Physiological Adapation

112 Questions | Total Attempts: 56

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Physiological Adapation

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Questions and Answers
  • 1. 
    Pulse oximetry measures
    • A. 

      Peripheral blood flow

    • B. 

      Venous oxygen saturation

    • C. 

      Central arterial flow

    • D. 

      Arterial oxygen saturation

  • 2. 
    When you are ausculating Mrs Rose's chest , you hear low-pitched, coarse sounds primarily on expiration. This best describes
    • A. 

      Rhonchi (or sonorous wheezes)

    • B. 

      Sibilant wheezes

    • C. 

      Crackles

    • D. 

      Pleural friction rub

  • 3. 
    On another patient, Mr Paku you ausculate musical, squeaky sounds bilaterlly in his lung fields.  This is best described as
    • A. 

      Crackles

    • B. 

      Rhonchi (or sonorous wheezes)

    • C. 

      Sibilant wheezes

    • D. 

      Pleural friction rub

  • 4. 
    Your understanding of creps, rales or crackles is
    • A. 

      Indicative of pneumothorax

    • B. 

      Caused by consolidation, mass or atelectasis

    • C. 

      Indicative of a pleral friction rub

    • D. 

      Created when air is moving through smaller air passages narrowed by mucous or pus

  • 5. 
    Auscultation of the lungs should reveal which normal finding?
    • A. 

      Vesicular breath sounds in all lung fields posteriorly

    • B. 

      Bronchial breath sounds heard faintly over the apices of both lungs

    • C. 

      Bronchovesicular breath sounds over the periphery of the posterior chest wall

    • D. 

      No breath sounds heard at the most extreme margins of the anterior and posterior lungs

  • 6. 
    The best technique for checking tactile fremitus is to use the ulnar surface of the hand
    • A. 

      True

    • B. 

      False

  • 7. 
    When percussing over normal lung fields, the sound you would expect to hear would be
    • A. 

      Dull

    • B. 

      Sonorous

    • C. 

      Resonate

    • D. 

      Crackling

  • 8. 
    Mr James, age 75 is admitted to the hospital with shortness of breath(SOB), a temp of 40degrees and substernal chest pain. He has a history of emphysema and a recent upper respiratory infection. You ausultate a low-pitched grating sound over his left anterior chest that persists even when he holds his breath. You suspect which of the following?
    • A. 

      Tension pneumothorax

    • B. 

      Pericardial friction rub

    • C. 

      Plural friction rub

    • D. 

      Consolidation

  • 9. 
    When assessing John C, aged 64, who has chronic obstructive lung disease, the nurse assesses tactile fremitus
    • A. 

      When assissin tactile fremitus, ask the patient to whisper "1,2,3"

    • B. 

      When assissing tactile fremius, use the soft pads of your finger tips

    • C. 

      Fremius is increased in the presence of pneumothorax or chronic obstructive lung disease

    • D. 

      Fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia

  • 10. 
    Which of the following statements regarding percussion is INCORRECT?
    • A. 

      Involves tapping the body lightly as in indirect, direct or immediate percussion, or fist percussion

    • B. 

      Requires the patient to say "99" or "a" during percussion

    • C. 

      Assists in the detection of fluid or air in a cavity

    • D. 

      Enables the determination of postion, size and density of underlying sturctures

  • 11. 
    The nurse notes that thoracic expansion is greater on the left side than the right and -
    • A. 

      Refers the client ot a physician for additional examination

    • B. 

      Documents this as a variation but within normal findings

    • C. 

      Instructs the client to rest bridfly then repeats the examination again

    • D. 

      Asks the client to repeat the numbers "99" while observing chest wall movements

  • 12. 
    You are working with a client who has respiratory disease.  You find that this client is able to breathe only in an upright or standing position.  In charting, you could describe the diffiuclty breathing in any psoition other than an upright or standing positon, or you could use the term for this condition, which is -
    • A. 

      Bradynpnea

    • B. 

      Tachypnea

    • C. 

      Orthopnea

    • D. 

      Eupnea

  • 13. 
    An appropriate nursing intervention for a patient with pneumonia with the nursing diagnoisis of ineffective airway clearance related to thick secretions would be
    • A. 

