NUR 401 Practice Exam | Questions and Answers (Complete Solutions)

NUR 401 Practice Exam | Questions and Answers (Complete Solutions) When caring for a client who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. Art ...

NUR 401 Practice Exam | Questions and Answers (Complete Solutions) When caring for a client who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. Arterial oxygen saturation 90% b. Apical pulse 110 beats/min c. Blood pressure 88/56 mm Hg d. Urinary output 15 mL for 2 hours A client is recovering from a cystoscopy. The nurse would expect to assess which of the following regarding the client's urine after the procedure? a. Hematuria b. Blood clots c. Pink-tinged d. Anuria Explanation: The bladder and urethra are usually irritated as a result of the procedure. This causes pink-tinged urine. Large amounts of blood in the urine, anuria, or blood clots are not expected findings after this procedure. A client with congestive heart failure and pulmonary edema develops early symptoms of acute renal failure (ARF). The nurse plans care for the client based on the knowledge that collaborative care of the renal failure will be directed towards which of the following goals? a. Diluting nephrotoxic substances b. Replacing fluid volume c. Promoting diuresis d. Maintaining cardiac output Rationale: The primary goal of treatment for ARF is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing ARF, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct. Which of the following is the proper positioning for a client experiencing hypovolemic shock? a. Trendelenburg b. Reverse Trendelenburg c. Supine with head on a pillow d. Supine with feet elevated During discharge teaching for the client with sickle cell anemia, which of the following precipitating factors for sickle cell crisis should the nurse instruct the client to avoid? a. Exposure to crowds b. Limiting fluids to 2 L per day c. Excessive dietary iron intake d. Caffeine and alcohol intake Rationale: Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. A client with chronic lymphocytic leukemia is hospitalized for the treatment of severe hemolytic anemia. Which of the following is an appropriate nursing intervention for the client? a. Plan care to alternate periods of rest and activity. b. Isolate the client from visitors and other clients. c. Encourage increased intake of fluid and fibre in the diet. d. Provide a diet high in vitamin K and folic acid. Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. High vitamin K diets might be used for a patient with a bleeding disorder. There is no indication that the patient is neutropenic, so isolation is not needed. Increased intake of fluid and fiber will not improve the anemia. A client is scheduled for a fistula creation due to end-stage renal disease. The nurse would include which of the following in teaching the client about the fistula? a. A vein and an artery will be attached surgically. b. The fistula can be used 2 to 4 weeks after the surgery for dialysis treatment. c. The arm should be immobilized for 4 to 6 weeks. d. One needle will be inserted for each dialysis treatment. A 12 years old is admitted to the emergency department after being stung by a bee. The client's mother tells the nurse that her son has an allergy to bees and he has been stung before. In what order of priority will the nurse address the complications? 1. Airway swelling 2. Hypotension 3. Tachypnea 4. Tachycardia a. 2, 4, 1, 3 b. 1, 2, 3, 4 c. 1, 3 ,2, 4 d. 3, 1, 2, 4 A client with multiple trauma is brought to the emergency department. The nurse initiates two peripheral intravenous (IV) sites and begins fluid resuscitation with which of the following fluids? a. Dextran b. 3.0% saline c. Dextrose 5% in water in one-half normal saline d. 0.9% saline Fluid resuscitation is accomplished by using normal saline, that is, 0.9% saline. A client asks the nurse what effect dialysis will have on the medications he is currently taking. What is the nurse's best response? a. Dangerously low blood pressure may occur if antihypertensives are taken before dialysis b. Once-daily medications are best taken before dialysis treatments c. Dialysis treatments remove all medications from the blood. d. Medications are not removed during dialysis treatments a. Dangerously low blood pressure may occur if antihypertensives are taken before dialysis Once daily medications should be taken after dialysis if possible, dialysis treatments don't remove all medications from the blood, and some medications are removed during dialysis. Which of the following nursing interventions will be included for a client experiencing an acute sickle cell crisis? a. Administration of platelets & monitoring vitals b. Heparin therapy & iron replacement c. Blood transfusion & monitoring of CBC d. Administration of oxygen & pain management They don't need platelets, just RBCs are affected, could use heparin to dissolve possible clots from sickled cells but iron isn't needed so this rules out option B, blood transfusions doesn't make sense, they do need oxygen and pain management