WEEK 10-12 Fundamentals questions

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The nurse is teaching a patient with diverticulitis about increasing fiber intake. Which of the following foods should the nurse recommend?

a. White bread

b. Cream of wheat

c. Carrots

d. Bananas

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1

The nurse is teaching a patient with diverticulitis about increasing fiber intake. Which of the following foods should the nurse recommend?

a. White bread

b. Cream of wheat

c. Carrots

d. Bananas

Answer: d

A high-fiber diet consists of fiber rich-fruits such as bananas, oranges, apples, dark vegetables, whole breads, and grains and nuts. White bread, cream of wheat, and carrots are low in fiber.

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2

A patient is prescribed furosemide and is at risk of hypokalemia. Which food choice would be beneficial to manage this potential side effect?

a. Applesauce

b. Oranges

c. Cauliflower

d. Blueberries

Answer: b

Furosemide is a loop diuretic that can contribute to low potassium levels. Foods high in potassium include bananas, oranges, potatoes, cooked spinach, cooked broccoli, and peas. Applesauce, cauliflower, and blueberries are foods recommended on a low-potassium diet.

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3

Which of the following actions should be taken by the nurse when caring for a patient receiving total parenteral nutrition (hyperalimentation)? (Select all that apply.)

a. Change the IV tubing every 24 hours according to facility protocol.

b. Monitor patient blood glucose levels every 6 hours.

c. Weigh the patient weekly.

d. Administer through a peripheral IV line.

e. Use an infusion pump for administration.

f. Use routinely with intact GI tract.

TPN tubing is to be changed every 24 hours and per facility protocol. Glucose is a part of the TPN solution; thus, blood glucose levels are monitored at least every 6 hours. Clients are weighed daily. TPN must be administered through a central venous catheter or peripherally inserted central catheter and must be administered using an infusion pump for safety purposes. TPN is used only when the GI tract cannot be used; thus, an intact GI tract would be a contraindication for TPN use.

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4

A patient is a newly diagnosed diabetic. The nurse prioritizes education focused on which of the following nutritional choices?

a. Limiting carbohydrates

b. Increasing simple sugars

c. Maintaining 2500 calorie diet

d. Limiting sodium intake

Answer: a

The body turns carbohydrates into glucose and eating too many carbohydrates can cause the blood glucose levels to elevate. Diabetics should avoid simple sugars. Diabetic diets recommend less than 2500 calories. Sodium intake is not the main focus of a diabetic diet.

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5

The nurse evaluates that nutritional education for a patient on a clear liquid diet has been effective when the patient selects which food item to comply with this order?

a. Pudding

b. Ice cream

c. Chicken broth

d. Rice

Answer: c

Chicken broth is a clear liquid and is easily digestible. Pudding and ice cream are opaque and would be part of a full-liquid diet. Rice is not included in a liquid diet.

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6

The nurse instructs a patient with renal failure who is receiving hemodialysis about the type of diet needed to be consumed. The nurse determines that the patient understands the education if the patient selects which diet?

a. High in calories

b. Low in sodium, phosphorus, and protein

c. Low in fiber

d. High in potassium

Answer: b

Clients with kidney problems have difficulty maintaining fluid and electrolyte balance. There are challenges with excreting sodium, phosphorus, and protein, as well as potassium.

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7

The nurse has placed a nasogastric tube for a patient requiring enteral feeding. The nurse validates placement through pH measurement and using clinical judgment. What gold standard should be used to confirm placement prior to using the tube?

a. Auscultation

b. Presence of bowel sounds

c. X-ray

d. Patient affirmation

Answer: c

The gold standard for confirming tube placement is by x-ray All of the other methods have more room for error and are not recommended.

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8

Which of the following nutrients is most helpful in preventing birth defects and should be taken by women of childbearing age?

a. Folic acid

b. Magnesium

c. Calcium

d. Selenium

Answer: a

Folic acid has been shown to reduce neural tube defects of the brain and spinal cord by more than 70% and is the most recommended nutrient to be taken to prevent birth defects.

