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36 Cards in this Set
- Front
- Back
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In counseling a couple in which the man has an autosomal recessive disorder, and the woman has no gene for the disorder, the nurse uses Punnett squares to show the couple that the probability of their having a child with the disorder is?
a. 0% b. 25% c. 50% d. 75% |
A. 0%
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A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as?
a. personality cahnges b. frequent loose stools c. facial muscle spasms d. generalized weakness |
D. generalized weakness
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A patient is receiving intravesical bladder chemotherapy. The nurse will monitor for?
a. nausea b. alopecia c. mucositis d. hematuria |
d. hematuria
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Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound treatment?
a. ketorolac (Toradol) b. lorazepam (Ativan) c. gabapentin (neurontin) d. hydromorphone (dilaudid) |
D. Dilaudid
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A patient with the following arterial blood gas results: ph 7.32, Pao2 88, 37 mm Hg, and HCO 16 mEq/L. The nurse interprets these results as ?
a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis |
a. metabolic acidosis
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After the nurse determines that a patient has the following risk factors for melanoma, factor should be the focus of patient teaching related to prevention?
a. the patient has multiple dysplastic nevi b. the patient is fair skinned and has blue eyes c. the patient's mother died of a malignant melanoma d. the patient uses a tanning booth throughout the winter |
d. The patient uses a tanning booth throughout the winter
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A patient who has an infusion of 50% dextrose prescribed asked the nurse why a peripherally inserted central catheter must be inserted. Which explanation by the nurse is correct?
a. The prescribed med can be given much more rapidly when the patient has a central line b. there is a decreased risk for infection when 50% dextrose is infused through a central line c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line d. The required blood glucose monitoring is more accurate when samples are obtained from a central line |
c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line
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A patient is admitted to the hospital with Pneumocystis jiroveci pneumonia (pcp) and HIV testing is positive. Based on diagnostic testing established by the centers for disease control and prevention (CDC) the patient is diagnosed as having?
a. acute infection b. early chronic infection c. intermediate chronic infection d. late chronic infection or AIDS |
d. late chronic infection or AIDS
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When caring for a patient with hyponatremia, which actions will the nurse anticipate taking?
a. restrict patient's oral free water intake b. avoid use of electrolyte containing drinks c. infuse a solution of 5% dextrose in 0.45% saline d. administer vasopressin (ADH) |
a. restrict patient's oral free water intake
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A 76 year old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a
a. red wound b. yellow wound c. full-thickness wound d. stage III pressure wound |
b. yellow wound
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A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage?
a. I b. II c. III 4. IV |
C. III
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A patient with metastatic cancer of the colon experiences sever vomiting following each administration of chemo. An important nursing intervention for the patient is to
a. teach about the importance of nutrition during treatment b. have the patient eat large meals when the nausea is not present c. offer dry crackers and carbonated fluids during chemo d. admin prescribed antiemetics 1 hour before the treatments |
d. admin prescribed antiemetics 1 hour before the treatments
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A pregnant woman with a history or early chronic HIV infection is seen at the clinic. Which information will the nurse include when teaching the patient?
a. The antiretroviral medications used to treat HIV infection are teratogenic b. Most infants born to HIV positive mothers are not infected with the virus c. Since she is at an early stage of HIV infection, the infant will not contract HIV d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral drug therapy (ART) |
b. Most infants born to HIV positive mothers are not infected with the virus
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The nurse has just received change of shift report about the following four patients. Which patient will the nurse assess first?
a. the patient has multiple black wounds on his feet and ankles b. THe newly admitted patient with a stage IV pressure ulcer on the coccyx c. the patient who needs to be medicated with analgesics before a scheduled dressing change d. the patient who has been receiving immunosuppressent medications and has a temp of 102 F |
d. the patient who has been receiving immunosuppressent medications and has a temp of 102 F
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The nurse notes several angiomas on the legs of a 73 year old patient. which action should the nurse take?
a. assess the patient for evidence of liver disease b. discuss the adverse effects of sun exposure on the skin c. educate the patient about possible skin changes with aging d. suggest that the patient make an appointment with a dermatologist |
a. assess the patient for evidence of liver disease
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A patient has a circular, flat, reddened lesion about 5cm in diameter on his ankle. To determine whether the lesion is related to blood vessel dilation, the nurse will?
a. elevate the patient's leg b. press firmly on the lesion c. check the temp of the skin around the lesion d. palpate the dorsal pedis and posterior tibial pulses |
b. press firmly on the lesion
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A patient who has burns on the back band chest from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first?
a. stay at the bedside and reassure the patient b. administer the ordered morphine sulfate IV c. assess orientation and level of consciousness d. use pulse oximetery to check the oxygen saturation |
d. use pulse oximetery to check the oxygen saturation
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A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to?
a. obtain wound cultures b. start antibiotic therapy c. redress the wound with wet to dry dressings d. continue to monitor the wound for purulent drainage |
a. obtain wound cultures
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When assessing a patient who spilled hot oil on his right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. the patient states that they are verity painful. The nurse will document the injury as
a. full thickness skin destruction b. deep full thickness skin destruction c. deep partial thickness skin destruction d. superficial partial thickness skin destruction |
c. deep partial thickness skin destruction
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A patient seeks medical care after sharing needles for heroin injection with a friend who has Hep B. To provide immediate protection from infection, the nurse expects to administer?
a. corticosteroids b. gamma globulin c. hep B vaccine d. fresh frozen plasma |
b. gamma globulin
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A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L. Which of these prescribed therapies that the patient has been receiving should the nurse question?
