Chicago State University: NURS MISC Exam 3 Questions and Answers,100% CORRECT

Chicago State University: NURS MISC Exam 3 Questions and Answers A 30-year-old African American had surgery 6 months ago and the incision site is now raised,indurated, and shiny. This is most likely which type of tissue growth? Select one: a. Angioma b. Keloid c. Melanoma d. Nevus A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient’s laboratory test findings to include Select one: a. an RBC count of 4,500,000/mL. b. A hematocrit (Hct) value of 38%. c. Normal red blood cell (RBC) indices. d. Hemoglobin count of 7.2 g/dl A client develops large, red patches covered with thick, silvery scales on the arms and knees. Which of the following skin diseases is suspected? Select one: a. Tinea capitis. b. Psoriasis. c. Tinea Corporis d. Eczema A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mmHg, a pulse of 110 beats/minute, and a urine output of 20 ml over the the past hour. The nurse reports the findings to the physician and anticipates which prescription? Select one: a. Administer a diuretic to increase urine output b. Increasing the amount of intravenous (IV) Lactated Ringer’s solution administered per hour c. Changing the IV Lactated Ringer’s solution to one that contains 5% Dextrose d. Transfusing 1 unit of packed red blood cells (PRBC) A client with chronic skin lesions on the face and arms admits to the nurse of being unable to look in the mirror. Based on this information, which of the nursing diagnoses would the nurse identify? Select one: a. Deficient knowledge related to lack of understanding of use of cover-up techniques b. Anxiety related to personal appearance c. Disturbed body image related to perception of unsightly lesions d. Social isolation related to poor self-image A client with left-sided heart failure is progressing to pulmonary edema. The nurse assesses the client and reports which of the following manifestations? Select one: a. Dry, hacking cough b. Bilateral crackles c. Peripheral pitting edema d. Fever above 36.8 º C or 101.5 º F A client with pulmonary edema is currently receiving 6 L/min of oxygen per nasal cannula. The most recent arterial blood gas (ABG) results indicate the following: pH = 7.28, PaCO2 = 53 mm Hg, PaO2= 54 mm Hg, HCO3 + 24 mm Hg. As the nurse, you anticipate that the physician will order which of the following? Select one: a. Add an ampule of sodium bicarbonate to the client’s current IV fluids. b. Change nasal cannula to partial rebreather mask at 8 L/min oxygen c. Intubate the client and place on mechanical ventilation d. Change nasal cannula to face mask at 6 L/min oxygen A female client develops a red macule on her leg after camping for the weekend. The client complains of a rash with round rings around the site, headache, neck stiffness, and pain. The nurse should suspect the client has developed which of these conditions? Select one: a. Meningitis b. Lyme disease c. Polymyositis d. Infectious dermatitis A home health nurse is visiting a client with severe chronic obstructive pulmonary disease (COPD) who is complaining of increased shortness of breath. The client is on home oxygen at 2 L/min via an oxygen concentrator and a nasal cannula with a respiratory rate of 23 breath/min. The most appropriate nursing action is to Select one: a. Call emergency services to come to the home b. Conduct further assessment of the client’s respiratory status c. Reassure the client of been unnecessary anxious d. Consider increasing the oxygen to 4 L/min during the home visit A homeless client arriving at the ED has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? Select one: a. A pink, edematous hand b. Fiery red skin with edema in the nails bed c. Black fingertips surrounded by an erythematous rash d. A white color to the skin, which is insensitive to touch A nurse is assessing the respiratory status of a patient following a thoracentesis. Which finding would indicate further assessment is needed? Select one: a. Scattered crackles, unchanged from baseline b. Diminished breath sounds on the affected side c. Equal bilateral chest expansion d. Respiratory rate of 22 breaths/minutes A nurse is assigned to a 52 years old male client with chest tube. During the morning round, the chest tube is accidentally disconnected from the collection chamber. What is the nurse immediate action? Select one: a. Attempt to reach out on the floor for the disconnected tube and reconnect it b. Clamp the tube c. Immediately place the end in a container of sterile saline or water until a new drainage system can be connected. d. Call code bleu or rapid response A nurse is assigned to a client with chest tube. During the morning assessment, the chest tube accidentally is removed from the patient. What is the nurse immediate action? Select one: a. Call code bleu or rapid response b. Apply pressure immediately with an occlusive, one way tented, or petroleum dressing and notify the doctor on the unit c. Attempt to reach out on the floor for the disconnected tube and reconnect it d. Placed the disconnected end in a container of sterile water A nurse is carrying for a client on mechanical ventilation. While sitting at the nurse station, she hears a low pressure alarm sounds in the room. She ran in the room, checks the patient and is unsuccessful to determine the cause of the alarm. On further assessment, she notes the client is desaturating. Which initial action should the nurse take first? Select one: a. Start Cardiopulmonary Resuscitation b. Ventilate the client manually with the Ambu bag and call for help c. Check the client’s Blood Pressure d. Administer oxygen A patient has just been diagnosed with allergic rhinitis