# Kaplan Study Guide II

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240,000 / 8000=
30 mL

8000/1=240,000/x

8000x=240,000

x=30 mL

30 mL=1 ounce

300/150=
2 tablets

10/5=
2 tablets

250/500
=0.5 tablet

15/2.5=
6 tablets

250/125=
2 tablets

12/8=
1.5 mL

1.25/0.25=
5 tablets

60/10=
6 tablets

Hypocalcemia

Hematuria

Edema

Hypernatremia

### When measuring the central venous pressure, it is MOST important for the nurse to take action?

Place the manometer at level of the right atrium.

Hypokalemia

### When any type of transfusion reaction occurs, the nurse's FIRST action should be what?

Stop the transfusion

### The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction?

Kidney pain, hematuria, cyanosis

### The nurse determines a patient has a deep partial thickness burn injury of the back. Which is the BEST initial nursing action?

Gently clean and then leave the neck area alone

### In order to deliver 3,000 ml of D5W in 24 hours using an administration set that delivers 15 drops/mL, the nurse should regulate the flow rate to deliver how many drops/minute?

First calculate # of mL per hour by dividing 3,000/24 = 125 mL per hour.

Then, 125 X 15 (number of drops) = 1875

Then, divide 1875 by 60 minutes = 31.25 or 31 drops per minute

### Following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. Which action is MOST appropriate for the nurse to take initially?

Check the type and cross-match it with another nurse.

### The nurse performs an assessment on a patient sustaining burn injury in an apartment fire. The nurse is MOST concerned if which is observed?

The patient has singed nasal hair.

Check the site

### A patient receives magnesium sulfate IV for treatment of pregnancy induced hypertension (PIH). The nurse knows that it is MOST important to have what at the bedside?

Reflex hammer and calcium gluconate

### The nurse cares for a patient receiving blood transfusion. The nurse observes which if fluid overload occurs during transfusion?

Increased pulse rate
Increased BP
Increased respirations

### The nurse instructs a patient with full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the patient selects which menu?

Meat and orange juice

Hyperkalemia

15 cm

Pneumothorax

### The nurse knows which patient is MOST likely to manifest symptoms of fluid volume deficit?

A patient diagnosed with Addison's disease

### The nurse cares for a patient diagnosed with a fractured right hip. The patient's lab values are: Hgb 15, Hct 46%, sodium 140 mEq/L, potassium 6.2 mEq/L, and chloride 100 mEq/L. The nurse is MOST concerned if which is observed?

An episode of ventricular fibrillation

### The nurse observes a student nurse begin an IV on an elderly patient. The nurse should intervene if which is observed?

The student nurse marks the time on the IV bag with a permanent marker
(can contaminate the solution - use time taping)

### The nurse evaluates a patient's fluid balance. Which finding MOST likely requires an intervention?

Output is 800 mL less than intake
(intake & output should be within 200-300 cc of each other)

### The nurse monitors a patient receiving a blood transfusion. The nurse should intervene if which is observed?

The blood infuses at 10 mL/min for the first 15 min.

### The nurse cares for an older man admitted to the hospital for persistent vomiting and abdominal pain. A nasogastric (NG) tube is inserted & connected to suction, & an intravenous infusion of 1,000 ml of D5W with 20 mEq of potassium chloride is started to infuse at 100 ml per hour. The nurse understands potassium chloride has been added to the infusion for which reason?

Replaces the potassium lost in the gastric fluid

### Which laboratory finding should the nurse expect to find if a patient is diagnosed with fluid volume deficit?

Specific gravity 1.034

### A nurse assesses a patient who has sustained a burn injury. The burn area is blistered and painful. Which classification best describes the burned area?

Deep partial thickness

### In order to administer 1,000 mL of D5W, 40 mEq of KCl at 100 mL/hour using an administer set that delivers 60 drops/mL, the nurse should adjust the flow rate to delivery how many drops/minute?

100 X 60 = 6000

6000/60=100

100 drops per minute

Intravenously

### The nurse cares for a patient during the shock phase after suffering a full thickness burn injury. The nurse understands which finding is expected during this phase?

Decreased urine output

### The nurse counsels a patient about how to maintain an adequate intake of protein. The nurse determines that further teaching is required if the patient chooses which of the following foods?

Orange juice and white toast

### To promote evening rest for patients who are immobilized in bed, it is MOST important for the nurse to provide which of the following?

daytime activities

### The home care nurse visits an elderly client living alone on a limited income. The client's diet consists of primarily carbohydrates. Based on an understanding of the nutritional needs of the elderly, which of these interpretations of the client's diet by the nurse is most justified?

