Adult 1 Exam #4

What nursing responsibilities are done to obtain a clean-catch urine specimen from a patient (select all that apply)? a. Use sterile container. b. Must start the test with full bladder. c. Insert catheter immediately after voiding. d. Have the patient void, stop, and void in container. e. Have the patient clean the meatus before voiding.

26. a, d, e. A clean-catch urine specimen is obtained in a sterile container after cleaning the meatus. The patient will void a small amount in the toilet, stop, and then void in the container to catch the urine midstream. The first morning specimen is best for a urinalysis. A full bladder is necessary for a urine flow study. A urinary catheter is inserted immediately after voiding to assess residual urine.

20. A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Keep the patient's room darkened. b. Encourage oral fluids to 3000 ml daily. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.

ANS: A A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Since the patient will be nauseated during an acute attack, fluids are administered intravenously. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort.

A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. is much less likely to clot. b. increases patient mobility. c. can accommodate larger needles. d. can be used sooner after surgery.

ANS: A AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility

Which nursing action is of highest priority for a 68-year-old patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain? a. Administer prescribed analgesics. b. Monitor temperature every 4 hours. c. Encourage increased oral fluid intake. d. Give antiemetics as needed for nausea.

ANS: A Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

36. Which of these nursing activities is appropriate for the RN working in the eye clinic to delegate to experienced nursing assistive personnel (NAP)? a. Application of a warm compress to a patient's hordeolum b. Assessment of a patient with possible bacterial conjunctivitis c. Instruction about hand washing for a patient with herpes keratitis d. Administration of antiviral drops to a patient with a corneal ulcer

ANS: A Application of cold and warm packs is included in NAP education and the ability to accomplish this safely would be expected for a nursing assistant working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid? a. Joint pain b. Tachycardia c. Postural hypotension d. Increase in creatinine level

ANS: A Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

28. A patient is scheduled for a right cataract extraction and intraocular lens implantation at an ambulatory surgical center in 2 weeks. During the preoperative assessment of the patient in the physician's office, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. for a white pupil in the patient's right eye. c. how long that the patient has had the cataract. d. for a history of reactions to general anesthetics.

ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. Cataract surgery is done using local anesthetics rather than general anesthetics. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not impact on the perioperative care.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first? a. Check blood pressure and heart rate. b. Administer morphine sulfate 4 mg IV. c. Transport to radiology for an intravenous pyelogram. d. Insert a urethral catheter and obtain a urine specimen.

ANS: A Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important once the patient's cardiovascular status has been determined and stabilized.

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP)? a. Change the ostomy appliance. b. Choose the appropriate ostomy bag. c. Monitor the appearance of the stoma. d. Assess for possible urinary tract infection (UTI).

ANS: A Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the registered nurse (RN).

When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation? a. The patient has metastatic lung cancer. b. The patient has poorly controlled type 1 diabetes. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.

ANS: A Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

24. A patient with hearing loss asks the nurse about the use of a cochlear implant. Which information will the nurse include when replying to the patient? a. Cochlear implants require training in order to receive the full benefit. b. Cochlear implants are not useful for patients with congenital deafness. c. Cochlear implants are most helpful as an early intervention for presbycusis. d. Cochlear implants improve hearing in patients with conductive hearing loss.

ANS: A Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.

3. A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Administer the HCV vaccine and immune globulin. c. Teach the patient about ribavirin (Rebetol) treatment. d. Explain that the infection will resolve over a few months.

ANS: A Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection.

23. An older adult patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. b. Keep the volume low on the hearing aids for the first week while adjusting to them. c. Add the second hearing aid after making the initial adjustment to the first hearing aid. d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

ANS: A Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care? a. Teach the patient about the use of antifungal medications. b. Tell the patient to avoid tub baths until the symptoms resolve. c. Instruct the patient to refer recent sexual partners for treatment. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Monilial urethritis is caused by a fungus and antifungal medications such as nystatin (Mycostatin) or fluconazole (Diflucan) are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.

7. A patient is diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which of these actions will be included in the plan of care? a. Discussing the need for sexually transmitted disease testing b. Applying topical corticosteroids to prevent further inflammation c. Assisting with applying for community visual rehabilitation services d. Educating about the use of antiviral eyedrops to treat the infection

ANS: A Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for STD testing. AIC is treated with antibiotics; antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate.

33. A patient who had cataract extraction and intraocular lens implantation the previous day calls the eye clinic and gives the nurse all of the following information. Which information is the priority to communicate to the health care provider? a. The patient has eye pain rated at a 5 (on a 0-10 scale). b. The patient has questions about the ordered eyedrops. c. The patient has poor depth perception when wearing an eye patch. d. The patient complains that the vision has "not improved very much."

ANS: A Postoperative cataract surgery patients usually experience little or no pain, so pain at a 5 on a 10-point pain level may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring.

35. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.

ANS: A Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Oatmeal with cream, half a banana, and herbal tea c. Split-pea soup, whole-wheat toast, and nonfat milk d. Cheese sandwich, tomato soup, and cranberry juice

ANS: A Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

A 44-year-old patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented first? a. Assist the patient to soak in a 15-minute sitz bath. b. Insert a straight urethral catheter and drain the bladder. c. Encourage the patient to drink several glasses of water. d. Teach the patient how to do isometric perineal exercises.

ANS: A Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possible

19. The nurse is assessing a patient who has recently been treated with amoxicillin (Amoxil) for acute otitis media of the right ear. Which assessment data obtained by the nurse is of most concern? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. The patient frequently asks the nurse to repeat information. d. The patient states that the right ear has a feeling of fullness.

ANS: A The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

11. A patient being admitted to the hospital has an eye patch in place and tells the nurse "I had a recent eye injury, so I need to wear this patch for a few weeks." Which nursing diagnosis will the nurse include in the plan of care? a. Risk for falls related to current decrease in stereoscopic vision b. Ineffective health maintenance related to inability to see surroundings c. Disturbed body image related to eye trauma and need to wear eye patch d. Ineffective denial related to inability to admit the impact of the eye injury

ANS: A The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective denial, disturbed body image, or ineffective health maintenance.

After change-of-shift report, which patient should the nurse assess first? a. Patient with a urethral stricture who has not voided for 12 hours b. Patient who has cloudy urine after orthotopic bladder reconstruction c. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg d. Patient who voided bright red urine immediately after returning from lithotripsy

ANS: A The patient information suggests acute urinary retention, a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.

In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care? a. Place the patient on bed rest. b. Start continuous pulse oximetry. c. Discontinue the retention catheter. d. Restrict the patient's oral protein intake.

