Final Review 19-32

A 30-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which topic would the nurse plan to teach the patient? a. 1-Antitrypsin testing b. Leukotriene modifiers c. Use of the nicotine patch d. Continuous pulse oximetry

a. 1-Antitrypsin testing

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination instead of the live attenuated influenza vaccine? (Select all that apply.) a. A 76-yr-old nursing home resident b. A 36-yr-old female patient who is pregnant c. A 42-yr-old patient who has a 15 pack-year smoking history d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-yr-old patient who has allergies to penicillin and cephalosporins

a. A 76-yr-old nursing home resident b. A 36-yr-old female patient who is pregnant d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis

Which activities can thenurse working in theoutpatient clinic delegate to a licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Explain potassium hydroxide testing to a patient with a skin infection. e. Teach a patient about site care after a punch biopsy of an upper arm lesion.

a. Administer patch testing to a patient with allergic dermatitis. c. Apply a sterile dressing after the health care provider excises a mole.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select all that apply.) a. Age b. Blood pressure c. Respiratory rate d. O2 saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

a. Age b. Blood pressure c. Respiratory rate e. Presence of confusion f. Blood urea nitrogen (BUN) level

A patient is scheduled for a computed tomography (CT) scan of thechest with contrast media. Which assessment findings would thenurse report to thehealth care provider before thepatient goes for theCT? (Select all that apply.) a. Allergy to shellfish b. Patient reports claustrophobia c. Elevated serum creatinine level d. Recent bronchodilator inhaler use e. Inability to remove a wedding band

a. Allergy to shellfish c. Elevated serum creatinine level

What intervention prevents hypertrophic scarring during the rehabilitation phase of burn recovery? a. Applying pressure garments b. Repositioning the patient every 2 hours c. Performing active ROM at least every 4 hours d. Applying a water-based moisturizer to healed skin

a. Applying pressure garments

A patient with late-stage cirrhosis develops portal hypertension. Which complications can develop from this condition? (select all that apply) a. Ascites b. Esophageal varices c. Decreased bilirubin d. Decreased spleen size e. Increased albumin levels

a. Ascites b. Esophageal varices

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) ―whenever I take a deep breath.‖ Which action will the nurse take first? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

a. Auscultate for breath sounds.

Which instructions would thenurse provide for a patient who has impetigo? a. Clean thecrusted areas with soap and water. b. Spread an alcohol-based cleanser on thelesions. c. Avoid use of antibiotic ointments on thelesions. d. Use petroleum jelly to soften crusted areas.

a. Clean thecrusted areas with soap and water.

Nursing care of a patient with Stage 4 lung cancer would include a. Coordinating a referral to palliative care b. Limiting visitors to decrease infection risk c. NPO status and starting parenteral nutrition d. Avoiding talking about the cancer diagnosis

a. Coordinating a referral to palliative care

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Report of sharp chest pain with deep breathing c. Scattered crackles and wheezes heard bilaterally d. Respiratory rate 28 breaths/min while ambulating

a. Cough productive of bloody, purulent mucus

The clinic nurse is teaching a patient with acute sinusitis. Which interventions would the nurse plan to include in the teaching session? (Select all that apply.) a. Decongestants can be used to relieve swelling. b. Avoid blowing the nose to decrease the risk of nosebleed. c. Taking a hot shower will promote sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

a. Decongestants can be used to relieve swelling. c. Taking a hot shower will promote sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

Which results are expected patient outcomes of thenurse providing thorough preoperative teaching? (Select all that apply.) a. Decreased anxiety b. Reduced postoperative fear c. Diminished patient satisfaction d. Shorter length of hospitalization e. Increased recovery time after discharge f. Decreased development of complications

a. Decreased anxiety b. Reduced postoperative fear d. Shorter length of hospitalization F. Decrease development of complications

lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (AP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

a. Document the amount of drainage every 8 hours.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degree s.b. Give enteral feedings at no more than 10 mL/hr. c. Suction the endotracheal tube every 2 to 4 hours. d. Limit the use of positive end-expiratory pressure.

a. Elevate head of bed to 30 to 45 degree

Which action by the nurse would support ventilation for a patient with chronic obstructive pulmonary disease (COPD).? a. Encourage the patient to sit upright and lean forward. b. Have the patient rest with the head elevated 15 degrees. c. Place the patient in the Trendelenburg position with pillows behind the head. d. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed.

a. Encourage the patient to sit upright and lean forward.

What should be included in the discharge teaching for the patient who had cataract surgery? (Select all that apply.) a. Eye discomfort is often relieved with mild analgesics. b. A decline in visual acuity is common for the first month. c. Stay on bed rest and limit activity for the first few weeks. d. Notify the provider if an increase in redness or drainage occurs. e. Following activity restrictions is essential to reduce intraocular pressure.

a. Eye discomfort is often relieved with mild analgesics. d. Notify the provider if an increase in redness or drainage occurs. e. Following activity restrictions is essential to reduce intraocular pressure.

A 35-year-old female patient is admitted to the emergency department with acute abdominal pain. Which medical diagnoses should you consider as possible causes of her pain? (select all that apply) a. Gastroenteritis b. Ectopic pregnancy c. Gastrointestinal bleeding d. Irritable bowel syndrome e. Inflammatory bowel disease

a. Gastroenteritis b. Ectopic pregnancy c. Gastrointestinal bleeding

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

a. Increased tactile fremitus

On auscultation of a patient's lungs, thenurse hears low-pitched, bubbling sounds during inhalation in thelower third bilaterally. How should thenurse document this finding? a. Inspiratory crackles at thebases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in theapices of both lungs d. Pleural friction rub in theright and left lower lobes

a. Inspiratory crackles at thebases

Which intervention would the nurse expect for a patient admitted with acute pancreatitis? a. Keep the patient NPO b. Abdominal paracentesis c. Start enteral feedings to prevent malnutrition d. Administer acetaminophen every 4 hours for pain reliefc

a. Keep the patient NPO

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment would the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Measure forced expiratory volume (FEV) flow rate.

a. Listen to the patient's breath sounds.

An older adult patient who has been diagnosed with age-related macular degeneration (AMD) asks thenurse what actions could help slow or avoid thepotential vision loss. Which recommendations would thenurse plan to make? (Select all that apply.) a. Maintain a healthy body weight. b. Do not smoke or use tobacco products. c. Include whole grains in your daily diet. d. Avoid eating dark green leafy vegetables. e. Consider taking an antioxidant supplement.

a. Maintain a healthy body weight. b. Do not smoke or use tobacco products. c. Include whole grains in your daily diet. e. Consider taking an antioxidant supplement.

