NR 464 - Exam 4 Questions With Complete Solutions
57. A female patient receiving IV vasopressin (Pitressin) for
esophageal varice rupture reports to the nurse that she feels sub-
sternal tightness and pressure across her chest. Which PRN
protocol should the nurse initiate?
a. Start an IV nitroglycerin infusion
b. Nasogastric lavage with cool saline
c. Increase the vasopressin infusion
d. Prepare for endotracheal intubation Correct Answers A
58. A client has been taking oral corticosteroids for the past five
days because of seasonal allergies. Which assessment finding is
of most concern to the nurse?
a. WBC count of 10,000 mm3
b. Serum glucose of 115 mgdL
c. Purulent sputum
d. Excessive hunger Correct Answers C
59. A client who is receiving chemotherapy asks the nurse.
"Why is so much of my hair falling out each day?" Which
response by the nurse best explains the reason for alopecia?
,a. Chemotherapy affects the cells of the body that grow rapidly,
both normal and malignant
b. Alopecia is a common side effect you will experience during
long-term steroid therapy
c. Your hair will grow back completely after your course of
chemotherapy is completed
d. The chemotherapy causes permanent alterations in your hair
follicles that lead to hair loss Correct Answers A
60. A client taking a thiazide diuretic for the past six months has
a serum potassium level of (unreadable - i think it is low based
on answer). The nurse anticipates which change in prescription
for the client?
a. The dosage of the diuretic will be decreased
b. The diuretic will be discontinued
c. A potassium supplement will be prescribed
d. The dosage of the diuretic will be increased Correct Answers
C
61. A client taking furosemide (Lasix), reports difficulty
sleeping. What questions is important for the nurse to ask the
client?
a. What dose of medication are you taking?
,b. Are you eating foods rich in potassium?
c.Have you lost weight recently?
d. At what time do you take your medication? Correct Answers
D
62. The nurse assesses a client with advanced cirrhosis of the
liver for signs of hepatic encephalopathy. Which finding should
the nurse consider an indication of progressive hepatic
encephalopathy?
a. An increase in abdominal girth
b. Hypertension and bounding pulse
c. Decreased bowel sounds
d. Difficulty in handwriting Correct Answers D
63. A splint is prescribed for nighttime use by a client with RA.
Which statement by the nurse provides the most accurate
explanation for use of the splints?
a. Prevention of deformities
b. Avoidance of joint trauma
c. Relief of joint inflammation
d. Improvement in joint strength Correct Answers A
64. Physical examination of a comatose patient reveals
decorticate posturing. Which statement is accurate regarding this
patient's status based upon this finding?
, a. A cerebral infectious process is causing the posturing
b. Severe dysfunction of the cerebral cortex has occured
c. There is a probably dysfunction of the midbrain
d. The patient is exhibiting signs of a brain tumor Correct
Answers B
65. An adult client is admitted to the hospital burn unit with
second and third degree burns over 40% of the body surface
area. In assessing the potential for skin regeneration, what
should the nurse remember about third degree burns?
a. Regenerative function of the skin is absent because the dermal
layer has been destroyed
b. Tissue regeneration will begin several days following return
of normal circulation
c. Debridement of eschar will delay the body's ability to
regenerate normal tissue
d. Normal tissue formation will be preceded by scar formation
for the first year Correct Answers A
66. In assessing cancer risk, the nurse identifies which woman as
being at greatest risk of developing breast cancer?
a. A 35 year old multipara who never breastfed
57. A female patient receiving IV vasopressin (Pitressin) for
esophageal varice rupture reports to the nurse that she feels sub-
sternal tightness and pressure across her chest. Which PRN
protocol should the nurse initiate?
a. Start an IV nitroglycerin infusion
b. Nasogastric lavage with cool saline
c. Increase the vasopressin infusion
d. Prepare for endotracheal intubation Correct Answers A
58. A client has been taking oral corticosteroids for the past five
days because of seasonal allergies. Which assessment finding is
of most concern to the nurse?
a. WBC count of 10,000 mm3
b. Serum glucose of 115 mgdL
c. Purulent sputum
d. Excessive hunger Correct Answers C
59. A client who is receiving chemotherapy asks the nurse.
"Why is so much of my hair falling out each day?" Which
response by the nurse best explains the reason for alopecia?
,a. Chemotherapy affects the cells of the body that grow rapidly,
both normal and malignant
b. Alopecia is a common side effect you will experience during
long-term steroid therapy
c. Your hair will grow back completely after your course of
chemotherapy is completed
d. The chemotherapy causes permanent alterations in your hair
follicles that lead to hair loss Correct Answers A
60. A client taking a thiazide diuretic for the past six months has
a serum potassium level of (unreadable - i think it is low based
on answer). The nurse anticipates which change in prescription
for the client?
a. The dosage of the diuretic will be decreased
b. The diuretic will be discontinued
c. A potassium supplement will be prescribed
d. The dosage of the diuretic will be increased Correct Answers
C
61. A client taking furosemide (Lasix), reports difficulty
sleeping. What questions is important for the nurse to ask the
client?
a. What dose of medication are you taking?
,b. Are you eating foods rich in potassium?
c.Have you lost weight recently?
d. At what time do you take your medication? Correct Answers
D
62. The nurse assesses a client with advanced cirrhosis of the
liver for signs of hepatic encephalopathy. Which finding should
the nurse consider an indication of progressive hepatic
encephalopathy?
a. An increase in abdominal girth
b. Hypertension and bounding pulse
c. Decreased bowel sounds
d. Difficulty in handwriting Correct Answers D
63. A splint is prescribed for nighttime use by a client with RA.
Which statement by the nurse provides the most accurate
explanation for use of the splints?
a. Prevention of deformities
b. Avoidance of joint trauma
c. Relief of joint inflammation
d. Improvement in joint strength Correct Answers A
64. Physical examination of a comatose patient reveals
decorticate posturing. Which statement is accurate regarding this
patient's status based upon this finding?
, a. A cerebral infectious process is causing the posturing
b. Severe dysfunction of the cerebral cortex has occured
c. There is a probably dysfunction of the midbrain
d. The patient is exhibiting signs of a brain tumor Correct
Answers B
65. An adult client is admitted to the hospital burn unit with
second and third degree burns over 40% of the body surface
area. In assessing the potential for skin regeneration, what
should the nurse remember about third degree burns?
a. Regenerative function of the skin is absent because the dermal
layer has been destroyed
b. Tissue regeneration will begin several days following return
of normal circulation
c. Debridement of eschar will delay the body's ability to
regenerate normal tissue
d. Normal tissue formation will be preceded by scar formation
for the first year Correct Answers A
66. In assessing cancer risk, the nurse identifies which woman as
being at greatest risk of developing breast cancer?
a. A 35 year old multipara who never breastfed
