Adult Health 2 Final Exam Study Guide

Alternate periods of activity with periods of rest.

Nursing intervention for a patient with severe hemolytic anemia:

Place a sign on the door directing visitors to the nurse's station. Restrict fresh fruits/vegetables. Strict hand-washing, Antibiotics, Temperature assessment every 4 hours.

Nursing interventions for a patient with severe neutropenia and infection include? (select all that apply)

O2 at 89%

Packing to treat a nosebleed - most immediate action by nurse

Put on sterile gloves and use a sterile catheter to suction patient

Patient has a trach with rhonchi heard bilaterally and is unsuccessful in coughing up secretions - what should you do?

Take no further action; normal

Patient has continuous bubbling in the suction-control chamber - which action is most appropriate by the nurse?

Dyspnea Fever Hypotension

Patient is post-op after a thoracentesis - what are some signs of further complications?

I will brush my teeth and floss twice daily. I will need to plan for trips to the lab for regular blood work.

Patient is prescribed Phenytoin (Dilantin) for anticonvulsant. Which statements indicate proper understanding?

Patient can independently clean trach

Patient just had a trach placed and has a nursing diagnosis of hopelessness r/t loss of control. What is a good goal for the patient to have?

pH 7.38, PaCO2 40 mm Hg, HCO3 25

Patient with severe bronchial pneumonia is receiving oxygen, respiratory/nebulizer treatments, antibiotics, and IV fluids. Which ABG shows effective treatment?

Positive fecal occult test

The most common sign of colorectal cancer is?

Place the client on a cardiac monitor.

A nurse working in the ED admits a client with renal failure and a serum K+ of 8.0. Which action will the nurse implement FIRST?

The patient is experiencing difficulty breathing with a laryngeal stridor.

A patient has a serum Ca level of 7.0 mEq/L. Which assessment finding is most important to report to the health care provider?

Lung sounds

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is MOST important for the nurse to monitor while the patient is receiving the infusion?

"Are you concerned about developing breast cancer?"

A patient tells the nurse "I would like to use a home genetic test to see if I will develop breast cancer." Which response is best?

Altered nutrition, less than body requirements, related to inability to digest and absorb nutrients.

A patient undergoes a total gastrectomy with an anastomosis of the esophagus to the jejunum for treatment of gastric cancer. The nurse anticipates long term indication for which nursing diagnosis?

Discontinue the heparin & flush the IV lines with normal saline.

A patient who has been receiving heparin infusion & Coumadin for a DVT is diagnosed with heparin induced thrombocytopenia when her platelet count drops to 110,000/uL. Which action should the nurse include in the plan of care?

Metabolic acidosis

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas results: pH 7.32, PaO2 88 mm Hg, PaCo2 37 mm Hg, and HCO3 17 mEq/L. How should the nurse interpret these results?

Ask the health care provider to order a metabolic panel to review electrolytes.

A patient who is taking furosemide for treatment of hypertension complains of generalized weakness. It is MOST appropriate for the nurse to take which action?

Refer the patient to a qualified genetic counselor.

A patient with a family history of cystic fibrosis asks for information about genetic testing. Which response by the nurse is MOST appropriate to help the patient with family planning?

Vital signs and symptoms of hypovolemia

A patient with an upper GI bleed is admitted to the ER vomiting copious amounts of blood. Which information should the nurse obtain first during the initial assessment?

I should report a feeling of restlessness, lethargy or a loss of memory to my doctor. I should avoid ASA and NSAIDs.

A patient with cirrhosis is being discharged from the hospital. The nurse knows that patient teaching has been successful when the patient states? (select all that apply)

This result is above the recommended levels

A patient with type 2 diabetes has an A1C (glycated hemoglobin) of 8.1%. What is the interpretation of this result?

Reported weight gain. Serum sodium level of 120 mg/dL. Decreased LOC.

A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate ADH (SIADH=excessive ADH). The nurse will monitor carefully for? (select all that apply)

males, females

A sex-linked trait appears more often in __________ than __________

Determine what kind of physical activities the patient usually enjoys.

To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take?

Diagnostic testing

Type of genetic testing used to confirm or rule out a clinical diagnosis?

Carrier screening

Type of genetic testing used to identify a gene mutation in an asymptomatic female who has a family history of an X-linked recessive family condition. One or both parents may possess a copy of the gene.

Used to measure lung volumes and capacities. Lung disease. Respiratory risks. Do not smoke 6-8 hours prior to test. Pt should NOT use an inhaler 4-6 hrs before the test begins.

What is a pulmonary function test (PFT) used for?

Reverse isolation

What type of room/care would you give to a patient following a bone marrow transplant?

Vitamin B12 injections

What would the nurse most likely administer for a patient with pernicious anemia?

Gastrointestinal

When a person with hepatitis A is symptomatic, the majority of their symptoms are noted in which of the following body systems?

Milk carton

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food item from the patient's tray?

Monitor IV sites for redness, swelling, or tenderness.

Which action can an RN caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Auscultate breath sounds

Which action should the nurse take first if the patient complains of acute chest pain and dyspnea soon after insertion of a central IV catheter?

