50 Shades of Practice Questions 1.

The nurse is caring for a client diagnosed with a pneuomothorax who had a chest tube inserted four days ago. There is no fluctuation/tidaling in the water seal compartment of the closed chest drainage system. Which action should the nurse take first? A. B. C. D. Notify the clients health care provider. Prepare the client for a chest x-ray. Medicate the client for removal of the chest tube. Assess the clients bilateral lung sounds.

2. The 28 year old female client diagnosed with rheumatoid arthritis is to receive a regimen of immumosuppressive medications. Which intervention should the nurse implement prior to administering the medications? A. B. C. D. Ask the client if she has discussed the treatment with her husband. Check the clients laboratory work prior to administration. Determine if the client is pregnant or on birth control pills. Confirm the client has signed an informed consent for investigational drugs.

3. The client diagnosed with adult respiratory distress syndrome (ARDS) is transferred to the intensive care unit and placed on a ventilator. Which intervention should the nurse implement first? A. B. C. D. Collaborate with the respiratory therapist. Ensure the manual resuscitation bag is at the clients bedside. Check and maintain the ventilator settings. Monitor the clients pulse arterial blood gas results.

4. The client diagnosed with rule out myasthenia gravis (MG) is administered the Tensilon (endrophonium chloride ) test. Which response supports the client does not have MG? A. B. C. D. The client has no apparent change in muscle strength The client reports decreased pain in the hands. The client has no pallor in the fingers. The client shows a marked improvement of muscle strength.

5. The client diagnosed with Systemic Lupus Erthematosus (SLE) is being discharged from the medical unit. Which discharge instructions should the nurse discuss with the client?

A. Encourage the client to not go in the sunlight betweet 1000-1600. B. Explain that some dyspnea is expected and does not need immediate attention. C. Tell the client that the hands and feet may change colors if exposed to cold or heat. D. Explain that with continued therapy the client can be cured. 6 . The client has a right sided chest tube inserted 3 days ago for a pneumothorax. Which action should the nurse take if there is no fluctuation/tidaling in the water seal compartment? A. B. C. D. Obtain an order for a STAT chest x-ray. Increase the amount of wall suction. Strip the chest tube to remove any clot. Monitor the clients pulse oximeter reading..

7. The client has the following ABGs: pH 7.33, PaO2 94, PaCO2 45, HCO3 20. A. B. C. D. Administer sodium bicarbonate. Administer oxygen via nasal cannula. Have the client cough and deep breath. Take no action because ABGs are normal.

8. The client is admitted to the emergency room with chest trauma. What signs/symptoms would the nurse assess that would indicate a pneumothorax? A. Lung consolidation. B. Asymmetrical chest expansion C. Polycythemia D. Dullness on percussion 9. The client is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotrachial tube (ET) care? A. B. C. D. Provide the client with mouth care daily. Obtain a daily chest x-ray. Ensure the clients ET is deflated at all times. Move the ET from side to side in the mouth.

10. The client newly diagnosed with myasthenia gravis (MG) is being discharged home. Which intervention should the nurse discuss with the client? A. B. C. D. Discuss the importance of taking medication on time. Teach the client to increase fiber in diet. Teach client how to perform active range of motion exercises. Teach the client how to care for the clients feeding tube.

11. The clients purified protein derivative (PPD) test for tuberculosis (Tb) is positive. Which instruction should the nurse discuss with the client? A. B. C. D. Instruct the client to get another PPD test in one month. Discuss the importance of taking medication for Tb every day. Explain that a positive reaction means exposure to the Tb bacilli. Tell the client the results must be reported to the Public Health Department.

12. The health-care provider ordered STAT arterial blood gasses for the client in respiratory distress. The ABG results are: pH 7.33, PaO2 92, PaCO2 48, HCO3 24. Which action should the nurse implement? A. B. C. D. Continue to monitor the client without taking any action. Encourage client to take deep breaths and cough. Administer 1 amp of sodium bicarbonate IV push. Notify the respiratory therapist of the ABG results.

