Final ?

Front 1

The nurse is aware that an infant is more at risk for dehydration because the infant:

Select one:

a. has kidneys that reabsorb water from the intravascular space.

b. has a larger body surface compared with body weight.

c. has fat that absorbs water.

d. urinates more frequently

Back 1

Infants are more at risk for dehydration because they have a larger body surface compared with body weight

Front 2

The nurse concludes these signs are the result of an inadequate supply of:

Select one:

a. potassium (K+).

b. calcium (Ca2+).

c. phosphates (PO43).

d. sodium (NA+).

Back 2

The symptoms of a potassium level below 3.5 mEq/L are abdominal pain, urinary retention, confusion, decreased reflexes, and ECG changes

Front 3

A patient with congestive heart failure has gained 1.1 pounds over the last 24 hours. The nurse is aware that this weight gain represents a fluid retention of _____ L.

Select one:

a. 1.0

b. 0.5

c. 0.25

d. 2.0

Back 3

Each 2.2 pounds of weight equals 1 kg, which in turn equals 1.0 L of fluid. Therefore, 1.1 pounds equals 0.5 kg and is equal to 0.5 L of fluid.

Front 4

The nurse instructs the patient on a vegetarian diet that protein intake can be supported by including complementary proteins in the diet with such foods as: (Select all that apply.)

Select one or more:

a. tofu stir-fried with vegetables.

b. bean soup with cornbread.

c. lean fish with green beans.

d. peanut butter on whole wheat bread.

e. apples and cheese.

Back 4

bean soup with cornbread

tofu stir-fried with vegetables

peanut butter on whole wheat bread

Front 5

The patient who is prescribed a diuretic for fluid-volume excess is discharged home. The patient verbalizes understanding of his disease process when he says:

Select one:

a. "I can put catsup on my scrambled eggs."

b. "I can snack on salted popcorn."

c. "I will snack on raisins."

d. "I will avoid apricots."

Back 5

"I will snack on raisins."

Front 6

A patient who is experiencing severe diarrhea is losing excessive bicarbonate ions. This patient is at risk for developing:

Select one:

a. metabolic alkalosis.

b. metabolic acidosis.

c. respiratory alkalosis.

d. respiratory acidosis.

Back 6

Metabolic acidosis can be caused by either an excessive loss of bicarbonate ions or an excessive retention of hydrogen ions

Front 7

A patient drank a cup of coffee, a half glass of orange juice, and half a carton of milk with breakfast. Using common equivalents of food containers as a guide, the nurse notes on the intake column of the intake and output sheet that the patient consumed _____ mL.

Select one:

a. 600

b. 360

c. 400

d. 420

Back 7

420

Front 8

A patient with a history of severe chronic obstructive pulmonary disease (COPD) is most likely to have:

Select one:

a. metabolic alkalosis.

b. respiratory alkalosis.

c. metabolic acidosis.

d. respiratory acidosis.

Back 8

People with COPD are prone to chronic respiratory acidosis because of the retained CO2.

Front 9

The protein requirement for the day is for a 132 lb. patient (formula)

Back 9

equal to the number of kilograms of weight (convert lb to kg) multiplied by 0.8 (i.e., 132/2.2 = 48).

Front 10

A patient with a serum potassium value of less than 3.5 mEq/L is

Back 10

hypokalemic

Front 11

The nurse would be sure the diet of a patient in an The nurse would be sure the diet of a patient in an extended care facility who has a large pressure ulcer on his sacrum would include foods rich in vitamin:

Select one:

a. C.

b. A.

c. E.

d. B1 (thiamine).

Back 11

Vitamin C helps protect the body against infections and promotes wound healing.

Front 12

A patient with healthy kidneys experiences metabolic alkalosis resulting from episodes of vomiting. The nurse takes into consideration that the kidneys can clear the alkaline substances and fully stabilize the patient's pH in approximately:

Select one:

a. 1 week.

b. 3 days.

c. 3 to 5 minutes.

d. 12 to 24 hours.

Back 12

The compensatory ability of the kidneys takes more time to work than does the compensatory action of the lungs; 3 days are needed for the kidneys to stabilize pH within normal range.

Front 13

The nurse emphasizes the dietary recommendations made by the American Heart Association is to limit cholesterol intake to _____ mg/day.

Select one:

a. 425

b. 500

c. 400

d. 300

Back 13

The American Heart Association recommends an intake of cholesterol to 300 mg/day or less

Front 14

The patient asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that a(n):

Select one:

a. ileostomy has effluent that is more formed, whereas a colostomy has effluent that is liquid.

b. colostomy is an opening into the colon, whereas an ileostomy is an opening at the ileum.

c. ileostomy requires irrigating, whereas a colostomy requires catheterizing.

d. ileostomy is performed to remove stool from the colon, whereas a colostomy is the removal of lower portions of bowel, diverting intestinal contents.

