NUR 120Review

Gastrointestinal System DisordersNeurological/Neurosensory System DisordersUrinary System and Fluid electrolytes DisordersMusculoskeletal DisordersHematological/ImmunologicalIntegumentary DisordersHIPPARestraintsEstablishing goalsOutcome EvaluationsMath – PO, IVPB, IV- ml/hr, IV- gtt/min KVO, IV- gtt/min

1. The nurse is caring for a group of clients with variety of gastrointestinal problems . Which factor can influence the occurrence of both diarrhea and constipation?

a. Increased metabolic rateb. High-solute tube feedingsc. Side effects of medicationsd. Inability to perceive bowel cues

2. When obtaining a client’s health history the client tells the nurse, “ I’ve got gastroesophageal reflux disease.” Which most serious adaptation associated with this disorder should the nurse expect the patient to develop?

a. Diarrheab. Heartburnc. Gastric fullnessd. Esophageal erosion

3. The client is diagnosed with hiatal hernia and a history of chronic heartburn. The nurse suggests that the client avoid which of the following habits?a. Sleep with head of the bed raised 6 inch blocks.b. Take histamine receptor antagonist medication regularly.c. Eat small frequent bland meals .d. Lie down flat after eating.

4. The nurse will be admitting a client for observation and post procedure care who was undergone esophagogastroduodenoscopy (EGD). Which plan would the nurse do as a priority when the client arrives?

a. Nurse will measure client’s temperature.

b. Nurse will monitor complaints of heartburn

c. Nurse will monitor for return of gag reflex

d. Nurse will give warm gargles for sore throat

5. The nurse prepares an IV infusion of 1000 ml 5% Dextrose in Lactated Ringers at 80/ml per hour to be administered to client. The infusion started at 0900. When would the nurse expect the completion time for the bag?a. 1530b. 1730c. 1930d. 2130

6. The nurse is caring for an elderly client who is chronically constipated. Which factor will the nurse consider most likely contributed to the condition?a. Advance ageb. Overuse of laxativesc. Diet high in fiber and fluidsd. Sedentary lifestyle

7. A client presents to the urgent center with complaints of abdominal pain. Suddenly the client vomits bright red blood. Which most immediate action would the nurse do?a. The nurse will perform complete abdominal

assessment.b. The nurse will take the client’s vital signs.c. The nurse will obtain a thorough history of

the recent health status.d. The nurse will prepare to insert a

nasogastric tube and test pH and occult blood.

8. The nurse is caring for a client with nasogastric tube (NGT). Which nursing assessment should the nurse prioritized when observed?a. Deep slow respiration.b. Increased oxygen saturation.c. Respiratory rate of 16 bpm.d. Ashen gray color.

9. A client is straining excessively when attempting to have a bowel movement. Which of the most important reason prompted the nurse to instruct the client to avoid straining on defecation? a. Straining may precipitate

incontinence.b. Straining may impair sphincter control.c. Straining can result to dysrhythmias.d. Straining may precipitate hemorrhoids.

10. A client complaints of constipation. Which food will the nurse encourage the client to eat to prevent constipation?a. Applesauceb. Bananasc. Cheesed. Beans

A client with ileostomy is experiencing stools that contain too much liquid. Which food should the nurse instruct to be eliminated from the diet to thickened the stool?a. Branb. Pastac. Boiled Riced. Low-fat cheese

The client is being discharge to go home after subtotal gastrectomy. Which of the following should the nurse teaches the client to minimize the risk of dumping syndrome?a. Sit up for two hours after eating.b. Eat only two large meals a day.c. Avoid drinking liquid during meal.d. Eat highly concentrated carbohydrate

foods.

The nurse has taught a client newly diagnosed with diabetes mellitus about blood sugar monitoring. Which blood glucose level stated by the client to the nurse determines that the client understands the information that requires reporting?a. 350 mg/dl and aboveb. 250 mg/dl and abovec. 200 mg/dl and aboved. 150 mg/dl and above

The nurse is caring for a client with a stroke who has unilateral neglect. The nurse reinforces instructions to the family regarding home care. Which of the following would be included in the nurse’s instructions?a. Assist the client from the affected side.b. Assist the client from the unaffected

side.c. Place personal items directly in front of

the client.d. Discourage the client from scanning

the environment.

The nurse is planning to teach a client with a leg cast how to stand on crutches. Which of the following is considered appropriate plan to tell the client by the nurse regarding where to place the crutches?a. 3 inches to the front and side of the client’s toes.b. 8 inches to the front and side of the client’s

toes.c. 15 inches to the front and side of the

client’s toes.d. 20 inches to the front and side of the

client’s toes.

The nurse has given the client with fiberglass leg cast instructions on the cast care at home. The nurse determines that the client needs further instructions if the client makes which of the following statements?a. “ I should avoid walking on wet slippery floors.b. “ I’m not supposed to scratch the skin underneat the cast”. c. “ It’s OK to wipe dirt off the top of the cast

with a damp cloth.d. If the cast gets wet, I can dry it with a hair

dryer turn to the hottest setting”.

A 54 year old female with a familial history of heart disease presents to the physician’s office inquiring about hormone replacement therapy. Which of the following should the nurse inquire from the client to make sure it is appropriate for the client to begin HRT?

a. Nurse will ask if the client exercises regularly .b. Nurse will ask if the client is currently a smoker.c. Nurse will ask if client eats low-cholesterol diet.d. Nurse will ask if client has taken oral

contraceptives before.

A client has history of gout is also diagnosed with urolithiasis, and the stones are determine to be of the uric acid type. Which food item should the nurse instruct to client to limit its intake?a. Milk.b. Liver.c. Apples.d. Carrots.

A client with thrombotic brain attack (stroke) experiences periods of emotional lability. The client alternately laughs and cries and intermittently becomes irritable and demanding. Which of the following situation best explains the client’s behaviora. The client is not adapting well to the disability.b. The problem is likely to get worse before it

gets better”.c. The client is experiencing the usual sequela of

a stroke.d. The client is experiencing side effects of

prescribed anticoagulants.

Which nursing intervention is the most effective in preventing urinary tract infections? a. Teach female clients to wipe from the

back to the front after urinating.b. Instruct the clients to use bath powder to

absorb perineal perspiration.c. Advise client to report burning on

urination to the physician.d. Encourage the patient to drink at least

two quartz of fluid daily.

A nurse is providing instruction to a female client about the procedure for collecting a midstream clean catch urine sample. Which statement indicates an understanding of the procedure? a. “ I should douche before collecting the specimen”.b. “ I should cleanse the perineum from front to back”c. “ I should collect the urine in the cup as soon as I begin to urinate”.d. “ I can collect the specimen tonight and drop it off at the clinic in the morning.

A nurse notes documentation of the stage 3 pressure ulcer in a client’s record. Which of the following does the nurse expect to note on data collection of the client?a. A deep ulcer that extends into muscle and bone.b. An area in which the top layer of skin is

missing.c. A deep ulcer that extends into the dermis

and the subcutaneous tissue. d. A reddened area that returns to normal skin

color after 15 to 20 minutes of pressure relief.

Which of the following client is at greatest risk for developing a pressure ulcer?a. 25 year old client who has spina bipida and

is wheelchair bound.b. 75 year old client who is bedfast with

terminal COPD.c. 82 year old client post CVA with mild

hemiplegia.d. 70 year old client following a total hip

replacement.

Which of the following diagnostic tests is most relevant for assessing the risk of developing a pressure ulcer for a 73 year old client with no major health issues?a. Serum albumin.b. White blood cells.c. Red blood cells.d. Serum potassium.

Which of the following is an appropriate nursing intervention for a client at risk for developing a pressure ulcer.a. Massaging directly over reddened area to

help improve circulation.b. Positioning the HOB at a 45 degree angle to

improve tissue perfusion.c. Using hot, soapy water to clean the client to

remove fecal/urine incontinence.d. Repositioning a bedfast client at least every

two hours to minimize pressure.

Which of the following is the best explanation concerning the use of digital imaging in management of pressure ulcer?a. Assessment of pressure ulcer status based on

photographs accurately reflects the patient’s true pressure ulcer

status.b. Use to assess the progress of decubitus ulcers that are

diagnosed as stage 3 and stage 4.c. To identify the location of the pressure ulcer.d. Digital imaging of the pressure ulcer provides a visual

record to avoid too much writing duirng documentation.

A previously healthy client with a long leg cast is on prescribed bedrest. The nurse plans to institute which general measure in client care?a. Request low fiber diet.b. Increase fluids to 3 liter per day.c. Reposition every 4 to 6 hours.d. Check neurovascular status daily.