The patient should increase the intake of protein.

### The nurse observes a staff member prepare to leave the room of a patient on droplet precautions. The nurse should intervene if which of the following is observed?

The staff member holds onto the outer surface of the facemask while pulling mask away from face.

### The nurse identifies which of the following findings is characteristic of chronic pain?

Weight loss or gain, fatigue

### The nurse explains to the patients the MOST vitamin C can be found in which of the following juices?

Fresh orange juice

### The nurse identifies which of the following lab findings reflects the signs and symptoms of infection?

White blood cell count of 16,000/mm3

GI bleeding

### The nurse performs discharge teaching for a patient receiving sodium warafin (Coumadin). The nurse determines further teaching is required if the patient makes which of the following statements?

I should look for yellow-tinged complexion.

### On the first postoperative day, a patient develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. The nurse understands which of the following complications of surgery is probably developing?

Atelectasis

has a prolonged action

### The nurse cares for a postoperative client with a nasogastric tube. Which observation by the nurse is the MOST reliable indication the nasogastric tube is correctly positioned?

pH of aspirate is 3.

### The nurse prepares four patients for surgery. The nurse is MOST concerned about the psychological adjustment of which of the following patients?

A 26-year-old man scheduled for the Whipple procedure due to cancer of the pancreas.

### A client is admitted to the hospital with a temperature of 101 degrees F and a WBC count of 3,000/mm3. The nurse should institute which of the following precautions?

Neutropenic precautions

### The nurse identifies which of the following diets BEST meets the needs of a person with multiple wounds?

High-vitamin C, high-protein, high-carbohydrate diet.

### Several days postoperatively, a patient complains of pain, tenderness, and redness of the right calf. Which of the following are critical signs and symptoms the nurse should assess for NEXT?

Chest pain and shortness of breath.

### The home care nurse cares for a client diagnosed with a fractured humerus due to a fall in the home. Which of the following observations, if made by the nurse, requires an immediate intervention?

The client ambulates wearing socks

High Fowler's

### The nurse observes a staff member enter the patient's room wearing a protective respiratory device. The nurse determines care is appropriate if the staff member is caring for which of the following patients?

A patient diagnosed with varicella

### The nurse understands the purpose of a drain in a wound is to

keep the tissues close together so that healing can occur

### The nurse notes that an elderly patient has a reddened area on the coccyx. Which of the following actions should the nurse take FIRST?

Reposition the patient every 1-2 hours.

### A patient returns from abdominal surgery with an order for morphine sulfate IV q 3-4 hours prn for pain. During the first 24 hours after surgery, which of the following actions by the nurse is BEST?

Administer pain medication every 3 hours.

### Which of the following actions is essential for the nurse to take after administration of a preoperative medication to a patient?

Raise the side rails of the bed.

### In which of the following situations should the nurse consider withholding morphine until further assessment is completed?

Patient's level of consciousness fluctuates from alert to lethargic.

### A patient with acute pain has a physician's order for morphine 8 mg IV every 3-4 hours prn for pain. The patient asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should take which of the following actions?

Assess location, character and intensity of pain.

### The nurse understands which of the following behaviors is helpful to facilitate a patient to have bowel elimination?

Increase dietary bulk

Obese

### A client comes to the emergency room after puncturing a foot with a dirty, rusty nail. The client states the last Td immunization was 6 years ago. Which of the following actions should the nurse take FIRST?

Determine how many Td immunizations the client has received.

### A patient requires a dressing change. The LPN/LVN nurse assigned to care for the patient reports to the registered nurse that she/he once observed a similar dressing change while in nursing school, but has never performed the procedure. The registered nurse should take which action?

Complete the dressing change while the LPN/LVN observes

### The nurse instructs a patient about how to successfully establish a regular exercise program. The nurse determines further teaching is needed if the patient makes which of the following statements?

I should start by running 5 miles every day.

### The nurse cares for a patient with an abdominal wound. The nurse notes there is a purulent drainage wound. Which of the following actions should the nurse take FIRST?

Place the patient on contact precautions

### When teaching correct body mechanics to a nurse's aide, which of the following suggestions by the nurse is MOST appropriate?

Bend knees when lifting objects

### The nurse assesses an elderly client in the outpatient clinic. The nurse expects the client to make which of the following statements?

Eating just does now appeal to me anymore.

