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1 / 25
Category:
Medical-Surgical
The client experienced left CVA. Assessment findings include which of the following. Select all that apply.
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The correct answer is: Left homonymous hemianopsia, Right sided weakness and uncoordinated movements are manifestations of Left CVA. Choices C and D are manifestations of right CVA.
2 / 25
Category:
Medical-Surgical
The patient has second degree burns from scalding from boiling water. Which of the following are characteristics of second degree burns? Select all that apply.
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The correct answer is: Second degree burns affect the epidermis and dermis; the area appears reddish, moist, with blisters or vesicles, it is painful, it is partial thickness burns.
3 / 25
Category:
Medical-Surgical
The patient has been diagnosed to have DM. Health teachings on foot care should include which of the following? Select all that apply.
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The correct answer is: Foot care is necessary in clients with DM to prevent gangrene formation. Choice D is incorrect. Cutting lateral edges of the toenails and removing ingrown may cause trauma that may lead to gangrene. Choice D is incorrect. Cutting lateral edges of the toenails and removing ingrown may cause trauma that may lead to gangrene. Choice E is incorrect. Lotion, cream, powder should not be applied in spaces between the toes. These may cake and cause infection.
4 / 25
Category:
Nursing Management
A patient is admitted to the hospital with a diagnosis of pneumonia. Which of the following nursing interventions are appropriate for this patient? Select All that Apply.
The correct Answers: Deep breathing exercises can help improve lung expansion and oxygenation. Oxygen therapy can help improve oxygenation in patients with pneumonia. Monitoring for signs of respiratory distress is important to detect worsening of the condition. Antibiotics are often used to treat pneumonia caused by bacteria.
The correct Answers: Deep breathing exercises can help improve lung expansion and oxygenation. Oxygen therapy can help improve oxygenation in patients with pneumonia. Monitoring for signs of respiratory distress is important to detect worsening of the condition. Antibiotics are often used to treat pneumonia caused by bacteria.
The correct Answers: Deep breathing exercises can help improve lung expansion and oxygenation. Oxygen therapy can help improve oxygenation in patients with pneumonia. Monitoring for signs of respiratory distress is important to detect worsening of the condition. Antibiotics are often used to treat pneumonia caused by bacteria.
5 / 25
Category:
Nursing Management
A patient is admitted to the hospital with a diagnosis of deep vein thrombosis (DVT).
Actions to take
Potential conditions
Parameters to monitor
Prolonged immobility
Obesity
Hormonal therapy
Formation of a DVT
Pulmonary embolism
Chronic venous insufficiency
Post-thrombotic syndrome
Which of the following actions to take could have been mitigated through early mobilization and exercise?
The correct answer: Prolonged immobility. Early mobilization and exercise can help prevent DVT by improving blood flow and reducing the risk of blood clot formation.
The correct answer: Prolonged immobility. Early mobilization and exercise can help prevent DVT by improving blood flow and reducing the risk of blood clot formation.
The correct answer: Prolonged immobility. Early mobilization and exercise can help prevent DVT by improving blood flow and reducing the risk of blood clot formation.
6 / 25
Category:
Patient Safety
A patient is admitted to the hospital with a diagnosis of pneumonia. Which of the following actions to take could have been modified through preventive measures?
The correct answers: Smoking cessation and influenza vaccination can help reduce the risk of developing pneumonia.
The correct answers: Smoking cessation and influenza vaccination can help reduce the risk of developing pneumonia.
The correct answers: Smoking cessation and influenza vaccination can help reduce the risk of developing pneumonia.
7 / 25
Category:
Priority Nursing Action
Scenario: A patient with a history of hypertension is admitted to the hospital for a surgical procedure.
Actions to take
Potential conditions
Parameters to monitor
Inadequate blood pressure control before surgery
Noncompliance with medication regimen
Unidentified underlying medical conditions
Hypotension during surgery
Tissue hypoxia
Organ damage
Increased mortality risk
Which of the following actions to take could have been prevented with better patient education?
The correct answer: Patient education can help improve adherence to medication regimens and blood pressure control, reducing the risk of hypotension during surgery.
The correct answer: Patient education can help improve adherence to medication regimens and blood pressure control, reducing the risk of hypotension during surgery.
