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3100 Final Exam Review.
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3100 Final Exam ReviewOne hour after receiving a dose of lispro insulin (Humalog), a patient begins sweating
and develops tremors and dizziness. His blood glucose level signals hypoglycemia (low
blood glucose). Which type of adverse reaction to insulin is this patient most likely
experiencing?
1) Dose-related
2) Patient sensitivity
3) Allergic
4) Anaphylactic - ANS-Correct Answer: 1
Dose-related adverse effects occur when undesired effects result from known
pharmacological effects of medication, such as those that occur as a result of the
patient's insulin dose. Patient sensitivity occurs when a patient is unusually susceptible
to the effects of the drug. In allergic reactions, the immune system identifies a
medication as a foreign substance that should be neutralized or destroyed. An
anaphylactic reaction is a life-threatening allergic reaction.
To promote exercise for Mrs. Gonzales, the nurse's best statement would be:
1) "I know exercising is hard, but you are just going to have to do it to remain healthy."
2) "Gaining weight and getting out of shape takes time; reversing this also takes time."
3) "I know exactly how you feel; I absolutely hate to exercise, too."
4) "The problem was probably the exercise program you participated in." - ANS-Correct
Answer: 2
Many patients feel they have tried to exercise but that it did not make a difference, and
they give up. Remind them that gaining weight and getting out of shape takes time and
that reversing these changes also takes time. Patients may not begin to see the effects
of an exercise program for at least 12 weeks.
What is the preferred site of intramuscular injection for children who are walking?
1) Dorsogluteal
2) Rectus femoris
3) Vastus lateralis
4) Ventrogluteal - ANS-Correct Answer: 4
The ventrogluteal site, located on the lateral hip, involves the gluteus medius and
gluteus minimus muscles. This is the site of choice for intramuscular injections for adults
and young children who are walking. Because it is located away from major blood
vessels and nerves, it is the safest and least painful site. The dorsogluteal site consists
of the gluteal muscles of the buttocks. Because this site is in close proximity to the
sciatic nerve and superior gluteal artery, it is contraindicated for use in infants, children,
,and adults. The rectus femoris site, located in the anterior thigh, is no longer
recommended for infants and children. The vastus lateralis muscle, located in the
anterolateral thigh, is the preferred site for young infants, particularly before walking
age, because it is usually the best developed and contains no large nerves or blood
vessels, minimizing the risk for injury.
Mrs. Lore required a colostomy after surgery for colon cancer. She has refused to
participate in the care of her colostomy or meet with a support member from the ostomy
society. She will not look at the site and describes the colostomy as disgusting. Based
on these data, the priority nursing diagnosis for Mrs. Lore is:
1) Anxiety related to colostomy.
2) Disturbed Body Image related to colostomy.
3) Disturbed Body Image related to incontinence of stool.
4) Impaired Skin Integrity related to fecal drainage. - ANS-Correct Answer: 2
Mrs. Lore is having difficulty adjusting to her colostomy. The colostomy is covered by a
collection device, so there is no incontinence. There is no evidence of either anxiety or
actual skin impairment.
To obtain the most accurate culture information of a chronic wound, the nurse would
recommend:
1) tissue biopsy.
2) swab culture.
3) sterile culture.
4) needle aspiration culture. - ANS-Correct Answer: 1
A tissue biopsy, in which a piece of tissue is removed from the wound bed and
analyzed, provides the most definitive information about infection status of a chronic
wound. Chronic wounds are frequently colonized with bacteria; therefore, surface
culture (swab) would not be accurate.
Which of the following clients would have the most difficulty maintaining
thermoregulation?
1) Young child playing soccer during the summer
2) Middle-aged adult snow skiing
3) Young adult playing golf on a hot day
4) Older adult raking leaves on a cold day - ANS-Correct Answer: 4
Older adults have more difficulty maintaining body heat because of their slower
metabolism, loss of subcutaneous fat, and decreased vasomotor control.
When a patient with heartburn takes antacids, for which problem is he especially at
risk?
, 1) Diarrhea
2) Constipation
3) Stomach ulceration
4) Flatulence - ANS-Correct Answer: 2
Antacids slow peristalsis, placing the patient at risk for constipation. Antibiotics increase
the risk for diarrhea. Stomach ulceration is an adverse effect associated with
nonsteroidal anti-inflammatory drugs (NSAIDs). Iron supplementation may cause
flatulence.
Mr. Vann has a 3 cm × 2 cm eschar on the right heel. The initial treatment choice for this
wound is:
1) elevate the right heel off the surface of the bed.
2) request a surgical consult for débridement of the area.
3) apply a hydrocolloid to promote autolytic débridement of the wound.
4) request an order for an enzymatic débridement medication. - ANS-Correct Answer: 1
A black wound (eschar) requires débridement of the necrotic tissue except at the heel.
The Agency for Healthcare Quality and Research (AHQR) does not recommend
débridement of this site. Therefore, your best treatment choice would be elevation of the
heel off of the bed. This will relieve pressure to the affected area.
The nurse is obtaining the history of a newly admitted patient. Which element in the
patient's history places the patient at risk for urinary tract infection?
1) Hypertension
2) Hypothyroidism
3) Diabetes mellitus
4) Hormonal contraceptive use - ANS-Correct Answer: 3
Diabetes mellitus places the patient at risk for urinary tract infection because glucose in
the urine provides a medium favorable for bacterial growth. Hypertension,
hypothyroidism, and hormonal contraceptive use are not directly related to an increased
risk for urinary tract infection
Which of the following clients has indications of orthostatic hypotension? A client whose
blood pressure is:
1) 118/68 when standing and 110/72 when lying down
2) 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing
3) 126/72 lying down and 133/80 when sitting, and reports shortness of breath
4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy -
ANS-Correct Answer: 4
Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving
to a standing position, with complaints of feeling dizzy and/or faint.
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