ANS: A The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

42. A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin

ANS: A The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.

A 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert a urinary retention catheter. b. Schedule an intravenous pyelogram (IVP). c. Draw blood for a serum creatinine level. d. Administer lorazepam (Ativan) 0.5 mg PO.

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test but does not need to be done urgently.

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Check the fistula site for a bruit and thrill. b. Assess the rate and quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

ANS: A The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

12. A patient in the eye clinic is scheduled for refractometry. Which information will the nurse include in patient teaching? a. "You will need to wear sunglasses for a few hours after the exam." b. "The surface of your eye will be numb while the doctor does the exam." c. "You should not take any of your eye medicines before the examination." d. "The doctor will shine a bright light into your eye during the examination."

ANS: A The pupil is dilated by using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

12. Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

ANS: A The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

5. The nurse administering α-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for a. leukopenia. b. hypokalemia. c. polycythemia. d. hypoglycemia.

ANS: A Therapy with ribavirin and α-interferon may cause leukopenia. The other problems are not associated with this drug therapy.

4. The nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from ultraviolet light because ultraviolet sunlight exposure is associated with the development of a. cataracts. b. glaucoma. c. anisocoria. d. exophthalmos.

ANS: A Ultraviolet light exposure is associated with the accelerated development of cataracts. Glaucoma is caused by increased intraocular pressure, exophthalmos is associated with hyperthyroidism, and anisocoria can occur normally in a small percentage of the population or may be caused by injury or central nervous system disorders.

30. Which action should the RN who is working in the eye and ear clinic delegate to an LPN/LVN? a. Use a Snellen chart to check a patient's visual acuity. b. Evaluate a patient's ability to insert soft contact lenses. c. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D. d. Assess the external auditory canal for signs of irritation caused by a hearing aid.

ANS: A Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient education are higher level skills that require RN education and scope of practice.

5. Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 40 feet and the right eye can see at 20 feet what a person with normal vision can see at 50 feet. The nurse records which of the following findings as visual acuity? a. OS 20/40; OD 20/50 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

ANS: A When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.

46. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)? a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about α-interferon therapy. d. Give hepatitis B immune globulin. e. Teach about choices for oral antiviral therapy.

ANS: A, B, D The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

21. Which observation by the nurse when examining a patient's auditory canal and tympanic membrane is a priority to report to the health care provider? a. There is a cone of light visible. b. The tympanum is bluish-tinged. c. Cerumen is present in the auditory canal. d. The skin in the ear canal is dry and scaly.

ANS: B A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

It is most important that the nurse ask a patient admitted with acute glomerulonephritis about a. history of kidney stones. b. recent sore throat and fever. c. history of high blood pressure. d. frequency of bladder infections.

ANS: B Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection (UTI).

23. The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

ANS: B After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.

ANS: B Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values also would be monitored in patients with CKD but would not affect whether the captopril was given or not.

8. Which topic will the nurse include in patient teaching after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of antibiotic eyedrops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 24 hours after the surgery

ANS: B Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery, and the patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed since a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

6. Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 20 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.

ANS: B Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

24. The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's skin has multiple spider-shaped blood vessels on the abdomen.

ANS: B Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

35. The charge nurse observes a newly hired nurse performing all of the following interventions for a patient who has just arrived in the postanesthesia care unit after having right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

ANS: B Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

43. A 36-year-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is most important to communicate to the health care provider? a. Weight loss of 2 lb (1 kg) b. Positive urine pregnancy test c. Hemoglobin level of 10.4 g/dL d. Complaints of nausea and anorexia

ANS: B Because ribavirin is teratogenic, the medication will need to be discontinued immediately. Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and may require actions such as patient teaching, but they would not require immediate cessation of the therapy.

A 58-year-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma due to a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Urine output is 20 mL/hr for 2 hours. c. Incisional pain level is reported as 9/10. d. Crackles are heard at bilateral lung bases.

ANS: B Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.

Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

ANS: B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate

The nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes daily about the increased risk for a. kidney stones. b. bladder cancer. c. bladder infection. d. interstitial cystitis.

ANS: B Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking.

The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient complains of feeling bloated after the inflow.

ANS: B Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

Which nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician? a. Educate patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for reasons for increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

ANS: B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

11. Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

ANS: B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

A 22-year-old female patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuria d. Burning with urination

ANS: B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).

1. Which information will the nurse include when teaching a patient about routine glaucoma testing? a. The test involves reading a Snellen chart at a distance of 20 feet. b. Application of a Tono-pen to the surface of the eye will be needed. c. The examination includes checking the pupil's reaction to a bright light. d. Medications to dilate the pupil will be used before testing for glaucoma.

ANS: B Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders.

4. A patient is seen at a clinic for repeated hordeolum of the eyes during the last 6 months. To help prevent further infection, the nurse advises the patient to a. apply cold compresses at the first sign of recurrence. b. discard all open or used cosmetics used near the eyes. c. wash the scalp and eyebrows with an antiseborrheic shampoo. d. be evaluated for the presence of sexually transmitted diseases (STDs).

ANS: B Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STD testing.

When planning teaching for a 59-year-old male patient with benign nephrosclerosis the nurse should include instructions regarding a. preventing bleeding with anticoagulants. b. monitoring and recording blood pressure. c. obtaining and documenting daily weights. d. measuring daily intake and output volumes.

ANS: B Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.

A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Milk of magnesia 30 mL c. Calcium phosphate (PhosLo) d. Acetaminophen (Tylenol) 650 mg

ANS: B Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

4. The nurse will plan to teach the patient diagnosed with acute hepatitis B about a. side effects of nucleotide analogs. b. measures for improving the appetite. c. ways to increase activity and exercise. d. administering α-interferon (Intron A).

ANS: B Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

27. The nurse at the outpatient surgery unit obtains all of this information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information has the most immediate implications for the patient's care? a. The patient has not eaten anything for 8 hours. b. The patient takes three antihypertensive medications. c. The patient gets nauseated with general anesthesia. d. The patient has had blurred vision for several years.

ANS: B Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Blurred vision is an expected finding with cataracts. Cataract extraction and intraocular lens implantation are done using local anesthesia.

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating a. milk and cheese. b. sardines and liver. c. legumes and dried fruit. d. spinach, chocolate, and tea.

ANS: B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

12. To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse will evaluate the patient for improvement in a. eye pain. b. visual field. c. blurred vision. d. depth perception.

ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual field. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

22. When the nurse is admitting a 78-year-old patient, the patient repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

ANS: B Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend the nurse.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)? a. Pyridium may cause photosensitivity b. Pyridium may change the urine color. c. Take the Pyridium for at least 7 days. d. Take Pyridium before sexual intercourse.

