Med-Surg2

¡Supera tus tareas y exámenes ahora con Quizwiz!

SHORT ANSWER 1. When assessing a patient with possible PAD, the nurse obtains a brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the patient's ankle-brachial index (ABI) as ______.

0.78 or 0.79 Rationale: The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP. Cognitive Level: Application Text Reference: p. 901 Nursing Process: Implementation NCLEX: Physiological Integrity

4. A patient in the outpatient clinic has positive serologic testing for anti-HCV. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Teach the patient that the HCV will resolve in 2 to 4 months. c. Administer immune globulin and the HCV vaccine. d. Instruct the patient on self-administration of a-interferon

A Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy with a-interferon or other medications is started. HCV has a high percentage of conversion to the chronic state so the nurse should not teach the patient that the HCV will resolve in 2 to 4 months. Immune globulin or vaccine is not available for HCV. Cognitive Level: Application Text Reference: p. 1092 Nursing Process: Planning NCLEX: Physiological Integrity

41. A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the nurse the reason for the test. Which response should the nurse give? a. The skin test will determine if you have a tuberculosis infection. b. The skin test will indicate whether you have active tuberculosis. c. The skin test is used to decide which antibiotic therapy will work best. d. The skin test is done prior to notification of the public health department.

A Rationale: A positive skin test will indicate whether the patient has been infected with tuberculosis. It does not indicate active infection, which will be established through chest x-ray and sputum culture. Initial drug treatment with 4 antibiotics uses a standardized protocol. Although the public health department should be notified if the patient has TB, the nurse should focus on the patient, rather than on the public health concerns. Cognitive Level: Application Text Reference: p. 571 Nursing Process: Implementation NCLEX: Physiological Integrity

15. A 36-year-old patient who has a history of thromboangiitis obliterans (Buerger's disease) is admitted to the hospital with a gangrenous lesion of the right small toe. When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient? a. Cessation of smoking b. Maintenance of appropriate weight c. Control of serum lipid levels d. Demonstration of meticulous foot care

A Rationale: Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease. Cognitive Level: Application Text Reference: p. 908 Nursing Process: Planning NCLEX: Physiological Integrity

27. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte imbalances associated with acute pancreatitis include a. muscle twitching and finger numbness. b. paralytic ileus and abdominal distention. c. hypotension. d. hyperglycemia.

A Rationale: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance. Cognitive Level: Analysis Text Reference: p. 1122 Nursing Process: Assessment NCLEX: Physiological Integrity

18. After 2 months of TB treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). The nurse discusses the treatment regimen with the patient with the knowledge that a. directly observed therapy (DOT) will be necessary if the medications have not been taken correctly. b. the positive sputum smears indicate that the patient is experiencing toxic reactions to the medications. c. twice-weekly administration may be used to improve compliance with the treatment regimen. d. a regimen using only INH and rifampin (Rifadin) will be used for the last 4 months of drug therapy.

A Rationale: After 2 months of therapy, negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. The nurse will need to initiate DOT if the patient has not been consistently taking the medications. Toxic reactions to the medications would not result in a positive sputum smear. Twice weekly medication administration is not one of the options for therapy. INH and rifampin are used for the last 4 months of drug therapy only if the initial four-drug regimen has been effective as evidenced by negative sputum smears. Cognitive Level: Application Text Reference: pp. 571-572 Nursing Process: Implementation NCLEX: Physiological Integrity

30. When the nurse is caring for the patient with pancreatic cancer, which nursing diagnosis is a priority? a. Chronic pain related to tumor pressure on abdominal structures b. Imbalanced nutrition: less than required related to anorexia c. Impaired skin integrity related to itching secondary to jaundice d. Grieving related to potentially terminal diagnosis

A Rationale: All of these nursing diagnoses are appropriate for a patient with pancreatic cancer, but treating the patient's pain is the priority because the patient will be unable to meet outcomes for the other nursing diagnoses unless the pain is controlled. Cognitive Level: Application Text Reference: pp. 1122, 1126 Nursing Process: Diagnosis NCLEX: Physiological Integrity

21. A 63-year-old patient is newly diagnosed with type 2 diabetes. When developing an education plan, the nurse's first action should be to a. assess the patient's perception of what it means to have type 2 diabetes. b. demonstrate how to check glucose using capillary blood glucose monitoring. c. ask the patient's family to participate in the diabetes education program. d. discuss the need for the patient to actively participate in diabetes management.

A Rationale: Before planning education, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. Cognitive Level: Application Text Reference: p.1264 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

31. The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an automobile accident if a. the breath sounds on one side are decreased. b. there are wheezes audible throughout both lungs. c. there is a sucking sound with each patient breath. d. paradoxic movement of the chest is noted.

A Rationale: Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the pleural space compresses the lung on that side. Wheezes that are heard in both lungs indicate airway narrowing, but not pneumothorax. A sucking sound with inspiration is heard with an open pneumothorax. Paradoxic chest movement is associated with flail chest. Cognitive Level: Application Text Reference: p. 586 Nursing Process: Assessment NCLEX: Physiological Integrity

32. A 19-year-old male patient with CF and his wife are considering having a child. Which statement by the patient indicates that the nurse's teaching has been effective? a. "We will plan on having genetic counseling before we make a decision." b. "My erectile dysfunction will make it more difficult to have a child." c. "It is likely that I will die before any children we have are grown." d. "There should not be any problems as long as I take my medications.

A Rationale: Children of patients with CF are either CF carriers or have the disease. Most men with CF are sterile, but erectile dysfunction is not associated with CF. The life expectancy for CF is getting longer, with a mean age of 35. Despite appropriate therapy, the couple is likely to experience problems becoming pregnant. Cognitive Level: Application Text Reference: p. 659 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

4. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to a. splint the chest when coughing. b. maintain fluid restrictions. c. wear the nasal oxygen cannula. d. try the pursed-lip breathing technique.

A Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange in patients with chronic obstructive pulmonary disease (COPD) but will not improve airway clearance in pneumonia. Cognitive Level: Application Text Reference: p. 568 Nursing Process: Implementation NCLEX: Physiological Integrity

19. The nurse has identified the collaborative problem of potential complication: pulmonary embolism for a patient with left-calf DVT. Which nursing action is appropriate to include in the plan of care? a. Maintain bed rest as ordered. b. Administer oxygen to keep O2 saturation >90%. c. Apply compression gradient stockings. d. Remind the patient to dorsiflex the feet and rotate the ankles.

A Rationale: Decreasing muscle activity of the leg will help prevent thrombus dislodgement. There is no need to administer oxygen unless the patient develops a pulmonary embolism. Compression gradient stockings are ordered after resolution of the DVT to prevent further DVT. Exercising the muscles in the legs may prevent a new DVT, but it may dislodge the current thrombus if the patient has a DVT. Cognitive Level: Application Text Reference: p. 912 Nursing Process: Planning NCLEX: Physiological Integrity

2. A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of these ordered medications should the nurse give first? a. Azithromycin (Zithromax) b. Acetaminophen (Tylenol) c. Guaifenesin (Robitussin) d. Codeine phosphate (Codeine)

A Rationale: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. Cognitive Level: Application Text Reference: pp. 563, 566 Nursing Process: Implementation NCLEX: Physiological Integrity

18. A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient's arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may a. require administration of insulin while taking prednisone. b. develop acute hypoglycemia during the RA exacerbation. c. have rashes caused by metforminprednisone interactions. d. need a diet higher in calories while receiving prednisone.

A Rationale: Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a complication of RA exacerbation or prednisone use. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient is likely to have an increased appetite when taking prednisone, but it will be important to avoid weight gain for the patient with RA. Cognitive Level: Application Text Reference: pp. 1258, 1267 Nursing Process: Planning NCLEX: Physiological Integrity

18. The health care provider orders a continuous IV heparin infusion for a patient with swelling and pain of the upper leg caused by a DVT. While the patient is receiving the heparin infusion, the nurse should a. avoid any IM medications to prevent localized bleeding. b. notify the health care provider if the partial thromboplastin time (PTT) value is greater than 50 seconds. c. have vitamin K available in case reversal of the heparin is needed. d. monitor posterior tibial and dorsalis pedis pulses with the Doppler.

A Rationale: IM injections are avoided in patients receiving anticoagulation. A PTT of 50 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by DVT. Cognitive Level: Application Text Reference: pp. 913, 916 Nursing Process: Planning NCLEX: Physiological Integrity

45. All of the following orders are received for a patient who has just been admitted with probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first? a. Obtain blood cultures from two sites. b. Give ciprofloxin (Cipro) 400 mg IV. c. Send to radiology for chest radiograph. d. Administer aspirin suppository.

A Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last. Cognitive Level: Application Text Reference: p. 566 Nursing Process: Implementation NCLEX: Physiological Integrity

36. After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful? a. The patient disposes of the open insulin vials after 4 weeks. b. The patient draws up the regular insulin in the syringe and then draws up the glargine. c. The patient stores extra vials of both types of insulin in the freezer until needed. d. The patient's family prefills the syringes weekly and stores them in the refrigerator.

A Rationale: Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Freezing alters the insulin molecule and should not be done. Cognitive Level: Application Text Reference: p. 1261 Nursing Process: Evaluation NCLEX: Physiological Integrity

11. While teaching a patient with asthma the appropriate use of a peak flow meter, the nurse instructs the patient to a. take and record peak flow readings when having asthma symptoms or an attack. b. increase the doses of long-term control medications for peak flows in the red zone. c. use the flow meter each morning after taking asthma medications. d. empty the lungs and then inhale rapidly through the mouthpiece.

A Rationale: It is recommended that patients check peak flows when asthma symptoms or attacks occur to compare the peak flow with the baseline. Increased doses of rapidly acting b2-agonists are indicated for peak flows in the red zone. Peak flows should be checked every morning before using medications. Peak flows are assessed during rapid exhalation. Cognitive Level: Application Text Reference: pp. 625, 628 Nursing Process: Implementation NCLEX: Physiological Integrity

7. Which finding would be the best indication to the nurse that the patient having an acute asthma attack was responding to the prescribed bronchodilator therapy? a. Wheezes are more easily heard. b. The oxygen saturation is 89%. c. Vesicular breath sounds resolve. d. The respiratory effort decreases.

A Rationale: Louder wheezes indicate that more air is moving through the airways and that the bronchodilator therapy is working. An oxygen saturation level less than 90% indicates continued hypoxemia. Vesicular breath sounds are normal. A decreased effort may indicate that the patient is becoming too fatigued to breathe effectively and needs mechanical ventilation. Cognitive Level: Application Text Reference: p. 617 Nursing Process: Evaluation NCLEX: Physiological Integrity

6. After repair of an abdominal aortic aneurysm, the nurse notes that the patient does not have popliteal, posterior tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for the nurse to take first? a. Review the preoperative assessment form for data about the pulses. b. Notify the surgeon and anesthesiologist. c. Document that the pulses are absent and recheck in 30 minutes. d. Elevate the lower extremities on pillows.

A Rationale: Many patients with aortic aneurysms also have peripheral arterial disease, so the nurse should check the preoperative assessment to determine whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms suggest graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 30 minutes before taking action. Elevating the legs will decrease blood flow. Cognitive Level: Application Text Reference: p. 898 Nursing Process: Implementation NCLEX: Physiological Integrity

6. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. administer IV morphine sulfate 2 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase dopamine (Intropin) infusion by 2 mcg/kg/min. d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.

A Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output but will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea. Cognitive Level: Analysis Text Reference: pp. 828-829 Nursing Process: Implementation NCLEX: Physiological Integrity

21. A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will a. dilate arterial and venous blood vessels, decreasing ventricular preload and afterload. b. improve the ability of the ventricular myocardium to contract, strengthening contractility. c. enhance the speed of impulse conduction through the heart, increasing the heart rate. d. increase calcium sensitivity in vascular smooth muscle, boosting systemic vascular resistance.

A Rationale: Nesiritide, a recombinant form of BNP, causes both arterial and venous vasodilation, leading to reductions in preload and afterload. Inotropic medications, such as dopamine and dobutamine, may be used in ADHF to improve ventricular contractility. Nesiritide does not increase impulse conduction or calcium sensitivity in the heart. Cognitive Level: Application Text Reference: p. 829 Nursing Process: Implementation NCLEX: Physiological Integrity

16. When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored urine. d. thickening of the nails.

A Rationale: Noninfectious hepatitis is a toxic effect of INH, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. Cognitive Level: Application Text Reference: pp. 572-573 Nursing Process: Implementation NCLEX: Physiological Integrity

14. A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis. c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.

A Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy. Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes. Intensive insulin therapy and an insulin pump are comparable in glucose control. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Implementation NCLEX: Physiological Integrity

27. A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange? a. Sitting up at the bedside in a chair and leaning slightly forward b. Resting in bed with the head elevated to 45 to 60 degrees c. In the Trendelenburg's position with several pillows behind the head d. Resting in bed in a high-Fowler's position with the knees flexed

A Rationale: Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg's position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well. Cognitive Level: Application Text Reference: p. 634 Nursing Process: Implementation NCLEX: Physiological Integrity

15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan? a. "Take vitamin B6 daily to prevent peripheral nerve damage." b. "Read a newspaper daily to check for changes in vision." c. "Schedule an audiometric examination to monitor for hearing loss." d. "Avoid wearing soft contact lenses to avoid orange staining."

A Rationale: Peripheral neurotoxicity associated can be prevented by taking vitamin B6 when being treated with INH. Visual changes, hearing problems, and orange staining are adverse effects of other TB medications. Cognitive Level: Application Text Reference: p. 573 Nursing Process: Planning NCLEX: Physiological Integrity

11. The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant a. turns the patient over to the right side. b. splints the patient's chest during coughing. c. elevates the patient's head to 45 degrees. d. assists the patient to get up to the bathroom.

A Rationale: Positioning the patient with the left (or "good" lung) down will improve oxygenation. The other actions are appropriate for a patient with pneumonia. Cognitive Level: Application Text Reference: p. 569 Nursing Process: Implementation NCLEX: Physiological Integrity

32. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to a. turn, cough, and deep breathe every 2 hours. b. choose low-fat foods from the menu. c. perform leg exercises hourly while awake. d. ambulate the evening of the operative day.

A Rationale: Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation. Cognitive Level: Application Text Reference: p. 1131 Nursing Process: Planning NCLEX: Physiological Integrity

24. Postural drainage with percussion and vibration is ordered bid for a patient with chronic bronchitis. The nurse will plan to a. carry out the procedure 3 hours after the patient eats. b. maintain the patient in the lateral positions for 20 minutes. c. perform percussion and vibration before placing the patient in the drainage position. d. give the ordered albuterol (Proventil)

A Rationale: Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 to 15 minutes. Percussion and vibration are done after the postural drainage. Bronchodilators are administered before chest physiotherapy. Cognitive Level: Application Text Reference: p. 647 Nursing Process: Planning NCLEX: Physiological Integrity

28. Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? a. Give the patient a snack of cheese and crackers. b. Have the patient drink a glass of orange juice or nonfat milk. c. Administer a continuous infusion of 5% dextrose for 24 hours. d. Assess the patient for symptoms of hyperglycemia.

A Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity

22. A patient with COPD asks the home health nurse about home oxygen use. The nurse should teach the patient that long-term home O2 therapy a. can improve the patient's prognosis and quality of life. b. may cause oxygen dependency in patients with COPD. c. is used only for patients who have severe end-stage respiratory disease. d. should never be used at night because the patient cannot monitor its effect.

A Rationale: Research supports the use of home oxygen to improve quality of life and prognosis. Oxygen dependency is not an issue for patients with COPD. Although most patients using home oxygen have SpO2 levels less than 89% on room air, it would not be appropriate to tell the patient that he or she was at the end stage of the disease. Oxygen use at night can improve sleep quality and is frequently recommended. Cognitive Level: Application Text Reference: p. 644 Nursing Process: Implementation NCLEX: Physiological Integrity

11. The nurse has been teaching the patient to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the patient that indicates a need for additional instruction is, a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I will buy the 0.5-ml syringes because the line markings will be easier to see." c. "I should draw up the regular insulin first after injecting air into the NPH bottle." d. "I do not need to aspirate the plunger to check for blood before I inject the insulin."

A Rationale: Rotating sites is no longer necessary because all insulin is now purified human insulin, and the risk for lipodystrophy is low. The other patient statements are accurate and indicate that no additional instruction is needed. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

37. A patient with primary pulmonary hypertension is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the patient reports decreased exertional dyspnea. b. the blood pressure is less than 140/90 mm Hg. c. the heart rate is between 60 and 100 beats/minute. d. the patient's chest x-ray indicates clear lung fields.

A Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective. Cognitive Level: Application Text Reference: p. 601 Nursing Process: Evaluation NCLEX: Physiological Integrity

19. The nurse makes a diagnosis of impaired gas exchange for a patient with COPD in acute respiratory distress, based on the assessment finding of a. a pulse oximetry reading of 86%. b. dyspnea and respiratory rate of 36. c. use of the accessory respiratory muscles. d. the presence of crackles in both lungs.

A Rationale: The best data to support the diagnosis of impaired gas exchange are abnormalities in the ABGs or pulse oximetry. The other data would support a diagnosis of risk for impaired gas exchange. Cognitive Level: Application Text Reference: pp. 650-651 Nursing Process: Diagnosis NCLEX: Physiological Integrity

5. A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with viral hepatitis and has just been admitted to the hospital. In planning care for the patient, the nurse assigns the highest priority to the patient outcome of a. maintaining adequate nutrition. b. establishing a stable home environment. c. increasing activity level. d. identifying the source of exposure to hepatitis.

A Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as having adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis. Cognitive Level: Application Text Reference: p. 1097 Nursing Process: Planning NCLEX: Physiological Integrity

22. Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA). The nurse recognizes that this measure is important to identify a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. b. fluid overload resulting from aggressive fluid replacement. c. the presence of hypovolemic shock related to osmotic diuresis. d. cardiovascular collapse resulting from the effects of hyperglycemia.

A Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Fluid overload, hypovolemia, and cardiovascular collapse are possible complications of DKA, but cardiac monitoring would not detect theses. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity

19. A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of INH. b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. recommendation guidelines for bacille Calmette-Guérin (BCG) vaccine.

A Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection. Cognitive Level: Application Text Reference: p. 572 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

23. The occupational nurse at a manufacturing plant where there is high worker exposure to beryllium dust will monitor workers for a. shortness of breath. b. chest pain. c. elevated temperature. d. barrel-chest.

A Rationale: The nurse will monitor for the earliest signs of occupational lung disease, which are dyspnea and a cough. The other symptoms are also consistent with occupational lung disease but would occur much later, after significant lung involvement has occurred. Cognitive Level: Application Text Reference: pp. 577-578 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

47. A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse's first action should be to a. elevate the head of the bed. b. administer the ordered pain medication. c. notify the patient's health care provider. d. offer emotional support and reassurance.

A Rationale: The patient has symptoms consistent with a pulmonary embolism; elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). Cognitive Level: Application Text Reference: p. 599 Nursing Process: Implementation NCLEX: Physiological Integrity

20. A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient's technique of SMBG, the nurse identifies a need for additional teaching when the patient a. chooses a puncture site in the center of the finger pad. b. washes the puncture site using soap and water. c. says the result of 130 mg indicates good blood sugar control. d. hangs the arm down for a minute before puncturing the site.

A Rationale: The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective. Cognitive Level: Application Text Reference: p. 1270 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

22. A patient with cancer of the liver has severe ascites, and the health care provider plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, the nurse a. asks the patient to empty the bladder. b. positions the patient on the right side. c. obtains informed consent for the procedure. d. assists the patient to lie flat in bed.

A Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flatwithout compromising breathing. The health care provider is responsible for obtaining informed consent. Cognitive Level: Application Text Reference: p. 1111 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

17. When teaching a patient with type 2 diabetes about taking glipizide (Glucotrol), the nurse determines that additional teaching about the medication is needed when the patient says, a. "Since I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." b. "If I overeat at a meal, I will still take just the usual dose of medication." c. "If I become ill, I may have to take insulin to control my blood sugar." d. "I should check with my doctor before taking any other medications because there are many that will affect glucose levels."

A Rationale: The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide. Cognitive Level: Application Text Reference: p. 1275 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

19. An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient a. has BP of 88/42. b. has an apical pulse rate of 56. c. complains of feeling tired. d. has 2+ pedal edema.

A Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of b- Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. badrenergic blockade will initially worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Assessment NCLEX: Analysis

26. While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. obtain a glucose reading using a finger stick. b. administer 1 mg glucagon subcutaneously. c. have the patient eat a candy bar. d. have the patient drink 4 ounces of orange juice.

A Rationale: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity

1. A patient with a history of a 4-cm abdominal aortic aneurysm is admitted to the emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include a. immediate surgery. b. a STAT angiogram. c. a paracentesis when vital signs are stabilized with fluid replacement. d. admission to intensive care for observation and diagnostic testing.

A Rationale: The patient's history and clinical manifestations are consistent with rupture into the retroperitoneal space, and the patient will need immediate surgery to have a chance at survival. The other listed treatments will all be too time consuming. Cognitive Level: Application Text Reference: p. 895 Nursing Process: Planning NCLEX: Physiological Integrity

40. A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Check the patient's O2 saturation. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

A Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. There is no indication that the oxygen saturation has decreased The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider. Cognitive Level: Application Text Reference: p. 597 Nursing Process: Assessment NCLEX: Physiological Integrity

29. The health care provider prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The nurse teaches the patient that the drug is considered effective if the patient experiences a. normal-appearing stools. b. decreased jaundice. c. improved appetite. d. reduced abdominal pain

A Rationale: The patient's steatorrhea should improve if the pancreatic enzymes are effective. The pancreatin will not decrease jaundice, improve appetite, or reduce abdominal pain. Cognitive Level: Application Text Reference: p. 1125 Nursing Process: Evaluation NCLEX: Physiological Integrity

16. Glyburide (Micronase, DiaBeta, Glynase) is prescribed for a patient whose type 2 diabetes has not been controlled with diet and exercise. When teaching the patient about glyburide, the nurse explains that a. glyburide stimulates insulin production and release from the pancreas. b. the patient should not take glyburide for 48 hours after receiving IV contrast media. c. glyburide should be taken even when the blood glucose level is low in the morning. d. glyburide decreases glucagon secretion.

A Rationale: The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, since hypoglycemia can occur with this category of medication. Metformin should be held for 48 hours after administration of IV contract, but this is not necessary for glyburide. Cognitive Level: Application Text Reference: pp. 1265-1266 Nursing Process: Implementation NCLEX: Physiological Integrity

6. A patient with acute hepatitis B asks the nurse if treatment is available for the condition. The nurse explains to the patient that a. because no medication is available to treat acute viral hepatitis, adequate nutrition and rest are the most important treatments. b. lamivudine (Epivir) can decrease viral load and liver damage in patients with acute hepatitis B, but it must be taken for at least 1 year. c. patients with acute hepatitis B can be given HBIG to help reduce the symptoms. d. various antiviral drugs are available to treat acute hepatitis B, but serious side effects limit their use.

A Rationale: There are no drug therapies to treat acute hepatitis, although a-interferon and nucleoside analogs (i.e., lamivudine) may be used to treat chronic hepatitis B. Immune globulin may be given within 24 hours after exposure to prevent hepatitis B, but it is not used to decrease symptoms for patients with acute hepatitis. Cognitive Level: Application Text Reference: p. 1093 Nursing Process: Implementation NCLEX: Physiological Integrity

32. Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication? a. Amitriptyline will help prevent the transmission of pain impulses to the brain. b. Amitriptyline will improve sleep and make you less aware of nighttime pain. c. Amitriptyline will decrease the depression caused by the pain. d. Amitriptyline will correct some of the blood vessel changes that cause pain.

A Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics. Cognitive Level: Application Text Reference: p. 1285 Nursing Process: Implementation NCLEX: Physiological Integrity

5. When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-colored?"

A Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. Cognitive Level: Application Text Reference: pp. 1255, 1258 Nursing Process: Assessment NCLEX: Physiological Integrity

1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to a. auscultate the lung sounds. b. assess the orientation. c. check the capillary refill. d. palpate the abdomen.

A Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority. Cognitive Level: Application Text Reference: pp. 824-825 Nursing Process: Assessment NCLEX: Physiological Integrity

12. A 32-year-old patient is seen in the clinic for dyspnea associated with the diagnosis of emphysema. The patient denies any history of smoking. The nurse will anticipate teaching the patient about a. a1-antitrypsin testing. b. use of the nicotine patch. c. continuous pulse oximetry. d. effects of leukotriene modifiers.

A Rationale: When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in a1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with emphysema. Cognitive Level: Application Text Reference: p. 632 Nursing Process: Planning NCLEX: Physiological Integrity

38. A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure, the nurse will plan to a. position the patient sitting upright on the edge of the bed and leaning forward. b. instruct the patient about the importance of incentive spirometer use after the procedure. c. start a peripheral intravenous line to administer the necessary sedative drugs. d. remove the water pitcher and remind the patient not to eat or drink anything for 8 hours

A Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure and there are no restrictions on oral intake, since the patient is not sedated or unconscious. Cognitive Level: Application Text Reference: p. 596 Nursing Process: Planning NCLEX: Physiological Integrity

For a client with hyperthyroidism, treatment is most likely to include: a) a thyroid hormone antagonist. b) thyroid extract. c) emollient lotions. d) a synthetic thyroid hormon

A) A thyroid hormone antagonist Thyroid hormone antagonists, which block thyroid hormone synthesis, combat increased production of thyroid hormone. Treatment of hyperthyroidism also may include radioiodine therapy, which destroys some thyroid gland cells, and surgery to remove part of the thyroid gland; both treatments decrease thyroid hormone production. Thyroid extract, synthetic thyroid hormone, and emollient lotions are used to treat hypothyroidism.

The nurse is assigned to the care of a 64- year-old patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, which of the following should be the nurse's initial intervention? A) Assess patient's perception of what it means to have diabetes. B) Ask the patient to write down current knowledge about diabetes. C) Set goals for the patient to actively participate in managing his diabetes. D) Assume responsibility for all of the patient's care to decrease stress level.

A) Assess patient's perception of what it means to have diabetes In order for teaching to be effective, the first step is to assess the patient. Teaching can be individualized once the nurse is aware of what a diagnosis of diabetes means to the patient.

The surgeon was unable to save a patient's parathyroid gland during a radical thyroidectomy. The nurse should consequently pay particular attention to which of the following components of the patient's laboratory values? A) Calcium levels B) Potassium levels C) Blood glucose levels D) Sodium and chloride levels

A) Calcium levels The parathyroid gland plays a key role in maintaining calcium levels. Potassium, sodium, glucose, and chloride are not directly influenced by the loss of the parathyroid gland.

The nurse is assisting a diabetic patient to learn dietary planning as part of initial management of diabetes. The nurse would encourage the patient to limit intake of which of the following foods to help reduce the percent of fat in the diet? A) Cheese B) Broccoli C) Chicken D) Oranges

A) Cheese Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry.

The nurse has been teaching a patient with diabetes mellitus how to perform selfmonitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does which of the following? A) Chooses a puncture site in the center of the finger pad B) Washes hands with soap and water to cleanse the site to be used C) Warms the finger before puncturing the finger to obtain a drop of blood D) Tells the nurse that the result of 120 mg/dl indicates good control of diabetes

A) Chooses a puncture site in the center of the finger pad The patient should select a site on the sides of the fingertips, not on the center of the finger pad. This area contains many nerve endings and would be unnecessarily painful.

The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which of the following symptoms reported by the patient is considered one of the classic clinical manifestations of diabetes? A) Excessive thirst B) Gradual weight gain C) Overwhelming fatigue D) Recurrent blurred vision

A) Excessive thirst The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger)

Wallace Guterman, a 36-year-old construction manager, is being seen by a physician in the primary care group where you practice nursing. He presents with a huge lower jaw, bulging forehead, large hands and feet and frequent headaches. What could be causing his symptoms? a) Hyperpituitarism b) Panhyperpituitarism c) Hypopituitarism d) Panhypopituitarism

A) Hyperpituitarism Acromegaly is a condition in which GH is oversecreted after the epiphyses of the long bones have sealed. A client with acromegaly has coarse features, a huge lower jaw, thick lips, a thickened tongue, a bulging forehead, a bulbous nose, and large hands and feet. When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica are common.

D) Oranges Lab results are back for a 54-year-old patient with a 15-year history of diabetes. Which of the following lab results follows the expected pattern accompanying macrovascular disease as a complication of diabetes? A) Increased triglyceride levels B) Decreased low-density lipoproteins C) Increased high-density lipoproteins D) Decreased very-low-density lipoproteins

A) Increased trigylceride levels Macrovascular complications of diabetes include changes to largeand medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. For this reason, the patient should limit the amount of fat in the diet.

The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes? a) Insulin production insufficient b) Less common than type 1 diabetes c) Onset most common during adolescence d) Little to relation to pre-diabet

A) Insulin production insufficient Type 2 diabetes is characterized by insulin resistance or insufficient insulin production. It is more common in aging adults, and now accounts for 20% of all newly diagnosed cases. Type 1 diabetes is more likely in childhood and adolescence although it can occur at any age. It accounts for approximately 5% to 10% of all diagnosed cases of diabetes. Pre-diabetes can lead to type 2 diabetes.