The correct answer: Patient education can help improve adherence to medication regimens and blood pressure control, reducing the risk of hypotension during surgery.
8 / 25
Category:
Health Teachings
A patient with a history of heart failure is admitted to the hospital with a diagnosis of acute decompensated heart failure.
Actions to take
Potential conditions
Parameters to monitor
Noncompliance with medication regimen
Dietary indiscretion
Stressful life events
Worsening heart failure
Pulmonary edema
Renal failure
Arrhythmias
Which of the following action to take could have been addressed through patient education and support?
The correct answers: Dietary indiscretion and Stressful life events. Patient education can help individuals with heart failure understand the importance of dietary restrictions and stress management in preventing exacerbations.
The correct answers: Dietary indiscretion and Stressful life events. Patient education can help individuals with heart failure understand the importance of dietary restrictions and stress management in preventing exacerbations.
The correct answers: Dietary indiscretion and Stressful life events. Patient education can help individuals with heart failure understand the importance of dietary restrictions and stress management in preventing exacerbations.
9 / 25
Category:
Medical-Surgical
The patient is experiencing metabolic alkalosis. Which of the following electrolyte imbalances may occur? Select all that apply.
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The correct answer is: Metabolic alkalosis leads to hypokalemia, hypocalcaemia and hyperphosphatemia. In alkalosis there is increased excretion of potassium, calcium is damaged. As calcium decreases, there is inverse hyperphosphatemia.
10 / 25
Category:
Priority Nursing Action
A patient is admitted to the hospital with a diagnosis of pressure ulcers. Which of the following actions to take could have been addressed through regular skin assessments and repositioning?
Actions to Take
Potential Conditions
Parameters to Monitor
Mobility
Infection
Incontinence
Developement of pressure ulcers
Osteomyelitis
Inadequate Nutrition
Amputation
The correct answer: Immobility. Regular skin assessments and frequent repositioning can help prevent pressure ulcers by reducing the pressure on bony prominences.
The correct answer: Immobility. Regular skin assessments and frequent repositioning can help prevent pressure ulcers by reducing the pressure on bony prominences.
The correct answer: Immobility. Regular skin assessments and frequent repositioning can help prevent pressure ulcers by reducing the pressure on bony prominences.
11 / 25
Category:
Medical-Surgical
A patient had burns of the right hand from boiling water. Which of the following nursing actions are appropriate when caring for this patient? Select all that apply.
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The correct answer is: To stop the burning process, the body part with burns should be immersed in cold water. Jewelries should be removed because metals can be superhead and will cause further tissue injury. Applying dressings on the fingers separately prevents contractures and adhesions. Splints should be applied with the fingers curbed to allow flexion and extension exercises of the fingers. This will also prevent hyperextension deformity of the fingers.
12 / 25
Category:
Nursing Management
A patient is admitted to the hospital with a diagnosis of sepsis.
Actions to take
Potential conditions
Parameters to monitor
Infection
Immunosuppression
Pre-existing medical conditions
Development of sepsis
Organ dysfunction
Multiple organ failure
Increased mortality risk
Which of the following upstream events could have been prevented with effective infection control measures?
The correct answer: Infection. Effective infection control measures, such as hand hygiene and appropriate antibiotic use, can help prevent the development of infections that may lead to sepsis.
The correct answer: Infection. Effective infection control measures, such as hand hygiene and appropriate antibiotic use, can help prevent the development of infections that may lead to sepsis.
The correct answer: Infection. Effective infection control measures, such as hand hygiene and appropriate antibiotic use, can help prevent the development of infections that may lead to sepsis.
13 / 25
Category:
Nursing Management
A patient with a history of diabetes is admitted to the hospital with a diagnosis of diabetic retinopathy.
Actions to take
Potential conditions
Parameters to monitor
Poor glycemic control
Hypertension
Elevated triglycerides
Progression of diabetic retinopathy
Vision loss
Blindness
Which of the following actions to take could have been improved with better blood sugar management?
The correct answer: Poor glycemic control. Consistent and effective blood sugar management is crucial for preventing the progression of diabetic retinopathy.
The correct answer: Poor glycemic control. Consistent and effective blood sugar management is crucial for preventing the progression of diabetic retinopathy.