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9

The nurse is reviewing discharge instructions for a patient on a low-fat diet. The nurse determines that the patient understands the dietary instructions if the patient selects which of the following food choices containing unsaturated fat?

a. Beef

b. Hydrogenated oil

c. Ice cream

d. Almonds

Answer: d

Beef and ice cream are high in saturated fat; hydrogenated oil is high in trans fat. Almonds contain unsaturated fat, which helps to lower LDL cholesterol, reduce inflammation, and build stronger cell membranes in the body

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10

The nurse is instructing the patient in selecting food items that contain common sources of protein in the diet. Which of the following food choices can be included in the teaching as examples? (Select all that apply.)

a. Fish

b. Beans

c. Eggs

d. Apples

e. Avocado

Answer: a, b, c, e

Fish, meat, beans, eggs, milk, almonds, spinach, and avocados are all sources of protein. Apples do not contain protein.

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11

A nurse caring for a hospitalized patient with dehydration is told in the shift report that the patient’s laboratory results have just come in. The nurse recognizes which abnormal lab values that can reflect a fluid volume deficit? (Select all that apply.)

a.  Sodium (Na) level 150 mEq/L

b.  Potassium (K) level 3.5 mEq/L

c.  Calcium (Ca) level 9.5 mg/dL

d.  Blood urea nitrogen (BUN) 27 mg/dL

Answer: a, d

The sodium and BUN levels are elevated, which can often be seen in dehydrated clients. Normal sodium levels for adults range from 135 to 145 mEq/L. Normal BUN levels for adults range from 10 to 20 mg/dL.  The potassium and calcium values are within normal limits.

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12

A patient has reported a 2-kg (4.4-lb) weight gain over the past 3 days. Which assessment cues should the nurse recognize as additional evidence for a nursing diagnosis of Fluid Volume Overload (Hypervolemia)? (Select all that apply.)

a.       Third spacing/edema

b.      Potassium intake

c.       Bounding, rapid pulse

d.      Crackles in lungs

e.  Dry mucous membranes

Answer: a, c, d

An increased hydrostatic pressure or a decreased oncotic capillary pressure can cause fluid to move to the periphery, causing edema or third spacing. This can cause weight gain, as fluid is not removed by the kidneys from the bloodstream. Patients with fluid overload may have a rapid, bounding pulse and/or crackles in the lungs. Potassium intake and dry mucous membranes is not a sign of fluid retention.

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13

For a patient with a nursing diagnosis of Dehydration, the nurse recognizes which cues as signs and symptoms of dehydration? (Select all that apply).

a.       Hypertension

b.      Elevated urine specific gravity

c.       Dry mucous membranes

d.      Weak, thready pulse

e.       Pale yellow urine

Answer: b, c, d

Depending on the severity of fluid volume deficit, the patient may have hypotension. Hypertension occurs with fluid volume overload. With dehydration, the urine becomes concentrated with an elevated specific gravity and usually turns dark amber colored (not pale yellow). The skin is usually flushed and dry, and the pulse is weak and thready.

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14

The nurse is caring for a patient with hypocalcemia who does not like milk. Which food should the nurse encourage the patient to consume?

a.       Cod

b.      Eggs

c.       Spinach

d.      Tomatoes

Answer: c

Dark leafy vegetables such as spinach, kale, turnip greens, broccoli, Brussels sprouts, and cabbage are sources high in calcium.

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15

A nurse in the emergency department is caring for an adult patient with traumatic abdominal injuries. The patient’s pulse rate has increased from 90 to 120 beats/min over the past hour and the patient is experiencing orthostatic hypotension. For which imbalance should the nurse assess?

a.       Respiratory acidosis

b.      Extracellular fluid volume deficit

c.       Metabolic alkalosis

d.      Intracellular fluid volume excess

Answer: b

The elevated heart rate and orthostatic hypotension show extracellular fluid volume deficit. With the client’s injuries, there is the potential for internal bleeding. As circulating blood volume decreases, the heart rate increases to maintain normal cardiac output, and the patient may experience orthostatic hypotension and lightheadedness with position changes. Respiratory acidosis and metabolic alkalosis do not have as a symptom a rapidly increasing pulse rate. Intracellular fluid volume excess causes pulmonary congestion and cerebral edema.

