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. Notify the client’s health care provider.B. Prepare the client for a chest x-ray.C. Medicate the client for removal of the chest tube.D. Assess the client’s 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. Ask the client if she has discussed the treatment with her husband.B. Check the client’s laboratory work prior to administration.C. Determine if the client is pregnant or on birth control pills.D. 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. Collaborate with the respiratory therapist.B. Ensure the manual resuscitation bag is at the client’s bedside.C. Check and maintain the ventilator settings.D. Monitor the client’s 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. The client has no apparent change in muscle strengthB. The client reports decreased pain in the hands.C. The client has no pallor in the fingers.D. 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. Obtain an order for a STAT chest x-ray.B. Increase the amount of wall suction.C. Strip the chest tube to remove any clot.D. Monitor the client’s pulse oximeter reading..

7. The client has the following ABG’s: pH 7.33, PaO2 94, PaCO2 45, HCO3 20.

A. Administer sodium bicarbonate.B. Administer oxygen via nasal cannula.C. Have the client cough and deep breath.D. Take no action because ABG’s 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 expansionC. PolycythemiaD. 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. Provide the client with mouth care daily.B. Obtain a daily chest x-ray.C. Ensure the client’s ET is deflated at all times.D. 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. Discuss the importance of taking medication on time.B. Teach the client to increase fiber in diet.C. Teach client how to perform active range of motion exercises.D. Teach the client how to care for the client’s feeding tube.

11. The client’s purified protein derivative (PPD) test for tuberculosis (Tb) is positive. Which instruction should the nurse discuss with the client?

A. Instruct the client to get another PPD test in one month.B. Discuss the importance of taking medication for Tb every day.C. Explain that a positive reaction means exposure to the Tb bacilli.D. 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. Continue to monitor the client without taking any action.B. Encourage client to take deep breaths and cough.C. Administer 1 amp of sodium bicarbonate IV push.D. 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. Altered fluid and electrolytesB. Anticipatory grievingC. Potential for care giver strainD. 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. Notify the respiratory therapist immediatelyB. Use the manual resuscitation bag to ventilate the clientC. Check the client’s ventilator settingsD. Assess the client’s 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. Place client in high Foweler’s position.B. Document the amount of drainage in the collection chamber.C. Monitor the client’s hemoglobin and hematocritD. Maintain the client on strict bed restE. 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 client’s pulse oximeter reading is 90% after 1 hour of oxygen at 10L.B. The client’s ABG’s are pH 7.35, PaO2 85, PaCO2 43, HC03 24C. 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. The client has scanning speech and muscle weaknessB. The client has ascending paralysis of the lower extremitiesC. The client has ptosis and nystagmusD. 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. Notify the respiratory therapistB. Check the client’s pulse oximeter readingC. Administer oxygen via nasal cannulaD. Elevate the client’s 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. Determine why the client is bucking the ventilator.B. Suction the client’s airway for secretions.C. Notify the respiratory therapist immediately.D. 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. WheezesB. RhonchiC. CracklesD. Decreased breath sounds

21. While suctioning a patient’s tracheostomy tube, the nurse notes a heart rate of 60 bpm. What should the nurse do?

A. Stop suctioning and provide oxygen.B. Turn the patient onto his left side.C. Give atropineD. Continue suctioning to remove the mucus

22. What should be given to a patient with Addions’s disease before exposure to stress?

A. 8oz of waterB. Capillary blood glucose monitoring qidC. Hydrocortisone IMD. Take his usual dose of hydrocortisone

23. What assessment should the nurse perform during and addisonian crisis?

A. Weigh the patientB. Test urine for ketonesC. Assess vital signsD. Give oral hydrocortisone

24. In a patient with HIV, what is the purpose of monitoring CD4 levels?

A. detect presence of opportunistic infections.B. monitor level of viral loadC. evaluate the extent of immune system damageD. detect resistance to antigens

25. A patient has SLE. Which instruction should the nurse give?

A. “Corticosteroids may be stopped when symptoms are relieved.”B. “Monitor your temperature.”C. “Exposure to sunlight will help control skin rashes.”D. “There are no activity limitations.”