Management of a patient after a lung transplant includes which measures? (select all that apply) a. Mechanical ventilation in the early postoperative period b. Assisting with a lung biopsy if acute rejection is suspected c. IV fluid therapy accompanied by accurate intake and output d. Immunosuppressant therapy, which usually involves a 3 drug regimen e. Pulmonary clearance measures, including deep-breathing and coughing

a. Mechanical ventilation in the early postoperative period b. Assisting with a lung biopsy if acute rejection is suspected c. IV fluid therapy accompanied by accurate intake and output d. Immunosuppressant therapy, which usually involves a 3 drug regimen e. Pulmonary clearance measures, including deep-breathing and coughing

Which factors would the nurse include in discharge criteria for a Phase II patient? (select all that apply) a. Nausea and vomiting controlled. b. Ability to drive themselves home. c. No respiratory depression present. d. Written discharge instructions understood. e. Opioid pain medication given 45 minutes ago.

a. Nausea and vomiting controlled. c. No respiratory depression present. d. Written discharge instructions understood. e. Opioid pain medication given 45 minutes ago.

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action would the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

a. Notify the health care provider.

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. O2 saturation of 99% b. Heart rate 106 beats/min c. Crackles audible at lung bases d. Respiratory rate 22 breaths/min

a. O2 saturation of 99%

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction would the nurse include in the discharge teaching? a. O2 use can improve the patient's quality of life. b. Travel is not possible with the use of O2 devices. c. O2 flow should be increased if the patient has more dyspnea. d. Storage of O2 requires large metal tanks that last 4 to 6 hours.

a. O2 use can improve the patient's quality of life.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

a. Observe for distended neck veins.

. A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. Which interventions would the nurse prioritize? (Select all that apply.) a. Obtain a bladder ultrasound scan. b. Perform a straight catheterization. c. Continue to monitor this normal finding. d. Evaluate the patient's fluid volume status.

a. Obtain a bladder ultrasound scan. d. Evaluate the patient's fluid volume status.

A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide the best gas exchange? a. On the left side b. On the right side c. In the tripod position d. In the high-Fowler's position

a. On the left side

A patient in thedermatology clinic has a thin, scaly erythematous plaque on theright cheek. Which action would thenurse take? a. Prepare thepatient for a skin biopsy. b. Teach theuse of corticosteroid cream. c. Explain how to apply tretinoin to theface. d. Discuss theneed for topical application of antibiotics.

a. Prepare thepatient for a skin biopsy.

10. Which patient behaviors would the nurse promote for healthy eyes? (select all that apply) a. Protective sunglasses when bicycling b. Taking part in a smoking cessation program c. Supplementing diet intake of vitamin C and beta-carotene d. Washing hands thoroughly before putting in or taking out contact lenses e. A woman avoiding pregnancy for 4 weeks after receiving MMR immunization

a. Protective sunglasses when bicycling b. Taking part in a smoking cessation program c. Supplementing diet intake of vitamin C and beta-carotene d. Washing hands thoroughly before putting in or taking out contact lenses

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Red-brown drainage from nasogastric tube b. Blood urea nitrogen (BUN) level 32 mg/dL c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

a. Red-brown drainage from nasogastric tube

Which health promotion information would the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

a. Resources for support in smoking cessation d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

Which statements describe therole of thecertified registered nurse anesthetist (CRNA) on thesurgical care team? (Select all that apply.) a. Selecting and administering theanesthesia and adjuvant drugs b. Developing and implementing a plan for delivering anesthesia c. Managing critically ill surgical patients in theintensive care unit d. Releasing or discharging patients from thepostanesthesia care area e. Establishing an airway and monitoring thepatient's pulmonary status

a. Selecting and administering theanesthesia and adjuvant drugs b. Developing and implementing a plan for delivering anesthesia d. Releasing or discharging patients from thepostanesthesia care area e. Establishing an airway and monitoring thepatient's pulmonary status

What nursing interventions can be used to manage burn pain? (select all that apply) a. Suggest pain management options. b. Use a pain-rating tool to monitor the patient's level of pain. c. Delay painful dressing changes until the patient's pain is completely relieved. d. Use a multimodal approach (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. Provide nonpharmacologic therapies (e.g., music therapy, distraction) to replace opioids in the acute phase of a burn injury.

a. Suggest pain management options. b. Use a pain-rating tool to monitor the patient's level of pain. d. Use a multimodal approach (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics).

A nurse is teaching a patient with contact dermatitis of thearms and legs about ways to decrease itching. Which information would thenurse include in theteaching plan? (Select all that apply.) a. Take cool or tepid baths to decrease itching. b. Add oil to your bath water to moisturize theaffected skin. c. Cool, wet clothes or compresses can be used to reduce itching. d. Use an over-the-counter (OTC) antihistamine to reduce itching. e. Rub yourself dry with a towel after bathing to prevent skin maceration.

a. Take cool or tepid baths to decrease itching. c. Cool, wet clothes or compresses can be used to reduce itching. d. Use an over-the-counter (OTC) antihistamine to reduce itching.

The charge nurse observes thefollowing actions being taken by a new nurse on theburn unit. Which action by thenew nurse would require immediate intervention by thecharge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn

a. The new nurse uses clean gloves when applying antibacterial cream to a burn

The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider? a. The patient appears somnolent. b. The patient reports feeling weak. c. The patient's blood pressure is 164/98. d. The patient's oxygen saturation is 90%.

a. The patient appears somnolent.

Prone positioning is being used for a patient with acute respiratory distress syndrome (ARDS). Which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.

a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.

The nurse is caring for a patient undergoing surgery for a knee replacement. Which factors are critical to the patient's safety during the procedure? (select all that apply) a. Universal protocol is followed. b. The ACP is an anesthesiologist. c. The patient has adequate health insurance. d. The patient's family is in the surgery waiting area. e. The patient's allergies are conveyed to the surgical team.

a. Universal protocol is followed. e. The patient's allergies are conveyed to the surgical team.

Which information would thenurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to thesun. b. Sun exposure may decrease theeffectiveness of themedication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.

a. Use a sunscreen with a high SPF when exposed to thesun.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The staff nurse has no symptoms of TB and has not had a positive TB skin test before. Which information would the occupational health nurse plan to teach the staff nurse? a. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine

a. Use and side effects of isoniazid

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has several drugs prescribed. Which drug would the nurse discuss with the health care provider before giving? a. Vancomycin (Vancocin) b. Pantoprazole (Protonix) c. Sucralfate (Carafate) d. Methylprednisolone (Solu-Medrol)

a. Vancomycin (Vancocin)

Assessment findings suggestive of peritonitis include (select all that apply) a. abdominal pain. b. rebound tenderness. c. a soft, distended abdomen. d. shallow respirations with bradypnea. e. observing that the patient is lying still

a. abdominal pain. b. rebound tenderness. e. observing that the patient is lying still

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. bicarbonate (HCO3-). c. mixed venous O2 (SvO2). d. compliance and resistance. e. partial pressure of O2 (PaO2).

a. acid-base balance. b. bicarbonate (HCO3-). e. partial pressure of O2 (PaO2).

A mother and her children have been diagnosed with pediculosis corporis at a health care center. An appropriate treatment is a. applying pyrethrins to the body. b. topical application of griseofulvin. c. moist compresses applied frequently. d. administration of systemic antibiotics.

a. applying pyrethrins to the body.

When caring for a patient with acute bronchitis, the nurse will prioritize interventions by a. auscultating lung sounds. b. encouraging fluid restriction. c. administering antibiotic therapy. d. teaching the patient to avoid cough suppressants.

a. auscultating lung sounds.

The key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is the a. carina. b. larynx. c. trachea. d. epiglottis.

a. carina.

Defense mechanisms that help protect the lung from inhaled particles and microorganisms include the (select all that apply) a. cough reflex. b. mucociliary escalator. c. alveolar macrophages. d. reflex bronchoconstriction. e. alveolar capillary membrane.

a. cough reflex. b. mucociliary escalator. c. alveolar macrophages. d. reflex bronchoconstriction.

A patient has jaundice with pale colored stools. This is most likely related to a. decreased bile flow into the intestine. b. increased production of urobilinogen. c. increased bile and bilirubin in the blood. d. increased production of cholecystokinin

a. decreased bile flow into the intestine

Common age-related changes in the auditory system include (select all that apply) a. drier earwax. b. tinnitus in both ears. c. auditory nerve degeneration. d. atrophy of the tympanic membrane. e. greater ability to hear high-pitched sounds.

a. drier earwax. b. tinnitus in both ears. c. auditory nerve degeneration. d. atrophy of the tympanic membrane.

Nursing care for a patient after a bone marrow biopsy and aspiration includes (select all that apply) a. giving analgesics as needed. b. preparing to start a blood transfusion. c. keeping the sterile pressure dressing intact. d. giving preprocedure and postprocedure antibiotic medications. e. monitoring vital signs and assessing the site for excess drainage or bleeding.

a. giving analgesics as needed. c. keeping the sterile pressure dressing intact. e. monitoring vital signs and assessing the site for excess drainage or bleeding.

A patient with anorexia nervosa shows signs of malnutrition. During initial refeeding, the nurse carefully assesses the patient for (select all that apply) a. hypokalemia. b. hypoglycemia. c. hypercalcemia. d. hypomagnesemia. e. hypophosphatemia.

a. hypokalemia. d. hypomagnesemia. e. hypophosphatemia.

The most appropriate therapy for a patient with acute diarrhea caused by a viral infection is to a. increase fluid intake. b. administer an antibiotic. c. administer an antimotility drug. d. quarantine the patient to prevent spread of the virus.

a. increase fluid intake.

Nursing interventions for a patient with severe anemia from peptic ulcer disease include (select all that apply) a. instructions for high-iron diet. b. taking vital signs every 8 hours c. monitoring stools for occult blood. d. teaching self-injection of erythropoietin. e. administration of cobalamin (vitamin B12) injections.

a. instructions for high-iron diet. c. monitoring stools for occult blood.

Key information from the patient's health history that relates to the hematologic system includes a. jaundice. b. bladder surgery. c. early menopause. d. multiple pregnancies.

a. jaundice.

The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring CBC b. optimal pain management and O2 therapy. c. blood transfusions if needed and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis. e. administration of IV iron and diet high in iron content.

a. monitoring CBC b. optimal pain management and O2 therapy. c. blood transfusions if needed and iron chelation.

Before injecting fluorescein for angiography, it is important for the nurse to (select all that apply) a. obtain an emesis basin. b. ask if the patient is fatigued. c. administer a topical anesthetic. d. inform patient that skin may turn yellow. e. assess for allergies to iodine-based contrast media.

a. obtain an emesis basin. d. inform patient that skin may turn yellow.

The nurse performs an abdominal assessment of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply) a. persistent abdominal pain. b. marked abdominal distention. c. diarrhea that is loose or liquid. d. colicky, severe, intermittent pain. e. profuse vomiting that relieves abdominal pain.

a. persistent abdominal pain. b. marked abdominal distention.

A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include (select all that apply) a. providing antipyretic for fever b. immediate treatment with antibiotics. c. a throat culture or rapid strep antigen test. d. supportive care, including cool, bland liquids. e. comprehensive history to determine possible cause.

a. providing antipyretic for fever c. a throat culture or rapid strep antigen test. d. supportive care, including cool, bland liquids. e. comprehensive history to determine possible cause.

The nurse would closely monitor patients exposed to a chlorine leak from a local factory for a. pulmonary edema. b. anaphylactic shock.

a. pulmonary edema.

When teaching a patient with melanoma, the nurse recognizes that the patient's prognosis is most dependent on a. the thickness of the lesion. b. the degree of asymmetry in the lesion. c. the amount of ulceration in the surrounding skin. d. how much color variation is present in the lesion.

a. the thickness of the lesion.

The nurse notes white lesions that resemble milk curds in theback of a patient's throat. Which question would thenurse ask? a. ―Are you taking any medications?‖ b. ―Do you have a productive cough?‖ c. ―How often do you brush your teeth?‖ d. ―Have you had an oral herpes infection?‖

a. ―Are you taking any medications?‖

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema

b. A patient with a respiratory rate of 38 breaths/min

A patient seen in the asthma clinic has recorded daily peak flowrates that are 70% of the baseline. Which action will the nurse plan to take next? a. Teach the patient about the use of oral corticosteroids. b. Administer a bronchodilator and recheck the spirometry. c. Recommend increasing the dose of the leukotriene inhibitor. d. Instruct the patient to keep the scheduled follow-up appointment.

b. Administer a bronchodilator and recheck the spirometry.

