NR324 / NR-324: Adult Health I Exam 1 Practice Quiz - Chamberlain College of Nursing

NR-324 Adult Health I NR 324: Exam 1 Practice Quiz A client is experiencing 8/10 incisional pain, resulting in a poor cough effort, and has course scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Medicate the patient with prescribed pain medication. b. Splint the patient’s chest during coughing. c. Observe the patient use the incentive spirometer. d. Assess the patient’s oxygenation using a pulse oximetry. RATIONALE: The nurse is worried that a patient who is not entirely reliable is being discharged home on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this patient? a. IV drug administration b. Remain in the hospital c. Direct observation therapy d. Isolation RATIONALE: The emergency department nurse is assessing a patient who has sustained a blunt injury to the right chest wall. Which findings indicate the presence of a pneumothorax? (Select all that apply) a. Decreased chest expansion on the right side b. The presence of a barrel chest c. Diminished or absent breath sounds on the affected side d. Tachypnea e. Tachycardia RATIONALE: A nurse is caring for a client with pneumonia who has a new tracheostomy requiring frequent suctioning. The nurse anticipates what possible clinical problems? (Select all that apply) a. Acute pain b. Hyponatremia c. Impaired gas exchange d. Fluid volume deficit e. Ineffective airway clearance RATIONALE: A client has been receiving IV fluids at 150 mL/hr. Which assessments indicate the client has fluid volume excess? (Select all that apply) a. Weak, thready pulses b. Stridor c. Distended neck veins d. S3 heart sound e. Pitting edema RATIONALE: A nurse is assessing a client with fluid volume excess and a sodium level of 120 mEq/L. What clinical manifestations would the nurse expect? (Select all that apply) a. Dry mucous membranes b. Headache c. Tachycardia d. Confusion e. Hypotension RATIONALE: Causes of hypervolemia include (Select all that apply) a. Increased intake of fluid and sodium b. Acute renal failure c. Diuretic therapy d. Potassium loss e. Chronic renal failure RATIONALE: A nurse is caring for a female client admitted for severe nausea, vomiting, and copious diarrhea. What data reflects the client's condition? a. Urine specific gravity 1.005 b. Sodium 135 c. Serum osmolality 292 d. BUN 5 e. Hematocrit 56% RATIONALE: A nurse is caring for a client whose potassium level is 3.0. What clinical manifestations are associated with this potassium level? (Select all that apply) a. Diarrhea b. Peaked T waves c. Constipation d. Leg cramps e. Shallow respirations RATIONALE: A nurse is caring for a client admitted for severe nausea, vomiting, and diarrhea. What is the nurse's priority action? a. Place the client on bedrest b. Monitor strict intake and output c. Obtain baseline weight d. Measure blood pressure RATIONALE: A nurse is caring for a client whose potassium level is 3.0. What interventions are in the nurse's plan of care? (Select all that apply) a. Increase potassium rich foods b. Administer sodium polystyrene by mouth c. Start a slow potassium drip IVPB at 10 mEq/hr d. Administer a diuretic e. Place client on a heart monitor RATIONALE: A nurse is caring for a client whose potassium level is 6.0. What clinical manifestations does the nurse expect? (Select all that apply) a. Irritability b. Diarrhea c. Flattened T waves d. Fatigue e. Abdominal cramping A nurse taking care of a client understands that which condition puts the client at risk for hyperkalemia a. Chronic kidney failure b. Diarrhea for the last four days c. Bowel obstruction with NG suction d. Newly diagnosed cirrhosis A client has returned from the OR post-op thyroidectomy. The nurse knows to monitor for what clinical manifestations indicating an electrolyte imbalance? (Select all that apply) a. Restlessness/irritability b. Muscle flaccidity c. Tetany d. Negative Trousseau's sign e. Positive Chvostek's sign RATIONALE: - A nurse recognizes that a client is at risk for respiratory alkalosis when which assessment findings are present? (Select all that apply) a. Anxiety b. Fever c. Narcotic use d. Hyperventilation e. Hyperkalemia f. Pain A nurse is caring for a client admitted for severe nausea, vomiting, and diarrhea. The client's vital signs are: T 100.0, BP 86/50, HR 120, RR 22. What is the nurse's priority action? a. Check client's oxygen saturation b. Start a 0.9% normal saline infusion c. Administer 3% normal saline d. Auscultate bowel sounds A nurse is caring for a client with metabolic alkalosis. The nurse knows a common cause of this imbalance is: a. Renal failure b. Hyperventilation c. NG suctioning d. High altitude RATIONALE: - A nurse is caring for a client experiencing an acute asthma exacerbation. Which intervention should the nurse implement first? a. Give 25 mcg of Fentanyl IVP b. Place the client on a cardiac monitor c. Start a 0.9% normal saline infusion d. Administer oxygen via non-rebreather A nurse caring for a client with COPD can expect to assess what clinical manifestations? (Select all that apply) a. Prolonged expiration b. Increased AP chest diameter c. Clubbing of the fingers d. Orthopnea e. Bradypnea A nurse is caring for a client with a chest tube. What interventions are included in the plan of care? (Select all that apply) a. Monitor the water seal chamber for tidaling b. Milk the tubing to facilitate drainage c. Clamp the tubing when the client is ambulating d. Ensure tubing has no kinks or obstruction e. Maintain the client in Fowler's position A client presents with a sudden onset of chest pain and shortness of breath. An elevated D-dimer indicates a pulmonary embolism. What is the nurse's priority action? a. Gain IV access and send client to CT b. Administer oxygen via non-rebreather c. Place client on a cardiac monitor d. Assess the client's lung sounds