      Administer oxygen as prescribed to maintain optimal oxygen levels

    • B. 

      Teach the patient how to cough effrectively to bring secretions to the mouth

    • C. 

      Provide analgesics ordered to promote comfort

    • D. 

      Perform postural drainage every hour

  • 14. 
    The posterior tibial pulse may be palpated o the inner (medial) aspect of the ankle -
    • A. 

      True

    • B. 

      False

  • 15. 
    Which of the following indicates the normal location of the apical pulse in an adult?
    • A. 

      Fifth left intercostal space, medial to mid-clavicular line

    • B. 

      Fourth left intercostal space, mid-clavicular line

    • C. 

      Fifth intercostal space, anterior axillary line

    • D. 

      Fourth intercostal space, left sternal border

  • 16. 
    Which of the following statements regarding cardiac landmarks and auscultation is CORRECT?
    • A. 

      Erb's point is located midsternum in the epigastice area

    • B. 

      Listening to heart sounds through clothing may be reliable

    • C. 

      The forward sitting and left lateral decubitus postions aid in detecting murmurs

    • D. 

      The mitral area is in the second left intercostal space

  • 17. 
    To accurately assess the carotid pulse
    • A. 

      Place two fingers of each hand firmly over the right and left temples at the same time

    • B. 

      Palpate firmly with tow fingers in the inguinal space between the navel and sympysis pubis

    • C. 

      Place the fingers gently in the space between the biceps and triceps muscle

    • D. 

      Plapate each carotid pulse independently at the sternocleidomatoid muscle

  • 18. 
    Which of the following statements accurately describes a pulse deficit
    • A. 

      The apical pulse is greater than the radial pulse

    • B. 

      The peripheral pulse is not palpable

    • C. 

      A condition in which the arterial pulse is less than 60 bpm

    • D. 

      The pulse is palpable but easy to obliterate

  • 19. 
    Mr Pain was admitted to coronary care with a diagnosis of myocardial infarction. 2 days follwoing Mr Pain has a temp of 37.9 degress. The nurse should
    • A. 

      Encouirage deep breathing and coughing every 2 hours

    • B. 

      Record the temperature and monitor vital signs at routine intervals

    • C. 

      Auscultate the chest for diminished breath sounds

    • D. 

      Notify the physician immediately about the tempreture

  • 20. 
    Which perpheral pulse may be palpated at the upper surface of the foot?
    • A. 

      Dorsal plantar

    • B. 

      Posterior tibial

    • C. 

      Femoral

    • D. 

      Dorsalis Pedis

  • 21. 
    When assessing cyanosis, the nurse will utilise which of the following guiding principles?
    • A. 

      Central cyanosis is best identified around the umbilicus

    • B. 

      Central cyanosis may be due to a cold room, venous obstruction, or anxiety

    • C. 

      Sluggish or reduced blood flow contribute to peripheral cyanosis

    • D. 

      Perpheral cyanosis is best identified in the conjuctiva and tongue

  • 22. 
    Mary L aged 48 has been taking antihypertnesive medication for 6 months.  Recently she experiences a "near fainting" episode. Whcih of the following statements will best guide the nurse assessing Mary?
    • A. 

      The nurse should assiss Mary's bp with Mary supine, sitting and standing

    • B. 

      Bp should be measured in both arms whenver the nurse assesses Mary

    • C. 

      A fall in systolic pressure of 5-15 mmHg is significant and indicates postural hypotension

    • D. 

      Causes of postual hypotension are unknown

  • 23. 
    Which anatomic structure slows the spread of electrical current through the myocardium?
    • A. 

      The sinoatrial (SA)node

    • B. 

      The atrioventricular (AV)node

    • C. 

      The atrial conducting pathways

    • D. 

      The bundle of HIS

  • 24. 
    The nurse detects a possible irregularity in the rhythm of a client's pulse and will
    • A. 

      Count the client's apical pulse for a full minute

    • B. 

      Record this as normal for the client

    • C. 

      Use a stethoscope to check the brachial pulse

    • D. 

      Count the radial pulse again for 15 seconds and multiply by 4

  • 25. 
    Which of the following is accurate regarding the S1 heart sound?
    • A. 

      It is caused by the opening of the mitral and closing of the tricupsid valves

    • B. 