ANS: B Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Pyridium does not cause photosensitivity. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI.

40. Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? a. Advise limiting alcohol intake to 1 drink daily. b. Schedule for liver cancer screening every 6 months. c. Initiate administration of the hepatitis C vaccine series. d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually.

ANS: B Patients with chronic hepatitis are at higher risk for development of liver cancer, and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.

31. A 34-year old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration? a. Ribavirin (Rebetol, Copegus) 600 mg PO bid b. Pegylated α-interferon (PEG-Intron, Pegasys) SQ daily c. Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

ANS: B Pegylated α-interferon is administered weekly. The other medications are appropriate for a patient with chronic hepatitis C infection.

2. Which assessment information obtained by the nurse when performing an eye examination for a 78-year-old patient indicates that more extensive examination of the eyes is needed? a. The patient's sclerae are light yellow in color. b. The patient complains of persistent photophobia. c. The pupil recovers slowly after being stimulated by a penlight. d. There is a whitish gray ring encircling the periphery of the iris.

ANS: B Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 78-year-old patient.

39. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Assisting the patient to choose the diet

ANS: B Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.

When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

ANS: B Since hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output, but does not correct the cause of the renal failure.

10. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix). due. Which action should the nurse take? a. Administer both drugs. b. Administer the spironolactone. c. Withhold the spironolactone and administer the furosemide. d. Withhold both drugs until discussed with the health care provider.

ANS: B Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

37. Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient has increased pain after eating. d. The patient complains of chronic heartburn.

ANS: B Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

7. The nurse is observing a student who is preparing to perform an ear examination of a 24-year-old patient. The nurse will need to intervene if the student a. chooses a speculum smaller than the ear canal. b. pulls the auricle of the ear down and backward. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

ANS: B The auricle should be pulled up and back when assessing an adult. The other actions are appropriate when performing an ear examination.

5. Which topic will the nurse plan to include when teaching the patient with herpes simplex keratitis of the left eye about management of the infection? a. How to apply an occlusive dressing to the affected eye b. Need for frequent hand washing and avoiding touching the eyes c. Application of antibiotic drops to the left eye several times daily d. Use of corticosteroid ophthalmic ointment to decrease inflammation

ANS: B The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids typically are not ordered because they can contribute to a longer course of infection and more complications.

9. Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis? a. Maintaining good nutrition b. Avoiding alcohol ingestion c. Taking lactulose (Cephulac) d. Using vitamin B supplements

ANS: B The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

33. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify sources of hepatitis exposure.

ANS: B The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

When the nurse is caring for a patient who has been admitted with a severe crushing injury after an industrial accident, which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 56 mg/dL

ANS: B The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening.

1. To evaluate the effectiveness of the prescribed bifocals for a patient with myopia and presbyopia, the nurse in the eye clinic will check the patient for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.

ANS: B The lenses are prescribed to correct the patient's near and distant vision. The nurse also may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data will not evaluate whether the patient's bifocals are effective.

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Complaint of flank pain b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1° F (57.8° C)

ANS: B The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

13. A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

ANS: B The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.

A 58-year-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which nursing diagnosis is a priority for the patient? a. Activity intolerance related to rapidly increased weight b. Excess fluid volume related to low serum protein levels c. Disturbed body image related to peripheral edema and ascites d. Altered nutrition: less than required related to protein restriction

ANS: B The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites.

A 56-year-old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

ANS: B The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.

A 34-year-old male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of a. recent kidney trauma. b. gonococcal urethritis. c. recurrent bladder infection. d. benign prostatic hyperplasia.

ANS: B The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.

15. During the nursing history, a patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about: a. tympanometry. b. rotary chair testing. c. pure-tone audiometry. d. bone-conduction testing.

ANS: B The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Elevate the patient's arm above the level of the heart. b. Report the patient's symptoms to the health care provider. c. Remind the patient about the need to take a daily low-dose aspirin tablet. d. Educate the patient about the normal vascular response after AVG insertion.

ANS: B The patient's complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? a. Obtain renal ultrasound. b. Insert retention catheter. c. Infuse normal saline at 50 mL/hour. d. Draw blood for complete blood count.

ANS: B The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.

15. A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is appropriate? a. Grieving related to current loss of functional vision b. Anxiety related to the possibility of permanent vision loss c. Situational low self-esteem related to loss of visual function d. Risk for falls related to inability to see environmental hazards

ANS: B The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact and the patient is not at a high risk for falls. There is no indication of impaired self-esteem at this time.

7. A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Are you taking corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"

ANS: B The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in function. c. readiness for enhanced coping related to need for information. d. self-care deficit, toileting, related to denial of altered body function.

ANS: B The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient's insistence that only the ostomy nurse care for the stoma indicates that denial is not present.

2. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.

ANS: B The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

14. To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

ANS: B The protein in the blood in the gastrointestinal (GI) tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

Which action will the nurse anticipate taking for an otherwise healthy 50-year-old who has just been diagnosed with Stage 1 renal cell carcinoma? a. Prepare patient for a renal biopsy. b. Provide preoperative teaching about nephrectomy. c. Teach the patient about chemotherapy medications. d. Schedule for a follow-up appointment in 3 months.

ANS: B The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.

6. Which nursing action is included when assessing a patient's visual field? a. Position the patient 20 feet from the Snellen chart. b. Have the patient cover one eye while facing the nurse. c. Instruct the patient to follow a moving object using only the eyes. d. Shine a light into one pupil and observe the response for both pupils.

ANS: B To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. The other actions are needed to test for visual acuity, extraocular movements, and consensual pupil response.

32. The nurse notes that nursing assistive personnel (NAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by NAP indicates that the nurse should intervene immediately? a. NAP raise the side rails on the bed. b. NAP turn on the patient's television. c. NAP turn the patient to the right side. d. NAP place an emesis basin at the bedside.

ANS: B Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate.

A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the nurse teach the patient to avoid (select all that apply)? a. Milk b. Liver c. Spinach d. Chicken e. Cabbage f. Chocolate

ANS: B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.

Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. The patient's blood pressure is 150/92. c. There is a nontender lump in the axilla. d. The patient has a round, moonlike face.

ANS: C A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, moon face, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.

3. When performing an eye examination, the nurse will assess for accommodation by: a. covering one eye for 1 minute and noting the pupil reaction when the cover is removed. b. shining a light into the patient's eye and watching the pupil response in the opposite eye. c. observing the pupils when the patient focuses on a close object and then on a distant object. d. touching the patient's pupil with a small piece of sterile cotton and watching for a blink reaction.

