Select All That Apply Practice Exam Flashcards

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Answer: Metabolic alkalosis

A nasogastric tube attached to low suction continuously removes gastric secretions, which are rich in hydrochloric acid (HCl). The loss of these acidic contents leads to a decrease in hydrogen ions and a compensatory increase in bicarbonate in the body. This imbalance results in metabolic alkalosis, characterized by an elevated blood pH and bicarbonate level.

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely observe?

Answer: Respirations that are abnormally deep, regular, and increased in rate

Kussmaul's respirations are a specific type of hyperventilation characterized by abnormally deep, regular, and increased rate of breathing. This pattern is a compensatory mechanism the body uses to blow off excess carbon dioxide and reduce acidosis, commonly observed in conditions like diabetic ketoacidosis (DKA) where the body is attempting to correct metabolic acidosis.

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

Answer: Monitor for hemorrhage.

Post-operative care for retinal detachment surgery focuses on protecting the eye and preventing complications. Monitoring for hemorrhage, administering prescribed eye medications, and maintaining the eye patch or shield are crucial for healing and preventing re-detachment. Educating the client on symptoms of re-detachment is also vital for early intervention if it recurs.

A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?

Answer: Postural blood pressure changes

Hyponatremia (low sodium) often leads to fluid shifts and can cause hypovolemia or affect vascular tone. Postural blood pressure changes, or orthostatic hypotension, are a classic sign of fluid volume deficit and electrolyte imbalances, including hyponatremia. This occurs as the body struggles to maintain blood pressure upon changing positions due to reduced circulating volume or impaired vascular response.

A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?

Answer: A 10-year-old female client with a urinary tract infection

Children, especially those with active infections like a urinary tract infection, should generally avoid herbal medications unless specifically prescribed and closely monitored by a healthcare provider. Herbal remedies may interact with prescribed medications, have unknown dosages or purity, or cause adverse effects in children whose bodies metabolize substances differently than adults. It's safer to rely on conventional, evidence-based treatments for infections in children.

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.

Answer: Notify the registered nurse.

An infant with Tetralogy of Fallot experiencing cyanosis and a drop in oxygen saturation is having a 'tet spell,' a medical emergency. Immediate interventions include notifying the RN, administering 100% oxygen to improve oxygenation, administering morphine sulfate to calm the infant and reduce pulmonary vasoconstriction, and administering IV fluids to increase circulating volume and improve pulmonary blood flow.

A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.

Answer: Oliguria

Severe preeclampsia is characterized by specific clinical findings indicating significant organ dysfunction. A blood pressure of 168/116 mm Hg (systolic ≥160 or diastolic ≥110) is a key diagnostic criterion. Proteinuria of 3+ (or ≥5g in 24 hours) indicates significant kidney involvement, and oliguria (urine output <500 mL in 24 hours) is another sign of renal impairment.

A nurse is monitoring a client with Graves' disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.

Answer: Fever

Thyrotoxicosis, or thyroid storm, is a severe and life-threatening complication of hyperthyroidism characterized by an extreme surge in thyroid hormones. This leads to a dramatic increase in the body's metabolic rate, resulting in hyperthermia (fever), severe tachycardia, and profound agitation. Bradycardia and pallor are not typical signs; instead, clients often present with flushed skin and an elevated heart rate.

A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

Answer: Diabetic mellitus client

Metabolic acidosis occurs when the body produces too much acid or the kidneys are unable to remove enough acid. Clients with uncontrolled diabetes mellitus are at high risk for diabetic ketoacidosis (DKA), where the body produces acidic ketones. Renal failure clients cannot excrete acids effectively, and malnourished individuals can develop lactic acidosis or starvation ketosis, all leading to metabolic acidosis.

The nurse should understand regulations of nursing practice as put forth by the Nurse Practice Act. Identify the statement which is incorrect.

Answer: The Nurse Practice Act is a series of statutes enacted by the federal government in order to regulate the practice of nursing.

