitis. How should the nurse most accurately describe this complication when documenting?
a)
Rupture of the cannula with a lump under the skin
b)
Pale, cool skin with swelling at the puncture site
c)
Firm, cool, raised, painful area at the puncture site; oozing and purulent drainage
d)
Puncture site red, warm, with an oozing drainage
39.
What instruction should a nurse provide to a patient when removing a central catheter?
a)
Lean forward and cough.
b)
Take a deep breath and bear down.
c)
Breathe deeply through the mouth.
d)
Lie on the right side.
40.
An older adult patient is assessed by a nurse as showing signs of fluid volume excess. What signs should the nurse assess?
a)
Redness, warmth, and drainage of fluid at the IV site
b)
Redness, warmth, and tenderness at the IV site
c)
Complaints of shortness of breath and pounding pulse
d)
Puffiness of face, dyspnea, and pain at the IV site
41.
Where is the best place to begin to select a vein for an initial intravenous (IV) site in a left-handed patient?
a)
Antecubital vein of the right arm
b)
Antecubital vein of the left arm
c)
Right forearm
d)
Left forearm
42.
What action should the nurse implement when discontinuing an intravenous (IV) line?
a)
Remove the dressing, remove the catheter, dispose of the used equipment in the sharps container, and chart observations and actions.
b)
Observe the site for redness, swelling, and pain, and put on sterile gloves. Remove the dressing catheter and chart the findings and action.
c)
Observe the site for redness, swelling, and pain, and put on clean gloves. Remove the dressing and catheter, place a 2 ´ 2 dressing over the site, and chart the findings and action.
d)
Observe the site for redness, swelling, and pain and put on clean gloves. Remove the dressing and catheter; chart the findings and action.
43.
What portion of the internal nose traps particles and kills bacteria?
a)
Turbinates
b)
Mucous membrane
c)
Vestibular formations
d)
Cilia
44.
What is the function of the tonsils and adenoids in small children?
a)
Help promote antibody formation
b)
Assist in some digestive processes
c)
Protect against bacterial infections of the throat
d)
Support blood cell production
45.
A patient comes into the clinic complaining of a runny nose and facial pain. What should the nurse’s initial assessment include?
a)
Assessment for nasal drainage and sinus tenderness
b)
Transillumination and nasal speculum examination
c)
Palpation of the frontal and maxillary sinuses and tonsillar inspection
d)
Turbinate assessment and assessment for patency of the nares
46.
When a patient with sleep apnea says, “I’m not wearing that silly mask. I look like something out of Star Wars,” what should the nurse remind the patient about the function of the mask?
a)
Increases oxygen intake
b)
Stimulates regular respirations
c)
Sounds an alarm when the oxygen concentration drops
d)
Uses positive pressure to keep the airway open
47.
Which assessment should indicate the necessity for a nurse to suction a patient with a tracheostomy?
a)
Becomes restless and has increases in vital signs
b)
Has decreased peak airway pressure
c)
Shows diaphoresis
d)
Is coughing frothy mucus
48.
A patient complains that he wants an antibiotic medication for his cold. What is the best response by the nurse?
a)
“Antibiotics are not effective with viral infections.”
b)
“You will get better faster without the antibiotics.”
c)
“You might try echinacea or vitamin C.”
d)
“A cold is not that serious. Try forcing fluids.”
49.
What should the initial action of a nurse be when providing first aid to a person with spontaneous epistaxis?
a)
Apply direct pressure for 3 to 5 minutes.
b)
Have the person sit down and lean forward.
c)
Have the person lie down and apply an ice pack.
d)
Have the person clear the nasal passages by blowing the nose.
50.
The patient has had anterior nasal packing placed for severe epistaxis. The nurse notes that he is swallowing frequently. What should a nurse suspect?
a)
The patient’s throat is dry.
b)
Posterior packing is uncomfortable.
c)
The patient is bleeding.
d)
The patient’s saliva production is excessive.
51.
The patient’s saliva production is excessive.
a)
Smoking and highly seasoned foods
b)
Alcohol and voice strain
c)
Nasal congestion and frequent coughing
d)
Respiratory infections and voice strain
52.
Which nursing concern takes priority in the care of a patient after a laryngectomy?
a)
Encouraging nutrition
b)
Avoiding infection
c)
Establishing a communication system
d)
Ensuring adequate fluid intake
53.