and sinusitis. What medication would the nurse anticipate the physician will order first? Select one: a. mast cell unstabilizers b. antihistamines c. corticosteroid inhaler d. oxygen A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction- control chamber of the collection device. Which action by the nurse is appropriate? Select one: a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax. A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness? Select one: a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? Select one: a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient’s white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest. A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a “barrel chest.What does this pathology result from? Select one: a. An increase in the lateromedial area from hypertrophy of mucous glands in the bronchi b. An increased anteroposterior diameter caused by overinflation of the alveoli and flattening of the diaphragm c. A decrease in anteroposterior diameter caused by chronic dilation of the bronchi d. A widening of the sternocostal area secondary to chronic constriction of smooth muscles in the airways leading to bronchospasms An adult 52 years-old Caucasian client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? Select one: a. An acute superficial infection of the dermis and lymphatics b. An epidermal and lymphatic infection caused by staphylococcus c. An inflammation of the epidermis only d. A skin infection of dermis and underlying hypodermis with erythematous lesions An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the half of the posterior torso. Using the rules of nines, what should be the extent of the burn injury? Select one: a. 18% b. 24% c. 36% d. 48% As a nurse in the ED you are assigned to a triage team admitting adult clients. FOUR adult clients are in the process of getting admitted with the respective disorders: lyme disease, acne vulgaris, actinic keratosis and cellulitis. Which diagnosis is at risk of develooping skin cancer? Select one: a. Acne vulgaris b. Actinic keratosis c. Lyme disease d. Cellulitis As a nurse you are assessing a client’s skin and finds an elevated, solid lesion on the client’s great toe. It is pink, nontender, and 0.5 cm in size. Which of the following is the most appropriate action by the nurse? Select one: a. Gather more information about the lesion from the client b. Notify the physician immediately c. Determine what the client has been doing to treat the lesion d. Instruct the client to cover the lesion with an adhesive bandage Darrell Johnson is a 62-year-old male who comes to the Emergency Department (ED) with a 4-day history of increased sputum production, a change in the character of sputum, increased shortness of breath, and a fever of 101° F. He has a smoking history of 2 packs a day for the past 20 years, and he smoked 1 pack a day prior to that, beginning at the age of 14. He reports that he had asthma as a child and that he has been treated with albuterol (Ventolin) inhalers from time to time as an adult. Mr. Johnson has been hospitalized twice with pneumonia; the most recent pneumonia-related hospitalization was 2 years ago. The physical examination of this client reveals the following: T 101 F, P 115, RR 30, BP 120/80. Respirations are shallow and labored, barrel chest, skin dry and warm to touch, with poor turgor and clubbed fingernails.Which assessment is most important to the nurse to complete next? Select one: a. Auscultate breath sounds b. Determine pupillary response to light c. Observe for jugular vein distention d. palpate pedal pulses Laboratory values for client Johnson's ABGs are as followed: PH 7.28, PCO2 55, HCO3 25, PO2 89. What is the nurse accurate interpretation of these results? Select one: a. Metabolic Acidosis b. Respiratory Acidosis c. Metabolic Alkalosis d. Respiratory Alkalosis Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from: Select one: a. Hypovolemic shock and renal failure. b. Arrhythmias with cardiac arrest. c. Adrenal failure. d. Infection. Mr Johnson also has a history of HTN and is currently taking Metoprolol Tartrate 50 mg. Prior to the administration of the medication by the PM shift RN, patient reports increased bronchospasm and his HR is 54, BP 98/60. What is the nurse best action? Select one: a. Administer the medications as ordered b. Hold and call the physician c. Call imaging for C-XRAY PA LAT finding d. Ask the patient if he would like his medications crushed with applesauce. Patient presents to the ER with the following symptoms-hoarseness, dyphagia, halitosis, hemoptysis,fatigue and weakness. What condition do they likely have? Select one: a. Cancer of the lungs b. Tonsilitis c. Cancer of the larynx d. Inflammation of the adenoids The 75-year-old patient asks the nurse if the Pneumovax immunization he took when he was 65 is still protecting him. Which reply is most accurate? Select one: a. Pneumovax protects you for your lifetime. b. Immunity afforded you by Pneumovax lasts only 2 years. c. Pneumovax protection varies according to your risk factors and living situation. d. After 5 years, you need a repeat dose of Pneumovax for full immunity. The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, andagitated. The patient’s temperature is 100° F, and his pulse, blood pressure, and respirations are elevatedsince the last assessment 6 hours ago. What action should the nurse take first? Select one: a. Auscultate the patient’s lungs. b. Assess the patient’s oxygen saturation. c. Administer the mild sedative as ordered. d. Administer an ordered analgesic for discomfort. The condition in which the airways of the alveoli lose their elasticity, impeding