13. The home health nurse is caring for the client with AIDS dementia. Which nursing care problem is priority? A. B. C. D. Altered fluid and electrolytes Anticipatory grieving Potential for care giver strain Risk for injury

14. The nurse is caring for a client on a mechanical ventilator. The client is in respiratory distress. Which intervention should the nurse implement first? A. B. C. D. Notify the respiratory therapist immediately Use the manual resuscitation bag to ventilate the client Check the clients ventilator settings Assess the clients oxygen saturation

15. The nurse is caring for a client with a right sided chest tube secondary to a hemothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. A. B. C. D. E. Place client in high Fowelers position. Document the amount of drainage in the collection chamber. Monitor the clients hemoglobin and hematocrit Maintain the client on strict bed rest Observe the site for subcutaneous emphysema

16. The nurse suspects the client may be developing adult respiratory distress syndrome. (ARDS) Which finding would confirm the diagnoses of ARDS? A. The clients pulse oximeter reading is 90% after 1 hour of oxygen at 10L. B. The clients ABGs are pH 7.35, PaO2 85, PaCO2 43, HC03 24 C. The client has crackles in the lower lobes of both lungs anterior and posterior. D. The client has left sided jugular venous distension and frothy sputum 17. Which assessment data would the nurse expect to find in the client diagnosed with Multiple Sclerosis? A. B. C. D. The client has scanning speech and muscle weakness The client has ascending paralysis of the lower extremities The client has ptosis and nystagmus The client has pericardial friction rub and crackles in the lungs.

18. Which intervention should the nurse implement first for a client who is experiencing respiratory distress? A. B. C. D. Notify the respiratory therapist Check the clients pulse oximeter reading Administer oxygen via nasal cannula Elevate the clients head of the bed

19. Which intervention should the nurse implement first for the client on a ventilator whose high alarm indicates there is an increase in the peak airway pressure? A. B. C. D. Determine why the client is bucking the ventilator. Suction the clients airway for secretions. Notify the respiratory therapist immediately. Sedate the client with a muscle relaxant.

20. A client with lung cancer develops a pleural effusion. Which breath sound is associated with a pleural effusion? A. B. C. D. Wheezes Rhonchi Crackles Decreased breath sounds

21. While suctioning a patients tracheostomy tube, the nurse notes a heart rate of 60 bpm. What should the nurse do? A. B. C. D. Stop suctioning and provide oxygen. Turn the patient onto his left side. Give atropine Continue suctioning to remove the mucus

22. What should be given to a patient with Addionss disease before exposure to stress? A. B. C. D. 8oz of water Capillary blood glucose monitoring qid Hydrocortisone IM Take his usual dose of hydrocortisone

23. What assessment should the nurse perform during and addisonian crisis? A. B. C. D. Weigh the patient Test urine for ketones Assess vital signs Give oral hydrocortisone

24. In a patient with HIV, what is the purpose of monitoring CD4 levels? A. B. C. D. detect presence of opportunistic infections. monitor level of viral load evaluate the extent of immune system damage detect resistance to antigens

25. A patient has SLE. Which instruction should the nurse give? A. B. C. D. Corticosteroids may be stopped when symptoms are relieved. Monitor your temperature. Exposure to sunlight will help control skin rashes. There are no activity limitations.

26. A patient has impaired gas exchange. Which is the best outcome? A. B. C. D. The patient has normal breath sounds in all lung fields. The patient decreases daily activities to a minimum The patient maintains a decreased cough effort to lessen fatigue. The patient restricts fluid intake to prevent overhydration.

27. Which instruction should the nurse give before a bronchoscopy? A. B. C. D. Do not walk Do not talk Do not cough Do not eat

28. A patient on mechanical ventilation is receiving pancuronium (pavulon) IV as needed. Which finding indicates that the patient needs another pancuronium dose? A. B. C. D. lip movement ventilatory-patient dyssychrony leg movement finger movement

29. A nurse is giving neostigmine (Prostigmine) to a patient with myasthenia gravis. Which intervention should the nurse implement? A. give the medication 45 minutes before meals B. give the medication on an empty stomach C. give the medication for complaints of muscle weakness or difficulty swallowing D. warn the patient that he will experience mouth dryness

30. A nurse is monitoring a patient for adverse reactions to dantrolene (Dantrium). Which adverse reaction to dantrolene is most common? A. B. C. D. muscle weakness excessive tearing urine retention slurred speech

31. A patient with SLE has severe back pain. She has been taking prednisone daily for 6 months. Which adverse effect of long-term corticosteroid therapy is causing the pain? A. B. C. D. truncal obesity muscular wasting hypertension osteoporosis

