Nsg 323 Final Practice Test

Meeting the patients physiologic and safety needs is the priority. Physical care focuses on the need for oxygen, nutrition, pain relied, mobility, elimination, and skin care. The pt is not experiencing oxygenation problems; the priority is to treat the severe pain with pain medication.

A potassium level of 2.1 indicates severe hypokalemia (low potassium levels). Lasix (furosemide) is a loop diuretic that can cause potassium loss. Therefore, the patient will most likely be switched to Spironolactone, which is a potassium-sparing diuretic. Spironolactone helps to retain potassium in the body and can help correct the low potassium levels caused by Lasix. Hydrochlorothiazide and bumetanide are also diuretics but are not potassium-sparing like Spironolactone.

Only a biopsy is a definitive means of diagnosing cancer because it actually identifies the pathological cells.

The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.

The scientific rationale for conducting a spiritual care assessment is that spirituality provides a sense of meaning and purpose for many clients. This means that understanding and addressing a client's spiritual needs can contribute to their overall well-being and quality of life. It recognizes the importance of spirituality in the holistic care of individuals, acknowledging that it can play a significant role in their physical, emotional, and psychological well-being.

The correct answer is "Tumor, Node, Metastasis." The TNM system is used for staging and grading neoplasms, which refers to the extent and spread of cancer in the body. "Tumor" refers to the size and invasiveness of the primary tumor, "Node" refers to the involvement of nearby lymph nodes, and "Metastasis" refers to the presence of cancer cells in distant organs or tissues. This system helps in determining the prognosis and guiding treatment decisions for cancer patients.

The correct answer is to hold the dose of Lasix and notify the doctor for further orders. Diarrhea can lead to fluid and electrolyte imbalances, including low potassium levels. Lasix is a diuretic that can further decrease potassium levels. Therefore, it is important to hold the dose and notify the doctor to assess the patient's condition and determine if any adjustments need to be made to the medication regimen.

Stable angina occurs during activities but goes away when the patient rests. Variant and Prinzmetal angina are the same and occur at rest during cycles. Unstable angina is chest pain felt during rest and is more severe.

If a patient's chest pain is not relieved with 3 doses of Nitroglycerin, taken 5 minutes apart, they should call 911 immediately. The patient should never exceed more than 3 doses of Nitroglycerin or take 2 doses at one time.

Frequently silence is related to the overwhelming feelings experienced at the end of life. Silence can also allow time to gather thoughts. Listening to the silence sends a message of acceptance and comfort.

The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient’s needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.

T1 means that the tumor is increasing in size to about 2 cm, and that no regional lymph nodes are present in the brain. M0 means no distant metastasis has occurred.

Option C: Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren’t detectable in people without cardiac injury.

When monitoring cellulitis, marking the initial border and monitoring change is the appropriate assessment to use. Cellulitis is a bacterial skin infection that can spread rapidly, so it is important to track the progression of the infection. By marking the initial border and monitoring any changes, such as increased redness, swelling, or spreading of the infection, healthcare providers can assess the effectiveness of treatment and determine if further intervention is necessary. Monitoring drainage amount or color on dressing and assessing pain may provide additional information, but they are not specific to monitoring cellulitis.

An increase in three areas: thirst, intake of fluids, and hunger are considered the primary manifestations of Diabetes Type I. These symptoms are indicative of excessive glucose levels in the blood, which leads to increased thirst and fluid intake to try and dilute the glucose. The increased hunger is a result of the body's inability to properly use glucose for energy. These symptoms would require follow-up investigation to confirm a diagnosis of Diabetes Type I.

The nurse should teach the patient to monitor their heart rate. This is important because the pacemaker is responsible for regulating the patient's heart rate. By monitoring their heart rate, the patient can ensure that the pacemaker is functioning properly and that their heart is beating at a normal rate. This can help in identifying any potential issues or abnormalities with the pacemaker or the patient's heart rhythm.

Frequent swallowing after a tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are not unusual in a 3-year old after surgery

Talk to the child in a warm, soothing tone to provide sensory stimulation.
A, B, D: All these options are correct interventions for a child who has failure to thrive.

To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

Safety is always priority.

An AD lets you participate in decisions about your health care. This statement is the most appropriate response because it accurately explains the purpose of an advanced directive. It emphasizes the client's autonomy and their ability to have a say in their own healthcare decisions. It also highlights the importance of the client's involvement in their own care planning process.

A 39 year old female with asthma is not a candidate for a beta blocker medication because beta blockers can cause bronchoconstriction and worsen symptoms in patients with asthma.

Outbreaks of infectious meningitis are most likely to occur in dense community groups such as college campuses, jails, and military installations.

A potassium level of 2.0 is considered critically low (normal range is 3.5-5.0 mEq/L). To correct this deficiency, the most appropriate and effective method would be to administer potassium intravenously through an infusion. This allows for a controlled and gradual increase in potassium levels, ensuring patient safety and preventing complications associated with rapid administration. Oral supplements may not be effective in cases of severe deficiency, and intramuscular injections may not provide the immediate correction needed.

The grief experience for the caregiver of the patient with a chronic illness often begins long before the death. This is called anticipatory grief. Acceptance of the expected loss is associated with more positive outcomes.

Options A, B, and D are all risks for developing endocarditis. Remember that any thing that allows entry of bacteria into the system can potentially cause endocarditis. Option C is not relevant.

Rheumatoid fever results from improperly treated group beta-hemolytic streptococcal infections, usually pharyngitis. Therefore, prompt treatment of streptococcal throat infections with an antibiotic is a key preventive measure.