The Nurse Practice Act (NPA) is a series of statutes enacted by *state* legislatures, not the federal government, to regulate nursing practice within that specific state. It defines the scope of practice, establishes the Board of Nursing, and outlines licensure requirements and disciplinary actions. Nurses are legally and ethically responsible for knowing the provisions of the NPA in the state where they are licensed and practice.

The Boards of Nursing have the right to revoke, deny, or suspend any license to practice as a practical/vocational nurse within their jurisdiction. There are several causes or actions which are considered to be causes for disciplinary action by the Board of Nursing. Identify the cause for disciplinary action which is incorrect.

Answer: Informing your superior that you cannot assume nursing duties until sufficient preparation for the specific duty has been provided.

Informing a superior about a lack of preparation for a specific nursing duty is a responsible and ethical action that prioritizes patient safety. This demonstrates professional accountability and adherence to the nurse's scope of practice and competence. Conversely, falsifying records, patient abuse, or unprofessional conduct are clear violations of the Nurse Practice Act and are grounds for disciplinary action.

A nurse is planning assignments for the upcoming shift. Which of the following would be the most appropriate assignment for the nursing assistant?

Answer: Perform a bed bath on a diabetic patient who is bedridden.

Performing a bed bath is a routine activity of daily living (ADL) that falls within the scope of practice for a nursing assistant. It does not require the assessment, critical thinking, or specialized nursing judgment that licensed nurses provide. The other options involve tasks like feeding a stroke patient (risk of aspiration, requires assessment), obtaining vital signs (interpretation needed), or accompanying an Alzheimer's patient (potential for complex behavioral management), which are more appropriate for licensed nursing staff.

Vitamin K is typically given during the immediate post delivery period to the healthy newborn infant. The IM injection is administered in the vastus lateralis muscle of the infant’s thigh. What is the MOST appropriate response for the nurse to give if questioned by the parents about the reason for the injection?

Answer: “This is a Vitamin K injection. Infants are deficient in Vitamin K for the first 5-8 days of life. Vitamin K helps their blood clot. This injection is administered to all healthy newborns to help their blood clot better”.

This response provides accurate and comprehensive information regarding the purpose of Vitamin K administration in newborns. Infants are born with low Vitamin K levels due to an immature liver and a sterile gut, which can impair blood clotting and increase the risk of bleeding. The injection helps prevent potentially serious bleeding disorders until the infant's own Vitamin K production is sufficient.

A nurse has received orders to administer a RhoGAM injection IM to a postpartum patient. Which situation is NOT a contraindication for administration of this injection?

Answer: Administration of the injection within 72 hours after delivery.

RhoGAM is administered to Rh-negative mothers who have delivered an Rh-positive infant to prevent Rh sensitization, and it is most effective when given within 72 hours postpartum. Therefore, administering the injection within this timeframe is the correct and indicated action, not a contraindication. Contraindications include a history of allergic reaction to human immunoglobulins or if the patient is Rh-positive, as RhoGAM is only for Rh-negative individuals.

A nursing student is asked by her nursing instructor to explain and give an example of Erik Erikson’s Identity vs. Role Confusion psychosocial development stage. The MOST appropriate answer would be:

Answer: This stage occurs in adolescence (12-20 years), when the adolescent is confused about who he is. An example is when the adolescent obtains a tattoo, which he feels shows the world who he really is.”

Erik Erikson's stage of Identity vs. Role Confusion typically occurs during adolescence (ages 12-20 years). During this period, adolescents explore various roles, beliefs, and behaviors to develop a strong sense of self and personal identity. The example of getting a tattoo to express individuality aligns with this developmental task of self-discovery and defining who they are.

The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:

Answer: Facial swelling

Facial swelling, particularly periorbital edema (swelling around the eyes), is a significant and often early indicator of worsening preeclampsia and fluid retention. While ankle edema is common in normal pregnancy, facial swelling is more concerning and warrants priority assessment for pregnancy-induced hypertension. Pulse deficits and diminished reflexes are not primary or early signs of preeclampsia itself.