Practice Exam Flashcards

Which individual is at greatest risk for developing hypertension?

Answer: 45 year-old African American attorney

The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?

Answer: Gastric lavage PRN

Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

Answer: thrombus formation

Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:

Answer: Manage pain

The immediate goal of therapy is to alleviate the client’s pain.

What would the nurse expect to see while assessing the growth of children during their school age years?

Answer: Yearly weight gain of about 5.5 pounds per year

School age children gain about 5.5 pounds each year and increase about 2 inches in height.

At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to

Answer: go get a blood pressure check within the next 48 to 72 hours

The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However, immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

Answer: A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.

The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

Answer: Should be taken in the morning

Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

A 3-year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

Answer: Notify the healthcare provider of the child’s status

These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?

Answer: Bed wetting

In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

Answer: Chlamydia

Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

Answer: An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10.

Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

When teaching a client with coronary artery disease about nutrition, the nurse should emphasize

Answer: Avoiding very heavy meals

Heavy meals increase the workload on the heart by diverting blood flow to the digestive system and increasing metabolic demand. For a client with coronary artery disease, this increased myocardial oxygen demand can precipitate angina or other cardiac events. Eating smaller, more frequent meals helps to reduce this cardiac strain, making it a safer nutritional approach.

Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?

Answer: The level of drug is 100 mL at 8 AM and is 80 mL at noon

A basal rate of 10 mL per hour means that over 4 hours (from 8 AM to noon), 40 mL of medication should have infused. If the drug level only decreased by 20 mL (from 100 mL to 80 mL), it indicates that the pump delivered less than half of the prescribed basal rate. This discrepancy strongly suggests that the pump is malfunctioning and not delivering the medication as ordered.

The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?

Answer: Spinal column manipulation

Chiropractic treatment is a healthcare profession focused on the diagnosis, treatment, and prevention of musculoskeletal disorders, particularly those affecting the spine. Chiropractors primarily use manual therapy, including spinal manipulation, to restore proper alignment and function of the body, believing this impacts overall health and well-being.

The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?

Answer: Decrease in level of consciousness

A decrease in the level of consciousness (LOC) in a client post-CVA is a critical neurological change that can indicate worsening cerebral edema, increased intracranial pressure, or re-bleeding. This finding requires immediate assessment and intervention as it can rapidly lead to further brain damage, herniation, or other life-threatening complications.

A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?

Answer: Moist, productive cough

Cystic fibrosis is a progressive disease, and while a positive sweat test and meconium ileus are early indicators, and bulky greasy stools are common, a moist, productive cough typically develops later. This type of cough signifies significant lung damage and chronic infection, which usually progresses over time rather than being present at initial diagnosis in a young child.

The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should

Answer: Send him to the emergency room for evaluation

Lethargy and confusion following a fall, especially in an elderly client, are red flag symptoms indicating a potential head injury such as a concussion or subdural hematoma. These neurological changes require immediate medical evaluation in an emergency room setting to diagnose the extent of injury and prevent further complications.

Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?

Answer: No special orders are necessary for this examination

A KUB (Kidney, Ureter, Bladder) radiograph is a plain X-ray of the abdomen used to visualize basic anatomical structures without the need for contrast. Therefore, it does not require any special client preparation such as NPO status, enemas, or specific medications prior to the examination.

The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?

Answer: “When you can climb 2 flights of stairs without problems, it is generally safe.”

The ability to climb two flights of stairs without experiencing chest pain or shortness of breath is a common and practical guideline for assessing a client's cardiac tolerance for activities like sexual intercourse after a myocardial infarction. This level of exertion indicates that the heart can safely handle the physiological demands of sexual activity. It provides a measurable benchmark for recovery.