Multiple Response:A nurse is assisting in developing a plan of care for a client at risk for seizures. Select all interventions to include in the plan if the client experiences a seizure.a. Restrain the client’s extremities.b. Place the client in a supine position.c. Monitor and document post-seizure status.d. Place an oral airway between the client’s teeth.e. Note the time the seizure began and how it

progressed.f. Remove any objects that could cause harm

away from the client.

A nurse tells a client that the physician prescribed Ibuprofen (Advil) 0.4 g for mild pain. The client tells the nurse that the medication bottles states Ibuprofen (Advil) 200 mg tablets and asks the nurse about the number of tablets to take. How many tablet(s) will the nurse instruct the client to take?

a. 4 tabletsb. 1 tabletsc. 2 tabletsd. 8 tablets

Prioritizing/Ordered response:A client arrives in the PACU following colectomy. After listening to the verbal report from the anesthesia provider, the nurse collects initial data collection actions. (number 1 is the first action)

a. Checks for airway patency. _____b. Checks level of consciousness. ______c. Counts the HR and determines the rhythm._____d. Counts the rate and checks the quality of

respirations._____

The physician’s order reads: Tobramycin sulfate (Nebcin), 7.5 mg intramuscularly twice daily. The medication label reads: 10 mg/ml. The nurse prepares how many milliliters to administer one dose?a. 0.75 mlb. 0.50 mlc. 7.5 mld. 5.7 ml

The nurse reinforces home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin (Dilantin). Which instruction should the nurse include?a. Monitoring the child’s intake and output daily.b. Providing oral hygiene especially care of the

gums.c. Administering the medication 1 hour before food

intake.d. Checking the child’s blood pressure before the

administration of the medication.

The client with AIDS has nursing diagnosis of fatigue. The nurse plans to teach which of the following strategies to conserve energy after discharge from the hospital?a. Bathe before eating breakfast.b. Sit for as many activities as possible.c. Stand in the shower instead of taking a

bath.d. Group all task to be performed early in

the morning.

The client is diagnosed with thrombophlebitis of the left leg. The nurse documents in the nursing care plan that the client should be placed on bed rest. Which position is appropriate for the client in positioning the legs?a. The left leg kept flat.b. Left leg elevated.c. The left leg in a dependent position.d. The left leg flexed under the other leg.

A client with type 2 DM was recently hospitalized for Hyperglycemic hyperosmolar nonketotic syndrome (HHNS). On discharge from the hospital, the client expresses concern about the recurrence of HHNS. Which statement by the nurse is therapeutic?a. “ I’m sure this won’t happen again.”b. “ Don’t worry, your family will help

you.”c. “ I think you might need to go to a

nursing home.”d. ‘You have concerns about the

treatment for your condition?”

A nurse is assigned to care for a client with AIDS who is receiving Amphotericin B ( Fungizone) for a fungal respiratory infection. Which of the following indicates an adverse reaction to the medication?a. Hypokalemiab. Hyperkalemiac. Hypocalcemiad. Hypercalcemia

The nurse has instructed a client about a low-sodium diet. The nurse determines that the client understands the information if the client selects which of the following dairy products as appropriate for use?a. Yogurtb. Whole milkc. Powdered milkd. American cheese

The nurse is caring for a client at risk for aspiration who begins to experience seizure activity while in bed. Which action by the nurse prevent aspiration from occuring?a. Raise the head of the bed.b. Loosen restrictive clothing.c. Remove the pillow and raise the

padded side rails.d. Position the client on the side, if

possible with the head flexed forward.

The nurse is assigned to care for a client with a history of asthma. In the event that the client experiences an asthma attack, the nurse should do which of the following first?a. Obtain a set of vital signs.b. Prepare to administer oxygen at 21%.c. Place the client in a high-fowler’s position.d. Obtain an IV cannula for starting an IV

line.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). Which findings noted in the client indicates the presence of an opportunistic respiratory infection?a. Colitis and ulcerated perirectal lesions.b. White plaques located on the oral

mucosa.c. Opthalmic nerve involvement causing

blindness.d. Fever, exertional dyspnea, and non-

productive cough.

A client who has been receiving log term diuretic therapy is admitted to the hospital with a diagnosis of dehydration (fluid volume deficit). The nurse should check for which sign and symptom that correlates with the fluid imbalance?a. Decrease pulse.b. Bibasilar cracklesc. Dry mucous membranes.d. Increase blood pressure

Other s/s of fluid volume deficit (dehydration)1. Increase pulse and respiration.2. Weight loss3. Poor skin turgor.4. Dry mucous membrane.5. Concentrated urine with increased specific gravity.6. Increased hematocrit and 7. Altered level of cocnsciousness.