A patient asks the nurse how air goes from the nose to the lung. The nurse draws the route according to which sequence?
a)
Trachea, larynx, bronchi
b)
Pharynx, trachea, bronchi, alveoli
c)
Bronchi, trachea, bronchioles
d)
Larynx, trachea, alveoli, bronchi
54.
A nurse charts that a patient has had periods of tachypnea during the night. What does this means in regard to the respiration rate?
a)
Below 12 breaths/min
b)
Uneven, with periods of apnea
c)
Gradually deepening, then shallow, and then periods of apnea
d)
Above 20 breaths/min
55.
A 90-year-old patient complains to the nurse of shortness of breath after walking up a flight of stairs. What age-related change should the nurse explain results in this problem?
a)
Flexible rib cage
b)
High-arched diaphragm
c)
Increased chest movement
d)
Enlarged bronchioles
56.
To auscultate breath sounds in the right middle lobe from the anterior aspect, the nurse should place the diaphragm of the stethoscope at which intercostal space?
a)
second
b)
third
c)
fourth
d)
fifth
57.
What should the nurse suspect regarding the bronchus when auscultating coarse crackles in the lower right lobe?
a)
Partially filled with fluid
b)
Narrowed by spasm
c)
Partially filled with thick mucus
d)
Completely obstructed
58.
Which nursing intervention is inappropriate in the immediate postprocedure care of a patient who has had a fiberoptic bronchoscopy?
a)
Place the patient in a semi-Fowler position.
b)
Offer fluids to assess swallowing ability.
c)
Assess for diminished breath sounds.
d)
Assess for stridor.
59.
What is the importance of the nurse closely monitoring bilateral breath sounds and chest movement after a thoracentesis?
a)
Fluid may quickly accumulate as a result of inflammation.
b)
The lung may have been punctured during the procedure.
c)
Severe bronchospasm may cause atelectasis.
d)
Asthma may result after the procedure.
60.
Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?
a)
1 day after injection with a 10-mm area of redness and swelling
b)
2 days after injection with a 5-mm area of redness and swelling
c)
4 days after injection with a 3-mm area of redness and swelling
d)
5 days after injection with a 2-mm area of redness and swelling
61.
A nurse performs an Allen test before performing the arterial stick for an arterial blood gas. What does this test assess?
a)
Respiratory function
b)
Tidal volume
c)
Concentration of oxygen
d)
Perfusion of the hand
62.
Which assessment indicates to the nurse that the chest tube in a water seal drainage device is working correctly?
a)
Constant bubbling in the suction control chamber
b)
Decrease of accumulation in the drainage chamber
c)
Fluctuation of the column of water in the water seal
d)
Constant bubbling in the water seal chamber
63.
What symptoms should a nurse expect to see in a patient with hypoxemia?
a)
Restlessness, tachycardia, and tachypnea
b)
Bradycardia, cyanosis, and restlessness
c)
Dyspnea, flushed face, and tachycardia
d)
Cyanosis, nausea, and bradycardia
64.
What should a nurse prepare when assessing paradoxical movement in a patient with a flail chest who has significant dyspnea?
a)
Thoracotomy
b)
Intubation
c)
Thoracentesis
d)
Body cast
65.
How should a nurse position a patient during a thoracentesis?
a)
Side-lying with bed in a Trendelenburg position
b)
High Fowler position with feet elevated
c)
Sitting on the side of the bed bent over bedside table
d)
Prone with the bed elevated
66.
How does the ventilator function of positive end-expiratory pressure assist the patient?
a)
Keeps pressure in the lungs after expiration
b)
Delivers 100% oxygen on inspiration
c)
Allows the patient to control expiratory pressure
d)
Delivers an inhalant medication under positive pressure
67.
A nurse assesses wheezes in a patient with asthma. What should the nurse know is the cause of wheezes?
a)
Increased thickness of respiratory secretions
b)
Use of accessory muscles of respiration
c)
Tachypnea and tachycardia
d)
Movement of air through narrowed airways
68.
Which nursing intervention enhances the nutritional status of a patient with COPD?
a)
Offer small, frequent meals.
b)
Encourage extra liquids with meals.
c)
Assist the patient to exercise before meals.
d)
Supply information about nutrition.
69.
What should a nurse focus on when assessing for major sources of infection in a patient with COPD?
a)
Stasis of respiratory secretions
b)
Low body weight
c)
Episodes of postural hypotension
d)
Delayed antigen-antibody response
70.