so D is most correct. A client is diagnosed with acute kidney failure. He is complaining of nausea, pain in the abdomen, diarrhea, and muscular weakness. Also, the nurse notes an irregularity in pulse. Based on these findings, which imbalance is this indicative of? a. Hyponatremia b. Hypercalcemia c. Hyperkalemia d. Hypouricemia the other ones don't make sense, definitely not C or D, and hyponatremia doesn't cause muscle weakness Taking into consideration Canadian national statistics, which of the following clients has the highest risk factors present for spinal cord injury? a. An 65 year old man being discharged home after having his hip replaced, that Has a prescription for corticosteroids and pain medications b. A 32 year old woman who receives dialysis three times per week, who likes to play hockey on the weekend c. A 10 year old female diagnosed with diabetes, who enjoys riding her bicycle d. A 19 year old male who has a history of asthma, that tells you about his new car that his grandparents bought for him as a graduation present A client is diagnosed with stage 3 chronic kidney disease (CKD). The client is treated with conservative management, including erythropoietin injections. After teaching the client about management of CKD, the nurse determines that teaching has been effective when the client states which of the following? a. "I need to take the erythropoietin to boost my immune system and help prevent infection." b. "I will try to increase my intake of fruits and vegetables." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to try to get more protein from dairy products." Rationale: The patient with CKD who is not receiving dialysis is generally taught to restrict fluids. The patient would need to measure urine output and then add 600 ml for insensible losses to calculate an appropriate oral intake. Erythropoietin is given to increase red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD. In preparation for hemodialysis, a client has an arteriovenous native fistula created in the left forearm. To assess and maintain the patency of the fistula postoperatively, what should the nurse do? a. Irrigate the fistula site daily with low-dose heparin. b. Assess the blood pressure in the affected arm. c. Auscultate the fistula site for a bruit. d. Assess the rate and quality of the radial pulse. The nurse is preparing to administer a unit of blood to a client who is anemic. What is the maximum safe administration time? a. 6 hours b. 1 hour c. 2 hours d. 4 hours Which of the following assessment findings would the nurse expect in the client with a lower urinary tract infection (UTI)? a. Dysuria b. Flank pain c. Nausea d. Oliguria When the nurse discusses foods high in iron with a client who has iron- deficiency anemia, the client tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. It is an appropriate goal for the client to increase dietary intake of which of the following? a. Nuts and cornmeal b. Eggs and fish c. Milk and milk products d. Legumes and dried fruit Legumes and dried fruits are high in iron and low in fat and cholesterol. A 21-year-old client is having a sickle cell crisis for the first time in many years. He asks the nurse why the sickling causes such pain. The nurse should explain that the pain of sickling is caused by which of the following? a. Deposition of sickled red cells in the bone marrow b. Tissue hypoxia caused by small blood vessel occlusion c. Bacterial or viral infections of organs that caused the sickling d. Spasms of the blood cells as they change shape A client is experiencing bladder spasms after a transurethral resection of the prostate (TURP). The client has a continuous bladder irrigation (CBI) system in situ. The nurse should do which of the following? a. Discontinue the urinary catheter b. Notify the urologist c. Administer an antispasmodic medication as ordered d. Apply a cold compress to the pubic area Rupi's ppt says "Bladder spasms can occur (may administer anti-spasmodic meds and for pain - analgesics)" only contact dr if you see hematuria During discharge teaching for a client with sickle cell anemia, the nurse asks the client about possible precipitating factors for sickling crisis. Which of the following does the nurse include in her teaching plan for the client to avoid? a. Caffeine b. Sugar & gluten c. Strenuous exercise & dehydration d. Exposure to cold The nurse has instructed a client who is receiving hemodialysis about dietary management. Which diet choice by the client indicates that the teaching has been successful? a. Cheese sandwich, tomato soup, and cranberry juice b. Oatmeal with cream, half a banana, and herbal tea c. Split-pea soup, whole-wheat toast, and nonfat milk d. Scrambled eggs, English muffin, and apple juice Rationale: Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate. A 77 year old client has been admitted with a hemorrhagic stroke. Which of the following drug order should the nurse question? a. Methyldopa b. Dexamethasone c. Phenytoin d. Heparin The nurse is planning care for a client who has sustained a spinal cord