CJE PRACTICE EXAM 1 Questions with Answers Correct

Yellowish sclera. Possible side effect related to liver damage - ANSWERSThe nurse is caring for a client with tuberculosis who is receiving isoniazid and rifampin for tuberculosis. Which adverse effect should the nurse be most concerned with? 1 Blurred vision. 2 Yellowish sclera. 3 Nausea and vomiting. 4 Decreased urine output. Acute confusion Dry cough - Vague sign Acute confusion - Correct - sign of infection in an older adult Increased temperature - Older adult may not exhibit normal signs of infection Purulent drainage from incision - Older adult may not exhibit normal signs of infection - ANSWERSWhat would the nurse expect to find in the care of an 80-year-old client who is experiencing a complication after a right knee replacement? The patient is post-op day 1. 1 Dry cough 2 Acute confusion 3 Increased temperature 4 Purulent drainage from incision 48-year-old African-American male who is obese and father and mother have type 2 DM. - ANSWERSWhich of these clients should the nurse consider at greatest risk for developing type 2 diabetes mellitus? 1 48-year-old African-American male who is obese and father and mother have type 2 DM. 2 50-year-old male hemoglobin A1C of 5.5% during a routine physical examination. 3 A 30-year-old female who delivered a 9-pound baby. 4 A 62-year-old male with an elevated triglyceride level. "You should add a thickener all liquids and make sure he sits upright while eating." - ANSWERSThe nurse is assessing a client with Parkinson's disease who has been admitted to the hospital because of significant weight loss. Assessment data reveals a masklike facial expression and slurred speech. A swallowing evaluation reveals some difficulty swallowing. The client's daughter asks the nurse, "How am I supposed to feed him at home?" What is an appropriate response by the nurse? 1 "He will be scheduled for surgery to have a feeding tube placed". 2 "It's best to feed him only three meals a day to reduce the chance of choking." 3 "Make sure he drinks all liquids through a straw and recline in chair while eating." 4 "You should add a thickener all liquids and make sure he sits upright while eating." "It appears you are hearing voices again. Tell me what you are hearing." - ANSWERSThe nurse is caring for a client who has been admitted to the psychiatric in-client unit with schizophrenia. While talking with the nurse alone, the client suddenly stops midsentence, turns to stare at the wall and states, "I told you I can't do that!" What is an appropriate response by the nurse? 1 "I will talk to you later when you can pay attention." 2 "I will leave the room if you continue to not pay attention" 3 "Is your mother talking to you again? I wish she would leave you alone." 4 "It appears you are hearing voices again. Tell me what you are hearing." "I know that my blood pressure is high when my nose starts bleeding." Correct - Hypertension is usually asymptomatic. A nose bleed can occur with high blood pressure, but it can occur for many other reasons as well. It is quite common that the client's blood pressure is high and the client experiences no symptoms. It is important to help clients understand that they cannot rely on one particular symptom to tell if their pressure is elevated. It would be very dangerous for clients to think their blood pressure is only high if they have a nose bleed. - ANSWERSThe nurse is participating in the discharge plans for a client with hypertension. Which statement by the client would cause concern? 1 "I am at risk for stroke or heart attack if my blood pressure is not controlled." 2 "I know that my blood pressure is high when my nose starts bleeding." 3 "I will take my blood pressure two times a day for at least 7 days." 4 "I will ask my spouse to start walking with me in the mornings." pH 7.50. CO2 28. pH 7.50. Correct - pH level is elevated with respiratory alkalosis pH 7.30. A low pH can indicate respiratory acidosis carbon dioxide (CO2 ) 50. A high CO2 can indicate respiratory acidosis CO2 28. Correct - In respiratory alkalosis, the client is blowing off too much CO2 which leads to a low level. Oxygen saturation 85%. Oxygen levels are usually normal in respiratory alkalosis. Bicarbonate 25. Bicarbonate levels are usually normal in respiratory alkalosis - ANSWERSThe nurse is reviewing the client's lab values who has respiratory alkalosis. Which results should the nurse expect? Select all that apply 1 pH 7.50. 2 pH 7.30. 3 Carbon dioxide (CO2 ) 50. 4 CO2 28. 5 Oxygen saturation 85%. 6 Bicarbonate 25. "I will continue smoking but decrease the number of cigarettes." Correct - Smoking cessation can lower the risk for stroke - ANSWERSA nurse is teaching a group of middle-aged men about stroke prevention. Which statement by a client requires further teaching? 1 "I will start an exercise program to lose weight." 2 "I have to stop my daily trip to the donut shop for breakfast". 3 "I will decrease my consumption of beer to only one per day." 4 "I will continue smoking but decrease the number of cigarettes." Establish intravenous access Administer atropine External pacing if needed Obtain baseline CBC and electrolytes - ANSWERSThe nurse is participating in the emergency management of a client with sinus bradycardia who reports the "room is spinning, chest pain, which is 8 out of 10, and shortness of breath. In what order should these steps be conducted? Establish intravenous access Obtain baseline CBC and electrolytes Administer atropine External pacing if needed Document findings and continue to monitor. Document findings and continue to monitor. Correct - No further action is required because these are expected findings. - ANSWERSThe nurse is assessing the surgical incision of a client after the bandage was removed by the health care provider on post-op day 1. The incision is well-approximated with slight swelling under the staples, and dark crusting on the incision line. What should the nurse do next? 1 Report crusting on the incision line to surgeon. 2 Document findings and continue to monitor. 3 Call surgeon and request antibiotics. 4 Report swelling to the surgeon. "I will place a lock on the cabinet where my medications are stored." "I cannot assume my child is protected by the child-resistant lids on cleaning supplies." - ANSWERSThe nurse is conducting a poison prevention class for parents of toddlers. Which statement by a parent indicates correct understanding of the teaching? Select all that apply 1 "I will place a lock on the cabinet where my medications are stored." 2 "I know my child is safe because I keep my cleaning supplies in an upstairs closet." 3 "I cannot assume my child is protected by the child-resistant lids on cleaning supplies." 4 "My child will not touch any cleaning supplies under my sink because of the fear of punishment." 5 "I put my medicines in the top shelf of the medicine cabinet where my child can't reach them." Notify the health care provider. Notify the health care provider. Correct - Oliguria can indicate acute kidney injury Reassess client in an hour A brief period of oliguria can decrease perfusion to kidneys Add 2 to 3 liters of oral fluids. Since urine output did not increase with fluid bolus, adding oral fluid will not help at this point Measure intake and output. Intake and output will continue but is not a priority at this time. - ANSWERSThe nurse is caring for a client with dehydration who is receiving a bolus of 0.9 normal saline intravenously. Assessment finding includes a urine output of 40 ml over a two-hour period. What is the nurse's priority action? 1 Notify the health care provider. 2 Reassess client in an hour. 3 Add 2 to 3 liters of oral fluids. 4 Measure intake and output.