      It has a higher pitch than the second heart sound

    • C. 

      It is recorded as normal if a splitting of the sound is heard

    • D. 

      It is normally heard loudest at the apex of the heart

  • 26. 
    Which of the following statements is correct regarding an arterial bruit
    • A. 

      It may be be an indicator of dehydration

    • B. 

      It is a low pictched blowing sound heard normally over large arteries

    • C. 

      It is best detected using the diaphram of the stethoscope

    • D. 

      It is often indicative of atherosclerosis

  • 27. 
    Which of the following statements about using the bell of stethoscope to assess heart sounds is correct?
    • A. 

      It is ineffective for detecting murmurs or rubs

    • B. 

      None of these

    • C. 

      It must be placed lightly on the skin

    • D. 

      It is most useful for hearing high pictched sounds

  • 28. 
    When ausculating heart sounds, what do you assess?
    • A. 

      Presence of rubs or murmurs

    • B. 

      Rhythm

    • C. 

      Rate

    • D. 

      All of the above

  • 29. 
    When the nurse gathers baseline information on a client, the nurse will check the bp in both arms to detect deficits. There should be no more than how many mmHg difference between the two?
    • A. 

      15

    • B. 

      25

    • C. 

      18

    • D. 

      10

  • 30. 
    Mrs Jones has been admitted to your unit complaining of left sided weakness and difficulty speaking.  From the following assessments, identify the data that BEST represents a NURSING assessment
    • A. 

      Left sided weakness and speech deficit indicates probable stroke

    • B. 

      Neurological exam reveals partial paralysis and aphasic speech

    • C. 

      Brain scan shows evidence of a clot in the middle cerebral artery

    • D. 

      Unable to communicate basic needs and perform hygiene measures with left hand

  • 31. 
    What is the most reliable indicator of a change in neurologic status in a conscious patient?
    • A. 

      Pupil reaction

    • B. 

      Motor strength

    • C. 

      Cranial nerve abnormality

    • D. 

      Level of consciousness

  • 32. 
    Mr Toms aged 28 years was admitted the previous evening following a concussion while playing rugby. The RN asks you the following questions. What are the four qauick elements of a neurological check
    • A. 

      Orientation,memory, pupils, motor strength

    • B. 

      Short-term memory, pupils, cranial nerves, vital signs

    • C. 

      Consciousness, cranial nerves, motor response, pupils

    • D. 

      Arousal, gag reflex, motor response, pupils

  • 33. 
    The Glasgow Coma Scale (GCS) is used to evaluate
    • A. 

      Level of consiousness

    • B. 

      Orientation

    • C. 

      Pupil responses

    • D. 

      Motor dysfunction

  • 34. 
    Hemianopsia (or hemianopia)
    • A. 

      Is associated with dysfunction of cranial nerve three

    • B. 

      Refers to the loss of right, left or bi-temporal peripheral vision

    • C. 

      Is associated with dysfunction of cranial nerve eight

    • D. 

      Refers to the loss of vestibular function

  • 35. 
    Having the client/patient stand with feet together and eyes closed is a test of
    • A. 

      Cerebellar function

    • B. 

      Paresthesia

    • C. 

      Superficial reflexes

    • D. 

      The trochlear nerve

  • 36. 
    James Feld, aged 67 years, experienced a cerebrovasuclar accident (CBA). He is able to answer yes or no to simple questions, but has difficulty speaking.  His words are difficult to understand, although he continues to make efforts to speak. Mr Feld is most likely experiencing
    • A. 

      Willis or paraphasia

    • B. 

      Global aphasia

    • C. 

      Wernicke's or receptive aphasia

    • D. 

      Broca's, or motor aphasia

  • 37. 
    A person should he able to maintain his/her balance when standing on one foot for
    • A. 

      5 seconds on either side

    • B. 

      10 seconds on either side

    • C. 

      An equal length of time on each side

    • D. 

      5 seconds on either side and touching one's nose

  • 38. 
    Where does the hearts electrical stimulus originate from?
    • A. 

      Sino-atrial node(SA)node

    • B. 

      Bundle of His

    • C. 

      Right bundle branch

    • D. 

      Purkinje fibres

  • 39. 
    What does the T wave represent
    • A. 

