NUR 1023 FINAL EXAM – SEVERAL COMBINED

NUR 1023 FINAL EXAM – SEVERAL COMBINED 1. Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process? A thymectomy. 2. Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? Ptosis and diplopia. 3. The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client’s significant others? Discuss ways to help prevent choking episodes. 4. Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? Progressive ascending paralysis of the lower extremities and numbness. 5. Which statement by the client supports the diagnosis of Guillain-Barré syndrome? “I had a really bad cold just a few weeks ago.” 6. The client diagnosed with Guillain-Barré syndrome asks the nurse, “Will I ever get back to normal? I am so tired of being sick.” Which statement is the best response by the nurse? “You should make a full recovery within a few months to a year.” 7. The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? Monitor the client’s serum blood glucose levels frequently. 8. The client diagnosed with ALS asks the nurse, “I know this disease is going to kill me. What will happen to me in the end?” Which statement by the nurse would be most appropriate? “Most people with ALS die of respiratory failure.” 9. The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client’s lung sounds. 4. Obtain a pulse oximeter reading. 10. The client is to receive a 200-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump? 400ml 11. The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? Assist the client to prepare an advance directive. 12. The client is in the terminal stage of ALS. Which intervention should the nurse implement? Perform passive ROM every two (2) hours. 13. The health-care provider wants an SvO2 level on a patient with a pulmonary artery catheter. From where should this sample be taken? Distal lumen 14. The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP) on a patient. What action should be taken to ensure for the patient’s safety? Inflate the balloon 1.5 mL 15. The nurse wants to evaluate a patient’s right heart preload. Which approach should be used to obtain this measurement Measure the central venous pressure 16. The nurse suspects that a patient is experiencing a complication from a pulmonary artery catheter. What findings did the nurse use to make this clinical determination? Select all that apply. Bleeding Elevated body temperature Acute onset of shortness of breath Development of a cardiac dysrhythmia 17. The nurse is preparing to determine a patient’s left heart afterload. What measurements are needed to make this calculation? Select all that apply Cardiac output Mean arterial pressure Central venous pressure 1. The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. “You can see black smoke when carbon monoxide is in the air.” b. “If you are experiencing carbon monoxide poisoning, your skin will begin turning blue.” c. “The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire.” d. “It is important to have carbon monoxide detectors in your home, because this is an odorless gas.” 1. Which assessment finding does the nurse interpret as demonstrating a client’s fluid resuscitation adequacy? a. Decreased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity 1. Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client’s room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another. 1. A Nurse is panning care for a client who has prerenal acute kidney injury (AKI) Following abdominal aortic aneurysm repair. Urinary output is 60mL in the past 2hr and blood pressure is 92/58mm Hg. The nurse should expect which of the following interventions? Prepare to administer a challenge 2. A Nurse is assessing a client who has prerenal acute kidney injury (AKI) which of the following findings should the nurse expect? Select all that apply Elevated creatinine/ reduced urine output 3. In providing an educational in-service to the nursing staff about peritoneal dialysis, which information does the nurse include in this presentation? The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis. 4. Which statement by the family member of a client who has a Sengstaken- Blakemore tube placed to threat complications of liver disease indicates understanding of this treatment modality? The tube provides compression to stop esophageal bleeding 5. A client with chronic kidney disease is experiencing manifestations of anemia. Based on this date, which statement does the nurse anticipate for this client? Administer erythropoietin (epoetin) injections 6. The nurse is assessing a client in the ER with the following signs and symptoms; painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the umbilicus. The RN recognizes this as which sign? Cullen’s sign 7. The nurse is caring for a client receiving hourly peritoneal dialysis exchanges. During a one-hour exchange, the nurse infuses 2,000mL of dialysate and 1,900 mL of outflow is returned. During the exchange, the client drinks 8oz of apple juice, 2 cups of water and voids 150mL of urine. Calculate and record the client’s intake in millimeters and use numerical values only. 820 8. On which scientific rationale should a nurse base the response when a client asks, what does an elevated PSA test mean? An elevated PSA can result from several different causes 9. A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is bright red and thick with clots. What is the nurse’s best action? Increase the rate of the bladder irrigation 10. A client with cholecystitis is placed on a low-fat, high-protein diet. Which nutrient should the nurse teach the client to include in this diet? Skim Milk 11. Which assessment data indicate to the nurse that the client may be experiencing decreased clotting factors as a complication of cirrhosis? Epistaxis 12. Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching? I can eat foods high in fat now that acute stage is over 13. A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? Assess level of consciousness 14. Which of the following findings should a nurse expect in a client with endstage kidney disease? Select all that apply Anuria/ Marked azotemia/ crackles in the lungs/ proteinuria 15. In administering lactulose to the client with hepatic encephalopathy, the nurse correlates effectiveness of this medication to which mechanism of action? Decrease production of ammonia 16. A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What does the nurse conclude in the purpose of the Ttube? Permit drainage of bile 17. A client has an IV of D5W 250mL to which 100mg of morphine is added. The healthcare provider prescribes 14mg of morphine per hour for end of life palliative treatment of a client with liver failure. At how many mL per hour should the nurse set the infusion pump? Round to the nearest whole number and use numerical values only. 35 18. The nurse is planning education for an adolescent client recently diagnosed with hepatitis. The client moved back to the parent’s home. Which recommendation to the parents will best prevent