The correct answer: Poor glycemic control. Consistent and effective blood sugar management is crucial for preventing the progression of diabetic retinopathy.
14 / 25
Category:
Medical-Surgical
Which of the following findings indicate effective management of CHF. Select all that apply.
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The correct answer is: Effective management of CHF produce the following expected outcome: increased cardiac output, increased urine output, decreased weight, lowering of BP, may include stronger pulse, normal breath sounds.
15 / 25
Category:
Medical-Surgical
During the emergent phase of burns, which of the following assessment findings does the licensed nurse expect? Select all that apply.
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The correct answer is: The emergent phase of burns is also called shock phase or fluid accumulation phase. This occurs during the first 48 hours of burns. The fluid shifting is fromIVC to ISC due to vasodilation. This results from the heat and release of histamine in response to tissue injury.
16 / 25
Category:
Nursing Management
A patient is admitted to the hospital with a diagnosis of pneumonia.
Actions to take
Potential conditions
Parameters to monitor
Smoking history
Chronic obstructive pulmonary disease (COPD)
Immunosuppression
Development of pneumonia
Respiratory failure
Sepsis
Increased mortality risk
Which of the following actions to take could have been modified through lifestyle changes?
The correct answer: Smoking history. Smoking cessation can reduce the risk of developing pneumonia, especially in individuals with underlying respiratory conditions.
The correct answer: Smoking history. Smoking cessation can reduce the risk of developing pneumonia, especially in individuals with underlying respiratory conditions.
The correct answer: Smoking history. Smoking cessation can reduce the risk of developing pneumonia, especially in individuals with underlying respiratory conditions.
17 / 25
Category:
Nursing Management
A patient with diabetes mellitus is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). Which of the following nursing interventions are appropriate for this patient? Select All that Apply.
That correct answers: Insulin is essential for treating DKA. Frequent monitoring of blood glucose levels is necessary to assess the effectiveness of treatment. IV fluids are needed to replace fluid and electrolyte losses. Hypokalemia is a common complication of DKA, so monitoring for signs of this electrolyte imbalance is important.
That correct answers: Insulin is essential for treating DKA. Frequent monitoring of blood glucose levels is necessary to assess the effectiveness of treatment. IV fluids are needed to replace fluid and electrolyte losses. Hypokalemia is a common complication of DKA, so monitoring for signs of this electrolyte imbalance is important.
That correct answers: Insulin is essential for treating DKA. Frequent monitoring of blood glucose levels is necessary to assess the effectiveness of treatment. IV fluids are needed to replace fluid and electrolyte losses. Hypokalemia is a common complication of DKA, so monitoring for signs of this electrolyte imbalance is important.
Hypothyroidism Management
18 / 25
Category:
Medical-Surgical
Which of the following are expected manifestations of a patient with hypothyroidism. Select all that apply.
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The correct answer is: Hypothyroidism is characterized by hypometabolism, decreased body heat production and hypercalcemia (“Everything is low, slow and dry.”). Choices A, B and C are manifestations of hyperthyroidism.
19 / 25
Category:
Medical-Surgical
The patient with burns is experiencing dehydration. Which of the following signs and symptoms indicate dehydration? Select all that apply.
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The correct answer is: Dehydration is characterized by elevated body temperature, tachycardia, tachypnea due to sympathetic nervous stimulation. Decreased urine output, dark concentrated urine and weight loss also occur. Fluid loss from the body will result to hypotension due to decrease in circulating volume.
20 / 25
Category:
Nursing Management
A patient is admitted to the hospital with a diagnosis of heart failure. Which of the following nursing interventions are appropriate for this patient? Select All that Apply.
Correct Answers: Daily weights can help monitor fluid status in patients with heart failure. Diuretics can help reduce fluid retention and alleviate symptoms of heart failure. A low-sodium diet can help reduce fluid retention. Beta-blockers can help improve heart function and reduce symptoms of heart failure.
Correct Answers: Daily weights can help monitor fluid status in patients with heart failure. Diuretics can help reduce fluid retention and alleviate symptoms of heart failure. A low-sodium diet can help reduce fluid retention. Beta-blockers can help improve heart function and reduce symptoms of heart failure.