Back 14

The colostomy is an opening into the colon, with formed effluent requiring irrigation, whereas the ileostomy is an opening in the ileum, with liquid effluent requiring catheterizing

Front 15

An adult male patient who cannot void has an order to have a urinary catheter inserted. Which size catheter would be most appropriate to use?

Select one:

a. 16 French

b. 22 French

c. 12 French

d. 18 French

Back 15

The average-sized urinary catheter used for an adult male is 18 to 20 French.

Front 16

The statement made by a patient that would delay a scheduled CT scan would be:

Select one:

a. "I have terrible claustrophobia."

b. "I have just been started on metformin."

c. "I have an implanted pacemaker."

d. "I am allergic to penicillin."

Back 16

"I have just been started on metformin."

Front 17

nurse is digitally removing a fecal impaction from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:

Select one:

a. temperature increases from 98.8° F to 99.0° F.

b. pulse rate decreases from 78 to 52 beats/min.

c. blood pressure increases from 110/84 to 118/88 mm Hg.

d. respiratory rate increases from 16 to 24 breaths/min.

Back 17

pulse rate decreases from 78 to 52 beats/min:

bradycardia

Front 18

For the patient who just had a liver biopsy performed, the nurse should position him:

Select one:

a. prone for 1 hour.

b. on his left side-lying for 4 hours.

c. supine for 3 hours.

d. on his right side-lying for 2 hours.

Back 18

The patient should be turned onto the right side for 2 hours after the procedure to minimize bleeding from the site.

Front 19

The nurse is aware that patients who are not candidates for magnetic resonance imaging (MRI) include patients with: (Select all that apply.)

Select one or more:

a. bleeding tendencies.

b. a hip prostheses.

c. allergy to iodine.

d. cardiac pacemakers.

e. previous radiological treatment.

Back 19

hip prostheses

cardiac pacemakers

Front 20

A patient who is on an anticoagulant (Coumadin) asks, "What did the physician mean when he said I was to have my blood tested every 2 weeks?" The nurse explains, "It is important to monitor the effects of the drug to see how long it takes your blood to clot. The blood test the physician was talking about is the:

Select one:

a. erythrocyte sedimentation rate (ESR)."

b. activated partial thromboplastin time (APTT)."

c. complete blood count (CBC)."

d. international normalized ratio (INR)."

Back 20

international normalized ratio (INR)."

Front 21

The nurse explains to the patient that the significance of the hematocrit is that it:

Select one:

a. will decrease when the patient is in shock.

b. indicates the number of circulating white blood cells.

c. refers to the separation of blood cells from plasma.

d. indicates the value of the hemoglobin.

Back 21

The hematocrit refers to the relationship of blood cells to plasma in the circulating volume.

The correct answer is: refers to the separation of blood cells from plasma.

Front 22

The nurse obtaining a wound culture would:

Slect one:

a. rotate the swab vigorously in the wound bed.

b. rinse the exudate on the swab with normal saline.

c. use clean gloves.

d. place the swab in the culture tube without touching the sides.

Back 22

place the swab in the culture tube without touching the sides.

Front 23

The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing intervention in the care of such a patient would be to:

Select one:

a. place a graduated cylinder near the commode.

b. obtain an order for indwelling urinary catheter.

c. attach a urinary leg bag.

d. place a sieve over the commode.

Back 23

place a sieve over the commode.

Front 24

The nurse caring for a severely dehydrated patient who has a Foley catheter in place assesses the patient to confirm adequate urine perfusion by the urine output of _____ mL.

Select one:

a. 30

b. 60

c. 15

d. 45

Back 24

30 mL

Front 25

An elderly male patient needs to have a condom catheter applied. An appropriate technique is to:

Select one:

a. apply povidone-iodine to the penis before catheter application.

b. apply an adhesive strip in a circle around the base of the penis.

c. shave the perineal area before beginning.

d. leave 1 to 2 inches between the tip of the penis and the drainage part of the catheter.

Back 25

leave 1 to 2 inches between the tip of the penis and the drainage part of the catheter.

Front 26

An ambulatory clinic patient telephones to report diarrhea and to ask for advice on medication to manage it. The best response by the nurse is, "Do not use antidiarrheal medication for longer than _____ hours without calling back for an appointment."

Select one:

a. 96

b. 72

c. 48

d. 24

Back 26

48 hours

Front 27

An adult patient has an order to have his urinary catheter irrigated with normal saline. The nurse plans to draw up how much solution into the sterile irrigation syringe?

Select one:

a. 30 to 40 mL

b. 1 to 20 mL

c. 50 to 60 mL

d. 20 to 30 mL

Back 27

The appropriate amount of solution to draw into the syringe for irrigation is 30 to 40 mL in an adult patient, which provides effective irrigation without risking overdistention of the bladder.

Front 28

A patient wants to know what was meant when the doctor said that his white blood cell (WBC) count had a shift to the left. The nurse explains that a shift to the left indicates:

Select one:

a. an increase in the number of immature WBCs.

b. the relative effectiveness of the antibiotic therapy.

c. an improvement in an infectious process.

d. that the infection is viral in nature.

