Nurs 384 Final Study Guide
With Complete Solution
1. A patient with left-sided weakness that started 60 minutes earlier is
admitted to the Emergency Department and diagnostic tests are ordered.
Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiography (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Non-contrast computed tomography (CT) scan - ANSWER Answer D
Non-contrast computed tomography (CT) scan
Rationale: To screen for stroke symptoms quickly a non-contrast CT scan is
required before administering tissue plasminogen activator (tPA) within 4.5
hours. Giving tPA sooner reduces damage to brain tissue. Diagnostic tests
can reveal the possible causes of the stroke but they are not as urgent as the
CT scan.
2. A 72-year-old patient with a history of a transient ischemic attack (TIA) has
an order for aspirin 160 mg daily. When the nurse administers medications
the patient says I don't need the aspirin today. I don't have a fever. Which
action should the nurse take?
a. Document that the ASA was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
,c. Explain that aspirin is ordered to decrease stroke.
d. Call the healthcare provider to clarify the medication order - ANSWER
Answer C Explain that aspirin is ordered to decrease stroke.
Rationale: Patients who have experienced TIAs are prescribed aspirin to
prevent further occurrences. If a patient refuses to take the medication
simply documenting the refusal is insufficient. It's not required to confirm
the order with the healthcare provider. It's important to understand that
aspirin is not given to relieve headaches or pains.
3. A 37-year-old female is hospitalized with Acute Kidney injury (AKI). Which
information is most useful to the nurse in evaluating improvement in kidney
function?
a. Urine volume
b. Creatinine level
c. Glomerular filtration rate
d. Blood urea nitrogen (BUN) level - ANSWER Answer C Glomerular filtration
rate
Rationale: The best way to evaluate kidney function is by using GFR
(glomerular filtration rate) and taking into account protein intake. It's worth
mentioning that patients with AKI (acute kidney injury) may have normal or
high urine output which doesn't indicate kidney function. Also relying only
on creatinine levels is not a dependable method to assess renal function.
4. A patient with acute glomerulonephritis is hospitalized with hyperkalemia.
Which information will the nurse monitor to evaluate the effectiveness of the
prescribed calcium gluconate IV?
,a. Urine volume
b. Calcium level
c. Cardiac rhythm
d. Neurologic status - ANSWER Answer C Cardiac Rhythm
Rationale: Calcium gluconate helps prevent dysrhythmia that might be
caused by hyperkalemia. The nurse will also monitor the other data but these
will not help determine the effectiveness of the calcium gluconate.
5. Which finding will the nurse expect when assessing a 58-year-old patient
with knee osteoarthritis?
a. Discomfort with joint movement
b. Heberden and Bouchard nodes
c. Redness and swelling of the knee joint.
d. Stiffness that increases with movement - ANSWER Answer A Discomfort
with joint movement
Rationale: Initial symptoms of OA include pain with joint movement.
Heberden nodules occur on the fingers. Redness of the Joint is more strongly
associated with rheumatoid arthritis (RA). Stiffness is worse right after the
patient rests and decreases with joint movement.
6. A nurse is reviewing the medical history of a client who has end-stage
kidney disease. The nurse should identify that which of the following factors
in the client's history is a contraindication for receiving hemodialysis?
a. History of hemophilia
, b. Difficulty with ambulation
c. Decreased WBC count
d. Iodine allergy - ANSWER Answer: A History of hemophilia
Rationale: The nurse should identify that a history of a major bleeding
disorder is a contraindication for hemodialysis. A client who has hemophilia
bleeds excessively following minor breaks in the skin and is at high risk for
extreme blood loss during hemodialysis treatment.
7. A nurse is planning care for a client who has acute glomerulonephritis. The
nurse should plan to provide which of the following interventions?
a. Weigh the client daily.
b. Encourage the client to drink 2 to 3 L of fluid per day.
c. Instruct the client to ambulate every 2 hr.
d. Check the client's blood glucose level - ANSWER Answer:A Weigh the
client daily.
Rationale: The nurse should monitor fluid retention by weighing the client
daily. A decrease in weight indicates the effectiveness of the therapy.
8. A 70 years old patient is being admitted with a possible stroke. Which
information from the assessment indicates that the nurse should consult with
the health care provider before giving the prescribed aspirin?
a. . The patient has dysphasia
b. The patient has atrial fibrillation
c. The patient reports that symptoms began with a severe headache.
