1
Q
Ch. 8
Best action to take when there is a language barrier?
A
Retrieve an interpreter
2
Q
Ch. 51
S/sx of HHNKS?
A
Extreme thirst, dehydration with poor skin turgor, dry mucus membranes, mental changes, hypotension, tachycardia, fever, hypokalemia, and hyponatremia
3
Q
Ch. 51
Nurse is describing action of insulin in the body to a client newly diagnosed with type 1 diabetes. What would the nurse explain as being the primary action?
A
It carries glucose into body cells.
4
Q
Ch. 20
With first generation antihistamines, what are common side effects?
A
Drowsiness, dry mouth, urinary hesitancy
5
Q
Ch. 20
Safety warnings for nurses for the older adult taking first generation antihistamines
A
Increased fall risk d/t sedative side effects, teach client to refrain from driving or using dangerous equipment when drowsy
6
Q
Ch. 21
What might be revealed on a chest x-ray for a client with occupational lung diseases?
A
Fibrotic changes in lungs
7
Q
Ch. 20
What might the parent report in a child that has enlarged adenoids?
A
They snore
8
Q
Ch. 22
When is the presence of a third heart sound normal?
A
In pediatric clients
9
Q
Ch. 22
Which change of condition may indicate potential increasing R sided heart failure? SATA.
A
JVD
Increased dyspnea
Increased palpitations
Increased weakness on ambulation
10
Q
Ch 22.
The nurse is caring for a post cardiac cath client in recovery. Which of the following is a priority nursing consideration?
A
Dressing assessment, bleeding
11
Q
Ch. 22
How does blood circulate through the body? Place the pattern of circulation in the correct order beginning in the right atrium. Using these options… pulmonary vein, pulmonary artery, left atrium, right ventricle, aorta, left ventricle.
A
Right ventricle
Pulmonary artery
Pulmonary vein
Left atrium
Left ventricle
Aorta
12
Q
Ch. 22
When auscultating a client’s heart sounds the nurse notes a murmur at the left fourth intercostal space and lateral to the sternum. Which valve would the nurse document this?
A
Tricuspid valve
13
Q
Ch. 22
Nurse is assessing a client that has dyspnea and considering the process of gas exchange. Which structural characteristic of capillaries best enables gas exchange at the cellular level?
A
Capillaries are one cell-layer thick.
14
Q
Ch. 22
Nurse is reviewing lab work for a client whose CO2 level is elevated. You are most correct to suspect an impairment of the?
A
Alveoli
15
Q
Ch 22.
Client asks the nurse how a heartbeat occurs. Nurse explains the condition system of the heart beginning with the SA node. Place the conduction sequence of the heart in order.
A
AV node
Bundle of His
Bundle branches
Purkinje fibers
16
Q
Ch. 23
What should the nurse tell the students about the inflammatory response in thrombophlebitis?
A
The inflammatory response is caused by accumulated waste products in the blocked vessel.
17
Q
Ch. 23
Caring for a client with Buerger’s disease. What is most important to teach a client with this?
A
Smoking cessation
18
Q
Ch 23.
You are caring for a client who is scheduled for sympathectomy. What disease process would a sympathectomy be performed to relieve vasospasm?
A
Thromboangiitis obliterans (Buerger’s disease)
19
Q
Which arrhythmia is normal but proceeds normally through the conduction pathway at a faster-than-usual rate (100-150 bpm)?
A
Sinus tachycardia
20
Q
Ch. 26
Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent?
A
Disrupting the heart during period of ventricular repolarization
21
Q
Ch 24.
Client is being evaluated for mitral stenosis vs mitral insufficiency. Which symptom would the nurse find in either?
A
Murmur
22
Q
Ch. 25
When administering lasix nurse should be cautious of what in the client?
A
Monitor serum potassium levels, dehydration/encourage fluids, can increase fall risk because hypotensive side effects
23
Q
What is an important instruction for a client who is diagnosed with Raynaud’s disease to prevent an attack?
A
Avoid situations that contribute to ischemic episodes.
Keep the hands warm avoid the cold if possible (bc this is the cause)
Avoid triggers
24
Q
Most common cause of peripheral arterial problems in the older adult?
A
Atherosclerosis
25
Client presents with characteristics of atherosclerosis. What characteristic would the client display?
Fatty deposits in the lumen of arteries
26
In tx of CAD medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-blockers in the nursing management of CAD?
To decrease workload of the heart
27
Ch. 25
What is the action/intended use of atenolol?