ANS: C Accommodation is defined as the ability of the lens to adjust to various distances. The other nursing actions also may be part of the eye examination, but they do not test for accommodation.

21. The home health nurse observes a patient taking these actions when self-administering eardrops. Which patient action indicates a need for more teaching? a. The patient leaves the ear wick in place while administering the drops. b. The patient lies down before and for 2 minutes after administering the drops. c. The patient gets the eardrops out of the refrigerator just before administering the drops. d. The patient holds the tip of the dropper 1 cm above the ear while administering the drops.

ANS: C Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate.

19. Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

ANS: C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate? a. Monitor the patient's intake and output over night. b. Have the patient drink small amounts of fluid frequently. c. Use an ultrasound scanner to check the postvoiding residual volume. d. Reassure the patient that this is normal after rectal surgery because of anesthesia.

ANS: C An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours.

2. A patient is seen in the ophthalmology clinic and diagnosed with recurrent staphylococcal and seborrheic blepharitis. The nurse will plan to teach the patient about a. saline irrigation of the eyes. b. surgical removal of the lesion. c. using baby shampoo to clean the lids. d. the use of cool compresses to the eyes.

ANS: C Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

A 28-year-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time? a. Complications of renal transplantation b. Methods for treating severe chronic pain c. Discussion of options for genetic counseling d. Differences between hemodialysis and peritoneal dialysis

ANS: C Because a 28-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.

Nursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in patients admitted to the hospital? a. Encouraging adequate oral fluid intake b. Testing urine with a dipstick daily for nitrites c. Avoiding unnecessary urinary catheterizations d. Providing frequent perineal hygiene to patients

ANS: C Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.

25. A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.

ANS: C Because the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

A 46-year-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take? a. Teach the patient to take the prescribed Bactrim for 3 more days. b. Remind the patient about the need to drink 1000 mL of fluids daily. c. Obtain a midstream urine specimen for culture and sensitivity testing. d. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

ANS: C Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic.

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider? a. The patient is voiding every 4 hours. b. The patient is using opioids for pain. c. The patient has seen clots in the urine. d. The patient is anxious about the cancer.

ANS: C Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.

18. A patient with chronic otitis media is scheduled for a tympanoplasty. Before surgery, the nurse teaches the patient that postoperative expectations include a. keeping the head elevated. b. the need for prolonged bed rest. c. avoidance of coughing or blowing the nose. d. continuous antibiotic irrigation of the ear canal.

ANS: C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse? a. Blood urea nitrogen level is 70 mg/dL. b. Urine output over the last 2 hours is 30 mL. c. Audible crackles bilaterally over the posterior chest to the midscapular level. d. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.

ANS: C Crackles heard to a high level indicate a need for rapid actions such as assessment of oxygen saturation, reporting the findings to the health care provider, initiating oxygen therapy, and dialysis. The other findings will also be reported, but are typical of Goodpasture syndrome and do not require immediate nursing action.

41. A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam? a. Start the hepatitis B immunization series. b. Teach the patient about hepatitis A immune globulin. c. Ask whether the patient has been screened for hepatitis C. d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).

ANS: C Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed. Although routine hepatitis B immunization is recommended for infants, children, and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-borne infections. Because the patient has already had hepatitis A, immunization and anti-HAV IgM levels will not be needed.

36. The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.

ANS: C Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

31. The camp nurse is caring for a patient who is complaining of bilateral eye pain after a campfire log exploded, sending sparks into the patient's eyes. Which of these actions will the nurse take first? a. Apply ice packs to the eyes. b. Flush the eyes with sterile saline. c. Cover the eyes with dry sterile patches and protective eye shields. d. Apply antiseptic ophthalmic ointment from the first aid kit to the eyes.

ANS: C Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. Except in the case of chemical exposure, the nurse should not begin treatment until the patient has been assessed by a health care provider and orders are available.

26. Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.

ANS: C Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with a. antibiotics. b. antifungals. c. anticoagulants. d. antihypertensives.

ANS: C Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.

Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation? a. Heart rate b. Blood urea nitrogen (BUN) level c. Urine output d. Creatinine clearance

ANS: C Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)? a. Creatinine 1.2 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

ANS: C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when EPO is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider, but will not affect whether the medication is administered

The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following? a. "I should stop having coffee and orange juice for breakfast." b. "I will buy calcium glycerophosphate (Prelief) at the pharmacy." c. "I will start taking high potency multiple vitamins every morning." d. "I should call the doctor about increased bladder pain or odorous urine."

ANS: C High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.

17. A patient with external otitis has an ear wick placed and a new prescription for antibiotic otic drops. After the nurse provides patient teaching, which patient statement indicates that more instruction is needed? a. "I may use aspirin or acetaminophen (Tylenol) for pain relief." b. "I should apply the eardrops to the cotton wick in my ear canal." c. "I should clean my ear canal daily with a cotton-tipped applicator." d. "I may use warm compresses to the outside of my ear for comfort."

ANS: C Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful.

9. The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a new patient at the eye clinic. Which information given by the patient will have the most implications for the patient's treatment? a. "I use aspirin when I have a sinus headache." b. "I have had frequent episodes of conjunctivitis." c. "I take metoprolol (Lopressor) daily for angina." d. "I have not had an eye examination for 10 years."

ANS: C It is important to note whether the patient takes any β-adrenergic blockers because this category of medications also is used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

29. When admitting a patient for surgery, the nurse learns that the patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to a. obtain more information about the cause of the patient's vision loss. b. obtain information from the spouse about the patient's special needs. c. make eye contact with the patient and ask about any need for assistance. d. perform an evaluation of the patient's visual acuity using a Snellen chart.

ANS: C Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment.

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? a. Demonstrate the use of the Credé maneuver. b. Teach exercises to strengthen the pelvic floor. c. Place a bedside commode close to the patient's bed. d. Use an ultrasound scanner to check postvoiding residuals.

ANS: C Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.

When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed since retained fluid is removed during dialysis. c. More protein will be allowed because of the removal of urea and creatinine by dialysis. d. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.

ANS: C Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene? a. The LPN/LVN administers erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate in the hallway. c. The LPN/LVN gives the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.

ANS: C Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

22. The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. in the morning. c. with each meal. d. for abdominal pain.

ANS: C Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

13. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "These are normal side effects of the drug, which should become less noticeable with time." b. "If you occlude the puncta after you administer the drops, it will help relieve these side effects." c. "The drops are uncomfortable, but it is very important for you to use them as prescribed to retain your vision." d. "These symptoms are caused by glaucoma and may indicate a need for an increased dosage of the eyedrops."

ANS: C Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma.

