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NEW QUESTION # 413
A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client's serum potassium level to be?
- A. unrelated to the pH
- B. normal
- C. elevated
- D. low
Answer: C
Explanation:
Hyperkalemia occurs in a state of acidosis because potassium moves from injured cells into the bloodstream.
Physiological Adaptation
NEW QUESTION # 414
Which of the following represents a normal serum potassium level?
- A. 4.0 mEq/L
- B. 1.5 mEq/L
- C. 3.0 mEq/L
- D. 6.0 mEq/L
Answer: A
Explanation:
Explanation/Reference:
Explanation:
Normal serum potassium levels fall in a range of 3.5-5.5mEq/L. The other choices listed fall below or above this range. Reduction of Risk Potential
NEW QUESTION # 415
Which is the most common microorganism associated with gastritis?
- A. cytomegalovirus
- B. H. pylori
- C. syphilis
- D. mycobacterium
Answer: B
Explanation:
Section: Physiological Integrity
Explanation:
H. pylori is the most common microorganism associated with gastritis.
The other microorganisms listed might be associated with gastritis but to a lesser degree.
NEW QUESTION # 416
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:
- A. introjection.
- B. regression.
- C. rationalization.
- D. conversion.
Answer: B
Explanation:
Crying is a regressive behavior. The ego returned to an earlier, comforting, and less-mature way of behaving in the face of disappointment. Conversion involves the transformation of anxiety into a physical symptom. Introjection involves intense unconscious identification with another person. Rationalization involves the unconscious process of developing acceptable explanations to justify unacceptable ideas, actions, or feelings.Psychosocial Integrity
NEW QUESTION # 417
Which of the following individuals may legally give informed consent?
- A. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- B. an 86-year-old male with advanced Alzheimer's disease
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Answer: C
Explanation:
Section: Safe and Effective Care Environment
Explanation:
The 72-year-old client scheduled for heart transplant surgery may give informed consent for the surgery. There are no age limitations with the exception of minors.
Choices "an 86-year-old male with advanced Alzheimer's disease", "a 14-year-old girl needing an appendectomy who is not an emancipated minor" and "6-month-old baby needing bowel surgery" are incorrect.
An individual with advanced Alzheimer's disease is incompetent to make decisions.
Only an emancipated minor may give consent (a 14-year-old child who lives alone, away from family, and is totally independent).
Infants are unable to give consent.
NEW QUESTION # 418
The nurse can best communicate to a client that he or she has been listening by:
- A. making a judgment about the client's problem.
- B. saying, "I understand what you're saying."
- C. offering a leading question such as, "And then what happened?"
- D. restating the main feeling or thought the client has expressed.
Answer: D
Explanation:
Restating allows the client to validate the nurse's understanding of what has been communicated. It's an active listening technique. Regarding Choice 2, judgments should be suspended in a nurse-client relationship. Choice 3 is incorrect because leading questions ask for more information rather than showing understanding. Choice 4 communicates understanding, but the client has no way of measuring the understanding.
PsychosocialIntegrity
NEW QUESTION # 419
A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. cirrhosis
- C. psoriasis
- D. lupus
Answer: B
Explanation:
Section: Physiological Integrity
Explanation:
A client with cirrhosis is at risk for developing a high ammonia level.
NEW QUESTION # 420
Which of the following is a predisposing factor for cancer of the tongue?
- A. obesity
- B. tobacco use
- C. sun exposure
- D. eating sweets
Answer: B
Explanation:
Section: Physiological Integrity
Explanation:
Tobacco use is a predisposing factor for cancer of the tongue; the other choices are not.
NEW QUESTION # 421
Someone who has received a recent tattoo should be screened for __________.
- A. syphilis
- B. herpes
- C. tuberculosis
- D. hepatitis
Answer: D
Explanation:
Section: Safe and Effective Care Environment
Explanation
Explanation:
Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed.
Tuberculosis is an airborne pathogen, while herpes and syphilis are spread directly (such as through sexual contact).
NEW QUESTION # 422
Which of these is not an early indicator of increased intracranial pressure?
- A. Cushing's reflex
- B. Cheyne-Stokes respirations
- C. decorticate posture
- D. widening pulse pressure
Answer: A
Explanation:
Section: Physiological Integrity
NEW QUESTION # 423
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction.
Which of the following nursing actions is most appropriate?
- A. Notify the physician.
- B. Turn the client on her left side.
- C. No action is necessary.
- D. Administer O2.
Answer: C
Explanation:
Section: Physiological Integrity
Explanation:
It is an early deceleration as a result of head compression, and at this time no action is necessary.
Close observation of the mother and baby is needed.
NEW QUESTION # 424
The physician wants to know if a client is tolerating his total parenteral nutrition. Which of the following laboratory tests is likely to be ordered?
- A. a glucose tolerance test
- B. liver function tests
- C. triglyceride level
- D. a complete blood count
Answer: B
Explanation:
The liver is the primary organ for digestion. Liver function tests measure the blood level of enzymes produced by the liver: prothrombin time/partial prothrombin time, serum glutamic oxaloacetic and pyruvic transaminases, gamma glutamyl transpeptidase, albumin, and alkalinephosphatase. Choice 1 measures the body's ability to clear triglycerides, the primary component of fats. Failure to clear triglycerides from the bloodstream indicates a problem with storage or the ingestion of too much fat. Choice 3 measures the blood glucose at intervals after a glucose-rich solution is ingested; it is used for diagnosing diabetes. Choice 4 is used to evaluate blood components.Pharmacological Therapies
NEW QUESTION # 425
Which of the following patients would be least likely to develop hypernatremia?
