MISCELANEOUS - ADULT HEALTH FINAL

Vasopressin 0.2 unit/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 100 units/250 mL normal saline. How many mL/hr will the nurse infuse?

ANS: 30 There are 0.4 unit/1 mL. An infusion of 30 mL/hr will result in the patient receiving 0.2 units/min as prescribed.

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

ANS: A, B, D, C The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

A patient with chronic pain who has been receiving morphine sulfate 20 mg IV over 24 hours is to be discharged home on oral sustained-release morphine (MS Contin) administered twice a day. What dosage of MS Contin will be needed for each dose to obtain an equianalgesic dose for the patient? (Morphine sulfate 10 mg IV is equianalgesic to morphine sulfate 30 mg orally.)

ANS: MS Contin 30 mg/dose Morphine sulfate 20 mg IV over 24 hours will be equianalgesic to MS Contin 60 mg in 24 hours. Because the total dose needs to be divided into two doses, each dose should be 30 mg.

A patient who is lethargic and with deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: A

Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with esophageal varices who has a rapid heart rate b. A patient with a history of gastrointestinal bleeding who has melena c. A patient with nausea who has a dose of metoclopramide (Reglan) due d. A patient who is crying after receiving a diagnosis of esophageal cancer

ANS: A A patient with esophageal varices and a rapid heart rate indicate possible hemodynamic instability caused by GI bleeding. The other patients do not indicate acutely life-threatening complications.

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a patient's dislocated shoulder. What action does the nurse anticipate? a. Starting an IV in the patient's unaffected arm b. Securing an airtight fit for the inhalation mask c. Preparing for placement of an epidural catheter d. Giving deep sedation under physician supervision

ANS: A For MAC, IV sedatives, such as the benzodiazepines, are given. Therefore, the patient needs IV access. Inhaled and epidural agents are not included in MAC. RNs who are trained and are allowed by agency protocols and state nurse practice acts can provide moderate to deep sedation. However, the provider of MAC must be an anesthesia care provider since it may be necessary to change to general anesthesia during the procedure.

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? a. The patient is experiencing stridor. b. The patient reports generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

ANS: A Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.

A patient who has been receiving diuretic therapy is admitted to the emergency departmentwith 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? a. Digoxin (Lanoxin) 0.25 mg/day b. Ibuprofen 400 mg every 6 hours c. Lantus insulin 24 U every evening d. Metoprolol (Lopressor) 12.5 mg/day

ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will need to do more assessment about the other medications, but they are not of as much concern with the potassium level.

Which statement, if made by a new circulating nurse, reflects understanding of the irculating nurse role? a. "I will assist in preparing the operating room for the patient." b. "I will don sterile gloves to obtain items from the unsterile field." c. "I will assist with suturing of incisions and maintaining hemostasis." d. "I will remain gloved while performing activities in the sterile field."

ANS: A Preparing the operating room for the patient describes the role of a circulating nurse. All other answer options describe specific roles and actions of scrub nurses. The circulating nurse performs activities in the unsterile field and is not scrubbed, gowned, or gloved. The scrub nurse follows the designated scrub procedure, is gowned and gloved in sterile attire, and performs activities in the sterile field.

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patient's PaO2 is 45 mm Hg. b. The patient's PaCO2 is 33 mm Hg. c. The patient's respirations are shallow. d. The patient's respiratory rate is 32 breaths/min.

ANS: A The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. What should the nurse do when the patient arrives on the orthopedic unit after surgery? a. Assess the surgical site for hemorrhage. b. Remove the prosthesis and wrap the site. c. Place the patient in a side-lying position. d. Keep the residual limb elevated on a pillow.

ANS: A The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture.

Which patient should the nurse assess first after receiving change-of-shift report? a. A 30-yr-old patient who has a distended abdomen and tachycardia b. A 60-yr-old patient whose ileostomy has drained 800 mL over 8 hours c. A 40-yr-old patient with ulcerative colitis who had six liquid stools in 4 hours d. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool

ANS: A The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT (Select all that apply.)? a. Allergy to shellfish b. Patient reports claustrophobia c. Elevated serum creatinine level d. Recent bronchodilator inhaler use NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NURSINGTB.COM e. Inability to remove a wedding band

ANS: A, C Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging or pulmonary spirometry.

Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? (Select all that apply.) a. Monitor serum calcium. b. Teach about the need for strict bed rest. c. Explain the use of sustained-release opioids. d. Support the left leg when repositioning the patient. e. Assist family and patient as they discuss the prognosis.

ANS: A, C, D, E The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity is important to maintain function and avoid complications associated with immobility. Adequate pain medication, including sustained-release and rapid-acting opioids, is needed for the severe pain often associated with bone cancer. The prognosis for metastatic bone cancer is poor, so the patient and family need to be supported as they deal with the reality of the situation.

A nurse assesses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management? (Select all that apply) a. Confusion b. Hypoglycemia c. Poor cough effort d. Shallow breathing e. Elevated temperature

ANS: A, C, D, E Inadequate pain control can decrease tidal volume and cough effort, leading to complications such as pneumonia with increases in temperature. Poor pain control may lead to confusion through a variety of mechanism, including hypoventilation and poor sleep quality. Stressors such as pain cause increased release of corticosteroids that can result in hyperglycemia.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain. b. The patient with neutropenia who has a temperature of 101.8° F. c. The patient with thrombocytopenia who has oozing gums after a tooth extraction. d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours.

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.

ANS: B After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Urine output d. Edema presence

ANS: B 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. 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.

A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO32- 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

ANS: B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Acidosis does not cause intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure.

A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem? a. Acute pain b. Risk for infection c. Activity intolerance d. Risk for constipation

ANS: B A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first postoperative day, so the problems caused by immobility are not as likely. Pain management is important, but the most important action is to prevent infection.

What laboratory value should the nurse check before administering captopril to a patient with stage 2 chronic kidney disease? a. Glucose b. Potassium c. Creatinine d. Phosphate

ANS: B Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect whether the captopril was given or not.

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 10.2 g/dL d. White blood cells 11,900/μL

ANS: B Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response.

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

ANS: B Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the prescribed opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

ANS: B Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). What should the nurse explain about the action of the medication? a. "It decreases nausea and vomiting." b. "It inhibits development of stress ulcers." c. "It lowers the risk for H. pylori infection." d. "It prevents aspiration of gastric contents."

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

ANS: B Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse indicates a need for further teaching? a. The patient ambulates around the room. b. The patient's visitors bring in fresh peaches. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection.

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Patient reports severe back pain. b. Serum calcium level is 15 mg/dL. c. Patient reports no stool for 5 days. d. Urine sample has Bence-Jones protein.

ANS: B Hypercalcemia may lead to complications such as dysrhythmias or seizures and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening.

A patient with gout has a new prescription for losartan (Cozaar). What should the nurse plan to monitor? a. Blood glucose b. Blood pressure c. Erythrocyte count d. Lymphocyte count

ANS: B Losartan may be effective for treating older patients with gout and hypertension. Losartan promotes urate excretion and may normalize serum urate. Losartan, an angiotensin II receptor antagonist, should lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

A patient with a deep partial thickness burn has been receiving hydromorphone through patient-controlled analgesia (PCA) for 1 week. The nurse caring for the patient during the previous shift reports that the patient wakes up frequently during the night reporting pain. What action by the nurse is appropriate? a. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. Consult with the health care provider about using a different treatment protocol to control the patient's pain. c. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

ANS: B PCAs are best for controlling acute pain. This patient's history indicates a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.

Which additional information should the nurse consider when reviewing the laboratory results for a patient's total calcium level? a. The blood glucose b. The serum albumin c. The phosphate level d. The magnesium level

ANS: B Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to misinterpretation of calcium levels. The other laboratory values will not affect total calcium interpretation.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. What is the nurse's priority action? a. Teach the patient about restricting dietary sodium. b. Assess the patient for manifestations of acute heart failure. c. Ask the patient about the use of the prescribed medications. d. Have the patient recall the dietary intake for the past 3 days.

ANS: B The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for 8 hours. d. Skin tenting over the sternum is prolonged.

ANS: B The blood pressure indicates that the patient may be developing hypovolemic shock because of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient reports level 7 (0- to 10-point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

ANS: B The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Place a "No Visitors" sign on the door. d. Omit fruits and vegetables from the diet.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. While unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

Which action in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist? a. Teach the patient about what to expect in the operating room (OR). b. Pass sterile instruments and supplies to the surgeon and scrub technician. c. Monitor and interpret the patient's echocardiogram (ECG) during surgery. d. Give the postoperative report to the postanesthesia care unit (PACU) nurse.

ANS: B The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patient's condition, and the admission assessment require registered nurse (RN) level education and scope of practice. A surgical technologist is not usually trained to interpret ECG rhythms

A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

ANS: B The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? a. Bruising b. Neutropenia c. Increasing fatigue d. Thrombocytopenia

ANS: B The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.

A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first? a. Infuse normal saline at 50 mL/hr. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Schedule pelvic magnetic resonance imaging

ANS: B The patient data indicate that the patient may have acute kidney injury caused by the BPH. The initial therapy will be to insert a catheter. The other actions are also appropriate, but they can be implemented after the acute urinary retention is resolved

A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. Restrict the patient to bed rest. b. Encourage 4000 mL of fluids daily. c. Institute routine seizure precautions. d. Assess for positive Chvostek's sign.

ANS: B The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.

A patient has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. What should the nurse encourage the patient to increase in the diet? a. Iron b. Protein c. Calories d. Carbohydrate

ANS: B The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Plan for emergency tracheostomy. b. Administer IV calcium gluconate. c. Prepare for endotracheal intubation. d. Begin thyroid hormone replacement.

ANS: B The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Thyroid hormone replacement may be needed eventually but will not improve the symptoms of hypocalcemia.

A patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Decreased alertness since admission c. Weight gain of 2 pounds (1 kg) over 2 days d. Serum sodium level of 138 mEq/L (138 mmol/L)

ANS: B The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, and serum sodium level will be reported but do not indicate a need for rapid action to avoid complications.

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg.

ANS: B The patient's lung sounds indicate that pulmonary edema may be developing because of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

The nurse is caring for a patient who has diabetes and reports chronic, burning leg pain even when taking oxycodone (OxyContin) twice daily. Which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain? a. Aspirin b. Amitriptyline c. Celecoxib (Celebrex) d. Acetaminophen (Tylenol)

ANS: B The patient's pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants are effective for treating this type of pain. The other medications are more effective for nociceptive pain.

A patient admitted with burns over 30% of the body surface 2 days ago now has dramatically increased urine output. Which action should the nurse plan to support maintaining kidney function? a. Monitoring white blood cells (WBCs). b. Continuing to measure the urine output. c. Assessing that blisters and edema have subsided. d. Encouraging the patient to eat adequate calories.

ANS: B The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. WBCs may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning

A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. What safety priority should the nurse identify for this patient? a. Acute pain b. Risk for aspiration c. Impaired tissue integrity d. Disturbed visual perception

ANS: B The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient's airway.

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? a. Specific gravity of 1.007 b. Protein of 65 mg/dL (0.65 g/L) c. Glucose of 45 mg/dL (1.7 mmol/L) d. White blood cell (WBC) count of 4 cells/L

ANS: B The protein level is high. The specific gravity, WBCs, and glucose values are normal.

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? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

ANS: B The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should start cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result should the nurse expect? a. Elevated hematocrit b. Decreased serum sodium c. Increased serum chloride d. Low urine specific gravity

ANS: B When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that apply.) a. Chest x-ray b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot

ANS: B, C, D, F Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems but are not routinely included in screening.

A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. Which assessment findings should the nurse consider to be possible physiologic reactions to the stressful news? (Select all that apply.) a. Bradycardia b. Decreased appetite c. Epigastric discomfort d. Decreased respiratory rate e. Elevated blood glucose levels

ANS: B, C, E The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates.

Which statement best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? a. Performs the same responsibilities as the anesthesiologist. b. Gives intraoperative anesthetics ordered by the anesthesiologist. c. Releases or discharges patients from the postanesthesia care area. d. Manages a patient's airway with direct supervision of the anesthesiologist.

ANS: C A nurse anesthetist is a registered nurse who has graduated from an accredited nurse anesthesia program (minimally a master's degree program) and successfully completed a national certification examination to become a CRNA. The CRNA scope of practice includes, but is not limited to, the following: 1. Performing and documenting a preanesthetic assessment and evaluation 2. Developing and implementing a plan for delivering anesthesia 3. Selecting and initiating the planned anesthetic technique

A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. What additional effect of the medication should the nurse monitor? a. Increased serum sodium b. Decreased urinary output c. Elevated serum potassium d. Evidence of fluid overload

ANS: C Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.