      Ventricular depolarisation

    • B. 

      Atrial repolarisation

    • C. 

      Ventricular repolarisation

    • D. 

      Atrial and ventricular repolarisation

  • 40. 
    Normal duration of the PR interval is
    • A. 

      3-5 small squares (0.12-0.20 seconds)

    • B. 

      7-8 small squares (0.28-0.32 seconds)

    • C. 

      6 small squares (0.24 seconds)

    • D. 

      1-2 small squares (0.04-0.08 seconds)

  • 41. 
    What does the QRS represent?
    • A. 

      Depolarisation of the ventricles

    • B. 

      Depolarisation of the Purkinje fibres

    • C. 

      Depolarisation of the atria septum

    • D. 

      Repolarisation of the atria

  • 42. 
    Which blood type is the "universal donor"
    • A. 

      O +

    • B. 

      O -

    • C. 

      AB+

    • D. 

      A -

  • 43. 
    Factors affecting flow rate of the IV are a) phlebitis b) height of container c) postional IV d) air trapped in tubing
    • A. 

      A, b

    • B. 

      A, b, c

    • C. 

      A,b,c,d

    • D. 

      A,c,d

  • 44. 
    Hypotonic is a term which means that a solution has
    • A. 

      A higher osmotic pressure than the blood

    • B. 

      A lower osmotic pressure than the blood

    • C. 

      The same osmotic presure as blood

    • D. 

      Ability to carry oxygen to cells

  • 45. 
    When evaluating the laboratory results for a patient with increased secretion of the anterior pituitary hormones, the nurse would expect to find
    • A. 

      Decreased serum thyroxine levels.

    • B. 

      Elevated serum aldosterone levels.

    • C. 

      An increase in urinary free cortisol.

    • D. 

      Low urinary excretion of catecholamines.

  • 46. 
    When the nurse is obtaining the health history, which statement by a patient indicates further assessment of thyroid function may be necessary?
    • A. 

      “I notice my breasts are tender lately.”

    • B. 

      “I am so thirsty that I drink all day long.”

    • C. 

      “I get up several times at night to urinate.”

    • D. 

      “I feel a lump in my throat when I swallow.”

  • 47. 
    A patient is admitted with a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test?
    • A. 

      Urinary 17-ketosteroids

    • B. 

      Antidiuretic hormone level

    • C. 

      Growth hormone stimulation test

    • D. 

      Adrenocorticotropic hormone level

  • 48. 
    The nurse is interviewing a patient who has a possible thyroid disorder. Which question will provide the most useful information?
    • A. 

      “What methods do you use to help cope with stress?”

    • B. 

      “Have you experienced any blurring or double vision?”

    • C. 

      “Do you have to get up at night to empty your bladder?”

    • D. 

      “Have you had any recent unplanned weight gain or loss?”

  • 49. 
    When a patient in the outpatient clinic has an order for blood cortisol testing, which instruction will the nurse provide for the patient?
    • A. 

      “Avoid adding any salt to your foods for 24 hours before the test.”

    • B. 

      “You will need to lie down for 30 minutes before the blood is drawn.”

    • C. 

      “Come to the laboratory to have the blood drawn early in the morning.”

    • D. 

      “Do not have anything to eat or drink before the blood test is obtained.”

  • 50. 
    A patient has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for
    • A. 

      Calcitonin levels.

    • B. 

      Catecholamine levels.

    • C. 

      Thyroid hormone levels.

    • D. 

      Parathyroid hormone levels.

  • 51. 
    During a physical examination, the nurse finds that a patient’s thyroid gland cannot be palpated. The most appropriate action by the nurse is to
    • A. 

      Palpate the patient’s neck more deeply.

    • B. 

      Document that the thyroid was nonpalpable.

    • C. 

      Notify the health care provider immediately.

    • D. 

      Teach the patient about thyroid hormone testing.

  • 52. 
    When a patient has clinical manifestations of hypothyroidism, which laboratory value should the nurse review to determine whether the hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland?
    • A. 

      Thyroxine (T4) level

    • B. 

      Triiodothyronine (T3) level

    • C. 

      Thyroid-stimulating hormone (TSH) level

    • D. 

