NURS 2480 FINAL EXAMS 2020 QUESTIONS AND ANSWERS ELABORATION

NURS 2480 FINAL EXAMS 2020 QUESTIONS AND ANSWERS ELABORATION 1. The male client asks the nurse, “Why am I experiencing erectile dysfunction (ED)?” The nurse reviews the client’s medications. The nurse recognizes that which classification increases the risk for ED? a. Non-steroidal anti-inflammatory drugs. b. Antihypertensive medications. c. Anticoagulant medications. d. Histamine H2 inhibitors. Answer: B 2. The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne precautions, the nurse must confirm which? a. The tuberculin skin test is negative b. No acid-fast bacteria are in the sputum. c. The client has received anti-tuberculin medication for three days. d. The client’s temperature has returned to normal. Answer: B 3. The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration? a. Failure to follow routine policy and procedures. b. Caring for too many clients. c. Responsible for administering numerous medications. d. Unfamiliar with monk of the new pharmaceuticals ordered. Answer: A 4. The nurse prepared to administer buspirone 15 mg to the client. The nurse recognized this medication is MOST appropriate for which client? 1. The 45 year old woman diagnosed with pancreatitis reporting nausea and vomiting. 2. The 27 year old woman diagnosed with panic attacks. 3. The 60 year old man diagnosed with coronary artery disease with a blood pressure of 172/94. 4. The 38 year old man diagnosed with schizophrenia reporting auditory hallucinations. Answer#2 5. The home care nurse instructs the client receiving long-term prednisone therapy. Which information should the nurse include? a. There is an increased risk for developing infections. b. There is a resistance to developing infections. c. The client should follow a high-protein diet. d. There are changes in fat distribution over several areas of the body. Answer: D 6. After receiving report from the evening shift charge nurse, which client should the nurse see FIRST? 1. A 69-year –old diagnosed with chronic obstructive pulmonary disease requesting a sleeping pill. 2. A 52-year old client diagnosed with pancreatitis reporting abdominal pain. 3. A 67-year old client diagnosed with pneumonia with a pulse oximeter reading of 88% 4. A 78 year old client diagnosed with coronary artery disease with a blood pressure of 155/88. Answer#3 SAO2 95-99% 7. The nurse cares for the client diagnosed with spinal cord injury at the level of T1. The nurse notes the client is flushed and sweating profusely. The client reports a headache and nausea. The vital signs are blood pressure 140/98 and heart rate 38 beats per minute. Which action should the nurse take FIRST? 1. Administer antihypertensive medication. 2. Palpate the client’s bladder. 3. Position the client in a supine position. 4. Place the client on a cardiac monitor. Answer#2 ASSESS FIRST ;IPPA (she inspected and now palpate) 8. The nurse cares for the client just admitted to the surgical unit from recovery after a total hip replacement. It is MOST important for the nurse to take which action? 1. Elevate the affected extremity on pillows. 2. Position the client in high Fowler’s position. 3. Place the client in Buck’s traction. 4. Position the client with the legs abducted. Answer#4 ABDUCTION SPLINTER OR TWO PILLOWS BETWEEN LEGS 9. The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective? 1. “I should use this medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” Answer#4 10. The nurse instructs the client about stable angina. The nurse determines teaching is effective if the client makes which statement? a. Angina pain usually feels like being stabbed with a knife b. Each time I have angina, my heart is damaged. c. My chest pain can occur if I overexert myself. d. If I have chest pain, then I’m probably having another heart attack. Answer: C 11. The nurse on a medical-surgical unit received report. Which clients should the nurse see FIRST? 1. The client diagnosed with heart failure and dementia trying to get out of bed. 2. The client two days after a total hip replacement with a hemoglobin of 12.9 gm/dl. 3. The client receiving one unit of packed red blood cells with an IV pump sounding an alarm. 4. The client 12 hours after a laparoscopic cholecystectomy states, “My shoulder hurts”. Answer#3 12. The nurse cares for the unconscious client diagnosed with a closed head injury. There is no family present. What is the MOST appropriate action for the nurse to take? 1. Wait until a family member is contacted before treating the client. 2. Request the attending health care provider to sign the consent form. 3. Begin treatment on the client under the doctrine of implied emergency consent. 4. Delegate the unit secretary to call every number listed on the client’s cell phone. Answer#3 13. The client diagnosed with type 1 diabetes reports to the nurse, “I feel really nervous and jittery all over”. The nurse notes regular insulin was administered two hours ago. Which action should the nurse take FIRST? 1. Review all medications the client has received. 2. Determine the client’s recent dietary intake. 3. Administer a simple carbohydrate. 4. Request laboratory draw serum blood glucose. Answer#2 14. The parent of an adolescent diagnosed with hemophilia calls the nurse to discuss the adolescent’s desire to participate in sports. Which activity should the nurse recommend? a. Soccer b. Gymnastics c. Swimming d. Snowboarding Answer: C 15. The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should assign the client to a room with which client? A. A client diagnosed with Cushing’s Syndrome. B. A client Diagnosed with cellulitis of the left leg. C. A Client diagnosed with acute peritonsillar abscess. D. A client diagnosed with acute pelvic inflammatory disease. Answer: A 16. The school nurse identifies several children who have food allergies. Which sequence should the nurse teach the staff to follow if an allergic reaction is observed in a child? 1. Call 911, call the physician, administer EpiPen, call the parents 2. Administer the EpiPen, call 911, call the physician, call the parents v 3. Call the physician, administer the EpiPen, call 911, call the parents 4. Call the parents, administer the EpiPen, call the physician Answer#2 17. The psychiatric nursing team consists of one registered nurse and three nursing assistants. Which patient should be assigned to the registered nurse? 1. A 56-year-old male alcoholic who will attend his first Alcoholics Anonymous meeting tomorrow. 2. A 16-year-old girl with anorexia nervosa who is showing a daily weight gain. 3. A 40-year-old man receiving clozapine (Clozaril) who is complaining of a sore throat and fine hand tremors. 4. A 50-year-old woman with a history of depression who received her third dose of amitriptyline (Elavil) yesterday. Answer#3 18. A client is admitted to the emergency department with deep partial-thickness burns of the arms and chest sustained in a house fire. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST? 1. Administer morphine 5 mg IV 2. Ask the patient to verbalize what is bothering her. 3. Teach the patient diaphragmatic and pursed-lip breathing. 4. Listen to breath sounds Answer#4 19. A client diagnosed with type 1 diabetes comes to the outpatient clinic with complaints of pain of the right leg and foot. If a diagnosis of peripheral arterial occlusion is made, which of the following symptoms does the nurse expect to see? 1. The skin on the right lower leg appears flushed and diaphoretic. 2. The patient cannot distinguish between sharp and dull pressure on his right leg. 3. The patient says his right leg is larger than his left leg. 4. The patient has moderate swelling distal to the malleols on his right foot. Answer#2 20. A patient is admitted to the psychiatric unit with depression and suicidal ideation. Which action is MOST important for the nurse to take? 1. Instruct the patient to check in with the staff every 15 minutes, and encourage her to comply 2. Ask the staff to assess the patient’s suicidal thoughts every 30 minutes 3. Observe the patient every 15 minutes, and add several unscheduled observations 4. Establish a schedule for the staff to check the patient every 15 minutes Answer#3 21. The physician order phenytoin (Dilantin) 200 mg PO daily for a teenager. It is MOST important for the nurse to include which of the following instructions when teaching the client? 1. Visit your dentist frequently 2. If you miss a dose, take an extra one the next day 3. Avoid contact sports for the next several weeks 4. Be sure to take the medication between meals Answer#1 (causes gingival hyperplasia and bleeding). 22. A client with a history of liver disease is brought to the hospital by her family. The family is frightened because the client has become increasingly drowsy, gets disoriented and agitated, and sleeps during the day and is awake at night. The nurse expects the physician to order which of the following? 1. Soapsuds enemas until clear in A.M. 2. A barium enema in A.M. 3. Magnesium hydroxide (Milk of Magnesia) 25 g PO daily 4. Lactulose (Chronulac) 200 g retention enema q 6 h. Answer#4 Hepatic portal hypertension (increase in pressure in portal vein 23. An elderly client returns to the room after a colostomy. Because the client has become confused and repeatedly climbs over the side rails, the physician orders a Posey vest restraint. The nurse should take which of the following actions? 1. Check the patient every 30 to 60 minutes and release the restraint every 2 hours. 2. Place the patient’s hospital gown over the restraint so that the restraint is not noticeable to his visitors. 3. Apply the Posey vest restraint loosely so the patient doesn’t feel restricted. 4. Place a sign over the patient’s bed explaining the use of the Posey vest restraint. Answer#1 24. A newborn receives an Apgar score of 3 at 1 minute after birth. The nurse knows that a score of 3 indicates which of the following? 