A patient with asthma asks the purpose of learning how to use a peak expiratory flow rate (PEFR) device. What is the nurse’s best response regarding PEFR?
a)
Dilates the bronchi to relieve dyspnea
b)
Measures expired air to evaluate ventilation
c)
Soothes inflamed bronchi, reducing spasm
d)
Liquefies sputum for easier expectoration
71.
Which assessment made by a nurse indicates that respiratory arrest is imminent in a patient with asthma?
a)
agitation
b)
tachycardia
c)
Absence of wheezing
d)
flaring nares
72.
What is increased in hypertension that in turn causes an increase in the work of the heart?
a)
preload
b)
stroke volume
c)
contractility
d)
afterload
73.
A 49-year-old patient has multiple risk factors for coronary artery disease. Which risk factor is considered modifiable?
a)
family history
b)
age
c)
smoking
d)
male gender
74.
A nurse records the finding of a normal sinus rhythm (NSR) when the P, Q, R, S, and T are all present in the electrocardiographic complex. What additional information should the nurse document?
a)
Rate of 82 seconds
b)
PR interval of 0.36 second
c)
QRS complex of 0.16 second
d)
Inverted T
75.
On auscultation, a nurse detects a heart murmur. What should the nurse know that a heart murmur indicates?
a)
Valves that do not close correctly
b)
Pericardium that is inflamed
c)
Decrease in pacemaker cells
d)
Loud ventricular gallop
76.
A stress test is scheduled for a 41-year-old patient. What action should the nurse implement to prepare the patient for the examination?
a)
Have the patient sign a consent form.
b)
Give the patient a special heart diet.
c)
Prepare the patient for sedation.
d)
Remove all metal objects.
77.
What action should a nurse expect to implement when a patient returns from a cardiac catheterization?
a)
Ambulate the patient in the hall.
b)
Check the puncture site.
c)
Monitor the gag reflex.
d)
Remove the gel from all sites on the skin.
78.
A nurse assesses an inverted T wave on the ECG of a patient who had an acute MI two days earlier. How should the nurse interpret this finding?
a)
Normal recovery
b)
New MI
c)
Abnormal wave form
d)
Congestive heart failure
79.
Laboratory tests are performed to identify damage to the heart muscle. Which test is elevated the earliest with heart damage?
a)
Creatine phosphokinase-MB (CPK-MB)
b)
Lactate dehydrogenase (LDH)
c)
Lipid profile
d)
Troponin
80.
A patient is scheduled for a heart catheterization. What action should the nurse implement in preparation for this examination?
a)
Ask the patient about allergies to seafood or iodine.
b)
Remove all metal objects.
c)
Give the patient a special heart diet.
d)
Test arterial blood gases (ABGs).
81.
A patient with acute congestive heart failure has jugular vein distention, crackles bilaterally, and dyspnea. Which nursing diagnosis should have the highest priority?
a)
Activity intolerance
b)
Excess fluid volume
c)
Anxiety
d)
Ineffective Coping
82.
A patient is receiving digoxin 0.25 mg/day. What should the nurse do prior to administering this medication?
a)
Count an apical pulse for 15 seconds.
b)
Hold the dose if the apical rate is 57 beats/min.
c)
Give the dose if the apical rate is 59 beats/min.
d)
Double the dose if the rate is 62 beats/min.
83.
What is a normal age-related change in older adults that makes them susceptible to cardiovascular disease?
a)
Increase in cardiac output
b)
Increase in stroke volume
c)
Stiff peripheral vessels
d)
Oxygen capacity improvement
84.
A 69-year-old patient reports a burning, aching pain in the legs when walking to the mailbox. These symptoms are relieved with rest. What should the nurse suspect?
a)
Venous insufficiency
b)
Claudication
c)
Phlebitis
d)
Rest pain
85.
A nurse assesses a patient’s capillary refill time as less than 3 seconds. What does this assessment indicate?
a)
Hypertension
b)
Tissue perfusion
c)
Excess fluid volume
d)
Increased blood viscosity
86.
What is a characteristic of a venous stasis ulcer?
a)
Painlessness
b)
Poikilothermy
c)
Pale color
d)
Location near the groin
87.
A nurse is educating a patient regarding a stress test on a treadmill. Teaching includes that this test is a noninvasive procedure. What additional information is appropriate for the nurse to include?
a)
Is monitored continuously by blood pressure and an electrocardiogram
b)
Will last about 1 hour
c)
Is meant to stimulate claudication and dyspnea
d)
Will require a period of bedrest afterward
88.