a. infuse 5% dextrose in water at 125 ml/hr b. admin IV morphine sulfate 4mg every 2 hours PRN c. give IV metoclopramide (Reglan) 10 mg every 6hours PRN for nausea d. admin 3% saline if serum sodium drops to less than 128 mEq/L |
a. infuse 5% dextrose in water at 125 ml/hr
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A patient who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. The nurse will anticipate teaching the patient about?
a. the benefits of daily exercise b. foods that are higher in protein c. treatment with anti fungal agents d. a change in antiretroviral therapy |
d. a change in antiretroviral therapy
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A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. Which finding by the nurse indicates a possible adverse effect of the medication?
a. thinning of the affected skin b. alopecia of the affected areas c. reddish brown discoloration of the skin d. dryness and scaling in the areas of treatment |
a. thinning of the affected skin
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Which instruction will be included when teaching a patient with possible allergies about intradermal skin testing?
a. do not eat anything for 6 hours before the test b. take an oral antihistamine about an hour before the test c. plan to wait in the clinic for 20 - 30 minutes after the test d. reaction to the testing will occur about 48 - 72 hours later |
c. plan to wait in the clinic for 20 - 30 minutes after the test
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The nurse obtains all the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern?
a. BP of 90/40 b. urine output is 30 ml over the last hour c. oral fluid intake is 100 ml over last 8 hours d. there is prolonged skin tenting over the sternum |
a. BP of 90/40
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A patient is admitted to the burn unit with burns to the upper body and head after a garage fire. Initially wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and ausculatate the lungs again b. notify the HCP and prepare for endotracheal intubation c. document the results and continue to monitor the patient's respirations d. Reposition the patient in high Fowlers position and reassess breathing |
b. notify the HCP and prepare for endotracheal intubation
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Antiretroviral therapy (ART) is being considered for an HIV infected patient who has a CD4 cell count of 400/ul. What factor is the most important to consider when determining whether ART will be started for this patient?
a. patient support system b. HIV genotype and phenotype c. potential medication side effects d. patient ability to comply with ART schedule |
d. patient ability to comply with ART schedule
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A patient diagnosed with systemic lupus erythematosus (SLE) is scheduled for plasmapheresis. The nurse plans to teach the patient that plasmapheresis will?
a. eliminate eosinophils and basophils from the blood b. remove antibody-antigen complexes from the circulation c. prevent foreign antibodies from damaging various body tissue d. decrease the damage to organs caused by attacking T-lymphocytes c. |
b. remove antibody-antigen complexes from the circulation
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A patient is diagnosed with basal cell carcinoma (BCC) of the face. Which information should be included in patient teaching?
a. treatment plans include watchful waiting b. screening for metastasis will be important c. low dose systemic chemotherapy is used to treat BCC d. minimizing sun exposure will reduce risk for future BCC |
d. minimizing sun exposure will reduce risk for future BCC
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During a routine health examination, a30 year old patient tells the nurse about a family history of colon cancer. What action should the nurse take next?
a. educate the patient for the need of a colonoscopy at the age of 50 b. teach the patient how to do home testing for fecal occult blood c. obtain more information form the patient about the family history d. schedule a sigmoidoscopy to provide baseline data about the patient |
c. obtain more information form the patient about the family history
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A patient with a large stomach tumor that is attached to the liver is scheduled to have a debunking procedure. The nurse explains that the expected outcome of the surgery is
a. relief of pain by cutting sensory nerves in the stomach b. control of the tumor growth by removal of malignant tissue c. decrease in tumor size to improve the effects of other therapy d. promotion of better nutrition by relieving pressure in the stomach |
c. decrease in tumor size to improve the effects of other therapy
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During the emergent phase elf burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion ?
a. check skin turgor b. monitor daily weight c. assess mucous membranes d. measure hourly urine output |
d. measure hourly urine output
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When taking a health history of a patient, the nurse discovers that patient works as a roofer. The nurse will plan to teach the patient how to self assess for clinical manifestations of ? (select all that apply)
a. alopecia b. intertrigo c. wrinkling d. erythema e. actinic keratosis |
c. wrinkling
d. erythema e. actinic keratosis |
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A nurse is providing teaching to a client about skin cancer. Which of the following should the nurse explain are risk factors for skin cancer. (select all that apply)
a. increasing age b. exposure to chemical pollutants c. long term exposure to the sun d. increased pigmentation e. genetics f. Immunosuppression |
a. increasing age
b. exposure to chemical pollutants c. long term exposure to the sun e. genetics f. Immunosuppression |
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During the emergent stage of burn management for a client with burns of 30% of the body the nurse should assess the client for which of the following? (select all that apply)
a. hyponatremia b. hyperkalemia c. hypoglycemia d. Increased hematocrit e. "fever spikes" |
b. hyperkalemia
d. Increased hematocrit e. "fever spikes" |
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A 35 - year - old client is brought to the emergency department with second and third degree burns over 15% of the body. Admission vitals signs are blood pressure 100/50, heart rate 130 beats/minute and respiratory rate 26 breaths/minute. What nursing interventions are appropriate for this client? select all that apply
a. clean the burns with hydrogen peroxide b. cover the burns with saline soaked towels c. begin an intravenous infusion of lactated ringer's solution d. place ice directly on the burn areas e. administer 6mg of IV morphine f. administer tetanus prophylaxis, as ordered |
c. begin an intravenous infusion of lactated ringer's solution
e. administer 6mg of IV morphine f. administer tetanus prophylaxis, as ordered |
