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Final Exam NUR2571 : Professional Nursing II Exam /
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Question I A client who has completely eliminated fats from the diet should be assessed for a deficiency of: l. bile.
- minerals. salt. vitamins A, D, E, and K. Question 2 The nurse is planning care for a client diagnosed with Graves' disease. Which of the following nursing interventions would be appropriate for this client's care? Provide frequent meals. Question 3 A pregnant client is receiving treatment for hyperthyroidism. Which of the following medications would the Nurse expect to see? Propylthiouracil Question 4 Which statement made by the older adult client alerts the nurse needs for further assessment specifically for fluid and electrolyte imbalances? "l don't drink liquids after 5 PM so I dont have to get up at night." A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause?
b; "Do you usc diuretics or laxatives?"
b. "Let's see if the occupational therapist can provide you with some utensils that are easier for you to use Question 11 Which action by the nurse is most effective to prevent becoming exposed to the Human Immunodeficiency Virus? Always use standard precautions with all clients in the workplace Question 12 The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. Which is the best nursing intervention for this client? Initiate seizure precautions with padded siderails Question 13 A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The client's purified protein derivative test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate? Place the client in Airborne precautions Question 14 A client who is receiving Highly Active Antiretroviral Therapy tells the nurse, "The doctor said that my viral load is reduced. What does this mean?" What is the nurse's best response? The HAART medications are working well right now Question 15 I out of I points What intervention does the nurse implement to provide for client safety during intradermal allergy testing? a Stay with the client and ensure that emergency equipment is in the room.
Question 16 A client has received diphenhydramine and is currently oriented but drowsy. What is the best action for the nurse to take? Document the response and continue to monitor. . Question 17 0 out of I EX)ints A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable due to acute congestion. Which action by the nurse is most appropriate? b Have another nurse call the Rapid Response Team. question 18 Which skin integrity intervention best assists a client with pruritus? a. 'Keep your fingernails cut short and keep them clean."
. "Drinking extra fluids decreases stimulation of itch receptors." c. "Wear soft. breathable clothing made from material like cotton." d."Avoid immersing the areas in water and dry thoroughly aftcr bathing." Question 19 A client has a furuncle in the axilla. Which statement by the client indicates a good understanding of how to care for this condition? a. "I'll apply cortisone cream to reduce the inflammation." b."l will squeeze the lesion until all pus is removed." c."l'll keep my arm down at my side to prevent spread." "l will cleanse the area and apply warrn compress and antibiotic cream." Question 20 The nurse is caring for four clients with asthma. Which client does the nurse assess first? a. Client with a barrel chest and clubbed fingernails
I out Of I points The nurse assesses a client with pneumonia and notes no audible lung sounds on the left side and decreased lung expansion. What is the nurse's best action? Further assess lung sounds, Vitals, Notify Healthcare Provider Question 25 I out of I points Which is the highest priority goal to set for a client with pneumonia? a. Absence of cyanosis b Maintenance of Sa02 of 95% c. Walking 20 feet three times daily d. Absence of confusion ANS: B Question 26 I out of I points A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? Decrease In tissue perfusion Question 27 The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? c• I have to stop halfway up the stairs to catch my breath." Question 28 The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure?
b My shoes fit really tight lately." Question 29 A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a Place the client in a high Fowler's position. Question 30 0 OF 1 The client with heart failure has been prescribed intravenous nitroglycerin and furosemide for pulmonary edema. Which is the priority nursing intervention? b Monitor the client's blood pressure. Question 31 A client is taking triamterene-hydrochlorothiazide and furosemide. What assessment finding requires action by the nurse? Potassium of 2.9 mEq/L ANS: D Question 32 I out or I A client with high cholesterol is beginning treatment with simvastatin. What priority instruction does the nurse give this client? Report any muscle tenderness to your health care provider." Question 33 I out Of I The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with? Peripheral arterial disease Question 34 I of I
O out of I B"ints Which risk factor does the nurse assess for to determine a client's cause of anemia? Chronic alcoholism Question 40 A client is newly diagnosed with sickle cell anemia. Which clinical manifestation does the nurse expect to see in this client? fatigue weakness general malaise skin pallor, tachycardia, SOB Dyspnea with activity Question 41 I out or I points A client is newly diagnosed with sickle cell anemia. Which information does the nurse included in the client's discharge instructions? Be aware of symptoms crisis Question 42 I out of I points A client who is receiving a unit of red blood cells begins to report chest and lower back pain. Which action does the nurse take first? Stop the transfusion, Question 43 The nurse is preparing to transfuse a third unit of red blood cells to a client. Which laboratory result is the nurse most concerned about? Potassium level of 5L5 mg/dL Question 44 I out of I points A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity?
Tonic-clonic seizure Question 45 0 out of I points The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client? Elevation of the back rest will help with aspirations Maintaining the back rest elevation at greater than 30 degrees Question 46 I out of I B)ints The nurse is providing health education at a community center. Which instruction does the nurse include as part of client education for the prevention of low back pain? a Participate in an exercise program to strengthen muscles. " Question 47 I out of I points Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? Respiratory pattern and airway Question 48 (J or I r»ints The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client? Progressive, ascending weakness and paresthesia Question 49 0 out of I rx»ints The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the
evaluated." Question 55 I out of I The nurse is caring for a client with Méniére's disease. The client asks the nurse how to prevent another acute episode from occurring. Which is the nurse's best response? "Stop or reduce smoking " Question 56 I out of I points The nurse conducts a physical assessment for a client with abdominal pain. Which finding I leads the nurse to suspect appendicitis? Severs. steady right lower (RLQ) pain or Positive obturator and iliopaoA muscle test Question 57 The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? Heart rate and rhythm Question 58 The nurse reviews a health teaching for a client with Crohn's disease, Which instruction does the nurse provide for the client? A. "You should have a colonoscopy every few years." Question 59 I out of I rx»ints The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed?