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16

A 75-year-old patient with chronic obstructive pulmonary disease (COPD) gets arterial blood gases ordered. What is the nurse’s interpretation of the arterial blood gas results (pH 7.33, PCO2 58, PO2 83, HCO3 33)?

a.       Partially compensated metabolic alkalosis

b.      Partially compensated respiratory acidosis

c.       Uncompensated metabolic acidosis

d.      Uncompensated respiratory alkalosis

Answer: b

Patients with COPD tend to have chronic carbon dioxide retention. The patient is slightly acidotic (i.e., arterial pH below 7.35) with a higher than normal partial pressure of carbon dioxide (PCO2), which is inverse and therefore respiratory in nature. The compensatory response to respiratory acidosis is buffering, as indicated by the higher than normal bicarbonate (HCO3-) level. The increase in bicarbonate only partially shifts the pH toward normal, but partial compensation prevents the acid-base imbalance from becoming life-threatening. The kidneys will continue to compensate in an attempt to bring the pH into the normal range.

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17

The nurse is assessing the intravenous (IV) site in the right antecubital and notices that the area about 1 inch around it is cool, swollen, firm, and tender to touch. Which action should the nurse take first?

a.       Take patient’s temperature.

b.      Apply an ice pack to site.

c.       Stop infusion and remove IV catheter.

d.      Call the primary care provider immediately.

Answer: c

The area around an IV infiltration is cool, swollen, firm, and tender to touch. The first intervention to take for an infiltrated IV is to stop the infusion and discontinue the IV/remove the catheter. Applying cold compresses may be appropriate for hyperosmolar fluids but only after the IV infusion has been stopped. Taking the temperature would be an assessment to make if the complication of infection is suspected. The primary care provider does not need to be notified unless grade 3 or 4 infiltrations are noted (> 6 inches edema).

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18

Which activity is important to include in the plan of care for a patient with a peripherally inserted central catheter (PICC)? (Select all that apply.)

a.       Change the PICC dressing only when it becomes soiled or loose.

b.      Change the IV tubing every 5 to 7 days.

c.   Take blood pressure in the arm without the PICC line.

d.  Use only macrodrip tubing with IV infusions through the PICC line.

e.    Use alcohol-impregnated disinfection caps on needleless ports when not in use.

Answer: c, e

PICC dressings should be changed every 5 to 7 days regularly using sterile technique for transparent dressings and gauze dressings must be changed every 48 hours. This is to keep the site sterile and prevent central line associated blood stream infections (CLABSIs). Dressings should also be changed whenever wet, soiled, or loose. PICC IV tubing is usually changed every 24 hours depending on facility policy. Never take blood pressure in an arm with a PICC. Macrodrip or microdrip tubing can be used for infusions through a PICC. Green or orange disinfection caps are alcohol impregnated and should be used to keep ports clean when not in use.

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19

The nurse has just begun an infusion of packed red blood cells (PRBCs). Which of the following cues should the nurse recognize as indicating a transfusion reaction that warrants stopping the infusion? (Select all that apply.)

a.       Patient complains of weakness and fatigue.

b.      Patient complains of feeling itchy.

c.       Patient is shivering and complains of chills.

d.      Temperature increased from 99.1° degrees to 101.3° F.

      e.   Patient complains of nausea.

Answer: b, c, d

Weakness and fatigue are commonly experienced in anemic patients needing a blood transfusion. Itching or hives can be a sign of an allergic reaction. Shivering/chills can indicate hemolytic or nonhemolytic reactions as well as infection due to bacterial contamination. An increased temperature of more than 2 degrees Fahrenheit indicates a reaction; the infusion should be stopped and primary care provider and blood bank notified. Nausea is not a side of effect of a transfusion reaction.

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20

Place the following steps in the correct sequence for starting a peripheral intravenous infusion.

a. Insert needle until there is blood return.

b. Cleanse the site using chlorhexidine and allow to air-dry.

c. Apply tourniquet for maximum of 1 minute while palpating veins and then release.

d. Release tourniquet.

e. Stabilize, connect, and flush with normal saline.

f. Gather all equipment and perform hand hygiene.

g. Dispose of needle in sharps container and document.

h. Use securement device or sterile dressing with label.

i. Reapply tourniquet using a quick-release knot.

F C I B A D E H G

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21

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which significant finding does the nurse anticipate when inspecting the chest?

a. A ratio of 1 : 2 when comparing the side and front views of the chest

b. A barrel chest

c. A concave shape to the sternum

d. A severe lateral curvature of the spine

Answer: b

Chronic air trapping in COPD can cause a barrel-shaped chest. The intercostal spaces pull the chest out, and the accessory muscles of breathing may compensate to enlarge the chest cavity, causing the anteroposterior diameter of the chest to increase. The chest diameter ratio of 1:2 is the normal finding for a person who does not have hyperinflation of the lungs. A concave sternum is not an expected finding with COPD. A lateral curvature of the spine is consistent with scoliosis, which is not an expected finding for most patients with COPD.

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22

What is the desired outcome related to the nursing diagnosis of Impaired Airway Clearance?

a. Patient’s respiratory secretions will become thicker so they are not moved when coughing.

b. Patient’s respiratory secretions will have a thinner consistency after being given a mucolytic agent.

c. Patient will have improved range of motion while in bed.

d. Patient’s respiratory rate will increase from 16 to 28 breaths/min during hospitalization.

Answer: b

The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of secretions. Improved range of motion is related to musculoskeletal problems. The normal respiratory rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired.

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23

The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The patient has albuterol treatments scheduled every 6 hours and PRN and is on oxygen 2L/min via nasal cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering the patient’s room to administer medications, the nurse notes that the patient is in acute respiratory distress. Which priority interventions would the nurse take to safely manage the care of this patient? (Select all that apply.)

a. Place patient in upright position.

b. Call respiratory therapy.

c. Increase oxygen to 7 L/min per nasal cannula.

d. Assess vital signs

e. Listen to lung sounds.

f. Administer metoprolol.

Answer: a, b, d, e

When a person is having difficulty breathing, placing the individual in an upright position (Fowler or semi-Fowler) helps to increase the effectiveness of breathing by placing less pressure on the chest from the bed. The nurse would put the patient in an upright position to improve breathing. Respiratory therapy should come to assess the patient, to administer a second breathing treatment, and evaluate oxygen requirements depending on the facility. It is important to assess vital signs and lung sounds to determine what has changed with the patient since the last assessment. Do not administer

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24

When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen?

a. Nasal cannula at a flow rate of 2 L/min

b. Nasal cannula at a flow rate of 5 L/min

c. Simple mask at a flow rate of 6 L/min

d. Nonrebreather mask at a flow rate of 5 L/min

Answer: d

A nonrebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen in the reservoir bag and may result in the person developing hypoxemia. The accepted range of oxygen delivery with a nonrebreather mask is 10 to 15 L/min. The amount that can be delivered by nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the range for a face mask is 5 to 10 L/min.

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25

The nurse knows that which of the following nursing actions are indicated when suctioning a patient with a tracheostomy? (Select all that apply.)

a. Decrease the patient’s oxygen flow rate before beginning the deep suctioning.

b. Assess heart rate, respiratory rate, oxygen saturation, and lung sounds prior to suctioning.

c. Suction intermittently for no more than 10 to 15 seconds.

d. Flush the artificial airway with 5 mL of normal saline to loosen secretions.

e. Reassess heart rate, respiratory rate, oxygen saturation, and lung sounds after suctioning.

f. Document time, amount, and characteristics of secretions.

Answer: b, c, e, f

Assess heart rate, respiratory rate, oxygen saturation, and lung sounds before suctioning to provide a baseline for detecting changes in the patient’s condition. Reassess after suctioning to determine whether suctioning was beneficial to the patient. Oxygen is removed during the suctioning procedure, and the amount of time spent suctioning needs to be limited to 10 to 15 seconds. In some cases, the nurse provides extra oxygen before and during suctioning procedures, and decreasing the oxygen is contraindicated, therefore it would not be appropriate to decrease the flow rate. Documentation ensures that changes are noticed and that other members of the interprofessional team are aware of the patient’s condition. Evidence-based practice shows that flushing with sterile NSS has no benefit because saline does not mix with secretions and the procedure may have negative effects for the patient.

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26

A patient admitted with a history of chronic obstructive pulmonary disease (COPD) admits to smoking 1 pack of cigarettes per day for the last 40 years. When developing a plan of care for the patient, the nurse includes smoking cessation as a priority education goal. Which interventions would the nurse include in the patient education? (Select all that apply.)

a. Alternative therapies

b. Nicotine replacements

c. Support groups

d. Switching to e-cigarettes

e. Counseling

f. Decreasing the number of cigarettes smoked by half

g. Educating about the risks of smoking

Answer: a, b, c, e, g

Providing the patient with alternative therapy—such as meditation or relaxation techniques, nicotine replacement therapy, support groups, and counseling—are all tools to help a person quit smoking. Education about the risks of smoking gives the patient factual information about the long-term effects. Changing to e-cigarettes and decreasing the amount of cigarettes by half does not eliminate inhalation of nicotine and other harmful substances.

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27

The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient who has bluish discoloration around the lips?

a. Increased PaCO2 levels

b. Hemoglobin that is not saturated with oxygen

c. Elevated white blood cell count

d. Decreased PaCO2 levels

Answer: b

Cyanosis occurs due to hypoxemia, which is a low level of oxygen in the blood. Hemoglobin that is not saturated with oxygen causes a bluish discoloration of the skin. Increased or decreased levels of carbon dioxide (CO2) may indicate an acid-base imbalance. An elevated white blood cell count may indicate an infection.

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28

During handoff to the oncoming shift, the nurse includes in the SBAR report that the patient needs to be evaluated by speech therapy for which of the following reasons?

a. Persistent aspiration of liquids

b. Hypoventilation due to smoking

c. Hyperventilation due to anxiety

d. Decreased respiratory effort due to scoliosis

Answer: a

Aspiration pneumonia results from abnormal entry of material from the mouth and stomach into the trachea and lungs. Patients should be evaluated for whether they have a decreased gag reflex or decreased level of consciousness. The speech therapist can perform a swallow study to determine whether thin liquids are being aspirated into the lung and recommend a regimen of thickened liquids and swallow exercises to prevent aspiration. A speech therapist would not be consulted in cases of hypoventilation or hyperventilation. Nursing measures and consulting the primary care practitioner are proper steps for these findings. A physical therapist may be consulted if scoliosis is hampering the patient’s respirations.

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29

A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe?

a. Increased PaCO2

b. Decreased hemoglobin

c. Decreased PaO2 levels

d. Increased PaO2 levels

Answer:  c

Chronically elevated level of carbon dioxide in the chemoreceptors become tolerant of high levels. The carbon dioxide ceases to be the patient’s trigger to breathe; therefore, what drives the patient to breathe is the hypoxic (low oxygen) drive. A person normally uses increased PaCO2 levels as the drive to breathe. A patient with COPD has chronic elevation of PaCO2 and has lost sensitivity to it as a drive to breathe. Instead, a decreased PaO2 level becomes the drive to breathe.

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30

Which questions would be included during a focused history on a cardiac patient to help the nurse determine the significance of the cues? (Select all that apply.)

a. Are you having pain?

b. Where is the pain located?

c. Do you attend religious services regularly?

d. Do you have increased fatigue?

e. Do you have any episodes of dizziness?

Answer: a, b, d, e

Asking questions and providing time for the patient to answer is essential to helping determine what is occurring. Pain assessment is important to determine a pattern of pain. Cardiac events can contribute to fatigue and abnormal heart rhythms may contribute to dizziness. Although knowledge of a patient’s religious affiliation may be important in certain settings, it is not part of a focused assessment of a cardiac patient.

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31

A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? SATA

A, history of consuming one glass of wine daily

B. Loss in height of 2 in (5.1 cm)

C. BMI of 18

D. Kyphotic curve at upper thoracic spine

E. History of lactose intolerance

B, C, D, E

More than 3 glasses of wine daily would have been a risk factor

Loss of 2 inches is indicating fractures to vertebral column

Low body weight indicates low bone mass

Kyphotic curve suggests osteoporosis due to factures of vertebra causing the curve

Lactose intolerance indicates possible lack of calcium intake

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32

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which action should the nurse take?

A. Apply heat to the puncture site

B. Place the client in supine position

C. Turn the client every 1 hr

D. Ambulate the client within the first hour postprocedure

B.

Apply cold therapy to decrease bleeding and swelling

the client should remain in a supine position for the first 1-2 hrs post surgery

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33

A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following should the nurse include?

A. white bread

B. Kale

C. Apples

D. Brown Rice

B.

White bread is carbs, Apples are fiber, Brown rice is carbs

green leafy vegetables are good sources of Calcium

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34

A nurse is performing health screenings at a health fair. Which clients have a risk factor for osteoporosis?

A. 40 year old taking prednisone for 4 months

B. 30 year old who jogs 3 miles daily

C. 45 year old who takes phenytoin for seizures

D. 65 year old who has a sedentary lifestyle

E. 70 year old who has smoked for 50 years

A, C, D, E

Weight bearing activities decrease risk for osteoporosis

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35

A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following should the nurse include?

A. Remove throw rugs

B. Use prescribed assistive devices

C. Remove clutter from the environment

D. wear soft-bottomed shoes

E. Maintain lighting of doorways

A,B,C, E

client should wear rubber bottomed shoes to prevent slipping

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36

A nurse is admitting a client who reports nausea, vomitting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? SATA

A. Decreased skin turgor

B. Concentrated urine

C. Bradycardia

D. Low-grade fever

E. Tachypenia

A, B, D, E

Tachycardia is a manifestation - fast heart rate

Tachypnea - increased respirations

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37

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5lb) in 48 hr. Which of the following manifestations of fluid volume excess should the nurse expect? SATA

A. Dyspnea

B. Edema

C. Bradycardia

D. Hypertension

E. Weakness

A, B, D, E

Dyspnea - difficulty breathing

Edema- swelling due to fluid build up

Bradycardia- increased heart rate- heart rate goes down for Overload

Increased fluid leads to increased BP

Weakness is due to excess fluid retained that depletes energy and increases body workload

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38

A nurse is assessing a client who is dehydrated. Which of the following finding should the nurse expect?

A. Moist skin

B. Distended neck veins

C. Increased urinary output

D. Tachycardia

D.

Increased urine, distended neck veins, and moist skin are symptoms of fluid volume excess

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39

A nurse is caring for a client in a long-term care facility who has become weak, confused, and experienced dizziness when standing. The client’s temperature is 38.3 C (100.9 F), P 92, R 20, BP 108/60. Which action should the nurse take?

A. Initiate fluid restrictions to limit intake

B. Check for peripheral edema

C. Encourage the client to ambulate to promote oxygenation

D. Monitor for orthostatic hypotension

D.

offer fluids for dehydration, monitor for poor skin turgor with dehydration, keep client in bed as they are fall risk when dehydrated

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40

A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching?

A. Hemodialysis restores kidney function

B. Hemodialysis replaces hormonal function of the renal system

C. Hemodialysis allows an unrestricted diet

D. Hemodialysis returns a balance to blood electrolytes

D.

Does not restore kidney function, replace hormone function, or allow unrestricted diet

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41

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? SATA

a. Review the medications the client currently takes

b. assess the av fistula for a bruit

c. calculate the clients hourly urine output

d. measure the clients weight

e. check blood electrolytes

f. use the access site area for venipuncture

a,b,d,e

Urine output does not determine kidney function

never use the access site area for venipuncture because the compression from the tourniquet can cause loss of the vascular acess

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42

A nurse is planning postprocedure care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? SATA

A. check BUN and creatinine

B. Administer medications the nurse withheld prior to dialysis

C. observe for findings of hypovolemia

D. assess the access site for bleeding

E. Evaluate BP on the arm with the AV access.

A, B, C, D

Never measure BP on the extremity that has the AV access site

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43

A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. What action should the nurse take?

A. administer an opioid

B. Monitor for hypertension

C. Assess level of consciousness

D. Increase the dialysis exchange rate

C.

Do not administer opioid

want to monitor for hypo not hypertension

decrease exchange rate to slow rapid changes in fluid and electrolytes

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44

A nurse is planning care for a client who will undergo peritoneal dialysis. Which actions should the nurse take SATA?

A. Monitor Blood glucose levels

B. Report cloudy dialysate return

C. Warm Dialysate in a microwave oven

D. Assess for SOB

E. Check the access site dressing for wetness

F. Maintain medical asepsis when accessing the catheter insertion site

A, B, D, E

Avoid warming solution in microwave oven because it warms unevenly

surgical not medical asepsis

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45

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings which of the following actions should the nurse take?

A. elevate the client’s legs for 10 minutes 2-3 times daily while wearing stockings

B. Apply the stockings in the mornings upon awakening and before getting out of bed

C. Roll the stockings down to the knees to relieve discomfort on the legs

D. Remove the stockings while out of bed for 1 hr four times a day to allow the legs to rest

B. Apply in the mornings and before getting out of bed to reduce venous stasis and assists in the venous return of blood to the heart. Legs are less edematous at the same time

Elevate for 20 minutes 4-5 times daily

Rolling stockings can restrict circulation and cause edema

Stockings should remain in place throughout the day, remove before going to bed, elevate legs before reapplying stockings if removed for reasons such as bath or shower

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46

A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the findings should the nurse expect?