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective? a. "I will buy seven new catheters weekly and use a new one every day." b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will clean the catheter carefully before and after each catheterization." d. "I will need to take prophylactic antibiotics to prevent any urinary tract infections."

ANS: C Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.

16. When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I always sleep with the radio on." Which follow-up question is most appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed any ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

ANS: C Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Have you noticed any ringing in your ears?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

13. The nurse is assessing a 48-year-old patient for presbyopia. Which equipment will the nurse need to obtain before the examination? a. Penlight b. Tono-pen c. Jaeger chart d. Snellen chart

ANS: C Presbyopia is the normal loss of near vision that occurs with age and is assessed using a Jaeger chart. The Snellen chart, penlight, and the Tono-pen are used when assessing for other visual disorders.

Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the a. blood urea nitrogen (BUN) and creatinine. b. blood glucose level. c. patient's bowel sounds. d. level of consciousness (LOC).

ANS: C Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse's decision to give the medication.

A 63-year-old male patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the physician? a. Cloudy appearing urine b. Hypotonic bowel sounds c. Heart rate 102 beats/minute d. Continuous stoma drainage

ANS: C Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

A 68-year-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? a. Application of ostomy appliances b. Barrier products for skin protection c. Catheterization technique and schedule d. Analgesic use before emptying the pouch

ANS: C The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.

10. In order to assess the visual acuity for a patient in the outpatient clinic, the nurse will need to obtain a (an) a. penlight. b. Amsler grid. c. Snellen chart. d. ophthalmoscope.

ANS: C The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and Amsler grid also may be used during an eye examination, but they are not helpful in assessing visual acuity.

45. In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area where the nurse will assess for this change. a. 1 b. 2 c. 3 d. 4

ANS: C The area around the umbilicus should be indicated. Cullen's sign consists of ecchymosis around the umbilicus. Cullen's sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine output b. Calcium level c. Cardiac rhythm d. Neurologic status

ANS: C The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene? a. Taping the catheter to the skin on the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Disconnecting the catheter from the drainage tube to obtain a specimen d. Using an alcohol-based gel hand cleaner before performing catheter care

ANS: C The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.

A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question? a. NPO for 6 hours before IVP procedure b. Normal saline 500 mL IV before procedure c. Ibuprofen (Advil) 400 mg PO PRN for pain d. Dulcolax suppository 4 hours before IVP procedure

ANS: C The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The blood urea nitrogen (BUN) and creatinine levels are elevated. c. The patient's central venous pressure (CVP) is decreased. d. The patient has level 8 (on a 10-point scale) incisional pain.

ANS: C The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

After a ureterolithotomy, a female patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care? a. Provide teaching about home care for both catheters. b. Apply continuous steady tension to the ureteral catheter. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops.

ANS: C The health care provider should be notified if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Because the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.

Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider? a. The blood urea nitrogen (BUN) level is 67 mg/dL. b. The creatinine level is 3.0 mg/dL. c. Urine output over an 8-hour period is 2500 mL. d. The glomerular filtration rate is <30 mL/min/1.73m2.

ANS: C The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

A 32-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider? a. Infuse 5% dextrose in normal saline at 75 mL/hr. b. Order regular diet after patient is awake and alert. c. Give ketorolac (Toradol) 10 mg PO PRN for pain. d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.

ANS: C The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

16. To decrease the risk for future hearing loss, which action should the nurse working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer rubella immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to very amplified music. d. Teach patients to regularly irrigate the ear to decrease cerumen impaction.

ANS: C The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Cerumen may need to be regularly removed for older patients, but this is not a routine need for younger adults. Only women of childbearing age who have not been previously vaccinated or exposed to rubella will require immunization. Otoscopic examinations are not necessary for all patients.

34. Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure (BP), heart rate, and respirations. d. Place the patient in the supine position.

ANS: C The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in a supine position.

17. To prepare a 56-year-old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

ANS: C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

When preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach about a. premedicating to prevent nausea. b. obtaining wigs and scarves to wear. c. emptying the bladder before the medication. d. maintaining oral care during the treatments.

ANS: C The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not usually experienced with intravesical chemotherapy.

27. When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.

ANS: C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Obtain blood to check the blood urea nitrogen (BUN) level. c. Check the patient's blood pressure. d. Give prescribed PRN antiemetic drugs.

ANS: C The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions also may be appropriate, based on the blood pressure obtained.

15. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Place the patient on a pressure-relieving mattress. d. Perform passive range of motion daily.

ANS: C The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of a. replacing fluid volume. b. preventing hypertension. c. maintaining cardiac output. d. diluting nephrotoxic substances.

ANS: C The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

37. A patient with a head injury after a motor vehicle accident arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Elevate the head to 45 degrees. b. Administer the ordered analgesic. c. Check the patient's oxygen saturation. d. Examine the eye for evidence of trauma.

ANS: C The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions also are appropriate but are not the first action the nurse will take.

18. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

ANS: C The risk of infection is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for urgent action.

32. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. 40-year-old with chronic pancreatitis who has gnawing abdominal pain b. 58-year-old who has compensated cirrhosis and is complaining of anorexia c. 55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

ANS: C This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL. a. 400 b. 800 c. 1000 d. 1400

ANS: C Usually fluid replacement should be based on the patient's measured output plus 600 mL/day for insensible losses.

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. choosing diuretic fluids such as coffee. d. drinking 2000 to 3000 mL of fluid a day.

ANS: D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

29. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

ANS: D A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

21. The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.

ANS: D Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

20. The nurse in the eye clinic is examining a 65-year-old patient who says "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Inform the patient that these spots may indicate damage to the retina. d. Use an ophthalmoscope to examine the posterior chamber of the eyes.

ANS: D Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a. The patient denies pain with voiding. b. The urine dipstick is negative for nitrites. c. The antistreptolysin-O (ASO) titer is decreased. d. The periorbital and peripheral edema is resolved.

ANS: D Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy? a. Blood in urine b. Left flank bruising c. Left flank discomfort d. Decreased urine output

ANS: D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

14. A patient arrives in the emergency department complaining of eye itching and pain caused by sleeping with contact lenses in place. To facilitate further examination of the eye, the nurse will anticipate the need for: a. a tonometer. b. eye patching. c. a refractometer. d. fluorescein dye.

ANS: D Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be visualized using fluorescein dye. The other items listed would not be helpful in determining the cause of this patient's symptoms.

10. A patient with a left retinal detachment has a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The use of bilateral eye patches to reduce movement of the operative eye b. The need to wear dark or tinted glasses to protect the eyes from bright light c. The procedure for sterile dressing changes when the eye dressing is saturated d. The purpose of maintaining the head in a prescribed position for several weeks

ANS: D Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure.

Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)? a. Blood urea nitrogen (BUN) level b. Urine output c. Creatinine level d. Calculated glomerular filtration rate (GFR)

ANS: D GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

25. Which teaching will the nurse implement for a patient who has just been diagnosed with viral conjunctivitis? a. Explain the purpose of antiviral eyedrops. b. Show how to perform eye irrigation safely. c. Instruct about how to insert soft contact lenses. d. Demonstrate appropriate hand-washing technique.

ANS: D Hand washing is the major means to prevent the spread of conjunctivitis. Antiviral drops and eye irrigation will not be helpful in shortening the disease process. Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva.

1. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

ANS: D Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for a. creatinine. b. potassium. c. total cholesterol. d. serum phosphate.

ANS: D If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

A 68-year-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care? a. Restrict fluids between meals and after the evening meal. b. Apply absorbent incontinent pads liberally over the bed linens. c. Insert an indwelling catheter until the symptoms have resolved. d. Assist the patient to the bathroom every 2 hours during the day.

ANS: D In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

A 55-year-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan? a. Assist the patient to the bathroom q3hr. b. Place a commode at the patient's bedside. c. Demonstrate how to perform the Credé maneuver. d. Teach the patient how to perform Kegel exercises.

ANS: D Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.

A patient complains of leg cramps during hemodialysis. The nurse should first a. reposition the patient. b. massage the patient's legs. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

20. Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness

ANS: D Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

28. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

ANS: D NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

18. When taking a health history from a new patient in the outpatient clinic, which information may indicate the need to perform a focused hearing assessment? a. The patient uses albuterol (Proventil) for acute asthma. b. The patient takes atenolol (Tenormin) to prevent angina. c. The patient uses acetaminophen (Tylenol) frequently for headaches. d. The patient has taken ibuprofen (Advil) for 20 years to treat arthritis.

ANS: D Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

17. Which finding by the nurse during the admission assessment for a patient may indicate that the patient is at risk for falls while hospitalized? a. Lateralization with Weber test b. Positive result for Rinne testing c. Inability to hear a low-pitched whisper d. Nystagmus when head is turned rapidlY

ANS: D Nystagmus suggests that the patient may have problems with balance related to disease of the vestibular system. The other tests are used to check hearing; abnormal results for these do not indicate potential problems with balance.

26. Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1? a. Application of corticosteroid ophthalmic ointment to the eyes. b. Application of povidone-iodine (Betadine) gel around the eye. c. Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs). d. Importance of taking all of the ordered oral acyclovir (Zovirax).

ANS: D Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Although Betadine gel may be applied to the skin around the eyes for herpes zoster (varicella) infections, it is not used for herpes simplex infections. NSAIDs can be used to treat the pain associated with keratitis.

Which assessment data reported by a 28-year-old male patient is consistent with a lower urinary tract infection (UTI)? a. Poor urine output b. Bilateral flank pain c. Nausea and vomiting d. Burning on urination

ANS: D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient slows the inflow rate when experiencing pain. b. The patient leaves the catheter exit site without a dressing. c. The patient plans 30 to 60 minutes for a dialysate exchange. d. The patient cleans the catheter while taking a bath every day.

ANS: D Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for a. vasodilation. b. poor skin turgor. c. bounding pulses. d. rapid respirations.

ANS: D Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

38. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

ANS: D Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

14. A patient who is being admitted to the hospital for abdominal pain and nausea tells the nurse about a history of glaucoma. Which of these prescribed medications should the nurse question? a. morphine sulfate 4 mg IV b. diazepam (Valium) 5 mg IV c. betaxolol (Betoptic) 0.25% eyedrops d. scopolamine patch (Transderm Scop) 1.5 mg

ANS: D Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient.

30. Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Draw blood for hepatitis serology testing. c. Discuss the need to increase caloric intake. d. Review the patient's current medication list.

ANS: D Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

16. Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

ANS: D TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

8. When obtaining a health history from a 52-year-old patient, which patient statement is most important to communicate to the health care provider? a. "My vision seems blurry now when I read." b. "I have noticed that my eyes are drier now." c. "It is hard for me to see when I drive at night." d. "The peripheral part of my vision is decreased."

ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.

After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first? a. Document the QRS interval. b. Notify the patient's health care provider. c. Look at the patient's current blood urea nitrogen (BUN) and creatinine levels. d. Check the chart for the most recent blood potassium level.

ANS: D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.

8. Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters should also be monitored, but they are not directly associated with the patient's current symptoms.

44. A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice? a. Patient who is receiving chemotherapy for liver cancer b. Patient who is receiving treatment for acute hepatitis C c. Patient who has a wound infection after cholecystectomy d. Patient who requires pain management for chronic pancreatitis

ANS: D The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection.

9. In reviewing a 50-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. b. pupil reaction. c. color perception. d. peripheral vision

ANS: D The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.

34. Which assessment finding in a patient who was struck in the right eye with a baseball is a priority for the nurse to communicate to the health care provider in the emergency department? a. The patient complains of a right-sided headache. b. The sclerae on the right eye have broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" blocking part of the visual field.

ANS: D The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye with a ball.

11. A patient with age-related macular degeneration has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will need to use bright lights to read for at least the next week." b. "I will use drops to keep my pupils dilated until my appointment." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will keep covered with long-sleeved shirts and pants for the next 5 days."

ANS: D The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

6. A new patient with 20/200 vision (with the use of corrective lenses) is being cared for by the nurse in the eye clinic. The nurse will plan to teach the patient about a. how to use a cane safely. b. how to access audio books. c. where Braille instruction is available. d. where to obtain specialized magnifiers.

ANS: D Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.

19. Which action will the nurse include in the plan of care for a patient who has vestibular disease? a. Check Rinne and Weber tests. b. Face the patient when speaking. c. Enunciate clearly when speaking. d. Monitor the patient's ability to ambulate safely.

ANS: D Vestibular disease affects balance so the nurse should monitor the patient during activities that require balance. The other action might be used for patients with hearing disorders.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-year-old female patient with cystitis when the patient states which of the following? a. "I can use vaginal antiseptic sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient's a. urine osmolality. b. serum potassium. c. blood glucose level. d. blood urea nitrogen (BUN) and creatinine.

ANS: D When a patient at risk for chronic kidney disease (CKD) receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin

3. Which action should the nurse take when assisting a totally blind patient to walk to the bathroom? a. Take the patient by the arm and lead the patient slowly to the bathroom. b. Have the patient place a hand on the nurse's shoulder and guide the patient. c. Stay beside the patient and describe any obstacles on the path to the bathroom. d. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.