A patient inquires how something as simple as walking could help his venous vascular disorder. What is the best response by the nurse when explaining the benefits of walking?
a)
Improves the strength of the vascular walls
b)
Boosts venous circulation through leg muscle activity
c)
Increases cardiac output
d)
Clears plaques from the veins
89.
Which instruction is most appropriate for a patient with arterial insufficiency?
a)
Frequently allow the legs to dangle dependently.
b)
Rub the legs vigorously.
c)
Stand often to keep blood flow in the legs.
d)
Walk barefoot.
90.
Which statement made by a patient indicates to the nurse that a teaching plan for the use of warfarin was not effective?
a)
“I don’t take aspirin anymore.”
b)
“I read that grapefruit interferes with warfarin.”
c)
“I’m drinking too much tea. My urine looks like tea.”
d)
“I wear my medical alert bracelet all the time.”
91.
An obese postsurgical patient complains of sudden discomfort in her leg. The nurse assesses the leg and finds it cold and pale with no pedal or popliteal pulse. What should the nurse suspect?
a)
Venous thrombosis
b)
Arterial occlusion
c)
Vascular spasm
d)
Paresthesia
92.
What assessment should a nurse perform on a patient after the repair of an abdominal aortic aneurysm?
a)
Periorbital edema
b)
Tremor or facial twitching
c)
Rising blood pressure
d)
Bowel sounds
93.
A patient inquires if his blood pressure is normal. What is the nurse’s most accurate response regarding the definition of normal blood pressure?
a)
Less than 144/90 mm Hg
b)
Less than 138/86 mm Hg
c)
Less than126/82 mm Hg
d)
Less than 120/80mm Hg
94.
A patient is being evaluated every week for possible hypertension and is classified as prehypertensive. Which assessment would support this conclusion?
a)
Blood pressure reading over 120/80 mm Hg for two consecutive visits
b)
Blood pressure reading over 130/85 mm Hg for over 2 months
c)
Blood pressure reading over 140/95 mm Hg for 2 months
d)
Blood pressure reading over 144/100 mm Hg at one visit
95.
What does treatment for essential hypertension focus on?
a)
Daily medication with mild diuretics
b)
Low-dose vasodilators
c)
Reduction of modifiable risks
d)
Combination of vasodilators and diuretics
96.
What is the focus of treatment for secondary hypertension?
a)
Smoking cessation program
b)
Strenuous exercise program
c)
Weight-loss program designed to reduce weight rapidly
d)
Specific etiologic disease
97.
What do blood pressure readings need to exceed for a patient to be diagnosed with hypertension?
a)
120/80 mm Hg
b)
130/90 mm Hg
c)
140/90 mm Hg
d)
150/100 mm Hg
98.
An 89-year-old patient is taking an antihypertensive medication. What should the nurse include when providing home care teaching?
a)
Get up out of bed slowly.
b)
Take hot baths.
c)
Report sexual dysfunction immediately.
d)
Stop taking the drug if side effects occur.
99.
Which lifestyle change has the greatest effect on reducing hypertension?
a)
Sodium restriction
b)
Reduction in alcohol consumption
c)
Daily aerobic exercise
d)
Weight reduction
100.
A nurse is educating a group of patients regarding Dietary Approaches to Stop Hypertension (DASH) diet. What recommendation should the nurse include as a source of protein and fat?
a)
lean red meat
b)
whole grains
c)
low fiber
d)
sugar
101.
A nurse is caring for a patient hemorrhaging from a peptic ulcer when the patient complains of a sharp sudden pain and has a rapidly deteriorating condition. What is the best first action of the nurse?
a)
Roll the patient flat and assess the vital signs.
b)
Notify the charge nurse.
c)
Suction the mouth.
d)
Prepare for intravenous infusions.
102.
A home health nurse is assigned to follow-up on a patient recently diagnosed with gastroesophageal reflux disease (GERD). Which primary symptom should the nurse take into consideration when updating the nursing interventions on this patient’s care plan?
a)
nausea
b)
vomiting
c)
anorexia
d)
heartburn
103.
When assisting with the admission of a new resident to a long-term care facility, a nurse notes a current history of peptic ulcer disease. What type of pain should the nurse expect the resident to describe?
a)
sharp
b)
dull
c)
burning
d)
stabbing
104.