1. The newborn has a congenital defect. 2. The newborn is in a state of acidosis. 3. The newborn requires resuscitation. 4. The newborn has a life-threatening anomaly. 25. The nurse teaches the client about albuterol 2 inhalations every 6 hours by metered dose inhaler. Which statement, if made by the client, indicates to the nurse that further teaching is necessary? 1. “While I am taking this medicine, I may have bad dreams and diarrhea.” 2. “If I forget to take this medicine, I should take it as soon as possible.” 3. “I should hold my breath for 5 seconds after I breathe in the medicine.” 4. “When I take the medicine I should inhale and then compress the container.” Answer#4 26. An older client is brought to the emergency department by the client’s spouse. The client complains of severe headache. The nurse notes the client has slurred speech, as well as facial droop and weak hand grip on the left side. The nurse expects the physician to order which of the following tests? 1. Lumbar puncture 2. CT scan 3. Myelogram 4. Endoscopy 27. A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He has been prescribed haloperidol (Haldol). What is the priority action? 1. Encourage him to look at you and stay with him until the spasms pass. 2. Place the patient on aspiration precautions until the spasms subside. 3. Obtain an order for intramuscular or IV diphenhydramine (Benadryl). 4. Obtain an order for and administer an antiseizure medication. 28. You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the health care provider about a change in the drug therapy? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client coughs often during the visit. 4. Client says, "I get dizzy sometimes." 29. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest. 30. You are making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient's only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician? 1. The patient says that her right leg aches all night 2. The right calf is warm to the touch and is larger than the left calf. 3. The patient is unable to remember her husband's first name. 4. There are multiple ecchymotic areas on the patient's arms. 31. You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest 32. You are monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol (Tenormin) and has a first-degree heart block, with a rate of 58 beats/min 33. A 25-year-old G2P1 patient has come to the obstetric triage room at 32 weeks reporting painless vaginal bleeding. You are providing orientation for a new RN on the unit. Which statement by the new RN to the patient would require your prompt intervention? 1. "I'm going to check your vital signs." 2. "I'm going to apply a fetal monitor to check the baby's heart rate and to see if you are having contractions." 3. "I'm going to perform a vaginal examination to see if your cervix is dilated." 4. "I'm going to feel your abdomen to check the position of the baby." 34. You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? 1. 3-year-old who has paroxysmal coughing and whose sibling has pertussis 2. 5-year-old who has a new pruritic rash and a possible chickenpox infection 3. 62-year-old who has a history of a methicillin- resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight 35. the nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment finding should the nurse expect to observe? SATA 1. pallor 2. edema xia 4. proteinuria 5. weight loss 6. decrese serum lipids 36. Ventricular fibrillation is identified in an unresponsive 50-year-old client who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 J. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine (Adrenalin) 1 mg IV. 4. Intubate and manually ventilate. 37. At 9:00 PM, you admit a 63-year-old with a diagnosis of acute MI. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase [Activase]) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine (Pepcid) for esophageal reflux. 3. The client has ST-segment elevations on the 12-lead ECG. 4. The client has had continuous chest pain since 8:00 AM. 39. The nurse witnesses a co-worker put one of two narcotic tablets in the co- workers purse twice during the shift. Which action should the nurse take? a. Confront the co-worker b. Consult other staff about observation c. Inform the nursing supervisor d. Write an incident report 40. You are providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that you intervene immediately? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter 3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution 4. Telling the patient that the PRBCs may cause a serious transfusion reaction 40. You are the charge nurse on the medical unit. Which infection control activity should you delegate to an experienced UAP? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharge H H Place the child in knee-chest position. 42. A 19-year-old G1P0 patient at 40 weeks' gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? (Select all that apply.) 1. Check deep tendon reflexes. 2. Observe for vaginal bleeding 3. Check the respiratory rate. 4. Note the urine output. 5. Monitor for calf pain. 43. You have just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6° F (39.2° C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. 3. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. 4. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure. 44. The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess first? Select one: A 55-year-old patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the unlicensed assistive personnel refill his water pitcher b. A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L (6.2 mmol/L) A 48-year-old patient with Cushing disease with a weight gain of 1.5 lb (0.7 kg) over the past 4 days A 21-year-old patient with diabetes insipidus whose urine output overnight was 2000 mL 45. the nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which finding indicate the presence of a side effect associated with this medication? SATA 1. insomnia 2. weight loss 3. bradycardia 4. constipation 5. mild heat intolerance 46. The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? 1. 58-year-old on airborne precautions for tuberculosis (TB) 2. 65-year-old who just returned from bronchoscopy and biopsy 3. 72-year-old who needs teaching about the use of incentive spirometry 4. 69-year-old with COPD who is ventilator dependent 47. As the shift begins, you are assigned to care for the following patients. Which patient should you assess first? 1. 38-year-old with Graves disease and a heart rate of 94 beats/min 2. 63-year-old with type 2 diabetes and fingerstick glucose level of 137 mg/dL 3. 58-year-old with hypothyroidism and a heart rate of 48 beats/min 4. 49-year-old with Cushing disease and dependent edema rated as 1+ 48. which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? 1. Auscultating breath sounds bilaterally. 2. monitoring the respiratory rate 3. Verifying the amount of cuff inflation 4. assessing the client’s skin color 49. You are caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes priority? 1. A deviated trachea 2. Unequal pupils 3. Ecchymosis in the flank area 4. Irregular apical pulse 50. A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? a. Quick to anger and frustration Inability to discriminate words Aphasia and cautiousness d. Impulsiveness and smiling 51. The client in the psychiatric unit tells the nurse, “I know you are trying to poison me, I’m not taking those pills”, which statement, if made by the nurse is MOST appropriate? 1. It’s alright if you don’t want to take the pills right now. You can take them later. 2. I’m not trying to poison you, why do you say that? 3. It sounds like you are afraid that the staff might hurt you, this is a medication to help you. 4. These pills came straight from the pharmacy just like everyone else’s. Why do you think they are poisonous? Answer#3 52. The nurse on the pediatric unit receives report from the previous shift. Which client should be seen FIRST? 1. The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285 mg/dl. 2. The 2 year old diagnosed with asthma whose pulse oximeter reading is 97%. 3. The 6 year old recovering from an appendectomy with a temperature of 100.3 degrees F (37.9 degrees C). 4. The 10 year old with cerebral palsy with a newly placed enteral nutrition Answer#1 RISK FOR DKA 53. An LPN/LVN, under your supervision, is providing nursing care for a client with GBS. What observation should you instruct the LPN/LVN to report immediately? 1. Reports of numbness and tingling 2. Facial weakness and difficulty speaking 3. Rapid heart rate of 102 beats/min 4. Shallow respirations and decreased breath sounds 54. Two weeks ago, a 63-year-old client with heart failure received a new prescription for carvedilol (Coreg) 3.125 mg orally. When evaluating the client in the cardiology clinic, you obtain the following data. Which finding is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles 55. You have received orders to initiate phototherapy on a 36-hour-old newborn with an elevated bilirubin level. What instructions will you give the student nurse who is assisting in the care of the infant? 1. Cover the infant's eyes with a mask. 2. Monitor the infant's temperature closely. 3. Keep the infant "nothing by mouth" (NPO) during the treatment. 4. Apply ointment to the infant's skin prior to light exposure. 5. Offer the infant sterile water feedings during the treatment. 56. While assessing a 29-year-old G2P2 patient who had a normal spontaneous vaginal delivery 30 minutes ago, you note a large amount of red vaginal bleeding. What would be your first priority nursing action? 1. Check vital signs. 2. Notify the provider. 3. Firmly massage the uterine fundus. 4. Put the baby to breast. R d. Simple pneumothorax d. A D&C will be performed to remove the products of conception.