Number the following physiologic occurrences in the order they occur in the formation of urine. Begin with 1 for the fist occurrence and number through 6 for the last occurrence in the formation of urine. ____ a. Blood is filtered in the glomerulus. ____ b. Reabsorption of water in the loop of Henle. ____ c. Reabsorption of electrolytes, glucose, amino acids, and small proteins in the tubules. ____ d. Acid-base regulation with conservation of bicarbonate (HCO3-) and secretion of excess H+ in the distal tubule. ____ e. Active reabsorption of chloride (Cl-) ions and passive reabsorption of sodium (Na+) ions in the ascending loop of Henle. ____ f. Ultrafiltrate flows from Bowman's capsule and passess down the tubules without blood cells, platelets, or large plasma proteins.

Rationale: Blood is filtered in the glomerulus and the ultrafiltrate flows from the Bowman's capsule to the tubules for reabsorption of essential materials and secretion of the nonessential ones. In the proximal convoluted tubule, most electrolytes, glucose, amino acids, and small proteins are reabsorbed. Water is conserved in the loop of Henle with chloride and sodium reabsorbed in the ascending loop. The distal convoluted tubules complete final water balance and acid-base balance.

What are common diagnostic studies done for a patient with severe renal colic (select all that apply)? a. CT scan b. Urinalysis c. Cystoscopy d. Ureteroscopy e. Abdominal ultrasound

a, b, e. Testing would include urinalysis to see crystals and look for red blood cells. Abdominal ultrasound and CT scan may also be done.

The right atrium myocytes secrete atrial natriuretic peptide (ANP)when there is increased plasma volume. What actions does ANP take to produce a large volume of dilute urine (select all that apply)? a. Inhibits renin b. Increases ADH c. Inhibits angiotensin II action d. Decreases sodium excretion e. Increases aldosterone secretion

a, c Rationale: Atrial natriuretic peptide (ANP) responds to increased atrial distention by increasing sodium excretion and inhibiting renin, ADH, and angiotensin action. Aldosterone secretion is also suppressed. ANP also causes afferent arteriole relaxation that increases the glomerular filtration rate (GFR).

Which important functions of regulation of water balance and acid-base balance occur in the distal convoluted tubules of the nephron (select all that apply)? a. Secretion of H+ into filtrate b. Reabsorption of water without ADH c. Reabsorption of Na+ in exchange for K+ d. Reabsorption of glucose and amino acids e. Reabsorption of water under ADH influence f. Reabsorption of Ca+2 under parathormone influence

a,c,e,f Rationale: The distal tubules regulate water and acid-base balance by reabsorption of water under antidiuretic hormone (ADH) influence, secreting H and reabsorbing bicarbonate, reabsorption of Na+ in exchange for K+, and reabsorption of Ca+2 with the influence of parathormone. The reabsorption of water without ADH occurs in the proximal convoluted tubule and the descending loop of Henle. The reabsorption of glucose and amino acids occurs in the proximal convoluted tubule. Active reabsorption of Cl- and passive reabsorption of Na+ occurs in the ascending loop of Henle.

Which urine specific gravity value would indicate to the nurse that the patient is receiving excessive IV fluid therapy? a. 1.002 b. 1.010 c. 1.025 d. 1.030

a. A urine specific gravity of 1.002 is low, indicating dilute urine and the excretion of excess fluid. Fluid overload, diuretics, or lack of ADH can cause dilute urine. Normal urine specific gravity is 1.003 to 1.030. A high urine specific gravity indicates concentrated urine that would be seen in dehydration.

In which clinical situation would the increased release of erythropoietin be expected? a. Hypoxemia b. Hypotension c. Hyperkalemia d. Fluid overload

a. Erythropoietin is released when the oxygen tension of the renal blood supply is low and stimulates production of red blood cells in the bone marrow. Hypotension causes activation of the renin-angiotensin-aldosterone system, as well as release of ADH. Hyperkalemia stimulates the release of aldosterone from the adrenal cortex and fluid overload does not directly stimulate factors affecting the erythropoietin release by the kidney.

A patient with an obstruction of the renal artery causing renal ischemia exhibits hypertension. What is one factor that may contribute to the hypertension? a. Increased renin release b. Increased ADH secretion c. Decreased aldosterone secretion d. Increased synthesis and release of prostaglandins

a. Renin is released in response to decreased arterial blood pressure (BP), renal ischemia, decreased extracellular fluid (ECF), decreased serum Na+ concentration, and increased urinary Na+ concentration. It is the catalyst of the reninangiotensin- aldosterone system, which raises stimulated. ADH is secreted by the posterior pituitary in response to serum hyperosmolality and low blood volume. Aldosterone is secreted only after stimulation by angiotensin II. Kidney prostaglandins lower BP by causing vasodilation.

The physician documented that the patient has urinary retention. How should the nurse explain this when the nursing student asks what it is? a. Inability to void b. No urine formation c. Large amount of urine output d. Increased incidence of urination

a. Retention is the inability to void. Anuria is no urine formation. Polyuria is a large amount of urine output over time. Frequency is increased incidence of urination.

What is the most likely reason that the BUN would be increased in a patient? a. Has impaired renal function b. Has not eaten enough protein c. Has decreased urea in the urine d. May have nonrenal tissue destruction

a. The blood urea nitrogen (BUN) is increased in patients with renal problems. It may also be increased when there is rapid or extensive tissue damage from other causes. Low protein intake may cause a low BUN.

A urinalysis of a urine specimen that is not processed within 1 hour may result in erroneous measurement of a. glucose. b. bacteria. c. specific gravity. d. white blood cells.

b. Bacteria in warm urine specimens multiply rapidly and false or unreliable bacterial counts may occur with urine that has been sitting for periods of time. Glucose, specific gravity, and WBCs do not change in urine specimens but pH becomes more alkaline, RBCs are hemolyzed, and casts may disentigrate.

Priority Decision: Following a renal biopsy, what is the nurse's priority? a. Offer warm sitz baths to relieve discomfort. b. Test urine for microscopic bleeding with a dipstick. c. Expect the patient to experience burning on urination. d. Monitor the patient for symptoms of a urinary infection.

b. Bleeding from the kidney following a biopsy is the most serious complication of the procedure and urine must be examined for both gross and microscopic blood, in addition to vital signs and hematocrit levels being monitored. Following a cystoscopy the patient may have burning with urination and warm sitz baths may be used. Urinary infections are a complication of any procedure requiring instrumentation of the bladder.

