Lecture 92 Study Set

When making decisions about patient care, which term would the nurse associate with the act of integrating current research and statistical information? Collaboration Supervision Informatics Evidence-based practice

Evidence-based practice

Which condition would be an expected risk when a 72-year-old patient who is dehydrated receives normal saline as an IV infusion? Electrolyte imbalance Cellular dehydration Acid-base imbalance Fluid overload

Fluid overload

Which assessment would the nurse make immediately if a patient's serum potassium is reported to be 5.6 mEq/L? Paresthesia Bowel sounds Recent diarrhea Heart rate

Heart rate

Which mechanism in the body compensates for a low pH? Decreases release of bicarbonate Decreases respiratory rate Increases respiratory rate Retains carbon dioxide

Increases respiratory rate

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? Select all that apply. One, some, or all responses may be correct. - Client's purposeful body movement in arranging the papers on the bedside table - Pain pattern, including precipitating and alleviating factors - Vital signs, such as increased blood pressure and heart rate - The client's family statement about increases in pain with ambulation - Pain history, including location, and quality of pain

Pain pattern, including precipitating and alleviating factors Pain history, including location, and quality of pain

Which adverse effect of morphine indicates the need for naloxone administration? Respiratory depression Blurred vision Urinary retention Mental confusion

Respiratory depression

Which manifestation in a client who has syndrome of inappropriate antidiuretic hormone (SIADH) would the nurse expect to find upon assessment? Decrease of vasopressin Preservation of salt Presence of pedal edema Retention of water

Retention of water

The laboratory report of a patient with cancer shows serum sodium levels of 108 mEq/L. Which complication would the nurse anticipate in the patient? Neutropenia Seizures Somnolence syndrome Amnesia

Seizures

Which arterial blood gas laboratory values would be seen in metabolic alkalosis? pH 7.28, carbon dioxide 54 pH 7.49, bicarbonate 32 pH 7.53, carbon dioxide 28 pH 7.31, Bicarbonate 18

pH 7.49, bicarbonate 32 (pH high, Bicarbonate high)

The nurse conducts preoperative teaching for a patient who is scheduled for abdominal surgery. The patient asks why he should splint the incisional area during coughing and deep breathing. The best response by the nurse is: - "Splinting helps to decrease nausea after surgery." - "Splinting helps to prevent infection at the incision site." - "Splinting helps to control bleeding at the incision site." - "Splinting helps to support the area and keep pain at a minimum."

- "Splinting helps to support the area and keep pain at a minimum."

Which serum calcium level puts a patient at high risk for coma? 10 mg/dL 12 mg/dL 14 mg/dL 8mg/dL

14 mg/dL

Which potassium level would indicate that therapy for hyperkalemia was effective? 4.6 mEq/L 5.6 mEq/L 2.6 mEq/L 7.6 mEq/L

4.6 mEq/L

As a patient advocate, which action is the primary role of the nurse in pain management? - Assessing the level of pain - Administering pain medication - Contacting the health care provider for a medication prescription - Accepting the patient's report of pain

Accepting the patient's report of pain

Which parameter would the nurse examine to assess a patient's acid-base balance? Sodium level Calcium level Bicarbonate level Potassium level

Bicarbonate level

A client receiving morphine is being monitored by the nurse for adverse effects of the medication. Which clinical finding warrants immediate action by the nurse? Select all that apply. One, some, or all responses may be correct. Bradycardia Hypertension Bradypnea Unconsciousness Lacrimation Yawning Polyuria Dilated pupils

Bradycardia Bradypnea Unconsciousness

A patient who has just undergone a Whipple procedure for pancreatic cancer has frank blood and an increased output from the biliary drainage tubes. Which action by the nurse is priority? Contact the surgeon Assess the patient's vital signs Clamp the nasogastric tube Document the output.

Contact the surgeon

Which instruction would the nurse include when teaching a spouse and patient with hepatitis C about preventing the spread of infection? "Drink only bottled water." "Do not share toothbrushes." "Donate blood only once yearly." "You should use a separate bathroom."

"Do not share toothbrushes."

Which instruction would the nurse include when teaching a spouse and patient with hepatitis C about preventing the spread of infection? "Drink only bottled water." "Donate blood only once yearly." "Do not share toothbrushes." "You should use a separate bathroom."

"Do not share toothbrushes."

Which statement by the nurse would be most useful in differentiating between nociceptive and neuropathic pain? "Is your pain constant or does it come and go?" "Please rate your pain using a scale of 0 to 10". "When did you first notice your pain?" "Please describe what your pain feels like."

"Please describe what your pain feels like."

Which finding would the nurse expect when assessing a client with compensated metabolic acidosis? - Mental instability - Deep and rapid respirations - Muscle twitching - Tachycardia and cardiac dysrhythmias

- Deep and rapid respirations

Which substance causes the collecting tubules in the kidneys to reabsorb sodium as part of a blood pressure (BP) control system? Aldosterone Sodium Renin Angiotensin-converting enzyme

Aldosterone

Which symptom presents in a patient with acute pancreatitis and indicates complications? Select all that apply. One, some, or all responses may be correct. Vertigo Depression Darkened urine Jaundice Clay-colored stools

Darkened urine Jaundice Clay-colored stools

The nurse is reviewing the medications prescribed for a patient with peptic ulcer disease (PUD). Which drug treats Helicobacter pylori infection? Nizatidine Pantoprazole Metronidazole Aluminum hydroxide

Metronidazole

Which clinical findings in a patient indicate ulcerative colitis? Bowel fistulas Thickened bowel wall Inflammation of the ileum and colon Presence of blood and mucus in the stool

Presence of blood and mucus in the stool

Which enzyme acts on angiotensinogen to split off angiotensin I as part of a blood pressure (BP) control system? Renin Aldosterone Sodium Angiotensin-converting enzyme

