EXN105A2

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  1. Which dietary instruction should the nurse teach a patient to prevent constipation?
    A) Increase intake or highly refined breads and cereals.
    B) Increase the amount of coffee or tea you drink daily.
    C) Eat foods high in fiber like fresh fruit.
    D) Use laxatives daily.
    C) Eat foods high in fiber like fresh fruit.
    (this multiple choice question has been scrambled)
  2. Which is a factor in the development of total urinary incontinence?
    A) decreased glomerular filtration rate
    B) constriction of the renal arteries
    C) impaired sensory nerves
    D) decreased abdominal muscle tone
    C) impaired sensory nerves
    (this multiple choice question has been scrambled)
  3. When planning to digitally remove a patient's fecal impaction, the nurse should be aware that which problem could be caused by vagal stimulation during removal?
    A) dysrhythmias
    B) diarrhea
    C) hypertension
    D) hemorrhoids
    A) dysrhythmias
    (this multiple choice question has been scrambled)
  4. A patient's urinalysis results are pH of 5.7, protein ), glucose negative, ketones negative, RBC ), and specific gravity of 1.034. What do these results indicate?
    A) alkalosis
    B) infection
    C) dehydration
    D) hypoxia
    C) dehydration
    (this multiple choice question has been scrambled)
  5. Which problem can be caused by the administration of more than three consecutive tap water enemas?
    A) water intoxication
    B) bowel infection
    C) bowel perforation
    D) dehydration
    A) water intoxication
    (this multiple choice question has been scrambled)
  6. Which clinical manifestation is indicative of a fecal impaction?
    A) passage of small, hard stool daily
    B) tarry stools
    C) seepage of liquid stool
    D) flatulence
    C) seepageĀ  of liquid stool
    (this multiple choice question has been scrambled)
  7. The nurse is planning care for a patient who has been experiencing constipation. Which is an appropriate expected outcome for this patient?
    A) eliminate a soft, formed stool every one to two days.
    B) pass liquid stool once per day.
    C) pass a large amount of flatus once per day.
    D) eliminate soft stool three times per day.
    A) eliminate a soft, formed stool every one to two days.
    (this multiple choice question has been scrambled)
  8. What is the primary function of the kidneys?
    A) to excrete urine and waste and regulate acid-base balance
    B) to regulate volume and composition of extracellular fluid
    C) to produce erythropoietin and activate vitamin D
    D) to secrete renin and control blood pressure
    B) to regulate volume and composition of extracellular fluid
    (this multiple choice question has been scrambled)
  9. Which statement indicates that a patient needs further ostomy care teaching?
    A) "I should empty and pouch when it is 1/3 to 1/2 full of drainage."
    B) "I may reuse the pouch by rinsing it out and allowing it to air dry."
    C) "I should apply a new skin barrier daily."
    D) "I can get my stoma wet in the shower."
    C) "I should apply a new skin barrier daily."
    (this multiple choice question has been scrambled)
  10. The nurse is administering a cathartic to a patient who has just had a barium enema. The patient says, "I don't need this, I just had a bowel movement yesterday. "Which is the nurse's best response?
    A) "The cathartic will prepare you for the next part of your test."
    B) "The cathartic will reduce your chanceĀ of becoming constipated after this test."
    C) "The cathartic will prevent your body from absorbing the barium and turning your stools white."
    D) "You still had stool in your colon and now we need another set of X rays."
    B) "The cathartic will reduce your chance of becoming constipated after this test."
    (this multiple choice question has been scrambled)
  11. A patient who is newly admitted says to the nurse, "I experience an accidental leakage of urine whenever I cough, sneeze, or laugh." Which type of incontinence is the patient describing?
    A) functional
    B) urge
    C) stress
    D) overflow
    C) stress
    (this multiple choice question has been scrambled)
  12. Which data indicates that the nurse's dietary interventions for a patient with a history of urinary tract infection has been effective?
    A) Dipstick is positive for ketones.
    B) RBCs are present in the urine.