Reduces HR and decrease consumption of oxygen by myocardium, helps prevent angina attacks
28
If a client has mitral valve insufficiency and has developed HF and pulmonary edema what is the best tx?
Correct the problem, surgery
29
Ch. 27
What is one subject you would need to include in your presentation as a possible consequence of untreated chronic HTN?
Stroke
30
What type of blood can an O+ client get?
O+ and O-
31
S/S of chronic anemia
Postural hypotension, pallor, fatigue, chills, rapid heart and respiratory rates
32
S/S of acute anemia
Signs of hypovolemic shock – extreme pallor, tachycardia, hypotension, reduce urine output, altered consciousness 
33
What type of immunity do you get from measles?
Naturally acquired active
34
If a client has sudden Joint pain and swelling with no identifiable cause what disorder is this?
Autoimmune disorder
(Body attacking itself)
35
How is HIV transmitted?
Blood, semen, Breastmilk, vaginal secretions 
36
What happens in HIV when a markedly decreased T4 cell count goes low and infections occur?
HIV is converted to———>> AIDS 
37
What does flaccid mean?
Floppy and doesn’t respond to stimuli
38
What is cranial nerve eight?
Ears
39
What is cranial nerve 2?
Eyes
40
What is cranial nerve 11?
Shoulders
41
What is cranial nerve 12?
 Tongue
42
What does somnolent mean?
Response to stimuli but is delayed
43
What indicates increased intracranial pressure?
stiff neck, systolic goes up wich widens pulse pressure
44
What kind of stroke do we give TPA for ?
ischemic and given within 3 hours of onset IV
45
When do ischemic strokes occur?
24-48 hrs they slowly develop
46
What happens in a hemorrhagic stroke?
A sudden drop in BP, breathing, and heart rate
47
What kind of stroke causes right side weakness?
 Left side stroke
48
What kind of stroke causes left side weakness?
Right side stroke
49
S/S of spinal shock?
Immediate loss of all cord functions below the point of injury, hypotension, bradycardia, warm, dry skin 
50
 What does poikilothermic mean?
Body temperature of the environment
(Client can’t maintain body temp)
51
T/F
With spinal shock ; The client doesn’t sweat below the level of injury
True
52
What is the most important question to ask if a client has a head injury?
Do you take any blood thinners?
53
What skull fracture is the most dangerous?
Basillar bc it interferes with spinal cord
54
What is the role of the occupational therapist?
ADLs and exercise muscles under voluntary control 
55
What is important when administering an enema?
instill slowly, do not advance high in colon, wait appropriate amount of time, take client to bathroom when needed, when you put in suppository tape cheeks to ensure it is inserted
56
What happens if you don’t have an eye quiver during a caloric stimulation test?
It means there is an inner ear disorder
57
Macular degeneration affects what type of vision?
Central vision
58
An elderly client with macular degeneration Has received injections of angiogenesis Inhibitors. What assessment finding would indicate the condition is worsening?
Central vision impairment
59
A client is diagnosed with Ménière’s disease. The nurse would most likely expect the client to report which of the following?
Vertigo, nystagmus
60
Redness of ear canal, pus, and normal otitis externa indicates what?
Ear infection
61
What type of hearing loss with an ear infection may occur and patient will complain of?
Conductive hearing loss and pain and discomfort
62
Why be careful with PPI medications?
Will cause weakened bones
63
Why should you be careful when taking Pepcid?
Can affect the heart and you shouldn’t take more than 2 wks
64
Prochlorrperazine antiemetic intended use?
Control N/V by inhibiting vomiting center
65
In a client with chron’s disease why can’t they have an antidiarrheal medication with atropine?
It is opiate based, will eat their guts
66
The instructor is teaching a group of students about Chron disease and antidiarrheal agents. The instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-based antidiarrheal?
Diphenoxylate with atropine
67
A client scheduled for a total cholectomy has been taking the immunosuppressive agent, azathioprine (Imuran). When should the client be told to discontinue the medication to prevent negative effects on tissue healing?
1 month before surgery
68
A client has choleythiasis, they do not absorb which vitamins? They will be deficit in these.
ABDEK (fat-soluble)
69
Client is status post resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean?
The client is not responding to stimuli
70
Client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
VIII (8)
71
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?
XII (12)
72
The nurse is assessing the assigned client’s LOC during morning rounds. Nurse speaks the client’s name, strokes the client’s hand, and moves the client’s shoulder. There is a delay, and then the client states, “what do you want?” Which LOC should the nurse document?
Somnolent
73
What body fluids does the nurse inform them will transmit HIV?
Semen, breast milk, blood, and vaginal secretions
74
Clients T4-cell count is 200, and the client has been diagnosed with pneumocystitis pneumonia. What does this indicate to the nurse?
The client has converted from HIV infection to AIDS
75
Client is experiencing chronic anemia. What sx does the nurse expect to find for this client when collecting objective data?
Postural hypotension
76
Albumin is a protein in the plasma portion of the blood. Under normal conditions, albumin cannot pass through the wall of a capillary. What significance is this for the vascular compartment?
Helps retain fluid in the vascular compartment
77
The nurse will be assisting the physician with a bone marrow aspiration. Where should the nurse cleanse, clip hair, and drape the skin prior to the procedure?
Over the posterior superior iliac crest
78
Which condition is characterized by the formation of abnormal spongy bone around the stapes?
Otosclerosis
79
What is blood pressure?
Force of blood against arterial walls
80
Client develops crackles bilaterally; 3-pillow orthopnea, and S3 heart sound; and a cough with pink, frothy sputum. What do these signs and symptoms indicate?
Development of left sided heart failure
81
When a nurse is caring for a client diagnosed with neuro deficit who has begun responding to those around him, what therapy should the nurse suggest to help strengthen muscles that are under voluntary control?
Occupational therpy
82
The nurse is caring for a client with paraplegia in the acute care setting. Client’s last BM was 4 days ago. Which action is best to assist client in accomplishing the goal of an enema?
Instill enema slowly (1-2 oz at a time) followed by a waiting period.
83
Health teaching for a patient who suffers from motion sickness would include recommending the use of which of the following OTC drugs?
Dramamine
84
A client is prescribed amitriptyline, an antidepressant for incontinence. The nurse explains that this drug is an effective tx for which reasons? SATA.
Increases bladder neck resistance
Decreases involuntary bladder contractions
85
Which stage of a pressure injury is exhibited by deeply ulcerated tissue, exposing muscle and bone?
Stage IV
86
Incubation period for mono
30-50 days
87
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?
Naturally acquired active immunity
88
When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?
Artificially acquired active immunity
89
Client has had mumps when he was 9 yrs old. He had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?
Naturally acquired active immunity
90
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?
Passive immunity transferred by the mother
91
Client will be receiving a hep B vaccine series prior to employment in a dialysis center. What type of immunity will this provide?
Artificially acquired active immunity
92
Which immunoglobulin promotes release of vasoactive chemicals such as histamine when a client is having an allergic reaction?
IgE
93
A client has been having joint pain and swelling and is diagnosed with rheumatoid arthritis. The sx began suddenly without any identifiable cause, and client has significant joint destruction. What type of disease is this considered?
Autoimmune
94
Cranial nerve XI (11)
Head and shoulder movement
95
Cranial nerve II (2)
Optic nerve; sight
96
Which of the following assessment findings indicate an increasing ICP in a client with head trauma? SATA.
Elevated systolic BP
Wide pulse pressure
Stiff neck
97
The nurse knows that when a client experiences a stroke on the right side of the brain common deficits include what?
L side hemiplegia
Tendency to distractability
Neglect of objects and people on the left side
98
A CVA is suspected, the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA and a client with CVA requires which of the following criteria?
Presence of an ischemic stroke
Administered within 3 hours of onset of symptoms
99
Which nursing assessment finding is most indicative of a hemorrhagic stroke?
Sudden onset of breathing alterations.
pt drops to ground, breathing, BP, hr, drops initially.
100
Client is admitted with weakness, expressive aphasia, and right hemianopia. The MRI reveals an infarct. The nurse understands the symptoms to be of which of the following findings?
Left-sided CVA
101
Nurse suspects that a newly admitted client is in spinal shock. What is a sx of spinal shock? SATA.
Bladder distention
Poikilothermia
No perspiration below the level of injury
102
Important question to ask a client with a head injury?
Do you take any blood thinners?
103
The ICU unit has four clients received from a motor vehicle accident. Which client would the nurse assess first?
Client with a basilar skull fracture
104
Physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the test is indicative of what?
Inner ear disorder
105
Which structure within the eye is noted to drain fluid from the anterior chamber?
Canal of Schlemm
106
A client with fracture develops compartment syndrome that requires surgical intervention. The nurse would prepare client for which?