With Complete Solution
1. A patient with left-sided weakness that started 60 minutes earlier is
admitted to the Emergency Department and diagnostic tests are ordered.
Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiography (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Non-contrast computed tomography (CT) scan - ANSWER Answer D
Non-contrast computed tomography (CT) scan
Rationale: To screen for stroke symptoms quickly a non-contrast CT scan is
required before administering tissue plasminogen activator (tPA) within 4.5
hours. Giving tPA sooner reduces damage to brain tissue. Diagnostic tests
can reveal the possible causes of the stroke but they are not as urgent as the
CT scan.
2. A 72-year-old patient with a history of a transient ischemic attack (TIA) has
an order for aspirin 160 mg daily. When the nurse administers medications
the patient says I don't need the aspirin today. I don't have a fever. Which
action should the nurse take?
a. Document that the ASA was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
,c. Explain that aspirin is ordered to decrease stroke.
d. Call the healthcare provider to clarify the medication order - ANSWER
Answer C Explain that aspirin is ordered to decrease stroke.
Rationale: Patients who have experienced TIAs are prescribed aspirin to
prevent further occurrences. If a patient refuses to take the medication
simply documenting the refusal is insufficient. It's not required to confirm
the order with the healthcare provider. It's important to understand that
aspirin is not given to relieve headaches or pains.
3. A 37-year-old female is hospitalized with Acute Kidney injury (AKI). Which
information is most useful to the nurse in evaluating improvement in kidney
function?
a. Urine volume
b. Creatinine level
c. Glomerular filtration rate
d. Blood urea nitrogen (BUN) level - ANSWER Answer C Glomerular filtration
rate
Rationale: The best way to evaluate kidney function is by using GFR
(glomerular filtration rate) and taking into account protein intake. It's worth
mentioning that patients with AKI (acute kidney injury) may have normal or
high urine output which doesn't indicate kidney function. Also relying only
on creatinine levels is not a dependable method to assess renal function.
4. A patient with acute glomerulonephritis is hospitalized with hyperkalemia.
Which information will the nurse monitor to evaluate the effectiveness of the
prescribed calcium gluconate IV?
,a. Urine volume
b. Calcium level
c. Cardiac rhythm
d. Neurologic status - ANSWER Answer C Cardiac Rhythm
Rationale: Calcium gluconate helps prevent dysrhythmia that might be
caused by hyperkalemia. The nurse will also monitor the other data but these
will not help determine the effectiveness of the calcium gluconate.
5. Which finding will the nurse expect when assessing a 58-year-old patient
with knee osteoarthritis?
a. Discomfort with joint movement
b. Heberden and Bouchard nodes
c. Redness and swelling of the knee joint.
d. Stiffness that increases with movement - ANSWER Answer A Discomfort
with joint movement
Rationale: Initial symptoms of OA include pain with joint movement.
Heberden nodules occur on the fingers. Redness of the Joint is more strongly
associated with rheumatoid arthritis (RA). Stiffness is worse right after the
patient rests and decreases with joint movement.
6. A nurse is reviewing the medical history of a client who has end-stage
kidney disease. The nurse should identify that which of the following factors
in the client's history is a contraindication for receiving hemodialysis?
a. History of hemophilia
, b. Difficulty with ambulation
c. Decreased WBC count
d. Iodine allergy - ANSWER Answer: A History of hemophilia
Rationale: The nurse should identify that a history of a major bleeding
disorder is a contraindication for hemodialysis. A client who has hemophilia
bleeds excessively following minor breaks in the skin and is at high risk for
extreme blood loss during hemodialysis treatment.
7. A nurse is planning care for a client who has acute glomerulonephritis. The
nurse should plan to provide which of the following interventions?
a. Weigh the client daily.
b. Encourage the client to drink 2 to 3 L of fluid per day.
c. Instruct the client to ambulate every 2 hr.
d. Check the client's blood glucose level - ANSWER Answer:A Weigh the
client daily.
Rationale: The nurse should monitor fluid retention by weighing the client
daily. A decrease in weight indicates the effectiveness of the therapy.
8. A 70 years old patient is being admitted with a possible stroke. Which
information from the assessment indicates that the nurse should consult with
the health care provider before giving the prescribed aspirin?
a. . The patient has dysphasia
b. The patient has atrial fibrillation
c. The patient reports that symptoms began with a severe headache.