### The nurse identifies which of the following changes in the pattern of urinary elimination is usually associated with aging?

Sphincter reflexes decreased

Underweight

### Wet-to-dry dressing changes are ordering for a patient. After the first dry dressing is removed, the patient yells at the nurse, "Ouch, that really hurts. Are you sure you are doing it right?" Which of the following statements is the BEST response by the nurse?

This type of dressing cleans the wound so that it can heal. I'll bring you some pain medication.

### After administering pain medication to a patient, it is MOST important for the nurse to take which of the following actions?

Determine whether the medication is effective

### A woman has a left modified radical mastectomy. Upon transfer from the recovery room to the surgical unit, the nurse notices that the Hemovac drain is half filled with blood. Which of the following actions should the nurse take FIRST?

Look at the recovery room record.

### A 5-year old is scheduled for a tonsillectomy and adenoidectomy. The child is given midazolam (Versed) preoperatively. THe nurse understands the purpose for administering this medication is to:

provides sedation and anxiety reduction

### A liver scan is ordered for a patient prior to surgery. The nurse understands which of the following BEST describes the procedure?

The patient will be asked to lie still while a scanning probe is passed back and forth over the body.

### The nurse knows that serum albumin is used as an indicator of malnutrition because

serum albumin is easy to measure, and can indicate a protein deficiency that may not be detected on physical examination.

### The nurse understands that psoriasis is:

a chronic autoimmune reaction.

### A patient with ovarian cancer experiences severe pain. Which of the following principles should the nurse remember when caring for this patient?

Pain medication is more effective if given before pain becomes severe

### When witnessing the patient's signature during informed consent, it is MOST important for the nurse to make which of the following assessments?

Does the patient give consent voluntarily?

### An elderly client is admitted to the hospital to undergo abdominal sugary. Admitting orders include activity as desired, standard bowel prep, and an intravenous infusion of 5% dextrose in water to infuse at 75 cc per hour starting at 6 pm on the evening before surgery. The nurse understands that the primary purpose of administering intravenous fluids to a patient prior to surgery includes which of the following?

Ensure the client remains adequately hydrated

1 lb per week

### On the morning before surgery, a patient signs an operative consent form. Soon afterward, the patient tells the nurse that the patient does not want the surgery. Which of the following actions should the nurse take FIRST?

Encourage the patient to discuss reasons for canceling the surgery.

### Which of the following fears is most important for the nurse to consider when planning care for a 4-year old about to have surgery?

Fear of mutlilation

### The nurse knows which of the following statements describes an important consideration when spinal anesthesia is used?

Patients must be protected from injury since sensation is impaired

### A 53-year-old is admitted to the hospital for hematuria. He has no previous history of illness, is married and has three children in high school. Which task of middle adulthood would most likely be disturbed by a physical disability?

Assisting his children to grow to adulthood

### The nurse identifies a staff member is using standard precautions appropriately if which of the following is observed?

The staff member places contaminated linens in a leak-proof bag.

### The nurse cares for a patient beginning heparin therapy. The nurse knows which of the following laboratory tests is used to monitor the effectiveness of heparin?

Partial thromboplastin time

### The nurse understands which of the following is the primary reason that elderly adults have constipation?

They have less activity and decreased muscle tone

Anemia

### Which of the following nursing actions is MOST important when caring for a client in pain?

Establish a trusting relationship with the patient

### While a patient is being treated for a wound infection, it is MOST important for the nurse to routinely perform which of the following actions?

Check and record the patient's temperature

### The nurse understands that which of these common foods are the most likely cause of eczema and should be eliminated from the diet?

Milk, wheat, egg whites

### The nurse expects which of the following physiological changes to occur to a patient during episodes of acute pain?

Decreased skin temperature

### The nurse understands the MOST common reason for insertion of a nasogastric tube in a postop patient diagnosed with a duodenal ulcer include which of the following?

Decompress the stomach

Dark urine

### The home care nurse visits a client with diagnosis of ulcerative colitis. The client complains of perineal irritation due to frequent stools. Which of the following suggestions by the nurse is BEST?

Clean the perineal area with soap and water after each bowel movement.

### The nurse in the outpatient client is counseling a client with a diagnosis of cholecystits. The nurse determines teaching is sucessful if the client makes which of the following statements?

We eat a lot of broiled fish and chicken.

### The nurse on the surgical unit cares for several clients with new colosotomies. Immediately after surgery, the nurse identifies which of the following stomas is expected?