Renin

Which complication is common for a patient with pancreatic cancer to develop? Eructation Dyspepsia Infection Venous emboli

Venous emboli

Which patient with an indwelling urinary catheter would the nurse reassess to determine if continued catheterization is necessary? Select all that apply. One, some, or all responses may be correct. - 3-day postoperative patient - Incontinent patient with perineal skin breakdown - Comatose patient with hourly intake and output - Incontinent older adult in long term care - Patient in postanesthesia care unit (PACU)

- 3-day postoperative patient - Incontinent older adult in long term care - Patient in postanesthesia care unit (PACU)

As a patient advocate, which action is the primary role of the nurse in pain management? - Accepting the patient's report of pain - Assessing the level of pain - Contacting the health care provider for a medication prescription - Administering pain medication

- Accepting the patient's report of pain

A patient suspected of having cholecystitis presents with severe upper epigastric pain radiating to the right shoulder. The patient is vomiting and has abdominal distention. Which finding do these symptoms indicate? - Biliary colic - Liver involvement - Positive Blumberg sign - Chronic cholecystitis

- Biliary colic

A client sustains fractured ribs as a result of an accident. Which clinical indicator suggests the client may be experiencing a complication of fractured ribs? - Bowel sounds are auscultated in the lower chest - Diminished breath sounds on the affected side - Report of pain when taking deep breaths - Client is observed splinting the fracture site

- Diminished breath sounds on the affected side

Which condition is a risk factor for distributive shock? - Diminished immune response - Presence of cardiomyopathies - Use of Ginkgo biloba - Diminished thirst reflex

- Diminished immune response

Which definition is correct to explain the nursing process? - Procedures used to implement client care - Mechanisms applied to determine nursing goals for the client - Sequence of steps to meet the client's needs - Activities employed to identify a client's problem

- Sequence of steps to meet the client's needs

A patient is experiencing bleeding related to peptic ulcer disease (PUD). Which action would the nurse take? - Starting a large-bore IV - Administering IV pain medication - Monitoring the patient's anxiety level - Preparing equipment for intubation

- Starting a large-bore IV

When caring for a patient receiving an opioid analgesic medication via patient-controlled analgesia (PCA), which action will the nurse implement immediately when witnessing the patient's spouse activate the PCA button? - Ensure that the patient's spouse is familiar with the medication side effects. - Discontinue the patient's use of the PCA. - Notify the patient's primary health care provider. - Advise the patient and the spouse that only the patient may activate the PCA.

Advise the patient and the spouse that only the patient may activate the PCA.

Which food does the nurse recommend to a patient when the assessment findings include an ST depression on the ECG strip and a potassium level of 3.1 mEq/L? Blueberries and cabbage Bananas and avocados Salted nuts and canned beans Pretzels and beef broth

Bananas and avocados

Which laboratory changes are most likely in a patient whose immune system is being overwhelmed by the human immune deficiency virus (HIV)? CD4+ T-cell counts rise, viral numbers fall CD4+ T-cell counts fall, viral numbers rise CD4+ T-cell and viral numbers rise CD4+ T-cell counts and viral numbers fall

CD4+ T-cell counts fall, viral numbers rise

Which laboratory value would the nurse expect to be decreased when reviewing the laboratory results for a patient with hypovolemic shock because of blood loss? Select all that apply. One, some, or all responses may be correct. Hemoglobin Potassium Hematocrit Sodium Lactic acid

H&H

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation? - Implementation - Assessment - Evaluation - Planning

Implementation

Which laboratory result would the nurse review for a patient suspected of having cholecystitis? Select all that apply. One, some, or all responses may be correct. Liver function tests Alkaline phosphate Hematocrit White blood cells Platelets

Liver function tests Alkaline phosphate White blood cells

Which laboratory result would the nurse review for a patient suspected of having cholecystitis? Select all that apply. One, some, or all responses may be correct. Platelets Hematocrit Liver function tests White blood cells Alkaline phosphate

Liver function tests White blood cells Alkaline phosphate

Which organs play a major role in maintaining pH balance in the body? Select all that apply. One, some, or all responses may be correct. Lungs Brain Pancreas Kidneys Small intestine

Lungs Kidneys

A laboratory report for a patient shows the following results: pH 7.32 PaO 2 77 mm Hg; PaCO 2 50 mm Hg. Bicarbonate 24 mEq/L These findings are consistent with which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

Which acid-base imbalance would the nurse anticipate that a patient with morbid obesity may develop? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Respiratory acidosis

A patient is experiencing bleeding related to peptic ulcer disease (PUD). Which action would the nurse take? Administering IV pain medication Preparing equipment for intubation Monitoring the patient's anxiety level Starting a large-bore IV

Starting a large-bore IV

Which instruction would the nurse include in the discharge plan for a female patient diagnosed with ulcerative colitis (UC) who is going home on loperamide for symptomatic management of diarrhea? - "Be aware of the symptoms of toxic megacolon that we discussed." - "Pregnancy should be avoided." - "If diarrhea decreases, you should let your health care provider know." - "You will need to decrease your dose of sulfasalazine."

- "Be aware of the symptoms of toxic megacolon that we discussed."

When assessing a patient with a history of multiple renal calculi formations, the nurse would associate which patient statement with increasing the patient's risk for future stone development? - "I exercise regularly." - "I eat fibrous fruits." - "I eat large amounts of protein." - "I drink a large amount of fluids."

- "I eat large amounts of protein."