32. A patient with AIDS is receiving zidovudine (AZT Retrovir). Which laboratory value indicates an adverse reaction to zidovudine? A. B. C. D. Platelet count of 240000 Fasting blood glucose of 104 Serum calcium of 8.9 Hemoglobin of 1.2

33. A nurse is preparing a teaching plan for a client with rheumatoid arthritis. Which dietary recommendation may help the client reduce inflammation? A. B. C. D. Fish oil Vitamin D Iron-rich foods Calcium carbonate

34. Which diagnostic test should the nurse expect to see ordered as a screening tool for rheumatoid arthritis? A. B. C. D. Anitnuclear antibody titer Complete Blood Count Erythrocyte Sedimentation Rate Rheumatoid Factor

35. SLE primarily attacks which tissue? A. B. C. D. Connective Heart Lung Nerve

36. The client with MS is prescribed the muscle relaxant baclofen. Which statement by the client indicates that the client needs more teaching? A. B. C. D. This medication will cause drowsiness so I should be careful. I should not drink any type of alcohol or take antihistamines. I will increase the fiber in my diet and increase fluid intake. I stopped taking the medication because I cant afford it.

37. The client with MS is having trouble maintaining balance. Which intervention should the nurse discuss with the client.? A. B. C. D. Discuss obtaining a motorized wheelchair Teach the client to stand with the feet slightly apart Encourage the client to narrow his or her base of support Explain the need to balance activity with rest

38. The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome dementia. Which action by the unlicensed assistive personnel requires immediate intervention by the nurse? A. B. C. D. The UAP is helping the client to sit on the bedside chair The UAP is wearing sterile gloves to bath the patient The UAP is helping the client shave and brush his teeth. The UAP is providing a back massage to the client.

39. Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis? A. B. C. D. Identify specific measures to avoid fatigue and undue stress Instruct client to pad bony prominences, especially the sacral area Provide calm assurance when caring for the client Explain the possibility of having a splenectomy to help control symptoms.

40. Which surgical procedure should the nurse anticipate the client with Myasthenia Gravis undergoing to help prevent the signs and symptoms of the disease process? A. B. C. D. There is no surgical option A transsphenoidal hypophysectomy A thymectomy An adrenalectomy

41. The client diagnosed with ARDS is transferred to the intensive care unit and placed on a ventilator. Which intervention should the nurse implement first? A. B. C. D. Confirm the ventilator settings are correct Verify the ventilator alarms are functioning properly Assess the respiratory status and pulse oximeter reading Monitor the clients blood gas results.

42. A client with Myasthenia Gravis is admitted to the hospital, and the nursing history reveals that the client is taking Mestinon. The nurse assessed the client for side effects of the medication and asks the client about the presence of: A. B. C. D. Mouth ulcers Muscle cramps Feelings of depression Unexplained weight gain.

43. A client with myasthenia gravis is experiencing prolonged periods of weakness, and the physician orders a Tensilon test. A test dose is administered and the client becomes weaker. The nurse interprets this test result as: A. B. C. D. Normal Positive Myasthenic crisis Cholinergic crisis

44. A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. The nurse monitors for which earliest clinical manifestation of ARDS? A. B. C. D. Cyanosis and pallor Diffuse crackles and rhonchi on chest auscultation Increase in respiratory rate from 18 to 30 bpm Haziness or white out appearance of lungs on chest radiograph

45. Which patient is most likely to develop SLE? A. B. C. D. 25 yo white male 25 yo jewish female 27 yo black female 35 yo Hispanic male

46. A patient with multiple injuries has aspiration pneumonia. What is this patient at highest risk for? A. B. C. D. ARDS COPD Renal failure Bronchial asthma

47. Which of the following is not associated with MS? A. B. C. D. Degeneration of the axons and plaque formations Degeneration of the basal ganglia Demyelination throughout the CNS Periodic exacerbations and remissions

48. Which test indicates and acute addisonian crisis? A. Serum glucose of 236 B. Serum sodium of 156 C. Serum potassium of 6.7 D. BUN of 2.3 49. What are the signs of a tension pneumothorax? A. B. C. D. tachypnea, cyanosis, hyperexpansion hypotension, dyspnea, decreased breath sounds A and B Jugular venous distention

50. What medication order would the nurse question for the AIDS patient taking a protease inhibitor? A. B. C. D. Zocor (simvastitin) Lipitor (atorvastatin) Benedryl (diphenhydramine) Aspirin