Back 28

An increase in immature WBCs causes the left side of the report to show large numbers and indicates an infection.

Front 29

A nurse is caring for a patient with prostate enlargement who has an indwelling catheter. As the nurse is attaching a portion of the catheter to the patient's abdomen, the patient asks why this is being done. The correct response is:

Select one:

a. "This will prevent the Foley catheter from kinking."

b. "Taping it in this way enhances the draining of your bladder."

c. "Taping the catheter to your abdomen will prevent pulling on the meatus."

d. "The catheter can't be pulled out if it is taped to your abdomen."

Back 29

When the catheter is taped to the abdomen, it prevents pulling on the meatus, thus decreasing irritation.

Front 30

A patient who is scheduled for a cardiac catheterization asks what the catheterization will reveal that an electrocardiogram would not. The nurse explains that the catheterization shows:

Select one:

a. the entire heart to find evidence of cancer.

b. electrical activity of the heart action.

c. oxygen concentration at various sites.

d. heart rhythm.

Back 30

Cardiac catheterization is a procedure that determines the function of the heart, valves, and coronary circulation with its attendant oxygen concentration.

Front 31

A nurse is assisting a patient with a new continent ileostomy to catheterize the internal reservoir to drain the ileostomy. When the catheter meets resistance from the internal valve, the nurse should:

Select one:

a. coat the opening with petroleum jelly or a water-soluble lubricant.

b. withdraw the catheter and start again with a new one.

c. have the patient take a deep breath and apply gentle pressure over the area.

d. ask the patient to bear down and hold her breath.

Back 31

have the patient take a deep breath and apply gentle pressure over the area.

Front 32

The nurse instructs a patient with a new colostomy against eating food that may cause an obstruction. These foods include: (Select all that apply.)

Select one or more:

a. cucumbers.

b. tomatoes.

c. spicy foods.

d. whole-kernel corn.

e. shrimp.

Back 32

whole-kernel corn

tomatoes

shrimp

Front 33

A patient who underwent prostate surgery is admitted to the surgical unit with a catheter that is used to provide continuous irrigation. The nurse recognizes this catheter is a(n):

Select one:

a. de Pezzer catheter.

b. Coudé catheter.

c. Alcock.

d. Malecot.

Back 33

An Alcock catheter is used for bladder irrigation following prostate surgery.

Front 34

The patient who was admitted after vomiting for 3 days would show an abnormally low blood pressure because of a fluid shift from:

Select one:

a. intravascular to the interstitial.

b. intracellular to the extracellular.

c. interstitial to intravascular.

d. interstitial to the intracellular.

Back 34

If intravascular fluid, a type of extracellular fluid within the blood vessels, shifts from the plasma in the vascular space out to the interstitial space, a drop in blood volume occurs.

Front 35

The nurse takes into consideration that a patient who abuses alcohol is at risk for a vitamin deficiency in:

Select one:

a. ascorbic acid.

b. thiamine.

c. iron.

d. cyanocobalamin.

Back 35

Thiamine deficiency is often present in patients who abuse alcohol.

Front 36

When caring for a patient receiving total parenteral nutrition, the nurse knows that it is essential to:

Select one:

a. monitor for blood glucose.

b. check for flow rate every shift.

c. order electrolytes daily.

d. monitor IV site every shift.

Back 36

Total parenteral nutrition contains a high concentration of glucose, and monitoring blood glucose every 6 to 8 hours will determine patient tolerance.

Front 37

A 10-month-old infant has had watery green stool for 2 days and refuses the bottle. The nurse is aware that the primary concern for this baby is:

Select one:

a. diaper rash.

b. weight loss.

c. metabolic acidosis.

d. metabolic alkalosis.

Back 37

Loss of bowel contents leads to metabolic acidosis. The child will lose weight and will probably have diaper rash, but the primary concern is the electrolyte imbalance.

Front 38

The nurse is aware that the patient who suffered a brain injury with cerebral edema will most likely receive a fluid that is:

Select one:

a. enhanced with vitamin B.

b. hypertonic.

c. isotonic.

d. hypotonic.

Back 38

Hypertonic fluids draw fluid from the intracellular space and reduce edema.

The correct answer is: hypertonic

Front 39

A nurse is assisting a patient with a new continent ileostomy to catheterize the internal reservoir to drain the ileostomy. When the catheter meets resistance from the internal valve, the nurse should:

Select one:

a. ask the patient to bear down and hold her breath.

b. coat the opening with petroleum jelly or a water-soluble lubricant.

c. have the patient take a deep breath and apply gentle pressure over the area.

d. withdraw the catheter and start again with a new one.

Back 39

For some patients the taking of a deep breath relaxes muscles and allows passage of the catheter.

The correct answer is: have the patient take a deep breath and apply gentle pressure over the area