A nurse is preparing a client for surgery. Which of the following is component of the care plan?a. Be sure that the prescribed preoperative

studies are performed.b. Instruct the client to avoid oral hygiene

on the morning of surgery.c. Verify that the client has remined NPO

for 24 hours before surgery.d. Report any increase in blood pressure on

the day of the surgery to the physician.

The client with AIDS is experiencing shortness of breath because of Pneumocystis jeroveci pneumonia. The nurse plans to do which of the following to assist the client in performing activities of daily living?a. Provide supportive care.b. Provide small frequent meals.c. Offer food with low microbial content.d. Provide meals and snacks with high

protein, high calorie, and high nutritional value.

A nurse is assisting in planning care for the client with aldosteronism. The nurse plans to monitor which of the following?a. Hypoglycemia.b. Fluid overload.c. Urinary retentiond. Gastrointestinal bleeding.

The nurse is monitoring a client with AIDS for early signs of Kaposi’s Sarcoma. Which of the following should the nurse observes on the client concerning client’s lesions?a. Unilateral, raised, and bluish purple in color.b. Unilateral, red, raised, and resembling a

blister.c. Bilateral, flat, and brownish and scaly in

appearance.d. Bilateral flat, and pink, turning to dark violet

or black in color.

The nurse performs a neurovascular check on a client with a newly applied cast. Close observation and further evaluation will be necessary if the nurse notes?a. Capillary refill of 6 seconds.b. Palpable pulses distal to the cast.c. Blanching of the nail bed when depressed.d. Sensation where the area distal to the cast is

pinched.

A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse plans to provide which type of wound care to the fasciotomy.a. Dry sterile dressing.b. Hydrocolloid dressing.c. Moist sterile saline dressing.d. One half-strength betadine dressing.

A nurse is caring for a client who has developed compartment syndrome from a severely fractured arm, and the client asks how this can happen. The nurse’s response is based on the understanding that:a. A bone fragment has injured the nerve

supply in the area.b. An injured artery causes impaired arterial

perfusion through the compartment.c. Bleeding and swelling cause increased

pressure in an area that cannot expand.d. The fascia expands with injury, causing

pressure on underlying nerves and muscles.

A nurse is caring for a client who had abdominal surgery. While caring for the client, the client complains of pain in the calf. Which action by the nurse is appropriate to be implemented?a.Ask the client to walk and observe the gait.b.Lightly massage the area to relieve muscle

painc.Observe the calf for temperature, color,

and size.d.Administer PRN Meperidine Hydrochloride

(Demerol) as ordered.

The nurse monitoring the respiratory status of the client treated for the acute exacerbation of COPD. Which initial finding indicates a deterioration in ventilation?a. Cyanosis.b. Barrel chest.c. Hyperinflated chest.d. Rapid, shallow respirations.

A client id due for a dose of Bumetamide (Bumex). The nurse temporary withholds the dose and notifies the physician if which laboratory result is noted. a. Sodium 137 mFq/Lb. Chloride 106 mEq/Lc. Potassium 2.9 mEq/Ld. Magnesium 2.5 mg/dL

The nurse is collecting data from a male client with DM who has been taking insulin for many years. The client states that currently he is experiencing periods of hypoglycemia followed by periods of hyperglycemia. Which of the following should the nurse determine as the most likely cause for this occurrence? a. Eating snacks between meals.b. Initiating the use of insulin pump.c. Injecting insulin in the site of

lipodystrophy.d. Adjusting insulin according to the blood

glucose level.

Which of the following laboratory data indicate a potential complication associated with Type 1 diabetes mellitus?a. Ketonuria.b. Potassium 4.2 mEq.c. Blood Glucose of 112 mg/dl.d. BUN 18 mg/dl.

During a routine visit to the physician’s office, an older client with DM complains of vision changes. The client describes vision blurring, with difficulty reading and driving at night? Which of the following medical diagnosis would the nurse consider developing regarding client’s complaints?

a. Cataractsb. Glaucomac. Papilledemad. Detached retina

A nurse is assigned to care for a client who just undergone eye surgery. The nurse plans to instruct the client which activity is permitted in the post operative period?a. Readingb. Bending overc. Lifting objectsd. Watching television