Place the client in a private room on contact isolation.

Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with C-diff?

The pain has lasted longer than 30 minutes. The pain does not subside with rest.

Which assessment data collected by the nurse, who is admitting a patient with chest pain, suggests that the pain is caused by an acute myocardial infarction? (select all that apply)

The patient states that the pain "goes away" with one sublingual nitro tablet.

Which information given by the patient admitted with chronic stable angina will help the nurse to confirm the diagnosis?

The patient is difficult to arouse.

Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider?

Chronic overexposure to the sun. Recurrent herpes simplex infection. Frequent use of alcohol and tobacco.

Which information obtained from the nursing history does the nurse identify as a risk factor for oral cancer? (select all that apply)

Help the patient modify favorite high-fat recipes by using monounsaturated oils when possible.

Which nursing intervention will be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes?

Newborn screening Carrier testing Prenatal testing

Which of the following are types of genetic screening? (select all that apply)

Patient with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes.

Which patient should the nurse assess first?

Initial hemoglobin & hematocrit levels may be within normal limits. Clinical symptoms are the most reliable way to evaluate the effect and degree of blood loss. A patient who has acute blood loss may have postural hypotension and increased heart rate.

Which statements describe anemia related to acute blood loss? (select all that apply)

Patellar and triceps reflexes are absent.

You are assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding should you report to the health care provider immediately?

Check all stools for occult blood.

You are caring for a patient with an exacerbation of chronic myelogenous leukemia. The platelet count is 100,000. Which nursing intervention is appropriate based on the lab value?

I should be concerned if I have abdominal cramping and gas after the procedure. I can use cherry gelatin as a clear liquid when I am prepping for the procedure. I should not be concerned if I have rectal bleeding after the procedure.

A client is scheduled for a colonoscopy and the nurse has provided teaching. What statement by the client indicates a need for further teaching? (select all that apply)

Cigarette smoking

#1 risk factor for both renal and bladder cancer:

Hypercalcemia

A client has been on bed rest for a week. They complain of bone pain and painful urination. Calcitonin is prescribed. Which electrolyte imbalance would the nurse suspect with this problem & treatment?

Impaired gas exchange

A 27-year-old mother was seen in the clinic for signs of fatigue. She has a history of iron deficiency anemia. She complains of dizziness when standing and SOB with activity. Based on the information given, which nursing diagnosis should be given priority?

"I could choose a nasal spray rather than injections of B12."

A 52-year-old patient with a new diagnosis of pernicious anemia. The nurse determines the patient understands the teaching when the patient states:

Hgb of 8.6 g/dL

A 62-year-old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's lab findings to include:

Work with the client to establish a trusting relationship.

A female client who has been hospitalized for an unrelated problem has a large pearly white lesion on her lip, to which she continues to apply lipstick that she will not remove for inspection. The client refuses to discuss the lesion with the nurse or health care provider. What action by the nurse is best?

Assess temperature every 4 hours.

A female patient is admitted with the following lab results: Hgb 12.8, Ca 9, leukocytes 3,000. Which of the following interventions would you anticipate?

Assign the patient to a room near the nurses station.

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

Pinch lower portion of the nose for 10-15 minutes. Place the patient in a sitting position. Keep patient quiet.

Actions a nurse should take when a patient develops a nosebleed

Pseudoephedrine can be used to relieve congestion. Taking a hot shower will increase sinus drainage and decrease pain. Saline nasal spray to wash out secretions; head in upright position.

Acute sinusitis - intervention the nurse should plan to include in teaching

A 23-year-old who is complaining of fatigue.

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?

Changes in your liver cause drugs to be metabolized differently.

An older adult client has had an instance of drug toxicity and asks why this happens since the client has been on this medication for years at the same dose. What response by the nurse is best?

Na 154 mEq/L (154 mmol/L)

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Mutation

Any change that occurs in a gene or chromosome is called a:

Apple juice Apple sauce Apple pie

Appropriate items for a patient who just received a bone marrow transplant?

I will take a stool softener if I feel constipated. I should take the iron with OJ an hour before eating. I should increase fluid intake & fiber intake while taking iron tabs. I should take iron tabs with a vitamin C supplement.

Appropriate understanding when taking oral ferrous sulfate includes: (select all that apply)

Have patient use an ergonomic keyboard and mouse. Corticosteroid injections. Wrist splint.

Carpal tunnel syndrome - what are treatments to decrease pain in a patient with carpal tunnel syndrome?

Acute hemolytic transfusion reaction.

Chills, fever, low back pain, dark urine, hypotension, chest pain, & labored respirations are clinical manifestations of?

Visual disturbances

Clinical manifestations the nurse should identify as early signs of a migraine with aura:

Retention of HCO3/bicarb by kidneys.

Compensating mechanism with respiratory acidosis:

0.45% sodium chloride

Desired effect of moving extracellular to intracellular space would be caused by which following solution?

I will keep my head elevated for 48 hours to decrease swelling and pain

Discharge instructions after a rhinoplasty

Use pillows to elevate ankle above the heart. Limit movement of the ankle.

Discharge instructions that are appropriate for a patient with a sprained ankle

Has a precipitating factor and is relieved by rest and nitro.

During assessment, the nurse questions the patient closely about the characteristics of his chest pain based on the knowledge that chronic stable angina:

Increase urinary output, especially during waking hours.

During the nursing history and physical of a patient with heart failure, which finding might the nurse expect related to the patient's diagnosis?

Decrease the incidence of infection.

Filgrastin (neupogen) is administered subq (SQ) to:

Obtain signed consent. Set IV pump rate to infuse the unit of blood within 4 hours. Obtain vital signs before the unit of blood is started and 15 minutes after the transfusion has started.

Hematocrit (Hct) of 22.3% and Hemoglobin (Hgb) of 7.7. The doctor ordered 2 units of packed red blood cells (PRBCs) to be transfused. Which interventions should the nurse implement? (select all that apply)

Auscultate for bruit

Hemodialysis and internal fistula—to ensure patency the nurse will:

Infuse KCl at a rate of 10 mEq per hour.

IV potassium chloride 20 mEq is prescribed for treatment of a patient with hypokalemia. Which action should the nurse take?

Monitor for skin breakdown Consult enterostomal therapy Assess patient for psychological stressors

Ileal conduit (urinary drainage) patient planning:

I will take the sublingual nitro tablets as soon as I get any chest pain. I will stop what I am doing and sit down before I put the nitroglycerin under my tongue. I will leave on my nitroglycerin patch regardless of taking any sublingual nitroglycerin.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that teaching has been effective? (select all that apply)

Keep the patient in semi-fowlers position

Laryngectomy and radial neck dissections - what is the priority for the airway of this patient?

Iodine dye for an IVP (IV contrast used)

Metformin (Glucophage) cannot be given in the presence of:

"Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches."

Migraine headaches and prescribed a beta blocker—in patient education the nurse will include:

You will need to be NPO for 8 hours before the procedure. You will be kept NPO after the procedure until your gag reflex returns.

Mr. J is scheduled for an EGD. Which of the following statements will the nurse include in the teaching plan? (select all that apply)

Assist the family in understanding the changes in behavior Plan for seizure precautions and anti-seizure activity

Nursing care of the patient with a brain tumor:

Maintain fluid intake of 2-3 L/day to dilute Ca.

Nursing intervention for a patient with multiple myeloma?

"I will need to avoid orange juice for breakfast."

Spironolactone is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

Deep vein thrombosis (DVT)

The D-Dimer test is used to rule out:

Keep a record of seizure activity Avoid OTC meds

The client has been newly diagnosed with epilepsy—discharge instructions should include:

Gradually decreasing LOC.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has an NG tube to low suction, & is NPO. Which assessment finding would be priority for the nurse to report to the health care provider?

Remove the unit of blood and prepare to send it to the blood bank. Replace the blood transfusion with a liter of NS. Obtain vital signs.

The nurse determines that a patient is having a hemolytic blood transfusion reaction. Which of the following actions should the nurse perform INITIALLY? (select all that apply)

Chronic stable angina pain can be relieved with rest. Chronic stable angina is relieved by sublingual nitro. A precipitating event such as walking up a flight of stairs typically precedes chest pain.

The nurse is admitting a patient who has a suspected myocardial infarction and has a history of chronic stable angina. Which of the following findings will help the nurse distinguish chronic stable angina pain from an MI? (select all that apply)

Increase weight bearing activity. Administer loop diuretics. Encourage fluid intake up to 4,000 mL/day. Administer Calcitonin.

The nurse is caring for a patient who has hypercalcemia. Which nursing action should the nurse anticipate? (select all that apply)

Explain the need for smoking cessation Instruct the patient to drink skim milk Instruct the patient to avoid egg yolks and foods prepared with whole eggs.

The nurse is discussing modifiable risk factors for CAD (coronary artery disease). Which instructions should be included in the teaching plan? (select all that apply)

Limit intake of colas, coffee, tea Limit sodium intake Drink 300 mL of water daily

The nurse is preparing a renal calculi patient for discharge—which statements indicate the patient has proper understanding?

Liver

The nurse knows that a client with prolonged prothrombin time values probably has dysfunction in which organ?

Bilirubin levels

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the lab results for what?

BP of 85/40

The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern?

Restrict sodium and fluid intake

The nurse plans which outcome to help prevent HF and HTN in chronic renal insufficiency patients:

Determines how well the heart tolerates exercise. Requires that the patient refrain from smoking or doing strenuous exercise for 3 hours prior to the test. Includes continuous monitoring of ECG and vital signs.

The nurse prepares the patient for a stress test by explaining that the procedure (select all that apply):

Early sign of oral cancer

The nurse reads a clients chart and sees that the health care provider assessed mucosal erythroplasia. What should the nurse understand that this means for the client?

Edema Proteinuria

The nurse should expect the presence of which symptoms of nephrotic syndrome?

Blood pressure is 88/54. Cardiac monitor shows a HR of 54 beats/min.

The nurse will suspect the patient with stable angina is experiencing a side effect (SE) of the prescribed labetalol if the (select all that apply):