- A. a patient with chronic renal insufficiency
- B. a patient taking anabolic steroids
- C. a patient with extensive thermal burns
- D. a patient with diabetes insipidus
Answer: A
Explanation:
Section: Physiological Integrity
NEW QUESTION # 426
Select the following fire emergency interventions in correct sequential order.
- A. C, A, D, B
- B. C, A, B, D
- C. C, B, A, D
- D. A, C, B, D
Answer: B
Explanation:
Section: Safe and Effective Care Environment
Explanation
Explanation:
The RACE acronym is used to prioritize and sequence the steps that must be followed when a fire occurs.
R stands for rescue patients;
A is pulling the fire alarm;
C is to contain the fire by closing doors, etc.; and
E is extinguishing the fire with a fire extinguisher when possible.
NEW QUESTION # 427
Hazards of improper splinting include ___________.
- A. reduced distal circulation
- B. aggravation of a bone or joint injury
- C. all of the above
- D. delay in transport of a client with a lifethreatening injury
Answer: C
Explanation:
Section: Physiological Integrity
Explanation:
Hazards of improper splinting include aggravation of a bone or joint injury, reduced distal circulation, and delay in transport of a client with a life-threatening injury.
NEW QUESTION # 428
A patient has been ordered to get Klonapin for the first time. Which of the following side effects is not associated with Klonapin?
- A. Ataxia
- B. Salivation elevated
- C. Diplopia
- D. Drowsiness
Answer: C
Explanation:
A-C are associated side effects of Klonapin.
NEW QUESTION # 429
Which of the following attitudes is essential in a nurse who assists clients during crises?
- A. feeling that work requires identification with all of a client's problems
- B. taking an active role in guiding the process
- C. wanting to help clients solve all problems identified
- D. viewing crisis intervention as the first step in solving bigger problems
Answer: D
Explanation:
Section: Psychosocial Integrity
Explanation:
Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. Assessment of the present problem should be viewed as necessary. Time and limitations of crisis work need to be remembered.
Complete diagnostic assessment is unnecessary, and unrelated material should not be explored. Referrals might be necessary for other identified problems.
NEW QUESTION # 430
Idiopathic thrombocytopenia purpura is __________.
- A. treated with immune system boosting medications
- B. highly similar to disseminated intravascular coagulation (DIC)
- C. caused by the over production of platelets
- D. a bleeding disorder that is characterized with too few platelets
Answer: D
Explanation:
Section: Safe and Effective Care Environment
Explanation:
Idiopathic thrombocytopenia purpura is bleeding disorder that is characterized with too few platelets, not the over production of platelets. Disseminated intravascular coagulation (DIC) is characterized with blood coagulation and not bleeding.
The treatments of idiopathic thrombocytopenia purpura can include immune system depressants, not stimulants, prednisone, high-dose gamma globulin and anti RhD therapy.
NEW QUESTION # 431
Which of the following clients require airborne precautions?
- A. a client with fever, chills, vomiting, and diarrhea
- B. a client diagnosed with AIDS
- C. a client with abdominal pain and purpura
- D. a client suspected of varicella (chickenpox)
Answer: D
Explanation:
Explanation/Reference:
Explanation:
Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask. Safety and Infection Control
NEW QUESTION # 432
An episiotomy is __________.
- A. releasing the red plug from the cervix just before crowning occurs
- B. the severance of the umbilical cord between mother and child
- C. a surgical incision of the perineum to prevent tearing during delivery
- D. an incision in the abdomen with which the baby can be delivered through
Answer: C
Explanation:
Section: Physiological Integrity
Explanation:
An episiotomy is a surgical incision of the perineum and the posterior vaginal wall to quickly enlarge the opening for the baby to pass through; this incision prevents tearing during a vaginal delivery.
The releasing of the red plug is known as the bloody show.
The baby delivered through an incision in the abdomen is a Caesarian delivery.
Umbilical severance or cutting and clamping of the cord both apply to the procedure of separating mother and child after childbirth.
NEW QUESTION # 433
Medical records indicate a patient has developed a condition of respiratory alkalosis.
Which of the following clinical signs would not apply to a condition of respiratory alkalosis?
- A. Muscle tetany
- B. Syncope
- C. Anxiety
- D. Numbness
Answer: C
Explanation:
Section: Safe and Effective Care Environment
Explanation:
Anxiety is a clinical sign associated with respiratory acidosis.
NEW QUESTION # 434
When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
- A. eupnea
- B. bradychardia
- C. warm, dry skin
- D. tachycardia
Answer: D
Explanation:
Explanation/Reference:
Explanation:
The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and cool skin.
Bradycardia might occur much later in the process when the condition is severe. Eupnea is normal respirations in rate and depth. Physiological Adaptation
NEW QUESTION # 435
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. sedation.
- C. constipation.
- D. addiction.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation. Basic Care and Comfort
NEW QUESTION # 436
As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?
- A. says "Mine!" when playing with toys
- B. tries to jump rope
- C. builds towers with several blocks
- D. tries to color within the lines
Answer: A
Explanation:
Toddlers are possessive and struggle for independence. The other play activities are too advanced for a 2-year-old child.Health Promotion and Maintenance
NEW QUESTION # 437
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