Which urinalysis results most likely indicate a urinary tract infection (UTI)? a. Yellow; protein 6 mg/dL; pH 6.8; 102/mL bacteria b. Cloudy, yellow; WBC >5/hpf; pH 8.2; numerous casts c. Cloudy, brown; ammonia odor; specific gravity 1.030; RBC 3/hpf d. Clear; colorless; glucose: trace; ketones: trace; osmolality 500 mOsm/kg (500 mmol/kg)

b. Cloudiness in a fresh urine specimen, WBC count above 5 per high-power field (hpf), and the presence of casts are all indicative of urinary tract infection (UTI). The pH is usually elevated because bacteria in urine split the urea alkaline ammonia. Cloudy, brown urine usually indicates hematuria or the presence of bile. Colorless urine is usually very dilute. Option a is characteristic of normal urine.

The male patient is admitted with a diagnosis of benign prostatic hyperplasia (BPH). What urination characteristics should the nurse expect to assess in this patient? a. Oliguria b. Hesitancy c. Hematuria d. Pneumaturia

b. Hesitancy is difficulty starting the urine stream and is common with benign prostatic hyperplasia (BPH). Oliguria is scanty urine formation and output. Hematuria is blood in the urine. Pneumaturia is urine containing gas, as is caused by a fistula between the bowel and bladder.

Which volume of urine in the bladder would cause discomfort and require urinary catheterization? a. 250 mL b. 500 mL c. 1200 mL d. 1500 mL

b. When the amount of urine in the bladder has reached 1200 mL, the person would need relief and probably catheterization. The bladder capacity ranges from 600 to1000 mL. When there is 250 mL of urine in the bladder, the person will usually feel the urge to urinate and 400 to 600 mL will be uncomfortable.

Which diagnostic study would include assessing for iodine sensitivity, teaching the patient to take a cathartic the night before the procedure, and telling the patient that a salty taste may occur during the procedure? a. Cystometrogram b. Renal arteriogram c. Intravenous pyelogram (IVP) d. Kidneys, ureters, bladder (KUB)

c. A cathartic the evening before the procedure and sensitivity to iodine are important for both intravenous pyelogram (IVP) and renal arteriogram but the salty taste is only a possibility with IVP. The cystometrogram involves filling the bladder with water or saline to measure tone and stability. The kidneys, ureters, and bladder (KUB) is an x-ray that may have bowel preparation.

The mother of an 8-year-old girl has brought her child to the clinic because she is wetting the bed at night. What terminology should the nurse use when documenting this situation? a. Ascites b. Dysuria c. Enuresis d. Urgency

c. Enuresis is involuntary urination at night. Ascites is excess fluid in the intraperitoneal cavity. Dysuria is painful urination. Urgency is the feeling of needing to void immediately.

Which statement accurately describes glomerular filtration rate (GFR)? a. The primary function of GFR is to excrete nitrogenous waste products. b. Decreased permeability in the glomerulus causes loss of proteins into the urine. c. The GFR is primarily dependent on adequate blood flow and adequate hydrostatic pressure. d. The GFR is decreased with prostaglandins cause vasodilation and increased renal blood flow.

c. GFR is primarily dependent on adequate blood flow and hydrostatic pressure. The glomerulus filters the blood. The GFR is the amount of blood filtered each minute by the glomeruli, which determines the concentration of urea in the blood. Increased permeability in the glomerulus causes loss of proteins in the urine. The prostaglandins increase the GFR with increased renal blood flow.

What is a factor that contributes to an increased incidence of urinary tract infections in aging women? a. Length of the urethra b. Larger capacity of bladder c. Relaxation of pelvic floor and bladder muscles d. Tight muscular support at the urinary sphincter

c. Relaxation of female urethra, bladder, vagina, and pelvic floor muscles may contribute to stress and urge incontinence and urinary tract infections. The short urethra of women allows easier ascension and colonization of bacteria in the bladder than occurs in men and the urethra does not lengthen with age. The bladder capacity of men and women is the same but decreases with aging.

Which test is most specific for renal function? a. Renal scan b. Serum creatinine c. Creatinine clearance d. Blood urea nitrogen (BUN)

c. The rate at which creatinine is cleared from the blood and eliminated in the urine approximates the GFR and is the most specific test of renal function. The renal scan is useful in showing the location, size, and shape of the kidney and general blood perfusion.

What accurately describes a normal physical assessment of the urinary system by the nurse? a. Auscultates the lower abdominal quadrants for fluid sounds b. Palpates an empty bladder at the level of the symphysis pubis c. Percusses the kidney with a firm blow at the posterior costovertebral angle d. Positions the patient prone to palpate the kidneys with a posterior approach

c. To assess for kidney tenderness, the nurse strikes the fist of one hand over the dorsum of the other hand at the posterior costovertebral angle. The upper abdominal quadrants and costovertebral angles are auscultated for vascular bruits in the renal vessels and aorta and an empty bladder is not palpable. The kidneys are palpated through the abdomen, with the patient supine.

A 78-year-old man asks the nurse why he has to urinate so much at night. The nurse should explain to the patient that as an older adult, what may contribute to his nocturia? a. Decreased renal mass b. Decreased detrusor muscle tone c. Decreased ability to conserve sodium d. Decreased ability to concentrate urine

d. Decreased renal blood flow and altered hormone levels result in a decreased ability to concentrate urine that results in an increased volume of dilute urine, which does not maintain the usual diurnal elimination pattern. A decrease in bladder capacity also contributes to nocturia but decreased bladder muscle tone results in urinary retention. Decreased renal mass decreases renal reserve but function is generally adequate under normal circumstances.

Priority Decision: After a patient had a renal arteriogram and is back on the clinical unit, what is the most important action by the nurse? a. Observe for gross bleeding in the urine. b. Place the patient in high Fowler's position. c. Monitor the patient for signs of allergy to the contrast medium. d. Assess peripheral pulses in the involved leg every 30 to 60 minutes.

d. During a renal arteriogram, a catheter is inserted, most commonly at the femoral artery. Following the procedure the patient is positioned with the affected leg extended with a pressure dressing applied. Peripheral pulse monitoring is essential to detect the development of thrombi around the insertion site, which may occlude blood supply to the leg. Gross bleeding in the urine is a complication of a renal biopsy. Allergy to the contrast medium should be established before the procedure.

The patient complains of "wetting when she sneezes." How should the nurse document this information? a. Nocturia b. Micturition c. Urge incontinence d. Stress incontinence

d. Stress incontinence is involuntary urination with increased pressure when sneezing or coughing and is seen with weakness of sphincter control. Nocturia is frequent urination at night. Micturition is the evacuation of urine. Urge incontinence is involuntary urination is preceded by urinary urgency.