Fasciotomy
107
Client diagnosed with first degree strain. How would the nurse differentiate the first-degree strain from other strains?
Client has some edema, with muscle spasms but is able to walk without assistive devices.
108
A client has a dysfunction in one of his glands that is causing decrease in the level of calcium in the blood. The nurse know which gland should be evaluated for dysfunction?
Parathyroid gland
109
Client with hypoparathyroidism experiences muscles spasms/tingling what might they need?
Calcium
110
Which statement by the client needs further clarification by the nurse about herpes zoster?
“Once I get the infection, I cannot get it again.”
111
Cause of shingles?
Reactivated virus
112
A 65 yr old female after transvaginal bladder suspension c/o pelvic pain and voiding difficulty. Which dx is appropriate?
Impaired urinary elimination
113
Post op day 2 after a cystectomy with ileal conduit, the stoma is dark purple and cool, and urine output is minimal. What should the nurse do?
Notify surgeon immediately.
114
A student asks why bladder obstruction causes upper tract problems. Which explanation is correct?
Hydonephrosis and renal impairment
115
A nurse is assessing a client with complaints of urge incontinence, expects the client to state which of the following?
“I cannot stop the urine from coming when I have to urinate.”
116
Client is receiving a diuretic medication as part of the tx for heart disease. Which nursing interventions related to the diuretic would be appropriate for the LPN to implement from the care plan?
Accurate I & O
Daily weights
Vital signs 4x/day
117
A client has an indwelling catheter after a total hip arthroplasty and is unable to void after the catheter is removed. The LPN is to perform an in-and-out catheterization. The client asks why the indwelling catheter cannot be replaced and stay in until it is easier to get in and out of bed. Which is correct for the LPN to tell the client?
Having a catheter puts you at risk for UTIs
118
Why are clients who are incontinent prescribed antidepressants?
It decreases contractions of bladder and increases bladder, neck, resistance
119
What stage of a pressure sore exposes muscle?
Stage 4
120
What skin disorder developed years after an infection with varicella(chickenpox)?
Shingles
121
T/F
Herpes lies dormant in nerve roots and can reactivate
True
122
What do the parathyroids regulate?
Calcium
123
What do clients with hypoparathyroidism experience?
Muscle spasms and tingling.
124
Why is it important to give calcium to a client with hypoparathyroidism?
because their body cannot maintain normal calcium levels on its own
125
A client with a fracture developed compartment syndrome that requires surgical intervention the nurse would most likely prepare the client for which of the following?
Fasciotomy
126
A client is diagnosed with a first degree strain of the left ankle related to running 5 miles a day how would the nurse differentiate the first- degree strain from other strains and sprains
The client has some edema of the left ankle With muscle spasms But is able to walk without assistive devices
127
A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion
He has been typed and crossmatched for 2 units of packed red blood cells and found to
have type O blood. What type of blood will the nurse administer to this client?
Type O
128
A client is admitted to the emergency department with significant blood loss. The physician orders 2 units of packed red blood cells to be transfused immediately.
Which blood groups would be compatible with his O Rh-positive blood group?
Rh-positive or O Rh-negative
129
The nurse is performing a skin assessment on a client who points out a small, round, flat area of skin that is a different color than the surrounding tissue. What term should the nurse use to document this finding?
Macule
130
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus.
How would the nurse document this type of lesion?
Pustule
131
A patient has sustained a left femur fracture in a skiing accident. When is the nurse aware that the complication of a fat emboli typically occurs and should be monitored for closely
48-72 hours
132
A client comes in with a head injury, what would alert the nurse when looking at the clients MAR?
Client is on Coumadin (warfarin)
133
Reason for chest tubes after thoracic surgery
Draining secretions, air, and blood from the thoracic cavity
134
The nurse obtains report on a client with symptoms of sharp chest pain and tachycardia.
The nurse begins to collect and critical think through assessment data. Which client symptom distinguishes between a myocardial infarction and myocarditis?
Relief of pain when sitting up
135
What is hematopoiesis?
Manufacture and development of red blood cells
136
Major fnx of erythrocytes?
Transportation of O2 to the tissues and removal of CO2
137
Why would it be important to assess a client for fractures with multiple myeloma?
Osteoclasts breakdown bone cells so pathologic fractures occur
138
The nurse suspects that a newly admitted client is in spinal shock. What is a symptom(s) of spinal shock? SATA.
Bladder distention, Poikilothermia, No perspiration below the level of the injury
PNE 162
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