Final
1. Upon auscultating the chest of an older patient who recently experienced an MI, the nurse hears an S3 and lung crackles. Because of these findings, the nurse should assess for what other condition?
A:HEART FAILURE
2. A patient w/ essential thrombocytopenia has a platelet count of 1.6 million/mm3. What is the nurses priority assessment? SATA
A: central, increased blood glucose levels, HTN
3. Nurse is providing care for a client who has recently been diagnosed with COPD. When educating the client about the prevention of exacerbations, the nurse should prioritize which topic?
A: identifying specific causes of exacerbations
4. Client is being treated for polycythemia vera, and the nurse is providing health education. Which practice should the nurse recommend to prevent the complications of this health problem?
A: avoiding tight and restrictive clothing on the legs
5. Client with pericarditis is experiencing sharp, pleuritic chest pain that improves. when. sitting up and leaning forward. The nurse anticipates finding which sound on auscultation?
A: A pericardial friction rub at the left lower sternal border
6. Which of the following is a complication of acute glomerulonephritis?
A: Edema
7. Which of the following is a hallmark symptom of heredity hemochromatosis?
A: bronze skin pigmentation
8. A patient is caring for 4 patients with leukemia. After the hand off report, which client should the nurse see first?
A:A patient who had 2 bloody diarrhea stools this am
9. What should the nurse include in the discharge education for a patient diagnosed with laryngitis?
A: rest the voice and increase fluids
10. What patient with a history of heart failure presents with increased dyspnea orthopnea, and a cough that worsens when laying down. which nursing actions are the most appropriate to address these symptoms? SATA
A: monitor urinary output, administer prescribed diuretic
11. A patient with an abdomen aortic aneurysm arrives at the ED, which finding is consistent with rupture into the abdomen cavity?
A: abdominal distention
12. A public health nurse has been asked to provide a health promotion session for men at a wellness center. What should the nurse include when providing education about prostate cancer?
A: African American men are twice as likely to die from prostate cancer
13. What physiological change best describes cyanosis?
A: accumulation of deoxygenated hemoglobin producing a blue tinged discoloration
14. A nurse is caring for a patient diagnosed with polycythemia vera. Which of the following should the nurse include in the patient and family education?
A: take anticoagulants as prescribed
15. A patient with known atherosclerosis asks why they are at risk for myocardial infraction (MI). Which explanations should the nurse include? SATA
A: coronary artery narrowing reduces oxygen delivery to the myocardium
inflammation contributes to plaque instability, Plaque rupture can trigger thrombus formation
16. Which statement best explains the role of the prostate gland?
A: it produces fluid that nourishes and protects sperm
17. Patient with multiple myeloma is admitted with complaints of excessive thirst, fatigue, and nausea. Lab results show an elevated serum calcium level of 12.1 mg/dl. which nursing interventions are appropriate? SATA
A: Prepare to administer prescribed bisphosphonates
Assess patient for renal calculi
Monitor for constipation and decreased bowel sounds
Encourage oral fluid intake unless contraindicated
18. Patient with CKD is experiencing anemia with a decreased erythropoietin level. which nursing intervention is most appropriate for managing the clients anemia?
A: prepare the patient for ESA therapy
19. A patient with hemophilia A is admitted with joint pain and swelling what is thee nurses priority intervention?
A: administer factor VIII replacement
20. Which of the following statement about synchronization during electrical cardioversion are accurate?
A: The synchronizer must be manually reactivated if another cardioversion is needed
The defibrillator synchronizes with the QRS complex to avoid discharging during the T wave
A visible indicator on the ECG monitor confirms detection of the QRS complex
21. Patient with a recent history of streptococcal pharyngitis present with fever, chest pain, and a new heart murmur. Which nursing intervention is most appropiate?