A nurse is attending a client in labor and is monitoring the duration and frequency of her uterine contractions. The client asks the nurse how the body knows how to give birth. Which hormone intensifies the contractions of the uterus and enables the uterus to push out the fetus? a) Oxytocin b) Insulin c) Prolactin d) Melanocyte

A) Oxytocin During labor, the positive feedback system is exemplified by the hormone oxytocin. Oxytocin intensifies the contractions of the uterus and enables the uterus to expel the fetus. Prolactin, melanocyte, and insulin are not responsible for the contractions of the uterus. Prolactin is a hormone secreted by the anterior lobe of the pituitary that stimulates milk production in women following pregnancy. Melanocyte-stimulating hormone influences skin pigmentation. Insulin is the key regulator of carbohydrate, protein, and fat metabolism and storage.

Lydia Kranston, a three-year-old female, is being seen by a physician in the endocrinology group where you practice nursing. She has a significant height deficit and is being seen for diagnostic purposes. What could be the cause of her disorder? a) Pituitary disorder b) Adrenal disorder c) Thyroid disorder d) Parathyroid disorder

A) Pituitary disorder Pituitary disorders usually result from excessive or deficient production and secretion of a specific hormone. Dwarfism occurs when secretion of GH is insufficient during childhood

A patient has sought care because of a loss of 25 lb over the past 6 months, during which the patient claims to have made no significant dietary changes. The nurse should assess the patient for potential A) Thyroid disorders. B) Diabetes insipidus. C) Pituitary dysfunction. D) Parathyroid dysfunction.

A) Thyroid disorders Hyperthyroidism is associated with weight loss. Alterations in pituitary function, such as diabetes insipidus, and parathyroid dysfunction are not commonly associated with this phenomenon.

Which of the following hormones would the nurse identify as being secreted by the thyroid gland? a) Thyroxine b) Parathormone c) Somatotropin d) Thymosin

A) Thyroxine The thyroid gland secretes thyroxine (T4 or tetraiodothyronine), triiodothyronine (T3), and calcitonin. Parathormone is secreted by the parathyroid glands. Thymosin is secreted by the thymus gland. Somatotropin is secreted by the anterior pituitary gland.

Which of the following may be a potential cause of hypoglycemia in the patient diagnosed with diabetes mellitus? a) The patient has not consumed food and continues to take insulin or oral antidiabetic medications. b) The patient has consumed food and has not taken or received insulin. c) The patient has not been exercising. d) The patient has not been compliant with the prescribed treatment regimen.

A) the patient has not consumed food and continues to take insulin or oral antidiabetic medications. Hypoglycemia occurs when a patient with diabetes is not eating at all and continues to take insulin or oral antidiabetic medications. Hypoglycemia does not occur when the patient has not been compliant with the prescribed treatment regimen. If the patient has eaten and has not taken or received insulin, DKA is more likely to develop

A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.6 mEq/L. The nurse considers that which of the following could be a contributing factor for this lab result (select all that apply)? A) The level may be increased as a result of dehydration that accompanies hyperglycemia. B) The patient may be excreting extra sodium and retaining potassium because of malnutrition. C) The level is consistent with renal insufficiency that can develop with renal nephropathy. D) The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.

A,C,Malnutrition does not cause sodium excretion accompanied by potassium retention; thus it is not a contributing factor to this patient's potassium level. The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. Kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis since potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH.

The nurse is teaching a 54-year-old patient with diabetes about proper composition of the daily diet. The nurse explains that the guideline for carbohydrate intake is which of the following? A) 80% of daily intake B) Minimum of 80 g/day C) Minimum of 130 g/day D) Maximum of 130 g/day

C) Minimum of 130 g/day The recommendation for carbohydrate intake is a minimum of 130 g/day. Low-carbohydrate diets are not recommended for diabetes management.

4. The health care provider prescribes finasteride (Proscar) for a 56-year-old male patient who has a BPH symptom score of 12 on the AUA Symptom Index. When teaching the patient about the drug, the nurse informs him that a. his interest in sexual activity may decrease while he is taking the medication. b. he should change position from lying to standing slowly to avoid dizziness. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

Answer: A Rationale: A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Orthostatic hypotension is a side effect of the !-blocking agents. Improvement in symptoms of obstruction takes 3 to 6 months. The medication does not cause hypertension. Cognitive Level: Application Text Reference: p. 1417 Nursing Process: Implementation NCLEX: Physiological Integrity

5. When taking a patient history during assessment of the musculoskeletal system, the nurse identifies an increased risk for the patient who reports a. that a parent became much shorter with aging. b. a sprained ankle 2 years previously. c. a family history of tuberculosis. d. taking over-the-counter (OTC) ibuprofen (Advil) for occasional aches.

Answer: A Rationale: A family history of height loss with aging may indicate osteoporosis, and the patient may need to consider preventative actions, such as calcium supplements. A sprained ankle 2 years previously will not cause any current or future musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk. Cognitive Level: Application Text Reference: p. 1621 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

14. A patient with a history of renal calculi is hospitalized with gross hematuria and severe colicky left flank pain that radiates to his left testicle. In planning care for the patient, the nurse gives the highest priority to the nursing diagnosis of a. acute pain related to irritation by the stone. b. deficient fluid volume related to inadequate intake. c. risk for infection related to urinary system damage. d. risk for nausea related to pain and renal colic.

Answer: A Rationale: Although all the diagnoses are appropriate, the initial nursing actions should focus on relief of the acute pain. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Diagnosis NCLEX: Physiological Integrity

2. Trimethoprim and sulfamethoxazole (Bactrim) BID for 7 days is ordered for a patient who has a recurrent relapse of an Escherichia coli UTI. The nurse instructs the patient to a. take the antibiotic for the full 7 days, even if symptoms improve in a few days. b. return to the clinic in 3 days so that a urine culture can be done to evaluate the effectiveness of the drug. c. increase the effectiveness of the drug by taking it with cranberry juice to acidify the urine. d. take two of the pills a day for 5 days, and reserve the rest of the pills to take if the symptoms reappear

Answer: A Rationale: Although an initial infection may be treated with a shorter course of antibiotics, the patient with a recurrent infection should take the antibiotic for 7 days. Success of treatment is evaluated by resolution of symptoms rather than by a repeat culture. Acidifying the urine when a patient is taking sulfa antibiotics may lead to stone formation. The patient is instructed to take all the antibiotics. Cognitive Level: Application Text Reference: p. 1157 Nursing Process: Implementation NCLEX: Physiological Integrity

26. Following rectal surgery, a patient voids about 50 ml of urine every 30 to 60 minutes. Which nursing action is most appropriate? a. Use an ultrasound scanner to check for residual urine after voiding. b. Have the patient take small amounts of fluid frequently throughout the day. c. Reassure the patient that this is normal after rectal surgery due to anesthesia. d. Monitor the patient's intake and output over the next few hours.

Answer: A Rationale: An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours. Cognitive Level: Application Text Reference: p. 1182 Nursing Process: Implementation NCLEX: Physiological Integrity

16. A patient with a confirmed urinary stone in the proximal left ureter undergoes extracorporeal shock-wave lithotripsy. Which information is most important for the nurse to collect after lithotripsy? a. Urine output b. Pain level c. Appearance of the site d. Patient temperature

Answer: A Rationale: Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to monitor the urine output. The patient may have pain as the stones pass and bruising at the site, but these are not unexpected. Extracorporeal shock wave lithotripsy (ESWL) is not associated with a risk for infection. Cognitive Level: Application Text Reference: p. 1172 Nursing Process: Assessment NCLEX: Physiological Integrity

32. A patient has a cystectomy and a Kock continent diversion created for treatment of bladder cancer. During postoperative teaching of the patient, it is important that the nurse include instructions regarding a. application of ostomy appliances. b. catheterization technique and schedule. c. use of barrier products for skin protection. d. analgesic use before emptying the pouch

Answer: B Rationale: The Kock pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful. Cognitive Level: Application Text Reference: p. 1190 Nursing Process: Implementation NCLEX: Physiological Integrity

20. A 53-year-old man tells the nurse he has not been able to function sexually for several years but is now interested in using Viagra (sildenafil). In responding to the patient's interest, the nurse a. questions the patient about any prescription drugs he is taking. b. tells the patient that Viagra is an appropriate treatment for only a few types of ED. c. asks the patient about any previous treatment for hydrocele. d. reassures the patient that a gradual decline in erectile function is common with aging.

Answer: A Rationale: Because some medications can cause ED and patients using nitrates should not take Viagra, the nurse should ask about prescription drug use. Viagra is a helpful therapy for most types of ED. Hydrocele is not a risk factor for ED or a contraindication to erectogenic drugs. Severe ED is not a normal consequence of aging in a 53-year-old patient. Cognitive Level: Application Text Reference: p. 1435 Nursing Process: Implementation NCLEX: Physiological Integrity

1. Based on the nurse's understanding of the physiology of bone and cartilage, the injury that the nurse would expect to heal most rapidly is a a. fracture of the midhumerus. b. torn knee cruciate ligament. c. fractured nose. d. severely sprained ankle.

Answer: A Rationale: Bone is dynamic tissue that is continually growing. Nasal fracture, sprains, and ligament tears injure cartilage, tendons, and ligaments, which are slower to heal. Cognitive Level: Application Text Reference: p. 1615 Nursing Process: Assessment NCLEX: Physiological Integrity

27. A patient in the hospital has a history of urinary incontinence. Which nursing action will be included in the plan of care? a. Place a bedside commode near the patient's bed. b. Use an ultrasound scanner to check urine residual after the patient voids. c. Demonstrate the use of the Credé maneuver to the patient. d. Teach the use of Kegel exercises to strengthen the pelvic floor

Answer: A Rationale: Environmental changes can make it easier for the patient to avoid incontinence for patients with urinary incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence. Cognitive Level: Application Text Reference: p. 1181 Nursing Process: Planning NCLEX: Physiological Integrity

2. A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. b. information about penile implants used for ED is available if he is interested. c. there are many methods of sexual expression that can be alternatives to sexual intercourse. d. sterility will not be a problem after surgery because sperm production will not be affected

Answer: A Rationale: Erectile problems are rare, but retrograde ejaculation may occur after TURP. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. Cognitive Level: Application Text Reference: p. 1418 Nursing Process: Implementation NCLEX: Physiological Integrity

25. After her bath, a 62-year-old patient asks the nurse for a perineal pad, saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient? a. Teach the patient how to perform Kegel exercises. b. Demonstrate how to perform Credé's maneuver. c. Place commode at the patient's bedside.

Answer: A Rationale: Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence. Cognitive Level: Application Text Reference: pp. 1181-1184 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

1. A patient with an open fracture of the left tibia and soft tissue damage underwent a surgical reduction and fixation of the tibia with debridement of nonviable tissue and drain placement. When assessing the patient during the postoperative period, the nurse will be most concerned about a. fever with chills and night sweats. b. light yellow drainage from the wound. c. pain on movement of the affected limb.

Answer: A Rationale: Fever, chills, and night sweats are suggestive of osteomyelitis. The other clinical manifestations are typical after a fracture repair. Cognitive Level: Application Text Reference: p. 1669 Nursing Process: Assessment NCLEX: Physiological Integrity

4. A patient has chronic osteomyelitis of the left femur, which is being managed at home with self-administration of IV antibiotics. On a home visit, the nurse identifies the nursing diagnosis of ineffective therapeutic regimen management when the nurse finds that the patient a. is unable to plantar-flex the foot on the affected side. b. uses crutches to avoid weight bearing on the affected leg. c. takes and records the oral temperature twice a day. d. is irritable and frustrated with the length of treatment required.

Answer: A Rationale: Footdrop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective management of the osteomyelitis. Cognitive Level: Application Text Reference: p. 1672 Nursing Process: Diagnosis NCLEX: Health Promotion and Maintenance

11. Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. An appropriate nursing intervention for this patient is to teach the patient a. pelvic floor muscle training. b. the use of belladonna and opium suppositories. c. how to perform intermittent selfcatheterization. d. to restrict oral fluid intak

Answer: A Rationale: Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L. Cognitive Level: Application Text Reference: p. 1428 Nursing Process: Planning NCLEX: Physiological Integrity

18. When planning care for a patient who will be treated with 2 days of bed rest for low back pain, which intervention will the nurse include? a. Telling the patient about the importance of a high fiber and fluid intake b. Instructing the patient to avoid positioning the knee in the flexed position c. Educating the patient that continuous heat application will reduce pain d. Teaching the patient that the prone position will help relieve back pain

Answer: A Rationale: Prevention of constipation caused by immobility is a goal for the patient with low back pain. The knee should be flexed to prevent pressure on the muscles and support structures of the spine. Heat and cold should be alternated. The prone position places more strain on the back and should be avoided. Cognitive Level: Application Text Reference: p. 1676 Nursing Process: Planning NCLEX: Physiological Integrity

14. The nurse determines that teaching regarding diet for a patient with osteoporosis has been successful when the patient selects which of these meals as having the highest amount of calcium? a. Sardine sandwich on whole wheat bread, one cup of fruit yogurt, and one cup of skim milk b. Two-egg omelet with American cheese, one slice of whole-wheat toast, and a half grapefruit c. Ham and Swiss cheese sandwich on wholewheat bread, steamed broccoli, and an apple d. Chicken stir-fry with bok choy, onions, and snap peas and one cup of steamed brown rice

Answer: A Rationale: Sardines, yogurt, and milk are all high in calcium. The other choices have some foods that are high in calcium but also include foods that are low in calcium, such as eggs, apples, and grapefruit. Cognitive Level: Application Text Reference: p. 1689 Nursing Process: Evaluation NCLEX: Physiological Integrity

8. A patient whose work involves loading and unloading boxes has a history of chronic back pain. Which statement after the nurse has taught the patient about correct body mechanics indicates that the teaching has been effective? a. "I plan to start doing sit-ups and leg lifts to strengthen the muscles of my back." b. "I will try to sleep with my hips and knees extended to prevent back strain." c. "I can tell my boss that I need to change to a job where I can work at a desk." d. "I will keep my back straight when I need to lift anything higher than my waist."

Answer: A Rationale: Sit-ups and leg lifts will help to strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes are needed, but sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the elbows. Cognitive Level: Application Text Reference: p. 1677 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

23. Following an open-loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented? a. Assist the patient to take a 15-minute sitz bath. b. Encourage the patient to drink several glasses of water. c. Teach the patient how to do isometric perineal exercises. d. Insert a straight catheter and drain the bladder

Answer: A Rationale: Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids, this would not be appropriate when the patient is experiencing retention. Kegel exercises are helpful in the prevention of incontinence. Catheter insertion increases the risk for infection. Cognitive Level: Application Text Reference: p. 1179 Nursing Process: Implementation NCLEX: Physiological Integri

37. A 26-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having knee surgery. Which of the routine postoperative orders is most important for the nurse discuss with the health care provider? a. Give ketorolac (Toradol) 10 mg PO PRN for pain. b. Infuse 5% dextrose in normal saline at 75 ml/hr. c. Obtain BUN, creatinine, and electrolytes in 2 hours. d. Order regular diet after patient is awake and alert.

Answer: A Rationale: The NSAIDs should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Implementation NCLEX: Physiological Integrity

17. A 32-year-old man scheduled for a unilateral orchiectomy for testicular cancer is admitted to the hospital the morning of surgery. He is accompanied by his wife but does not talk to her and does not initiate interaction with the nurse. The most appropriate action by the nurse is to a. ask the patient if he has any questions or concerns about the diagnosis and treatment. b. tell the patient's wife that concerns about sexual function are common with this diagnosis. c. teach the patient that impotence is rarely a problem after unilateral orchiectomy. d. document the patient's lack of communication on the chart and continue preoperative care.

Answer: A Rationale: The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, it is inappropriate for the nurse to initiate teaching. It would be inappropriate for the nurse to provide patient teaching without further assessment of the patient's teaching needs and concerns. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation. Cognitive Level: Application Text Reference: p. 1428 Nursing Process: Implementation NCLEX:Psychosocial Integrity

11. A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient? a. Fluid-volume excess related to low serum protein levels b. Altered nutrition: less than required related to protein restriction c. Activity intolerance related to increased weight and fatigue d. Disturbed body image related to peripheral edema and ascites

Answer: A Rationale: The patient has massive edema, so the priority problem at this time is the excess of fluid volume. The other nursing diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites. Cognitive Level: Application Text Reference: pp. 1167-1168 Nursing Process: Diagnosis NCLEX: Physiological Integrity

36. A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about a. the need to empty the bladder prior to treatment. b. premedicating to prevent nausea. c. the importance of oral care during treatment. d. where to obtain wigs and scarves.

Answer: A Rationale: The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not experienced with intravesical chemotherapy. Cognitive Level: Application Text Reference: p. 1180 Nursing Process: Implementation NCLEX: Physiological Integrity

8. A patient with symptomatic BPH is scheduled for visual laser ablation of the prostate (VLAP) at an outpatient surgical center. The nurse will plan to teach the patient a. how to care for an indwelling urinary catheter. b. that the urine will appear bloody for several days. c. to expect an immediate improvement in urinary force. d. that an intraprostatic urethral stent will be placed.

Answer: A Rationale: The patient will have indwelling catheter for up to a week and will need to be instructed on catheter care to avoid problems such as infection. There is minimal bleeding with this procedure. It will take several weeks before the full benefits of the procedure take effect. Stent placement is not included in the procedure. Cognitive Level: Application Text Reference: pp. 1420-1422 Nursing Process: Planning NCLEX: Physiological Integrity

26. When planning teaching for a patient who has had a unilateral orchiectomy and chemotherapy for testicular cancer, the nurse will include information about the need for a. regular follow-up appointments to detect other types of malignancies. b. aspiration of sperm from the remaining testis if infertility occurs. c. testosterone supplements to help maintain erectile function. d. application of ice to the scrotum to minimize pain and swelling.

Answer: A Rationale: The patient will need regular follow-up to detect secondary malignancies that may occur as the result of the chemotherapy. Since infertility occurs as a result of damage to the remaining testis by chemotherapeutic drugs, aspiration of sperm is not used to treat infertility. The remaining testis will produce adequate testosterone. Application of ice will be used to reduce postoperative swelling immediately after surgery, but will not be needed at the time chemotherapy is complete. Cognitive Level: Application Text Reference: p. 1432 Nursing Process: Planning NCLEX: Physiological Integrit

10. A patient is seen at the urgent care center following a blunt injury to the left knee. The knee is grossly swollen and very painful, but the skin is intact. During an arthrocentesis on the patient's knee, the nurse would expect the aspirated fluid to appear a. sanguineous. b. purulent and thick. c. straw colored. d. white, thick, and ropelike.

Answer: A Rationale: The patient's clinical manifestations suggest hemarthrosis, and the appearance of blood in the synovial fluid is expected. Purulent fluid occurs when there is a joint infection. Straw-colored fluid is normal and will not be expected when the knee is swollen and painful. Thick fluid suggests infection. Cognitive Level: Comprehension Text Reference: p. 1628 Nursing Process: Assessment NCLEX: Physiological Integrity

6. Which information obtained during the nurse's assessment of the patient's nutritionalmetabolic pattern may indicate the risk for musculoskeletal problems? a. The patient is 5 ft 2 in and weighs 180 lb. b. The patient prefers whole milk to nonfat milk. c. The patient dislikes fruits and vegetables. d. The patient takes a multivitamin daily.

Answer: A Rationale: The patient's height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems. Cognitive Level: Application Text Reference: p. 1621 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

11. After teaching a patient with a bunion about how to prevent further problems, the nurse will determine that more teaching is needed if the patient says, a. "I will wear soft slippers whenever possible." b. "I will throw away my high heel shoes." c. "I will use the bunion pad to relieve the pain." d. "I will take ibuprofen (Motrin) when I need it."

Answer: A Rationale: The shank of the shoe should be rigid enough to support the foot. The other patient statements indicate that the teaching has been effective. Cognitive Level: Application Text Reference: pp. 1684-1685 Nursing Process: Evaluation NCLEX: Physiological Integrity

3. The nurse determines that instruction regarding prevention of future UTIs for a patient with cystitis has been effective when the patient states, a. "I will empty my bladder every 3 to 4 hours during the day." b. "I can use vaginal sprays to reduce bacteria." c. "I will wash with soap and water before sexual intercourse." d. "I will drink a quart of water or other fluids every day."

Answer: A Rationale: Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

24. A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, "My symptoms have gotten a lot worse this week." Which response by the nurse is most appropriate? a. "The prostate gland normally changes slightly in size from day to day, and this may be making your symptoms worse." b. "Have you been taking any over-the-counter (OTC) medications recently?" c. "Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate?" d. "I will talk to the doctor about ordering a prostate specific antigen test."

Answer: B Rationale: Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer and is not indicated in this patient, who has already been diagnosed with BPH. Cognitive Level: Application Text Reference: p. 1421 Nursing Process: Assessment NCLEX: Physiological Integrity

30. A patient undergoes a nephrectomy for massive trauma to the kidney resulting from a fall from a scaffold. Which assessment data obtained postoperatively are most important to communicate to the surgeon? a. Blood pressure is 102/48. b. Urine output is 20 ml/hr for 2 hours. c. Crackles are heard at both lung bases. d. Incisional pain level is 8/10.

Answer: B Rationale: Because the urine output should be at least 0.5 ml/kg/hr, a 40-ml output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life-threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain. Cognitive Level: Application Text Reference: p. 1188 Nursing Process: Assessment NCLEX: Physiological Integrity

16. When evaluating the effectiveness of treatment for a patient who is being treated for Paget's disease with calcitonin (Cibacalcin) and ibandronate (Boniva), the nurse will ask the patient about a. weight loss. b. skeletal pain. c. decreased appetite. d. frequent cough.

Answer: B Rationale: Bone pain is one of the common early manifestations of Paget's disease, and the nurse should ask about improvement in pain levels to determine whether the treatment is effective. Weight loss, anorexia, and frequent cough are not symptoms of Paget's disease. Cognitive Level: Application Text Reference: p. 1690 Nursing Process: Evaluation NCLEX: Physiological Integrity

3. When the health care provider tells a patient that the pain in the patient's knee is caused by bursitis, the patient asks the nurse to explain just what bursitis is. The nurse's best response would be to tell the patient bursitis is an inflammation of a. the fibrocartilage that acts as a shock absorber in the knee joint. b. a small, fluid-filled sac found at many joints. c. any connective tissue that is found supporting the joints of the body. d. the synovial membrane that lines the area between two bones of a joint.

Answer: B Rationale: Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa. Cognitive Level: Comprehension Text Reference: p. 1618 Nursing Process: Implementation NCLEX: Physiological Integrit

17. A patient is receiving gentamicin (Garamycin) 80 mg IV twice daily for acute osteomyelitis. Which action should the nurse take before administering the gentamicin? a. Obtain the patient's oral temperature. b. Review the patient's BUN and creatinine levels. c. Ask the patient about any nausea. d. Change the wet-to-dry dressing.

Answer: B Rationale: Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration. Cognitive Level: Application Text Reference: p. 1670 Nursing Process: Assessment NCLEX: Physiological Integrity

7. After teaching a patient with interstitial cystitis about management of the condition, the nurse determines that further instruction is needed when the patient says, a. "I will have to stop having coffee and orange juice for breakfast." b. "I should start taking a high-potency multiple vitamin every morning." c. "I should call the doctor about increased bladder pain or odorous urine." d. "I will buy some calcium glycerophosphate (Prelief) at the pharmacy."

Answer: B Rationale: High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching. Cognitive Level: Application Text Reference: p. 1164 Nursing Process: Evaluation NCLEX: Physiological Integrity

13. Leuprolide (Lupron) and bicalutamide (Casodex) are prescribed for a patient with cancer of the prostate. In teaching the patient about these drugs, the nurse informs the patient that side effects may include a. low blood pressure. b. decreased sexual drive. c. urinary incontinence. d. frequent infections.

Answer: B Rationale: Hormonal therapy blocks the effects of testosterone and decreases libido. Hypotension is associated with the !-blockers used for BPH. Urinary incontinence may occur after prostate surgery, but it is not an expected medication side effect. Risk for infection is increased in patients receiving chemotherapy. Cognitive Level: Comprehension Text Reference: p. 1426 Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient is hospitalized for initiation of regional antibiotic perfusion for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care? a. Frequent weight-bearing exercise b. Immobilization of the right leg c. Avoid administration of NSAIDs d. Support right leg in a flexed position

Answer: B Rationale: Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. NSAIDs are frequently prescribed to treat pain. Flexion of the affected limb is avoided to prevent contractures. Cognitive Level: Application Text Reference: pp. 1670-1671 Nursing Process: Planning NCLEX: Physiological Integrity

12. Following discharge teaching for a patient who has had a transurethral prostatectomy for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. "I will increase fiber and fluids in my diet to prevent constipation." b. "I should call the doctor if I have any incontinence at home." c. "I will avoid heavy lifting or driving until I get approval from my health care provider." d. "I should continue to schedule yearly appointments for prostate exams."

Answer: B Rationale: Incontinence is common for several weeks after a TURP. The other patient statements indicate that the patient has a good understanding of post-TURP instructions. Cognitive Level: Application Text Reference: p. 1422 Nursing Process: Evaluation NCLEX: Physiological Integrity

5. A 34-year-old patient with diabetes mellitus is hospitalized with fever, anorexia, and confusion. The health care provider suspects acute pyelonephritis when the urinalysis reveals bacteriuria. An appropriate collaborative problem identified by the nurse for the patient is potential complication a. hydronephrosis. b. urosepsis. c. acute renal failure. d. chronic pyelonephritis.

Answer: B Rationale: Infection can easily spread from the kidney to the circulation, causing urosepsis. A patient with a urinary tract obstruction will be at risk for hydronephrosis. Acute renal failure is not a common complication of acute pyelonephritis unless urosepsis and septic shock develop. Chronic pyelonephritis may occur after recurrent upper UTIs. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Diagnosis NCLEX: Physiological Integrity

17. The composition of a patient's renal calculus is identified as uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid a. spinach, chocolate, and tomatoes b. organ meats and fish with fine bones. c. milk and dairy products. d. legumes and dried fruits.

Answer: B Rationale: Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium containing stones. Cognitive Level: Application Text Reference: pp. 1170-1171 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

17. The composition of a patient's renal calculus is identified as uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid a. spinach, chocolate, and tomatoes. b. organ meats and fish with fine bones. c. milk and dairy products. d. legumes and dried fruits.

5. Which statement by a patient who is scheduled for an above-the-knee amputation for treatment of an osteogenic sarcoma of the right tibia indicates that patient teaching is needed? a. "I wish that I did not have to have chemotherapy after this surgery." b. "I do not mind the surgery because it will finally cure the cancer." c. "I know that I will need lots of physical therapy after surgery." d. "I will use the patient-controlled analgesia to help control my pain level after surgery."

Answer: B Rationale: Osteogenic sarcoma is an aggressive cancer with early metastasis and is not considered cured by surgery alone. Postoperative chemotherapy will also be required. The other patient statements indicate that patient teaching has been effective. Cognitive Level: Application Text Reference: p. 1674 Nursing Process: Evaluation NCLEX: Physiological Integrity

12. An assessment finding that alerts the nurse to the presence of osteoporosis in a middleaged patient is a. the presence of bowed legs. b. measurable loss of height. c. an aversion to dairy products. d. statements about frequent falls.

Answer: B Rationale: Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis. Cognitive Level: Comprehension Text Reference: p. 1687 Nursing Process: Assessment NCLEX: Physiological Integrity

RENAL 1. When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about a. flank pain. b. pain with urination. c. poor urine output. d. nausea.

Answer: B Rationale: Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI. Cognitive Level: Application Text Reference: p. 1157 Nursing Process: Assessment NCLEX: Physiological Integr

RENAL 1. When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about a. flank pain. b. pain with urination. c. poor urine output. d. nausea

15. A couple is seen at the infertility clinic because they have not been able to conceive. When performing a focused examination to determine any possible causes for infertility, the nurse will check the man for the presence of a. hydrocele. b. varicocele. c. epididymitis. d. paraphimosis.

Answer: B Rationale: Persistent varicoceles are commonly associated with infertility. Hydrocele, epididymitis, and paraphimosis are not risk factors for infertility. Cognitive Level: Comprehension Text Reference: p. 1431 Nursing Process: Assessment NCLEX: Physiological Integrity

29. The nurse observes a nursing assistant (NA) doing all of the following when caring for a patient with a retention catheter. Which action requires that the nurse intervene? a. The NA uses an alcohol-based hand cleaner before performing catheter care. b. The NA disconnects the catheter from the drainage tube to obtain a specimen. c. The NA uses soap and water when cleaning around the urinary meatus. d. The NA tapes the catheter to the skin on the patient's upper inner thigh

Answer: B Rationale: The catheter should not be disconnected from the drainage tube because this increases the risk for UTI. The other actions are appropriate and do not require any intervention. Cognitive Level: Application Text Reference: p. 1186 Nursing Process: Assessment NCLEX: Physiological Integrity

23. The doctor is considering whether to prescribe testosterone replacement therapy for a 62-year-old man who is concerned about a gradual decrease in sexual performance. Which information obtained by the nurse is most important to communicate to the doctor? a. The patient states that he has noticed a decrease in energy level for a few years. b. The patient has had a gradual decrease in the force of his urinary stream. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient's symptoms have increased steadily over the last few years.

Answer: B Rationale: The decrease in urinary stream may indicate BPH or prostate cancer, which are contraindications to use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a helpful therapy for the patient. Cognitive Level: Application Text Reference: p. 1437 Nursing Process: Assessment NCLEX: Physiological Integrity

27. A patient with acute urinary retention associated with BPH is admitted to the emergency department. The patient has had no urine output for 16 hours, and the laboratory work shows a blood urea nitrogen (BUN) level of 50 mg/dl and a creatinine of 3.0 mg/dl. The nurse will anticipate a health care provider order to a. schedule the patient for inpatient hemodialysis. b. insert a retention catheter. c. start an IV line for fluid administration. d. administer furosemide (Lasix).

Answer: B Rationale: The patient data indicate that the patient may have hydronephrosis and acute renal failure caused by the BPH; the initial therapy will be to insert a catheter. Hemodialysis may be needed if the elevation in BUN and creatinine persists, but it will not be ordered initially. Fluid administration and furosemide administration will increase the bladder distension. Cognitive Level: Application Text Reference: p. 1415 Nursing Process: Planning NCLEX: Physiological Integrity

15. The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to strain all urine and to a. report the pain level when the stone passed. b. collect the stone and bring it to the clinic. c. record the time that the stone passed. d. save a urine specimen to check for blood.

Answer: B Rationale: The patient should save the stone for analysis of the stone composition, which will help in determining treatment. Reporting the pain level and recording the time the stone passed are not essential. Hematuria is common with urinary calculi, so it is not necessary to test the urine for blood. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Implementation NCLEX: Physiological Integrity

12. A patient is admitted to the hospital with nephrotic syndrome after taking an OTC nonsteroidal antiinflammatory drug (NSAID) a week earlier. Which assessment data will the nurse expect to find related to this illness? a. Low blood pressure b. Recent weight gain c. Poor skin turgor d. High urine ketones

Answer: B Rationale: The patient with a rapid-onset nephrotic syndrome will have rapid weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Cognitive Level: Application Text Reference: p. 1167 Nursing Process: Assessment NCLEX: Physiological Integrity

33. Following a cystectomy, a patient has an ileal conduit created. The nurse identifies the nursing diagnosis of risk for infection related to altered urinary structures. An appropriate nursing intervention for this problem is to a. clamp the drainage bag while the patient sleeps. b. empty the drainage appliance every 2 to 3 hours or when it is one-third full. c. use liquid antiseptic in the appliance to decrease bacterial colonization. d. drain the conduit every 4 hours using a sterile catheter.

Answer: B Rationale: The patient with an ileal conduit will have an appliance to hold urine, which should be emptied to avoid reflux of urine back into the conduit. The drainage bag should not be clamped. The use of a liquid antiseptic will not decrease risk for infection. Unlike a continent pouch, the ileal conduit will drain continuously and is not drained with a catheter. Cognitive Level: Application Text Reference: p. 1193 Nursing Process: Implementation NCLEX: Physiological Integrity

2. The nurse is assessing the passive range of motion of a patient's shoulder. The patient complains of pain during circumduction when the nurse moves the arm behind the patient. Which question should the nurse ask? a. "Do you ever have trouble making it to the toilet?" b. "Do you have difficulty in putting on a jacket?" c. "Are you able to feed yourself without difficulty?" d. "How well are you able to sleep at night?

Answer: B Rationale: The patient's pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not impact the patient's ability to feed himself or herself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping. Cognitive Level: Application Text Reference: pp. 1620-1622 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

34. Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in body function. c. ineffective health maintenance related to refusal to participate in care. d. self-care deficit, toileting, related to denial of altered body function.

Answer: B Rationale: The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. There are no data suggesting that the impact on lifestyle is a concern for the patient. The patient may be at risk for ineffective health maintenance if the lack of participation in care continues, but the patient's behavior is normal 2 days after surgery. The patient does not appear to be in denial. Cognitive Level: Application Text Reference: p. 1191 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

7. The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? a. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." b. "The irrigation is needed to keep the catheter from being occluded by blood clots." c. "Normal production of urine is maintained with the irrigations until healing occurs." d. "Antibiotics are being administered into the bladder with the irrigation solution."

Answer: B Rationale: The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or maintain urine production. Antibiotics are given by the IV route, not through the bladder irrigation. Cognitive Level: Comprehension Text Reference: pp. 1420-1421 Nursing Process: Implementation NCLEX: Physiological Integrity

16. In teaching a male patient to perform testicular self-examination, the nurse includes the information that a. the only structure normally felt in the scrotal sac is the testis. b. the examination should be done when the scrotum is warm. c. an appointment with the health care provider is needed if one testis is larger than the other. d. an examination should be performed whenever the patient showers or bathes.

Answer: B Rationale: The testes will hang lower in the scrotum when the temperature is warm, and it will be easier to palpate. The epididymis is also normally palpable in the scrotum. One testis is normally larger. The patient should perform testicular self-examination (TSE) monthly. Cognitive Level: Comprehension Text Reference: p. 1433 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

19. A 22-year-old man tells the nurse at the health clinic that he has recently become unable to achieve an erection. When assessing for possible etiologic factors, which question should the nurse ask first? a. "Have you been experiencing an unusual amount of stress?" b. "Do you have any history of an erection that lasted for 6 hours or more?" c. "Are you using any recreational drugs or drinking a lot of alcohol?" d. "Do you have any chronic diseases, such as diabetes mellitus?"

Answer: C Rationale: A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and chronic illness also contribute to ED, but they are not common etiologic factors in younger men. Cognitive Level: Application Text Reference: p. 1434 Nursing Process: Assessment NCLEX: Physiological Integrity

3. A 41-year-old man asks the nurse what he can do to decrease the risk of BPH. The nurse explains that a. riding a bicycle raises prostate specific antigen levels and may increase BPH risk. b. prevention is not possible because prostatic enlargement occurs with normal aging. c. decreasing butter and margarine and increasing fruits in the diet may help. d. taking a daily vitamin E supplement has reduced prostate size in some men.

Answer: C Rationale: A diet high in saturated fats, found in foods like butter, is associated with an increased risk for BPH. Individuals who eat more fruits and vegetables may be at lower risk. Riding a bicycle does increase prostatespecific antigen (PSA) levels, but this is not associated with development of BPH. Dietary changes and increased exercise do appear to help prevent BPH. Vitamin E supplements do not decrease prostate size. Cognitive Level: Comprehension Text Reference: p. 1415 Nursing Process: Implementation NCLEX: Physiological Integrity

18. To prevent the recurrence of renal calculi, the nurse teaches the patient to a. avoid all sources of dietary calcium. b. drink diuretic fluids such as coffee. c. drink 2000 to 3000 ml of fluid a day. d. use a filter to strain all urine.

Answer: C Rationale: A fluid intake of 2000 to 3000 ml daily is recommended help flush out minerals before stones can form. Patients are not advised to avoid all calcium-containing foods and a high calcium intake may decrease the incidence of some types of stones. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones. Cognitive Level: Application Text Reference: p. 1172 Nursing Process: Implementation NCLEX: Physiological Integrity

8. While testing the patient's muscle strength, the nurse finds that the patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should documents the patient's muscle strength as level a. 1. b. 2. c. 3. d. 4.

Answer: C Rationale: A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance. Cognitive Level: Comprehension Text Reference: p. 1622 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

8. When admitting a patient with acute glomerulonephritis, the nurse will ask the patient about a. history of high blood pressure. b. frequency of UTIs. c. recent sore throat and fever. d. family history of kidney disease.

Answer: C Rationale: Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, UTI, or related to family history. Cognitive Level: Application Text Reference: p. 1165 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient is noted to be anemic. Which hormone will affect the development of red blood cells in this patient? a) Epinephrine b) Erythropoietin c) Secretin d) Insuli

B) Erythropoietin The kidneys produce erythropoietin, a hormone that stimulates the bone marrow to produce red blood cells. Insulin is a pancreatic hormone that decreases blood sugar. The gastrointestinal mucosa produces the hormone of secretin. Epinephrine is a hormone that causes vasoconstriction to elevate blood sugar.

18. When performing discharge teaching for a patient who has undergone a vasectomy in the health care provider's office, the nurse instructs the patient that a. he may have temporary erectile dysfunction (ED) because of postoperative swelling. b. he should not have sexual intercourse until his 6-week follow-up visit. c. he should continue the use of other methods of birth control for 6 weeks. d. he will notice a decrease in the appearance and volume of his ejaculate.

Answer: C Rationale: Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the patient should use contraception for 6 weeks. ED that occurs after vasectomy is psychologic in origin and not related to postoperative swelling. The patient does not need to abstain from intercourse. The appearance and volume of the ejaculate are not changed because sperm are a minor component of the ejaculate. Cognitive Level: Comprehension Text Reference: pp. 1433-1434 Nursing Process: Implementation NCLEX: Physiological Integrity

7. When the nurse is assessing a new patient in the clinic, which information about the patient's medications will be of most concern? a. The patient takes hormone replacement therapy (HRT) to prevent "hot flashes." b. The patient takes a daily multivitamin and calcium supplement. c. The patient has severe asthma and requires frequent therapy with steroids. d. The patient has migraine headaches which are treated with NSAIDs.

Answer: C Rationale: Corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems. Cognitive Level: Application Text Reference: p. 1619 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

25. When obtaining a focused health history for a patient with possible testicular cancer, the nurse will ask the patient about any history of a. testicular torsion. b. STD infection. c. undescended testicles. d. testicular trauma.

Answer: C Rationale: Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty. STD infection, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer. Cognitive Level: Comprehension Text Reference: pp. 1430-1431 Nursing Process: Assessment NCLEX: Physiological Integrity

14. The nurse will teach the patient with chronic bacterial prostatitis that a. PSA elevation indicates that he has concurrent prostate cancer. b. Nonsteroidal antiinflammatory drugs (NSAIDs) usually provide adequate pain control. c. sexual intercourse and masturbation will relieve symptoms. d. antibiotics should be taken for 7 to 10 days.

Answer: C Rationale: Ejaculation helps drain the prostate and relieve pain. PSA elevation may be due to the prostatitis. NSAIDs are prescribed, but are often inadequate to control pain. Antibiotics should be continued for 4 to 16 weeks. Cognitive Level: Application Text Reference: p. 1429 Nursing Process: Implementation NCLEX: Physiological Integrity

10. A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment with a. antibiotics. b. antihypertensives. c. anticoagulants. d. corticosteroids.

Answer: C Rationale: Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis. Cognitive Level: Application Text Reference: p. 1175 Nursing Process: Planning NCLEX: Physiological Integrity

38. Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider? a. Dysuria b. Temperature 100.1° F c. Left-sided flank pain d. Hematuria

Answer: C Rationale: Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Assessment NCLEX: Physiological Integrity

19. In planning teaching for a patient with benign nephrosclerosis, the nurse should include instructions regarding a. measuring daily intake and output amounts. b. obtaining and documenting daily weights. c. monitoring and recording blood pressure. d. preventing bleeding caused by anticoagulants.

Answer: C Rationale: Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis. Cognitive Level: Application Text Reference: p. 1175 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

5. A patient with irritative and obstructive bladder symptoms has an enlarged prostate on digital rectal examination (DRE) and an elevated PSA level. The nurse will anticipate that the patient will need teaching about a. uroflometry studies. b. cystourethroscopy. c. transrectal ultrasonography (TRUS). d. magnetic resonance imaging (MRI).

Answer: C Rationale: In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to help differentiate BPH from prostatic cancer. Uroflowmetry studies will help determine the extent of urine blockage and treatment, but a differential diagnosis will be obtained first. Cystourethroscopy may be used after TRUS if the diagnosis is still uncertain. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process. Cognitive Level: Application Text Reference: p. 1416 Nursing Process: Planning NCLEX: Physiological Integrity

24. A 78-year-old patient is admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. In developing a plan of care for the patient, an appropriate nursing intervention for the patient's incontinence is to a. insert an indwelling catheter. b. apply absorbent incontinent pads. c. assist the patient to the bathroom q2hr. d. restrict fluids after the evening meal

Answer: C Rationale: In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for UTI. Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration. Cognitive Level: Application Text Reference: pp. 1183-1185 Nursing Process: Planning NCLEX: Physiological Integrity

4. To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics, the nurse suggests that the patient use the OTC urinary analgesic phenazopyridine (Pyridium) but cautions the patient that this preparation a. contains methylene blue, which turns the urine blue or green. b. should be taken on an empty stomach for maximum effect. c. causes the urine to turn reddish orange and can stain underclothing. d. frequently causes allergic reactions and should be stopped if a rash occurs.

Answer: C Rationale: Patients should be taught that Pyridium will color the urine deep orange and stain underclothing. Urised may turn the urine blue or green. The medication can cause gastrointestinal distress and should be taken with food. Although an allergic reaction may occur, this is not common. Cognitive Level: Comprehension Text Reference: p. 1158 Nursing Process: Implementation NCLEX: Physiological Integrity

13. A 58-year-old woman who has been menopausal for 5 years is diagnosed with osteoporosis following densitometry testing. The woman has been concerned about her risk for osteoporosis because her mother has the condition. In teaching the woman about her osteoporosis, the nurse explains that a. with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. b. estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis. c. even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. d. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.

Answer: C Rationale: Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help to prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis. Cognitive Level: Application Text Reference: p. 1689 Nursing Process: Implementation NCLEX: Physiological Integrity

19. Which of these nursing actions included in the care of a patient after laminectomy can the nurse delegate to an experienced nursing assistant? a. Evaluation of the effectiveness of the PCA b. Monitoring plantar and dorsiflexion of the feet c. Logrolling the patient from side to side every 2 hours d. Determining the patient's readiness to ambulate

Answer: C Rationale: Repositioning a patient is included in the education and scope of practice of nursing assistants, and an experienced nursing assistant would be familiar with logrolling. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient's readiness to ambulate after surgery require higher-level nursing education and scope of practice. Cognitive Level: Application Text Reference: pp. 1683-1684 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

9. The nurse establishes a nursing diagnosis of excess fluid volume related to inflammation at the glomerular basement membrane in a patient with acute glomerulonephritis. To best evaluate whether the problem identified in the nursing diagnosis has resolved, the nurse will monitor for a. proteinuria. b. elevated creatinine. c. periorbital edema. d. hematuria.

Answer: C Rationale: Resolution of the excess fluid volume is best evaluated by changes in edema. The other data may indicate whether the glomerulonephritis is resolving but do not provide data about fluid volume. Cognitive Level: Application Text Reference: p. 1165 Nursing Process: Evaluation NCLEX: Physiological Integrity

7. The nurse identifies a nursing diagnosis of pain related to muscle spasms for a patient with acute low back pain associated with acute lumbosacral strain. An appropriate nursing intervention for this problem is to teach the patient to a. twist gently from side to side to maintain range-of-motion in the spine. b. place a small pillow under the upper back to flex the lumbar spine gently c. keep the head elevated slightly and flex the knees when resting in bed. d. avoid the use of cold because it will exacerbate the muscle spasms.

Answer: C Rationale: Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain. Cognitive Level: Application Text Reference: pp. 1676-1677 Nursing Process: Planning NCLEX: Physiological Integrity

1. To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine. b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain.

Answer: C Rationale: The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms with BPH. Cognitive Level: Application Text Reference: pp. 1415-1416 Nursing Process: Assessment NCLEX: Physiological Integrity

4. During assessment of the musculoskeletal system of a 74-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit two years ago. The nurse will plan to teach the patient about a. diskography studies. b. magnetic resonance imaging (MRI). c. dual-energy x-ray absorptiometry (DEXA). d. myelographic testing.

Answer: C Rationale: The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Diskography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic test for osteoporosis. Cognitive Level: Application Text Reference: pp. 1619, 1625 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

3. A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching? a. The reason for taking oral antibiotics for 7 to 10 days after discharge b. The need for daily aerobic exercise to help maintain muscle strength c. How to monitor and care for the long-term IV catheter site d. How to apply warm packs safely to the leg to reduce pain

Answer: C Rationale: The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection. Cognitive Level: Application Text Reference: p. 1670 Nursing Process: Implementation NCLEX: Physiological Integrity

13. A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first? a. Draw blood for blood urea nitrogen (BUN) and creatinine. b. Administer lorazepam (Ativan) 0.5 mg. c. Insert 16 French retention catheter. d. Schedule for IVP.

Answer: C Rationale: The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently. Cognitive Level: Application Text Reference: p. 1185 Nursing Process: Implementation NCLEX: Physiological Integrity

10. A 64-year-old man undergoes a perineal radical prostatectomy for stage C prostatic cancer. Postoperatively, the nurse establishes the nursing diagnosis of risk for infection related to a. urinary stasis. b. urinary incontinence. c. possible fecal contamination of the surgical wound. d. placement of a suprapubic catheter into the bladder.

Answer: C Rationale: The perineal approach increases the risk for infection because the incision is located close to the anus and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery. Cognitive Level: Application Text Reference: p. 1425 Nursing Process: Diagnosis NCLEX: Physiological Integrity

9. When assessing the musculoskeletal system, the nurse's initial action will usually be to a. have the patient move the extremities against resistance. b. feel for the presence of crepitus during joint movement. c. observe the patient's body build and muscle configuration. d. check active and passive range of motion for the extremities.

Answer: C Rationale: The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments are also included in the assessment but are usually done after inspection. Cognitive Level: Comprehension Text Reference: p. 1621 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

31. A patient undergoing a left ureterolithotomy returns to the surgical unit with a left ureteral catheter and a urethral catheter in place. When caring for the patient, the nurse will plan to a. aspirate the ureteral catheter if output decreases. b. clamp the ureteral catheter unless output from the urethral catheter stops. c. keep the patient on bed rest until the ureteral catheter is discontinued. d. teach the patient about home care for both catheters.

Answer: C Rationale: To avoid displacing the ureteral catheter, the patient is usually on bed rest until the catheter is removed. Aspiration of the ureteral catheter might damage tissue in the renal pelvis. The catheter is not clamped. The patient is not usually discharged with a ureteral catheter in place. Cognitive Level: Application Text Reference: p. 1187 Nursing Process: Planning NCLEX: Physiological Integrity

15. When administering alendronate (Fosamax) to a patient, the nurse will first a. administer the ordered calcium carbonate. b. be sure the patient has recently eaten. c. assist the patient to sit up at the bedside. d. ask about any leg cramps or hot flashes.

Answer: C Rationale: To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates. Cognitive Level: Application Text Reference: p. 1689 Nursing Process: Implementation NCLEX: Physiological Integrity

20. A 32-year-old patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time? a. Differences between hemodialysis and peritoneal dialysis b. Complications of renal transplantation c. Methods for treating chronic and severe pain d. Importance of genetic counseling

Answer: D Rationale: Because a 32-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain. Cognitive Level: Application Text Reference: p. 1176 Nursing Process: Implementation

6. A 72-year-old patient with benign prostatic hyperplasia and a history of frequent UTIs is admitted to the hospital with chills, fever, and nausea and vomiting. To determine whether the patient has an upper UTI, the nurse will assess for a. suprapubic pain. b. foul-smelling urine. c. bladder distension. d. costovertebral angle (CVA) tenderness

Answer: D Rationale: CVA tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Assessment NCLEX: Physiological Integrity

22. When obtaining the health history for a 30-year-old patient who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for a. interstitial cystitis. b. UTI. c. kidney stones. d. bladder cancer.

Answer: D Rationale: Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, UTI, or kidney stones will not be reduced by quitting smoking. Cognitive Level: Application Text Reference: p. 1178 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

35. The nurse working in a urology clinic receives a call from a patient who had a transurethral resection with fulguration for bladder cancer 3 days previously. Which information given by the patient is of most concern to the nurse? a. The patient is voiding every 4 hours at night. b. The patient is using opioids for pain. c. The patient is very anxious about the cancer. d. There are clots in the urine.

Answer: D Rationale: Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure. Cognitive Level: Application Text Reference: p. 1179 Nursing Process: Assessment NCLEX: Physiological Integrity

9. A patient with a herniated intravertebral disk undergoes a laminectomy and diskectomy. Following the surgery, the nurse should position the patient on the side by a. elevating the head of the bed 30 degrees and having the patient extend the legs while turning to the side. b. turning the patient's head and shoulders and then the hips, keeping the patient centered in the bed. c. having the patient turn by grasping the side rails and pulling the shoulders over. d. placing a pillow between the patient's legs and turning the entire body as a unit

Answer: D Rationale: Logrolling is used to maintain correct body alignment after laminectomy. The other positions will create misalignment of the spine. Cognitive Level: Application Text Reference: p. 1683 Nursing Process: Implementation NCLEX: Physiological Integrity

11. A patient suffers an injury to the shoulder while playing football. To identify abnormalities of cartilage and soft tissue surrounding the joint, the nurse would expect the patient to be evaluated with a. radioisotope bone scanning. b. arthroscopy. c. standard x-rays. d. magnetic resonance imaging (MRI).

Answer: D Rationale: MRI is most useful in assessing for soft tissue injuries. Bone scanning and standard radiographs are used to assess for injures or lesions of bone. Arthroscopy is used for visualizing the joints. Cognitive Level: Comprehension Text Reference: p. 1625 Nursing Process: Assessment NCLEX: Physiological Integrity

9. The health care provider orders a blood test for prostate-specific antigen (PSA) when an enlarged prostate is palpated during a routine examination of a 56-year-old man. When the patient asks the nurse the purpose of the test, the nurse's response is based on the knowledge that a. elevated levels of PSA are indicative of metastatic cancer of the prostate. b. PSA testing is the "gold standard" for making a diagnosis of prostate cancer. c. baseline PSA levels are necessary to determine whether treatment is effective. d. PSA levels are usually elevated in patients with cancer of the prostate.

Answer: D Rationale: PSA levels are usually elevated above the normal in patients with prostate cancer. PSA testing does not determine whether metastasis has occurred. A biopsy of the prostate is needed for a definitive diagnosis of prostate cancer. Success of treatment is determined by a fall in PSA to an undetectable level; the patient's baseline PSA is not needed to determine the success of treatment. Cognitive Level: Application Text Reference: p. 1423 Nursing Process: Implementation NCLEX: Physiological Integrity

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

Answer: D Rationale: Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics. Cognitive Level: Application Text Reference: p. 1188 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

13. A patient has a new order for open magnetic resonance imaging (MRI) to evaluate for right femur osteomyelitis. Which information obtained by the nurse indicates that the nurse should consult with the health care provider before scheduling an MRI? a. The patient is claustrophobic. b. The patient wears a hearing aid. c. The patient is allergic to shellfish. d. The patient has a pacemaker.

Answer: D Rationale: Patients with permanent pacemakers cannot have MRI. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Contrast medium will not be used, so shellfish allergy is not a contraindication to MRI. Cognitive Level: Application Text Reference: p. 1625 Nursing Process: Assessment NCLEX: Physiological Integrity

22. The nurse working in a health clinic receives calls from all these patients. Which patient should be seen by the doctor first? a. A 23-year-old man who states he had difficulty maintaining an erection last night b. A 44-year-old man who has perineal pain and a temperature of 100.4° F c. A 62-year-old man who has light pink urine after having a TURP 3 days ago d. A 66-year-old man who has a painful erection that has lasted over 9 hours

Answer: D Rationale: Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be treated immediately. The other patients do not require immediate action to prevent serious complications. Cognitive Level: Analysis Text Reference: p. 1430 Nursing Process: Assessment NCLEX: Physiological Integrity

6. A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to a. administer the ordered IV morphine sulfate, 4 mg. b. increase the flow rate of the continuous bladder irrigation. c. give the ordered the belladonna and opium suppository. d. manually instill 50 ml of saline and try to remove the clots.

Answer: D Rationale: The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot. Cognitive Level: Application Text Reference: pp. 1420-1421 Nursing Process: Implementation NCLEX: Physiological Integrity

6. A 20-year-old patient with a 6-year history of muscular dystrophy is hospitalized with a respiratory tract infection. Which nursing action will be included in the plan of care? a. Logroll the patient every 1 to 2 hours. b. Teach the patient about the muscle biopsy procedure. c. Provide the patient with a pureed diet. d. Assist the patient with active range-ofmotion (ROM) exercises.

Answer: D Rationale: The goal for the patient with muscular dystrophy is to keep the patient active for as long as possible. The patient would not be confined to bed rest and would not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but would not be ordered for a patient who already had a diagnosis. There is no indication that the patient requires a pureed diet. Cognitive Level: Application Text Reference: p. 1675 Nursing Process: Planning NCLEX: Physiological Integrity

21. When assessing a patient who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of a. recurrent renal calculi. b. kidney trauma. c. bladder infection. d. gonococcal urethritis.

Answer: D Rationale: The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with renal calculi, kidney trauma, or bladder infection. Cognitive Level: Application Text Reference: p. 1174 Nursing Process: Assessment NCLEX: Physiological Integrity

21. A 46-year-old man has had erectile dysfunction (ED) for about 3 years when he finally seeks help for the problem. He tells the nurse that he decided to seek help because his wife "is losing patience with the situation." The most appropriate nursing diagnosis for the patient is a. risk for anxiety related to inability to perform sexually. b. situational low self-esteem related to loss of satisfying sexual activity. c. ineffective sexuality patterns related to ED. d. ineffective role performance related to effects of ED.

Answer: D Rationale: The patient's statement indicates that the relationship with his wife is his primary concern. Although anxiety, low selfesteem, and ineffective sexuality patterns may also be concerns, the data in the stem suggest that addressing the role performance problem will lead to the best outcome for this patient. Cognitive Level: Application Text Reference: p. 1436 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

10. Following a laminectomy with a spinal fusion, a patient reports numbness and tingling of the right lower leg. The first action indicated by the nurse is to a. report the patient's complaint to the surgeon. b. check the vital signs for indications of hemorrhage. c. turn the patient to the side to relieve pressure on the operative area. d. check the chart for preoperative neuromuscular assessment data.

Answer: D Rationale: The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness. Cognitive Level: Application Text Reference: p. 1683 Nursing Process: Implementation NCLEX: Physiological Integrity

14. The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about a. an apical pulse rate of 106 beats/min. b. an oxygen saturation of 88% on room air. c. weight gain of 1 kg (2.2 lb) over 24 hours. d. decreased hourly patient urinary output.

B Rationale: A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action. Cognitive Level: Analysis Text Reference: pp. 829-830 Nursing Process: Assessment NCLEX: Physiological Integrity

22. When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient's room. b. puts on a surgical face mask before visiting the patient. c. brings food from a "fast-food" restaurant to the patient. d. hands the patient a tissue from the box at the bedside.

B Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. Cognitive Level: Application Text Reference: p. 574 Nursing Process: Implementation NCLEX: Physiological Integrity

32. The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurse's first action should be to a. have the patient use the incentive spirometer. b. medicate the patient with the ordered morphine. c. splint the patient's chest during coughing. d. assist the patient to sit up at the bedside.

B Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given. Cognitive Level: Application Text Reference: pp. 591, 594 Nursing Process: Implementation NCLEX: Physiological Integrity

28. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of a. cigarette smoking. b. alcohol use. c. diabetes mellitus. d. high-protein diet.

B Rationale: Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors. Cognitive Level: Comprehension Text Reference: p. 1118 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

22. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? a. Teach the patient the reasons for remaining on bed rest. b. Monitor the patient's BP every hour. c. Adjust the drip rate to keep the systolic BP >90 mm Hg. d. Call the health care provider about a decrease in urine output.

B Rationale: An experienced LPN/LVN would be able to monitor BP and would know to report significant changes to the RN. Teaching patients and making adjustments to the drip rate for vasoactive medications are RN-level skills. Because the health care provider may order changes in therapy based on the decrease in urine output, the RN should call the health care provider about the decreased urine output. Cognitive Level: Application Text Reference: pp. 827-829 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

8. When taking a health history for a new patient, which information given by the patient would indicate that screening for hepatitis C is appropriate? a. The patient had a blood transfusion after surgery in 1998. b. The patient reports a one-time use of IV drugs 20 years ago. c. The patient eats frequent meals in fastfood restaurants. d. The patient recently traveled to an undeveloped country.

B Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries. Cognitive Level: Application Text Reference: pp. 1090, 1098 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

31. A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."

B Rationale: Blood sugar increases after meals, so this will be the best time to exercise. NPH insulin will not peak until mid-afternoon and is safe to take before a morning run. Running can be done in either the morning or afternoon. If the glucose is very elevated, the patient should postpone the run. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity

33. The nurse caring for a patient with CF recognizes that the manifestations of the disease are caused by the pathophysiologic processes of a. inflammation and fibrosis of lung tissue. b. altered function of exocrine glands. c. failure of the mucus-producing goblet cells. d. thickening and fibrosis of the pleural linings.

B Rationale: CF is characterized by abnormal secretions of exocrine glands, mainly of the lungs, pancreas, and sweat glands. Damage to lung tissue develops late in the disease. The goblet cells continue to produce mucus. Cognitive Level: Comprehension Text Reference: pp. 655-656 Nursing Process: Assessment NCLEX: Physiological Integrity

35. A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis? a. Audible crackles at both lung bases b. 3+ edema in the lower extremities c. Loud murmur at the mitral area d. High systemic BP

B Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distension, and right upper-quadrant abdominal tenderness would be expected. Lung crackles, a murmur, and numbness and tingling are not caused by cor pulmonale. Cognitive Level: Application Text Reference: p. 602 Nursing Process: Assessment NCLEX: Physiological Integrity

8. A patient who has mild persistent asthma uses an albuterol (Proventil) inhaler for chest tightness and wheezing has a new prescription for cromolyn (Intal). To increase the patient's management and control of the asthma, the nurse should teach the patient to a. use the cromolyn when the albuterol does not relieve symptoms. b. use the cromolyn to prevent inflammatory airway changes. c. administer the cromolyn first for chest tightness or wheezing. d. administer the albuterol regularly to prevent airway inflammation.

B Rationale: Cromolyn is prescribed to reduce airway inflammation. It takes several weeks for maximal effect and is not used to treat acute asthma symptoms Albuterol is used as a rescue medication in mild persistent asthma and will not decrease inflammation. Cognitive Level: Application Text Reference: p. 620 Nursing Process: Implementation NCLEX: Physiological Integrity

3. A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, the nurse will ask the patient about a. abdominal tenderness. b. difficulty swallowing. c. changes in bowel habits. d. dizziness or weakness.

B Rationale: Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. Abdominal tenderness or changes in bowel habits are consistent with an abdominal aneurysm. Dizziness or weakness may occur if there is blood loss from the aneurysm, but this aneurysm was discovered accidentally, not because the patient was symptomatic. Cognitive Level: Application Text Reference: p. 895 Nursing Process: Assessment NCLEX: Physiological Integrity

16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements for a patient with COPD. An appropriate intervention for this problem is to a. have the patient exercise for 10 minutes before meals. b. offer high calorie snacks between meals and at bedtime. c. assist the patient in choosing foods with a lot of texture. d. increase the patient's intake of fruits and fruit juices.

B Rationale: Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice. Cognitive Level: Application Text Reference: pp. 649,652 Nursing Process: Planning NCLEX: Physiological Integrity

10. A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse, "I hate to exercise! Can't I just follow the diet to keep my glucose under control?" The nurse teaches the patient that the major purpose of exercise for diabetics is to a. increase energy and sense of well-being, which will help with body image. b. facilitate weight loss, which will decrease peripheral insulin resistance. c. improve cardiovascular endurance, which is important for diabetics. d. set a successful pattern, which will help in making other needed changes.

B Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control. Increased energy, improved cardiovascular endurance, and setting a pattern of success are secondary benefits of exercise, but they are not the major reason. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity

35. Which statement by the COPD patient indicates that the nurse's teaching about nutrition has been effective? a. "I will drink lots of fluids with my meals." b. "I will have ice cream as a snack every day." c. "I should exercise for 15 minutes before meals." d. "I should avoid much meat or dairy products."

B Rationale: High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD. Cognitive Level: Application Text Reference: p. 649 Nursing Process: Evaluation NCLEX: Physiological Integrity

5. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that a. hypertensive crisis may lead to development of acute heart failure in some patients. b. hypertension eventually will lead to heart failure by overworking the heart muscle. c. high BP increases risk for rheumatic heart disease. d. high systemic pressure precipitates papillary muscle rupture

B Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients. Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A b-hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the papillary muscle). Cognitive Level: Application Text Reference: p. 822 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

7. A nursing action that is indicated for the collaborative problem of potential complication: cardiac dysrhythmia in a patient who has had a repair of a descending thoracic aortic aneurysm is to a. assess level of consciousness and orientation hourly. b. titrate oxygen to keep O2 saturation greater than 90%. c. turn the patient every 1 to 2 hours while on bed rest. d. monitor hourly fluid intake and urine output levels

B Rationale: Hypoxemia may precipitate dysrhythmias in patients after aneurysm repair. Neurologic assessments, turning the patient, and monitoring intake and output are also appropriate nursing actions after aneurysm repair but will not have an effect on dysrhythmias. Cognitive Level: Application Text Reference: p. 897 Nursing Process: Implementation NCLEX: Physiological Integrity

11. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as a. administering sedatives to promote rest and decrease myocardial oxygen demand. b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed. c. administering oxygen per mask or nasal cannula. d. encouraging leg exercises to improve venous return.

B Rationale: Positioning the patient in a high- Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload. Cognitive Level: Application Text Reference: pp. 827-828 Nursing Process: Planning NCLEX: Physiological Integrity

12. A patient with type 1 diabetes has an unusually high morning glucose measurement, and the health care provider wants the patient evaluated for possible Somogyi effect. The nurse will plan to a. administer an increased dose of NPH insulin in the evening. b. obtain the patient's blood glucose at 3:00 in the morning. c. withhold the nighttime snack and check the glucose at 6:00 AM. d. check the patient for symptoms of hypoglycemia at 2:00 to 4:00 AM.

B Rationale: In the Somogyi effect, the patient's blood glucose drops in the early morning hours (in response to excess insulin administration), which causes the release of hormones that result in a rebound hyperglycemia. It is important to check the blood glucose in the early morning hours to detect the initial hypoglycemia. An increased evening NPH dose or holding the nighttime snack will further increase the risk for early morning hypoglycemia. Information about symptoms of hypoglycemia will not be as accurate as checking the patient's blood glucose in determining whether the patient has the Somogyi effect. Cognitive Level: Application Text Reference: pp. 1263-1264 Nursing Process: Planning NCLEX: Physiological Integrity

DIABETES 1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes a. the patient is totally dependent on an outside source of insulin. b. there is decreased insulin secretion and cellular resistance to insulin that is produced. c. the immune system destroys the pancreatic insulin-producing cells. d. the insulin precursor that is secreted by

B Rationale: In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately. The other information describes the physiology of type 1 diabetes. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity

25. A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat, cough, and fever. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dl, the nurse advises the patient to a. use only the lispro insulin until the symptoms of infection are resolved. b. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. c. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. d. limit intake to non-calorie-containing liquids until the glucose is within the usual range.

B Rationale: Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to DKA. Decreasing carbohydrate or caloric intake is not appropriate as the patient will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose. Cognitive Level: Application Text Reference: p. 1272 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

38. Which information given by an asthmatic patient during the admission assessment will be of most concern to the nurse? a. The patient says that the asthma symptoms are worse every spring. b. The patient's only asthma medications are albuterol (Proventil) and salmeterol (Serevent). c. The patient uses cromolyn (Intal) before any aerobic exercise. d. The patient's heart rate increases after using the albuterol (Proventil) inhaler.

B Rationale: Long-acting b2-agonists should be used only in patients who are also using another medication for long-term control (typically an inhaled corticosteroid). Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma. Cognitive Level: Application Text Reference: pp. 615, 621 Nursing Process: Assessment NCLEX: Physiological Integ

17. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the nurse gives the highest priority to the goal of a. controlling bleeding. b. maintenance of the airway. c. maintenance of fluid volume. d. relieving the patient's anxiety.

B Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. The other goals would also be important for this patient, but they are not as high a priority as airway maintenance. Cognitive Level: Application Text Reference: pp. 1107, 1114 Nursing Process: Planning NCLEX: Physiological Integrity

25. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery"; Which response by the nurse is most appropriate? a. Are you afraid that the surgery will be very painful? b. Tell me what you know about the various treatments available. c. Surgery is the treatment of choice for stage I lung cancer. d. Did you have bad experiences with previous surgeries?

B Rationale: More assessment of the patient's concerns about surgery is indicated; an open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment o fchoice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Cognitive Level: Application Text Reference: pp. 583-584 Nursing Process: Implementation NCLEX: Psychosocial Integrity

4. The health care provider has prescribed triamcinolone (Azmacort) metered-dose inhaler (MDI) two puffs every 8 hours and pirbuterol (Maxair) MDI 2 puffs four times a day for a patient with asthma. In teaching the patient about the use of the inhalers, the best instruction by the nurse is a. "Use the Maxair inhaler first, wait a few minutes, then use the Azmacort inhaler." b. "Using a spacer with the MDIs will improve the inhalation of the medications." c. "To avoid side effects, the inhalers should not be used within 1 hour of each other." d. "To maximize the effectiveness of the drugs, inhale quickly when using the inhalers."

B Rationale: More medication reaches the bronchioles when a spacer is used along with an MDI. There is no evidence that using a bronchodilator before a corticosteroid inhaler is helpful. The medications can be used at the same time. The patient should inhale slowly when using an MDI. Cognitive Level: Application Text Reference: p. 621 Nursing Process: Implementation NCLEX: Physiological Integrity

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

B Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective. Cognitive Level: Application Text Reference: p. 1120 Nursing Process: Evaluation NCLEX: Physiological Integrity

7. The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is normally alert and oriented. Which action should the nurse take next? a. Check the patient's pulse rate. b. Obtain an oxygen saturation. c. Notify the health care provider. d. Document the change.

B Rationale: New-onset confusion caused by hypoxia may be the first sign of pneumonia in older patients. The other actions are also appropriate in this order: check the pulse, notify the health care provider, and document the change in status. Cognitive Level: Application Text Reference: p. 565 Nursing Process: Implementation NCLEX: Physiological Integrity

3. During a diabetes screening program, a patient tells the nurse, "My mother died of complications of type 2 diabetes. Can I inherit diabetes?" The nurse explains that a. as long as the patient maintains normal weight and exercises, type 2 diabetes can be prevented. b. the patient is at a higher than normal risk for type 2 diabetes and should have periodic blood glucose level testing. c. there is a greater risk for children developing type 2 diabetes when the father has type 2 diabetes. d. although there is a tendency for children of people with type 2 diabetes to develop diabetes, the risk is higher for those with type 1 diabetes.

B Rationale: Offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes. The risk can be decreased, but not prevented, by maintenance of normal weight and exercising. The risk for children of a person with type 1 diabetes to develop diabetes is higher when it is the father who has the disease. Offspring of people with type 2 diabetes are more likely to develop diabetes than offspring of those with type 1 diabetes. Cognitive Level: Application Text Reference: p. 1256 Nursing Process: Implementation NCLEX: Physiological Integrity

34. The health care provider orders oral glucose tolerance testing for a patient seen in the clinic. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient had a viral illness 2 months ago. b. The patient uses oral contraceptives. c. The patient runs several days a week. d. The patient has a family history of diabetes.

B Rationale: Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. A viral 2 months previously illness may be associated with the onset of type 1 diabetes but will not falsely impact the OGTT. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. Cognitive Level: Application Text Reference: p. 1267 Nursing Process: Assessment NCLEX: Physiological Integrity

8. A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as a. pulsus alternans. b. paroxysmal nocturnal dyspnea. c. two-pillow orthopnea. d. acute bilateral pleural effusion.

B Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment NCLEX: Physiological Integrity

16. After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective? a. The patient places the hands in hot water when they turn pale. b. The patient exercises indoors during the winter months. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids the use of aspirin and the NSAIDs.

B Rationale: Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking aspirin and NSAIDs with Raynaud's phenomenon. Cognitive Level: Application Text Reference: p. 909 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

21. The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for DVT. The nurse determines that additional teaching is needed when the patient says, a. "I should wear a Medic Alert bracelet to indicate I am on anticoagulant therapy." b. "I should change my diet to include more green, leafy vegetables." c. "I will check with my health care provider before I begin or stop any medication." d. "I will need to have blood tests routinely to monitor the effects of the Coumadin."

B Rationale: Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green leafy vegetables. The other patient statements are accurate. Cognitive Level: Application Text Reference: p. 917 Nursing Process: Evaluation NCLEX: Physiological Integrity

3. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. hyperresonance on percussion. b. increased vocal fremitus on palpation. c. fine crackles in all lobes on auscultation. d. asymmetric chest expansion on inspection.

B Rationale: Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would expect to find increased vocal fremitus over the affected area of the lungs. The area would be dull to percussion. Fine crackles in all lobes would indicate a diffuse infection, which is more typical of viral pneumonias. Asymmetric chest expansion is not typical with pneumonia. Cognitive Level: Application Text Reference: p. 565 Nursing Process: Assessment NCLEX: Physiological Integrity

26. Which statement by a patient who is being discharged 5 days after an abdominal aortic aneurysm repair and graft indicates that the discharge teaching has been effective? a. "I will call the doctor if my temperature is higher than 101° F." b. "I will tell my dentist about this surgery the next time I have an appointment." c. "I should not need to take anything but acetaminophen (Tylenol) for my pain." d. "I am eager to get home so that I can pick up my 6-year-old granddaughter."

B Rationale: Prophylactic antibiotics may be ordered to prevent graft infection when the patient has any invasive procedures, including dental procedures. The patient is instructed to call if the temperature is higher than 100° F. After abdominal surgery, patients may need to use opioid pain medications on a PRN basis. Because heavy lifting is avoided for at least 4 to 6 weeks after surgery, the patient should not pick up a 6-year-old child. Cognitive Level: Application Text Reference: p. 898 Nursing Process: Evaluation NCLEX: Physiological Integrity

15. A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. a. NPH b. lispro c. detemir d. glargine

B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. Cognitive Level: Application Text Reference: p. 1260 Nursing Process: Planning NCLEX: Physiological Integrity

25. In planning care for a patient with acute pancreatitis, the nurse assigns the highest priority to the patient outcome of a. developing no acute complications. b. maintenance of normal respiratory function. c. expressing satisfaction with pain control. d. having adequate fluid and electrolyte balance.

B Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient. Cognitive Level: Application Text Reference: p. 1122 Nursing Process: Planning NCLEX: Physiological Integrity

7. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops a. a drop in heart rate to 54 beats/min. b. a systolic BP <90 mm Hg. c. any symptoms indicating cyanide toxicity. d. an increased amount of ventricular ectopy.

B Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After 48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy. Cognitive Level: Application Text Reference: p. 828 Nursing Process: Evaluation NCLEX: Physiological Integrity

10. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient a. says that the nitroglycerin patch will be used for any chest pain that develops. b. calls when the weight increases from 124 to 130 pounds in a week. c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime. d. makes an appointment to see the doctor at least once yearly.

B Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. Heart failure is a chronic condition that will require frequent follow-up rather than an annual health care provider examination. Cognitive Level: Application Text Reference: pp. 826, 833-834, 838 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

15. While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include a. transfer to a dementia care service. b. referral to a home health care agency. c. placement in a long-term-care facility. d. arrangements for around-the-clock care.

B Rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient to develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term-care, or around-theclock home care. Cognitive Level: Application Text Reference: pp. 836-837 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

12. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning patient teaching, the priority information for the nurse to include is the need for a. vitamin B supplements. b. abstinence from alcohol. c. maintenance of a nutritious diet. d. long-term, low-dose corticosteroids.

B Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease. Cognitive Level: Application Text Reference: pp. 1114-1115 Nursing Process: Planning NCLEX: Physiological Integrity

25. When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe COPD, the nurse should teach the patient that an appropriate exercise goal is to a. exercise until shortness of breath occurs. b. walk for a total of 20 minutes daily. c. limit exercise to activities of daily living (ADLs). d. walk until pulse rate exceeds 150.

B Rationale: The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150).

13. A patient receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between a. 8:00 and 10:00 AM. b. 4:00 and 6:00 PM. c. 7:00 and 9:00 PM. d. 10:00 PM and 12:00 AM.

B Rationale: The greatest insulin effect with this combination occurs mid afternoon. The patient is not at a high risk at the other listed times, although hypoglycemia may occur. Cognitive Level: Comprehension Text Reference: p. 1260 Nursing Process: Evaluation NCLEX: Physiological Integrity

36. The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The international normalized ratio (INR) is prolonged. b. The central line is disconnected. c. The oxygen saturation is 90%. d. The BP is 88/56.

B Rationale: The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion. Cognitive Level: Application Text Reference: p. 601 Nursing Process: Assessment NCLEX: Physiological Integrity

10. A patient with an acute attack of asthma comes to the emergency department, where ABGs are drawn. The nurse determines the patient is in the early phase of the attack, based on the ABG results of a. pH 7.0, PaCO2 50 mm Hg, and PaO2 74 mm Hg. b. pH 7.4, PaCO2 32 mm Hg, and PaO2 70 mm Hg. c. pH 7.36, PaCO2 40 mm Hg, and PaO2 80 mm Hg. d. pH 7.32, PaCO2 58 mm Hg, and PaO2 60 mm Hg.

B Rationale: The initial response to hypoxemia caused by airway narrowing in a patient having an acute asthma attack is an increase in respiratory rate, which causes a drop in PaCO2. The other PaCO2 levels are normal or elevated, which would indicate that the attack was progressing and that the patient is decompensating. Cognitive Level: Application Text Reference: pp. 614, 626 Nursing Process: Assessment NCLEX: Physiological Integrity

29. The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 ml of blood in the collection chamber. c. severe pain with each deep patient inspiration. d. subcutaneous emphysema at the insertion site.

B Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The severe pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. Cognitive Level: Application Text Reference: p. 586 Nursing Process: Assessment NCLEX: Physiological Integrity

42. All of the following information is obtained by the nurse who is caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which assessment data is most important to communicate to the health care provider? a. The patient has many abdominal bruises. b. The patient's BP is 90/46. c. The activated partial thromboplastin time is 2 times the patient baseline. d. The patient's stool is dark green and liquid.

B Rationale: The low BP may indicate that the patient is experiencing bleeding, a possible adverse effect of heparin therapy. Subcutaneous heparin administration is given into the subcutaneous tissue of the abdomen and abdominal bruising is not unusual. An aPTT 2 times the baseline indicates a therapeutic heparin level. The patient should be monitored for gastrointestinal bleeding, which would be indicated by black or red stools. Cognitive Level: Application Text Reference: p. 600 Nursing Process: Assessment NCLEX: Physiological Integrity

11. A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. The data indicate that it is most important for the nurse to monitor the patient's a. temperature. b. albumin level. c. hemoglobin. d. activity level.

B Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema. The other parameters should also be monitored, but they are not contributing factors to the patient's current symptoms. Cognitive Level: Application Text Reference: p. 1104 Nursing Process: Assessment NCLEX: Physiological Integrity

35. Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Fasting blood glucose of 130 mg/dl b. Noon blood glucose of 52 mg/dl c. Glycosylated hemoglobin of 6.9% d. Hemoglobin A1C of 5.8%

B Rationale: The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabeticpatient. Cognitive Level: Application Text Reference: pp. 1281-1282 Nursing Process: Assessment NCLEX: Physiological Integrity

27. A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon, maybe this week." The best response by the nurse is a. "Are you afraid that the treatment for your cancer will not be effective?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Would you like to talk to the hospital chaplain about your feelings?" d. "Do you think that taking an antidepressant medication would be helpful?"

B Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate. Cognitive Level: Application Text Reference: pp. 583-584 Nursing Process: Implementation NCLEX: Psychosocial Integrity

8. When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, the information that is most significant when the nurse is assessing for the return of peristalsis is a. absence of abdominal distention. b. passing of flatus with ambulation. c. dark brown nasogastric (NG) tube drainage. d. moderate abdominal tenderness.

B Rationale: The passing of flatus is the best indicator of returning bowel function. Because the patient usually has an NG tube in place, the absence of abdominal distention is not indicative of gastrointestinal (GI) function. The quality of NG tube drainage may indicate the presence of complications such as GI bleeding but does not provide useful information about GI function. Moderate abdominal tenderness is expected after abdominal surgery. Cognitive Level: Application Text Reference: p. 898 Nursing Process: Assessment NCLEX: Physiological Integrity

13. A patient who has active TB has just been started on drug therapy for TB. The nurse informs the patient that the disease can be transmitted to others until a. the chest x-ray shows resolution of the tuberculosis. b. three sputum smears for acid-fast bacilli are negative. c. TB medications have been taken for 6 months. d. sputum cultures on 3 consecutive days are negative.

B Rationale: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli. Chest x-rays help to determine the presence of active TB but are not utilized to monitor the effectiveness of treatment. Taking the medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Sputum cultures are used to diagnose the presence of active TB, but sputum smears are usually done to establish that treatment has been effective. Cognitive Level: Application Text Reference: p. 574 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

30. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependentrubor. The nurse teaches the patient that a. the feet should be soaked in warm water on a daily basis. b. flat-soled leather shoes are the best choice to protect the feet from injury. c. heating pads should always be set at a very low temperature. d. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure.

B Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems. Cognitive Level: Application Text Reference: p. 1287 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

14. A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene? a. The LPN/LVN administers the ordered aspirin 160 mg after breakfast. b. The LPN/LVN has the patient sit in a bedside chair for 90 minutes. c. The LPN/LVN assists the patient to ambulate 40 feet in the hallway. d. The LPN/LVN places the patient in a Fowler's position for meals.

B Rationale: The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for DVT. The other actions by the LPN/LVN are appropriate. Cognitive Level: Application Text Reference: p. 906 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

16. A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions about appropriate diet. The nurse determines that the teaching has been effective when the patient's choice of foods from the menu includes a. an omelet with cheese and mushrooms and milk. b. pancakes with butter and honey and orange juice. c. baked beans with ham, cornbread, potatoes, and coffee. d. baked chicken with french-fries, lowfiber bread, and tea.

B Rationale: The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia levels. The other choices are all higher in protein and would not be as appropriate for this patient. In addition, the patient's ascites indicate that a low-sodium diet is needed and the other choices are all high in sodium. Cognitive Level: Application Text Reference: p. 1110 Nursing Process: Evaluation NCLEX: Physiological Integrity

2. A 69-year old patient is admitted to the hospital for elective repair of an abdominal aortic aneurysm. The history includes hypertension for 25 years, hyperlipidemia for 15 years, and smoking for 50 years. The patient asks the nurse what caused the aneurysm. The nurse's best response includes the information that a. congenital weakness of arterial walls eventually results in an aneurysm. b. atherosclerotic plaques damage the artery and may lead to aneurysms. c. chronic infections of blood vessel walls may have contributed to the aneurysm. d. uncontrolled hypertension, hyperlipidemia, and smoking caused the aneurysm.

B Rationale: The patient's gender, age, and risk factor history indicate that the aneurysm was likely caused by atherosclerosis rather than a congenital weakness or chronic infection. Although the patient's BP, elevated lipids, and smoking undoubtedly have contributed to the atherosclerotic process, it is not appropriate for the nurse to imply that the patient is to blame. Cognitive Level: Application Text Reference: p. 894 Nursing Process: Implementation NCLEX: Physiological Integrity

9. A patient is admitted with an abrupt onset of jaundice, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Have you been around anyone with jaundice?" b. "Do you use any prescription or overthe- counter (OTC) drugs?" c. "Are you taking corticosteroids for any reason?" d. "Is there any history of IV drug use?"

B Rationale: The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Exposure to a jaundiced individual and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed. Cognitive Level: Application Text Reference: pp. 1099-1100 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

3. During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B vaccine has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgM. d. anti-HBc IgG

B Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV. Cognitive Level: Application Text Reference: pp. 1089, 1093 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

20. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs. An appropriate nursing intervention for this problem is to a. restrict dietary protein intake. b. arrange for a pressure-relieving mattress. c. perform passive range of motion QID. d. turn the patient every 4 hours.

B Rationale: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Dietary protein intake may be increased in patients with ascites to improve oncotic pressure. Turning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown. Cognitive Level: Application Text Reference: p. 1111 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

9. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to a. turn and reposition immobile patients at least every 2 hours. b. position patients with altered consciousness in lateral positions. c. monitor frequently for respiratory symptoms in patients who are immunosuppressed. d. provide for continuous subglottic aspiration in patients receiving enteral feedings.

B Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonias in immune compromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings. Cognitive Level: Application Text Reference: p. 567 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

21. A portocaval shunt is considered for a patient with cirrhosis following an episode of bleeding esophageal varices. The nurse plans to teach the patient that this procedure a. is likely to improve the patient's life expectancy. b. will increase the risk of hepatic encephalopathy. c. will help to decrease the incidence of peritonitis. d. is a first-line therapy for portal hypertension.

B Rationale: The risk for hepatic encephalopathy increases after shunt procedures because blood bypasses the portal system and ammonia is diverted past the liver and into the systemic circulation. Life expectancy is not improved. The risk for peritonitis is not decreased by a surgical procedure, which will increase infection risk. First-line procedures for portal hypertension are medications such as diureticsand albumin. Cognitive Level: Application Text Reference: p. 1108 Nursing Process: Planning NCLEX: Physiological Integrity

37. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate? a. The medication will inhibit the development of gastric ulcers. b. The medication will prevent irritation to the esophageal varices. c. The medication will decrease nausea and anorexia. d. The medication will reduce the risk for aspiration.

B Rationale: The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2 receptor blockade in this patient. Cognitive Level: Application Text Reference: p. 1108 Nursing Process: Implementation NCLEX: Physiological Integrity

7. Combination therapy of a-interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a patient with human immunodeficiency virus (HIV). The nurse will plan to monitor a. blood glucose. b. lymphocyte count. c. potassium level. d. serum creatinine.

B Rationale: Therapy with ribavirin and a-interferon may decrease lymphocyte counts. The other laboratory values should not be changed by the drug therapy. Cognitive Level: Application Text Reference: p. 1095 Nursing Process: Planning NCLEX: Physiological Integrity

33. A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent hemoglobin A1C was 6%. b. The patient takes metformin (Glucophage) every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 128 mg/dl.

B Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately. Cognitive Level: Application Text Reference: p. 1266 Nursing Process: Assessment NCLEX: Physiological Integrity

13. When teaching a patient with chronic obstructive pulmonary disease (COPD) about reasons to quit smoking, the nurse will explain that long-term exposure to tobacco smoke leads to a a. weakening of the smooth muscle the airways. b. decrease in the area available for oxygen absorption. c. lesser number of red blood cells for oxygen delivery. d. decreased production of protective respiratory secretions.

B Rationale: Tobacco smoke leads to an increase in proteolytic enzymes, which break down alveolar walls and lead to less alveolar surface area for gas exchange. Bronchial smooth muscle is not weakened by chronic smoking. Polycythemia is a common compensatory mechanism for patients with COPD. The quantity of respiratory secretions increases as a result of smoking. Cognitive Level: Application Text Reference: p. 633 Nursing Process: Implementation NCLEX: Physiological Integrity

36. When teaching the patient with COPD about exercise, which information should the nurse include? a. "Stop exercising if you start to feel short of breath." b. "Use the bronchodilator before you start to exercise." c. "Breathe in and out through the mouth while you exercise." d. "Upper body exercise should be avoided to prevent dyspnea."

B Rationale: Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD. Cognitive Level: Application Text Reference: p. 653 Nursing Process: Implementation NCLEX: Physiological Integrity

39. When taking an admission history of a patient with possible asthma who has new-onset wheezing and shortness of breath, the nurse will be most concerned about which information? a. The patient has a history of pneumonia 2 years ago. b. The patient takes propranolol (Inderal) for hypertension. c. The patient uses acetaminophen (Tylenol) for headaches. d. The patient has chronic inflammatory bowel disease.

B Rationale: b-blockers such as propranolol can cause bronchospasm in some patients. The other information will be documented in the health history but does not indicate a need for a change in therapy. Cognitive Level: Application Text Reference: p. 610 Nursing Process: Assessment NCLEX: Physiological Integrit

The patient received regular insulin 10 units subcutaneously at 8:30 pm for a blood glucose level of 253 mg/dl. The nurse plans to monitor this patient for signs of hypoglycemia at which of the following peak action times? A) 9:00 pm to 10:30 pm B) 10:30 pm to 11:30 pm C) 12:30 am to 1:30 am D) 2:30 am to 4:30 am

B) 10:30pm- 11:30pm Regular insulin exerts peak action in 2 to 3 hours, making the patient most at risk for hypoglycemia between 10:30 pm and 11:30 pm.

Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high? a) Hyperactivity b) Blurred vision c) Oliguria d) Increased energy

B) Blurred vision Blurred vision occurs when the blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes.

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker? a) Home health nurse b) Dietitian c) Psychiatrist d) Social worker

B) Dietitian The client should be referred to a dietitian, who will help him gain better control of his blood glucose levels. The client can care for himself, so a home health agency isn't necessary. The client shows no signs of needing a psychiatric referral, and referring the client to a psychiatrist isn't in the nurse's scope of practice. Social workers help clients with financial concerns; the scenario doesn't indicate that the client has a financial concern warranting a social worker at this time.

The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes which of the following statements? A) "I should only walk barefoot in nice dry weather." B) "I should look at the condition of my feet every day." C) "I am lucky my shoes fit so nice and tight because they give me firm support." D) "When I am allowed up out of bed, I should check the shower water with my toes."

B) I should look at the condition of my feet every day Patients with diabetes mellitus need to inspect the feet daily for broken areas that are at risk for delayed wound healing. Water temperature should be tested with the hands first. Properly fitted (not tight) shoes should be worn at all times.

NPH is an example of which type of insulin? a) Short-acting b) Intermediate-acting c) Rapid-acting d) Long-acting

B) Intermediate-acting NPH is intermediate-acting insulin.

After teaching a class about the endocrine system, the instructor determines that the students need additional instruction when they identify which of the following as an endocrine gland? a) Pancreas b) Kidneys c) Testes d) Adrenal gland

B) Kidneys Although the kidneys secrete renin and erythropoietin, they are typically not considered endocrine glands. The pancreas, adrenal glands, and testes are considered endocrine glands.

The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. Which of the following information would be appropriate for the nurse to include? A) Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. B) Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. C) Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. D) Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes

B) Microangiography is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin Microangiopathy occurs in diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Sexual impotency and slowed gastric emptying result from microangiopathy. Macroangiopathy can occur in either type 1 or type 2 diabetes.

Which of the following assessment parameters is of highest priority when caring for a patient undergoing a water deprivation test? A) Serum glucose B) Patient weight C) Arterial blood gases D) Patient temperature

B) Patient weight A patient is at risk for severe dehydration during a water deprivation test. The test should be discontinued and the patient rehydrated if the patient's weight drops more than 2 kg at any time. The other assessment parameters do not assess fluid balance.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: a) magnesium. b) phosphorus. c) sodium. d) potassium.

B) Phosphorus PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve and observes twitching of the mouth and tightening of the jaw. The nurse would document this finding as which of the following? a) Positive Trousseau's sign b) Positive Chvostek's sign c) Tetany d) Hyperactive deep tendon refl

B) Positive Chvostek's sign If a nurse taps the client's facial nerve (which lies under the tissue in front of the ear), the client's mouth twitches and the jaw tightens. The response is identified as a positive Chvostek's sign. The nurse may elicit a positive Trousseau's sign by placing a BP cuff on the upper arm, inflating it between the systolic and diastolic BP, and waiting 3 minutes. The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Deep tendon reflexes include the biceps, brachioradialis, triceps, and patellar reflexes. Tetany would be manifested by reports of numbness and tingling in the fingers or toes or around the lips, voluntary movement that may be followed by an involuntary, jerking spasm, and muscle cramping. Tonic (continuous contraction) flexion of an arm or a finger may occur.

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which of the following instructions regarding desmopressin acetate (DDAVP) would be most appropriate? A) The patient can expect to experience weight loss resulting from increased diuresis. B) The patient should alternate nostrils during administration to prevent nasal irritation. C) The patient should monitor for symptoms of hypernatremia as a side effect of this drug. D) The patient should report any decrease in urinary elimination to the health care provider

B) The patient should alternate nostrils during administration to prevent nasal irritation DDAVP is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. DDAVP can cause nasal irritation, headache, nausea, and other signs of hyponatremia.

When caring for a client with diabetes insipidus, the nurse expects to administer: a) furosemide (Lasix). b) vasopressin (Pitressin). c) 10% dextrose. d) regular insulin.

B) Vasopressin (Pitressin) Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus

A 54-year-old patient admitted with type 2 diabetes, asks the nurse what "type 2" means. Which of the following is the most appropriate response by the nurse? A) "With type 2 diabetes, the body of the pancreas becomes inflamed." B) "With type 2 diabetes, insulin secretion is decreased and insulin resistance is increased." C) "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." D) "With type 2 diabetes, the body produces autoantibodies that destroy b-cells in the pancreas."

B) With type 2 diabetes, insulin secretion is decreased and insulin resistance is increased In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin.

5. The nurse identifies a nursing diagnosis of risk for altered peripheral tissue perfusion related to bypass graft thrombosis for a patient following an abdominal aneurysm repair. An appropriate intervention to prevent this problem in the immediate postoperative period is to a. use a cooling blanket to maintain the patient's temperature within a normal range to prevent hypercoagulability. b. place the patient in Trendelenburg position to reduce pressure at the suture line and prevent leaking of blood at the site. c. administer IV fluids at a rate to keep the arterial BP within a normal range. d. perform passive range-of-motion (ROM) exercises to the legs hourly to promote venous return.

C Rationale: Administration of IV fluids to maintain BP within normal range will allow adequate blood flow to prevent thrombosis while preventing the risk of suture damage that can occur with high BP. Coagulation is not usually affected by temperature. The Trendelenburg position compromises respiratory status in postoperative patients. Passive ROM will not improve arterial blood flow through the graft. Cognitive Level: Application Text Reference: p. 897 Nursing Process: Planning NCLEX: Physiological Integrity

34. When providing discharge instructions to a patient following a laparoscopic cholecystectomy at an outpatient surgical center, the nurse recognizes that teaching has been effective when the patient states, a. "I should plan to limit my activities and not return to work for 4 to 6 weeks." b. "I can expect some reddish yellow drainage from the incisions for a few days." c. "I can remove the bandages on my incisions tomorrow and take a shower." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

C Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions; patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement. Cognitive Level: Application Text Reference: p. 1132 Nursing Process: Evaluation NCLEX: Physiological Integr

10. When teaching a patient recovering from hepatitis B about management of the illness, the nurse determines that additional teaching is needed when the patient says a. "I should not drink alcohol for at least the next year." b. "My family members should be tested for hepatitis B." c. "When the jaundice is gone, I have recovered from my illness and the infection is cured." d. "Until my tests for the virus are negative, I should use a

C Rationale: After the acute (icteric) phase, there is a convalescent phase lasting several months. The other patient statements are correct and indicate that teaching has been effective. Cognitive Level: Application Text Reference: pp. 1091, 1098 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

23. In planning care for a patient with a venous stasis ulcer on the right lower leg, the nurse understands that the most important intervention in promoting healing of the ulcer is a. adequate dietary intake of proteins and vitamins. b. prevention of infection with prophylactic antibiotics. c. application of external compression to the lower leg. d. keeping the ulcer moist with hydrocolloid dressings.

C Rationale: Although all the interventions are used, the most essential is compression of the leg to prevent the ulcer from becoming wider and deeper. Cognitive Level: Application Text Reference: p. 919 Nursing Process: Planning NCLEX: Physiological Integrity

24. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. The nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum a. calcium. b. bilirubin. c. amylase. d. potassium.

C Rationale: Amylase is elevated early in acute pancreatitis. Changes in bilirubin, calcium, and potassium levels are not diagnostic forpancreatitis. Cognitive Level: Comprehension Text Reference: pp. 1120-1121 Nursing Process: Assessment NCLEX: Physiological Integrity

40. A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurse's first action should be to a. determine when the dyspnea started. b. obtain the forced expiratory flow rate. c. listen to the patient's breath sounds. d. ask about inhaled corticosteroid use.

C Rationale: Assessment of the patient's breath sounds will help to determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with a FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds. Cognitive Level: Application Text Reference: p. 626 Nursing Process: Assessment NCLEX: Physiological Integrity

25. Which of these nursing actions in the care plan for a patient who had a repair of an abdominal aortic aneurysm 5 days previously is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Teach the patient the signs of possible wound infection. b. Monitor the quality and presence of the pedal pulses. c. Assist the patient in using a pillow to splint while coughing. d. Check the lower extremity strength and movement.

C Rationale: Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for an experienced nursing assistant. Patient teaching and assessment of essential postoperative functions such as circulation and movement are more appropriate for the RN-level education and scope of practice. Cognitive Level: Application Text Reference: pp. 897-898 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

20. An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is a. 12-lead electrocardiogram (ECG). b. arterial blood gases (ABGs). c. B-type natriuretic peptide (BNP). d. serum creatine kinase (CK).

C Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP. Cognitive Level: Application Text Reference: p. 827 Nursing Process: Assessment NCLEX: Physiological Integrity

24. A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis? a. "I have burning leg pains after I walk three blocks." b. "I wake up during the night because my legs hurt." c. "I can't get my shoes on at the end of the day." d. "I can never seem to get my feet warm enough."

C Rationale: Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of PAD. Cognitive Level: Application Text Reference: p. 920 Nursing Process: Implementation NCLEX: Physiological Integrity

13. The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient outcomes following patient teaching, the nurse determines a need for further instruction when the patient says, a. "I will have to buy some loose clothing that does not bind across my legs or waist." b. "I will change my position every hour and avoid long periods of sitting with my legs down." c. "I will use a heating pad on my feet at night to increase the circulation and warmth in my feet." d. "I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily."

C Rationale: Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful. Cognitive Level: Application Text Reference: p. 905 Nursing Process: Evaluation NCLEX: Physiological Integrity

5. When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to a. avoid eating or drinking for 4 hours before the forced expiratory volume in 1 second (FEV1)/forced expiratory volume (FEV) test. b. take oral corticosteroids at least 2 hours before the examination. c. withhold bronchodilators for 6 to 12 hours before the examination. d. use rescue medications immediately before the FEV1/FEV testing.

C Rationale: Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should also be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed. Cognitive Level: Application Text Reference: p. 614 Nursing Process: Planning NCLEX: Physiological Integrity

12. The nurse performing an assessment with a patient who has chronic peripheral arterial disease (PAD) of the legs would expect to find a. swollen, dry, scaly ankles. b. a positive Homans' sign. c. prolonged capillary refill. d. a draining ulcer on the heel.

C Rationale: Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease. Cognitive Level: Application Text Reference: p. 901 Nursing Process: Assessment NCLEX: Physiological Integrity

28. A patient with COPD tells the nurse, "At home, I only have to use an albuterol (Proventil) inhaler. Why did the doctor add an ipratropium (Atrovent) inhaler while I'm in the hospital? The appropriate response by the nurse is a. "Atrovent will dilate the airways and allow the Proventil to penetrate more deeply." b. "Atrovent is being used to decrease airway inflammation and sputum production." c. "Atrovent works differently to dilate the bronchi, and the two drugs together are more effective." d. "Atrovent is a potent bronchodilator and patients need to be hospitalized when receiving it."

C Rationale: Combining bronchodilators improves effectiveness. Atrovent does not have to be used before Proventil, it does not decrease airway inflammation, and it does not require hospitalization. Cognitive Level: Application Text Reference: p. 640 Nursing Process: Implementation NCLEX: Physiological Integrity

33. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the health care provider of a possible pneumothorax. d. take no further action with the collection device.

C Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled. Cognitive Level: Application Text Reference: p. 591 Nursing Process: Implementation NCLEX: Physiological Integrity

20. When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. To assess for cor pulmonale, the nurse will monitor the patient for a. elevated temperature. b. complaints of chest pain. c. jugular vein distension. d. clubbing of the fingers.

C Rationale: Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distension. The other clinical manifestations may occur in the patient with other complications of COPD but are not indicators of cor pulmonale. Cognitive Level: Application Text Reference: pp. 635-636 Nursing Process: Assessment NCLEX: Physiological Integrity

1. A patient with a history of asthma is admitted to the hospital in acute respiratory distress. During assessment of the patient, the nurse would notify the health care provider immediately about a. a pulse oximetry reading of 90%. b. a peak expiratory flow rate of 240 ml/min.

C Rationale: Decreased breath sounds and wheezing would indicate that the patient was experiencing an asthma attack, and immediate bronchodilator treatment would be indicated. The other data indicate that the patient needs ongoing monitoring and assessment but do not indicate a need for immediate treatment. Cognitive Level: Application Text Reference: pp. 608, 612, 614 Nursing Process: Assessment NCLEX: Physiological Integrity

17. An alcoholic and homeless patient is diagnosed with active TB. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Giving the patient written instructions about how to take the medications b. Teaching the patient about the high risk for infecting others unless treatment is followed c. Arranging for a daily noontime meal at a community center and give the medication then d. Educating the patient about the long-term impact of TB on health

C Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient. Cognitive Level: Application Text Reference: pp. 572, 575 Nursing Process: Implementation NCLEX: Physiological Integrity

46. The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess first? a. A 23-year-year-old patient with cystic fibrosis who has pulmonary function testing scheduled in 30 minutes b. A 35-year-old patient who was admitted the previous day with bacterial pneumonia and has a temperature of 100.2° F c. A 46-year-old patient who is complaining of dyspnea after having a thoracentesis an hour previously d. A 77-year-old patient with TB who has four antitubercular medications due in 15 minutes

C Rationale: Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires immediate evaluation by the nurse. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration. Cognitive Level: Application Text Reference: p. 596 Nursing Process: Planning NCLEX: Physiological Integrity

14. When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the patient to a. stand on one foot. b. ambulate with the eyes closed. c. extend both arms. d. perform the Valsalva maneuver.

C Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy. Cognitive Level: Comprehension Text Reference: p. 1106 Nursing Process: Assessment NCLEX: Physiological Integrity

38. A diabetic patient has a new order for inhaled insulin (Exubera). Which information about the patient indicates that the nurse should contact the patient before administering the Exubera? a. The patient has a history of a recent myocardial infarction. b. The patient's blood glucose is 224 mg/dl. c. The patient uses a bronchodilator to treat emphysema. d. The patient's temperature is 101.4° F.

C Rationale: Exubera is not recommended for patients with emphysema. The other data do not indicate any contraindication to using Exubera. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Assessment NCLEX: Physiological Integrity

24. A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to a. administer glargine (Lantus) insulin. b. initiate oxygen by nasal cannula. c. insert a large-bore IV catheter. d. give 50% dextrose as a bolus.

C Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a longacting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient's blood glucose and would be contraindicated. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Planning NCLEX: Physiological Integrity

29. A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse, "I did not have any of the usual symptoms of hypoglycemia." Which question by the nurse will help identify a possible reason for the patient's hypoglycemic unawareness? a. "Do you use any calcium-channel blocking drugs for blood pressure?" b. "Have you observed any recent skin changes?" c. "Do you notice any bloating feeling after eating?" d. "Have you noticed any painful new ulcerations or sores on your feet?"

C Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying. Calcium-channel blockers are not associated with hypoglycemic unawareness, although b-adrenergic blockers can prevent patients from having symptoms of hypoglycemia. Skin changes can occur with diabetes, but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet, neuropathy has not occurred. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity

16. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's a. weight increases from 120 pounds to 122 pounds over 3 days. b. liver is palpable 2 cm below the ribs on the right side. c. serum potassium level is 3.0 mEq/L after 1 week of therapy. d. has 1 to 2+ edema in the feet and ankles in the morning.

C Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause lifethreatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level. Cognitive Level: Application Text Reference: pp. 832-833 Nursing Process: Assessment NCLEX: Physiological Integrity

20. A patient with a DVT is started on IV heparin and oral warfarin (Coumadin). The patient asks the nurse why two medications are necessary. The nurse's best response to the patient is, a. "Heparin will start to dissolve the clot, and Coumadin will prevent any more clots from occurring." b. "Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant." c. "The heparin will work immediately, but the Coumadin takes several days to have an effect on coagulation." d. "Administration of two anticoagulants reduces the risk for recurrent deep vein thrombosis."

C Rationale: IV heparin is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. Heparin is not a thrombolytic drug. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another DVT. Cognitive Level: Application Text Reference: pp. 912, 913 Nursing Process: Implementation NCLEX: Physiological Integrity

44. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90. b. Pain level is 5/10 with a deep breath. c. Oxygen saturation is 89%. d. Respiratory rate is 24 when lying flat.

C Rationale: Oxygen saturation would be expected to improve after a thoracentesis; a saturation of 89 indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority. Cognitive Level: Application Text Reference: p. 596 Nursing Process: Assessment NCLEX: Physiological Integrity

26. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. The nurse explains to the patient that the major purpose of this treatment is a. control of fluid and electrolyte imbalance. b. relief from nausea and vomiting. c. reduction of pancreatic enzymes. d. removal of the precipitating irritants.

C Rationale: Pancreatic enzymes are released when the patient eats. NG suction and NPO status decrease the release of these enzymes. Fluid and electrolyte imbalances will be caused by NG suction and require that the patient receive IV fluids to prevent this. The patient's nausea and vomiting may decrease, but this is not the major reason for these treatments. The pancreatic enzymes that precipitate the pancreatitis are not removed by NG suction. Cognitive Level: Application Text Reference: p. 1120 Nursing Process: Implementation NCLEX: Physiological Integrity

21. The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. "How long have you lived in the United States?" b. "Is there any family history of TB?" c. "Have you received the BCG vaccine for TB?" d. "Do you take any over-the-counter (OTC) medications?"

C Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test; another method for screening (such as a chest x-ray) will be used in determining whether the patient has a TB infection. The other information may also be valuable but is not as pertinent to the decision about doing TB skin testing. Cognitive Level: Application Text Reference: p. 572 Nursing Process: Assessment NCLEX: Physiological Integrity

18. The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that this technique will assist respiration by a. loosening secretions so that they may be coughed up more easily. b. promoting maximal inhalation for better oxygenation of the lungs. c. preventing airway collapse and air trapping in the lungs during expiration. d. decreasing anxiety by giving the patient control of respiratory patterns.

C Rationale: Pursed-lip breathing increases the airway pressure during the expiratory phase and prevents collapse of the airways, allowing for more complete exhalation. Although loosening of secretions, improving inhalation, and decreasing anxiety are desirable outcomes for the patient with COPD, pursed-lip breathing does not directly impact these. Cognitive Level: Comprehension Text Reference: p. 646 Nursing Process: Implementation NCLEX: Physiological Inte

3. An asthmatic patient who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that a. Advair is a combination of long-acting and slow-acting bronchodilators. b. the two drugs work together to block the effects of histamine on the bronchioles. c. one drug decreases inflammation, and the other is a bronchodilator. d. the combination of two drugs works more quickly in an acute asthma attack.

C Rationale: Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid; they work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not used during an acute attack because the medications do not work rapidly. Cognitive Level: Application Text Reference: pp. 621 Nursing Process: Implementation NCLEX: Physiological Integrity

30. When developing a teaching plan for a patient newly diagnosed with PAD, which information should the nurse include? a. "Try to keep your legs elevated whenever you are sitting." b. "Exercise only if you do not experience pain." c. "It is important to try to stop smoking." d. "Put on support hose early in the day before swelling occurs."

C Rationale: Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD. Cognitive Level: Application Text Reference: p. 901 Nursing Process: Planning NCLEX: Physiological Integrity

13. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L (3.2 mmol/L). Before notifying the health care provider, the nurse should a. administer the furosemide and withhold the spironolactone. b. give both drugs as scheduled. c. administer the spironolactone. d. withhold both drugs until talking with the health care provider.

C Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider. Cognitive Level: Application Text Reference: p. 1107 Nursing Process: Implementation NCLEX: Physiological Integrity

12. A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen? a. After the patient rinses the mouth with mouthwash b. As soon as the order is received from the health care provider c. Right after the patient gets up in the morning d. After the skin test is administered

C Rationale: Sputum specimens are ideally collected in the morning because mucus is likely to accumulate during the night. The patient should rinse the mouth with water; mouthwash may inhibit the growth of the bacilli. There is no need to wait until the tuberculin skin test is administered. Cognitive Level: Application Text Reference: p. 572 Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet. b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods. c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring. d. educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.

C Rationale: The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening; it is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate interventions but are not the first nursing actions indicated. There is no evidence that the patient's weight gain is caused by excessive dietary intake of fat or calories, so the answer beginning "instruct the patient in a low-calorie, low-fat diet" describes an inappropriate action. Cognitive Level: Application Text Reference: p. 826 Nursing Process: Assessment NCLEX: Physiological Integrity

5. The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia? a. 24-year-old patient who has had temperatures ranging from 100.6° to 101° F b. 35-year-old patient who has had 600 ml of oral fluids in the last 24 hours c. 50-year-old patient who has an oxygen saturation of 91% on room air d. 72-year-old patient with a pulse o102 and a blood pressure (BP) of 90/56

C Rationale: The 50-year-old meets the Infectious Diseases Society of America (IDSA) hospital discharge criteria. The other patients do not meet the criteria for discharge. Cognitive Level: Application Text Reference: p. 563 Nursing Process: Planning NCLEX: Physiological Integrity

6. The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. A common etiologic factor for this nursing diagnosis in patients with asthma is a. anxiety about dyspnea. b. side effects of medications. c. work of breathing. d. fear of suffocation.

C Rationale: The activity intolerance patients with asthma experience is related to the increased effort needed to breathe when airways are inflamed and narrowed and interventions are focused on decreasing inflammation and bronchoconstriction. The other listed etiologies are not as appropriate for this diagnosis but would be appropriate for diagnoses seen in patients with asthma, such as social isolation, knowledge deficit, and anxiety. Cognitive Level: Application Text Reference: pp. 612, 624 Nursing Process: Diagnosis NCLEX: Physiological Integrity

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

C Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level since the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but these will not be affected by the bleeding episode. Cognitive Level: Application Text Reference: p. 1113 Nursing Process: Assessment NCLEX: Physiological Integrity

31. A patient who is admitted to the hospital with a sudden onset of severe right upper-quadrant pain that radiates to the right shoulder is diagnosed with cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider? a. The patient has an increase in pain after eating. b. The patient needs 4 mg of morphine for pain relief. c. The patient's stools are clay colored. d. The patient's urine is bright yellow.

C Rationale: The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider. Cognitive Level: Application Text Reference: p. 1128 Nursing Process: Assessment NCLEX: Physiological Integrity

7. A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient? a. The patient will have a diet and exercise plan that results in weight loss. b. The patient will state the reasons for eliminating simple sugars in the diet. c. The patient will have a glycosylated hemoglobin level of less than 7%. d. The patient will choose a diet that distributes calories throughout the day.

C Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes are also appropriate but are not as high in priority. Cognitive Level: Application Text Reference: p. 1273 Nursing Process: Planning NCLEX: Physiological Integrity

15. A patient with an acute exacerbation of COPD has the following ABG analysis: pH 7.32, PaO2 58 mm Hg, PaCO2 55 mm Hg, and SaO2 86%. The nurse recognizes these values as evidence of a. normal acid-base balance with hypoxemia. b. normal acid-base balance with hypercapnia. c. respiratory acidosis. d. respiratory alkalosis.

C Rationale: The elevated PaCO2 and low pH indicate respiratory acidosis. The patient is hypoxemic and hypercapnic, but the pH indicates acidosis, not a normal acid-base balance. Cognitive Level: Comprehension Text Reference: p. 650 Nursing Process: Assessment NCLEX: Physiological Integrity

6. During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n) a. fasting blood glucose level. b. urine dipstick for glucose. c. glycosylated hemoglobin level. d. oral glucose tolerance test.

C Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed. Cognitive Level: Application Text Reference: pp. 1258-1259 Nursing Process: Planning NCLEX: Physiological Integrity

14. Which of these is the best goal for the patient admitted with chronic bronchitis who has a nursing diagnosis of ineffective airway clearance? a. Patient denies having dyspnea. b. Patient's mental status is improved. c. Patient has a productive cough. d. Patient's O2 saturation is 90%.

C Rationale: The goal for the nursing diagnosis of ineffective airway clearance is to maintain a clear airway by coughing effectively. The other goals may be appropriate for the patient with COPD, but theydo not address the problem of ineffective airway clearance. Cognitive Level: Application Text Reference: p. 660 Nursing Process: Evaluation NCLEX: Physiological Integrity

3. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. incompetent jugular vein valves. c. elevated right atrial pressure. d. jugular vein atherosclerosis.

C Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45- degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or atherosclerosis. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment NCLEX: Physiological Integrity

23. A patient with end-stage liver disease who is to undergo a liver transplant tells the nurse, "I have a friend who has already rejected two kidney transplants. I am concerned that I will reject this liver." The nurse's best response to the patient is a. "Perhaps your friend did not have a good tissue match with the kidney transplants." b. "You would not be scheduled for a transplant if there was a concern about rejection." c. "The problem of rejection is not as common in liver transplants as in kidney transplants." d. "It is easier to get a good tissue match with liver transplants than with kidney transplants."

C Rationale: The liver is less susceptible to rejection than the kidney. The other statements are inaccurate or will not decrease the patient's anxiety. Cognitive Level: Application Text Reference: p. 1118 Nursing Process: Implementation NCLEX: Physiological Integrity

18. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, which nursing action will be included in the plan of care? a. Encourage the patient to cough and deep breathe. b. Insert the tube and verify its position q4hr. c. Monitor the patient for shortness of breath. d. Deflate the gastric balloon q8-12hr.

C Rationale: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the riskfor bleeding. The health care provider inserts the tube and verifies the position. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway. Cognitive Level: Application Text Reference: p. 1114 Nursing Process: Implementation NCLEX: Physiological Integrity

23. A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first? a. Start an infusion of regular insulin at 50 U/hr. b. Give sodium bicarbonate 50 mEq IV push. c. Infuse 1 liter of normal saline per hour. d. Administer regular IV insulin 30 U.

C Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated. Cognitive Level: Application Text Reference: p. 1280 Nursing Process: Implementation NCLEX: Physiological Integrity

26. An hour after a left upper lobectomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased leftsided breath sounds. The pleural drainage system has 100 ml of bloody drainage and a large air leak. Which action should the nurse take first? a. Assist the patient to deep breathe and cough. b. Milk the chest tube gently to remove any clots. c. Medicate the patient with the ordered morphine. d. Notify the surgeon about the large air leak.

C Rationale: The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 ml is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy. Cognitive Level: Application Text Reference: p. 594 Nursing Process: Implementation NCLEX: Physiological Integrity

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

C Rationale: The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse learns the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain. Cognitive Level: Analysis Text Reference: p. 1122 Nursing Process: Assessment NCLEX: Physiological Integrity

9. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to venous congestion. b. disturbed body image related to massive leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure

C Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate. Cognitive Level: Application Text Reference: p. 836 Nursing Process: Diagnosis NCLEX: Physiological Integrity

10. A patient recovering on a general surgical unit from an aortic valve replacement 1 week ago develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and a. elevate the left leg on a pillow. b. apply an elastic wrap to the leg. c. keep the patient in bed in the supine position. d. assist the patient in gently exercising the leg.

C Rationale: The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise with increase oxygen demand for the tissues of the leg. Cognitive Level: Application Text Reference: p. 907 Nursing Process: Implementation NCLEX: Physiological Integrity

31. A 26-year-old patient has had CF since birth and has severe lung changes and cor pulmonale as a result of the disease. An appropriate expected outcome is that the patient will a. engage in aerobic exercise without dyspnea. b. be weaned from home oxygen use. c. achieve a realistic attitude toward treatment. d. develop no CF-related complications

C Rationale: The patient's severe lung disease and cor pulmonale are late complications of CF, and a realistic attitude about what outcome can be expected from treatment is an appropriate outcome. Exercising without dyspnea and weaning from home oxygen therapy are not realistic outcomes for this patient with end-stage disease. The patient already has multiple CF-related complications and is likely to continue to develop complications. Cognitive Level: Application Text Reference: pp. 657-658 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

9. During assessment of a patient with a history of asthma, the nurse notes wheezing and dyspnea. The nurse will anticipate giving medications to reduce a. laryngospasm. b. pulmonary edema. c. airway narrowing. d. alveolar distention.

C Rationale: The symptoms of asthma are caused by inflammation and spasm of the bronchioles, leading to airway narrowing. Treatment for laryngospasm or pulmonary edema would not be appropriate. There are no medications used to treat alveolar distention. Cognitive Level: Comprehension Text Reference: pp. 608, 611-612 Nursing Process: Assessment NCLEX: Physiological Integrity

29. The nurse has completed teaching a patient about MDI use. Which patient statement indicates that further patient teaching is needed? a. "I will shake the MDI each time before giving the medication." b. "I will take a slow, deep breath in after pushing down on the MDI." c. "I will float the canister in water to decide whether I need to get a new MDI." d. "I will attach a spacer to the MDI to make it easier for me to use."

C Rationale: This method is no longer recommended as a means of determining whether the medication needs replacement. The other patient statements are accurate and indicate the patient understands how to use the MDI. Cognitive Level: Application Text Reference: p. 622 Nursing Process: Evaluation NCLEX: Physiological Integrity

36. A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will teach the patient that the medication is ordered to a. decrease systemic BP. b. prevent the development of ischemia. c. lower the risk for bleeding varices. d. reduce fluid retention and edema.

C Rationale: b-blockers have been shown to decrease the risk for bleeding in esophageal varices. Although propranolol will decrease BP and prevent cardiac ischemia, these are not the purposes for this patient. Propranolol will not decrease fluid retention or edema. Cognitive Level: Application Text Reference: p. 1107 Nursing Process: Implementation NCLEX: Physiological Integrity

The patient has an order to receive 45 mg of prednisone by mouth daily. Available are 10-mg tablets. How many tablets should the nurse prepare to give? A) 1.6 B) 2 C) 4.5 D) 6

C) 4.5 45 mg ÷ 10 mg = 4.5 tablets

Before discharge, what should a nurse instruct a client with Addison's disease to do when exposed to periods of stress? a) Perform capillary blood glucose monitoring four times daily. b) Drink 8 oz of fluids. c) Administer hydrocortisone I.M. d) Continue to take his usual dose of hydrocortisone.

C) Administer hydrocortisone I.M Clients with Addison's disease and their family members should know how to administer I.M. hydrocortisone during periods of stress. Although it's important for the client to keep well hydrated during stress, the critical component in this situation is to know how and when to use I.M. hydrocortisone. Capillary blood glucose monitoring isn't indicated in this situation because the client doesn't have diabetes mellitus. Hydrocortisone replacement doesn't cause insulin resistance.

The sounds of sirens announce the arrival of the latest trauma to address the trauma center where you practice nursing. Your heart is pounding, your mouth is dry. What gland is responsible for your physiologic response? a) Pineal gland b) Thyroid gland c) Adrenal glands d) Parathyroid gland

C) Adrenal glands The adrenal medulla secretes epinephrine and norepinephrine. These two hormones are released in response to stress or threat to life. They facilitate what has been referred to as the fight-or-flight response.

After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering? a) Sodium phosphorus b) Sodium bicarbonate c) Calcium gluconate d) Potassium chloride

C) Calcium gluconate Immediate treatment for a client who develops hypocalcemia and tetany after thyroidectomy is calcium gluconate. Potassium chloride and sodium bicarbonate aren't indicated. Sodium phosphorus wouldn't be given because phosphorus levels are already elevated.

What skin findings should a nurse pay particular attention to in a client with a history of endocrine problems? a) Rashes b) Skin breaks that heal quickly c) Excessive hair growth or loss d) Susceptibility to sunburn

C) Excessive hair growth or loss While assessing skin findings related to the endocrine system, the nurse inspects the skin for excessive oiliness or dryness, excessive or absent areas of pigmentation, excessive hair growth or loss, and skin breaks that heal poorly.

Which of the following would the nurse expect to find in a client with severe hyperthyroidism? a) Tetany b) Buffalo hump c) Exophthalmos d) Striae

C) Exophthalmos Exophthalmos that results from enlarged muscle and fatty tissue surrounding the rear and sides of the eyeball is seen in clients with severe hyperthyroidism. Tetany is the symptom of acute and sudden hypoparathyroidism. Buffalo hump and striae are the symptoms of Cushing's syndrome.

The nurse is educating a couple who has had difficulty with conception. The client asks about the hormone, which is responsible for the production of eggs. The nurse answers that this hormone is called: a) melanocyte-stimulating hormone b) luteinizing hormone (LH) c) follicle-stimulating hormone (FSH) d) interstitial cell-stimulating hormone (ICSH)

C) Follicle-stimulating hormone (FSH) FSH stimulates the growth and secretion of ovarian follicles in women and the production of sperm in men. LH is not responsible for stimulating the growth and secretion of ovarian follicles in women and the production of sperm in men. In women, LH stimulates ovulation and the formulation of the corpus luteum. In men, LH is called ICSH and it influences the secretion of testosterone and other sex hormones from specialized areas in the testes. Melanocyte-stimulating hormone influences skin pigmentation, and is not responsible for stimulating the growth and secretion of ovarian follicles in women and the production of sperm in me

Which statement indicates that a client with diabetes mellitus understands proper foot care? a) "I'll go barefoot around the house to avoid pressure areas on my feet." b) "I'll rotate insulin injection sites from my left foot to my right foot." c) "I'll wear cotton socks with well-fitting shoes." d) "I'll schedule an appointment with my physician if my feet start to ache.

C) I'll wear cotton socks with well-fitting shoes The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury

A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find? A) Central apnea B) Hypoventilation C) Kussmaul respirations D) Cheyne-Stokes respirations

C) Kussmaul respirations In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored.

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Because of the potential effects of this disease on electrolyte balance, the nurse should assess this patient for which of the following manifestations? A) Neurologic irritability B) Declining urine output C) Lethargy and weakness D) Hyperactive bowel sounds

C) Lethargy and weakness Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include polyuria, constipation, nausea and vomiting, lethargy, and muscle weakness

A 54-year-old patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 am. The nurse instructs the patient to only drink water after what time? A) 6:00 pm on the evening before the test B) 4:00 am on the day of the test C) Midnight before the test D) 7:00 am on the day of the test

C) Midnight before the test Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 am should not have any food or beverages containing any calories after midnight.

The surgeon was unable to spare a patient's parathyroid gland during a thyroidectomy. Which of the following assessments should the nurse prioritize when providing postoperative care for this patient? A) Assessing the patient's white blood cell levels and assessing for infection B) Monitoring the patient's hemoglobin, hematocrit, and red blood cell levels C) Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia D) Monitoring the patient's level of consciousness and assessing for acute delirium or agitation

C) Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia Loss of the parathyroid gland is associated with hypocalcemia. Infection and anemia are not associated with loss of the parathyroid gland, whereas cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.

Which of the following is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? A) Providing a dark, low-stimulation environment B) Closely monitoring the patient's intake and output C) Patient teaching related to levothyroxine (Synthroid) D) Patient teaching related to radioactive iodine therapy

C) Patient teaching related to levothyroxine (Synthroid) A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine (Synthroid). It is not necessary to carefully monitor intake and output, and low stimulation and radioactive iodine therapy are indicated in the treatment of hyperthyroidism.

A patient has been taking oral prednisone for the past several weeks after having a severe reaction to poison ivy. The nurse has explained the procedure for gradual reduction rather than sudden cessation of the drug. What is the rationale for this approach to drug administration? A) Prevention of hypothyroidism B) Prevention of diabetes insipidus C) Prevention of adrenal insufficiency D) Prevention of cardiovascular complications

C) Prevention of adrenal insufficiency Sudden cessation of corticosteroid therapy can precipitate lifethreatening adrenal insufficiency. Diabetes insipidus, hypothyroidism, and cardiovascular complications are not common consequences of stopping corticosteroid therapy suddenly.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a) Infusing I.V. fluids rapidly as ordered b) Administering glucose-containing I.V. fluids as ordered c) Restricting fluids d) Encouraging increased oral intake

C) Restricting fluids To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load

When instructing a patient regarding a urine study for free cortisol, it is most important for the nurse to tell the patient to A) Save the first voided urine in the am. B) Maintain a high-sodium diet 3 days before collection. C) Try to avoid stressful situations during the collection period. D) Complete at least 30 minutes of strenuous exercise before collecting the urine sample.

C) Try to avoid stressful situations during the collection period A urine study for free cortisol requires a 24-hour urine collection. The patient should be instructed to avoid stressful situations and excessive physical exercise that could unduly increase cortisol levels. The patient should also maintain a low-sodium diet before and during the urine collection period.

The health care provider initially orders bed rest for a patient with an open-book pelvic fracture. Which assessment data obtained by the nurse are most important to report to the health care provider? a. The bowel tones are absent. b. There is an unusual amount of pelvic movement. c. The patient complains of level 4 abdominal pain on a 10-point pain scale. d. There is bruising of the abdomen.

Correct Answer: A Rationale: Absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus, hemorrhage, or trauma to the bladder, urethra, or colon. Unusual pelvic movement, abdominal pain, and abdominal bruising would be expected with this type of injury.

A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benemid). Which information about the patient's home routine indicates a need for teaching regarding gout management? a. The patient takes one aspirin a day prophylactically to prevent angina. b. The patient sleeps about 8 to 10 hours every night. c. The patient generally drinks about 3 quarts of juice and water daily. d. The patient usually eats beef once or twice a week.

Correct Answer: A Rationale: Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout. Cognitive Level: Application Text Reference: p. 1716 Nursing Process: Assessment NCLEX: Physiological Integrity

1. A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has constant severe pain and is hospitalized for pain control and development of a painmanagement program. When doing the initial assessment, which question will be most appropriate to ask first? a.How would you describe your pain? b. How much medication do you take for the pain? c. How long have you had this pain? d. How many times a day do you medicate for pain?

Correct Answer: A Rationale: Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best first question. Cognitive Level: Application Text Reference: pp. 126, 131 Nursing Process: Assessment NCLEX: Physiological Integrity

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to a. assist the patient to eat with the left hand. b. provide oral care before and after meals. c. teach the patient the "chin-tuck" technique. d. provide a wide variety of food choices.

Correct Answer: A Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. Cognitive Level: Application Text Reference: p. 1522 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's a. ability to follow commands. b. visual fields. c. right-sided reflexes. d. emotional state.

Correct Answer: A Rationale: Because the patient with a leftsided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities. Cognitive Level: Application Text Reference: p. 1508 Nursing Process: Assessment NCLEX: Physiological Integrity

27. A patient with PAD has a new prescription for clopidogrel (Plavix). Which information should the nurse include when teaching the patient about this medication? a. "Call if you notice that your stools are black or have blood in them." b. "Take the Plavix on an empty stomach as soon as you get up." c. "Change position slowly to avoid dizziness while you are taking Plavix." d. "You should never use aspirin while you are taking the Plavix."

Correct Answer: A Rationale: Clopidogrel inhibits platelet function and increases the risk for GI bleeding. It can be taken without regard to food. Orthostatic hypotension is not an expected side effect of the medication. Aspirin may be prescribed concurrently with clopidogrel for some patients. Cognitive Level: Application Text Reference: p. 902 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply will be based on the information that these strategies a. impact the cognitive and affective components of pain. b. prevent transmission of nociceptive stimuli to the cortex. c. increase the modulating effect of the efferent pathways. d. slow the release of transmitter chemicals in the dorsal horn.

Correct Answer: A Rationale: Cognitive therapies impact on the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn. Cognitive Level: Comprehension Text Reference: p. 144 Nursing Process: Implementation

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask simple questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice facial and tongue exercises to improve motor control necessary for speech. d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.

Correct Answer: A Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond. Cognitive Level: Application Text Reference: p. 1520 Nursing Process: Implementation NCLEX: Physiological Integrity

3. The health care provider has prescribed naproxen (Naprosyn) twice daily for a patient with osteoarthritis (OA) of the hands. The patient tells the nurse after 3 weeks of use that the drug does not seem to be effective in controlling the pain. The nurse should teach the patient that a. another type of nonsteroidal antiinflammatory drug (NSAID) may be indicated because of variations in individual response to the drugs. b. it may take up to 4 to 6 weeks for NSAIDs to reach therapeutic levels in the blood. c. if NSAIDs are not effective in controlling symptoms, corticosteroids are the next drug of choice. d. adding a twice-daily aspirin to the naproxen may improve the effectiveness of the drug.

Correct Answer: A Rationale: Individual responses to NSAIDs can vary, so the health care provider may prescribe a different NSAID. Full effectiveness of NSAIDs occurs in 2 to 3 weeks. Corticosteroids are usually reserved for use in RA. Patients are instructed to avoid aspirin when taking NSAIDs because of the increased risk for bleeding and gastrointestinal irritation. Cognitive Level: Application Text Reference: p. 1697 Nursing Process: Implementation NCLEX: Physiological Integrity

The health care provider tells a patient to use ibuprofen (Motrin, Advil) to relieve pain after treating a laceration on the patient's forearm from a dog bite. The patient asks the nurse how ibuprofen will control the pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the a. production of pain-sensitizing chemicals. b. spinal cord transmission of pain impulses. c. sensitivity of the brain to painful stimuli. d. modulating effect of descending nerves.

Correct Answer: A Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by the NSAIDs. Cognitive Level: Application Text Reference: p. 128 Nursing Process: Implementation NCLEX: Physiological Integri

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine a. whether there is bruising at the shoulder area. b. whether the right arm is shorter than the left. c. the amount of pain the patient is experiencing. d. how much range of motion (ROM) is present.

Correct Answer: B Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The shoulder should be immobilized until it is evaluated by the health care provider.

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests "something for pain that will work quickly." The best way for the nurse to document this information is as a. breakthrough pain. b. neuropathic pain. c. somatic pain. d. referred pain.

Correct Answer: A Rationale: Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue. Cognitive Level: Application Text Reference: p. 132 Nursing Process: Implementation NCLEX: Physiological Integrity

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. An appropriate action by the nurse is to a. administer prescribed opioids to relieve the pain. b. explain the reasons for phantom limb pain. c. loosen the compression bandage to decrease incisional pressure. d. remind the patient that this phantom pain will diminish over time.

Correct Answer: A Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now. Cognitive Level: Comprehension Text Reference: pp. 1660-1661 Nursing Process: Implementation NCLEX: Physiological Integrity

A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You have an appointment with a physical therapist for tomorrow." b. "Leave the shoulder immobilizer on for the first few days to minimize pain." c. "The doctor will use the drop-arm test to determine the success of the procedure." d. "You should try to find a different position to play on the baseball team."

Correct Answer: A Rationale: Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of ROM. The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)

Correct Answer: A Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

The nurse determines that teaching regarding diet for a patient with osteoporosis has been successful when the patient selects which of these meals as having the highest amount of calcium? a. Sardine sandwich on whole wheat bread, one cup of fruit yogurt, and one cup ofskim milk b.Two-egg omelet with American cheese, one slice of whole-wheat toast, and a half grapefruit c.Ham and Swiss cheese sandwich on wholewheat bread, steamed broccoli, and an apple d.Chicken stir-fry with bok choy, onions, and snap peas and one cup of steamed brown rice

Correct Answer: A Rationale: Sardines, yogurt, and milk are all high in calcium. The other choices have some foods that are high in calcium but also include foods that are low in calcium, such as eggs, apples, and grapefruit. Cognitive Level: Application Text Reference: p. 1689 Nursing Process: Evaluation NCLEX: Physiological Integrity

When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with a. a warm bath followed by a short rest. b. a 10-minute routine of isometric exercises. c. stretching exercises to relieve joint stiffness. d. active range-of-motion (ROM) exercise

Correct Answer: A Rationale: Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased. Cognitive Level: Comprehension Text Reference: p. 1708 Nursing Process: Implementation NCLEX: Physiological Integrity

The hospice RN obtains the following information about a 72-year-old terminally ill patient with cancer of the colon. The patient takes oxycodone (OxyContin) 100 mg twice daily for level 6 abdomen pain on a 10-point scale. The pain has made it difficult to continue with favorite activities such as playing cards with friends twice a week. The patient's children are supportive of the patient's wish to stop chemotherapy but express sadness that the patient does not have long to live. Based on this information, which nursing diagnosis has priority in planning the patient's care? a. Impaired social interaction related to disabling pain b. Anxiety related to poor patient coping skills c. Disabled family coping related to patient/family conflict d. Risk for aspiration related to opioid use

Correct Answer: A Rationale: The assessment data indicate that the patient's priority is to be able to continue with favorite activities and that decreasing the pain level would accomplish this goal. There is no indication of anxiety, and the patient's and family's coping skills appear to be good. Although the patient is taking a large dose of oxycodone,there is no evidence that this has suppressed the respiratory rate or the gag/cough reflexes. Cognitive Level: Analysis Text Reference: p. 145 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

9. A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the patient that the cast can be removed only after the bone a. is strong enough to stand mild stress. b. union is complete on the x-ray. c. fragments are fully fused. d. healing has started.

Correct Answer: A Rationale: The cast may be removed when callus ossification has occurred. It is not necessary to wait until radiologic union or complete bone fusion occurs. Bone healing starts immediately after the injury, but the cast will need to be worn at least 3 weeks.

11. A patient in the emergency department is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. conscious sedation. b. a knee immobilizer. c. gentle knee flexion. d. cast application.

Correct Answer: A Rationale: The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or conscious sedation. Immobilization of the joint will be done after realignment. Later, gentle ROM exercises may be started if the joint is stable. Casting is not usually required for dislocations. Cognitive Level: Application Text Reference: p. 1632 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with severe ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the right hand and fingers. The nurse determines that the patient has realistic expectations of the outcome of surgery when the patient says, a. "I will be able to use my fingers to grasp objects better." b. "My fingers will appear normal in size and shape after this surgery." c. "This procedure will prevent further deformity in my hands and fingers." d. "I will not have to do as many hand exercises after the surgery."

Correct Answer: A Rationale: The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Cognitive Level: Application Text Reference: p. 1664 Nursing Process: Evaluation NCLEX: Physiological Integrity

A hospice patient is in continuous pain, and the health care provider has left orders to administer morphine at a rate that controls the pain. When the nurse visits the patient, the patient is awake but moaning with severe pain and asks for an increase in the morphine dosage. The respiratory rate is 10 breaths per minute. The most appropriate action by the nurse is to a. titrate the morphine dose upward until the patient states there is adequate pain relief. b. administer a nonopioid analgesic, such as ibuprofen, to improve patient pain control. c. tell the patient that additional morphine can be administered when the respirations are 12. d. inform the patient that increasing the morphine will cause the respiratory drive to fail.

Correct Answer: A Rationale: The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient's respiratory rate.

A patient who has severe peripheral arterial disease and ischemic foot ulcers is upset with the health care provider's recommendation to have an above-the-knee amputation. The patient tells the nurse, "If they want to cut off my leg, they should just shoot me instead." The most appropriate response to the patient's statement is, a. "Let's talk about how you feel this surgery will affect you." b. "If you do not want the surgery, you do not have to have it." c. "I understand why you are upset, but there really is no choice because your leg is so badly diseased." d. "Many people are able to function normally with a prosthesis after amputation, and you can too."

Correct Answer: A Rationale: The initial nursing action should be to assess how the patient feels about the amputation and what the patient knows about the procedure and rehabilitation process. Discussion about the patient's option to not have the procedure, the reason the procedure is needed, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state. Cognitive Level: Application Text Reference: p. 1659 Nursing Process: Implementation NCLEX: Psychosocial Integrity

The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? a. The patient sleeps with two pillows under the head. b. The patient has been taking 16 aspirins daily. c. The patient requires a 2 hour midday nap. d. The patient sits on a stool when preparing meals.

Correct Answer: A Rationale: The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective. Cognitive Level: Application Text Reference: pp. 1708-1709 Nursing Process: Evaluation NCLEX: Physiological Integrity

All these medications are ordered at 9:00 AM for a patient who has had a right-hip replacement the previous day and is scheduled to ambulate with the physical therapist for the first time at 9:45. Which medication should be given first? a. Oxycodone (Roxicodone) 5 mg PO b. Ceftriaxone (Rocephin) 500 mg IV c. Enoxaparin (Lovenox) 30 mg SC d. Psyllium (Metamucil) 1 tsp PO

Correct Answer: A Rationale: The pain medication should be given so that it has time to take effect before the patient is ambulated. The other medications will not affect whether the patient can ambulate or not, although the antibiotic and anticoagulant medications should be given as soon as possible in order to maintain therapeutic blood levels. Cognitive Level: Application Text Reference: p. 1647 Nursing Process: Implementation NCLEX: Physiological Integerity

10. A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. have the patient lift the buttocks by bending and pushing with the left leg. b. turn the patient partially to each side with the assistance of another nurse. c. place a pillow between the patient's legs and turn gently to each side. d. loosen the traction and have the patient turn onto the unaffected side.

Correct Answer: A Rationale: The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

31. When preparing a patient to ambulate the day after an ORIF for a hip fracture, which action is most important for the nurse to take? a. Administering the ordered oral opioid pain medication b. Instructing the patient about the benefits of ambulation c. Ensuring that the incisional drain has been discontinued d. Changing the hip dressing and document the appearance of the site

Correct Answer: A Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not impact on ambulation. Cognitive Level: Application Text Reference: pp. 1654, 1647 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to a. notify the patient's health care provider. b. check the patient's blood pressure. c. assess the external fixator pins for redness or drainage. d. elevate the extremity and apply ice over the wound site.

Correct Answer: A Rationale: The patient's clinical manifestations point to compartment syndrome and delay in diagnosis, and treatment may lead to severe functional impairment. There is no reason to suspect that patient's symptoms are caused by hypotension or hypertension or by infection at the pin sites. Elevation of or ice application to the leg will decrease arterial flow and further reduce perfusion. Cognitive Level: Application Text Reference: pp. 1650-1651 Nursing Process: Implementation NCLEX: Physiological Integrity

7. A 22-year-old patient started an exercise regimen 2 months ago that includes running 3 to 4 miles a day. The patient tells the nurse, "I enjoy my daily runs, but now I have shin splints." Which response by the nurse is appropriate? a. "You may be increasing your running time too quickly and need to cut back a little bit." b. "You need to have x-rays of your lower legs to be sure you do not have stress fractures." c. "You should expect some leg pain while running." d. "You should try speed-walking rather than running."

Correct Answer: A Rationale: The patient's information about running 3 to 4 miles daily after starting an exercise program only 2 months previously suggests that the shin splints are caused by overuse. Radiographs are not indicated for the type of injury described by the patient. Shin splints are not a normal or expected response to running. Because the patient expresses enjoyment of running, it would not be appropriate for the nurse to suggest a different sport. Cognitive Level: Application Text Reference: p. 1630 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient is receiving morphine sulfate intravenously (IV) for right flank pain associated with a kidney stone in the right ureter. The patient also complains of right inner thigh pain and asks the nurse whether something is wrong with the right leg. In responding to the question, the nurse understands that the patient a. is experiencing referred pain from the kidney stone. b. has neuropathic pain from nerve damage caused by inflammation. c.has acute pain that may be progressing into chronic pain. d.is experiencing pain perception that has been affected by the morphine received earlier.

Correct Answer: A Rationale: The spread of pain to uninjured tissue is termed referred pain. Neuropathic pain refers to pain caused by nerve damage rather than by tissue injury or damage. When pain has lasted less than 3 months and is associated with an acute event (such as a kidney stone), it is acute pain. Morphine administration will decrease the perception of pain intensity, but it will not change the location of the pain.

A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but needs help with hygiene, dressing, and eating. Which statement by the patient's wife indicates that discharge planning goals have been met? a. "I can provide the care my husband needs if I use the support and resources available in the community." b. "Because my husband will have continuous improvement in his condition, I won't need outside assistance in his care for very long." c. "I can handle all of my husband's needs thanks to the instructions you've given me." d. "I have arranged for a home health aide to provide all the care my husband will need."

Correct Answer: A Rationale: The statement that community resources will be used indicates a realistic outcome. The patient is unlikely to continue to improve to the point of needing no assistance. The wife is likely to be overwhelmed by the patient's needs if she attempts to manage without assistance. There is no indication that the patient will need a home health aide to meet all of his care needs. Cognitive Level: Application Text Reference: p. 1524 Nursing Process: Evaluation NCLEX: Physiological Integrity

Morphine 10 mg IV every 4 to 6 hours prn is ordered for a patient with a pancreatic tumor who has a distant history of opioid abuse. After 3 days of receiving the morphine every 6 hours, the patient tells the nurse that the medication is needed more frequently to control the pain. The best initial action by the nurse is to a. administer the morphine every 4 hours as needed. b. consult with the doctor about initiating an appropriate weaning protocol for the morphine. c.remind the patient that the previous substance abuse increases the risk for addiction. d. use alternative therapies such as heat or cold.

Correct Answer: A Rationale: These patient data indicate that tolerance for the morphine is developing and more frequent administration is needed to maintain pain control. A weaning protocol is not indicated, since the patient still has the pancreatic tumor and there is no indication that the physiologic basis of the pain has changed. Although the patient may be at risk for addiction, adequate pain management is the priority at present. Alternative therapies may be a useful adjuvant to the morphine but should not be the first nursing action. Cognitive Level: Application Text Reference: p. 148 Nursing Process: Implementation NCLEX: Physiological Integrity

A home health patient has a prescription for pentazocine (Talwin,) a mixed opioid agonist-antagonist. When teaching the patient and family about adverse effects, the nurse will plan to focus on how to monitor for a. agitation. b. respiratory depression. c. hypotension. d. physical dependence

Correct Answer: A Rationale: This category of opioids causes more neurologic side effects, such as agitation, than the pure opioid opioids. The benefits to this category include less hypotension and respiratory depression and the absence of physical dependence. Cognitive Level: Application Text Reference: p. 138 Nursing Process: Planning NCLEX: Physiological Integrity

6. The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have a. visual deficits. b. dysphasia. c. confusion. d. poor judgment.

Correct Answer: A Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion. Cognitive Level: Application Text Reference: p. 1507 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with extensive second-degree burns on the legs and trunk is using patient controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour to regain pain relief. The most appropriate action by the nurse is to a. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. b. consult with the patient's health care provider about adding a continuous morphine infusion to the PCA regimen at night. c. teach the patient to push the button every 10 minutes for an hour before going to sleep even if the pain is minimal. d. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

Correct Answer: B Rationale: Adding a continuous dose of the morphine at night will allow the patient to sleep without being awakened by the pain. Administering a dose of morphine when the patient awakens would not address the problem. Teaching the patient to administer unneeded medication before going to sleep might result in oversedation and respiratory depression. It is inappropriate for the nurse to administer the morphine while the patient sleeps because the nurse could not assess the pain level. Cognitive Level: Application Text Reference: p. 140 Nursing Process: Implementation NCLEX: Physiological Integrity

The biologic agent anakinra (Kineret) is prescribed for a patient who has moderately severe rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. symptoms of gastrointestinal (GI) irritation or bleeding. b. self-administration of subcutaneous injections. c. taking the medication with at least 8 oz of fluid. d. avoiding concurrently taking aspirin or NSAIDs.

Correct Answer: B Rationale: Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs and these should not be discontinued. Cognitive Level: Application Text Reference: pp. 1700, 1705-1706 Nursing Process: Implementation NCLEX: Physiological Integrity

13. Following the application of a hip spica cast for a patient with a fracture of the proximal third of the left femur, an appropriate nursing intervention is to a. use the cast support bar to reposition the patient every 2 to 3 hours. b. ask the patient about any abdominal discomfort or nausea. c. discuss the reasons for remaining on bed rest for several weeks. d. promote drying of the cast by placing the patient in a prone position every 4 hours.

Correct Answer: B Rationale: Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel. The patient should not be placed in the prone position until the cast has dried to avoid breaking the cast. Cognitive Level: Application Text Reference: p. 1640 Nursing Process: Implementation NCLEX: Physiological Integrity

When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex), which information is most important to communicate to the health care provider? a. The platelet count is 130,000/μl. b. The white blood cell count (WBC) is 1500/μl. c. The blood glucose is 130 mg/dl. d. The potassium is 5.2 mEq/L.

Correct Answer: B Rationale: Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The other laboratory values are also abnormal but are not far from normal values and would not have any immediate serious consequences. Cognitive Level: Application Text Reference: p. 1699 Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient with hip pain is diagnosed with osteoarthritis (OA). The nurse may need to teach the patient about the use of a. prednisone (Deltasone). b. capsaicin cream (Zostrix). c. sulfasalazine (Azulfidine). d. doxycycline (Vibramycin).

Correct Answer: B Rationale: Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

When teaching range-of-motion exercises to a patient who is having an acute exacerbation of rheumatoid arthritis (RA) with joint pain and swelling in both hands, the nurse teaches the patient that a. affected joints should not be exercised when pain is present. b. cold applications before exercise will decrease joint pain. c. exercises should be performed passively by someone other than the patient. d. regular walking may substitute for rangeof- motion (ROM) exercises on some days.

Correct Answer: B Rationale: Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises. Cognitive Level: Application Text Reference: pp. 1707, 1710 Nursing Process: Implementation NCLEX: Physiological Integrity

Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. A bladder retraining program for the patient should include a. limiting fluid intake to 1000 ml daily to reduce urine volume. b. assisting the patient onto the bedside commode every 2 hours. c. performing intermittent catheterization after each voiding to check for residual urine. d. using an external "condom" catheter to protect the skin and prevent embarrassment.

Correct Answer: B Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Planning NCLEX: Physiological Integrity

The nurse observes a patient doing all these activities after having a hip-replacement surgery. Which patient action requires that the nurse intervene immediately? a. The patient sits straight up on the edge of the bed. b. The patient leans over to pull shoes and socks on. c. The patient bends over the sink while brushing the teeth. d. The patient uses crutches with a swing-to gait.

Correct Answer: B Rationale: Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient. Cognitive Level: Application Text Reference: p. 1654 Nursing Process: Assessment NCLEX: Physiological Integrit

The health care provider plans to prescribe methotrexate (Rheumatrex) to a patient with newly diagnosed rheumatoid arthritis (RA). The patient tells the nurse, "That drug has too many side effects; I would rather wait until my joint problems are worse before beginning any drugs." The most appropriate response by the nurse is a. "You should tell the doctor how you feel so the two of you can make a decision together." b. "It is important to start methotrexate early in order to decrease the joint damage." c. "Methotrexate is not expensive and will be cheaper to take than other possible drugs." d. "Methotrexate is very effective and has no more side effects than the other available drugs."

Correct Answer: B Rationale: Disease-modifying anti-rheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible. Cognitive Level: Application Text Reference: pp. 1699, 1705 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

Correct Answer: B Rationale: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. Cognitive Level: Application Text Reference: pp. 1505, 1510 Nursing Process: Planning NCLEX: Physiological Integrity

A patient being treated for chronic musculoskeletal pain tells the nurse, "I feel depressed because I can't even go out and play a round of golf." The patient describes the pain as "aching" and says it is usually at a level 7 of a scale of 1 to10. Based on these assessment data, which patient goal is most appropriate? After treatment, the patient will a. state that pain is at a level 2 of 10. b. be able to play 1 to 2 rounds of golf. c. exhibit fewer signs of depression. d. say that the aching has decreased.

Correct Answer: B Rationale: For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 or 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse should also assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate. Cognitive Level: Application Text Reference: p. 135 Nursing Process: Planning NCLEX: Physiological Integrity

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient smokes a pack of cigarettes daily. b. The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg. c. The patient works at a desk and relaxes by watching television. d. The patient is 25 pounds above the ideal weight.

Correct Answer: B Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension. Cognitive Level: Application Text Reference: p. 1503 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first? a. Administer naproxen (Naprosyn) 500 mg PO. b. Wrap the ankle and apply an ice pack. c. Give acetaminophen with codeine (Tylenol #3). d. Take the patient to the radiology department for x-rays.

Correct Answer: B Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied. Cognitive Level: Application Text Reference: p. 1631 Nursing Process: Implementation NCLEX: Physiological Integrity

The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." b. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." c. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." d. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."

Correct Answer: B Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response (beginning, "A wire is threaded through the artery") describes the Merci procedure. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Implementation NCLEX: Physiological Integrity

35. When giving home-care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a. Keep the hand immobile to prevent soft tissue swelling. b. Call the health care provider for increased swelling or numbness. c. Keep the right shoulder elevated on a pillow or cushion. d. Avoid the use of NSAIDs for the first 48 hours after the injury.

Correct Answer: B Rationale: Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture. Cognitive Level: Application Text Reference: p. 1646 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic pain complains of nausea and abdominal fullness. The most appropriate initial action by the nurse is to a. consult with the health care provider about using a different opioid. b. administer the ordered metoclopramide (Reglan) 10 mg IV. c. tell the patient that the nausea will subside in about a week. d. order the patient a clear liquid diet until the nausea decreases.

Correct Answer: B Rationale: Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics are usually prescribed to treat this expected side effect. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops (in about a week), the nausea will subside; therefore, it would not be appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the metoclopramide and allow the patient to eat. Cognitive Level: Application Text Reference: p. 138 Nursing Process: Implementation NCLEX: Physiological Integrity

OSTEO/PAIN An assessment finding that alerts the nurse to the presence of osteoporosis in a middleaged patient is a. the presence of bowed legs. b. measurable loss of height. c. an aversion to dairy products. d. statements about frequent falls.

Correct Answer: B Rationale: Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis. Cognitive Level: Comprehension Text Reference: p. 1687 Nursing Process: Assessment NCLEX: Physiological Integrity

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

Correct Answer: B Rationale: Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee ROM. Cognitive Level: Application Text Reference: p. 1710 Nursing Process: Implementation

17. The nurse is assisting the patient who is recovering from an acute stroke and has rightside hemiplegia to transfer from the bed to the wheelchair. Which action by the nurse is appropriate? a.Positioning the wheelchair next to the bed on the patient's right side b. Placing the wheelchair parallel to the bed on the patient's left side c. Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed d. Moving the wheelchair a few steps from the bed and having the patient walk to the chair

Correct Answer: B Rationale: Placing the wheelchair on the patient's left side will allow the patient to use the left hand to grasp the left arm of the chair to transfer. If the chair is placed on the patient's right side or in front of the patient, it will be awkward to use the strong arm, and the patient will be at increased risk for a fall. Because the patient has hemiplegia, it is not appropriate to place the chair where the patient will need to walk to it. Cognitive Level: Application Text Reference: p. 1522 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Obtain the Glasgow Coma Scale score. b. Check the respiratory rate. c. Monitor the blood pressure. d. Send the patient for a CT scan.

Correct Answer: B Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed. Cognitive Level: Application Text Reference: p. 1511

A patient is to be discharged from the hospital 4 days after undergoing a total hip arthroplasty. A statement by the patient that indicates a need for additional discharge instructions is a. "I should not cross my legs while sitting." b. "I can sleep in any position that is comfortable for me." c. "I will use a toilet elevator on the toilet seat." d. "I will have someone else put on my shoes and socks."

Correct Answer: B Rationale: The patient needs to sleep in a position that allows excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching. Cognitive Level: Application Text Reference: p. 1654 Nursing Process: Evaluation NCLEX: Physiological Integrity

When getting a patient from the bed into the chair for the first time since having an ORIF of a hip fracture, the nurse should a. use a mechanical lift to transfer the patient from the bed to the chair. b. assist the patient to use a walker with partial weight bearing to assist in transfer to the chair. c. have the patient use crutches with a swing through gait to transfer. d. ask a nursing assistant to help the patient to stand at the bedside and pivot to the chair.

Correct Answer: B Rationale: The patient will use an assistive device such as a walker to help with the initial transfers and ambulation. A mechanical lift is not needed. Crutch walking is taught before discharge but would not be used for the initial transfer. The RN, not a nursing assistant, should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

A patient who has been hospitalized for 3 days with a hip fracture and Buck's traction has sudden onset shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer oxygen at 4 L/min by a nasal cannula. c. Notify the health care provider about the patient's symptoms. d. Check the patient's legs for swelling or tenderness.

Correct Answer: B Rationale: The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for deep vein thrombosis (DVT) are obtained. Cognitive Level: Application Text Reference: p. 1646 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with chronic cancer pain experiences breakthrough pain (level 9 of 10) and anxiety while receiving sustainedrelease morphine sulfate (MS Contin) 160 mg every 12 hours. All these medications are ordered for the patient. Which one will be most appropriate for the nurse to administer first? a. Ibuprofen (Motrin) 400-800 mg orally b. Immediate-release morphine 30 mg orally c. Amitriptyline (Elavil) 10 mg orally. d. Lorazepam (Ativan) 1 mg orally

Correct Answer: B Rationale: The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediaterelease morphine. The ibuprofen and amitriptyline may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of anti-anxiety agents for pain control is inappropriate because this patient's anxiety for this patient is caused by the pain. Cognitive Level: Analysis Text Reference: pp. 137, 140 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient undergoes a right below-the-knee amputation with an immediate prosthetic fitting. When the patient is returned to the nursing unit, the nurse should a. check the surgical site for hemorrhage. b. take the patient's vital signs frequently. c. keep the residual leg elevated on a pillow. d. place the patient in a prone position

Correct Answer: B Rationale: The vital signs should be monitored frequently to assess for hemorrhage because the nurse will not be able to visualize the surgical site. Flexion contracture of the hip would be encouraged by elevating the residual limb on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period. Cognitive Level: Application Text Reference: p. 1660 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient complains of an ongoing severe headache. b. The patient's blood pressure is 90/50 mm Hg. c. The cerebrospinal fluid (CFS) report shows red blood cells (RBCs). d. The patient complains about having a stiff neck.

Correct Answer: B Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a high level after a subarachnoid hemorrhage. A low or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider Cognitive Level: Analysis Text Reference: p. 1515 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in a dependent position. b. handle the cast with the palms of the hands. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness

Correct Answer: B Rationale: Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying

in developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is a. risk for constipation related to prolonged bed rest. b. activity intolerance related to deconditioning. c. risk for infection related to disruption of skin integrity. d. risk for impaired skin integrity related to immobility.

Correct Answer: C Rationale: A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely. Cognitive Level: Application Text Reference: p. 1638 Nursing Process: Diagnosis NCLEX: Physiological Integrity

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has atrial fibrillation. b. The patient has dysphasia. c. The patient states, "I suddenly developed a terrible headache." d. The patient has a history of brief episodes of right hemiplegia.

Correct Answer: C Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin. Cognitive Level: Application Text Reference: p. 1507 Nursing Process: Assessment NCLEX: Physiological Integrity

All the following medications are included in the admission orders for an 86-year-old patient with moderate degenerative arthritis in both hips. Which medication will the nurse use as an initial therapy? a. Aspirin (Bayer) 650 mg orally b. Oxycodone (Roxicodone) 5 mg orally c. Acetaminophen (Tylenol) 650 mg orally d. Naproxen (Aleve) 200 mg orally

Correct Answer: C Rationale: Acetaminophen is the best first-choice medication. The principle of "start low, go slow" is used to guide therapy when treating elderly adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Non-opioid analgesics are used first, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in elderly patients. Cognitive Level: Application Text Reference: pp. 135, 148 Nursing Process: Implementation NCLEX: Physiological Integerity

A patient with severe osteoarthritis of the left knee has undergone left-knee arthroplasty with replacement of the total knee joint with a plastic prosthesis. Postoperatively, the nurse expects care of the leg to include a. bed rest for 3 days with the left leg immobilized in an extended position. b. use of a compression bandage to hold the left knee in a flexed position. c. progressive leg exercises to obtain 90-degree flexion. d. early ambulation with full weight bearing on the left leg.

Correct Answer: C Rationale: After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The patient is ambulated the first postoperative day. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge, but it is not started early after surgery. Cognitive Level: Application Text Reference: p. 1664 Nursing Process: Planning NCLEX: Physiological Integrity

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Call the health care provider to clarify the medication order. c. Explain that the aspirin is ordered to decrease stroke risk. d. Tell the patient that the aspirin is used to prevent aches.

Correct Answer: C Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. Cognitive Level: Application Text Reference: pp. 1505, 1510 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with an intracapsular fracture of the left femur is placed in Buck's traction before surgery for a hip replacement. The patient asks why traction is necessary when surgery is planned. The nurse's response to the patient is based on the knowledge that traction a. will help prevent flexion contractures of the affected hip. b. is necessary to prevent displacement of the fracture. c. will decrease the incidence of painful muscle spasms d. is used to maintain the leg in the external rotation position.

Correct Answer: C Rationale: Buck's traction keeps the leg immobilized and reduces muscle spasm. Flexion contractures are not likely to occur during the short time before surgery. Displacement of the hip is prevented by keeping the patient on bed rest before surgery. The leg is externally rotated because of the hip fracture, not because of traction. Cognitive Level: Comprehension Text Reference: p. 1653 Nursing Process: Implementation NCLEX: Physiological Integrity

In teaching a patient with ankylosing spondylitis (AS) about the management of the condition, the nurse instructs the patient to a. sleep on the side with hips flexed. b. take slow, long walks as a form of exercise. c. perform daily deep-breathing exercises. d. take frequent naps during the day.

Correct Answer: C Rationale: Deep-breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps. Cognitive Level: Comprehension Text Reference: p. 1712 Nursing Process: Implementation NCLEX: Physiological Integrity

14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should a. apply an eye patch to the affected eye. b. approach the patient on the unaffected side. c. place objects necessary for activities of daily living on the patient's affected side. d. have the patient use the eye muscles to move the eyes through the entire visual field.

Correct Answer: C Rationale: During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side. Because homonymous hemianopsia affects half the visual field in each eye, use of an eye patch is not appropriate. Approaching the patient on the affected side is appropriate during the acute period but does not help the patient learn skills needed to compensate for the visual defect. The problem is with the visual field, not with the eye muscles, so practice moving the eyes through the visual field will not be effective. Cognitive Level: Application Text Reference: p. 1517 Nursing Process: Implementation NCLEX: Physiological Integrity

Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to a. apply a heating pad to reduce muscle spasms. b. wear an elastic compression bandage continuously. c. use pillows to keep the arm elevated above the heart. d. gently exercise the joint to prevent muscle shortening.

Correct Answer: C Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury

22. After falling at home, a patient is admitted to the emergency department, where x-rays confirm the presence of an extracapsular fracture of the femur. When assessing the patient, the nurse would expect to find a. bruising of the left hip and thigh. b. numbness in the left leg and hip. c. outward pointing toes on the left leg. d. weak or nonpalpable left leg pulses

Correct Answer: C Rationale: External rotation of the leg is a classic sign associated with a hip fracture. Bruising does not always appear rapidly, and bruising extending to the thigh might indicate hemorrhage. Numbness and decreased pulses are not typical of a hip fracture unless there is associated tissue swelling and trauma to blood vessels.

A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication? a. The patient has experienced a recent 5- pound weight loss. b. The patient's erythrocyte sedimentation rate (ESR) has increased. c. The patient's blood glucose is 166 mg/dl. d. The patient has no improvement in symptoms.

Correct Answer: C Rationale: Hyperglycemia is a side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication. Cognitive Level: Application Text Reference: p. 1699 Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient has a short-arm plaster cast applied at the outpatient center for a wrist fracture. An understanding of discharge teaching is apparent when the patient says, a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site for the next 24 hours." d. "I can rub lotion on any itching areas under the cast with a cotton-tipped applicator

Correct Answer: C Rationale: Ice application for the first 24 hours after a fracture will help to reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

The nurse is evaluating the effectiveness of imipramine (Tofranil), a tricyclic antidepressant, for a patient who is receiving the medication to help relieve chronic cancer pain. Which information is the best indicator that the imipramine is effective? a.The patient states, "I feel much less depressed since I've been taking the imipramine." b. The patient sleeps 8 hours every night. c. The patient says that the pain is manageable and that he or she can accomplish desired activities. d.The patient has no symptoms of anxiety.

Correct Answer: C Rationale: Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level. Cognitive Level: Application Text Reference: p. 130 Nursing Process: Evaluation NCLEX: Physiological Integrity

OA/RA A 60-year-old patient has osteoarthritis (OA) of the left knee. A finding that the nurse would expect to be present on examination of the patient's knee is a. Heberden's nodules. b. redness and swelling of the knee joint. c. pain upon joint movement. d. stiffness that increases with movement.

Correct Answer: C Rationale: Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement. Cognitive Level: Comprehension Text Reference: p. 1694 Nursing Process: Assessment NCLEX: Physiological Integrity

The health care provider prescribes methotrexate (Rheumatrex) for a 28-yearold woman with stage II moderate rheumatoid arthritis (RA). When obtaining a health history from the patient, the most important information for the nurse to communicate to the health care provider is that the patient has a. a history of infectious mononucleosis as a teenager. b. a family history of age-related macular degeneration of the retina. c. been trying to have a baby before her disease becomes more severe. d. been using large doses of vitamins and health foods to treat the RA.

Correct Answer: C Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy. Cognitive Level: Application Text Reference: p. 1699 Nursing Process: Assessment NCLEX: Physiological Integrity

A 22-year-old patient hospitalized with severe pain in the knees and a fever and shaking chills is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. has a parent who has reactive arthritis. b. recently returned from a trip to South America. c. is sexually active and has multiple partners. d. had several sports-related knee injuries as a teenager.

Correct Answer: C Rationale: Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis. Cognitive Level: Application Text Reference: p. 1713 Nursing Process: Assessment NCLEX: Physiological Integrity

When screening patients at a community center, the nurse will plan to teach ways to reduce risk factors for osteoarthritis to a a. 24-year-old man who participates in a summer softball team. b. 36-year-old woman who is newly diagnosed with diabetes mellitus. c. 49-year-old woman who works on an automotive assembly line. d. 56-year-old man who is a member of a construction crew.

Correct Answer: C Rationale: OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky. Cognitive Level: Application Text Reference: p. 1694 Nursing Process: Planning NCLEX: Physiological Integrity

A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. explain to the family that depression is normal following a stroke. b. have the family members leave the patient alone for a few minutes. c. teach the family that emotional outbursts are common after strokes. d. use a calm voice to ask the patient to stop the crying behavior.

Correct Answer: C Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Implementation NCLEX: Psychosocial Integrity

The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. that Plavix will reduce cerebral artery plaque formation. b. to monitor and record the blood pressure daily. c. to call the health care provider if stools are tarry. d. that Plavix will dissolve clots in the cerebral arteries.

Correct Answer: C Rationale: Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Implementation NCLEX: Physiological Integrity

A 58-year-old woman who has been menopausal for 5 years is diagnosed with osteoporosis following densitometry testing. The woman has been concerned about her risk for osteoporosis because her mother has the condition. In teaching the woman about her osteoporosis, the nurse explains that a.with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. b.estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis. c. even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. d. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.

Correct Answer: C Rationale: Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help to prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis. Cognitive Level: Application Text Reference: p. 1689 Nursing Process: Implementation NCLEX: Physiological Integrity

When teaching a patient with osteoarthritis (OA) of the left hip and lower lumbar vertebrae about management of the condition, the nurse determines that additional instruction is needed when the patient says, a. "I can use a cane if I find it helpful in relieving the pressure on my back and hip." b. "A warm shower in the morning will help relieve the stiffness I have when I get up." c. "I should try to stay active throughout the day to keep my joints from becoming stiff." d. "I should take no more than 1 g of acetaminophen four times a day to control the pain."

Correct Answer: C Rationale: Protection and avoidance of joint stressors are recommended for patients with OA, so this patient should alternate periods of rest with necessary activity. The other patient statements indicate that teaching has been effective. Cognitive Level: Application Text Reference: pp. 1696, 1701 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is a. risk for impaired skin integrity related to immobility. b. disturbed sensory perception related to brain injury. c. risk for aspiration related to inability to protect airway. d. impaired physical mobility related to weakness.

Correct Answer: C Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time. Cognitive Level: Application Text Reference: p. 1515 Nursing Process: Diagnosis NCLEX: Physiological Integrity

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. impaired verbal communication related to speech-language deficits. c. risk for injury related to denial of deficits and impulsiveness. d. ineffective coping related to depression and distress about disability.

Correct Answer: C Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. Cognitive Level: Application Text Reference: p. 1508 Nursing Process: Diagnosis NCLEX: Physiological Integrity

The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. There are fine crackles at the lung bases. c. The patient has difficulty talking. d. The blood pressure is 142/88 mm Hg.

Correct Answer: C Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual as a result of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient who has a proximal humerus fracture that is immobilized with a leftsided long-arm cast, and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers on the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

Correct Answer: C Rationale: The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side Cognitive Level: Application Text Reference: p. 1640 Nursing Process: Planning NCLEX: Physiological Integrity

A patient receiving prn intermittent IV administration of opiates following gastric surgery watches a favorite television program every morning. The patient does not request pain medication during this time and when questioned denies the need for medication. The nurse's evaluation of this situation is that a. lying quietly in bed is the best method of controlling the patient's incisional pain. b. encouraging the patient to watch other television programs will decrease the pain. c. the distraction of the television enables the patient to decrease the perception of pain. d. the patient's dose of opiates needs to be decreased because her pain is well controlled.

Correct Answer: C Rationale: The distraction of watching a favorite program decreases the perception of pain by various brain structures. Immobilization may help to reduce pain, but it is not the best method for pain relief because immobility can lead to multiple postoperative complications. Other television programs are not likely to provide an adequate level of distraction. The patient will continue to require opioid analgesics when not watching the favorite program. Cognitive Level: Application Text Reference: p. 144 Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers, wrists, and feet with swelling, redness, and limited movement of the joints. When developing the plan of care, the nurse recognizes that the most appropriate patient outcome at this time is to a. maintain a positive self-image. b. perform activities of daily living independently. c. achieve satisfactory control of pain. d. make a successful adjustment to disease progression.

Correct Answer: C Rationale: The focus during an acute exacerbation of RA is to manage pain effectively. The other outcomes are appropriate longterm outcomes. Cognitive Level: Application Text Reference: p. 1707 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." A nursing diagnosis that is most appropriate in this situation is a. situational low self-esteem related to increasing dependence on others. b. interrupted family processes related to effects of illness of a family member. c. disabled family coping related to inadequate understanding by patient's spouse. d. ineffective therapeutic regimen management related to hemiplegia and aphasia.

Correct Answer: C Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient's attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to a. splint the lower leg. b. elevate the left leg. c. check the popliteal, dorsalis pedis, and posterior tibial pulses. d. obtain information about the patient's tetanus immunization status.

Correct Answer: C Rationale: The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound. Cognitive Level: Application Text Reference: p. 1642 Nursing Process: Assessment NCLEX: Physiological Integri

A patient is admitted with facial injuries after a bicycle accident and has a repair of a fractured mandible. When doing postoperative teaching, the nurse will include information about a. the use of sterile technique for dressing changes. b. the importance of including high-fiber foods in the diet. c. when the patient may need to cut the immobilizing wires. d. self-administration of nasogastric tube feedings.

Correct Answer: C Rationale: The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw. Cognitive Level: Application Text Reference: p. 1657 Nursing Process: Implementation NCLEX: Physiological Integrity

3. A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as related to a. muscle spasms. b. meniscus injury. c. repetitive strain injury. d. carpal tunnel syndrome.

Correct Answer: C Rationale: The patient's occupation and the inflammation, pain, and weakness in the elbow and hand suggest a repetitive strain injury.Muscle spasms would be characterized by a palpable, firm muscle mass during the spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is characterized by weakness and numbness of the hand.

When administering alendronate (Fosamax) to a patient, the nurse will first a. administer the ordered calcium carbonate. b. be sure the patient has recently eaten. c. assist the patient to sit up at the bedside. d.ask about any leg cramps or hot flashes.

Correct Answer: C Rationale: To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates. Cognitive Level: Application Text Reference: p. 1689 Nursing Process: Implementation NCLEX: Physiological Integrity

When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? a. The patient complains of a "pounding" headache. b. The patient becomes restless and agitated. c. The patient has not voided for over 10 hours. d. The patient has cramping abdominal pain.

Correct Answer: C Rationale: Urinary retention is a common side effect of epidural opioids. Headache is not an anticipated side effect of morphine, although if there is a cerebrospinal fluid leak, the patient may develop a "spinal" headache. Sedation (rather than restlessness or agitation) would be a possible side effect. Hypotonic bowel sounds and constipation (rather than abdominal cramping) are concerns. Cognitive Level: Application Text Reference: p. 142 Nursing Process: Evaluation NCLEX: Physiological Integrity

When evaluating the crutch-walking technique of a patient with a right-leg long leg cast and no weight bearing on the right leg, the nurse determines that the patient is prepared to ambulate independently with the crutches on observing that the patient a. uses the bedside chair to assist in balance as needed when ambulating in the room. b. keeps the padded area of the crutch firmly in the axillary area when ambulating. c. advances the right leg and both crutches together and then advances the left leg. d. moves the left crutch with the left leg and then the right crutch with the right leg.

Correct Answer: C Rationale: When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. Cognitive Level: Application Text Reference: p. 1648 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

A 71-year-old obese patient has bilateral osteoarthritis (OA) of the hips. The nurse teaches the patient that the most beneficial measure to protect the joints is to a. use a wheelchair to avoid walking as much as possible. b. sit in chairs that do not cause the hips to be lower than the knees. c. use a walker for ambulation to relieve the pressure on the hips. d. eat according to a weight-reduction diet to obtain a healthy body weight.

Correct Answer: D Rationale: Because the patient's major risk factor is obesity, the nurse should teach the patient that weight loss is the best way to reduce stress on the hips. Avoiding activity by sitting in a wheelchair would likely increase the patient's weight; moderate activity is recommended for patients with OA. Sitting with the hips higher than the knees and using a walker would be recommended but are not as helpful as weight loss for this obese patient. Cognitive Level: Application Text Reference: p. 1701 Nursing Process: Implementation NCLEX: Physiological Integrity

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. When the patient has a follow-up visit 1 month later, the nurse recognizes that the patient's response to the treatment may be best evaluated by a. blood glucose testing. b. liver function tests. c. serum electrolyte levels. d. C-reactive protein level.

Correct Answer: D Rationale: C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids. Cognitive Level: Application Text Reference: pp. 1698-1699 Nursing Process: Evaluation NCLEX: Physiological Integrity

MUSCULO When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tacking down scatter rugs in the home is recommended. b. Occasional weight-bearing exercise will improve muscle and bone strength. c. Most falls happen outside the home. d. Buying shoes that provide good support and are comfortable to wear is recommended.

Correct Answer: D Rationale: Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but occasional exercise is not helpful in improving strength. Falls inside the home are responsible for many injuries. Cognitive Level: Application Text Reference: p. 1630 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient's home medications, which of these will be of most concern to the admitting nurse? a. Oxycodone (OxyContin) 80 mg twice daily b. Ibuprofen (Advil) 800 mg three times daily c. Amitriptyline (Elavil) 50 mg at bedtime d. Meperidine (Demerol) 25 mg every 4 hours

Correct Answer: D Rationale: Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management. Cognitive Level: Application Text Reference: p. 138 Nursing Process: Assessment NCLEX: Physiological Integrity

A 58-year-old patient has been diagnosed with osteoarthritis (OA) of the hands and feet. The patient tells the nurse, "I am afraid that I will be hopelessly crippled in just a few years!" The best response by the nurse is that a. progression of OA can be prevented with a regimen of exercise, diet, and drugs. b. OA is an inflammatory process with periods of exacerbation and remission. c. joint degeneration with pain and deformity occurs with OA by age 60 to 70. d. OA is common with aging, but usually it is localized and does not cause deformity.

Correct Answer: D Rationale: OA is localized to joints that have been injured or have high use. Although exercise, diet, and drugs can help to decrease symptoms and slow disease progression, they will not prevent progression of the disease. OA is progressive and does not have exacerbations and remissions, which are typical of RA. Joint degeneration and pain occur later in OA; joint deformity is not a common symptom. Cognitive Level: Application Text Reference: pp. 1701, 1704 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with lower-leg fractures has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? a. "You will need to remain on bed rest until bone healing is complete." b. "The external fixator can be removed during the bath or shower." c. "Prophylactic antibiotics are needed until the external fixator is removed." d. "You will need to assess and clean the pin insertion sites daily."

Correct Answer: D Rationale: Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used. Cognitive Level: Application Text Reference: p. 1641 Nursing Process: Implementation NCLEX: Physiological Integrity

4. When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to a. do stretching and warm-up exercises before starting work. b. wrap the wrists with a compression bandage every morning. c. use acetaminophen (Tylenol) instead of NSAIDs for wrist pain. d. obtain a keyboard pad to support the wrist while word processing.

Correct Answer: D Rationale: Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling. Cognitive Level: Application Text Reference: p. 1633 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question? a. Infuse normal saline at 75 ml/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

Correct Answer: D Rationale: Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 ml daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use. Cognitive Level: Application Text Reference: p. 1511 Nursing Process: Implementation NCLEX: Physiological Integrity

To obtain the most complete assessment data about a patient's chronic pain pattern, the nurse asks the patient a. "Can you describe where your pain is the worst?" b. "What is the intensity of your pain on a scale of 0 to 10?" c."Would you describe your pain as aching, throbbing, or sharp?" d.

Correct Answer: D Rationale: The assessment of chronic pain should focus on the impact of the pain on patient function and daily activities. The other questions are also appropriate to ask, but will not give as complete information. Cognitive Level: Application Text Reference: p. 134 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient who had arthroscopic surgery of the left knee 5 days previously is admitted with a red, swollen, and hot-to-touch knee. Which of these assessment data obtained by the nurse should be reported to the health care provider immediately? a. The white blood cell count is 14,200/μl. b. The patient rates the knee pain at 9 on a 10- point pain scale. c. The patient has recently taken ibuprofen (Motrin). d. The oral temperature is 104.1° F degrees.

Correct Answer: D Rationale: The elevated temperature suggests that the patient may have an infection and be in danger of developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately lifethreatening problems Cognitive Level: Application Text Reference: p. 1713 Nursing Process: Assessment NCLEX: Physiological Integrity

A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate?" a. "Your family may need some help to understand the impact of your rheumatoid arthritis." b. "You may need to see a family therapist for some help." c. "Perhaps it would be helpful for you and your family to get involved in a support group." d. "Tell me more about the situations that are causing stress."

Correct Answer: D Rationale: The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment. Cognitive Level: Application Text Reference: p. 1711 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

12. Following a motor-vehicle accident, a patient arrives in the emergency department with massive right lower-leg swelling. Which action will the nurse take first? a. Elevate the leg on pillows. b. Apply a compression bandage. c. Place ice packs on the lower leg. d. Check leg pulses and sensation.

Correct Answer: D Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

The nurse provides discharge instructions to a patient with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete and the residual limb is well molded. The nurse determines that teaching has been effective when the patient says, a. "I should change the limb sock when it becomes soiled or stretched out." b. "I should use lotion on the stump to prevent drying and cracking of the skin." c. "I should elevate my residual limb on a pillow 2 or 3 times a day." d. "I should lay on my abdomen for 30 minutes 3 or 4 times a day."

Correct Answer: D Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limp sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture. Cognitive Level: Application Text Reference: p. 1661 Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. offer the patient a sip of juice. b. order a varied pureed diet. c. assess the patient's appetite. d. assist the patient into a chair.

Correct Answer: D Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless. Cognitive Level: Application Text Reference: pp. 1518-1519 Nursing Process: Implementation NCLEX: Physiological Integrity

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Encouraging patient to cough and deep breath every 4 hours b. Inserting an oropharyngeal airway to prevent airway obstruction c. Assisting to dangle on edge of bed and assess for dizziness d. Applying intermittent pneumatic compression stockings

Correct Answer: D Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep vein thrombosis (DVT). Activities (such as coughing and sitting up) that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate. Cognitive Level: Application Text Reference: p. 1518 Nursing Process: Planning NCLEX: Physiological Integrity

A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes and a dry mouth. Which action by the nurse is most appropriate? a. Have the patient withhold the daily methotrexate (Rheumatrex) until talking with the health care provider. b. Reassure the patient that dry eyes and mouth are very common with RA. c. Teach the patient to use an antiseptic mouth wash tid. d. Suggest that the patient start using overthe- counter (OTC) artificial tears.

Correct Answer: D Rationale: The patient's dry eyes and oral mucous membranes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes and mouth are not side effects of methotrexate. Although dry eyes and mouth are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. Rinsing the mouth to decrease oral dryness is appropriate, but the frequent use of antiseptic mouthwashes is not appropriate unless the patient has oral symptoms that require this. Cognitive Level: Application Text Reference: p. 1726 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. intravenous heparin administration. b. transluminal angioplasty. c. surgical endarterectomy. d. tissue plasminogen activator (tPA) infusion.

Correct Answer: D Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke. Cognitive Level: Application Text Reference: p. 1512 Nursing Process: Planning NCLEX: Physiological Integrity

A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use the incentive spirometer unless specifically reminded. The patient rates the pain severity as an 8 on a 10-point scale but tells the nurse, "I can tough it out." In encouraging the patient to use pain medication, the best explanation by the nurse is that a. very few patients become addicted to opioids when using them for acute pain control. b. there is little need to worry about side effects because these problems decrease over time. c.there are many pain medications and if one drug is ineffective, other drugs may be tried. d.unrelieved pain can be harmful due to the effect on respiratory function and activity level.

Correct Answer: D Rationale: The patient's low activity level, lack of spirometer use, and statement to the nurse indicate that there is a lack of understanding about the purpose of postoperative pain management. The patient did not indicate a concern about becoming addicted, a desire for alternate medications, or anxiety about analgesic side effects. Cognitive Level: Application Text Reference: pp. 126, 131, 145 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. heparin via continuous intravenous infusion. b. prophylactic clipping of cerebral aneurysms. c. therapy with tissue plasminogen activator (tPA). d. oral administration of ticlopidine (Ticlid).

Correct Answer: D Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for TIA. Cognitive Level: Application Text Reference: p. 1505 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals a. a blood pressure of 100/65 mm Hg. b. anxiety, restlessness, and confusion. c. warm, reddened areas in the calf. d. pinpoint red areas on the upper chest.

Correct Answer: D Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.

14. The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. reports daily to the public health department. c. washes dishes and personal items after use. d. covers the mouth and nose when coughing.

D Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB. Cognitive Level: Application Text Reference: p. 574 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

33. An appropriate collaborative problem for the nurse to include in the care plan for a patient with cholelithiasis and obstruction of the common bile duct is a. potential complication: bleeding. b. potential complication: gastritis. c. potential complication: thromboembolism. d. potential complication: biliary cirrhosis.

D Rationale: With obstruction of the common bile duct, bile will back up into the liver and damage liver cells. Bleeding, gastritis, and thromboembolism are not common complications of biliary obstruction. Cognitive Level: Comprehension Text Reference: pp. 1128-1129 Nursing Process: Planning NCLEX: Physiological Integrity

17. A patient is seen in the clinic with COPD. Which information given by the patient would help most in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patient denies having any respiratory problems until the last 6 months. c. The patient's history indicates a 40 packyear cigarette history. d. The patient complains about having a productive cough every winter for 2 months.

D Rationale: A diagnosis of chronic bronchitis is based on a history of having a productive cough for several months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis. Cognitive Level: Application Text Reference: p. 629 Nursing Process: Assessment NCLEX: Physiological Integrity

41. When the nurse is caring for a patient with acute pancreatitis, which of these assessment data should be of most concern? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

D Rationale: A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications. Cognitive Level: Application Text Reference: p. 1119 Nursing Process: Assessment NCLEX: Physiological Integrity

37. The nurse has received a change-ofshift report about these patients with COPD. Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient who has a cough productive of thick, green mucus c. A patient with jugular vein distension and peripheral edema d. A patient with a respiratory rate of 38

D Rationale: A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient. Cognitive Level: Application Text Reference: pp. 612, 626 Nursing Process: Assessment NCLEX: Safe and Effective Care Environment

17. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. b-adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

D Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACEinhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The b-adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Implementation NCLEX: Physiological Integrity

20. During IV administration of amphotericin B ordered for treatment of coccidioidomycosis, the nurse increases the patient's tolerance of the drug by a. cooling the solution to 80° F before administration. b. keeping the patient flat in bed for 1 hour after the infusion is completed. c. diluting the amphotericin B in 500 ml of sterile water. d. giving diphenhydramine (Benadryl) 1 hour before starting the infusion.

D Rationale: Administration of an antihistamine before giving the amphotericin B will reduce the incidence of hypersensitivity reactions. Cooling the solution and keeping the patient flat after infusion are not indicated. Amphotericin B does not need to be diluted in 500 ml of fluid, although the nurse should ensure adequate hydration in the patient receiving this drug. Cognitive Level: Application Text Reference: p. 575 Nursing Process: Implementation NCLEX: Physiological Integrity

39. After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. "I will make an appointment to see the doctor every year." b. "I will not turn the home oxygen up higher than 2 L/minute." c. "I will be careful to use sterile technique with my central line." d. "I will write down my medications and spirometry in a journal."

D Rationale: After lung transplant, patients are taught to keep logs of medications, spirometry, and laboratory results. Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant and patients would not usually have a central IV line. Cognitive Level: Application Text Reference: p. 604 Nursing Process: Evaluation NCLEX: Physiological Integrity

34. All of these orders are received for a patient having an acute asthma attack. Which one will the nurse administer first? a. IV methylprednisolone (Solu-Medrol) 60 mg b. triamcinolone (Azmacort) 2 puffs per MDI c. salmeterol (Serevent) 50 mcg per DPI d. albuterol (Ventolin) 2.5 mg per nebulizer 35. Which statement by the COPD patient indicates that the nurse's teaching about nutrition has been effective?

D Rationale: Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly. Cognitive Level: Application Text Reference: p. 620 Nursing Process: Implementation NCLEX: Physiological Integrity

6. A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. ineffective airway clearance related to thick secretions. c. impaired transfer ability related to weakness. d. impaired gas exchange related to respiratory congestion.

D Rationale: All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. Cognitive Level: Application Text Reference: p. 566 Nursing Process: Diagnosis NCLEX: Physiological Integrity

2. The nurse recognizes that intubation and mechanical ventilation are indicated for a patient in status asthmaticus when a. ventricular dysrhythmias and dyspnea occur. b. loud wheezes are audible throughout thelungs. c. pulsus paradoxus is greater than 40 mm Hg. d. fatigue and an O2 saturation of 88% develop.

D Rationale: Although all of the assessment data indicate the need for rapid intervention, the fatigue and hypoxia indicate that the patient is no longer able to maintain an adequate respiratory effort and needs mechanical ventilation. The initial treatment for the other clinical manifestations would initially be administration of rapidly acting bronchodilators and oxygen. Cognitive Level: Application Text Reference: pp.612-613 Nursing Process: Assessment NCLEX: Physiological Integrity

9. A 72-year-old patient is hospitalized for an aortic dissection of the abdominal aorta that stabilizes with treatment. The nurse develops a teaching plan for the patient's discharge that includes information about a. gradually increasing exercise to improve cardiac function and BP control. b. appropriate use of nonsteroidal antiinflammatory agents (NSAIDs) to control any abdominal pain. c. holding prescribed b-blockers if dizziness or weakness occur to avoid injury. d. the use of antihypertensive medications to lower the risk of further dissection or bleeding.

D Rationale: Antihypertensive medications are prescribed to help control BP and prevent redissection, leaking, or rupture. Exercise will increase the BP and increase the risk for further dissection. NSAIDs decrease platelet function, and the patient should avoid use of this category of medications; in addition, the patient is taught to call the health care provider about any abdominal pain. The patient may experience some side effects of bblockade but should discuss any change in dose or medication with the health care provider. Cognitive Level: Application Text Reference: pp. 899-900 Nursing Process: Planning NCLEX: Physiological Integrity

24. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about a. reasons for annual sputum cytology testing. b. CT screening for lung cancer. c. erlotinib (Tarceva) therapy to prevent tumor risk. d. options for smoking cessation.

D Rationale: Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Tarceva may be used to in patients who have lung cancer, but not to reduce risk for developing tumors. Cognitive Level: Application Text Reference: pp. 582, 584 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

4. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. improvement in hourly urinary output. c. reduction in systolic BP. d. decreased dyspnea with the head of the bed at 30 degrees.

D Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles. The other assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful in evaluating this patient's response. Cognitive Level: Application Text Reference: p. 825 Nursing Process: Evaluation NCLEX: Physiological Integrity

23. A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective? a. "I will need to include more high-potassium foods in my diet." b. "I will expect to feel more short of breath for the next few days." c. "I will be sure to take the medication after eating something." d. "I will call for help when I need to get up to the bathroom."

D Rationale: Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparring, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of b-blocker therapy for heart failure, not for ACE-inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Evaluation NCLEX: Physiological Integrity

22. A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that a. exercises such as walking or jogging cause recurrence of varicosities. b. sitting at the work counter, rather than standing, is recommended. c. taking one aspirin daily will help prevent clotting around venous valves. d. compression stockings should be applied before getting out of bed.

D Rationale: Compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended to the patient who had just had sclerotherapy. Cognitive Level: Application Text Reference: pp. 918-919 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

19. A hospitalized diabetic patient receives 12 U of regular insulin mixed with 34 U ofNPH insulin at 7:00 AM. The patient is away from the nursing unit for diagnostic testing at noon, when lunch trays are distributed. The most appropriate action by the nurse is to a. save the lunch tray to be provided upon the patient's return to the unit. b. call the diagnostic testing area and ask that a 5% dextrose IV be started. c. ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. d. request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.

D Rationale: Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. Cognitive Level: Analysis Text Reference: p. 1268 Nursing Process: Implementation NCLEX: Physiological Integrity

29. While working in the outpatient clinic, the nurse notes that the chart states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information? a. "My fingers hurt when I go outside in cold weather." b. "Sometimes I get tired when I climb a lot of stairs." c. "When I stand too long, my feet start to swell up." d. "My legs cramp whenever I walk more than a block."

D Rationale: Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease. Cognitive Level: Application Text Reference: p. 900 Nursing Process: Assessment NCLEX: Physiological Integrity

13. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include a. avoid dietary sources of potassium because too much can cause digitalis toxicity. b. take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min. c. take the hydrochlorothiazide before bedtime to maximize activity level during the day. d. notify the health care provider immediately if nausea or difficulty breathing occurs.

D Rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the medications are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. Digoxin toxicity is potentiated by hypokalemia, rather than hyperkalemia. Patients should be taught to check their pulse daily before taking the digoxin and, if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption. Cognitive Level: Application Text Reference: p. 835 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

34. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. chest tubes to water-seal chest drainage. c. bedrest for the first 24 hours. d. frequent use of an incentive spirometer.

D Rationale: Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. Cognitive Level: Application Text Reference: pp. 596-597 Nursing Process: Planning NCLEX: Physiological Integrity

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

D Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen or antibodies for hepatitis B. Anti-HAV IgG would indicate past infection and lifelong immunity. Cognitive Level: Application Text Reference: p. 1089 Nursing Process: Assessment NCLEX: Physiological Integr

18. A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that a. heart transplants are experimental surgeries that are not covered by most insurance. b. the patient is too old to be placed on the transplant list. c. the diagnoses and symptoms indicate that the patient is not an appropriate candidate. d. candidacy for heart transplant depends on many factors.

D Rationale: Indications for a heart transplant include inoperable coronary artery disease and refractory end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Heart transplants are not considered experimental; rather, transplantation has become the treatment of choice for patients who meet the criteria. The patient is not too old for a transplant. The patient's diagnoses and symptoms indicate that the patient may be an appropriate candidate for a heart transplant. Cognitive Level: Comprehension Text Reference: p. 837 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

27. A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood. b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic byproducts. c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.

D Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate. Cognitive Level: Application Text Reference: pp. 1278-1279 Nursing Process: Implementation NCLEX: Physiological Integrity

12. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. eggs and other high-cholesterol foods. b. canned and frozen fruits. c. fresh or frozen vegetables. d. milk, yogurt, and other milk products.

D Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction. Cognitive Level: Application Text Reference: p. 833 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

9. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."

D Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. Cognitive Level: Application Text Reference: p. 1268 Nursing Process: Evaluation NCLEX: Physiological Integrity

30. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. complaints of severe pain. b. heart rate of 110 beats/min. c. a large bruised area on the chest. d. paradoxic chest movement.

D Rationale: Paradoxic chest movement indicates that the patient may have flail chest, which will severely compromise gas exchange and can rapidly lead to hypoxemia. Severe pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange. Cognitive Level: Application Text Reference: pp. 586, 588 Nursing Process: Assessment NCLEX: Physiological Integrity

8. Following discharge teaching, the nurse evaluates that the patient who was admitted with pneumonia understands measures to prevent a reoccurrence of the pneumonia when the patient states, a. "I will increase my food intake to 3000 calories a day." b. "I will need to use home oxygen therapy for 3 months." c. "I will seek medical treatment for any upper respiratory infections." d. "I will do deep-breathing and coughing exercises for the next 6 weeks."

D Rationale: Patients at risk for recurrent pneumonia should use the incentive spirometer or do deep breathing and coughing exercises or both for 6 to 8 weeks after discharge. Although caloric needs are increased during the acute infection, 3000 calories daily will lead to obesity and increase the risk for pneumonia. Patients with acute lower respiratory infections do not usually require home oxygen therapy. Upper respiratory infections require medical treatment onlywhen they fail to resolve in 7 days. Cognitive Level: Application Text Reference: p. 569 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

37. The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the a. thigh. b. buttock. c. arm. d. abdomen.

D Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Implementation NCLEX: Physiological Integrity

41. After teaching the patient with asthma about home care, the nurse will evaluate that the teaching has been successful if the patient states, a. "I will use my corticosteroid inhaler as soon as I start to get short of breath." b. "I will only turn the home oxygen level up after checking with the doctor first." c. "My medications are working if I wake up short of breath only once during the night." d. "No changes in my medications are needed if my peak flow is at 80% of normal."

D Rationale: Peak flows of 80% or greater indicate that the asthma is well controlled. Corticosteroids are long-acting, prophylactic therapy for asthma and are not used to treat acute dyspnea. Because asthma is an acute and intermittent process, home oxygen is not used. The patient who has effective treatment should sleep throughout the night without waking up with dyspnea. Cognitive Level: Application Text Reference: p. 628 Nursing Process: Evaluation NCLEX: Physiological Integrit

38. Which of these nursing actions included in the plan of care for a patient with cirrhosis can the nurse delegate to a nursing assistant? a. Assessing the patient for jaundice b. Assisting the patient in choosing the diet c. Palpating the abdomen for distention d. Providing oral hygiene before meals

D Rationale: Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs. Cognitive Level: Application Text Reference: pp. 1110-1115 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

30. A 23-year-old with cystic fibrosis (CF) is admitted to the hospital. Which intervention will be included in the plan of care? a. Schedule sweat chloride test to evaluate the effectiveness of therapy. b. Arrange for a hospice nurse to visit with the patient regarding home care. c. Place the patient on a low-sodium diet to prevent cor pulmonale. d. Perform chest physiotherapy every 4 hours to mobilize secretions.

D Rationale: Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium. Cognitive Level: Application Text Reference: p. 658 Nursing Process: Planning NCLEX: Physiological Integrity

28. A patient who is seen in the clinic tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. The nurse will anticipate teaching the patient about tests for a. coronary artery disease. b. familial hyperlipidemia. c. high BP. d. immune disorders

D Rationale: Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease. Cognitive Level: Application Text Reference: p. 909 Nursing Process: Planning NCLEX: Physiological Integrity

A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit? a) Weight loss b) Pale thick skin c) Hypotension d) Moon face

D) Moon face Clients who are receiving long-term high-dose corticosteroid therapy often develop a cushingoid appearance, manifested by facial fullness and the characteristic moon face. They also may exhibit weight gain, peripheral edema, and hypertension due to sodium and water retention. The skin is usually thin, and ruddy

23. A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, it is most important that the nurse a. give a high enough flow rate to keep the bag from collapsing. b. use an appropriate adaptor to ensure adequate oxygen delivery. c. drain moisture condensation from the oxygen tubing every hour. d. keep the air entrainment ports clean and unobstructed.

D Rationale: The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or non-rebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation. Cognitive Level: Comprehension Text Reference: p. 642 Nursing Process: Implementation NCLEX: Physiological Integrity

35. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern? a. The patient's skin has multiple spidershaped blood vessels on the abdomen. b. The patient has ascites and a 2-kg weight gain from the previous day. c. The patient complains of right upperquadrant pain with abdominal palpation. d. The patient's hands flap back and forth when the arms are extended.

D Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper-quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status. Cognitive Level: Application Text Reference: p. 1106 Nursing Process: Assessment NCLEX: Physiological Integrity

21. When a patient with COPD is receiving oxygen, the best action by the nurse is to a. avoid administration of oxygen at a rate of more than 2 L/min. b. minimize oxygen use to avoid oxygen dependency. c. administer oxygen according to the patient's level of dyspnea. d. maintain the pulse oximetry level at 90% or greater.

D Rationale: The best way to determine the appropriate oxygen flow rate is by monitoring the patient's oxygenation either by ABGs or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patient's perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level. Cognitive Level: Application Text Reference: p. 640 Nursing Process: Implementation NCLEX: Physiological Integrity

8. A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to a. delay eating the noon meal until after the swimming class. b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class. c. time the morning insulin injection so that the peak occurs while swimming. d. check glucose level before, during, and after swimming.

D Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

28. A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should a. position the patient so that the right chest is dependent. b. administer high-flow oxygen using a non-rebreathing mask. c. cover the sucking chest wound with an occlusive dressing. d. tape a nonporous dressing on three sides over the chest wound.

D Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The patient should receive oxygen, but this will have no effect on the development of tension pneumothorax. Cognitive Level: Application Text Reference: p. 586 Nursing Process: Implementation NCLEX: Physiological Integrity

10. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. Increased vocal fremitus is palpable over the right chest. c. The patient coughs up small amounts of green mucous. d. The patient's white blood cell (WBC) count is 9000/"l.

D Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. Cognitive Level: Application Text Reference: p. 569 Nursing Process: Evaluation NCLEX: Physiological Integrity

11. During an assessment of a 63-year-old patient at the clinic, the patient says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should a. ask about any skin color changes that occur in response to cold. b. check for the presence of tortuous veins bilaterally on the legs. c. assess for unilateral swelling, redness, and tenderness of either leg. d. attempt to palpate the dorsalis pedis and posterial tibial pulses.

D Rationale: The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to deep vein thrombosis (DVT). Cognitive Level: Application Text Reference: pp. 900-901 Nursing Process: Assessment NCLEX: Physiological Integrity

4. Several hours following a surgical repair of an abdominal aortic aneurysm, the patient develops left flank pain and a urinary output of 20 ml/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for a(n) a. additional antibiotic. b. increase in IV rate. c. complete blood count. d. blood urea nitrogen (BUN) and creatinine.

D Rationale: The pain and decreased urine output suggest a renal artery embolism, and monitoring of renal function is needed. The data are not consistent with the complications of infection, hypovolemia, or bleeding. Cognitive Level: Application Text Reference: p. 898 Nursing Process: Assessment NCLEX: Physiological Integrity

43. In developing a teaching plan for a patient who is being discharged with a warfarin (Coumadin) prescription after having a pulmonary embolus, the nurse will include information about a. where to schedule activated partial thromboplastin time testing. b. avoidance of a high protein diet. c. how to obtain enteric-coated aspirin. d. foods that are high in vitamin K.

D Rationale: The patient who is taking Coumadin should have a consistent vitamin K intake, since vitamin K interferes with the effect of the medication. INR testing, rather than aPTT testing, is used to monitor for a therapeutic level of Coumadin. Aside from vitamin K, there are no other dietary requirements associated with Coumadin use. Aspirin should be avoided when taking anticoagulant medications because of the effect on platelet function. Cognitive Level: Application Text Reference: p. 600 Nursing Process: Planning NCLEX: Physiological Integrity

4. A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that a. the high insulin levels associated with this syndrome damage the lining of blood vessels, leading to vascular disease. b. although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated. c. the liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production. d. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise.

D Rationale: The patient with IFG is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle changes. Glycosylated hemoglobin levels will not be elevated in IFG and the Hb A1C test is not included in prediabetes testing. Elevated insulin levels do not cause the damage to blood vessels that can occur with IFG. The liver does not produce increased levels of glucose in IFG. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Assessment NCLEX: Physiological Integrity

2. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6.7 mmol/L). The nurse will plan to teach the patient about a. use of low doses of regular insulin. b. self-monitoring of blood glucose. c. oral hypoglycemic medications. d. maintenance of a healthy weight.

D Rationale: The patient's impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemic for glucose control and does not need to self-monitor blood glucose. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Planning NCLEX: Physiological Integrity

26. A patient with severe COPD tells the nurse, "I wish I were dead! I cannot do anything for myself anymore." Based on this information, the nurse identifies the nursing diagnosis of a. hopelessness related to presence of longterm stress. b. anticipatory grieving related to expectation of death. c. ineffective coping related to unknown outcome of illness. d. disturbed self-esteem related to physical dependence.

D Rationale: The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Although hopelessness, anticipatory grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the patient does not mention long-term stress, death, or an unknown outcome as being concerns. Cognitive Level: Application Text Reference: p. 655 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

15. When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis, the patient complains that it causes diarrhea. The nurse explains to the patient that it is still important to take the drug because the lactulose will a. promote fluid loss. b. prevent constipation. c. prevent gastrointestinal (GI) bleeding. d. improve nervous system function.

D Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although the medication may promote fluid loss through the stool, prevent constipation, and prevent bearing down during bowel movements (which could lead to esophageal bleeding), the medication is not ordered for these purposes for this patient. Cognitive Level: Application Text Reference: p. 1109 Nursing Process: Implementation NCLEX: Physiological Integrity

17. A patient admitted to the hospital with DVT has health care provider's orders for bed rest with the feet elevated. The best method for the nurse to use in elevating the patient's feet is to a. place two pillows under the calf of the affected leg. b. place the patient in the Trendelenburg position. c. elevate the bed at the knee and put pillows under the feet. d. put one pillow under the thighs and two pillows under the lower legs.

D Rationale: The purpose of elevation of the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level. Cognitive Level: Application Text Reference: p. 916 Nursing Process: Implementation NCLEX: Physiological Integrity

GASTRO 1. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the exposure should include a. baseline hepatitis B antibody testing now and in 2 months. b. active immunization with hepatitis B vaccine. c. hepatitis B immune globulin (HBIG) injection. d. both the hepatitis B vaccine and HBIG injection.

D Rationale: The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity. Antibody testing may also be done, but this would not provide protection from the exposure. Cognitive Level: Application Text Reference: p. 1096 Nursing Process: Implementation NCLEX: Physiological Integrity

LOW RESP 1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Resting pulse oximetry (SpO2) of 85% b. Respiratory rate of 28 c. Large amounts of greenish sputum d. Weak, nonproductive cough effort

D Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. Cognitive Level: Application Text Reference: p. 568 Nursing Process: Diagnosis NCLEX: Physiological Integrity

The nurse performs a fingerstick blood glucose level of a client with diabetes before lunch. The nurse would notify the physician for which blood glucose level? a) 115 mg/dL b) 90 mg/dL c) 130 mg/dL d) 145 mg/dL

D) 145 mg/dL Ideally, with fingerstick testing, the blood sugar should measure 90 to 130 mg/dL before meals and <180 mg/dL one to two hours after meals.

Which of the following diagnostic tests are done to determine suspected pituitary tumor? Choose the correct option. a) Radiographs of the abdomen b) A radioimmunoassay c) Measuring blood hormone levels d) A computed tomography scan

D) A computed tomography scan A computed tomography or magnetic resonance imaging scan is done to detect a suspected pituitary tumor. Radiographs of the chest or abdomen are taken to detect tumors. Radiographs also determine the size of the organ and their location. However, measuring blood hormone levels helps determine the functioning of endocrine glands. A radioimmunoassay determines the concentration of a substance in plasma.

A hospitalized client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following would the nurse do first? a) Infuse 1000 mL D5W over a 12-hour period. b) Encourage the client to drink orange juice with added sugar. c) Check the client's urine for the presence of sugar and acetone. d) Administer 50% glucose intravenously.

D) Administer 50% glucose intravenously The unconscious, hypoglycemic client needs immediate treatment with IV glucose. If the client does not respond quickly and the blood glucose level continues to be low, glucagon, a hormone that stimulates the liver to release glycogen, or 20 to 50 mL of 50% glucose is prescribed for IV administration. A dose of 1,000 mL D5W over a 12-hour period indicates a lower strength of glucose and a slow administration rate. Checking the client's urine for the presence of sugar and acetone is incorrect because a blood sample is easier to collect and the blood test is more specific and reliable. An unconscious client cannot be given a drink. In such a case glucose gel may be applied in the buccal cavity of the mouth

The nurse would monitor for which of the following adverse changes in the patient's laboratory values as a result of being treated with dexamethasone (Decadron)? A) Sodium 130 mEq/L B) Calcium 8.2 mg/dl C) Potassium 4.9 mEq/L D) Blood glucose 162 mg/dl

D) Blood glucose 162 mg/dl Hyperglycemia or increased blood glucose level is an adverse effect of corticosteroid therapy.

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: a) weight gain in arms and legs. b) thick, coarse skin. c) hypotension. d) deposits of adipose tissue in the trunk and dorsocervical area.

D) Deposits of adipose tissue in the trunk and dorsocervical area Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

The nurse caring for a 54-year-old patient hospitalized with diabetes mellitus would look for which of the following laboratory test results to obtain information on the patient's past glucose control? A) Prealbumin level B) Urine ketone level C) Fasting glucose level D) Glycosylated hemoglobin level

D) Glycosylated hemoglobin level A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus the test can give an indication of glycemic control over approximately 2 to 3 months.

Which statement best indicates that a client understands how to administer his own insulin injections? a) "I need to wash my hands before I give myself my injection." b) "If I'm not feeling well, I can get a friend or neighbor to help me." c) "I need to be sure no air bubbles remain." d) "I wrote down the steps in case I forget what to do."

D) I wrote down the steps in case I forgot. The fact that the client has written down each step of insulin administration provides the best assurance that he'll follow through with all the proper steps. Awareness of air bubbles and hand washing indicate that the client understands certain aspects of giving an injection, but doesn't confirm he understands all of the steps. Saying that he can ask a friend or neighbor for help indicates a need for further instruction.

A patient's recent medical history is indicative of diabetes insipidus. The nurse would perform patient education related to which of the following diagnostic tests? A) Thyroid scan B) Fasting glucose test C) Oral glucose tolerance D) Water deprivation test

D) Water deprivation test A water deprivation test is used to diagnose the polyuria that accompanies diabetes insipidus. Glucose tests and thyroid tests are not directly related to the diagnosis of diabetes insipidus.

12. A patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. The nurse will plan to a. start an intravenous line. b. screen the patient for shellfish allergies. c. teach the patient that DEXA is noninvasive. d. give an oral sedative.

Rationale: DEXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required. Cognitive Level: Application Text Reference: p. 1625 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient has atrial fibrillation and takes warfarin (Coumadin). b. The patient takes a diuretic because of a history of hypertension. c. The patient's blood pressure is 144/90 mm Hg. d. The patient's speech is difficult to under

Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated. Cognitive Level: Application Text Reference: p. 1512 Nursing Process: Assessment NCLEX: Physiological Integrity

A client has a disorder of the pancreas. The nurse recognizes that which of the following hormones may be affected as a result? Select all that apply. a) Somatostatin b) Glucagon c) Aldosterone d) Insulin e) Epinephrine

Somatostatin, Glucagon, Insulin The pancreas lies below the stomach, with the head of the gland close to the duodenum. It is both an exocrine and an endocrine gland. The exocrine portion secretes digestive enzymes that the common bile duct carries to the small intestine. The hormone secreting cells of the pancreas, called the islets of Langerhans, release insulin, glucagon, somatostatin, and pancreatic polypeptide. Insulin lowers the level of blood glucose when it rises beyond normal limits. Glucagon raises blood sugar levels by stimulating glycogenolysis, the breakdown of glycogen into glucose, in the liver. Somatostatin helps maintain a relatively constant level of blood sugar by inhibiting the release of insulin and glucagons.

Med-Surg2

Conjuntos de estudio relacionados

Series 66 Chapter 9: Investment Recommendations - Risks and Returns

Management Study Guide: Effective Teamwork

Chapter 9 Physics

AIS Chapter 12: Accounting and Enterprise Software

History Ch 2 study guide

BUS 121 Test 2 Review

Chapter 10 Riders

PHY102

40th President of the United States - Ronald Reagan

Final Quiz Critical Care

Sersafe test

Nursing 104 Chapter 34 & 35 Study Guide

CFFP_1 Module Five Exam

Greeting people

EAQ Practice Questions

Unit 2

Mock Exam 1

Evolve Respiratory Quiz 1

SOCI 111 ch. 11 review quiz

Philosophy Midterm 1 CSUF