Which statement about the risks of lung cancer indicates a need for further teaching? - "People who do not smoke have minimal risk" "People who are addicted to smoking have a high risk" - "People who are passive smokers are at high risk" - "People who are exposed to air pollutants are not at risk"

- "People who are exposed to air pollutants are not at risk"

A client with chest trauma is admitted in the emergency department. Which intervention takes priority? - Release dressing in tension pneumothorax - Monitor cardiac rhythm - Assess client for pain - Ensure patent airway

- Ensure patent airway

A patient who is admitted with severe diabetic ketoacidosis has an arterial blood gas result that reveals a pH of 7.21. Which factor is causing this patient's acidosis? - Excessive intake of insulin - Excessive breakdown of fatty acids - Anaerobic metabolism - Excessive intake of alcoholic beverages

- Excessive breakdown of fatty acids

A patient who was involved in a motor vehicle accident arrives at the emergency department and requires immediate surgery to stop massive internal hemorrhaging. The patient is unconscious, and no family or spouse is present. Which action would the nurse anticipate? - Getting written consultation from two other health care providers before surgery. - Attempting to stop bleeding without surgery. - Holding surgery until next of kin is present. - Contacting a family friend to obtain consent

- Getting written consultation from two other health care providers before surgery.

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished? - Atmospheric pressure in the thoracic cavity - Neutral pressure in the pleural space - Intrapulmonic pressure in the thoracic cavity - Negative pressure in the pleural space

- Negative pressure in the pleural space

Which assessment data provide the nurse with the best indicator of pain the patient is experiencing? - Pain rating of 6 on a scale of 0 to 10 - Grimacing during movement - Withdrawing from socialization - Blood pressure 184/92 mmHg

- Pain rating of 6 on a scale of 0 to 10

Which clinical findings in a patient indicate ulcerative colitis? - Thickened bowel wall - Inflammation of the stomach - Presence of blood and mucus in the stool - Bowel fistulas

- Presence of blood and mucus in the stool

When performing preoperative teaching for a patient who smokes a pack of cigarettes a day, which instruction is a priority? - Instruct the patient in strategies for smoking cessation. -Teach the patient how to use the incentive spirometer. - Review the negative health impacts of tobacco. - Discuss with the patient the physiologic changes that smoking causes in the lungs.

-Teach the patient how to use the incentive spirometer.

Which substance causes the collecting tubules in the kidneys to reabsorb sodium as part of a blood pressure (BP) control system? Renin Angiotensin-converting enzyme Sodium Aldosterone

Aldosterone

Which term would the nurse use to reflect that a patient's arterial blood pH is greater than 7.45 in the patient's electronic health record? Acidosis Alkalosis Negative anion gap Positive base excess

Alkalosis

Elevation of which laboratory value is associated with jaundice for a patient with hepatitis? Alanine aminotransferase (ALT) Bilirubin Blood urea nitrogen (BUN) Aspartate aminotransferase (AST)

Bilirubin

Elevation of which laboratory value is associated with jaundice for a patient with hepatitis? Bilirubin Blood urea nitrogen (BUN) Alanine aminotransferase (ALT) Aspartate aminotransferase (AST)

Bilirubin

A patient has dry skin, a heart rate of 115 beats/min, a respiratory rate of 28 breaths/min, and weight loss of 1 lb in 1 day. Which condition would the nurse suspect? Hyperkalemia Dehydration Hyponatremia Fluid overload

Dehydration

Which condition would the nurse anticipate incorporating into the plan of care for a patient who reports sharp, shocklike, burning, shooting pain in the feet and legs that is associated with numbness? Diabetic neuropathy Pancreatitis Bone metastasis Rheumatoid arthritis

Diabetic neuropathy

Which clinical indicators would the nurse expect when an intravenous (IV) line has infiltrated? Select all that apply. One, some, or all responses may be correct. Edema Decreased flow rate Increased blood pressure Pallor Heat

Edema Decreased flow rate Pallor

The nurse is planning postoperative care for a patient who is scheduled to undergo total knee replacement. Which intervention best reflects the nurse's correct understanding of patient-centered postoperative goals and outcomes? - Providing total care for the patient throughout the post operative period. - Encouraging the patient to engage in early ambulation as ordered. - Prioritizing the use of narcotics for pain management. - Teaching the patient to turn at least every 8 hours after surgery.

Encouraging the patient to engage in early ambulation as ordered.

A patient who is admitted with severe diabetic ketoacidosis has an arterial blood gas result that reveals a pH of 7.21. Which factor is causing this patient's acidosis? Excessive intake of insulin Anaerobic metabolism Excessive intake of alcoholic beverages Excessive breakdown of fatty acids

Excessive breakdown of fatty acids

To prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor? Food intake Fluid and electrolyte balance Skin condition Fluid intake and output

Fluid and electrolyte balance

Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued? - Oxygen saturation reading is higher than 90% - Full re-expansion of the lungs seen on chest x-ray - Clear breath sounds heard in both lungs - Absence of bubbling in the water-seal chamber

Full re-expansion of the lungs seen on chest x-ray

The nurse is reviewing laboratory values for a patient recently admitted to the medical-surgical unit. Which laboratory result is of concern? Sodium: 137 mEq/L Chloride: 106 mEq/L Potassium: 3.5 mEq/L Magnesium: 6.2 mEq/L

Magnesium: 6.2 mEq/L

The nurse is caring for a patient who has acute gastritis. Which class of medication is likely to increase the patient's risk for bleeding? - NSAID's - Proton pump inhibitors - Narcotic analgesics - Angiotensin-converting -enzyme (ACE) inhibitors

NSAID's

When evaluating the laboratory results of a patient with diabetic ketoacidosis, which laboratory value indicates the body has fully compensated from this acid-base imbalance? Normal serum glucose Normal serum potassium Normal pH on arterial blood gases Normal bicarbonate on arterial blood gases

Normal pH on arterial blood gases

Which factor is the distinction between human immune deficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS)? Duration of infection Viral load Course of treatment Number of CD4+ T-cells

Number of CD4+ T-cells

A patient diagnosed with myocardial infarction has the following laboratory values: potassium 2.9 mEq/L, calcium 8.5 mg/dL, magnesium 1.8 mEq/L, and pH 7.39. What value should be reported to the health care provider first? pH 7.39 Calcium 8.5 mg/dL Magnesium 1.8 mEq/L Potassium 2.9 mEq/L

Potassium 2.9 mEq/L

Which factor increases the risk for developing pancreatic cancer? Select all that apply. One, some, or all responses may be correct. Smoking Vitamin deficiency Aging Chronic pancreatitis Cirrhosis

Smoking Chronic pancreatitis Cirrhosis

A patient with a history of hypertension asks the nurse what dietary changes are needed to control the blood pressure. Which item in the diet would the nurse recommend reducing? Calcium Iron Sodium Phosphorous

Sodium

Which nursing action reflects correct use of the Wong-Baker FACES Pain Rating Scale? - Encouraging the patient to choose a cartoon face that best represents the pain - Instructing the patient to choose a phrase that best describes the pain - Matching a face shown on the scale to the patients facial expression - Asking the patient to rate the pain using a horizontal 0-10 point scale

- Encouraging the patient to choose a cartoon face that best represents the pain

Which procedure is preferred for the removal of a large stone from the kidney pelvis? - Ureteroplasty - Nephrostomy - Pyelolithotomy - Nephrectomy

- Pyelolithotomy

Which complication is seen exclusively in patients with ulcerative colitis? Cholelithiasis Malabsorption Colorectal cancer Abscess formation

Colorectal cancer

A laboratory report for a patient shows the following results: pH 7.32; bicarbonate 24 mEq/L; partial pressure of arterial oxygen (PaO 2) 77 mm Hg; and partial pressure of arterial carbon dioxide (PaCO 2) 48 mm Hg. These findings are consistent with which acid-base imbalance? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

Respiratory acidosis

When providing discharge teachings to a patient with peripheral neuropathy secondary to diabetes, which patient statement indicates understanding of injury prevention? Select all that apply. One, some, or all responses may be correct. "I should never go barefoot." "I need to monitor my feet daily for blisters or skin breaks." "I can break in my shoes by wearing them all day." "I should quit smoking."

"I should never go barefoot." "I need to monitor my feet daily for blisters or skin breaks" "I should quit smoking."

The nurse is providing teaching to a patient with gastroesophageal reflux disease (GERD). Which statement by the patient indicates a need for further teaching? "Antacids should help provide some relief" "It's important for me to stop drinking alcohol" "I should sit up for about 20 minutes after I eat" "The belching I've been experiencing is probably because of my GERD"

"I should sit up for about 20 minutes after I eat"

A patient rates pain at a 2 or 3 on a pain rating scale of 0 to 10. Which statement describes the correct interpretation of this finding? "The patient has moderate pain." "The patient has mild pain." "The patient has no pain." "The patient has severe pain."

"The patient has mild pain."

Which assessment question would the nurse ask a postoperative patient before administering a prescribed pain medication that is prescribed every 4 hours PRN? - "what do you do for pain when you're at home?" - "Are you bleeding?" - "Are you really hurting every 4 hours?" - "Is your pain controlled between doses?"

- "Is your pain controlled between doses?"

A patient with diabetes who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order would the nurse accomplish first? - Use electric clippers to cut hair at the surgical site - Start an infusion of lactated Ringer's solution at 75 ml/hr - Administer one-half of the patient's usual Lispro insulin dose -Draw blood for glucose, electrolytes and complete blood count values

-Draw blood for glucose, electrolytes and complete blood count values

Utilizing the SBAR process to improve communication among members of the health care team, which term would the nurse associate with the "A" in SBAR? Analysis Assessment Administration Application

Assessment

While obtaining a client's health history, which factor would the nurse identify as predisposing the client to type 2 diabetes? Having diabetes insipidus Drinking a daily alcoholic beverage Eating low-cholesterol food Being 20 pounds (9 kg) overweight

Being 20 pounds (9 kg) overweight

Which two components combine to produce the carbonic acid responsible for an acid-base imbalance in a patient with pneumonia and a decreased blood pH? Lactic acid and water Oxygen and lactic acid Carbon dioxide and water Oxygen and carbon dioxide

Carbon dioxide and water

According to the Centers for Disease Control and Prevention (CDC) laboratory classifications for human immune deficiency virus (HIV), which class has defining features which include a CD4+ T-cell count of less than 200 cells/mm 3 (0.2 × 10 9/L) or a percentage of less than 14%? Class 0 Class 2 Class 1 Class 3

Class 3

Which electrolyte abnormality would the nurse anticipate when reviewing laboratory data for a patient admitted with metabolic acidosis? Hyponatremia Hypernatremia Hypokalemia Hyperkalemia

Hyperkalemia

A patient admitted with diabetic ketoacidosis was treated for metabolic acidosis with IV fluids and insulin. Which electrolyte imbalance would the nurse monitor for as the acid-base imbalance resolves? Hypokalemia Hyponatremia Hyperkalemia Hypernatremia

Hypokalemia

Which electrolyte abnormality would the nurse anticipate when reviewing laboratory data for a patient admitted with metabolic acidosis? Hypernatremia Hypokalemia Hyperkalemia Hyponatremia

Hyponatremia

The nurse educator is providing information about different insulin types. Which type of insulin can be safely mixed with regular human insulin in the same syringe? Isophane insulin neutral protamine hagedorn (NPH) Insulin lispro mix 75/25 Insulin glargine Insulin detemir

Isophane insulin neutral protamine hagedorn (NPH)

A client with a spontaneous pneumothorax asks, 'Why did they put this tube into my chest?' Which information would the nurse provide about the purpose of the chest tube? It removes air from the pleural space It checks for bleeding in the lung It monitors the function of the lung It drains fluid from the pleural space

It removes air from the pleural space

The nurse is reviewing laboratory values for a patient recently admitted to the medical-surgical unit. Which laboratory result is of concern? Sodium: 137 mEq/L Magnesium: 6.2 mEq/L Chloride: 106 mEq/L Potassium: 3.5 mEq/L

Magnesium: 6.2 mEq/L

Which is the purpose of an occlusive dressing over a client's sucking chest wound? - Seals of the major vessels - Protects the lung - Prevents additional contamination of the wound - Maintains negative pressure within the chest cavity

Maintains negative pressure within the chest cavity

Which acid-base imbalance would be expected in a patient who has been having acute diarrhea for more than 24 hours? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic Acidosis

Deep and rapid breaths consistent with Kussmaul respiration are found in patients with which type of acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis

For a patient with an acid-base imbalance, which method would the nurse use to determine the type of acid-base imbalance the patient is experiencing? Measure partial pressure of carbon dioxide Measure bicarbonate level Monitor arterial blood gases Assess serum pH level

Monitor arterial blood gases

Which parameter would the nurse monitor to assess a patient's response to fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. Monitoring urine output Monitoring pulse quality Monitoring serum bilirubin Monitoring white blood cell count Monitoring weight change

Monitoring urine output Monitoring pulse quality Monitoring weight change

When caring for a patient who is receiving morphine, the nurse prioritizes assessing for which medication side effect? Respiratory depression Constipation Nausea and vomiting Tolerance

Respiratory depression

The laboratory report of a patient with cancer shows serum sodium levels of 108 mEq/L. Which complication would the nurse anticipate in the patient? Seizures Somnolence syndrome Amnesia Neutropenia

Seizures

Which type of shock is the nurse concerned about for an older-adult patient with a history of diabetes mellitus who has a blood pressure of 90/60 mm Hg, a white blood cell (WBC) count of 14,000/mm 3, and a urine output of 0.2 mL/kg/hr? Hypovolemic Septic Obstructive Cardiogenic

Septic

Which laboratory result may indicate the need for a change in a furosemide prescription in a patient with heart failure (HF)? - Serum magnesium level of 1.9 mEq/L - Serum creatinine level of 1.0 mg/dL - Serum sodium level of 135 mEq/L - Serum potassium level of 2.8 mEq/L

Serum potassium level of 2.8 mEq/L

Which complication of gastroesophageal reflux disease (GERD) is common in older adults? Select all that apply. One, some, or all responses may be correct. Sleep Apnea Barrett esophagus Dementia Hiatal hernia Esophageal erosions/strictures Aspiration pneumonia

Sleep Apnea. Barrett esophagus Esophageal erosions/strictures Aspiration pneumonia

When assigning a task to assistive personnel (AP), which process will the nurse implement to ensure appropriate performance of the task? Delegation Quality improvement Collaboration Supervision

Supervision

A patient on IV therapy reports shortness of breath. The nurse finds that the patient has elevated blood pressure, puffiness around the eyes, and distended neck veins. Which situation would the nurse suspect? The patient is showing signs of catheter embolism. The patient is experiencing ecchymosis. The patient is suffering from speed shock. The patient is showing signs of circulatory overload.

The patient is showing signs of circulatory overload.

The nurse is assessing a patient's peripheral IV site. Which assessment data indicates the need for nursing intervention? Transparent dressing was changed 5 days ago. Tubing for the IV was last changed 48 hours ago. Patient states, "It really hurt when the nurse put the IV in." The vein feels hard and cordlike above the insertion site.

The vein feels hard and cordlike above the insertion site.

A patient on IV therapy reports shortness of breath. The nurse finds that the patient has elevated blood pressure, puffiness around the eyes, and distended neck veins. Which situation would the nurse suspect? - The patient is experiencing ecchymosis. - The patient is showing signs of circulatory overload. - The patient is showing signs of catheter embolism. - The patient is suffering from speed shock.

- The patient is showing signs of circulatory overload.

A patient is scheduled for a hernia repair under general anesthesia. Which information obtained by the nurse is most important to communicate to the surgeon and anesthesia care provider prior to surgery? - The patient's mother died after receiving general anesthesia for abdominal surgery. - The patient had a sip of water 3 hours before coming to the hospital. - The patient drinks a cup of coffee every day. - The patient stopped taking her daily aspirin 10 days ago.

- The patient's mother died after receiving general anesthesia for abdominal surgery.

The nurse is assessing a patient's peripheral IV site. Which assessment data indicates the need for nursing intervention? - Tubing for the IV was last changed 48 hours ago. - Patient states, "It really hurt when the nurse put the IV in." - Transparent dressing was changed 5 days ago. - The vein feels hard and cordlike above the insertion site.

- The vein feels hard and cordlike above the insertion site.

A patient who has acute pancreatitis is prescribed famotidine. The nurse explains that this drug is given for which purpose? - To decrease gastric acid secretion that often occurs with pancreatitis - To improve the patient's ability to absorb food as the disease is resolving - To elviate pain caused by the release of pancreatic enzymes - To minimize the side effects of other medication used to treat pancreatitis

- To decrease gastric acid secretion that often occurs with pancreatitis

For the patient newly diagnosed with diabetes, which priority information would the nurse teach the patient and the patient's family when everyone is not ready or willing to learn diabetes control during the hospital stay? Causes and treatment of hypoglycemia Causes and treatment of hyperglycemia Dietary control Insulin administration

Causes and treatment of hypoglycemia

A patient admitted with diabetic ketoacidosis was treated for metabolic acidosis with IV fluids and insulin. Which electrolyte imbalance would the nurse monitor for as the acid-base imbalance resolves? Hypokalemia Hyponatremia Hypernatremia Hyperkalemia

Hypokalemia

Which central vascular access device (CVAD) is indicated in patients who require IV therapy for more than a year? Tunneled central venous catheter Peripherally inserted central catheter Nontunneled percutaneous central venous catheter Implanted port

Implanted port

When a postoperative patient's oxygen saturation rate drops from 97% to 90%, the medical-surgical nurse elevated the patient's head of bed to a 45-degree angle and encouraged the patient to deep breathe and cough. Which part of the nursing process was a result of the nurse's clinical judgement? Evaluation Assessment Analysis Implementation

Implementation

Deep and rapid breaths consistent with Kussmaul respiration are found in patients with which type of acid-base imbalance? Metabolic acidosis Respiratory alkalosis Respiratory acidosis Metabolic alkalosis

Metabolic acidosis

Which acid-base imbalance would be expected in a patient who has been having acute diarrhea for more than 24 hours? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Metabolic acidosis

The nurse is reviewing the medications prescribed for a patient with peptic ulcer disease (PUD). Which drug treats Helicobacter pylori infection? Metronidazole Nizatidine Aluminum hydroxide Pantoprazole

Metronidazole

Which topic is included in preoperative patient teaching? Select all that apply. One, some, or all responses may be correct. Pain management Incentive spirometry Lower extremity exercises Incisional care Splinting

Pain management Incentive spirometry Lower extremity exercises Splinting

Which assessment data provide the nurse with the best indicator of pain the patient is experiencing? Pain rating of 6 on a scale of 0 to 10 Withdrawing from socialization Grimacing during movement Blood pressure 184/92 mmHg

Pain rating of 6 on a scale of 0 to 10

Which clinical indicators would the nurse expect when an intravenous (IV) line has infiltrated? Select all that apply. One, some, or all responses may be correct. Heat Edema Increased blood pressure Decreased flow rate Pallor

Pallor Edema Decreased flow rate

Which mechanism of injury might be the reason for a suspected spinal cord injury in a client with a direct injury to the vertebral column from a gunshot after a mass shooting? Hyperextension Excessive Rotation Penetrating trauma Hyperflexion

Penetrating trauma

A laboratory report for a patient shows the following results: pH 7.32; bicarbonate 24 mEq/L; partial pressure of arterial oxygen (PaO 2) 77 mm Hg; and partial pressure of arterial carbon dioxide (PaCO 2) 48 mm Hg. These findings are consistent with which acid-base imbalance? Respiratory alkalosis Metabolic acidosis Metabolic alkalosis Respiratory acidosis

Respiratory acidosis

The nurse is caring for a client after abdominal surgery and encourages the client to engage in deep-breathing exercises and turn from side to side. Which complication is the nurse trying to prevent? Metabolic acidosis Respiratory alkalosis Respiratory acidosis Metabolic alkalosis

Respiratory acidosis

Which intervention would the nurse expect to be prescribed for a patient with hyponatremia? - Small volume IV infusions of 3% normal saline - IV administration of 0.45% normal saline - Administration of furosemide - 2g Sodium diet

Small volume IV infusions of 3% normal saline

Which finding is consistent with a diagnosis of acute cholecystitis? Select all that apply. One, some, or all responses may be correct. Vomiting Eructation (Belching) Dysphagia Blumberg sign Right lower quadrant pain

Vomiting Eructation (Belching) Blumberg sign

Which statement by the nurse would be most useful in differentiating between nociceptive and neuropathic pain? "Please rate your pain using a scale of 0 to 10". Is your pain constant or does it come and go?" "Please describe what your pain feels like." "When did you first notice your pain?"

"Please describe what your pain feels like."

Which instruction would the nurse give a patient newly diagnosed with ulcerative colitis (UC) about diet and lifestyle choices? - "Lactose-containing foods should be reduced or eliminated from your diet." - "Raw vegetables and high-fiber foods may help diminish your symptoms." - "Drinking carbonated beverages will help with your abdominal distress." - "It's okay to smoke cigarettes, but you should limit them to half a pack per day."

- "Lactose-containing foods should be reduced or eliminated from your diet."

A registered nurse is explaining the Quality and Safety Education for Nurses (QSEN) competencies to a nursing student. Which information would the nurse provide about the competency teamwork and collaboration? - "Implement improvement methods to design and test changes to improve the quality and safety of the health care system". - "Work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care." - "Understand that the client is the source of control and full partner when providing compassionate and coordinated care". - "Use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making."

- "Work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care."

In which way will the nurse respond to a patient diagnosed with hepatitis A who asks the nurse how this disease may have been contracted? - "If you received a blood transfusion, you may have been exposed." - "The virus is airborne, so you may have contracted it from an infected person." - "You may have consumed foods contaminated with the virus." - "You may have been exposed if you had unprotected sexual intercourse."

- "You may have consumed foods contaminated with the virus."

Which of the following preoperative patients has the greatest risk of bleeding as a result of his or her medication? - A female patient who takes lisinopril (Prinvil) for the treatment of hypertension. - A male patient who was recently prescribe finasteride (Proscar) for treatment of benign prostatic hyperplasia. - A male patient who takes warfarin (Coumadin) for a history of a stroke. - A female patient who takes metformin (Glucophage) to control her type 2 diabetes.

- A male patient who takes warfarin (Coumadin) for a history of a stroke.

Which of the four assigned patients would the nurse see first? - A patient diagnosed with diabetic ketoacidosis (DKA) and scheduled subcutaneous insulin - A patient diagnosed with new onset type 1 diabetes who now has positive urine ketones - A patient diagnosed with hyperglycemic-hyperosmolar state (HHS) and receiving 0.9% sodium chloride at 250 ml/hr - A patient diagnosed with hypoglycemia has a blood glucose level of 72 mg/dL

- A patient diagnosed with new onset type 1 diabetes who now has positive urine ketones

Which of the four assigned patients would the nurse see first? - A patient diagnosed with hyperglycemic-hyperosmolar state (HHS) and receiving 0.45% sodium chloride at 100 ml/hr - A patient diagnosed with new onset type 1 diabetes who now has positive urine ketones - A patient diagnosed with hypoglycemia has a blood glucose level of 72 mg/dL - A patient diagnosed with diabetic ketoacidosis (DKA) and scheduled subcutaneous insulin

- A patient diagnosed with new onset type 1 diabetes who now has positive urine ketones

When caring for a patient receiving an opioid analgesic medication via patient-controlled analgesia (PCA), which action will the nurse implement immediately when witnessing the patient's spouse activate the PCA button? - Notify the patient's primary health care provider. - Discontinue the patient's use of the PCA. - Advise the patient and the spouse that only the patient may activate the PCA. - Ensure that the patient's spouse is familiar with the medication side effects.

- Advise the patient and the spouse that only the patient may activate the PCA.

Which task would the medical-surgical nurse appropriately delegate to assistive personnel? - Feed a newly admitted patient with dyphasia a late tray. - Administer an enema after inserting a suppository. - Perform wet to dry dressing changes. - Ambulate a patient with a walker in the hall.

- Ambulate a patient with a walker in the hall.

Which action is the priority when the preoperative nurse learns that a client is taking several herbal supplements? - Teach the client about herbal supplements. - Provide the client with information about the usefulness of herbal therapies. - Inform the client about taking supplemental vitamins rather than herbs. - Ask the client which herbs have been taken.

- Ask the client which herbs have been taken.

A patient with emphysema is in acute respiratory distress and is becoming more confused. Respirations remain rapid but are shallower. The most recent blood gas results are pH 7.29, partial pressure of arterial oxygen (PaO 2) 62 mm Hg, partial pressure of arterial carbon dioxide (PaCO 2) 56 mm Hg, and bicarbonate (HCO 3 -) 25 mEq/L. Which intervention would the nurse take? - Place the patient in a semi-Fowlers position - Evaluate the patient's need for sedation to assist with breathing - Call the Rapid Response Team - Administer the prescribed diuretic

- Call the Rapid Response Team

A diabetic patient, well controlled with insulin injections, is scheduled for a mastectomy today. The patient has been NPO since midnight, and the nurse notes that there are no preoperative orders regarding the daily insulin dose. The most appropriate action for the nurse to take is: - Call the health care provider to clarify if insulin should be given and at what dose. - Give the patient half the usual daily dose since she will not be eating in the morning. - Give the patient the usual daily dosage since the stress of surgery will increase the blood glucose. - Withhold any insulin since none is ordered and the patient is NPO,

- Call the health care provider to clarify if insulin should be given and at what dose.

Which chronic complication may occur in patients with diabetes? - Diabetic ketoacidosis caused by lack of insulin and ketosis - Hyperglycemic- hyperosmolar state caused by insulin deficiency and profound dehydration - Hypoglycemia from too much insulin or too little glucose - Cell death from macrovascular changes

- Cell death from macrovascular changes

Which chronic complication may occur in patients with diabetes? - Diabetic ketoacidosis caused by lack of insulin and ketosis - Hyperglycemic- hyperosmolar state caused by insulin deficiency and profound dehydration - Hypoglycemia from too much insulin or too little glucose - Cell death from macrovascular changes

- Cell death from macrovascular changes

Which information is needed for the nurse to respond to the patient's question, "Will this stone be able to pass on its own?" Select all that apply. One, some, or all responses may be correct. - Composition of the stone - The patient's history of stones - Location of the stone - Size of the stone - The patient's body mass index (BMI)

- Composition of the stone - Location of the stone - Size of the stone

A client with a history of hemoptysis and cough for the past 6 months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. Which is the nurse's priority? - Document the amount of sputum - Increase the frequency of cough and deep breathing exercises - Monitor vital signs every hour - Contact the primary health care provider

- Contact the primary health care provider

Which condition would the nurse anticipate incorporating into the plan of care for a patient who reports sharp, shocklike, burning, shooting pain in the feet and legs that is associated with numbness? - Rheumatoid arthritis - Bone metastasis - Pancreatitis - Diabetic neuropathy

- Diabetic neuropathy

Which laboratory assessment finding may indicate diabetes mellitus? - Fasting blood glucose of 100 mg/dL in an 80-year old adult - Glycosylated hemoglobin (HbA1C) of 7.5% in a 30-year-old adult - Glucose tolerance test of 139 mg/dL in a 23 year old pregnant woman - Random blood glucose level of 126 mg/dL in a patient asymptomatic for hyperglycemia

- Glycosylated hemoglobin (HbA1C) of 7.5% in a 30-year-old adult

Which laboratory assessment finding may indicate diabetes mellitus? - Glucose tolerance test of 139 mg/dL in a 23 year old pregnant woman - Random blood glucose level of 126 mg/dL in a patient asymptomatic for hyperglycemia - Glycosylated hemoglobin of 7.5% in a 30-year-old adult - Fasting blood glucose of 100 mg/dL in an 80-year old adult

- Glycosylated hemoglobin of 7.5% in a 30-year-old adult

Which statement describes a function of the circulating nurse? - Passes instruments to the surgeon and assistant. - Prepares the instrument table and organizes sterile equipment. - Identifies and assesses the patient. - Explains the type of anesthetic that will be used.

- Identifies and assesses the patient.

Which topic is included in preoperative patient teaching? Select all that apply. One, some, or all responses may be correct. Lower extremity exercises Incentive spirometry Pain management Incisional care Splinting

- Lower extremity exercises - Incentive spirometry - Pain management - Splinting

Which parameter would the nurse monitor to assess a patient's response to fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. - Monitoring pulse quality - Monitoring weight change - Monitoring white blood cell count - Monitoring urine output - Monitoring serum bilirubin

- Monitoring pulse quality - Monitoring weight change - Monitoring urine output

Which information does the nurse educator include when giving a classroom presentation about neuropathic pain? Select all that apply. - Neuropathic pain arises from the skin and musculoskeletal structures - Neuropathic pain involves the abnormal processing of stimuli - Examples of neuropathic pain include pain associated trauma and surgery - Subcategories of neuropathic pain include somatic and visceral pain - Neuropathic pain may occur in the absence of tissue damage or inflammation

- Neuropathic pain involves the abnormal processing of stimuli - Neuropathic pain may occur in the absence of tissue damage or inflammation

Which information does the nurse educator include when giving a classroom presentation about neuropathic pain? Select all that apply. - Subcategories of neuropathic pain include somatic and visceral pain - Examples of neuropathic pain include pain associated trauma and surgery - Neuropathic pain arises from the skin and musculoskeletal structures - Neuropathic pain may occur in the absence of tissue damage or inflammation - Neuropathic pain involves the abnormal processing of stimuli

- Neuropathic pain involves the abnormal processing of stimuli. - Neuropathic pain may occur in the absence of tissue damage or inflammation.

For which population may pre-exposure prophylaxis (PrEP) for the human immune deficiency virus (HIV) be appropriate? Select all that apply. One, some, or all responses may be correct. - Nonmonogamous heterosexually active men and women - Men who have sex with men - Injection drug users - Adults who are HIV positive and want to prevent transmission to partners - Adults who are HIV negative and in a relationship with a partner who is HIV positive

- Nonmonogamous heterosexually active men and women - Men who have sex with men - Injection drug users - Adults who are HIV negative and in a relationship with a partner who is HIV positive

A patient who has received a sedative preoperatively is ready for surgery when the nurse realizes that the informed consent form has not been signed. The surgeon explained the procedure earlier, and the patient reported no further questions. There is no family or next of kin present. Which action would the nurse take? - Obtain another nurse to witness the consent. - Have the patient sign the consent form. - Proceed with the surgery and get the signature after the procedure. - Notify the surgeon and anticipate surgery cancellation

- Notify the surgeon and anticipate surgery cancellation

Ten minutes after receiving scheduled preoperative sedative medications by IM injection, a patient asks to get up and use the bathroom. Which action by the nurse is most appropriate? - Allow the patient to walk to the bathroom independently. - Ask the patient to hold the urine, as a catheter will be placed in the operating room. - Offer the patient a bedpan/urinal and position in bed to promote voiding. - Assist the patient to the bathroom and stay next to the dor to assist as needed.

- Offer the patient a bedpan/urinal and position in bed to promote voiding.

Which medication is classified as an H 2 receptor antagonist? Select all that apply. One, some, or all responses may be correct. - Ranitidine - Famotidine - Lansoprazole - Metoclopramide - Nizatidine

- Ranitidine - Famotidine - Nizatidine

Which nursing intervention or practice is most effective in helping to prevent urinary tract infections (UTI) in hospitalized patients? - Recommending catheters be placed in all patients - Re-evaluating the need for indwelling catheters - Irrigating all catheters daily with sterile saline - Encouraging patients to drink fluids

- Re-evaluating the need for indwelling catheters

Which nutritional recommendation would the nurse provide to the patient with peptic ulcer disease (PUD)? - Consuming marshmallows - Increasing spicy food to destroy H.pylori bacteria - Taking a dose of syrup of ipecac with each meal - Reducing caffeine intake

- Reducing caffeine intake

Which lifestyle modification would the nurse teach the patient with gastroesophageal reflux disease (GERD)? - Eat at least 1 hour before going to bed - Sleep in the supine position with your head of bed flat - Remain upright for 1-2 hours after meals - Consume no more than three meals a day

- Remain upright for 1-2 hours after meals

Which features of the human immune deficiency virus (HIV) convert its ribonucleic acid (RNA) into DNA and insert it into the host's DNA? - RNA and lipid bilayer - P17 matrix and p24 capsid - Gp41 and gp120 docking proteins - Reverse transcriptase and integrase enzymes

- Reverse transcriptase and integrase enzymes

Which food would the nurse instruct the patient with urinary calcium oxalate stones to avoid to prevent future stone formation? Select all that apply. One, some, or all response may be correct. - Sardines - Rhubarb - Black tea - Organ meats - Spinach

- Rhubarb - Black tea - Spinach

Which finding would the nurse expect when assessing a client hospitalized for dehydration? Select all that apply. One, some, or all responses may be correct. - Skin on forehead remains tented after being pinched. - Weight loss of 4 ounces (0.11 kg over 4 days. - Protruding eyeballs - Postural hypotension - Client reports eating an average of two meals a day.

- Skin on forehead remains tented after being pinched. - Postural hypotension

The nurse is caring for a client with gastrointestinal reflux disease (GERD). Which information would the nurse provide the client to prevent worsening of the disorder? Select all that apply. One, some, or all responses may be correct. Sleep with head of bed elevated. Begin a weight-loss program. Wear loose-fitting clothing. Include vigorous exercise. Eat a snack before bed.

- Sleep with head of bed elevated. - Begin a weight-loss program. - Wear loose-fitting clothing.

When performing preoperative teaching for a patient who smokes a pack of cigarettes a day, which instruction is a priority? - Teach the patient how to use the incentive spirometer. - Review the negative health impacts of tobacco. - Instruct the patient in strategies for smoking cessation. - Discuss with the pathient the physiologic changes that smoking causes in the lungs.

- Teach the patient how to use the incentive spirometer.

Which explanation is the rationale for performing sponge, needle, and instrument counts in the operating room? - The hospital is not liable if a client is injured resulting from a retained sponge or instrument. - The nurse is responsible for performing sponge counts as part of routine surgical standards. - The primary health care provider is responsible for providing an accurate count of sponges and instruments. - The nursing student is liable for client injuries resulting from a retained sponge or instrument

- The nurse is responsible for performing sponge counts as part of routine surgical standards.