Which instruction given to a patient with irritable bowel syndrome (IBS) should lessen discomfort?
a)
Eat only whole grains.
b)
Take small bites and chew well.
c)
Include dietary fiber in at least two meals per day.
d)
Drink herbal teas and low-calorie cola drinks.
105.
A nurse is caring for a 34-year-old patient admitted with severe diarrhea that has been going on for 2 weeks. What assessment should the nurse anticipate?
a)
Edema of lower legs and feet
b)
Hypotension and fatigue
c)
Hypertension and hunger
d)
Metabolic alkalosis
106.
Stool softeners are prescribed to promote normal elimination of feces. What is the most appropriate way to ensure effectiveness of this type of drug?
a)
Mouth care
b)
Ambulation
c)
Adequate fluid intake
d)
High-fiber diet
107.
Which foods should an individual with diverticulosis avoid?
a)
Peanuts and raspberries
b)
Apples and pears
c)
Red meat and dairy products
d)
Bran and whole grains
108.
A nurse is caring for a patient diagnosed with diverticulosis and assesses a temperature of 102.4° F and abdominal rigidity. What should the nurse be aware is the most likely cause of these signs and symptoms?
a)
infection
b)
constipation
c)
perforation
d)
obstruction
109.
What is necessary to restrict when the ammonia level of a patient diagnosed with cirrhosis continues to rise?
a)
protein
b)
carbohydrates
c)
fats
d)
water-soluble vitamins
110.
What actions should a nurse implement to correctly assess the progress of ascites on a daily basis?
a)
Daily weights and abdominal girth measurements
b)
Intake-output and electrolyte levels
c)
Blood pressure and pulse
d)
Daily temperatures and oxygen levels
111.
A high ammonia level contributes to hepatic encephalopathy. Which nursing implementation needs to be added to the nursing care plan as this level continues to increase?
a)
Mouth care
b)
Increased frequency of neurologic checks
c)
Oxygen saturation monitoring
d)
Intake and output
112.
What is the highest nursing priority outcome when planning the care for the patient with pancreatitis?
a)
Patient claims satisfaction with pain control.
b)
Patient states an understanding of medications needed on discharge.
c)
Patient’s activity level tolerance shows an increase.
d)
Patient can maintain a normal bowel pattern.
113.
Which observation by a nurse would indicate blocked flow of bile from the liver to the intestine?
a)
Clay-colored stools
b)
jaundice
c)
High blood pressure
d)
tachycardia
114.
A nurse is assessing a patient with renal impairment. Which facial characteristic is a sign of fluid retention?
a)
Broken blood vessels around the nose
b)
Periorbital edema
c)
Rash on cheeks and neck
d)
Facial twitching
115.
What is true about the urine osmolality when the kidney is adequately functioning?
a)
Equal to the osmolality of the serum
b)
Approximately half of the serum
c)
In a ratio of 10:1 with the serum
d)
Equal to the excretion of urea
116.
Which urine test provides the most accurate measurement of renal function?
a)
BUN
b)
Phosphates
c)
Specific gravity
d)
Creatinine
117.
A patient comes to the medical clinic with complaints of urgency, frequency, pain in the area of the symphysis pubis, and dark cloudy urine. What should the nurse suspect that this patient has?
a)
Urinary calculi, probably located in the ureter
b)
Kidney infection, most likely pyelonephritis
c)
Cystitis, probably from bacterial contamination
d)
Interstitial cystitis (although rare in a male patient)
118.
A home health patient diagnosed with cystitis has been prescribed the medication phenazopyridine (Pyridium). When providing patient teaching, what should the nurse caution the patient about?
a)
Staying out of the heat
b)
Nausea
c)
Staining of clothing
d)
Skin Rash
119.
What discharge teaching is appropriate for the nurse to provide to a patient who has had a lithotripsy?
a)
Check for edema of the legs and ankles.
b)
Watch for stone debris in the urine in 1 to 4 weeks.
c)
Decrease fluid intake to 1000 mL/day.
d)
Remain on restricted activity for a week.
120.
A nurse is caring for a patient with an atrioventricular (AV) fistula in the forearm and assesses that a trill is absent when palpating the venous side of the fistula. What action should the nurse implement?
a)
Inject the ordered amount of heparin into the fistula.
b)
Apply warm compresses and lower the arm below the heart level.
c)
Send the patient to dialysis for remedy.
d)
Report to the charge nurse that the fistula is occluded.
121.