ANS: C The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

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

ANS: C 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.

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. A 23-yr-old who reports severe fatigue b. A 56-yr-old with frequent explosive diarrhea c. A 33-yr-old with a fever of 100.8° F (38.2° C) d. A 66-yr-old who has white pharyngeal lesions

ANS: C Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not have symptoms of potentially life-threatening problems.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. There are no signs of hemorrhage. b. Hemoglobin is within normal limits. c. Urine output 65 mL over the past hour. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: C Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.

A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first? a. Insert a urinary retention catheter. b. Administer epoetin alfa (Epogen). c. Place the patient on a cardiac monitor. d. Give sodium polystyrene sulfonate (Kayexalate).

ANS: C Because hyperkalemia can cause fatal dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL.

ANS: C Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.

Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for type and crossmatch. c. Administer 1 L of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction.

ANS: C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

A patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I plan to take the medication with food." b. "I should eat more potassium-rich foods." c. "I will call for help when I need to get up to use the bathroom." d. "I can expect to feel more short of breath for the next few days."

ANS: C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of -adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

What should the nurse explain to a patient being prepared for colposcopy with a cervical biopsy? a. It involves dilation of the cervix and biopsy of the tissue lining the uterus. b. It will take place in a same-day surgery center so that local anesthesia can be used c. It is similar to a speculum examination of the cervix and should cause little discomfort. d. It requires that the patient have nothing to eat or drink for 6 hours before the procedure.

ANS: C Colposcopy involves visualization of the cervix with a binocular microscope and is similar to a speculum examination. Anesthesia is not required and fasting is not necessary. A cervical biopsy may cause a minimal amount of pain.

A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted. Which assessment finding will the nurse expect? a. Restlessness b. Hypertension c. Pitting edema d. Food allergies

ANS: C Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.

The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Tender, bleeding gums d. Numbness of extremities

ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. The patient seems confused and short of breath with peripheral edema. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. Hemoglobin level d. White blood cell count

ANS: C Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor? a. Total protein b. Blood glucose c. Ionized calcium d. Serum phosphate

ANS: C Tetany is associated with hypocalcemia. The other values would not be useful for this patient.

A patient diagnosed with hypertension has been prescribed captopril. Which information is most important to teach the patient about this drug? a. Include high-potassium foods such as bananas in the diet. b. Increase fluid intake if dryness of the mouth is a problem. c. Change position slowly to help prevent dizziness and falls. d. Check the blood pressure in both arms before taking the drug.

ANS: C The angiotensin-converting enzyme (ACE) inhibitors often 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 drug. 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 drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

A patient in the surgical holding area is being prepared for a spinal fusion. Which action by a member of the surgical team requires immediate intervention by the charge nurse? a. Wearing street clothes into the nursing station b. Wearing a surgical mask into the holding room c. Walking into the hallway outside the operating room with hair uncovered d. Putting on a surgical mask, cap, and scrubs before entering the operating room

ANS: C The corridors outside the operating room (OR) are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR.

An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4 2-3 4.8 mg/dL (1.55 mmol/L)

ANS: C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal and should be reported, but do not require immediate action by the nurse.

Which information from a patient's urinalysis requires that the nurse notify the health care provider? a. pH 6.2 b. Trace protein c. WBC 20 to 26/hpf d. Specific gravity 1.021

ANS: C The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal.

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. What should the nurse do during the initial assessment of the patient? a. Remove the knife and assess the wound. b. Determine the presence of Rovsing sign. c. Check for circulation and tissue perfusion. d. Insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment.

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site

ANS: C The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum sodium level of 145 mEq/L who is asking for water b. Patient with serum potassium level of 5.0 mEq/L who reports abdominal cramping c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has soft tissue calcium-phosphate precipitates

ANS: C The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications.

A 20-yr-old woman is being admitted with electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? a. The patient uses laxatives daily. b. The patient's knuckles are macerated. c. The patient's serum potassium level is 2.9 mEq/L. d. The patient has a history of extreme weight fluctuations.

ANS: C The low serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly. The other information will also be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Send a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan.

ANS: C The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

Which action describes how the scrub nurse protects the patient with aseptic technique during surgery? a. Uses waterproof shoe covers. b. Wears personal protective equipment. c. Changes gloves after touching the upper arm of the surgeon's gown. d. Requires that all operating room (OR) staff perform a surgical scrub.