A: obtain blood cultures before starting antibiotics
22. Which are common manifestations of bladder cancer?
A: Flank pain, Painless Hematuria, UTI symptoms
23. A nurse is caring for a patient on the oncology unit. Which of these four patients should the nurse see first?
A: Patient diagnosed with neutropenia complaining of a sore throat
24. A patient with sickle cell disease arrive to the ED with chest pain, cough, fever, and shortness of breath. The nurse suspects acute chest syndrome. Which interventions would the nurse anticipate? SATA
A: Prepare the patient for a possible blood transfusion
Provide supplemental oxygen, Administer prescribed broad-spectrum antibiotics
25. The nurse reviewed the ECG rhythm for the patient, how does the nurse interpret the following rhythm?
A: Ventricular Fibrillation
26. a patient with a history of HTN and a previous MI is admitted with increasing fatigue and dyspnea on exertion. Based on these findings, which nursing actions are most appropriate? SATA
A: Perform a focused cardiovascular assessment
Assess the client's vital signs and oxygen sat
Encourage the client to rest and limit activities
27. A nurse is evaluating the effectiveness of treatment for a client with endometriosis who has been receiving GnRH agonist therapy for 3 months. Which finding indicates the therapy is effective?
A: reduction in pelvic pain and menstrual flow
28. A patient received a transfusion of platelets. The nurse evaluates the patient after the transfusion. Which results would demonstrate the benefit of this transfusion?
A: decreased oozing of blood from puncture sites/gums
29. A nurse is reviewing risk factors for atherosclerosis with a group of patients. Which conditions increase the risk of developing atherosclerosis? SATA
A: HTN, DM sedentary lifestyle, cigarette smoking, low HDL-C levels
30. A patient diagnosed with Hodgkin Lymphoma reports night sweats, unexplained fever, and a 15 pound unintended weight loss over 2 months. The nurse recognizes these findings as?
A: B symptoms, indicating a more advanced stage of the disease
31. A patient receiving treatment for severe anemia begins to exhibit decreased urine output. Increased confusion, and a rising respiratory rate. when planning this patients care, which nursing intervention should the nurse prioritze?
A: notify the provider and assess for signs of organ ischemia
32. A patient with sickle cell disease experiences a vasoocclusive crisis resulting in acute pain. Which multimodal analgesic is most appropriate?
A: provide IV opioids for pain, along with hydration and oxygen therapy as needed.
33. Which interventions are appropriate fro a patient with a spastic neurogenic bladder? SATA
A: intermittent catheters, timed voiding, external cathuse.
34. A patient chronic stable angina reports chest discomfort after walking up 2 flights of stairs. the nurse notes the pain resolves after resting 5 min. Which nursing action is most appropriate?
A: Document the finding as expected for stable angina
35. A patient is scheduled for a mechanical mitral valve replacement. Which teaching should the nurse prioritize during the pre op education?
A: you will require lifelong anticoagulation therapy after surgery.
36. Nurse caring for a patient who is being treated for leukemia in the hospital. Patient was able to maintain nutritional status for the 1st few weeks following the diagnosis but is now exhibiting early signs of malnutrition. In collab with the dietician, the nurse should implement what intervention?
A: provide the patient with several small, soft-textured meals each day.
37. A nurse caring for a patient diagnosed with primary myelofibrosis who reports early satiety, fatigue, and left upper quadrant discomfort. Which nursing interventions are most appropriate to include in the plan of care? Sata
A: Prepare the patient for a stem cell transplant evaluation if eligible
Encourage small, frequent meals to reduce abdominal discomfort
Monitor for signs of splenic rupture such as hypotension and abdominal discomfort
Assess for signs of thrombosis or bleeding
38. A nurse is teaching a patient with cardiomyopathy strategies to improve activity tolerance. Which instructions should the nurse include?
A: pace activities by alternating periods of activity with periods of rest.
39. Which diagnosis confirms Hodgkin lymphoma?
A: presence of Reed-Sternberg cells in a lymph node biopsy
40. A patient with aortic stenosis asks why they feel dizzy with exertion. Which explanation should the nurse provide?
A: the narrowed valve limits blood flow from the left ventricle to the body
41. then nurse observes a change in thee clients ECG rhythm. Based on the rhythm shown. what is the initial action the nurse should take?
A: check for responsiveness and a central pulse.