air flow and trapping air in distal alveoli, is called: Select one: a. asthma b. chronic bronchitis c. emphysema d. pneumonia The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? Select one: a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation Feedback The correct answer is: Increased tactile fremitus The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial- thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understand that which assessment would provide the most reliable indicator for adequacy? Select one: a. Vital signs b. Mental status c. Urine output d. Peripheral pulses Feedback The correct answer is: Urine output The nurse is assisting the physician with the insertion of a new tracheostomy tube. The physician asks for the obturator. The nurse correctly hands the physician which device? Select one: a. The guide for the tracheostomy tube to be inserted b. The scalpel used to make the tracheostomy stoma c. A single-cannula tracheostomy tube d. A cuffed tracheostomy tube Feedback The correct answer is: The guide for the tracheostomy tube to be inserted The nurse is caring for a client who sustained an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 26%. Based on this level, the nurse would anticipate noting which sign in the client? Select one: a. Coma b. Flushing c. Nausea/vomiting and dizziness d. Bradycardia Feedback The corrThe nurse is caring for a client during the emergent phase of a burn injury. Which of the following assessments would provide the nurse with the most accurate information regarding this client client’s full-thickness burns? Select one: a. Red, fluid-filled vesicles b. Serous exudates from as shiny, dark-brown wound c. Leathery, dry, hard skin d. Massive edema at the injury site Feedback The correct answer is: Leathery, dry, hard skinect answer is: Nausea/vomiting and dizziness The nurse is caring for a client during the emergent phase of a burn injury. Which of the following assessments would provide the nurse with the most accurate information regarding this client client’s full-thickness burns? Select one: a. Red, fluid-filled vesicles b. Serous exudates from as shiny, dark-brown wound c. Leathery, dry, hard skin d. Massive edema at the injury site Feedback The correct answer is: Leathery, dry, hard skin The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that the level of drainage has not increased over the last 3 hours. After assessing the patient’s respiratory status, what should the nurse do next? Select one: a. Raise the system above the patient’s heart. b. Check the tubing for kinks. c. Reposition the patient. d. Notify the physician. Feedback The correct answer is: Check the tubing for kinks. The nurse is caring for an adult client who suffered an inhalation injury from a wood stove. The carbon monoxide blood levels report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? Select one: a. coma b. Flushing c. Dizziness d. Tachycardia Feedback The correct answer is: Flushing The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? Select one: a. Decreased Heart rate b. Increased urinary output c. Increased Blood pressure d. Elevated hematocrit Feedback The correct answer is: Elevated hematocrit The nurse is caring for an adult client with full-thickness burns who sis receiving fluid replacement therapy. Which of the following would indicate that the client’s condition is deteriorating? Select one: a. An apical pulse of 80 b. 40 TO 65 ml/hr urine output c. Respiratory rate of 18/minute d. Systolic BP of 80 Feedback The correct answer is: Systolic BP of 80 The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experiencing by the client? Select one: a. Occasional pink-tinged sputum b. Stridor c. Respiratory rate of 24 breaths/minute d. few basilar lung crackles on the right Feedback The correct answer is: Stridor The nurse is evaluating the respiratory system of a client who admits to smoking half packet per day for 20 years prior to that. When evaluating the client’s risk of developing a respiratory disease, the nurse calculates that the client has a smoking history of how many packs over the years? Select one: a. 6.5 pack-years b. 15 pack-years c. 11.5 pack-years d. 10 pack-years Feedback The correct answer is: 10 pack-years The nurse is getting ready to administer medications to a 24 client with diagnosis of asthma. After verification of the 6 rights of medication administration, the nurse is both on metered dose inhalers for bronchodilation and inflammation. Which of the two medications should the nurse administer first? Select one: a. anti-inflammatory b. Bronchodilator c. Stool softener d. anti-nausea Feedback The correct answer is: Bronchodilator The nurse is preparing to teach a class of adult and elderly clients on the prevention of skin problems. Which of the following is a priority for the nurse to instruct clients to avoid? Select one: a. Vitamin E b. Alkaline soaps c. Radiation d. Excessive Sunlight exposure Feedback The correct answer is: Excessive Sunlight exposure The nurse is preparing to delegate which of the following nursing tasks to a licensed practical nurse? Select one: a. Monitor a client’s chest tube for bubbling b. Assess the client for tactile fremitus c. Administer morphine IV to a client experiencing a pulmonary embolism d. Perform a sputum culture for a client Feedback The correct answer is: Perform a sputum culture for a client The nurse is preparing a patient with empyema for a thoracentesis. Which of the following should the nurse have available in the event that the procedure is ineffective? Select one: a. An intubation tray b. A crash cart c. A chest tube insertion kit d. A ventilator Feedback The correct answer is: A chest tube insertion kit The nurse is preparing to care for a patient scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? Select one: a. Return of distal pulses b. Brisk bleeding from the site c. Decreased edema formation d. Formation of granulation tissue Feedback The correct answer is: Return of distal pulses The nurse is reviewing the plan of care for a patient following a tympanoplasty. Which intervention should the nurse implement in the immediate postoperative period? Select one: a. Keep the patient flat in bed. b. Encourage deep breathing and coughing. c. Reposition the patient quickly to reduce nausea and vomiting. d. Position the patient’s head with the affected ear touching the mattress. Feedback The correct answer is: Keep the patient flat in bed. The nurse is teaching a mother about caring for her 4 year-old with atopic dermatitis. Which of the following statements by the mother indicates that the teaching has been successful? Select one: a. I will avoid using fabric softeners in the laundry. b. I will keep my child out of the sun. c. We will all switch to soy milk. d. I’ll prevent the spread of dermatitis by using separate towels for the children Feedback The correct answer is: I will avoid using fabric softeners in the laundry. The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? Select one: a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site Feedback The correct answer is: 400 mL of blood in the collection chamber The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient’s postoperative care? Select one: a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction Feedback The correct answer is: Frequent use of an incentive spirometer The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? Select one: a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient’s room. Feedback The correct answer is: A surgical face mask is applied before visiting the patient. The patient comes to the emergency room complaining of abdominal pain. The nurse assesses dry,hot skin, fruity breath, and deep respirations. To which problem should the nurse attribute these findings? Select one: a. An insulin reaction b. Ketoacidosis c. Rebound hyperglycemia d. Hypoglycemia Feedback The correct answer is: Ketoacidosis The PCP has ordered albuterol (Ventolin) for patient Johnson , MDI, 2 puffs QID. What should the nurse monitor with the administration of this medication? Select one: a. Monitor Temperature b. Monitor Pulse and BP c. Measure I/O d. Monitor Central Venous Pressure Feedback The correct answer is: Monitor Pulse and BP Which information will the nurse include when teaching a patient with herpes simplex type 1 keratitis? Select one: a. Use of natamycin (Natacyn) antifungal eyedrops b. Application of corticosteroid ophthalmic ointment c. Avoidance of NSAIDS d. Completion of the prescribed series of oral acyclovir (Zovirax) Feedback The correct answer is: Completion of the prescribed series of oral acyclovir (Zovirax) Which nursing action is essential prior to administration of IV antibiotics Zosyn (Ampicillin/Sulbactam)? Select one: a. assess for the apical heart rate b. Obtain a sputum culture early in the morning c. Document Mr Johnson's daily weight d. Assess oxygen saturation Feedback The correct answer is: Obtain a sputum culture early in the morning Which of the following is a characteristic of a tension pneumothorax? Select one: a. Trachea deviation toward the affected side b. Symmetry of the thorax and equal breath sounds c. Tracheal deviation toward the unaffected side d. Decreased heart rate and decreased respirations rate Feedback The correct answer is: Tracheal deviation toward the unaffected side Which of the following is a characteristic of a tension pneumothorax? Select one: a. Trachea deviation toward the affected side b. Symmetry of the thorax and equal breath sounds c. Tracheal deviation toward the unaffected side d. Decreased heart rate and decreased respirations rate Feedback The correct answer is: Tracheal deviation toward the unaffected side Which of these statements about a nurse who has never had chickenpox caring for a client with herpes zoster during the draining, open lesions phase of the illness is TRUE? Select one: a. The nurse is at risk of contracting herpes zoster. b. The nurse may develop chickenpox as a result of this exposure. c. The nurse could contract herpes simplex virus type 1 or 2. d. The nurse would not be at risk for developing any condition if consistently using universal precautions. Feedback The correct answer is: The nurse may develop chickenpox as a result of this exposure. Which type of skin cancer is the most deadly? Select one: a. Squamous cell carcinoma b. Basal cell carcinoma c. Malignant Melanoma d. Granuloma Feedback The correct answer is: Malignant Melanoma While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? Select one: a. Call the physician to reinsert the tube b. Call the respiratory therapist to reinsert the tracheostomy c. Grasp the retention sutures to spread the opening d. Cover the tracheostomy site with a sterile dressing to prevent infection Feedback The correct answer is: Grasp the retention sutures to spread the opening You are a nurse caring for a client with chest tube drainage. During the morning round, she notes that there is gentle bubbling in the suction chamber. What is the nurse accurate interpretation of this finding? Select one: a. This is an abnormal finding and physician should be notified b. This is a normal finding c. This is an emergency and the rapid response team should be called d. It is a critical finding that requires immediate intervention Feedback The correct answer is: This is a normal finding