NUR 254 final exam

1. A client has notified the nurse that she has completely eliminated fats from her diet. The nurse recognizes this type of diet places the client at risk for a deficiency of which fat-soluble vitamins and/or minerals? a. Bile b. Minerals c. Salt d. Vitamins A, D, E, and K. 2. A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care? A. Providing a straw for consumption of liquids B. Encouraging larger bites C. Placing the client in at least Semi-Fowlers position during meals D. Instructing the client to throw head back when swallowing 3. A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? a. Oranges b. Cashews c. Red meat d. Yogurt 4. A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause? a. "Do you use sugar substitutes?" b. "Do you take diuretics or use laxatives?" c. "Do you have any kidney disease?" d. "Have your bowel habits changed recently?" 5. A client has metabolic alkalosis due to renal failure. Which laboratory results is the nurse most likely to assess as consistent with this condition? a. K+ 6.4 b. Mg+ 1.5 c. K+ 3.0 d. Ca+ 11.5 6. A new nurse demonstrates their understanding of a proper physical assessment of an abdomen when the four techniques of examination are completed in which order? a. Inspect, auscultate, percuss, palpate b. Inspect, auscultate, palpate, percuss c. Auscultate, percuss, palpate, inspect d. Auscultate, palpate, percuss, inspect 7. A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions is the highest priority for the nurse to take? A. Review the client's electrolyte values. B. Check the client's perianal skin integrity. C. Investigate the client's emotional concerns. D. Obtain a dietary history from the client. 8. The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the nurse's best response? a. "I'll have the nursing assistants set up your meal trays while you are in the hospital." b. "Let's see if the occupational therapist can provide you with some utensils that are easier for you to use." c. "I'll arrange for a home nursing assistant to help you with your meals after you are discharged from the hospital." d. "Let's see if the physical therapist can suggest some muscle strengthening exercises for you." 9. Which action by the nurse is most effective to prevent becoming exposed to the Human Immunodeficiency Virus? a. Always use Standard Precautions with all clients in the workplace. b. Place clients who are HIV positive in Contact Precautions. c. Wash hands before and after contact with clients who are HIV positive. d. Convert parenteral medications to an oral form for clients who are HIV positive. 10. A nurse is caring for a client who has HIV. Which of the following laboratory values should the nurse recognize as priority? a. CD4-T-cell count of 180 cells/mm3 b. Platelet count of 155, 000/mm3 c. WBC 5,500/mm3 d. Positive Western blot test 11. Which of the following activities cannot be delegated to an unlicensed assistive personnel (UAP)? a. Obtain daily weights. b. Record intake and output. c. Assess for pain while eating. d. Encourage client to eat. 12. A client who is receiving Combination Antiretroviral Therapy (cART; formerly HAART) tells the nurse, "The doctor said that my viral load is reduced. What does this mean?" What is the nurse's best response? a. "The medications are working well right to suppress the viral load." b. "You are not as contagious as you were anymore." c. "Your HIV infection is becoming resistant to your medications." d. "You are developing an opportunistic infection." 13. The nurse is caring for a client who is about to have immunotherapy initiated due to severe allergies. Knowing that this patient is being exposed to a known allergen, what intervention does the nurse implement to provide for client safety this allergy treatment? a. Stay with the client and ensure that emergency equipment is in the room. b. Pretreat the skin area to be tested with a cortisone-based cream. c. Apply oxygen by mask or nasal cannula before injecting the test agent. d. Cover the examination table and pillow with plastic or an ultrafine mesh. 14. A client has received diphenhydramine and now states she is drowsy. Upon further assessment the nurse notes the patient is alert and oriented to person, place, time and situation. What is the best action for the nurse to take? a. Perform a neurologic assessment every 2 hours. b. Document the response and continue to monitor. c. Prepare to administer epinephrine subcutaneously. d. Have the nursing assistant stimulate the client every hour. 15. A client is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which arterial blood gas (ABG) lab value would the nurse expect to see with this client? a. pH 7.29; PaCO2 32; HCO3 18 b. pH 7.47; PaCO2 45; HCO3 28 c. pH 7.33; PaCO2 49; HCO3 29 d. pH 7.46; PaCO2 34; HCO3 23