42. Nurse caring for a patient with SOB, heart palpitations, and dizziness. The nurse places the patient on the cardiac monitor and finds the patient is in atrial fibrillation at a rate of 190 beats per min and has a blood pressure of 120/75mmHg. Which action should the nurse anticipate?
A: administer a calcium channel blocker IV.
43. A nurse is teaching a patient with epididymitis about home care. Which instructions should be included? SATA
A: apply ice packs to scrotum, wear supportive underwear, avoid lifting heavy objects
take prescribed antibiotics.
44. A nurse on the telemetry unit assesses a patient with a history of HTN. What is the nurse assessing when theestethoscope is placed on the patients chest at the second intercostal space to the right of the sternum?
A: the aortic valve.
45. Which nursing interventions is most appropriate for a client with empyema?
A: assist with chest tube drainage care.
46. A patient presents with painless swelling in the groin and compression symptoms. What is the most likely diagnosis?
A: non-Hodgkin lymphoma
47. A nurse reviews a patients medication list before a cardiac stress test. Which medication requires clarification with the provider prior to testing?
A: metoprolol
48. During morning assessment, the nurse discovers a patient with is unresponsive and pulseless. The cardiac monitor displays asytole, after calling a code and initiating high quality chest compressions, which action should the nurse prepare for next?
A: administer EPI IV push next.
49. A patient with a history of angina reports new chest pain that occurs at rest and is not relieved by nitro. The nurse reviews the patients vital signs and notes BP 148/92, HR 110, RR24. Which action should the nurse take first?
A: place the patient in High-Fowler's position
50. A nurse is teaching lifestyle modifications for a patient with newly diagnosed HTN. Which patient statement indicates a need for further teaching?
A: "I will stop taking my medications if I have any dizziness with standing."
51. A nurse caring for a transgender woman who is taking estrogen therapy. Which nursing intervention should the nurse implement to monitor for complications associated with this medication?
A: monitor for signs of thromboembolism during routine assessments.
52. An asthma educator is teaching a patient newly diagnosed with asthma and the family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures highest airflow during which type of breath?
A: forced expiration.
53. Which nursing interventions are most appropriate for a patient with advanced chronic lymphocytic leukemia (CLL) experiencing fatigue and anemia? SATA
A: Administer erythropoiesis-stimulating agents as prescribed
Monitor Hgb and Hct levels
Provide rest periods between activities
54. The nurse is arriving at the beginning of her shift and has taken report on 4 patients on a med surg unit. Which patient should the nurse see first?
A: patient who is post-vaginoplasty with bright red blood and clots in her catheter first.
55. nurse is working in the ED and has four patients arrive at the same time. Which patient should the nurse see first?
A: patient complaining of severe throat pain, drooling, and trismus
56. Patient with a history of rheumatic heart disease is scheduled for a dental extraction. Which is the most appropriate nursing action to prevent infectiveendocarditis?
A: administer prophylactic antibiotics as prescribed prior to the dental procedure
57. A nurse interprets this cardiac rhythm on a 6 second ECG printout and identifies it as?
A: Atrial Flutter
58. Patient with a history of heart failure presents with increased dyspnea, orthopnea, and a cough that worsens when lying down. Which nursing actions are the most appropriate to address these symptoms? SATA
A: Monitor urine output, Administer a prescribed diuretic
59. A nurse caring for a patient who has been diagnosed with leukemia during the latest assessment, the nurse observes ecchymoses on the sacral area and petechiae on the forearms, in addition to notifying the provider, what action should the nurse take?
A: check the patient's most recent platelet (PLT) levels
60. The nurse is assessing a patient with severe anemia. Which clinical manifestation is associated with this condition?
A: tachycardia
61. Patient with hypertrophic cardiomyopathy asks why they must avoid activities like sprinting and heavy lifting. Which response is most appropriate?
A: "These activities make your heart work harder and can make the obstruction worse."
62. Female patient tell the nurse that they think they have a vaginal infection because the patient has noted dull pelvic pain with vaginal discharge, irregular vaginal bleeding, and malaise. Then nurse recognizes that the clinical manifestations described are typical of which infection?