      Thyrotropin-releasing hormone (TRH) level

  • 53. 
    When working with a patient who has diabetes mellitus, the nurse reviews the results of testing for glycosylated hemoglobin (HbA1C) to evaluate for
    • A. 

      Glucose levels 2 hours after a meal.

    • B. 

      Circulating, nonfasting glucose levels.

    • C. 

      Glucose control over the past 3 months.

    • D. 

      Hypoglycemic episodes in the past 90 days.

  • 54. 
    When a patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, the nurse will monitor for
    • A. 

      Decreased urinary output.

    • B. 

      Evidence of fluid overload.

    • C. 

      Increased serum sodium levels.

    • D. 

      Elevated serum potassium levels.

  • 55. 
    The nurse will plan patient care that will decrease the patient’s physical and emotional stress when the patient is undergoing
    • A. 

      A water deprivation test.

    • B. 

      Testing for serum T3 and T4 levels.

    • C. 

      A 24-hour urine test for free cortisol. .

    • D. 

      A radioactive iodine (I-131) uptake test

  • 56. 
    When reviewing the laboratory results for a patient’s total calcium level, which information will the nurse need to consider?
    • A. 

      The blood glucose is elevated.

    • B. 

      The phosphate level is normal.

    • C. 

      The serum albumin level is low.

    • D. 

      The magnesium level is normal.

  • 57. 
     When the nurse is caring for a patient who was admitted with tetany, which laboratory value should be monitored?
    • A. 

      Total protein

    • B. 

      Blood glucose

    • C. 

      Ionized calcium

    • D. 

      Serum phosphate

  • 58. 
    Which information about a patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test?
    • A. 

      The patient reports having occasional orthostatic dizziness.

    • B. 

      The patient has had a 10-pound weight gain in the last month.

    • C. 

      The patient drank several glasses of water an hour previously.

    • D. 

      The patient takes oral corticosteroids for rheumatoid arthritis.

  • 59. 
    After the nurse manager at the endocrine clinic has completed the orientation of a new RN, which action by the new RN who is caring for a patient with a goiter and possible hyperthyroidism indicates the charge nurse needs to do more teaching?
    • A. 

      The RN palpates the neck to check thyroid size.

    • B. 

      The RN checks the blood pressure on both arms.

    • C. 

      The RN orders nonmedicated eye drops to lubricate the patient’s eyes.

    • D. 

      The RN lowers the thermostat to decrease the temperature in the room.

  • 60. 
    When caring for a patient having a water deprivation test, which finding is most important for the nurse to communicate to the health care provider?
    • A. 

      The patient complains of intense thirst.

    • B. 

      The patient has a 5-lb (2.3 kg) weight loss.

    • C. 

      The patient feels dizzy when sitting up on the edge of the bed.

    • D. 

      The patient’s urine osmolality does not change after antidiuretic hormone (ADH) is given.

  • 61. 
    A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is most important for the nurse to communicate to the health care provider before the test?
    • A. 

      Bilateral poor peripheral vision

    • B. 

      Allergies to iodine and shellfish

    • C. 

      Recent weight loss of 20 pounds

    • D. 

      Complaints of ongoing headaches

  • 62. 
     Please interpret the rhythm below.
    • A. 

      Sinus bradycardia

    • B. 

      Idioventricular rhythm

    • C. 

      Type II second degree AV block

    • D. 

      Third degree heartblock

  • 63. 
    The rhythm below is best described as:Please interpret the above rhythm.
    • A. 

      Normal sinus rhytnm

    • B. 

      Atrial fibrillation

    • C. 

      Ventricular fibrillation

    • D. 

      Atrial flutter

  • 64. 
    The rhythm below is best described as:
    • A. 

      Supraventricular tachycardia

    • B. 

      Ventricular fibrillation

    • C. 

      Normal sinus rhythm

    • D. 

      First degree heart block

  • 65. 
    The rhythm below is best described as:
    • A. 

      Ventricular fibrillation

    • B. 

      Pulseless electrical activity

    • C. 

      Asystole

    • D. 

      Idioventricular rhythm

  • 66. 
    The rhythm above is best described as:
    • A. 

      Sinus tachycardia

    • B. 

      Ventricular tachycardia

    • C. 