This client has thrombocytopenia which is a common s/e of chemotherapy. This increases the clients risk for prolonged bleeding in response to even minor injury.

The nurse should interpret that the A1C result of 8.1% is above the recommended levels. A1C is a test that measures the average blood sugar levels over the past 2-3 months. For individuals with type 1 diabetes, the target A1C level is usually below 7%. Therefore, a result of 8.1% indicates that the client's blood sugar levels have been consistently higher than the recommended range. This may indicate poor glycemic control and the need for adjustments in the client's diabetes management plan.

The initial treatment for a newly diagnosed patient with Type 2 diabetes is usually a diet and exercise regime. This is because lifestyle modifications, such as healthy eating and regular physical activity, can help improve blood sugar control and reduce the need for medication. It is important to promote weight loss and a healthy lifestyle as the first step in managing Type 2 diabetes. Medications like Metformin or insulin may be added later if lifestyle changes alone are not sufficient to control blood sugar levels.

Hospice care focuses on holistic care of patients actively dying or not expected to improve. It helps patients face death with dignity and comfort. Euthanasia refers to the deliberate ending of a life. Palliative care is aggressively planned care that manages symptoms of patients whose disease process no longer responds to treatment. Aggressive medical treatment is aimed at stopping the disease process.

The only thing the RN can do id the care needed is maintenance and assistance with ADLs is suggest a HHA if the family can afford it, or teach the family how to help the client.

An infant with cleft palate would have difficulty in feeding despite stimulation for sucking.

The femoral or radial artery is used during a heart cath...not the brachial.

The given values indicate a pH level below the normal range (7.35-7.45), which suggests acidosis. The elevated PaCO2 (partial pressure of carbon dioxide) of 48 indicates respiratory acidosis, as an increase in PaCO2 leads to an increase in carbonic acid and a decrease in pH. The HCO3- (bicarbonate) level of 36 is within the normal range (22-28), ruling out metabolic acidosis. Therefore, the correct answer is respiratory acidosis.

Open-angle glaucoma causes painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. Blacks have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened.

Spoon-shaped nails, also known as koilonychia, are a classic sign of iron-deficiency anemia. In this condition, the nails become thin and concave, resembling a spoon. This occurs due to a decrease in the production of hemoglobin, which is responsible for carrying oxygen to the nails. Therefore, the presence of spoon-shaped nails suggests that the patient's iron-deficiency anemia is causing this abnormal nail shape.

Exposure to multiple mechanisms and sites of action will destroy more sub-populations of cells.

The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.

c.) is correct because it reflects the greatest risk or complication of thrombi or emboli that occurs with long-term atrial fibrillation. Coumadin is often given prophylactically to prevent stroke, clots, or emboli from developing when hospitalizing a patient with long-term atrial fibrillation.

Persistent cough, crackles (also called rales), and orthopnea are signs and symptoms of LEFT-sided heart failure...not right-sided heart failure.

Left= Lungs Right = Body

Answer: D. To decrease oxygen demand on the client’s heart

Option D: Morphine is administered because it decreases myocardial oxygen demand.
Options A, B, and C: Morphine will also decrease pain and anxiety while causing sedation, but isn’t primarily given for those reasons.

The correct answer is to go to the client's room and assess the client for hypoglycemia. This is the first intervention the nurse should implement because the client's symptoms of a headache and acting "funny" could be signs of hypoglycemia, which is a potential complication of receiving fast-acting insulin. Assessing the client's condition will help determine if their symptoms are due to low blood glucose levels and if immediate treatment is needed. Obtaining blood glucose, having the patient drink orange juice, and preparing to administer dextrose may be necessary interventions, but assessing the client's condition is the priority.

Remember risk factors for developing CAD include: smoking, family history, diabetes, being overweight or obese, and high cholesterol.

Inhaled beta-adrenergic agents, I.V. corticosteroids, and supplemental oxygen are used to reduce bronchospasm, improve oxygenation, and avoid intubation. Determining the trigger for the client’s attack and improving exercise tolerance are later goals. Typically, secretions aren’t a problem in status asthmaticus.

A health care provider's order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient's request but does not have the authority to place the DNR order in the care plan.

To help alleviate the RBCs from clumping together and sickling, oxygen and hydration are priority. In addition, pain needs to be addressed. Opioid medication is the best on a scheduled basis rather than PRN (as needed). Avoid keeping patient NPO unless needed (remember patient needs hydration). Avoid cold compresses (can lead to more sickling) but instead use warm compresses. The patient will need FOLIC ACID supplements to help with RBC creation rather than iron (iron can actually build up in the body and collect in the organs in patients with sickle cell disease). Patients definitely need to be on bedrest, and restrictive clothing or objects (blood pressure cuff etc.) should be removed to help blood flow.

Radiation therapy that is directed in or around the oral cavity has a variety of actions that increase the risk for dental cavities and tooth decay. The salivary glands are affected, which changes the composition of the person's saliva and often causes "dry mouth."

The given pH value of 7.6 indicates alkalosis, which means the blood is more basic than normal. The elevated HCO3- level of 38 suggests a primary metabolic alkalosis. The PaCO2 level of 53 is not consistent with respiratory acidosis, as it would be expected to be elevated in that case. Therefore, the most appropriate explanation for the given values is metabolic alkalosis.

pilocarpine is a miotic and it constrict pupils facilitates outflow of aqueous humor. Atropine dilates the pupil and decreases intraocular pressure by decreasing the secretion of aqueous humor, causing further increase of IOP. Lasix is a loop diuretic. Urokinase is a thrombolytic agent.