Correct Answers: Daily weights can help monitor fluid status in patients with heart failure. Diuretics can help reduce fluid retention and alleviate symptoms of heart failure. A low-sodium diet can help reduce fluid retention. Beta-blockers can help improve heart function and reduce symptoms of heart failure.
21 / 25
Category:
Nursing Management
A patient is receiving chemotherapy for breast cancer and is experiencing severe nausea and vomiting. Which of the following interventions can help alleviate these symptoms? Select All taht Apply.
Correct Answers: Antiemetics can help prevent nausea and vomiting associated with chemotherapy. Small, frequent meals can be easier to tolerate than large meals. Spicy or greasy foods can exacerbate nausea and vomiting.
Correct Answers: Antiemetics can help prevent nausea and vomiting associated with chemotherapy. Small, frequent meals can be easier to tolerate than large meals. Spicy or greasy foods can exacerbate nausea and vomiting.
Correct Answers: Antiemetics can help prevent nausea and vomiting associated with chemotherapy. Small, frequent meals can be easier to tolerate than large meals. Spicy or greasy foods can exacerbate nausea and vomiting.
22 / 25
Category:
Prioritization
A patient is admitted to the hospital with a diagnosis of acute myocardial infarction (AMI). Which of the following nursing interventions are appropriate for this patient? Select All that Apply.
The correct answers: Oxygen therapy can help improve oxygenation in patients with AMI. Monitoring cardiac rhythm is important to detect any arrhythmias. Thrombolytic therapy can help dissolve blood clots and restore blood flow to the heart. Beta-blockers can help reduce heart rate and blood pressure, which can improve cardiac function in patients with AMI.
The correct answers: Oxygen therapy can help improve oxygenation in patients with AMI. Monitoring cardiac rhythm is important to detect any arrhythmias. Thrombolytic therapy can help dissolve blood clots and restore blood flow to the heart. Beta-blockers can help reduce heart rate and blood pressure, which can improve cardiac function in patients with AMI.
The correct answers: Oxygen therapy can help improve oxygenation in patients with AMI. Monitoring cardiac rhythm is important to detect any arrhythmias. Thrombolytic therapy can help dissolve blood clots and restore blood flow to the heart. Beta-blockers can help reduce heart rate and blood pressure, which can improve cardiac function in patients with AMI.
23 / 25
Category:
Priority Nursing Action
A patient is admitted to the emergency department with a diagnosis of acute pancreatitis. Which of the following nursing interventions are appropriate for this patient? Select All that Apply.
Correct Answers: IV fluids are essential to maintain hydration and prevent shock in patients with acute pancreatitis. A CT scan is often used to diagnose and assess the severity of acute pancreatitis. Pain management is crucial for patients with acute pancreatitis.
Correct Answers: IV fluids are essential to maintain hydration and prevent shock in patients with acute pancreatitis. A CT scan is often used to diagnose and assess the severity of acute pancreatitis. Pain management is crucial for patients with acute pancreatitis.
Correct Answers: IV fluids are essential to maintain hydration and prevent shock in patients with acute pancreatitis. A CT scan is often used to diagnose and assess the severity of acute pancreatitis. Pain management is crucial for patients with acute pancreatitis.
24 / 25
Category:
Nursing Management
A patient with diabetes is admitted to the hospital for a urinary tract infection.
Actions to take
Potential conditions
Parameters to monitor
Poor glycemic control
Frequent urinary tract infections
Inadequate hygiene practices
Development of a diabetic foot ulcer
Infection of the foot ulcer
Osteomyelitis
Amputation
Which of the following Parameters to monitor could have been prevented with early identification and treatment of the diabetic foot ulcer?
The correct answer: Early identification and treatment of a diabetic foot ulcer can help prevent infection and subsequent complications.
The correct answer: Early identification and treatment of a diabetic foot ulcer can help prevent infection and subsequent complications.
The correct answer: Infection of the foot ulcer. Early identification and treatment of a diabetic foot ulcer can help prevent infection and subsequent complications.
25 / 25
Category:
Pharmacology
The client with hypertension in taking Atenolol (Tenormin). Nursing care of the client should include which of the following. Select all that apply.
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The correct answer is: Choice C is incorrect. Beta- blockers like Atenolol should be given on full stomach to prevent GI irritation.
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