26. A patient has impaired gas exchange. Which is the best outcome?

A. The patient has normal breath sounds in all lung fields.B. The patient decreases daily activities to a minimumC. The patient maintains a decreased cough effort to lessen fatigue.D. The patient restricts fluid intake to prevent overhydration.

27. Which instruction should the nurse give before a bronchoscopy?

A. Do not walkB. Do not talkC. Do not coughD. 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. lip movementB. ventilatory-patient dyssychronyC. leg movementD. 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 mealsB. give the medication on an empty stomachC. give the medication for complaints of muscle weakness or difficulty

swallowingD. 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. muscle weaknessB. excessive tearingC. urine retentionD. 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. truncal obesityB. muscular wastingC. hypertensionD. osteoporosis

32. A patient with AIDS is receiving zidovudine (AZT Retrovir). Which laboratory value indicates an adverse reaction to zidovudine?

A. Platelet count of 240000B. Fasting blood glucose of 104C. Serum calcium of 8.9D. 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. Fish oilB. Vitamin DC. Iron-rich foodsD. Calcium carbonate

34. Which diagnostic test should the nurse expect to see ordered as a screening tool for rheumatoid arthritis?

A. Anitnuclear antibody titerB. Complete Blood CountC. Erythrocyte Sedimentation RateD. Rheumatoid Factor

35. SLE primarily attacks which tissue?

A. ConnectiveB. HeartC. LungD. 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. “This medication will cause drowsiness so I should be careful.”B. “I should not drink any type of alcohol or take antihistamines.”C. ‘ I will increase the fiber in my diet and increase fluid intake.”D. “I stopped taking the medication because I can’t afford it.”

37. The client with MS is having trouble maintaining balance. Which intervention should the nurse discuss with the client.?

A. Discuss obtaining a motorized wheelchairB. Teach the client to stand with the feet slightly apartC. Encourage the client to narrow his or her base of supportD. 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. The UAP is helping the client to sit on the bedside chairB. The UAP is wearing sterile gloves to bath the patientC. The UAP is helping the client shave and brush his teeth.D. 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. Identify specific measures to avoid fatigue and undue stressB. Instruct client to pad bony prominences, especially the sacral areaC. Provide calm assurance when caring for the clientD. 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. There is no surgical optionB. A transsphenoidal hypophysectomyC. A thymectomyD. 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. Confirm the ventilator settings are correctB. Verify the ventilator alarms are functioning properlyC. Assess the respiratory status and pulse oximeter readingD. Monitor the client’s 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. Mouth ulcersB. Muscle crampsC. Feelings of depressionD. 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. NormalB. PositiveC. Myasthenic crisisD. 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. Cyanosis and pallorB. Diffuse crackles and rhonchi on chest auscultationC. Increase in respiratory rate from 18 to 30 bpmD. Haziness or ‘white out” appearance of lungs on chest radiograph

45. Which patient is most likely to develop SLE?

A. 25 yo white maleB. 25 yo jewish femaleC. 27 yo black femaleD. 35 yo Hispanic male

46. A patient with multiple injuries has aspiration pneumonia. What is this patient at highest risk for?

A. ARDSB. COPDC. Renal failureD. Bronchial asthma

47. Which of the following is not associated with MS?

A. Degeneration of the axons and plaque formationsB. Degeneration of the basal gangliaC. Demyelination throughout the CNSD. Periodic exacerbations and remissions

48. Which test indicates and acute addisonian crisis?A. Serum glucose of 236B. Serum sodium of 156C. Serum potassium of 6.7D. BUN of 2.3

49. What are the signs of a tension pneumothorax?

A. tachypnea, cyanosis, hyperexpansionB. hypotension, dyspnea, decreased breath soundsC. A and BD. Jugular venous distention

50. What medication order would the nurse question for the AIDS patient taking a protease inhibitor?

A. Zocor (simvastitin)B. Lipitor (atorvastatin)C. Benedryl (diphenhydramine)D. Aspirin