A: PID (Pelvic Inflammatory Disease)
63. Patient is receiving treatment for the diagnostic of hemophilia A. Which of the following is the most appropriate to include in the assessment of the patient?
A: joint pain.
64. Female patient is being treated for a DVT she developed post op about 1 week ago and was treated with unfractionated heparin. Today she presents to the clinic with petechiae on bilateral hands and feet. Lab results show a platelet count of 42,000/mm3. Based on the assessment, the nurse is concerned the pt is presenting with which condition?
A: HIT (Heparin Induced Thrombocytopenia )
65. A patient with a history and heart failure is admitted with complaints of fatigue and palpitations persisting for the past week. The patient is alert, orieented and hemodynamically stable with a blood pressure oof 118/76 mmHg. Upon reviewing the cardiac monitor, the nurse observes the rhythm as shown. Which nursing intervention is most appropriate at this timee?
A: Administer prescribed snticoagulant threapy
66. A patient with coronary artery disease is being educated on lifestyle modifications to manage their condition. Which statements by the patient indicate an understanding of the dietary changes needed? SATA
A: "I will reduce intake of red meats in my diet"
"I will include more fruits, vegetable, and fish in my diet"
"I will increase my consumption of whole grains"
67. A patient in the post transplant phase following a stem cell transplant. Which of the following nursing actions are appropriate?SATA
A: maintain protective isolation precautions
monitor for graft vs host disease
admin immunosuppressive meds as prescribed
68. Patient receiving RBCs develops SOB, crackles in the lungs, and increased blood pressure after 30 min of transfusion. Which action should the nurse take first?
A: stop the transfusion and notify the provider.
69. An oncology nurse is providing health education for a patient who has recently diagnosed with Leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia?
A: malignant leukemia cells crowd the bone marrow, impairing the production of normal RBC, platelets, and mature WBCs
70. A nurse is caring for a patient with pericarditis. If left untreated, thee client is at risk for cardiac tamponade. Which clinical manifestation is associated with cardiac tamponade?
A: muffled heart sounds.
71. Which diagnostic test determines ejection fraction, cardiovascular valvular changes, pericardial effusion, chamber enlargement, and ventricular hypertrophy and is the best tool when diagnosing heart failure?
A: ECHO (Echocardiogram).
72. A patient wit a permanent pacemaker reports intermittent palpitations and lightheadedness. The nurse observes that the pacemaker occasionally fails to capture. what action should the nurse take first?
A: contact provider for pacemaker interrogation.
73. A nurse is reviewing inerventions for a 32 year old patient diagnosed with viral rhinitis who is complaining of severe rhinorrhea.
ID which nursing education topics are INDICATED, and which are NOT INDICATED for patients with VIRAL rhinitis.
A: INDICATED:
use saline nasal sprays or aerosols to help soften secretions
hand hygiene/using proper cough etiquette is important ionpreventing the spread
control the environment at home and at work to decreased respiratory irritants
using guaifesen can promote easier drainage of nasal mucus
NOT INDICATED:
Complete all abx even if you feel better
repeated exposure to allergens will help you build tolerance
74. A nurse finds an adult patient unresponsive, pulseless and apneic on a medical surgical unit.
choose from the following dropbox below to fill in each blank
A: the initial nursing action for this patient is for the nurse to ( call for help and activate the emergency response team)
followed by ( Beginning high quality chest compressions at a rate of 100-120/min)
75. A patient with a recent viral infection is admitted with suspected pericarditis. The patient reports chest pain that. worsens with deep breathing and improves with leaning forward. The nurse prepares to implement the plan of care
complete the nursing care plan by selecting the intervention that best supports the patient in achieving the stated nursing goal?
A: MAINTAIN ADEQUATE PAIN CONTROL:
-admin prescribed NSAIDs to help with inflammation
EARLY DETECTION OF COMPLICATIONS
-monitor heart sounds for signs of cardiac tamponade
PROMOTE HEALING
-encourage rest and limit activity until pain subsides.
76. 64yr old male presents to the ED with crushing chest pain radiating to his left arm, SOB, and diaphoresis. The symptoms began approx. 1 hour ago, and the symptoms continue to worsen despite rest.
choose the condition the patient is most likely having, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to assess patientsprogress
A: POTENTIAL CONDITION(1)
-acute MI (Myocardial Infarction)
ACTIONS TO TAKE (2):
-obtain a STAT ECG
-admin nitro
PARAMETERS TO MONITOR (2)
-cardiac rhythm
-blood pressure
77. 68 yr old male presents to the ED with increasing SOB, fatigue, and swelling in his lower extremities. He has history of stage 3 CKD, HTN, and systolic heart failure (EF35%). He reports gaining 6 pounds over the past week and has not been able to lie flat at night due to dyspnea.
nurse determines which 3 complications are most concerning for this patient at this time? SATA
A: -fluid volume overload, pulmonary edema, acute kidney injury
78. CS CONT. 68 yr old male presents to the ED with increasing SOB, fatigue, and swelling in his lower extremities. He has history of stage 3 CKD, HTN, and systolic heart failure (EF35%). He reports gaining 6 pounds over the past week and has not been able to lie flat at night due to dyspnea.
complete the following sentence by choosing from the list of options.
A: in caring for the client the nurse should (Elevate head of bed) Then (Administer prescribed IV diuretic)
79. CS CONT. 68 yr old male presents to the ED with increasing SOB, fatigue, and swelling in his lower extremities. He has history of stage 3 CKD, HTN, and systolic heart failure (EF35%). He reports gaining 6 pounds over the past week and has not been able to lie flat at night due to dyspnea.
select the clinical findings that indicate worsening heart failure and CKD? SATA
A: BNP level of 820 pg/ml
weight gain of 6 ponds in 1 week
O2 sat of 90% on room air
potassium of 5.6 meq/l
80. CS CONT. 68 yr old male presents to the ED with increasing SOB, fatigue, and swelling in his lower extremities. He has history of stage 3 CKD, HTN, and systolic heart failure (EF35%). He reports gaining 6 pounds over the past week and has not been able to lie flat at night due to dyspnea.
which nursing interventions are most appropriate to address the patients correct condition? SATA
A: restrict fluid intake as prescribed
assess lung sounds and oxygen sat regularly
admin furosemide as prescribed
monitor daily weights
81. choose words from the drop down list to fill in each blank in the following sentence.
A patient with multiple myeloma presents with bone pain and fatigue. the nurse anticipates lab findings of (BLANK) and (BLANK)
A: 1. Hypercalcemia, 2.unknown
82. Complete the table by matching the clinical cue with the associated patho.
Eleavted BNP
A: Fluid overload and Ventricular stretch
83. Complete the table by matching the clinical cue with the associated patho.
Hyperkalemia
A: dehydration from high calorie diet
84: Complete the table by matching the clinical cue with the associated patho.
Dyspnea on exertion
A: pulmonary congestion
86. Complete the table by matching the clinical cue with the associated patho.
weight gain
A: sodium and water retention.
87. A patient weighing 90KG is prescribed amiodarone at 5 mcg/kg/min for ventricular tachycardia. The supply is amioodarone 500mg in 250 ml of 0.9% NS. Calculate the mL/hrto set the IV pump. Round to the nearest whole. number?
A: 14ml/hr
88. Clinical Findings that require immediate intervention
A: increased RR
increased creatine
89. Clinical Findings indicating improvement
A: weight loss of 2 pounds in 24 hours
reduced peripheral edema
improved oxygen saturation
decreased BNP level
90. Clinical Findings that require immediate intervention
A: sudden chest pain
formation of a large hard lump at insertion site
blood pressure 88/54 mmHg
91. Clinical Findings indicating improvement
A: mild bruising at insertion site
warm feet with palpable pulses
92. chest discomfort admitted to ED with acute myocarditis
appropriate nursing interventions for this patient.
A: educate pt that sports should be avoided fro at least 6 months
monitor for signs of heart failure
apply anti embolism stockings
93. chest discomfort admitted to ED with acute myocarditis
not appropriate nursing interventions for this patient.
A: encourage strenuous physical activity
administer NSAIDS as prescribed