medsurg

After receiving change-of-shift report, which patient should the nurse assess first?

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

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

Patient's ability to follow a complex medication regimen

A patient who has begun to awaken after 30 minutes in the post anesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate?

Assess for bladder distention.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?

Assess for sensation and strength in the legs.

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action?

Assess the patient's airway.

A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?

Assign the patient to a room near the nurse's station.

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of frequent, cramping gas pains. What action by the nurse is the most appropriate?

Assist the patient to ambulate.

The surgical unit nurse has just received a patient with a history of smoking from the post anesthesia care unit. Which action is most important at this time?

Auscultate for adventitious breath sounds

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

Auscultate the patient's breath sounds.

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

Encourage fluid intake up to 4000 mL every day.

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem?

Encourage the patient to purchase a wig or hat to wear when hair loss begins

In the post anesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?

Encourage the patient to take deep breaths.

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation?

Extremity numbness

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the post anesthesia care unit?

Increased anesthesia recovery time

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider?

Increased carcinoembryonic antigen (CEA)

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

Infuse 5% dextrose in water at 125 mL/hr.

The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?

"I rarely have the energy to get out of bed."

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

Lung sounds

An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching?

Many drugs interact with antiretroviral medications.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first?

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform?

Observe for swelling of the patient's lips and tongue.

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take?

Obtain a blood glucose measurement before any insulin administration.

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP) (select all that apply)?

Obtain and document baseline vital signs. Remove nail polish and apply pulse oximeter. Transport the patient by stretcher to the operating room

During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?

Obtain more information about the family history.

Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?

Offer the patient a urinal or bedpan.

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?

Oral saquinavir (Invirase)

After change-of-shift report on the oncology unit, which patient should the nurse assess first?

Patient who is neutropenic and has a temperature of 100.5° F (38.1° C)

Which patient should the nurse assess first?

Patient who is sneezing after subcutaneous immunotherapy

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

"After a couple of years I will be able to stop taking the cyclosporine."

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?

"Can you tell me more about the thoughts that you are having?"

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

"I will drink apple juice instead of orange juice for breakfast."

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?

"I will need follow-up examinations for many years after treatment before I can be considered cured."

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching?

"I will take oral antihistamines before going to work."

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

"Increase fluids if your mouth feels dry."

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies?

"Plan to wait in the clinic for 20 to 30 minutes after the testing."

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

"The patient has developed acquired immunodeficiency syndrome (AIDS)."

A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?

"Would you like to talk about options for the care of your children?"

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?

A 24-yr-old patient who received neck radiation and has blood oozing from the neck

A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first?

Administer a dose of epinephrine.

The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information?

Can you tell me what has been helpful to you in the past when coping with stressful events?

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Check the oxygen (O2) saturation.

A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?

Check the patient's blood pressure.

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?

Clean the perianal area carefully after every bowel movement.

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient?

Consequences of aging on cell-mediated immunity

The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week.

Consult with the health care provider about giving a lower allergen dose.

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 103 /µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 103 /µL. Which action should the nurse take?

Continue to prepare the patient for the surgical procedure.

On admission of a patient to the post anesthesia care unit (PACU), the blood pressure (BP) is 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Continue to take vital signs every 15 minutes.

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time?

Encourage adequate nutrition, exercise, and sleep

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?

Crackles heard at the lung bases

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?

Daily alcohol intake

A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Daily weight

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

Give the patient the PRN IV morphine sulfate 4 mg

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

Gradually decreasing level of consciousness (LOC)

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next?

Have the patient use the incentive spirometer.

Which action could the post anesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit?

Help with the transfer of the patient onto a stretcher.

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?

Hematuria

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan?

Hospitalization is required for several weeks after the stem cell transplant.

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value?

IgE

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?

Monitor ionized calcium level.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus.

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

Na+ 154 mEq/L (154 mmol/L)

Which patient exposure by the nurse is most likely to require post exposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?

Needle stick with a needle and syringe used for a venipuncture

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

Patient's breath sounds are clear to auscultation.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?

Perform a bladder scan.

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the post anesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first?

Perform the jaw-thrust maneuver.

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first?

Place a tourniquet above the site.

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?

Plasmapheresis removes antibody-antigen complexes from circulation.

A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

Remind the patient about the need to return for retesting to verify the results.

A patient who takes a diuretic and a -blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery?

Serum potassium 3.2 mEq/L

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

Serum sodium level of 120 mg/dL

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?

Serum sodium of 126 mEq/L

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?

Shortness of breath

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?

Take the patient's vital signs.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?

The UAP stands by the patient's bed for 30 minutes talking with the patient.

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?

The biopsy will help decide the treatment for my enlarged prostate."

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash?

The donor T cells are attacking the patient's skin cells.

An experienced nurse orients a new nurse to the post anesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?

The new nurse positions an unconscious patient on the side upon arrival in the PACU.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

The patellar and triceps reflexes are absent.

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time?

The patient drinks grapefruit juice every day.

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

The patient is experiencing laryngeal stridor.

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety?

The patient is planning to drive home after surgery.

The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

The patient reports missing some doses of zidovudine (AZT)

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?

The patient swims several days each week.

Which information in the preoperative patient's medication history is most important to communicate to the health care provider?

The patient takes garlic capsules every day.

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?

The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

The patient will maintain intact perineal skin.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

The patient's calf is swollen, warm, and painful.

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?

The patient's father died after general anesthesia for abdominal surgery.

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

Use the push-pause method to flush the CVAD after giving medications.

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is wrong." Which functional health pattern should the nurse further assess?

Value-belief

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?

White blood cells (WBC) 2700/µL

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?

age

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?

blue berry yogurt

The nurse working in the post anesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next?

cover the patient with a warm blanket.

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?

suggest use of a daily planner and encourage adequate rest and sleep

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?

the UAP assists the patient to use dental floss after eating.

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?

"I can buy aloe vera gel to use on my skin."

Which statement by a patient scheduled for surgery is most important to report to the health care provider?

"I had a heart valve replacement last year."

Which statement by a patient would alert the nurse to a risk for decreased immune function?

"I had my spleen removed after a car accident."

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

"Malignant tumors may spread to other tissues or organs."

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which initial response by the nurse is appropriate?

"Tell me more about what happened to your mother."

The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient?

"You will need to be retested in 2 weeks."

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

200 mL sanguineous fluid in the wound drain

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?

A patient who is recovering from an anaphylactic reaction to a bee sting

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

Administer the prescribed normal saline bolus and insulin.

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient?

Administration of immunosuppressant medications

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing?

Albumin level 2.2 g/dL

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take?

Alert the surgery center about a possible latex allergy.

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?

Apply prescribed anesthetic gel to oral lesions before meals.

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem?

Avoid giving the patient foods that are strongly disliked.

The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer?

Baked chicken

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient?

Discuss a change in antiretroviral therapy.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Check the patient's class schedule to help decide when the drugs should be taken.

The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?

Discuss risks associated with cigarette smoking during each patient encounter.

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved?

Decreased peripheral edema

A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?

Decreasing the tumor size will improve the effects of other therapy.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for an open cholecystectomy?

Deep breathing and coughing

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

Digoxin (Lanoxin) 0.25 mg/day

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate?

Discuss specific concerns regarding self-care.

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate?

Discuss the herb and supplement use with the patient's health care provider.

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?

Document the color and amount of drainage.

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct?

Document the patient's history and teach about clinical manifestations of a type I latex allergy.

A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he does not know what to say to his wife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care?

Dysfunctional family processes related to effect of illness on family members

A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer?

Gamma globulin

interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?

IL-2 enhances the body's immunologic response to tumor cells.

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

Infuse the KCl at a rate of 10 mEq/hour.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Mental status

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

Metabolic acidosis

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Patient who has had 10 liquid stools in the last 24 hours

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?

Notify the patient's health care provider.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Notify the surgeon that the informed consent process is not complete.

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?

Patient has crackles up to the midline posterior chest.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?

Potential complication: venous thromboembolism

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete?

Presence of the Chvostek's sign

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?

Prevention of HIV transmission between sexual partners

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching?

Provide additional time for the patient to understand preoperative instructions and carry out procedures.

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon?

Results of patient-donor cross matching are positive

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?

Rinse the mouth before and after each meal and at bedtime with a saline solution.

During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?

Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?

Risk for injury: seizures

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient?

Screening for malignancies

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

Serum calcium is 18 mg/dL.

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

Skim milk

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?

Stock the patient's room with the necessary personal protective equipment.

The nurse is preparing a patient on the morning of surgery. The patient refuses to remove a wedding ring, saying, "I've never taken it off since the day I was married." Which response by the nurse is best?

Suggest that the patient give the ring to a family member to keep.

A patient is transferred from the post anesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?

Take the patient's vital signs.

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery?

The patient's report that her last menstrual period was 8 weeks ago

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

There are crackles throughout both lung fields.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider?

There is a 2-cm wheal at the site of the allergen injection.

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

"Consider participating in a needle-exchange program."

A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate?

"The cancer involves only the cervix."

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?

"The hypertonic solution will be more rapidly diluted when given through a central line."

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administer a skin test by the cutaneous scratch method.

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Blood pressure is 90/40 mm Hg.

A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

Continue to use contraception while taking this medication.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care?

Establish time to take a short walk almost every day

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is most appropriate?

Explain that dry mouth is an expected side effect.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?

Explain to the patient that this is an expected finding.

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?

the patient's visitors bring in fresh peaches.

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day?

Administer prescribed analgesic medications before the activities.

Which example should the nurse use to explain an infant's "passive immunity" to a new mother?

Breastfeeding

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?

Flush a saline lock with normal saline.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

Respiratory alkalosis

A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate?

Administer prescribed antiemetics 1 hour before the treatments.

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is most effective for the nurse to take at this time?

Administer the prescribed PRN IV morphine sulfate.

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

Edema

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?

Stop the infusion if swelling is observed at the site

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?

Suggest that the health care provider order a basic metabolic panel.