Med/Surg

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

All are correct except for a. Oxygen Saturation. Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). The other information is also essential to assess, but are not used for CURB-65 scoring.

A nurse is conducting an assessment on a 50-year-old patient with Huntington's disease. Which assessment finding(s) would the nurse expect to note? Select one or more: a. weakness in upper extremeties b. lethargy c. Unsteady gait d. Slurred speech e. Inability to keep tongue from protruding

Correct Answers: c. Unsteady gait Correct d. Slurred speech Correct e. Inability to keep tongue from protruding Correct

Hypertensive Crisis Manifestations

Manifestations: • Rapid onset • Blurred vision • SBP >180 mmHg and DBP >120 mmHg • Headache • Confusion • Motor and sensory deficits

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? Select one: a. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks." b. "I will continue to do the deep breathing and coughing exercises at home." c. "I will call the doctor if I still feel tired after a week." d. "I will schedule two appointments for the pneumonia and influenza vaccines."

b. "I will continue to do the deep breathing and coughing exercises at home."

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? Select one: a. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg b. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg c. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg d. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

c. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg

The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased most at risk for impaired gas exchange? A patient Select one: a. with a blood glucose of 350 mg/dL b. with a heart rate of 100 beats/min and blood pressure of 100/60 c. with a hemoglobin of 8.5 g/dL d. who has been on anticoagulants for 10 days

c. with a hemoglobin of 8.5 g/dL A low hemoglobin indicates low carrying capacity for both oxygen and carbon dioxide.

An adolescent 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 administer? Select one: a. Hepatitis B vaccine b. Corticosteroids c. Fresh frozen plasma d. Gamma globulin

d. Gamma globulin The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with Select one: a. active range-of-motion (ROM) exercises. b. a short routine of isometric exercises. c. stretching exercises to relieve joint stiffness. d. a warm bath followed by a short rest.

d. a warm bath followed by a short rest. 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.

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to Select one: a. check the level of consciousness. b. obtain the blood pressure. c. obtain a 12-lead electrocardiogram (ECG). d. administer oxygen.

d. administer oxygen. The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.

A 40-year-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the Select one: a. prophylactic antibiotics to decrease the risk for aspiration pneumonia. b. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. c. lifestyle changes of improved nutrition and exercise that delay disease progression. d. option of genetic testing for the patient's children to determine their own HD risks.

d. option of genetic testing for the patient's children to determine their own HD risks. Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet is used for Parkinson's, not Huntington's and will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

A nurse is developing a plan of care for a 42-year-old female patient who was recently diagnosed with Myasthenia Gravis. The patient is currently taking Neostigmine (Prostigmin). Which of the following interventions should the nurse include in the plan of care? Select one or more: a. Discuss strategies to avoid fatigue and undue stress b. Assess patient for signs of hemiansiopia c. Avoid exposure to extreme cold or heat d. Assess the need for reproductive counseling

Correct Answers: a. Discuss strategies to avoid fatigue and undue stress c. Avoid exposure to extreme cold or heat d. Assess the need for reproductive counseling

The nurse should ask which of the following questions to detect the risk factors for metabolic acidosis? (Select all that apply): Select one or more: a. Have you been vomiting today? b. Which weight loss diet are you using? c. What type of antacid did you take? d. How long have you had diarrhea? e. Are you still feeling short of breath? f. When did your kidneys stop working?

Correct Answers: b. Which weight loss diet are you using? d. How long have you had diarrhea? f. When did your kidneys stop working? Risk factors for metabolic acidosis include decreased excretion of metabolic acid from oliguria or anuria (kidneys are not working); excessive production of metabolic acid from starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from diarrhea. Vomiting (loss of acid) causes metabolic alkalosis, as does overusing bicarbonate antacids. Shortness of breath might be related to a cause of respiratory acidosis.

Asthma Manifestation

MANIFESTATIONS • Chest tightness • Cough • Dyspnea • Wheezing • Tachypnea • Tachycardia • Anxiety • Apprehension

HTN Manifestation

Symptoms of severe hypertension • Fatigue • Dizziness • Palpitations • Angina • Dyspnea

Which of the following situations represent the use of evidence-based practice in clinical decision-making for client care? Select all that apply. Select one or more: a. Using a research-based scale to routinely assess a client's risk for skin breakdown. b. Using information about the client's preferences and values when planning care. c. Manually lifting a client rather than using a slider board to transfer a client from a bed to a stretch. d. Encouraging a client to take a laxative twice a week to prevent constipation.

The correct answer is: a. Using a research-based scale to routinely assess a client's risk for skin breakdown. b. Using information about the client's preferences and values when planning care. Evidence-based practice is an approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. Encouraging a client to take a laxative to prevent constipation promotes laxative dependency; rather, the nurse would encourage practices such as increased fluid intake and consumption of a high-fiber diet. Manually lifting a client rather than using a slider board to transfer a client from a bed to a stretch could result in injury to healthcare workers and does not reflect good practice; rather, the nurse would use assistive devices that will help prevent injury.

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? -Prepare an infusion of dopamine (Intropin). -Start 100% oxygen using a nonrebreather mask. -Inject epinephrine (Adrenalin) IM or IV. -Discontinue the antibiotic infusion. -Give diphenhydramine (Benadryl) IV.

The correct answer is: 1. Discontinue the antibiotic infusion. 2. Start 100% oxygen using a nonrebreather mask. 3. Inject epinephrine (Adrenalin) IM or IV. 4. Give diphenhydramine (Benadryl) IV. 5. Prepare an infusion of dopamine (Intropin). The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last.

A nursing instructor is talking about care coordination with nursing students. The instructor stresses which of the following to the students concerning care coordination? Select one: a. "Collaboration is a big part of care coordination." b. "A patient must ask for what they need in order to coordinate care." c. "Medical diagnoses are an integral part of care coordination." d. "The nurse does most of the work in care coordination."

a. "Collaboration is a big part of care coordination."

A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? Select one: a. "Once the dehydration is corrected, the patient's confusion should improve." b. "I can make a referral for a home health aide to assist with the patient." c. "I can show you how to care for the patient once you return home." d. "Don't worry; the patient should be fine once she is in a familiar environment."

a. "Once the dehydration is corrected, the patient's confusion should improve." Dehydration is the source of this patient's delirium. Once the dehydration resolves, the delirium should as well. Being in a familiar environment is helpful for people with dementia, but will not help with delirium. Home health is not indicated by the information provided. We expect that this patient will recover to baseline.

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? Select one: a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain b. 52-year-old with a BP of 212/90 who has intermittent claudication c. 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL d. 48-year-old with a BP of 172/98 whose urine shows microalbuminuria

a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain The patient with chest pain may be experiencing acute myocardial infarction, and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.

The health care provider has prescribed the following collaborative interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? Select one: a. Administer varicella vaccine. b. Naproxen (Aleve) 200 mg BID. c. Draw anti-DNA blood titer. d. Famotidine (Pepcid) 20 mg daily.

a. Administer varicella vaccine. Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? Select one: a. An elevation of the total white cell count indicates generalized inflammation b. Level of neutrophils provides guidelines to monitor a chronic infection. c. Eosinophil count will assist to identify the presence of a respiratory infection. d. White cell count will differentiate types of respiratory bacteria.

a. An elevation of the total white cell count indicates generalized inflammation An elevated white blood cell count indicate generalized inflammation. An elevated eosynophil count indicates parasitic infection. The other answers are not correct statements

A patient who is taking Lasix (furosimide) for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? Select one: a. Ask the health care provider to order a basic metabolic panel. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Assess for facial muscle spasms.

a. Ask the health care provider to order a basic metabolic panel. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia.

A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by "passive immunity." Which example should the nurse use to explain this type of immunity? Select one: a. Breastfeeding her infant b. Exposure to communicable diseases c. Early immunization d. Bone marrow donation

a. Breastfeeding her infant Colostrum provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. It requires that the infant has an immune response after exposure to an antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active immunity.

While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? Select one: a. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. b. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

a. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. The patient's allergy history and occupation indicate a risk of developing a latex allergy. The nurse should be prepared to manage any symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely.

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? Select one: a. Encourage fluid intake up to 4000 mL every day. b. Auscultate lung sounds every 4 hours. c. Maintain the patient on bed rest. d. Monitor for Trousseau's and Chvostek's signs.

a. Encourage fluid intake up to 4000 mL every day. To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

Care coordination models should be adopted in health care facilities. If models are not put into practice, the shortcomings of the health care system may display which of the following items? (Select all that apply.) Select one or more: a. Increased pharmacy costs b. Low birth weight newborns c. Poor health outcomes d. Cost inefficiencies e. Fragmented services f. Decrease in patients

a. Increased pharmacy costs b. Low birth weight newborns c. Poor health outcomes d. Cost inefficiencies e. Fragmented services

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk? Select one: a. Level of consciousness b. Lung sounds in lung bases c. Heart rate and blood pressure d. Urine output and color

a. Level of consciousness Level of consciousness is the assessment listed that most closely related to acid base balance. Remember, the question was not about hyperthyroidism, was it?

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? Select one: a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patient's chart. d. Teach the patient about the risk of magnesium-containing antacids

a. Notify the patient's health care provider. The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? Select one: a. The patient has a glass of low-fat milk with each meal. b. The patient avoids eating nuts or nut butters. c. The patient restricts intake of chicken and fish. d. The patient has two cups of coffee in the morning.

a. The patient has a glass of low-fat milk with each meal. For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? Select one: a. The patient puffs up the cheeks while exhaling. b. The patient's ratio of inhalation to exhalation is 1:3. c. The patient practices by blowing through a straw. d. The patient inhales slowly through the nose.

a. The patient puffs up the cheeks while exhaling. The patient should relax the facial muscles without puffing the cheeks while doing pursed lip breathing. The other actions by the patient indicate a good understanding of pursed lip breathing.

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? Select one: a. The patient was oriented and alert when admitted. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient is oriented to person but disoriented to place and time.

a. The patient was oriented and alert when admitted. The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

When administering a mental status examination to a patient with delirium, the nurse should Select one: a. choose a place without distracting stimuli. b. reorient the patient during the examination. c. administer an anxiolytic medication. d. wait until the patient is well-rested.

a. choose a place without distracting stimuli. Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

The main features of complex adaptive systems that are relevant to nursing leadership are Select one: a. focused on creating organizational change and looking at the whole versus individual parts. b. defined by efforts of leadership to mandate organizational change. c. autocratic in nature with a top-down structure for change. d. dependent on employees knowing what change is necessary and acting independently.

a. focused on creating organizational change and looking at the whole versus individual parts.

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? Select one: a. pH low, PaCO2 high, HCO3 - high b. pH low, PaCO2 low, HCO3 - low c. pH low, PaCO2 high, HCO3 - normal d. pH high, PaCO2 high, HCO3 - high

a. pH low, PaCO2 high, HCO3 - high

A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." An appropriate nursing diagnosis for the patient is Select one: a. social isolation related to embarrassment about the effects of SLE. b. activity intolerance related to fatigue and inactivity. c. impaired skin integrity related to itching and skin sloughing. d. impaired social interaction related to lack of social skills.

a. social isolation related to embarrassment about the effects of SLE. The patient's statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

The nurse and physician are explaining the home care that will be needed by a patient after discharge. The patient's spouse states angrily that it will not be possible to provide the care recommended. Knowing that patients are collaborative partners in the discharge process, what is the best response by the nurse? Select one: a. "Let me review what is needed again." b. "What concerns do you have about the prescribed care?" c. "It is important that you do what the physician has prescribed." d. "I can come back after you talk with your spouse about the care."

b. "What concerns do you have about the prescribed care?"

Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis? Select one: a. Exercises should be performed passively by someone other than the patient. b. Application of cold packs before exercise may decrease joint pain. c. Walking may substitute for range-of-motion (ROM) exercises on some days. d. Affected joints should not be exercised when pain is present.

b. Application of cold packs before exercise may decrease joint pain. 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 and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? Select one: a. Draw blood for rheumatoid factor analysis. b. Assess the nodules for skin breakdown or infection. c. Teach the patient about injections for the nodules. d. Discuss the need for surgical removal of the nodules.

b. Assess the nodules for skin breakdown or infection. Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? Select one: a. Liver function tests b. C-reactive protein level c. Blood glucose test d. Serum electrolyte levels

b. C-reactive protein level 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 in patients receiving corticosteroids.

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

b. Cough productive of bloody, purulent mucus Hemoptysis may indicate life-threatening hemorrhage and should be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications.

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? Select one: a. Basophils b. IgE c. Neutrophils d. IgA

b. IgE Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

When nurses discuss the "science of nursing," what does this phrase mean? Select one: a. Clinical competency b. Knowledge base c. Practice component d. Holistic care

b. Knowledge base Although there are many layers of care involved in nursing, the foundation for all aspects of nursing is the knowledge base. Without a strong knowledge base, nurses would not be able to develop clinical competency or practice, or provide holistic care.

The nurse is assessing a patient who has diabetic ketoacidosis. Her assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? Select one: a. Contact the physician immediately regarding this complication. b. Lubricate the patient's lips and allow continued hyperventilation. c. Request an order for pain medication and oxygen at 6 L/min. d. Have the patient breathe into a paper bag to stop hyperventilating.

b. Lubricate the patient's lips and allow continued hyperventilation. Hyperventilation is a compensatory response to metabolic acidosis and should be allowed to continue because it helps move the blood pH toward the normal range. Lubricating the lips is a supportive nursing intervention that prevents drying and cracking of the lips during hyperventilation. Although pain and hypoxia can trigger hyperventilation, they are not the cause in this patient. Interventions to stop hyperventilation are not appropriate when it is a compensatory response. Hyperventilation is an expected beneficial compensatory response to metabolic acidosis and does not require contacting the physician.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? Select one: a. Abnormal serum potassium level b. Presence of the Chvostek's sign c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

b. Presence of the Chvostek's sign The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

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

b. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone. Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting β2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but rather is used for maintenance therapy.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? Select one: a. There is sediment and blood in the patient's urine. b. There are crackles audible throughout both lung fields. c. The blood pressure increases from 120/80 to 142/94. d. The patient's radial pulse is 105 beats/minute.

b. There are crackles audible throughout both lung fields. Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? Select one: a. Central venous pressure (CVP) is normal. b. Urine output is 60 mL over the last hour. c. Hemoglobin is within normal limits. d. Mean arterial pressure (MAP) is 72 mm Hg.

b. Urine output is 60 mL over the last hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

Medical models coordinate medical services and were traditionally designed to be Select one: a. nursing oriented. b. diagnosis specific. c. community oriented. d. patient specific.

b. diagnosis specific.

A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately Select one: a. apply a compression stocking to the leg. b. keep the patient in bed in the supine position. c. assist the patient in gently exercising the leg. d. elevate the leg above the level of the heart.

b. keep the patient in bed in the supine position. 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 will increase oxygen demand for the tissues of the leg.

The nurse would identify which patient as having a problem of impaired gas exchange secondary to a perfusion problem? A patient with Select one: a. chronic obstructive pulmonary disease (COPD) b. peripheral arterial disease of the lower extremities c. chronic asthma d. severe anemia secondary to chemotherapy

b. peripheral arterial disease of the lower extremities Although all these patients might have impaired gas exchange, the patient with peripheral artery is the only one with a perfusion problem. COPD and asthma are obstructive disorders and anemia is a transport problem

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask first? Select one: a. "Did you take any acetaminophen (Tylenol) today?" b. "Have there been any recent stressful events in your life?" c. "Have you been consistently taking your medications?" d. "Have you recently taken any antihistamine medications?"

c. "Have you been consistently taking your medications?"

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? Select one: a. "I think I have asthma because I cough when dogs are near." b. "Is there a place that I can dispose of my unused morphine pills?" c. "I ran out of money and am cutting my insulin dose in half." d. "I want to lose at least 20 pounds without getting sick this time."

c. "I ran out of money and am cutting my insulin dose in half." Cutting an insulin dose in half is very likely to result in ketoacidosis, a life threatening emergency, within a short period of time. Coughing around dogs should be evaluated, but is not as urgent. Weight loss is an educational need and proper disposal of medications, while important, has no direct physical consequences.

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? Select one: a. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings." b. "I need to find another way to earn extra money." c. "I will plan to take oral antihistamines daily before going to work." d. "I will get a prescription for epinephrine and learn to self-inject it."

c. "I will plan to take oral antihistamines daily before going to work." Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

Which diagnosis indicates that the nurse should assess the patient most carefully for development of metabolic acidosis? Select one: a. Type B chronic obstructive pulmonary disease (COPD) and pneumonia. b. Severe hyperaldosteronism. c. A pancreatic fistula that is draining. d. Acute meningococcal meningitis.

c. A pancreatic fistula that is draining. The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from bicarbonate loss. Type B COPD and pneumonia cause respiratory acidosis by impairing carbonic acid excretion. Meningitis can stimulate hyperventilation, which causes respiratory alkalosis. Aldosterone facilitates renal excretion of hydrogen ions; hyperaldosteronism would cause metabolic alkalosis.

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? Select one: a. Assign the patient to a semi-private room and place an order for a low-salt diet. b. Place the patient on telemetry to monitor for peaked T waves. c. Assign the patient to a room near the nurse's station. d. Place the patient in a room nearest to the water fountain.

c. Assign the patient to a room near the nurse's station. The patient should be placed near the nurse's station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? Select one: a. Use of over-the-counter (OTC) laxatives b. Multivitamin/mineral use c. Daily alcohol intake d. Intake of dietary protein

c. Daily alcohol intake Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels.

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? Select one: a. Presence of edema b. Skin turgor c. Daily weight d. Hourly urine output

c. Daily weight Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? Select one: a. Decreased C-reactive protein (CRP) b. Positive antinuclear antibodies (ANA) c. Elevated blood urea nitrogen (BUN) d. Positive lupus erythematosus cell prep

c. Elevated blood urea nitrogen (BUN) The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.

The patient has severe metabolic alkalosis. Which intervention has the highest priority? Select one: a. Measure the urine output and skin turgor. b. Teach the family about metabolic alkalosis. c. Raise the side rails on the patient's bed. d. Administer intravenous NaHCO3 as ordered.

c. Raise the side rails on the patient's bed. Severe metabolic alkalosis causes a decreased level of consciousness; raising the side rails is a safety intervention in that situation. Safety interventions are a higher priority than teaching. An order to administer intravenous NaHCO3 to a patient with metabolic alkalosis should be questioned because it would make the alkalosis worse. Urine output and skin turgor are part of the assessment for extracellular fluid volume (ECV) deficit, but this is not a high priority in this situation.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? Select one: a. Large amounts of greenish sputum b. Respiratory rate of 28 breaths/minute c. Weak, nonproductive cough effort d. Resting pulse oximetry (SpO2) of 85%

c. Weak, nonproductive cough effort 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.

A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure? Select one: a. Administer oral corticosteroids 2 hours before the procedure. b. Ensure that the patient has been NPO for several hours before the test. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Give the rescue medication immediately before testing.

c. Withhold bronchodilators for 6 to 12 hours before the examination. Bronchodilators are held before pulmonary function testing (PFT) 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 be held before PFTs. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that Select one: a. a BP recheck should be scheduled in a few weeks. b. there is an immediate danger of a stroke and hospitalization will be required. c. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed. d. dietary sodium and fat content should be decreased.

c. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed. A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should Select one: a. ask the patient about any increase in libido. b. inspect the skin for rashes or discoloration. c. inquire about urinary tract problems. d. assess for the presence of chest pain.

c. inquire about urinary tract problems. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

The nurse advises a patient with myasthenia gravis (MG) to Select one: a. anticipate the need for weekly plasmapheresis treatments. b. protect the extremities from injury due to poor sensory perception. c. perform physically demanding activities early in the day. d. do frequent weight-bearing exercise to prevent muscle atrophy.

c. perform physically demanding activities early in the day. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus? Select one: a. 139/90 mm Hg b. 102/60 mm Hg c. 136/82 mm Hg d. 128/76 mm Hg

d. 128/76 mm Hg The goal for antihypertensive therapy for a patient with hypertension and diabetes mellitus is a BP <130/80 mm Hg. The BP of 102/60 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension? Select one: a. Teach the patient that headaches may occur with this medication. b. Instruct the patient to ask for help if heart palpitations occur. c. Encourage the use of hard candy to prevent dry mouth. d. Ask the patient to request assistance when getting out of bed.

d. Ask the patient to request assistance when getting out of bed. Labetalol decreases sympathetic nervous system activity by blocking both á- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? Select one: a. Have the patient cough forcefully. b. Notify the patient's health care provider. c. Administer the PRN morphine. d. Auscultate breath sounds.

d. Auscultate breath sounds. 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. Assessment should occur before administration of pain medications. 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.

A patient has just been diagnosed with hypertension and has been started on captopril (Capoten). Which information is important to include when teaching the patient about this medication? Select one: a. Increase fluid intake if dryness of the mouth is a problem. b. Include high-potassium foods such as bananas in the diet. c. Check blood pressure (BP) in both arms before taking the medication. d. Change position slowly to help prevent dizziness and falls.

d. Change position slowly to help prevent dizziness and falls. The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the medication, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

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? Select one: a. Hematocrit 28% b. Absence of skin tenting c. Blood pressure 110/72 mm Hg d. Decreased peripheral edema

d. Decreased peripheral edema Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

The nurse is caring for a patient with a progressive, degenerative muscle illness. The patient states that she would like to remain in her home with her daughter as long as possible. What action should the nurse take? Select one: a. Tell the patient to make plans to move to an assisted-living facility. b. Ask the patient to come in for daily physical therapy. c. Teach the patient muscle strengthening and stretching exercises. d. Discuss resources to help the patient and make appropriate referrals.

d. Discuss resources to help the patient and make appropriate referrals. It is important to honor the patient's preferences whenever possible, so the nurse will assess what resources are available and make the appropriate referrals.

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? Select one: a. Weight gain of 2 pounds (1 kg) above the admission weight b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Oral temperature of 100.1° F d. Gradually decreasing level of consciousness (LOC)

d. Gradually decreasing level of consciousness (LOC)

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? Select one: a. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. b. Administer 3% saline if serum sodium decreases to less than 128 mEq/L. c. Administer IV morphine sulfate 4 mg every 2 hours PRN. d. Infuse 5% dextrose in water at 125 mL/hr.

d. Infuse 5% dextrose in water at 125 mL/hr. Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

A nurse manager has recently overheard several negative comments made by nurses on the unit about other nurses on the unit. The manager recognizes that the nurses are exhibiting what type of behavior that is detrimental to collaboration? Select one: a. Personal vendetta b. Critical thinking c. Vertical violence d. Lateral violence

d. Lateral violence Lateral violence is the term used for disruptive personal attacks between colleagues. The nurses are not exhibiting critical thinking skills. The other terms are not correct.

Which of the following statements about leadership is false? Select one: a. It is important for all nurses to develop leadership skills b. Clinical leaders are needed in every setting to ensure that quality patient care is delivered and research findings are adopted to improve patient care c. Leaders are made, not born d. Leadership in health care is reserved for designated administrators and managers

d. Leadership in health care is reserved for designated administrators and managers

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? Select one: a. "To prevent another problem, I should eat less sodium during diarrhea." b. "I should try to slow my breathing so my acids and bases will be balanced." c. "Diarrhea removes fluid from the body, so I should drink more ice water." d. My blood became too acidic because I lost some base in the diarrhea fluid."

d. My blood became too acidic because I lost some base in the diarrhea fluid." This patient has lost base through diarrhea. Eating less sodium will not prevent the loss of base through stool. Ice water can upset the stomach and increase cramping. Having the patient try to modify respirations will not work and could be dangerous.

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? Select one: a. Metoprolol (Lopressor) 12.5 mg orally daily b. Lantus insulin 24 U subcutaneously every evening c. Ibuprofen (Motrin) 400 mg every 6 hours d. Oral digoxin (Lanoxin) 0.25 mg daily

d. Oral digoxin (Lanoxin) 0.25 mg daily Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? Select one: a. Plan for attendance at activities with several other patients on the unit. b. Allow food selections from a menu with several choices. c. Schedule frequent field trips off the unit for cognitive stimulation. d. Plan for a structured daily routine of events and caregivers.

d. Plan for a structured daily routine of events and caregivers. Predictable activities provide security for someone with a cognitive deficit. Unfamiliar environments can confuse them.

Which laboratory data is important to communicate to the health care provider for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis? Select one: a. The blood glucose is 90 mg/dL. b. The erythrocyte sedimentation rate is elevated. c. The rheumatoid factor is positive d. The white blood cell (WBC) count is 1500/µL.

d. The white blood cell (WBC) count is 1500/µL. 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 elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.

A nurse is performing discharge teaching on a 35-year-old female patient who was recently diagnosed with Multiple Sclerosis. Which of the following would be an important topic to include? Select one: a. What can be done to cure the disease b. How pregnancy can improve manifestations c. How to prevent sexually transmitted infections d. Why it is important to avoid extremes of heat and cold

d. Why it is important to avoid extremes of heat and cold Extremes of heat and cold can exacerbate MS. Look up the effect of MS on pregnancy. There is no known cure for MS. While preventing STD's may not be inappropriate, it is not related to MS.