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action would the nurse take? a. Turn and reposition the patient. b. Administer prescribed morphine. c. Clamp the chest tube in two places. d. Assist the patient with incentive spirometry.

b. Administer prescribed morphine.

The patient with a right-side pleural effusion has stable vital signs and O2 at 6 L/min via nasal cannula. A right-side chest tube is attached to straight drainage. Which actions would the nurse include in the plan of care? (select all that apply) a. Placing the patient on NPO status b. Administering analgesia as ordered c. Maintaining high-Fowler's position d. Encouraging deep breathing and coughing e. Monitoring color and amount of chest tube drainage

b. Administering analgesia as ordered c. Maintaining high-Fowler's position d. Encouraging deep breathing and coughing e. Monitoring color and amount of chest tube drainage

Which finding would indicate to thenurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 10.2 g/dL

b. Albumin level 2.2 g/dL

The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory failure after surgery? a. Older age and anemia b. Albumin level and weight loss c. Recent arthroscopic procedure d. Confusion and disorientation to time

b. Albumin level and weight loss

A patient with a head injury develops petechiae across the chest and abdomen and oozing from venipuncture sites. Which measures would the nurse include in the patient's care? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Use an electric razor for shaving. d. Provide oral care with glycerin swabs. e. Administer warfarin sodium as ordered.

b. Apply dressings to the sites. c. Use an electric razor for shaving.

Which action would the nurse take first when a patient develops epistaxis? a. Pack the affected nare tightly with an epistaxis balloon. b. Apply squeezing pressure to the nostrils for 10 minutes.

b. Apply squeezing pressure to the nostrils for 10 minutes.

When performing a skin assessment for an older adult, thenurse notes angiomas on thechest. Which action would thenurse take next? a. Suggest an appointment with a dermatologist. b. Assess thepatient for evidence of liver disease. c. Teach thepatient about skin changes with aging. d. Discuss theuse of sunscreen to prevent skin cancers.

b. Assess thepatient for evidence of liver disease.

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes and a weak cough effort. Which action would the nurse take? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient's room. d. Schedule a 4-hour rest period for the patient.

b. Assist the patient with staged coughing.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which prescribed action would the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository

b. Blood cultures from two sites

A patient with respiratory failure is increasingly lethargic, with a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. Which intervention would the nurse anticipate? a. Administration of 100% O2 by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)

b. Endotracheal intubation and positive pressure ventilation

Which action would thenurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist thepatient to a supine position for theirrigation. b. Fill theirrigation syringe with body-temperature solution. c. Use a sterile applicator to clean theear canal before irrigating. d. Occlude theear canal completely with thesyringe while irrigating.

b. Fill theirrigation syringe with body-temperature solution.

The patient diagnosed with pancreatic cancer underwent a Whipple procedure 2 days ago. Which clinical problem has the highest priority? a. Anticipatory grieving b. Fluid volume imbalance c. Impaired tissue integrity d. Nutritionally compromised

b. Fluid volume imbalance

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a. Pain at injection site b. Flushing and dizziness c. Respiratory rate 24 breaths/min d. Peak flow reading 75% of normal

b. Flushing and dizziness

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action would the nurse take? a. Teach the patient signs of hypoglycemia. b. Have the patient add dietary salt to meals. c. Suggest decreasing intake of dietary fat and calories. d. Teach the patient about pancreatic enzyme replacement.

b. Have the patient add dietary salt to meals.

The arterial blood gas (ABG) results of a patient with diabetes show metabolic acidosis. Which compensatory finding would thenurse expect? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

b. Kussmaul respirations

Which action by thenurse indicates a need to review respiratory assessment skills? a. Compares breath sounds from side to side at each level. b. Listens during theinspiratory phase, then moves thestethoscope.

b. Listens during theinspiratory phase, then moves thestethoscope.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, ―I wish I were dead! I'm just a burden on everybody.‖ Based on this information, which patient problem would the nurse identify? a. Fear of death b. Low self-esteem c. Anticipatory grieving d. Lack of knowledge

b. Low self-esteem

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How would the nurse determine the appropriate O2 flowrate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.

b. Maintain the pulse oximetry level at 90% or greater.

Which patient(s) have the greatest risk for aspiration pneumonia? (select all that apply) a. Patient who had thoracic surgery b. Patient with acute opioid overdose c. Patient who had a myocardial infarction d. Patient who is receiving nasogastric enteral feeding e. Patient who has a traumatic brain injury from blunt trauma

b. Patient with acute opioid overdose d. Patient who is receiving nasogastric enteral feeding e. Patient who has a traumatic brain injury from blunt trauma

Which action can thenurse working in theemergency department delegate to experienced assistive personnel (AP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections.

b. Perform Snellen testing of visual acuity for a patient with a history of cataracts.

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? (select all that apply) a. Notify the health care provider at once. b. Place the patient in semi-Fowler's position. c. Use a bag-valve-mask (BVM) and begin rescue breathing for the patient d. Instill 10 mL of normal saline into the tracheostomy tube to loosen secretions. e. Continue patient assessment, including O2 saturation, respiratory rate, and breath sounds.

b. Place the patient in semi-Fowler's position. e. Continue patient assessment, including O2 saturation, respiratory rate, and breath sounds.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions in a private hospital room c. Monitoring patient serology results to identify the infecting organism

b. Placing the patient on droplet precautions in a private hospital room

Which actions would the nurse use to reduce a patient's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Obtain arterial blood gases daily. b. Provide a ―sedation holiday‖ daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution.

b. Provide a ―sedation holiday‖ daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution.

A patient reports dizziness when bending over and nausea and dizziness associated with physical activities. Which exam would thenurse expect to prepare thepatient to undergo? a. Tympanometry b. Rotary chair testing c. Pure-tone audiometry d. Bone-conduction testing

b. Rotary chair testing

Which strategies would best aid the nurse communicate with a patient who has a hearing loss? (select all that apply) a. Overenunciate speech. b. Speak normally and slowly. c. Exaggerate facial expressions. d. Raise the voice to a higher pitch. e. Write out names or difficult words.

b. Speak normally and slowly. e. Write out names or difficult words.

During assessment of thepatient's skin, thenurse observes a similar pattern of discrete, small, raised lesions on theleft and right upper back areas. Which term would thenurse use to document thedistribution of these lesions? a. Confluent b. Symmetric c. Zosteriform d. Generalized

b. Symmetric

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which action would the nurse implement for a patient who has an impaired breathing pattern due to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use the pursed-lip technique. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.

b. Teach the patient how to use the pursed-lip technique

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action would the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Teach the patient to use the prescribed albuterol (Ventolin HFA). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.

b. Teach the patient to use the prescribed albuterol (Ventolin HFA).

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 58

b. The patient has subcutaneous emphysema on the upper thorax.

A patient who reports chronic itching of theankles continuously scratches thearea. Which assessment finding would thenurse expect? a. Hypertrophied scars on both ankles b. Thickening of theskin around theankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles

b. Thickening of theskin around theankles

Which equipment does thenurse need to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

b. Tuning fork

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6F (38.7C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

b. Use a swab to obtain a sample for a strep antigen test

An anticoagulant such as warfarin that interferes with prothrombin production will alter the clotting mechanism during a. platelet aggregation. b. activation of thrombin. c. the release of tissue thromboplastin. d. stimulation of factor activation complex.

b. activation of thrombin.

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. dyspnea and hypotension. b. apprehension and restlessness. c. cyanosis and cool, clammy skin. d. increased urine output and diaphoresis.

b. apprehension and restlessness.

A patient has a high blood level of indirect (unconjugated) bilirubin. One cause of this finding is that a. the gallbladder is unable to contract to release stored bile. b. bilirubin is not being conjugated and excreted into the bile by the liver. c. the Kupffer cells in the liver are unable to remove bilirubin from the blood. d. there is an obstruction in the biliary tract preventing flow of bile into the small intestine.

b. bilirubin is not being conjugated and excreted into the bile by the liver.

Teach the patient who is newly fitted with bilateral hearing aids to (select all that apply) a. replace the batteries monthly. b. clean the ear molds weekly or as needed. c. clean ears with cotton-tipped applicators daily. d. disconnect or remove the batteries when not in use. e. initially restrict usage to quiet listening in the home.

b. clean the ear molds weekly or as needed. d. disconnect or remove the batteries when not in use. e. initially restrict usage to quiet listening in the home.

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would ask the patient about a. folic acid intake. b. diet intake of iron. c. a history of gastric surgery. d. a history of sickle cell anemia.

b. diet intake of iron.

An 80-year-old man states that, although he adds a lot of salt to his food, it still does not have much taste. The nurse's response is based on the knowledge that the older adult a. should not have any changes in taste. b. has a loss of taste buds, especially for sweet and salt. c. has some loss of taste but no problems chewing food. d. loses some sense of taste related to the increased ability to smell.

b. has a loss of taste buds, especially for sweet and salt

When reviewing a patient's hematologic laboratory values after a splenectomy, the nurse would expect to find a. RBC abnormalities. b. increased WBC count. c. decreased hemoglobin. d. decreased platelet count.

b. increased WBC count.

During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient's knees and elbows. You would describe this finding as a. lentigo. b. psoriasis. c. actinic keratosis. d. seborrheic keratosis.

b. psoriasis.

The nurse teaches a patient scheduled for an electronystagmography that the test involves a. measuring ear drum movement in response to pressure. b. recording eye movements associated with ear irrigation. c. placing an electrode on the eardrum and assessing for dizziness. d. wearing headphones and determining which sounds can be heard.

b. recording eye movements associated with ear irrigation.

Health risks associated with obesity include (select all that apply) a. colorectal cancer. b. rheumatoid arthritis. c. polycystic ovary syndrome. d. nonalcoholic steatohepatitis. e. systemic lupus erythematosus.

b. rheumatoid arthritis. c. polycystic ovary syndrome. d. nonalcoholic steatohepatitis.

As gastric contents move into the small intestine, the bowel is normally protected from the acidity of gastric contents by the a. inhibition of secretin release. b. secretion of mucus by goblet cells. c. release of pancreatic digestive enzymes. d. release of gastrin by the duodenal mucosa.

b. secretion of mucus by goblet cells.

In teaching a patient who is using topical corticosteroids to treat acute dermatitis, the nurse should tell the patient that (select all that apply) a. the cream form is the most efficient system of delivery. b. short-term topical corticosteroid use usually does not cause systemic side effects. c. use a glove to apply a large amount of topical ointment to prevent further infection. d. abruptly stopping the use of topical corticosteroids may cause the dermatitis to reappear. e. systemic side effects from topical corticosteroids are likely if the patient is malnourished.

b. short-term topical corticosteroid use usually does not cause systemic side effects. d. abruptly stopping the use of topical corticosteroids may cause the dermatitis to reappear.

The nurse anticipates the preferred treatment for a patient with acute hepatitis A infection will include a. interferon. b. supportive care. c. hepatitis A vaccine. d. direct-acting antivirals.

b. supportive care.

When planning care for a patient at high risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on strict bed rest. b. using intermittent pneumatic compression devices. c. encouraging the patient to cough and deep breathe. d. encouraging a fluid intake of 2000 mL per 8-hour shift.

b. using intermittent pneumatic compression devices.

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include (select all that apply) a. encouraging regular exercise such as swimming. b. washing around the stoma daily with a moist washcloth. c. encouraging participation in postlaryngectomy support group. d. providing pictures and "hands-on" instruction for tracheostomy care. e. teaching how to hold breath and trying to gag to promote swallowing

b. washing around the stoma daily with a moist washcloth. c. encouraging participation in postlaryngectomy support group. d. providing pictures and "hands-on" instruction for tracheostomy care.

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? a. ―I will drink lots of fluids with my meals.‖ b. ―I can have ice cream as a snack every day.‖ c. ―I will exercise for 15 minutes before meals.‖ d. ―I will decrease my intake of beef and poultry.‖

b. ―I can have ice cream as a snack every day.‖

The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. ―I will drink lots of juices and other fluids to stay well hydrated.‖ b. ―I can use nasal decongestant spray until the congestion is gone.‖ c. ―I can take acetaminophen (Tylenol) to treat my sinus discomfort.‖ d. ―I will watch for changes in nasal secretions or the sputum that I cough up.‖

b. ―I can use nasal decongestant spray until the congestion is gone.‖

The nurse provides discharge instructions for a patient after a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. ―I can participate in fitness activities except swimming.‖ b. ―I must keep the stoma covered with an occlusive dressing.‖ c. ―I need to have smoke and carbon monoxide detectors installed.‖ d. ―I will wear a Medic-Alert bracelet to identify me as a neck breather.‖

b. ―I must keep the stoma covered with an occlusive dressing.‖

Which patient statement indicates that teaching about radiation therapy of the larynx was effective? a. ―I should not use any lotions on my neck.‖ b. ―I will need to carry a water bottle with me.‖ c. ―Until the radiation is complete, I may have diarrhea.‖ d. ―Alcohol-based mouthwashes will help clean my mouth.‖

b. ―I will need to carry a water bottle with me.‖

Which statement by the nurse to the patient's caregiver about the purpose of positive end-expiratory pressure (PEEP) is accurate? a. ―PEEP will push more air into the lungs during inhalation.‖ b. ―PEEP prevents the lung air sacs from collapsing during exhalation.‖ c. ―PEEP will prevent lung damage while the patient is on the ventilator.‖ d. ―PEEP allows the breathing machine to deliver 100% O2 to the lungs.‖

b. ―PEEP prevents the lung air sacs from collapsing during exhalation.‖

When the nurse is assessing the health perception-health maintenance pattern as related to gastrointestinal function, an appropriate question to ask is a. "What is your usual bowel elimination pattern?" b. "What percentage of your income is spent on food?" c. "Have you traveled to a foreign country in the last year?" d. "Do you have diarrhea when you are under a lot of stress?"

c. "Have you traveled to a foreign country in the last year?"

A patient with TB is admitted to the hospital and placed in a single patient room on airborne precautions. What should the nurse teach the patient? (select all that apply) a. No visitors will be allowed while in airborne isolation. b. Expect regular TB skin testing to evaluate for infection. c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for full length of time to prevent multidrug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation room.

c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for full length of time to prevent multidrug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation room.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic would the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy

c. Appropriate use of cough suppressants

Which action would thenurse take when teaching a patient with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a high-pitched tone of voice to provide instructions. c. Ask for permission to turn off thetelevision before teaching. d. Wait until family members have left before initiating teaching.

c. Ask for permission to turn off the television before teaching.

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on thefoot. Which items would thenurse gather for this procedure? a. Sterile gloves b. Patch test instruments c. Cotton-tipped applicators d. Syringe and intradermal needle

c. Cotton-tipped applicators

The nurse completes a shift assessment on a patient admitted in theearly phase of heart failure. Which sounds would thenurse most likely hear on auscultation? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous high-pitched sounds of short duration during inspiration d. Discontinuous low-pitched sounds of long duration during inspiration

c. Discontinuous high-pitched sounds of short duration during inspiration

Which actions will thenurse include in thesurgical time-out procedure before surgery? (Select all that apply.) a. Check for patency of IV lines. b. Have thesurgeon identify thepatient. c. Have thepatient state name and date of birth. d. Verify thepatient identification band number. e. Ask thepatient to state thesurgical procedure.

c. Have thepatient state name and date of birth. d. Verify thepatient identification band number. e. Ask thepatient to state thesurgical procedure.

A patient in thedermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from theupper back. For which type of biopsy would thenurse prepare? a. Shave biopsy b. Punch biopsy c. Incisional biopsy d. Excisional biopsy

c. Incisional biopsy

On admission to theburn unit, a patient with an approximate 25% total body surface area (TBSA) burn has thefollowing initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na + 135 mEq/L (135 mmol/L). Which prescribed action would be thenurse's priority? a. Monitoring urine output b. Scheduling additional laboratory tests c. Increasing therate of theordered IV solution d. Typing and crossmatching for a blood transfusion

c. Increasing therate of theordered IV solution

A patient with dark skin has been admitted to thehospital with acute decompensated heart failure. How would thenurse assess this patient for cyanosis? a. Inspect theskin color of theearlobes. b. Apply pressure to thepalms of thehands. c. Look at thelips and oral mucous membranes. d. Measure capillary refill time of thenail beds.

c. Look at thelips and oral mucous membranes.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action would the nurse take first?

c. Medicate the patient with prescribed morphine.

Which information would thenurse include in theteaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low-dose systemic chemotherapy is used to treat BCC.

c. Minimizing sun exposure reduces risk for future BCC.

On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called a. vitiligo. b. intertrigo. c. Nevus of Ota. d. telangiectasia.

c. Nevus of Ota.

When caring for a preoperative patient on theday of surgery, which actions can thenurse delegate to assistive personnel (AP)? (Select all that apply.) a. Teach incentive spirometer use. b. Explain routine preoperative care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport thepatient by stretcher to theoperating room.

c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport thepatient by stretcher to theoperating room.

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next? a. Give the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol). c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of these findings.

c. Obtain oxygen saturation using pulse oximetry.

A patient with chronic obstructive pulmonary disease (COPD) has been eating very little and has lost weight. Which intervention would be most important for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's menu order of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.

c. Offer high-calorie protein snacks between meals and at bedtime.

A teenaged male patient who is on a wrestling team is examined by thenurse in theclinic. Which assessment finding would prompt thenurse to teach thepatient about preventing thespread of pediculosis? a. Ringlike rashes with red, scaly borders over theentire scalp b. Red, hivelike papules and plaques with circumscribed borders c. Papular, wheal-like lesions with white deposits on thehair shaft d. Patchy areas of alopecia with small vesicles and excoriated areas

c. Papular, wheal-like lesions with white deposits on thehair shaft

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large, bruised area on the chest

c. Paradoxical chest movement

Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? a. Heart rate is between 60 and 100 beats/min. b. Patient's chest x-ray indicates clear lung fields. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.

c. Patient reports a decrease in exertional dyspnea.

Which finding would the nurse expect when assessing a patient with cor pulmonale? a. Chest pain b. Finger clubbing c. Peripheral edema d. Elevated temperature

c. Peripheral edema

Which observation about theskin of an older patient is thepriority for thenurse to discuss with thehealth care provider? a. Dry, scaly patches on theface b. Numerous varicosities on both legs c. Petechiae on thechest and abdomen d. Small dilated blood vessels on theface

c. Petechiae on thechest and abdomen

Using theillustrated technique, thenurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Reduced excursion d. Accessory muscle use

c. Reduced excursion

A patient with cystic fibrosis has blood glucose levels that are consistently between 180 to 250 mg/dL. Which action will the nurse expect to implement? a. Discuss the role of diet in blood glucose control. b. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals.

c. Teach the patient about administration of insulin.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

c. Teaching patients about the need for adult pertussis immunizations

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected. d. The international normalized ratio (INR) is prolonged.

c. The epoprostenol (Flolan) infusion is disconnected.

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is specific in confirming a diagnosis of chronic bronchitis? a. The patient relates a family history of bronchitis. b. The patient has a 30 pack-year cigarette smoking history. c. The patient reports a productive cough for 3 months of every winter. d. The patient has respiratory problems that began during the past 12 months.

c. The patient reports a productive cough for 3 months of every winter.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

c. The patient takes propranolol (Inderal) for hypertension.

The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flowmeter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone. d. The patient calls the health care provider when the peak flow is in the green zone.

c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/L. d. Increased tactile fremitus is palpable over the right chest.

c. The patient's white blood cell (WBC) count is 6000/L.

Which assessment finding for a patient with a history of asthma indicates that the nurse would take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min

c. Use of accessory muscles in breathing

Which patient risk factor would thenurse assign as thepriority focus of patient teaching? a. Multiple dysplastic nevi b. Light-skinned with blue eyes c. Using a tanning booth weekly d. Mother died of malignant melanoma

c. Using a tanning booth weekly

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care? a. Walk until pulse rate exceeds 130 beats/min. b. Stop exercising when you feel short of breath. c. Walk 15 to 20 minutes a day at least 3 times/wk. d. Limit exercise to activities of daily living (ADLs).

c. Walk 15 to 20 minutes a day at least 3 times/wk.

Which action would the nurse take to prepare a patient for spirometry? a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test.

c. Withhold bronchodilators for 6 to 12 hours before the examination.

The nurse monitors a patient with gastritis for pernicious anemia due to a. chronic autoimmune destruction of cobalamin stores in the body. b. progressive gastric atrophy from chronic breakage in the mucosal barrier and blood loss. c. a lack of intrinsic factor normally produced by acid-secreting cells of the gastric mucosa. d. hyperchlorhydria from an increase in acid-secreting parietal cells and degradation of RBCs.

c. a lack of intrinsic factor normally produced by acid-secreting cells of the gastric mucosa.

A common site for the lesions caused by atopic dermatitis is the a. buttocks. b. temporal area. c. antecubital space. d. plantar surface of the feet

c. antecubital space.

The discharge teaching plan for the patient after an acute episode of upper GI bleeding includes information about the importance of (select all that apply) a. limiting alcohol intake to 1 serving per day. b. only taking aspirin with milk or bread products. c. avoiding taking aspirin and drugs containing aspirin. d. only taking drugs prescribed by the health care provider. e. taking all drugs 1 hour before mealtime to prevent further bleeding.

c. avoiding taking aspirin and drugs containing aspirin. d. only taking drugs prescribed by the health care provider.

A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that a. chemotherapy will begin after the patient recovers from the surgery. b. both chemotherapy and radiation can be used as palliative treatments. c. follow-up colonoscopies will be needed to ensure that the cancer does not recur. d. a wound, ostomy, and continence nurse will visit the patient to identify the site for the ostomy.

c. follow-up colonoscopies will be needed to ensure that the cancer does not recur.

A patient with multiple myeloma becomes confused with an increased urine output. The laboratory finding that may explain these findings is: a. hyperkalemia. b. hyperuricemia. c. hypercalcemia. d. hypocalcemia.

c. hypercalcemia.

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough. b. increased chest expansion. c. increased residual volume. d. decreased lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

c. increased residual volume. d. decreased lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

When assessing the nutritional-metabolic pattern in relation to the skin, the nurse asks the patient about a. joint pain. b. the use of moisturizing shampoo. c. recent changes in wound healing. d. self-care habits related to daily hygiene.

c. recent changes in wound healing.

The nurse teaches a patient about pulmonary spirometry testing. Which statement by thepatient indicates teaching was effective? a. ―I should use my inhaler right before thetest.‖ b. ―I won't eat or drink anything 8 hours before thetest.‖ c. ―I will inhale deeply and blow out hard during thetest.‖ d. ―My blood pressure and pulse will be checked every 15 minutes.‖

c. ―I will inhale deeply and blow out hard during thetest.‖

Which instruction would the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. ―Avoid upper body exercises to prevent dyspnea.‖ b. ―Stop exercising if you start to feel short of breath.‖ c. ―Use the bronchodilator before you start to exercise.‖ d. ―Breathe in and out through the mouth while exercising.‖

c. ―Use the bronchodilator before you start to exercise.‖

A patient diagnosed with external otitis is being discharged from theemergency department with an ear wick in place. Which statement by thepatient indicates a need for further teaching? a. ―I will apply theeardrops to thecotton wick in theear canal.‖ b. ―I can use aspirin or acetaminophen (Tylenol) for pain relief.‖ c. ―I will clean theear canal daily with a cotton-tipped applicator.‖ d. ―I can use warm compresses to theoutside of theear for comfort.‖

c.. I will clean theear canal daily with a cotton-tipped applicator.‖

After receiving change-of-shift report on a medical unit, which patient would the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has crackles bilaterally in the lung bases c. A patient with emphysema who has an oxygen saturation of 90% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

d. A patient with septicemia who has intercostal and suprasternal retractions

The nurse supervises assistive personnel (AP) providing care for a patient who has right lower lobe pneumonia. Which action by the AP requires the nurse to intervene? a. AP assists the patient to ambulate to the bathroom. b. AP helps splint the patient's chest during coughing. c. AP transfers the patient to a bedside chair for meals. d. AP lowers the head of the patient's bed to 15 degrees.

d. AP lowers the head of the patient's bed to 15 degrees.

The nurse notes darker skin pigmentation in theskinfolds of a middle-aged patient who has a body mass index of 40 kg/m2 . Which action would thenurse take? a. Discuss theuse of drying agents to minimize infection risk. b. Instruct thepatient about theuse of mild soap to clean skinfolds. c. Teach thepatient about treating fungal infections in theskinfolds. d. Ask thepatient about a personal or family history of type 2 diabetes.

d. Ask thepatient about a personal or family history of type 2 diabetes.

The nurse palpates theposterior chest and notes absent fremitus while thepatient says ―toy boat‖. Which action would thenurse take next? a. Palpate theanterior chest and observe for barrel chest. b. Encourage thepatient to turn, cough, and deep breathe. c. Review thechest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

d. Auscultate anterior and posterior breath sounds bilaterally.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

d. Chest tube connected to suction

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action would the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

d. Elevate the head of the bed to a semi-Fowler's position.

The nurse is developing a health promotion plan for an older adult who worked in thelandscaping business for 40 years. thenurse will plan to teach thepatient how to self-assess for which skin changes? (Select all that apply.) a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis

d. Erythema e. Actinic keratosis

A patient with pneumonia has a fever of 101.4F (38.6C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem would the nurse assign as the priority? a. Fatigue b. Altered temperature c. Musculoskeletal problem d. Impaired respiratory function

d. Impaired respiratory function

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. Which procedure would the nurse anticipate assisting with to determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure? a. Obtaining a ventilation-perfusion scan b. Drawing blood for arterial blood gases c. Positioning the patient for a chest x-ray d. Inserting a pulmonary artery catheter

d. Inserting a pulmonary artery catheter

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

d. Lower the positive end-expiratory pressure (PEEP).

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention would the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.

d. Perform chest physiotherapy every 4 hours.

In reviewing a patient's medical record, thenurse notes that thelast eye examination revealed an intraocular pressure of 28 mm Hg. Which assessment at would thenurse plan to make? a. Visual acuity b. Pupil reaction c. Color perception d. Peripheral vision

d. Peripheral vision

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6F with a frequent cough and severe pleuritic chest pain. Which prescribed medication would the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

d. Piperacillin/tazobactam (Zosyn)

A patient newly diagnosed with asthma is being discharged. Which topic would the nurse include in the discharge teaching? a. Complications associated with O2 therapy b. Use of long-acting -adrenergic medications c. Side effects of sustained-release theophylline d. Self-administration of inhaled corticosteroids

d. Self-administration of inhaled corticosteroids

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.

d. Sputum smears for acid-fast bacilli are negative.

. What should a patient be taught after a hemorrhoidectomy? a. Take mineral oil before bedtime. b. Eat a low-fiber diet to rest the colon. c. Use a daily oil-retention enema to empty the colon. d. Take prescribed pain medications before a bowel movement.

d. Take prescribed pain medications before a bowel movement.

A patient is admitted to the emergency department with an open stab wound to the left chest. Which action would the nurse take?

d. Tape a nonporous dressing on three sides over the wound.

Which intervention would the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Assist the patient with chest physiotherapy and postural drainage. b. Teach the patient to avoid the use of over-the-counter expectorants. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

The nurse completes an admission assessment on a patient with asthma. Which information indicates a need for discussion with the health care provider about a change in therapy? a. The patient uses an albuterol inhaler before aerobic exercise. b. The patient's only medications are albuterol and salmeterol inhalers. c. The patient's heart rate increases slightly after using the albuterol inhaler. d. The patient used albuterol more often when symptoms were worse in the spring.

d. The patient used albuterol more often when symptoms were worse in the spring.

Which finding by thenurse performing an eye examination indicates that thepatient has normal accommodation? a. After covering one eye for 1 minute, thepupil constricts as thecover is removed. b. Shining a light into thepatient's eye causes pupil constriction in theopposite eye. c. A blink reaction occurs after touching thepatient's pupil with a piece of sterile cotton. d. The pupils constrict while fixating on an object being moved toward thepatient's eyes.

d. The pupils constrict while fixating on an object being moved toward thepatient's eyes.

A patient asks, "How does air get into my lungs?" The nurse bases their answer on knowledge that air moves into the lungs because of a. positive intrathoracic pressure. b. contraction of the accessory abdominal muscles. c. stimulation of the respiratory muscles by the chemoreceptors. d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.

d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.

Discharge teaching for the patient who underwent laparoscopic cholecystectomy should include the need to a. abstain from alcohol. b. avoid eating low-fat meals. c. obtain hepatitis A vaccine. d. call if there are changes in stool or urine color.

d. call if there are changes in stool or urine color.

A patient with cancer arising from granulocytic cells in the bone marrow will have a. a risk for bleeding. b. altered oxygenation. c. decreased production of antibodies. d. decreased phagocytosis of bacteria.

d. decreased phagocytosis of bacteria.

Because myelodysplastic syndrome arises from immature hematopoietic stem cells in the bone marrow, laboratory results the nurse would expect to find include a(n) a. excess of T cells. b. excess of platelets. c. deficiency of granulocytes. d. deficiency of all cellular blood components.

d. deficiency of all cellular blood components.

A patient is admitted to the hospital with diarrhea and dehydration. The nurse recognizes that increased peristalsis resulting in diarrhea can be related to a. sympathetic inhibition. b. mixing and propulsion. c. sympathetic stimulation. d. parasympathetic stimulation.

d. parasympathetic stimulation.

The nurse is teaching the patient and family that peptic ulcers are a. caused by a stressful lifestyle and other acid-producing factors, such as H. pylori. b. inherited within families and reinforced by bacterial spread of Staphylococcus aureus in childhood. c. promoted by factors that cause oversecretion of acid, such as excess diet fats, smoking, and alcohol use. d. promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H. pylori.

d. promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H. pylori.

Transfusion complications that can be decreased with leukocyte depletion or reduction of RBC transfusion are a. chills and hemolysis. b. leukostasis and neutrophilia. c. fluid overload and pulmonary edema. d. transmission of cytomegalovirus and fever.

d. transmission of cytomegalovirus and fever.

An optimal teaching plan for an outpatient with stomach cancer receiving radiation therapy should include information about a. cancer support groups, alopecia, and stomatitis. b. nutrition supplements, ostomy care, and support groups. c. prosthetic devices, wound and skin care, and grief counseling. d. wound and skin care, nutrition, drugs, and community resources.

d. wound and skin care, nutrition, drugs, and community resources.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? a. ―Do you take any over-the-counter (OTC) medications?‖ b. ―Do you have any family members with a history of TB?‖ c. ―How long has it been since you moved to the United States?‖ d. ―Did you receive the Bacille Calmette-Guérin (BCG) vaccine for TB?‖

d. ―Did you receive the Bacille Calmette-Guérin (BCG) vaccine for TB?‖

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? a. ―I will make an appointment to see the doctor every year.‖ b. ―I will stop taking the prednisone if I experience a dry cough.‖ c. ―I will not worry if I feel a little short of breath with exercise.‖ d. ―I will call the health care provider right away if I develop a fever.‖

d. ―I will call the health care provider right away if I develop a fever.‖

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. ―I am going to buy a rib binder to wear during the day.‖ b. ―I can take shallow breaths to prevent my chest from hurting.‖ c. ―I should plan on taking the pain pills only at bedtime so I can sleep.‖ d. ―I will use the incentive spirometer every hour or two during the day.‖

d. ―I will use the incentive spirometer every hour or two during the day.‖