A stoma is beefy-red

### The nurse cares for a patient with a Sengstaken-Blakemore tube to treat bleeding esophageal varices. The patient suddenly develops respiratory distress. Which of the following actions should the nurse take FIRST?

Cut the balloon port on the Sengstaken-Blakemore tube

### Immediately following a liver biopsy, the nurse should position the patient in which of the following positions?

On the right side

### The nurse cares for the patient admitted with acute cholecystitis. The patient states that she had severe nausea & vomiting & complains of abdominal pain radiating to the right shoulder. The nurse should question which of the following orders?

Morphine 15 mg IM q 4 hrs prn

### The nurse cares for a patient 18 hours after a gastrectomy. The nurse is MOST concerned if which of the following is observed?

The Levin's tube is attached to low continous suctioning.

Semi-Fowler's

### The nurse obtains a history from a patient suspected of having cirrhosis. Which of the statements, if made by the patients to the nurse, should the nurse recognize as MOST directly related to a patient's development of cirrhosis?

I have been drinking about a fifth of vodka a day for the last few months

### The nurse identifies which of the following diets BEST meets the nutritional needs of a patient diagnosed with cirrhosis?

High in protein & high in carbohydrates

### The nurse care for a patient with a nasogastric tube in place. The patient complains of discomfort in the back of the throat.Which of the following actions by the nurse is BEST?

Spray with viscous xylocaine solution

### The nurse cares for a patient receiving entreal feeding through a nasograstric tube. The physican orders isosorbide (Isordil) 2.5 mg sublingual as needed for chest pain. The nurse instructs the patient's spouse about the correct administration of medication. The nurse determines that teaching is effective if the patient's spouse makes which statment?

I should place the tablet under the patient's tongue.

### The nurse understands which of these factors is the MOST likely source of hepatitis D?

Receiving a blood transfusion

### The nurse instructs a patient about how to increase folic acid in the diet. The nurse determines teaching is effective if the patient makes which of the following statements?

My favorite lunch is a spinach salad.

### The nurse gives discharge instructions to the family of a patient diagnosed with hepatic encephalopahty. The nurse determines further teaching is necessary if the family makes which of the following statements?

Dad should eat meat at every meal

### The nurse instructs a patient about appropriate foods for a high-protein diet. The nurse determines that teaching is effective if the client chooses which of the following menus?

Broiled fish, cream of tomato soup topped with grated cheese and custard

### After chlecystectomy, a patient is returned to the unit with a nasogastric tube connected to a low intermittent suction, an IV of D5W, a T-tube in place, and a Penrose drain. The nurse understands that the purpose of the Penrose drain includes which of the following?

Remove accumulated bile and blood after surger

### THe nurse cares for a patient after a traditional cholecystectomy. The nurse should contact the physician if which of the following is observed?

800 cc bloody drainage the first day postop

### The nurse performs preoperative teaching for a patient scheduled for a colostomy. The nurse explains to the patient that 24 hours after the surgery colostomy drainage will be which of the following?

A scant amount of bright bloody drainage

### A patient is scheduled for bowel surgery and the physician orders a low-residue diet as a part of the bowel preparation. The nurse instructs the patient about foods allowed on a low-residue diet. The nurse determines that teaching is effective if the patient chooses which of the following menus?

Roast lamb, buttered rice and sponge cake

### The nurse obtains a history from a patient suspected of haivng a duodenal ulcer. The nurse expects the patient to make which of the following statements?

I have abdominal pain and tenderness

Fatigue

### A sexual contact of a patient with heptatitis B is given HBlg. THe nurse explains to the contact the purpose of the medication is to

temporarily increase the person's resistance to hepatitis

### The nurse cares for a patient after the physican performed a sigmoid colostomy due to cancer. The nurse instructs the patient about how to care for the stoma. The nurse knows that teaching is sucessful if the patient makes which of the following statments?

I will clean around the stoma with soap and water and pat dry

### The nurse performs a home care visit on a client with a diagnosis of right-sided cerebrovascular accident. The client's spouse complains about having frequent loose stools, and the physician diagnosed viral gastroenteritis. The nurse is MOST concerned if which of the following is observed?

The spouse prepares lunch for the client.

### The nurse understands which of the following is the principal reason for the use of enzyme inhibitors (Diamox) in a patient with pancreatitis?

Pancreatic enzymes escape into interstitial tissue.

### The nurse cares for a client diagnosed with colelithiasis. It is MOST important to instruct the client to avoid which of the following foods?

Cabbage, Cheese, Chocolate

Passive acquired

Example: