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N3134 FINAL EXAM – Questions With Comprehensive Solutions

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Terms in this set (21)


C. "I should not smoke"


Raynaud's disease is a disorder of the blood vessels that supply
blood to the skin and cause the distal extremities to feel numb
and cool in response to cold temperatures of stress. During a
Raynaud's attack, these arteries narrow, limiting blood circulation
A nurse is teaching a client who to affected areas. Strong emotion or exposure to the cold
was recently diagnosed with causes these areas to become white due to a lack of blood flow
Raynaud's disease about in the area. Affected areas then turn blue as tiny blood vessels
preventing the onset of dilate to allow more blood to remain in the tissues. When the
manifestations. Which of the flow of blood returns, the area becomes red and later returns to
following statements by the normal color. This can cause tingling, swelling and painful
client indicates an throbbing. The attacks can last from minutes to hours. If the
understanding of the teaching? condition progresses, blood flow to the area could become
permanently decreased, causing the fingers to become thin and
A. "I should limit my exposure to tapered, with smooth, shiny skin and slowly-growing nails. If an
sunlight" artery becomes blocked completely, gangrene or ulceration of
B. "I should avoid drinking the skin can occur. Smoking cessation can prevent the onset of
alcohol" the manifestations of Raynaud's disease.
C. "I should not smoke"
D. "I should limit of intake of A. Clients who have Raynaud's disease have poor blood
foods that are high in purine" circulation to the distal extremities. Exposure to sunlight
increases warmth and blood flow to the extremities.
B. Although drinking alcohol can interfere with some medications
and illnesses, it does not relate to the progression of Raynaud's
disease.
D. Foods high in purine such as organ meats are contraindicated
for clients who have gout, not Raynaud's disease.

A nurse in a provider's office is A. WBC 15,000 mm^3
reviewing the laboratory
findings of a client who reports This finding is above the expected reference range and is an
chills and aching joints. The indication of infection.
nurse should identify which of
the following findings as an B. Although an elevated ESR can indicate an infection, this finding
indication of an infection? is within the expected reference range.
C. A urine pH of 7.2 is within the expected reference range.
A. WBC 15,000 mm^3 D. A urine specific gravity of 1/0063 is within the expected
B. Erythrocyte sedimentation reference range.
rate (ESR) 15 mm/hr
C. Urine pH 7.2
D. Urine specificity gravity
1.0063

, A. Limit fluid intake

A nurse is teaching a client who
A client who has CKD should limit fluid intake to prevent
has chronic kidney disease
hypervolemia (excessive fluid overload).
(CKD). Which of the following
instructions should the nurse
B. A client who has CKD should increase caloric intake so that the
include?
body can use protein for protein synthesis instead of energy
consumption. Using protein for energy can lead to a negative
A. Limit fluid intake
nitrogen balance and malnutrition.
B. Limit caloric intake
C. A client who has CKD should limit phosphorus intake because
C. Eat a diet high in phosphorus
the kidneys are unable to excrete it.
D. Eat a diet high in protein
D. A client who has CKD should not eat excessive protein to
prevent the build-up of protein waste products and uremia.

C. Absence of hair on the legs


A progressive loss of hair is common with aging. However,
A nurse is assessing the
thinning or absence of hair on extremities indicates poor arterial
hematologic system of an older
circulation to that area. The nurse should look for further
adult client. The nurse should
indications of arterial insufficiency and report these findings to
report which of the following
the provider.
findings to the provider as a
possible indication of a
A. Although pallor can indicate a hematologic disorder such as
hematologic disorder?
hyperbilirubinemia, yellowing of the skin is common with aging.
Pallor is an unreliable indicator of anemia for an older adult.
A. Pallor
B. Although jaundice is an unreliable indicator of
B. Jaundice
hyperbilirubinemia for an older adult.
C. Absence of hair on the legs
D. Although poor nailbed capillary refill can indicate a
D. Poor nailbed capillary refill
hematologic disorder such as an arterial insufficiency, thickening
and discoloration of the nails are common with aging and are not
a reliable indicator of arterial insufficiency for an older adult.

D. Tissue hypoxia
A nurse is preparing an in-
service presentation about the In response to tissue hypoxia, the kidneys release erythropoietin,
basics of hematology. Which of which stimulates the production of erythrocytes (RBCs) in the
the following factors provides a bone marrow.
stimulus for the production of
RBCs? A. Venous stasis activates platelets and stimulates blood clotting,
it does not affect the production of RBCs.
A. Venous stasis B. Platelets are essential for blood clotting. A platelet deficiency
B. Thrombocytopenia does not affect the production of RBCs.
C. Inflammation C. Inflammation and infection trigger the production of white
D. Tissue hypoxia blood cells.



A. Tracheal deviation to the left
A nurse is caring for a client C. Absent breath sounds on the right side
following a right pleural D. Neck vein distention
thoracentesis. The nurse
measures a total of 35 mL of A tension pneumothorax can occur following a thoracentesis. A
purulent drainage. Which of the trachea that is deviated to the unaffected side instead of being in
following findings should the the center of the neck is a manifestation of a pneumothorax.
nurse recognize as an indication Absent breath sounds on the affected side and neck vein
of a tension pneumothorax. distention are also manifestations of a pneumothorax. As the
(Select all that apply). client's difficult breathing increases, the blood flow return
compresses, causing the neck veins to distend.
A. Tracheal deviation to the left
B. Temperature of 38.8 C (102 F) B. An elevated temperature is a sign of an infection and can be
C. Absent breath sounds on the associated with the purulent drainage obtained. However, this is
right side not a manifestation of a pneumothorax.
D. Neck vein distention E. Clients who experience a tension pneumothorax exhibit
E. Bradypnea respiratory distress and tachypnea until a chest tube is inserted
to re-inflate the lung.

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