    C) Urinary pH decreases from 7.0 to 5.4.
    D) Urine specific gravity increases.
    C) Urinary pH decreases from 7.0 to 5.4.
    (this multiple choice question has been scrambled)
  13. A patient who is breast-feeding is concerned that her infant's stool is yellow instead of brown. Which is an appropriate explanation for the nurse to give the patient?
    A) The infant may be dehydrated.
    B) A change in formula may be necessary.
    C) The infant may have an intestinal infection.
    D) The stool is normal for the infant.
    D) The stool is normal for the infant.
    (this multiple choice question has been scrambled)
  14. The nurse is planning to test a patient's stool specimen for blood. Which factor may lead to a false positive result?
    A) elevated temperature
    B) consistency of stool
    C) dietary intake
    D) hemoglobin level
    C) dietary intake
    (this multiple choice question has been scrambled)
  15. In catheterizing a male patient, the nurse should implement which action to prevent paraphimosis?
    A) Wear sterile gloves
    B) Lubricate the catheter 5 to 7 inches (12.7 to 17.8 centimeters)
    C) Anchor the catheter to the thigh.
    D) Replace the foreskin
    D) Replace the foreskin
    (this multiple choice question has been scrambled)
  16. What is the function of the brain's sleep control centers?
    A) to respond to fatigue with a rest signal
    B) to synchronize sleep patterns with light and darkness
    C) to actively inhibit wakefulness
    D) to regulate the transition from NREM to REM sleep
    C) to actively inhibit wakefulness
    (this multiple choice question has been scrambled)
  17. Which is a clinical manifestation of prolonged sleep deprivation?
    A) sudden muscle weakness
    B) hyperactive reflexes
    C) increased sensitivity to pain
    D) evening headaches
    C) increased sensitivity to pain
    (this multiple choice question has been scrambled)
  18. A patient is two days postoperative. While making rounds, the night nurse finds the patient unable to return to sleep. Which action should the nurse take initially?
    A) Bring the patient a glass of warm milk.
    B) Review the patient's sleep history.
    C) Assess the patient for pain.
    D) Administer a tranquilizer.
    C) Assess the patient for pain.
    (this multiple choice question has been scrambled)
  19. Which medications suppress REM sleep?
    A) tranquilizers
    B) hypnotics
    C) beta blockers
    D) antidepressants
    B) hypnotics
    (this multiple choice question has been scrambled)
  20. Which intervention is commonly used to assist a patient to fall asleep?
    A) Offer a bedtime snack.
    B) Perform passive range of motion exercises.
    C) Provide a back massage
    D) Administer a prescribed sedative.
    C) Provide a back massage.
    (this multiple choice question has been scrambled)
  21. Which observation best indicates that a patient is adequately hydrated?
    A) Fluid intake for 24 hours is 1,000 cc.
    B) Temperature is within normal limits.
    C) Urine is dark amber in color.
    D) Mucous membranes are moist.
    D) Mucous membranes are moist.
    (this multiple choice question has been scrambled)
  22. The nurse should give priority to which nursing diagnosis for a patient with hyperkalemia?
    A) fluid volume excess related to thirst
    B) risk of injury related to seizures
    C) altered tissue perfusion related to peripheral edema
    D) decreased cardiac output related to cardiac dysrhythmias
    D) decreased cardiac output related to cardiac dysrhythmias
    (this multiple choice question has been scrambled)
  23. Over the next 24 hours, a patient is to receive 4 liters of D5W. The IV administration set delivers 15 gtt/mL. At how many gtt/min should the infusion be regulated?
    A) 25-26
    B) 30-31
    C) 18-19
    D) 41-42
    D) 41-42
    (this multiple choice question has been scrambled)
  24. Which serum electrolyte value will be elevated in a patient who has been immobilized for an extended period?
    A) potassium
    B) calcium
    C) sodium
    D) magnesium
    B) calcium
    (this multiple choice question has been scrambled)
  25. Which finding is indicative of hyponatremia in a client experiencing diarrhea?
    A) weight gain
    B) increased blood pressure
    C) increasing confusion
    D) bradycardia
    C) increasing confusion
    (this multiple choice question has been scrambled)
  26. A patient who is unconscious is admitted to the emergency department. Arterial blood gas levels indicate pH 7.30, low bicarbonate level, low carbon dioxide level, and normal oxygen level. The nurse also notes an elevated potassium level. These findings indicate which acid-base imbalance?
    A) metabolic alkalosis
    B) respiratory alkalosis
    C) respiratory acidosis
    D) metabolic acidosis
    D) metabolic acidosis
    (this multiple choice question has been scrambled)
  27. Which assessment finding indicates that a patient with fluid volume excess has regained normal hydration status?
    A) The patient has lost weight.
    B) The patient has clear breath sounds.
    C) The patient has balanced intake and output.
    D) The patient has output of 30 to 45 mL per hour.
    B) The patient has clear breath sounds.
    (this multiple choice question has been scrambled)
  28. Which solution should be administered to rehydrate the cells of a patient with metabolic acidosis?
    A) normal saline
    B) human serum albumin
    C) 5% dextrose in half-strength saline
    D) lactated Ringer's
    D) lactated Ringer's
    (this multiple choice question has been scrambled)
  29. Which clinical manifestation is indicative of fluid volume deficit?
    A) elevated hemoglobin levels
    B) full bounding pulse
    C) adventitious breath sounds
    D) increased urine specific gravity
    D) increased urine specific gravity
    (this multiple choice question has been scrambled)
  30. A patient who exhibits poor skin turgor is showing signs of which problem?
    A) impaired circulation
    B) decreased oxygenation
    C) poor nutrition
    D) dehydration
    D) dehydration
    (this multiple choice question has been scrambled)
  31. Which medication order should the nurse anticipate for a patient whose serum potassium level is 6.8 mEq/L?
    A) triamterene (Dyrenium)
    B) spironolactone (Aldoctone)
    C) furosemide (Lasix)
    D) sodium polystyrene sulfonate (Kayexalate)
    D) sodium polystyrene sulfonate (Kayexalate)
    (this multiple choice question has been scrambled)
  32. A postoperative patient is to receive D5W intravenously. The nurse should monitor the patient for the development of which electrolyte imbalance?
    A) hyperchloremia
    B) hypocalcemia
    C) hyperkalemia
    D) hyponatremia
    D) hyponatremia
    (this multiple choice question has been scrambled)
  33. Why are infants at a greater risk for fluid imbalance than adults?
    A) Infants have smaller body surface area.
    B) Infants have immature kidneys.
    C) Infants have increased thirst.
    D) Infants have decreased metabolic rate.
    B) Infants have immature kidneys.
    (this multiple choice question has been scrambled)
  34. Which instruction should be included in the plan of care for a patient who is taking a thiazide diuretic?
    A) "Measure your abdominal girth daily."
    B) "Take a potassium supplement twice a day."
    C) "Increase your daily intake of oranges and bananas."
    D) "Omit the daily dose of potassium if leg cramps occur."
    C) "Increase your daily intake of oranges and bananas."
    (this multiple choice question has been scrambled)
  35. Which intervention should the nurse include when planning to administer potassium intravenously to a patient?
    A) Dilute the medication before administration.
    B) Measure output after administration.
    C) Change the IV site prior to administration.
    D) Administer the medication rapidly.
    A) Dilute the medication before administration.
    (this multiple choice question has been scrambled)
  36. How should the nurse interpret blood gas vales of pH 7.34, PaCO2 50, HCO3_ 28, and PO2 80?
    A) uncompensated respiratory acidosis
    B) compensated respiratory acidosis
    C) uncompensated metabolic acidosis.
    D) compensated metabolic acidosis
    B) compensated respiratory acidosis
    (this multiple choice question has been scrambled)
  37. The nurse should suspect hypocalcemia when the patient exhibits which signs?
    A) tingling of the fingers, muscle spasms, and tetany
    B) pale mucous membranes, shortness of breath, and lethargy
    C) night blindness, tachycardia and weakness
    D) bleeding tendencies, thirst, and hypotension
    A) tingling of the fingers, muscle spasms, and tetany
    (this multiple choice question has been scrambled)
  38. A 67 year old patient has shortness of brethe, numbness of the hands, respiratory rales, and slurred speech. Which of these findings is most clearly related to fluid overload?
    A) shortness of breathe
    B) respiratory rales
    C) numbness of the hands
    D) slurred speech
    B) respiratory rales
    (this multiple choice question has been scrambled)
  39. Which serum electrolyte value will be elevated in a patient who has had a high fever for an extended period?
    A) sodium
    B) magnesium
    C) potassium
    D) calcium
    A) sodium
    (this multiple choice question has been scrambled)
  40. Which electrolyte imbalance may develop as a result of immobility?
    A) hyperkalemia
    B) hyponatremia
    C) hypomagnesemia
    D) hypercalcemia
    D) hypercalcemia
    (this multiple choice question has been scrambled)
  41. How many mL is the desirable amount of fluid intake and loss for an adult in 24 hours?
    A) 1,500 mL
    B) 2,500 mL
    C) 3,500 mL
    D) 1,000 mL
    B) 2,500 mL
    (this multiple choice question has been scrambled)
  42. Which electrolyte imbalance would predispose a patient to digoxin toxicity?
    A) hypernatremia
    B) hypokalemia
    C) hypermagnesemia
    D) hypocalcemia
    B) hypokalemia
    (this multiple choice question has been scrambled)
  43. A patient with bone cancer is admitted with hypercalcemia. What is the most appropriate expected outcome for this patient?
    A) have a negative Chvostek's sign by the second day of care.
    B) avoid personal injury from seizures during hospitalization.
    C) achieve normal pattern and consistency of stool elimination
    D) manifest adequate tissue perfusion: normal vital signs for age.
    C) achieve normal pattern and consistency of stool elimination
    (this multiple choice question has been scrambled)
  44. Which is a cause of metabolic acidosis?
    A) gastric suction
    B) airway obstruction
    C) starvation
    D) hypokalemia
    C) starvation
    (this multiple choice question has been scrambled)
  45. Treatment with which type of pharmacologic agent may result in magnesium and water imbalance?
    A) glucocorticoid
    B) antibiotic
    C) bronchodilator
    D) sedative
    B) antibiotic
    (this multiple choice question has been scrambled)
  46. Which is a function of parathyroid hormone?
    A) to regulate the absorption of calcium
    B) to stimulate the production of renin
    C) to stimulate the production of antidiuretic hormone
    D) to regulate the retention of sodium
    A) to regulate the absorption of calcium
    (this multiple choice question has been scrambled)
  47. A patient may be susceptible to developing water intoxication after which intravenous therapy?
    A) 0.45% NaCl
    B) 3% NaCl
    C) lactated Ringers
    D) total parenteral nutrition
    A) 0.45% NaCl
    (this multiple choice question has been scrambled)
  48. Which assessment findings indicate that a patient has hypocalcemia?
    A) anorexia, nausea, and vomiting
    B) positive Trousseau's and Chvostek's signs
    C) low-grade fever and dry tongue
    D) prolonged QT interval and peaked T waves
    B) positive Trousseau's and Chvostek's signs
    (this multiple choice question has been scrambled)
  49. Which patient can be a universal recipient?
    A) O positive
    B) O negative
    C) AB positive
    D) AB negative
    C) AB positive
    (this multiple choice question has been scrambled)
  50. Which situation would indicate the development of hypovolemia in an adult?
    A) an increased postural blood pressure
    B) a gradually increasing temperature
    C) a drop in urinary output to below 30 mL/hr
    D) a decrease in the hematocrit level
    C) a drop in urinary output to below 30 mL/hr
    (this multiple choice question has been scrambled)
Author
ID
297137
Card Set
EXN105A2
Description
Excelsior N105 Form A-2
Updated
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