NR 226 - exam 2 test taking review questions.

NR 226: EXAM 2 REVIEW QUESTIONS 1. A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult? a. Intake and out ...

NR 226: EXAM 2 REVIEW QUESTIONS 1. A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult? a. Intake and output results b. Serum laboratory values c. Condition of the skin d. Presence of tenting 2. A nurse is caring for a patient with an intestinal stoma. Which intervention is most important? a. Cleansing the stoma with cool water b. Spraying an air-freshening deodorant in the room c. Selecting a bag with an appropriate-size stomal opening d. Wearing sterile nonlatex gloves when caring for the stoma 3. A nurse is caring for a patient who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis (DVT)? a. Utilization of compression stockings at night b. Deep breathing and coughing daily c. Leg exercises 10 times per hour when awake d. Elevation of the legs on 2 pillows 4. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis 5. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? a. Respiratory acidosis from inadequate ventilation b. Respiratory alkalosis from anxiety and hyperventilation c. Metabolic acidosis from calcium loss due to broken bones d. Metabolic alkalosis from taking analgesics containing base products 6. A patient is experiencing diarrhea and needs to replace potassium. Which nutrients selected by the patient indicate that additional teaching is necessary regarding nutrients high in potassium. Select all that apply. a. Beef boullion b. Orange juice c. Poached egg d. Warm tea e. avocado 7. A 750-mL tap-water enema is ordered for a patient. Which should the nurse do to best promote acceptance of the volume ordered? a. Administer the fluid slowly, and have the patient take shallow breaths b. Place the patient in the left lateral position, and slowly administer the fluid c. Have the patient take shallow breaths, and keep the fluid at body temperature d. Keep the fluid at body temperature, and place the patient in the left lateral position 8. A nurse collected information from several patients. Which information indicates the patient who has the highest risk for developing diarrhea? a. Is physically active b. Drinks a lot of fluid c. Eats whole-grain bread d. Is experiencing emotional problems 9. Sequential compression devices (SCD), are ordered for a postoperative patient. The patient asks the nurse, “Why do I have to wear these things? Which information should the nurse include in the response to the patient’s question? Select all that apply. a. Keeps the lower extremities warm b. Helps prevent deep vein thrombosis c. Accelerates the rate of wound healing d. Promotes circulation of blood back to the heart e. Eliminates the need for leg and foot exercises after surgery 10. A patient is admitted to the post anesthesia care unit (PACU) after abdominal surgery. The patient’s vital signs are blood pressure 150/90 mm Hg, pulse 88 and bounding, respirations 24 with some crackles. Which response does the nurse conclude that the patient most likely is experiencing? a. Hypoglycemia b. Hyponatremia c. Hyperkalemia d. Hypervolemia 11. A newly admitted patient reports not having had a good bowel movement in 10 days. Which questions should the nurse ask the patient to identify the possibility of fecal impaction? Select all that apply. a. “How long has it been since you had a formed stool?” b. “have you had small amounts of liquid stool?” c. “do you notice a bad odor to your breath?” d. “have you been eating food with fiber?” e. “are you having any vomiting?” 12. A nurse is caring for a postoperative client who suddenly becomes restless. The nurse should take which most appropriate action? a. Notify the physician b. Medicate the patient for pain c. Check the client’s vital signs d. Talk to the client in a calm voice 13. A client scheduled for an operative procedure states to the nurse, “I am not sure if I should have this surgery”. Which response should the nurse make to the client? a. “It is your decision” b. “Do not worry. Everything will be fine” c. “Why do you not want to have this surgery?” d. “Tell me what concerns you have about the surgery” 14. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? a. Eating more protein is optimal prior to testing b. Patient can take all of their scheduled medications, including aspirin, before obtaining specimen c. A red color change indicates a positive test d. The specimen cannot be contaminated with urine 15. A nurse is assessing a client who had diarrhea for 4 days. Which of the following findings should the nurse expect? Select all that apply a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema 16. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and “not feeling well”. The nurse notes warmth, edema, redness and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? a. Obtain a specimen for culture b. Apply a warm compress c. Administer analgesics d. Discontinue the infusion 17. The nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should not expect which of the following findings? Select all that apply. a. Flat neck veins b. Thready pulse c. syncope d. dark urine e. postural hypotension 18. A nurse is receiving a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? a. Starting an IV infusion of 0.9% sodium chloride b. Consulting with the dietician to increase intake of potassium c. Initiating continuous cardiac monitoring d. Preparing the patient for gastric lavage 19. A nurse is collecting data from a client who has a calcium level of 10.8 mEq/L. Which of the following findings should the nurse expect? Select all that apply a. Hyperreflexia b. Muscle weakness c. Positive Chvosktek’s sign d. Muscle cramps e. Kidney stones