ANS: C The sleeves of a sterile surgical gown are considered sterile only to 2 in above the elbows, so touching the surgeon's upper arm would contaminate the nurse's gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR.

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse to intervene? a. The student wears a mask in the semirestricted area. b. The student wears a hair cover in the semirestricted area. c. The student wears street clothes in the semirestricted area. d. The student wears surgical scrubs in the semirestricted area. .

ANS: C Wearing street clothes in the semirestricted area is not permitted. The surgical suite is divided into three distinct areas: unrestricted—staff and others in street clothes can interact with those in surgical attire; semirestricted—staff must wear surgical attire and cover all head and facial hair; and restricted—includes the operating room, the sink area, and clean core where masks are required in addition to surgical attire

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

ANS: C, D, E These actions are included in surgical time-out procedure. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

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? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

ANS: D Because spironolactone is a potassium-sparing diuretic, teach patients to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a recent weight gain of 9 pounds. b. The patient complains of dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L.

ANS: D A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will need to remain on bedrest for three days after surgery. b. An additional surgery in 8 to 12 weeks will be done to create an ileal-anal reservoir. c. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. d. The site where the stoma will be located will be marked on the abdomen preoperatively.

ANS: D A wound, ostomy, continence nurse (WOCN) should select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site should be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is created with this surgery. The patient will be encouraged to walk the day after surgery. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

ANS: D ABGs with a decreased pH and increased PaCO2 indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal, close to normal, or compensated.

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding requires immediate action? a. The bicarbonate level (HCO3 ?2-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.

ANS: D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.

ANS: D 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 is hypokalemic. Loose stools are associated with hyperkalemia.

Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? a. Ask the patient about any nausea. b. Obtain the patient's oral temperature. c. Change the prescribed wet-to-dry dressings. d. Review the patient's serum creatinine results.

ANS: D Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration

A patient who takes a nonsteroidal antiinflammatory drug (NSAID) daily for the management of severe rheumatoid arthritis has recently developed melena. What should the nurse anticipate teaching the patient? a. Substitution of acetaminophen (Tylenol) for the NSAID b. Use of enteric-coated NSAIDs to reduce gastric irritation c. Reasons for using corticosteroids to treat the rheumatoid arthritis d. Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa

ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating rheumatoid arthritis.

What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera? a. Place the patient on bed rest. b. Administer iron supplements. c. Avoid use of aspirin products. d. Monitor fluid intake and output.

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera. NURSINGTB.

A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. What should the nurse anticipate will be tested next? a. Calcitonin b. Catecholamine c. Thyroid hormone d. Parathyroid hormone

ANS: D Parathyroid hormone (PTH) is the major controller of blood calcium levels. Although calcitonin secretion is a counter mechanism to PTH, it does not play a major role in calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium level.

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication? a. Tachypnea b. Myoclonus c. Hypertension d. Laryngospasm

ANS: D Possible complications of inhalation anesthetics include coughing, laryngospasm, and increased secretions. Hypertension and tachypnea are not associated with general anesthetics. Myoclonus may occur with nonbarbiturate hypnotics but not with the inhalation agents.

A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia. Which information should the nurse explain to the patient? a. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. b. Estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. c. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. d. Calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

ANS: D Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy is no longer routinely given to prevent osteoporosis because of increased risk of heart disease as well as breast and uterine cancer. Corticosteroid therapy increases the risk for osteoporosis.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? a. Pancakes with syrup and bacon b. Whole wheat toast and fresh fruit c. Egg-white omelet and a half grapefruit d. Oatmeal with skim milk and fruit yogurt

ANS: D Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.

Which focused data should the nurse assess after identifying 4+ pitting edema on a patient who has cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? a. Lethargy b. Report of nausea c. Disorientation to time d. Weak chest movement

ANS: D The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles, which can lead to postoperative hypoxemia. Nausea, lethargy, and disorientation are possible adverse effects of anesthetic drugs, but they are not as great of concern as respiratory depression.

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? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest priority? a. Difficulty coping b. Disturbed body image c. Impaired nutritional status d. Risk for electrolyte imbalance

ANS: D The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are also appropriate for this patient but are not associated with immediate risk for fatal complications.

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

ANS: D This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

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? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

ANS: D Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon.