Midterm Review

Front 1

The nurse assesses that the patient has developed abdominal pain, urinary retention, and confusion. The nurse concludes these signs are the result of an inadequate supply of:

a. potassium (K+).

b. calcium (Ca2+).

c. phosphates (PO43).

d. sodium (NA+).

Back 1

potassium (K+).

Front 2

A patient with congestive heart failure has gained 1.1 pounds over the last 24 hours. The nurse is aware that this weight gain represents a fluid retention of _____ L.

Back 2

0.5

Front 3

The nurse inserting an NG tube through the nostril into the back of the throat of a patient would instruct the patient to

Back 3

The patient should be instructed to tip the head forward and begin to swallow to help advance the tube through the esophagus

Front 4

The nurse instructs the patient on a vegetarian diet that protein intake can be supported by including complementary proteins in the diet with such foods as: (Select all that apply.)

Select one or more:

a. tofu stir-fried with vegetables.

b. bean soup with cornbread.

c. lean fish with green beans.

d. peanut butter on whole wheat bread.

e. apples and cheese

Back 4

bean soup with cornbread:

tofu stir-fried with vegetables:

peanut butter on whole wheat bread:

Front 5

A patient has been identified as having a dietary deficiency of vitamin D. The nurse understands that this patient is also at risk for having a deficiency of:

Back 5

calcium

Front 6

The patient who is prescribed a diuretic for fluid-volume excess is discharged home. The patient verbalizes understanding of his disease process when he says:

Select one:

a. "I can put catsup on my scrambled eggs."

b. "I can snack on salted popcorn."

c. "I will snack on raisins."

d. "I will avoid apricots."

Back 6

"I will snack on raisins." : patient will lose electrolytes, especially potassium, because he is on a diuretic; snacks such as raisins and apricots are rich in potassium.

Front 7

A patient who is experiencing severe diarrhea is losing excessive bicarbonate ions. This patient is at risk for developing:

Back 7

metabolic acidosis : Metabolic acidosis can be caused by either an excessive loss of bicarbonate ions or an excessive retention of hydrogen ions.

Front 8

A patient drank a cup of coffee, a half glass of orange juice, and half a carton of milk with breakfast. Using common equivalents of food containers as a guide, the nurse notes on the intake column of the intake and output sheet that the patient consumed _____ mL.

Back 8

420: coffee cup is generally equivalent to 240 mL, a half glass of juice is 60 mL, and half a carton of milk is 120 mL.

Front 9

The nurse suggests to a diabetic patient to eat complex carbohydrates, which include: (Select all that apply.)

Select one or more:

a. sweet potatoes.

b. brown rice.

c. lima beans.

d. whole grain foods.

e. legumes.

Back 9

whole grain foods., brown rice., legumes

Front 10

The patient who was admitted after vomiting for 3 days would show an abnormally low blood pressure because of a fluid shift from:

Back 10

intravascular to the interstitial.

Front 11

A patient with a history of severe chronic obstructive pulmonary disease (COPD) is most likely to have:

Back 11

respiratory acidosis : retained CO2.

Front 12

The nurse is caring for a patient for whom a dose of IV potassium has been ordered. Prior to hanging the potassium, the nurse should:

Back 12

confirm the IV fluid running is compatible with potassium.--and A urine output of at least 30 ml/hr is essential prior to giving IV potassium.

Front 13

A patient with a serum potassium value of less than 3.5 mEq/L is

Back 13

hypokalemic

Front 14

The nurse would be sure the diet of a patient in an extended care facility who has a large pressure ulcer on his sacrum would include foods rich in vitamin:

Back 14

Vitamin C helps protect the body against infections and promotes wound healing.

Front 15

A patient with healthy kidneys experiences metabolic alkalosis resulting from episodes of vomiting. The nurse takes into consideration that the kidneys can clear the alkaline substances and fully stabilize the patient's pH in approximately:

Back 15

3 days.

Front 16

Before any diet tray is delivered to a patient, the nurse has the responsibility of:

Back 16

the diet on the tray with the diet sheet

Front 17

Fluid overload is suspected in an 82-year-old patient who is receiving total parenteral nutritional therapy (TPN) when the nurse assesses: (Select all that apply.)

Select one or more:

a. dyspnea.

b. complaint of headache.

c. increased pulse rate.

d. hyperactive bowel sounds.

e. excessive urine output.

Back 17

excessive urine output., increased pulse rate., dyspnea.

Front 18

A nurse gets a positive Chvostek's sign on a young woman with bulimia who has been giving herself frequent enemas containing phosphate. The nurse anticipates a laboratory finding of _____ mEq/L.

Back 18

calcium 6.5 : Chvostek's sign is an indicator of a reduced calcium level

Front 19

The nurse stresses to a patient that proteins, one of the biochemical substances used by the body, can be found in

Back 19

eggs., yogurt., fish., soybeans., nuts

Front 20

patient who is on an anticoagulant (Coumadin) asks, "What did the physician mean when he said I was to have my blood tested every 2 weeks?" The nurse explains, "It is important to monitor the effects of the drug to see how long it takes your blood to clot. The blood test the physician was talking about is the:

Back 20

international normalized ratio (INR)."

Front 21

An elderly patient has had a series of enemas in preparation for a gastrointestinal diagnostic procedure. Which electrolytes should be monitored following the enemas?

Back 21

Sodium and potassium

Front 22

The patient who has just returned to the unit after an angiography test should be assessed immediately for:

Back 22

bleeding or formation of a hematoma: bleeding at insertion site.

Front 23

A patient who is scheduled for a cardiac catheterization asks what the catheterization will reveal that an electrocardiogram would not. The nurse explains that the catheterization shows:

Back 23

oxygen concentration at various sites

Front 24

The statement made by a patient that would delay a scheduled CT scan would be:

Back 24

"I have just been started on metformin."

Front 25

The patient asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that a(n):

Back 25

The colostomy is an opening into the colon, with formed effluent requiring irrigation, whereas the ileostomy is an opening in the ileum, with liquid effluent requiring catheterizing

Front 26

The nurse has documented that a patient has had two episodes of steatorrhea, which means that the character of the stool is:

Back 26

frothy and foul smelling : stools with abnormally high fat content that are usually frothy, foul smelling, and float on water.

Front 27

A patient with a new colostomy should have the hole in the faceplate cut to allow _____ inch around the stoma

Back 27

The faceplate should allow 1/4

inch around the colostomy stoma

Front 28

An adult male patient who cannot void has an order to have a urinary catheter inserted. Which size catheter would be most appropriate to use?

Back 28

The average-sized urinary catheter used for an adult male is 18 to 20 French

Front 29

A nurse is digitally removing a fecal impaction from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:

Back 29

pulse rate decreases from 78 to 52 beats/min
: Stimulation of the sphincter may cause a vagal response as evidenced by bradycardia

Front 30

A nurse is reinforcing teaching with a patient who will begin a bowel training program. An intervention this program does not include is

Back 30

use of an enema.

Front 31

The nurse explains to the patient that the significance of the hematocrit is that it:

Back 31

refers to the separation of blood cells from plasma

Front 32

An ambulatory clinic patient telephones to report diarrhea and to ask for advice on medication to manage it. The best response by the nurse is, "Do not use antidiarrheal medication for longer than _____ hours without calling back for an appointment."

Back 32

Antidiarrheal medication should not be continued for more than 48 hours without calling a physician.

Front 33

An adult patient has an order to have his urinary catheter irrigated with normal saline. The nurse plans to draw up how much solution into the sterile irrigation syringe?

Back 33

The appropriate amount of solution to draw into the syringe for irrigation is 30 to 40 mL in an adult patient, which provides effective irrigation without risking overdistention of the bladder

Front 34

A patient wants to know what was meant when the doctor said that his white blood cell (WBC) count had a shift to the left. The nurse explains that a shift to the left indicates

Back 34

an increase in the number of immature WBCs

Front 35

A nurse is caring for a patient with prostate enlargement who has an indwelling catheter. As the nurse is attaching a portion of the catheter to the patient's abdomen, the patient asks why this is being done. The correct response is

Back 35

Taping the catheter to your abdomen will prevent pulling on the meatus."

Front 36

A nurse is assisting a patient with a new continent ileostomy to catheterize the internal reservoir to drain the ileostomy. When the catheter meets resistance from the internal valve, the nurse should:

Back 36

have the patient take a deep breath and apply gentle pressure over the area.

Front 37

The nurse instructs a patient with a new colostomy against eating food that may cause an obstruction. These foods include: (Select all that apply.)

Select one or more:

a. cucumbers.

b. tomatoes.

c. spicy foods.

d. whole-kernel corn.

e. shrimp.

Back 37

whole-kernel corn., tomatoes., shrimp

Front 38

A patient has just had a urinary drainage catheter removed. The nurse plans to measure intake and output for this patient for another _____ hours.

Back 38

12 to 24

Front 39

The nurse points out that age-related changes in the intestinal tract are relatively insignificant. The changes include: (Select all that apply.)

Select one or more:

a. decreased motility in the large intestine.

b. creation of excessive flatus.

c. atrophy of the villi in the small intestine.

d. increased incidence of hemorrhoids.

e. decreased absorption of fats and vitamin B12.

Back 39

With age there is a decrease in the villi in the small intestine that decreases the absorption of fats and vitamin B12. Motility frequently decreases in the large intestine