NUR 227 Exam 1

The nurse is teaching the patient about his upcoming bronchoscopy procedure. Which statement by the patient indicates an understanding of the procedure? "Any blood-tinged mucus is abnormal and I should notify the nurse immediately if this happens." "I will be allowed to take only small sips of water immediately after the procedure." "They will administer general anesthesia to me prior to the procedure." "I will not be allowed to eat or drink for about 6 hours before the procedure."

"I will not be allowed to eat or drink for about 6 hours before the procedure."

The patient with lung cancer is to undergo a thoracentesis. Which statement by the nurse is appropriate when preparing the patient for this procedure? "You will not be allowed to eat or drink anything after midnight the evening before the procedure." "You will be asked to cough occasionally and take deep-breathes during the procedure." "You will need to have a chest x-ray done directly after the procedure." "The anesthesiologist assist with sedation and anesthesia for the case."

"You will need to have a chest x-ray done directly after the procedure."

The doctor has ordered Voltaren 0.5 g bid po for a patient with arthritis. Available: 500 mg / tablet. How many tablets will you give? (NUMBER ONLY)

1 tablets

Pfizerpen 300,000 units IM q 12 h. Available: Pfizerpen 5 million units. If you add 18.2 mL of diluent to Pfizerpen this yields 250,000 units/mL. How many mL will you administer? (NUMBER ONLY)

1.2 mL

How long can tube feeding cans be open in the fridge? 8 hours 12 hours 24 hours 36 hours

24 hours

The doctor has ordered Minoxidil 0.04 g once a day for a patient with hypertension. Available: 10 mg/tablet. How many tablets will you give? (NUMBER ONLY)

4 tablets

Ordered: Biaxin 150 mg po twice a day. Available: Biaxin 125 mg/ 5 mL. How many mL will you administer per dose? (NUMBER ONLY)

6 mL

Your client is an adult that weighs 215 lbs. You determine that 215 lbs. is equivalent to _______ kg. (NUMBER ONLY)

97.7 kg

What is needed so that a nurse may remove a feeding tube? A Health Care Provider's Order A Dietician Consult Permission from the Patient 2/3rd's vote from all Nurses on the Unit

A Health Care Provider's Order

When assessing undermining and tunneling you document using what device as a guide? A sundile with the patients head at top A clock with 12 o'clock being at the patients head A clock with 12 o'clock being at the foot of the bed An approved measurement device specified by the provider

A clock with 12 o'clock being at the patients head

The nurse is working on an adult medical-surgical floor. Which patient should the nurse see first? A patient who is febrile and his IV piggyback antibiotic is one hour past due. A patient whose IV has infiltrated and needs a new IV started for hydration purposes. A patient who states he is in severe pain when he wakes up the morning after major abdominal surgery. A patient with a tracheostomy has adventitious breath sounds and indicates he needs to be suctioned.

A patient with a tracheostomy has adventitious breath sounds and indicates he needs to be suctioned.

A client is being admitted for the treatment of acute cellulitis of the thigh. The client asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that the characteristics of cellulitis include: A skin infection into the subcutaneous tissue and dermis. An epidermal and lymphatic infection caused by Staphylococcus. An inflammation of the epidermis only. An acute superficial infection of the lymphatics and dermis.

A skin infection into the subcutaneous tissue and dermis.

A patient is having major abdominal surgery tomorrow. During pre-op teaching, the nurse teaches the patient how to do deep breathing exercises after surgery by telling the patient to A. "Hold your abdomen firmly with a pillow, and take several deep breaths. " B. "Tighten your stomach muscles as you inhale, and breathe normally in and out of your mouth. " C. "Raise your shoulders to expand your chest and rib cage. D. "Sit in an upright position and perform 'huff breathing'".