A. Edema around the ankles and feet

B. Ulceration around the medial malleoli

C. Scaling eczema of the lower legs with stasis dermatitis

D. Pallor on elevation of the limbs, and rubor when the limbs are dependent

D. In PAD pallor is seen when extremities are elevated and rubor when lowered

Edema = venous stasis

Ulceration of medial malleoli = venous stasis

Scaling eczema of lower legs with stasis dermatitis = venous stasis

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47

A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include?

A. Wear tightly-fitted insulated socks with shoes when going outside

B. Elevate both legs above the heart when resting

C. Apply a heating pad to both legs for comfort

D. Place both legs in dependent position while sleeping

D. This can help alleviate swelling and discomfort

loose-fitting socks to promote circulation

Avoid elevation of legs as this can lead to restriction in arterial blood flow to the feet

No heating pad, loss of sensation due to disease, direct heat can burn the client

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48

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include? SATA

A. Avoid taking herbal supplements while taking this med

B. Monitor for Black tarry stools

C. Take this med when you have pain

D. Schedule a weekly PT test

E. Limit foods containing Vitamin K

A, B Herbal supps (Garlic, ginger, ginkgo, Ginseng) can increase risk of bleeding, Signs of GI bleeding (abdominal pain, coffee-ground emesis, black, tarry stools) report to provider

Take this med routinely as prescribed as it can take several weeks to be effective

PT and INR need to be monitored for Warfarin

Client taking Warfarin needs to be advised about Vitamin K foods

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49

A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed Warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give?

A. I will remind your provider that you are already receiving heparin

B. Your laboratory findings indicated that two anticoagulants were needed

C. It takes 3-4 days before the therapeutic effects of warfarin are achieved, and then heparin can be discontinued

D. Only one of these medications is being given to treat your DVT

C. Warfarin takes 3-4 days to become effective

Warfarin is prescribed 3-4 days before discontinuing Heparin

Iv heparin is monitored to to achieve adequate therapeutic levels in treating DVT

Heparin and Warfarin are both effective in treating DVT

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50

The nurse is screening a client for hypertension. The nurse should identify that which of the following actions by the client increase the risk for hypertension? SATA

A. drinking 8 oz of nonfat milk daily

B. Eating popcorn at the movie theater

C. Walking 1 mile a day a 12 min/mile pace

D. Consuming 36 oz of beer daily

E. Getting a massage once a week

B, D popcorn at movie theater is high in fat and sodium, consuming more than 24 oz of beer daily for men or 12 oz for women

low-fat beverages and foods, regular exercise, and stress management lower the risk for hypertension

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51

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider?

A. Takes psyllium daily as a fiber laxative

B. Drinks skim milk daily as a bed time snack

C. Takes metoprolol daily after meals

D. Drinks grapefruit juice daily with breakfast

C. Metoprolol can mask the effects of hypoglycemia in patients with type 2 diabetes mellitus

psyllium adverse affects do not include hypoglycemia

skim milk increase blood glucose and lowers cholesterol

Grapefruit juice increases blood glucose

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52

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 226/147 mm Hg. The client reports a headache and double vision. The client states, “I ran out of my diltiazem 3 days ago, and I am unable to purchase more.” Which of the following actions should the nurse take first?

A. Administer acetaminophen for headache

B. Provide brief teaching regarding the importance of not abruptly stopping an antihypertensive

C. Obtain IV access and prepare to administer an IV antihypertensive

D. Call social services for a referral for financial assistance in obtaining prescribed medication

C. client is at greatest risk for injury due to BP, this number can be life threatening and should be lowered asap IV is more rapid than oral

acetaminophen will treat the pain, but this is not the first action

Teaching is important for further compliance but not first action

social services will help connect financial resources but there is another action to take first

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53

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the statements by the client indicates understanding?

A. I should eat a lot of fruits and vegetables especially bananas and potatoes

B. I will report any changes in heart rate to my provider

C. I should replace the salt shaker on my table with a salt substitute

D. I will decrease the dose of this medication when i no longer have headaches and facial redness

B monitor HR and report to provider

This is a potassium sparing diuretic no need to increase potassium can lead to hyperkalemia

Salt substitutes are high in potassium, can lead to hyperkalemia in potassium sparing diuretic

continue to take med as prescribed even if symptoms are gone

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54

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day?

A. morning

B. immediately after lunch

C. immediately before dinner

D. bedtime

A. furosemide is a diuretic we want the peak to occur during waking hours

other times can interrupt sleep due to need to urinate.

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