      Supraventricular tachycardia

    • D. 

      Ventricular tachycardia

  • 67. 
     Please interpret the rhythm below.
    • A. 

      Sinus bradycardia

    • B. 

      Idioventricular rhythm

    • C. 

      Type II second degree AV block

    • D. 

      Third degree heartblock

  • 68. 
    The rhythm below is best described as:Please interpret the above rhythm.
    • A. 

      Normal sinus rhytnm

    • B. 

      Atrial fibrillation

    • C. 

      Ventricular fibrillation

    • D. 

      Atrial flutter

  • 69. 
    Which of the following complications is thought to be the most common cause of appendicitis?
    • A. 

      A fecalith

    • B. 

      Bowel kinking

    • C. 

      Internal bowel occlusion

    • D. 

      Abdominal bowel swelling

  • 70. 
    A 13 year old boy is being seen in the ER for a possible appendicitis, what is an important nursing action to perform when preparing the patient for an appendectomy?
    • A. 

      Administer saline enemas to cleanse the bowels

    • B. 

      Apply heat to reduce pain

    • C. 

      Measure abdominal girth

    • D. 

      Continuously monitor pain

  • 71. 
    Which of the following would indicate that a patient's appendix has ruptured?
    • A. 

      Diaphoresis

    • B. 

      Anorexia

    • C. 

      Pain at Mc Burney's point

    • D. 

      Relief from pain

  • 72. 
    Which of the following is a priority nursing intervention that should be implemented to manage a client with appendicitis?
    • A. 

      Encouraging oral intake of clear fluids

    • B. 

      Providing discharge teaching

    • C. 

      Assessing for symptoms of peritonitis

    • D. 

      Administering Tylenol for an elevated temperature

  • 73. 
    A nurse is caring for a chemically dependent client since two days.  What basic needs have priority when working with chemically dependent clients?
    • A. 

      Hydration

    • B. 

      Nutrition

    • C. 

      Physical activity

    • D. 

      Habit change

  • 74. 
    The normal inflammatory response is not always a reliable indicator of disease in the older adult because:
    • A. 

      Aging changes heighten the older adult's pain perception

    • B. 

      Cardiovascular changes heighten the erythema that develops around the infection site

    • C. 

      Changes in the hypothalamus diminish the ability of th eolder adult to produce a fever

    • D. 

      Change in the hypothalamus grossly elevate temperature changes in the older adult

  • 75. 
    A 16 year old patient is admitted to the neurology floor after being involved in a motor vehicle accident (MVA).  His head hit the windshield, and he is being admitted for observation.  During the afternoon he begins to complain of a headache, had two episodes of vomiting, and is more difficult to arouse.  The initial nurisng intervention is to:
    • A. 

      Do nothing; he needs his rest

    • B. 

      Place him in a recumbent position, administer oxygen, and notify the physician immediately

    • C. 

      Prepare him for emergency surgery

    • D. 

      Assess his neurological status, elevate the head of the bed slightly, and notify the physician immediately

  • 76. 
    A nurse is caring for a patient who is receiving total parenteral nutrition (TPN).  Appropriate nursing interventions for this patient include:
    • A. 

      Weighing daily, monitoring blood glucose levels, and weaning TPN gradually

    • B. 

      Assessing for degree of hunger every shift

    • C. 

      Monitoring liver, renal, and cardiovascular function

    • D. 

      Weighing every week, monitoring for glycosuria, and discontinuing TPN on the third day

  • 77. 
    A patient with a diagnosis of myocardial infarction ha ben admitted to the coronary care unit.   The nurse assesses the patient's breath sounds and hears fine crackles in the lower lung bases.  This symptom may indicate:
    • A. 

      Pneumonia

    • B. 

      Arrhythmias

    • C. 

      Lung congestion from heart failure

    • D. 

      An extension of the myocardial infarction

  • 78. 
    A patient has shallow respirations at 8 to 10 times per minute.  This hypoventilation results in acidosis by:
    • A. 

      Retaining carbon dioxide (CO2)

    • B. 

      Excreting needed CO2

    • C. 

      Excreting O2

    • D. 