injury 24 hours ago. Which of the following nursing assessments requires a priority intervention? a. Hypotension, bradycardia, and venous pooling in the extremities b. Level of consciousness, tachycardia, and decreased sensation in all four limbs c. Hypothermia, frequent coughing, and decreased bowel sounds in the LLQ d. Fever, hypertension, complaints of pain and weakness in the client's fingers An elderly client is diagnosed with a urinary tract infection. Which of the following will the nurse most likely assess in this client? a. Poor eating habits b. Vomiting c. Jaundice d. Change in mental status Explanation: The elderly tend to have symptoms of fever or hypothermia, poor appetite, lethargy, and a change in mental status. Newborns demonstrate jaundice. Infants can experience vomiting. Children tend to have poor eating habits A dialysis client has serum potassium of 6.2 mEq/L. Which of the following substances will likely be ordered? a. Kayelxalate b. Lasix c. Potassium Chloride d. Spironolactone A client is diagnosed with a hypoproliferative anemia. The nurse is aware that this type of anemia is attributable to which pathophysiologic process? a. Abnormality of RBCs b. Lack of production of RBCs c. Loss of RBCs d. Injury to the RBCs in circulation The nurse is providing health teaching to a client diagnosed with thrombocytopenia regarding the use of Aspirin. What will the nurse explain to the client as the reason for not taking Aspirin? a. This may contribute to the destruction of thrombocytes b. This can interfere with platelet aggregation c. This may lead to a masking of the fever often associated with thrombocytopenia d. This can change the brain's homeostatic blood flow mechanism Which of the following is the most common complication of Sickle Cell Disease (SCD)? a. Pneumonia b. Pulmonary hypotension c. Chronic renal failure d. Delayed clotting of blood A 52-year-old client has pernicious anemia with long-standing weakness and paresthesia of the feet and hands. The nurse determines that expected outcomes related to knowledge of the therapeutic regimen have been met when the client states which of the following? a. "I will increase sources of cobalamin (B12), such as muscle meats and liver, in my diet." b. "The feeling in my hands and feet will return when my hemoglobin level returns To normal." c. "I will need to have cobalamin (B12) injections regularly for the rest of my life." d. "I should plan for only part-time employment because of the chronic fatigue that pernicious anemia causes." A 47 year old client is diagnosed with Sickle Cell Disease (SCD). He asks the nurse why he cannot continue to receive blood transfusions whenever he needs it. What the nurse's best response? a. "The goal of transfusions with SCD is to increase the Hgb and Hct levels. Once this level is reached you no longer need additional treatments." b. "Transfusions are not usually provided to clients with SCD after the age of 45." c. "Chronic transfusions are not generally a common treatment for SCD as you can experience iron overload, be exposed to blood-borne infections, and develop multiple autoantibodies to blood." d. "Clients with SCD are not candidates for blood transfusions." A male patient is hospitalized with a subarachnoid hemorrhage secondary to a ruptured aneurysm. In which situation will the nurse contact the physician? a. Headache becomes more intense b. Ventricular pressure exceeds 15 c. Respiration rate drops to 16 d. Temperature rises to 37.8 Celsius You are teaching your client and their family about sickle-cell disease (SCD). Which of the following are identified as being some of the common symptoms? a. Anemia, periodic pain episodes, speech impairment b. Anemia, periodic pain episodes, low blood pressure, hearing difficulties c. Anemia, arrhythmias, high blood pressure, periodic pain episodes d. Anemia, periodic pain episodes, hand-foot syndrome, frequent infections Which of the following lab value result would be indicative of Chronic Kidney Disease (CKD)? a. Blood glucose b. Serum calcium and phosphate c. Serum Creatinine d. Red blood cells A client receiving chemotherapy for acute lymphocytic leukemia has pancytopenia and filgrastim (Neupogen) is prescribed. The nurse teaches the client that the reason for the use of this medication is which of the following? a. Prevention of hemorrhage complications in clients with thrombocytopenia b. Replacement of abnormal stem cells in the bone marrow with normal cells c. Improvement in the number and function of neutrophils d. Remission of the leukemia The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. The client inquires about Cheyne-Stokes respirations. What information would the nurse include in her explanation? a. "Cheyne-Stokes are rapid, deep breaths and irregular breathing without pauses." b. "They are progressively deeper breaths followed by shallower breaths with apneic periods." c. "They are rapid, deep breaths with abrupt pauses between each breath." d. "Cheyne-Stokes shallow breaths with an increased respiratory rate." A client is diagnosed as having a bowel tumor. Which of the following tests will confirm the diagnosis of malignancy? a. Computed Tomography scan b. Magnetic resonance imaging c. Abdominal ultrasound d. Biopsy of the tumor Which of the following individuals are at the highest risk for developing iron-deficiency anemia? a. Teen-aged girls, infants, pre-menopausal women, pregnant women b. Teen-aged girls, pregnant women, & older adults c. Teen-aged girls, pregnant women, those from all socioeconomic backgrounds & older adults d. Teen-aged girls and boys, pregnant women, those experiencing blood loss The physician orders two units of packed red blood cells for a client who has severe anemia. What is the most important action by the nurse to prevent a transfusion reaction when administering the blood? a. Administer the blood slowly for the first hour (no more than 2 mL/min). b. Two RNs check the serial numbers to verify the correct blood product for this client c. Transfuse blood at a rapid rate and keep the blood chilled during administration d. Stay with the client during the transfusion What is the most appropriate nursing intervention in order to assess for the presence of infection in a client with neutropenia? a. Monitor the mouth and perianal area every shift for signs of redness and swelling. b. Monitor the skin for temperature and diaphoresis. c. Monitor WBCs daily. d. Monitor temperature q4h. The student nurse's client returns from his transurethral resection of the prostate (TURP) with a 3 way Foley catheter connected to a continuous bladder irrigation (CBI). The client complains of abdominal cramping, and you note that the urine in the drainage bag is dark red with some clots present in the line coming from the catheter. Which of the following interventions demonstrates reliable understanding of the situation by the student nurse? a. Decrease the rate the irrigation solution and milk the drainage tubing b. Stop the infusing irrigation solution and notify the physician c. Increase the flow rate of the irrigation solution, and monitor the colour of the drainage d. Wait for the cramping to subside and then restart a new bag of irrigation solution You don't stop the flow of irrigation, it makes blood clots worse The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which of the following assessment signs would the nurse most likely expect to note in the client? a. Enlarged lymph nodes b. Weakness c. Fatigue d. Weight gain The nurse is preparing to administer a high-dose of methylprednisolone (Solumedrol) to a client diagnosed with a spinal cord injury. The nurse realizes that for this medication to be most effective the treatment should begin at what point in time after the injury? a. between 12 and 24 hours of injury. b. within 8 hours of injury. c. between 8 and 12 hours of injury. d. 48 hours after the injury. A elderly client has experienced a thrombotic right brain stroke and now his left arm is swollen. Which of the following conditions causes swelling after a stroke? a. Loss of muscle contraction decreasing venous return b. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side c. Muscle contractures secondary to spasticity d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus A father asks the nurse why his child with Sickle cell disease is having so many problems. What is the nurse's best response? a. Sickled cells increase the blood flow through the body and cause a great deal of pain. b. Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow. c. Bone marrow depression occurs because of the development of sickled cells. d. The sickled cells mix with the unsickled cells and cause the immune system to become depressed. The nurse determines that instruction regarding prevention of future UTIs for a client with cystitis has been effective when the client gives which of the following responses? a. "I will increase my fluid intake and empty my bladder every 2 to 4 hours during waking hours." b. "I should use an antiseptic vaginal deodorant spray twice a day to reduce the bacterial growth in the perineal area." c. "I will wash my perineal area with soap and water after each bowel movement and before and after sexual intercourse." d. "I will limit my fluid intake to 1000 mL/day to prevent symptoms of frequency and urgency." When caring for the client with cardiogenic shock and possible multiple organ dysfunction syndrome (MODS), what information obtained by the nurse will help confirm the diagnosis of MODS? a. The client has cool extremities and weak pedal pulses. b. The client has an elevated ammonia level and confusion. c. The client has crackles throughout both lung fields. d. The client complains of crushing chest pain at a level of 8 on a 10-point scale. A client in the emergency department is given intravenous diazepam (Valium) for seizures. When the seizures stop, the nurse notes that the client is lethargic and confused and has a respiratory rate of 10 breaths per minute. The nurse will expect to administer which of the following? a. Flumazenil (Romazicon) b. Respiratory support c. Toxicology testing d. Gastric lavage