"l will take a senna laxative at bcdtime to avoid becoming constipated. " Question 60 I of I rx-ants The nurse is caring for a client who is a vegan and has developed B 12 deficiency. Which foods does the nurse encourage the client to incl e in the diet? animal proteins like eggs fortified cereal tofu Question 61 I out of I mints The nurse is caring for a client who was started on total parenteral nutrition 2 days previously. The client reports blurred vision, dry mouth, and frequent urination. Which is the nurse's Asssess client blood sugar Question 62 I out of I points Which dietary modification does the nurse provide for a client with hyperthyroidism? a. Decreased calories and proteins and increased carbohydrates b. Elimination of carbohydrates and increased proteins and fats c Increased calories, proteins, and carbohydrates Supplemental vitamins and reduction of calories Question 63 I out of I points A client has hypothyroidism and has been started on levothyroxine. Which assessment finding leads the nurse to conclude that the treatment is effective? Heartrate is 70 beats/min and regular. Question 64
A client has the following arterial blood gases: pH 7.30, HC03— 17 mEq/L, PC02 25 mm Hg'. P02 98 mm Hg. Which intervention by the nurse is most appropriate? c Assist the physician in determining the cause. Partially compensated metabolic acidosis Question 69 I out or I Ix»ints A client has the following arterial blood gases (ABGS): pH 7.30, HC03— 22 mEq/L, PC02 55 m Hg, P02 86 mm Hg. Which intervention by the nurse takes priority? a Assessing the airway ANS. A Question 70 A client asks the nurse if there is an antihistamine that does not cause drowsiness. Which of the following medications would this client most likely prefer to treat allergic rhinitis?
- Fexofenadine Fexofenadine (Allegra) is a second-generation antihistamine, and second-generation antihistamines exhibit less sedation than first-generation medications such as diphenhydramine, chlorpheniramine Question 71 I out of I The nurse is assessing a client diagnosed with asthma. The client's breath sounds initially had wheezing but are diminishing until no audible sounds are heard. This has occurred because? swelling has increased, and it has blocked airways. Question 72 O of I points The nurse is to collect a stool specimen from a client diagnosed with cystic fibrosis. The nurse would expect to see?
bulky, foul-smelling stool. Question 73 O out Of I r»ints When the nurse is analyzing the results of a patient's arterial blood gases, which finding indicates the need for most immediate action? 'The partial pressure of oxygen in arterial blood (Pa02) is 59 mm Hg. Question 74 A client is receiving treatment for the diagnosis of hemophilia A. Which of the following should the nurse assess in this client? Question 75 I out or I F»ints A client is experiencing a transplantation rejection. The nurse realizes that this rejection is which type of hypersensitive reaction? Type 4 Question 76 I of I B'ints A client is experiencing intense pruritus from contact dermatitis. Which of the following would be helpful for this client? Administer hydroxyzine HCL as prescribed. Hydroxyzinc HCL is an antihistamine used to relieve pruritis associated with contact dermatitis. Covering the area with a warm compress could cause the area to itch more. The client should be instructed to avoid scratching. Ambulation will not help reducc the itchiness. Question 77 I out or I points
I out of I mints A client's wound is being debrided surgically. This type Of debridement is called: Question 81 A client is admitted with cutaneous infection caused by reactivation of the varicella chickenpox virus. This can be a sign of: Question 82 O of I points A middle-age male is experiencing itching, erythema, and circular red scaly lesions on his face. The lesions have a honey-colored crust. The nurse realizes that the child is most likely experiencing: I candidiasis. 2 herpes simplex. 3 impetigo. tinca corporis. ANS: 3 Impetigo is a common, superficial skin infection beginning as a focal erythema and progressing to pruritic vesicles, erosions, and honey-colored crusts. Oral herpes simplex would look like a cold sore. Tinca corporis has a circular, red, scaly border, and candidiasis is a proliferation of the normal yeast flora. Question 83 The nurse is instructing a client diagnosed with type 2 diabetes mellitus on diagnostic tests used to evaluate the control Of the disorder. The nurse should instruct the client on which of the following diagnostic tests that will provide this information? Fasting plasma glucose Glycosylated hemoglobin
Question 84 A client just experienced an episode of reflux with regurgitation. What assessment by the nurse is the priority? Auscultate the lungs for crackles Question 85 A client being treated for a spinal cord injury needs immediate ventilator support. The nurse realizes that this client's level of injury is most likely: C Question 86 A client receiving care for a spinal cord injury complains of a pounding headache, flushed skin. cardiac dysrhythmias and has a blood pressure of 200/100 mmHg. What is the first action the nurse should take? . Check the bladder for distension. Question 87 A client who is taking Spironolactone at home arrives in the emergency department complaining of unrelieved edema in the legs. The nurse share what data with the physician that indicates a need to withhold the medication? Potassium (s/s hyperkalemia) Question 88 Which Of the following recurring conditions most commonly occurs in in clients with cardiomyopathy? Heart failure