      Retaining too much O2

  • 79. 
    A client had a spontaneous vaginal delivery after 18 hours of labor.  Her excessive vaginal bleeding has now become a postpartum hemorrhage.  Immediate nursing care of this client should include which of the following interventions?
    • A. 

      Avoiding massaging the uterus

    • B. 

      Monitoring vital signs every hour

    • C. 

      Placing the client in Trendelenburg's position

    • D. 

      Elevating the head of the bed to increase blood flow

  • 80. 
    A client has a history of chronic renal failure and receives hemodialysis treatments three times a week thorugh an arteriovenous (AV) fistula in the left arm.  Which of the following interventions is included in this client's care?
    • A. 

      Keep the AV fistula site dry

    • B. 

      Keep the AV fistula wrapped in gauze

    • C. 

      Take the blood pressure in the left arm

    • D. 

      Assess the AV fistula for a bruit and thrill

  • 81. 
    A nurse is reviewing a patient’s medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct.
    • A. 

      Coumadin

    • B. 

      Celebrex

    • C. 

      Habitrol

    • D. 

      Finasteride

    • E. 

      Clofazimine

  • 82. 
    A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?
    • A. 

      Deep breathing techniques to increase O2 levels.

    • B. 

      Cough regularly and deeply to clear airway passages.

    • C. 

      Cough following bronchodilator utilization

    • D. 

      Decrease CO2 levels by increase oxygen take output during meals

  • 83. 
    A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?
    • A. 

      Streptokinase

    • B. 

      Atropine

    • C. 

      Acetaminophen

    • D. 

      Coumadin

  • 84. 
    A nurse is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?
    • A. 

      S. pneumonia

    • B. 

      H. influenza

    • C. 

      N. meningitis

    • D. 

      Cl. difficile

  • 85. 
    A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is.
    • A. 

      The life span of RBC is 45 days

    • B. 

      The life span of RBC is 60 days.

    • C. 

      The life span of RBC is 90 days.

    • D. 

      The life span of RBC is 120 days.

    • E. 

      RBC lasts for a person's lifetime

  • 86. 
    A nurse is reviewing a patient’s medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct.
    • A. 

      Coumadin

    • B. 

      Celebrex

    • C. 

      Habitrol

    • D. 

      Finasteride

    • E. 

      Clofazimine

  • 87. 
    A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration?
    • A. 

      Aspirin

    • B. 

      Levodopa

    • C. 

      Phenolphthalein

    • D. 

      Sulfasalazine

    • E. 

      None of the above.

  • 88. 
    A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
    • A. 

      IgA

    • B. 

      IgD

    • C. 

      IgE

    • D. 

      IgG

    • E. 

      None of the above.

  • 89. 
    A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
    • A. 

      Atherosclerosis

    • B. 

      Autonomic neuropathy

    • C. 

      Diabetic nephropathy

    • D. 

      Somatic neuropathy

    • E. 

      None of the above.

  • 90. 
    A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?
    • A. 

      Diverticulosis

    • B. 

      Hypercalcaemia

    • C. 

      Hypocalcaemia

    • D. 

      Irritable bowel syndrome

    • E. 

      None of the above

  • 91. 
    A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?
    • A. 

      A Guthrie test can check the necessary lab values.

    • B. 

      The urine has a high concentration of phenylpyruvic acid

    • C. 

      Mental deficits are often present with PKU.

    • D. 

      The effects of PKU are reversible.

  • 92. 
    A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?
    • A. 

      Deep breathing techniques to increase O2 levels.

    • B. 

      Cough regularly and deeply to clear airway passages.

    • C. 

      Cough following bronchodilator utilization

    • D. 

      Decrease CO2 levels by increase oxygen take output during meals

  • 93. 
    Possible age-related changes which may affect ventilation include select all that apply?
    • A. 

      Loss of elastic fibres in the lungs

    • B. 

      Clacification in the rub cartilage

    • C. 

      Reduced ciliary activity

    • D. 

      Hair on chest

    • E. 

      Anterior to posterior ratio 2:1

  • 94. 
    Increases in the resting pulse rate are associated with all of the following select all that apply?
    • A. 

      Infection and fever

    • B. 

      Decreases in blood pressure secondary to shock

    • C. 

      Sympathomimetic drugs

    • D. 

      Parasympathetic nervous system stimulation

    • E. 

      Moving bowel

  • 95. 
    A client is having an ECG to evaluate an atrial dysrhythmia.  To evaluate the atrial depolarization and contraction, the nurse will focus on the client's
    • A. 

      PR interval

    • B. 

      ST segment

    • C. 

      P wave

    • D. 

      QRS complex

  • 96. 
    When taking a bp which of the following is correct for the nurse to know select all that apply?
    • A. 

      Inflate the cuff 30mmHg above the point at which the radial or brachial pulse disappeared on palpation

    • B. 

      Remember that a systolic of 100 plus age in years is normal

    • C. 

      When using a mercury sphygmomanometer, view the meniscus at eye level

    • D. 

      Support the patients arm at heart level

  • 97. 
    Assessment of the neurogoic system includes the following areas select all that apply?
    • A. 

      Sensory and motor function, and reflexes

    • B. 

      Mental and emotional status

    • C. 

      Cranial nerve assessment

    • D. 

      Radial pulse

    • E. 

      PERRLA

  • 98. 
    When collecting subjective data froma person during a neurological assessment, ?
    • A. 

      Headaches

    • B. 

      Tingling or numbness

    • C. 

      Diffiulty swallowing

    • D. 

      PERRLA

  • 99. 
    An electrocardiogram (ECG) is ordered for Jack who is complaining of chest pain.  An early finding in the lead over an infarction area would be
    • A. 

      Disappearance of Q waves

    • B. 

      Flattened T waves

    • C. 

      Absence of P waves

    • D. 

      Elevated ST segments

  • 100. 
    Which of the folloing are the most common problem with IV therapy
    • A. 

      Catheter is out of place

    • B. 

      Patient refueses to cooperate

    • C. 

      Site is red, sore or swollen

    • D. 

      Children are ok with IV's

  • 101. 
    IV tubing must be changed every 72 hours
    • A. 

      True

    • B. 

      False

  • 102. 
    After placing client on the monitor you see this rhythm and feel no pulse that is your first acting?
    • A. 

      CPR

    • B. 

      Defibulation

    • C. 

      Epinephrine 1:10,000 1mg IV

    • D. 

      Assess the airway

  • 103. 
    The patient tell you that he is not felling well what is your first nursing acting if you see this on the monitor?
    • A. 

      Start CPR

    • B. 

      Call Code Blue

    • C. 

      Check the leads

    • D. 

      Check pulse

  • 104. 
    What drug will you question the doctor if he orders for this patients? select all that apply?The rhythm above is best described as: 
    • A. 

      Adenocard

    • B. 

      Atenolol

    • C. 

      Atropine

    • D. 

      Adenoline

  • 105. 
    Chronic lymphocytic leukemia is most common leukemia in what age group?
    • A. 

      Young adults

    • B. 

      Older adults

    • C. 

      Children

    • D. 

      Infants

  • 106. 
    A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration?
    • A. 

      Aspirin

    • B. 

      Levodopa

    • C. 

      Phenolphthalein

    • D. 

      Sulfasalazine

  • 107. 
    A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
    • A. 

      IgA

    • B. 

      IgD

    • C. 

      IgE

    • D. 

      IgG

  • 108. 
    A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
    • A. 

      Atherosclerosis

    • B. 

      Autonomic neuropathy

    • C. 

      Diabetic nephropathy

    • D. 

      Somatic neuropathy

  • 109. 
    A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?
    • A. 

      A Guthrie test can check the necessary lab values.

    • B. 

      The urine has a high concentration of phenylpyruvic acid

    • C. 

      Mental deficits are often present with PKU.

    • D. 

      The effects of PKU are reversible.

  • 110. 
    A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?
    • A. 

      Streptokinase

    • B. 

      Atropine

    • C. 

      Acetaminophen

    • D. 

      Coumadin

  • 111. 
    A nurse is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?
    • A. 

      S. pneumonia

    • B. 

      H. influenza

    • C. 

      N. meningitis

    • D. 

      Cl. difficile

  • 112. 
    A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is.
    • A. 

      The life span of RBC is 45 days

    • B. 

      The life span of RBC is 60 days.

    • C. 

      The life span of RBC is 90 days.

    • D. 

      The life span of RBC is 120 days.