A nurse assesses a Grey Turner sign in a patient who was admitted 2 days earlier after an automobile accident. What does this finding indicate?
a)
Retroperitoneal bleeding and bruising over the flank
b)
Hematuria with abdominal bruising
c)
Distended bladder with painful urination
d)
Bladder spasms on palpation of abdomen
122.
During a routine prenatal visit in the third trimester, a woman reports she is dizzy and lightheaded when she is lying on her back. The most appropriate nursing action would be to:
a)
Order an EKG.
b)
Report this abnormal finding immediately to her care provider.
c)
Teach the woman to avoid lying on her back and to rise slowly because of supine hypotension.
d)
Order a nonstress test to assess fetal well-being.
123.
A nurse is assessing a patient in the women’s clinic for Chadwick’s sign. How does the nurse perform this assessment?
a)
Auscultates the woman’s abdomen for fetal heart tones
b)
Inspects the vulva and vagina for a bluish tint
c)
Palpates the woman’s abdomen for a fluid wave
d)
Percusses the woman’s abdomen for uterine margins
124.
An instructor is explaining to students in the OB rotation that Goodell’s sign is which of the following?
a)
Bluish cervical discoloration
b)
Cervical softening
c)
False labor contractions
d)
Slowed fetal heart tones
125.
A pregnant woman in the perinatal clinic complains of occasional fainting. Which action by the nurse is best?
a)
Educate her that this is a frequent occurrence in pregnancy.
b)
Encourage her to carry small snacks with her at all times.
c)
Instruct her to lie down when the warning signs occur.
d)
Tell her to lie down on her left side if she has warning signs.
126.
A nurse is reviewing the prenatal care schedule for a woman who is 10 weeks pregnant. When does the nurse advise the woman to return for her next appointment?
a)
2 weeks
b)
4 weeks
c)
6 weeks
d)
8 weeks
127.
A student asks what the phrase “probable signs of pregnancy” means. The instructor provides which answer?
a)
Objective signs seen by an examiner; can be from other conditions
b)
Objective signs seen by an examiner; only caused by pregnancy
c)
Subjective signs reported by the patient; can be from other conditions
d)
Subjective signs reported by the patient; only caused by pregnancy
128.
A nurse reads in a pregnant woman’s chart that she is “para 3.” What does the nurse understand about this woman’s obstetrical history?
a)
Is now in her third trimester
b)
Currently pregnant with triplets
c)
Three babies born alive
d)
Three pregnancies delivered past 24 weeks of gestation
129.
A nurse is measuring the frequency of a laboring woman’s contractions. How does the nurse accomplish this correctly?
a)
Counts the number of contractions measured at the same intensity in 1 full minute
b)
Feels the fundus during the acme of the contraction and notes the fundal firmness
c)
Measures the beginning of one contraction to the beginning of the next contraction
d)
Measures the time from the beginning of one contraction to the end of the same contraction
130.
The nurse assesses a woman in labor and finds that her cervix is dilated to 9 cm. The nurse documents the woman to be in what phase of labor?
a)
first stage
b)
second stage
c)
third stage
d)
fourth stage
131.
The OB nurse assesses moderate baseline variability on the fetal heart monitor. What action by the nurse is best?
a)
Administer a bolus of IV fluids.
b)
Discontinue oxytocin, if it is being delivered.
c)
Document the findings in the woman’s chart.
d)
Perform fetal scalp or vibroacoustic stimulation.
132.
A nurse notes fetal heart rate decelerations that appear to start just prior to a uterine contraction with the fetal heart rate returning to normal by the end of the contraction. How does the nurse document this finding?
a)
Early deceleration
b)
Late deceleration
c)
Mild deceleration
d)
Variable deceleration
133.
A nurse suspects that a laboring woman has entered the second stage of labor by what assessment?
a)
Cervix is more than 50% dilated.
b)
Contractions are more frequent.
c)
Contractions are more intense.
d)
Woman has a strong urge to push.
134.
The perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This is best described as which stage of mothering?
a)
Taking charge
b)
Taking hold
c)
Taking in
d)
Taking time
135.
A nurse assesses a woman’s temperature 6 hours after a vaginal birth and finds it to be 100.4°F (38°C). What action by the nurse is best?
a)
Encourage the woman to drink plenty of fluids.
b)
Document the findings and notify the provider.
c)
Have the woman cough and deep breathe.
d)
Prepare to administer acetaminophen (Tylenol).
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