A. "Hold your abdomen firmly with a pillow, and take several deep breaths. "

A 68-year-old scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he Will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response by the nurse IS. A. "Who is available to help you at home after the surgery?" B. "I'm sure you will be able to manage at home after surgery. It is a simple procedurey C. "We will teach you everything you need to know to be able to care for yourself after surgery." D. "Your health insurance will pay for inpatient care only if complications develop during surgery"

A. "Who is available to help you at home after the surgery?"

How can the nurse best minimize a patient's risk for infection during tracheostomy care? Adhere to sterile technique when appropriate. Do not allow the patient to have visitors at the bedside. Monitor for indications that tracheostomy care is needed. Change the flow meter every 24 hours.

Adhere to sterile technique when appropriate.

The nurse is providing pre-op teaching to the patient who is scheduled for surgery tomorrow, with her husband at the bedside. The patient shares that she is afraid of surgery because her cousin died unexpectedly in surgery when having her tonsils removed. What is the nurse's best response? Confirm with the patient's husband that the information is true. Explain to the patient that it is normal to be afraid before having surgery. Reassure the patient that her surgery will go without complications. Ask the patient if anyone else in her family has had trouble when they had surgery due to the anesthesia.

Ask the patient if anyone else in her family has had trouble when they had surgery due to the anesthesia.

The patient on tube feeding complains of dyspnea and now has crackles. What do you suspect? Aspiration Air embolism Pneumothorax Feeding intolerance

Aspiration

If the patient gags or vomits during oropharyngeal suctioning this may elicit what kind of negative response? Aspiration and Concussion Asphyxiation and Fever Aspiration and Negative Vagal Stimulation Vegas Stimulation and Atrial Fibrilation

Aspiration and Negative Vagal Stimulation

A nurse IS caring for a patient in PACIJ who has received general anesthesia. During the immediate postoperative period, which nursing action takes the highest priority? A. Checking the dressing for bleeding B. Maintaining a patent airway C. Monitoring the vital signs D. Promoting urine output

B. Maintaining a patent airway

Five minutes after receiving the ordered preoperative Morphine by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? A. Carefully assist the patient to the bathroom. B. Offer the patient a urinal or bedpan. C. Ask the patient to wait until the drug has past it's peak action. D. Tell the patient that a bladder catheter will be placed in the operating room.

B. Offer the patient a urinal or bedpan.

When preparing a specimen for wound culture what would you place the specimen in for transport to the appropriate lab? Green top cylinder Appropriate Syringe Biohazard Bag Lab Messengers Backpack

Biohazard Bag

The nurse is assessing the patient admitted with clinical manifestations associated with acute endocarditis. The nurse recognizes which is the best diagnostic test to confirm this medical problem? Erythrocyte sedimentation rate (ESR) Blood cultures Complete blood count EKG

Blood cultures

On admission of a patient to the post-anesthesia care unit (PACU), the blood pressure (BP) is 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? A. Increase the IV fluid rate. B. Notify the anesthesia care provider. C. Continue to take vital signs every 15 minutes D. Administer oxygen therapy at 100% per mask

C. Continue to take vital signs every 15 minutes

If your patient has what condition might you suggest that he or she lean over a table with the arms propped up until breathing eases. Arrythmia COPD IBS CPAP

COPD

Which nursing action does NOT prevent CLABSI in your TPN line? Changing dressing daily Using sterile technique Using chlorhexidine to clean Wiping caps with alcohol before using

Changing dressing daily

Why does the nurse suction a small amount of sterile solution from the container prior to suctioning the patient's tracheostomy? It makes a cool sound. Check the equipment for proper functioning. That is how we were taught in Nursing School. To make sure the equipement is compatible.

Check the equipment for proper functioning

What is the nursing action to set up suction for a Jackson-Pratt drainage system? Attach to gown with safety pin. Connect to the wall on intermediate suction. Set the suction to lowest level possible. Compress the bulb, creating suction.

Compress the bulb, creating suction.

The nurse is caring for a patient who has been in a motorcycle accident and has a pleural chest tube inserted. If the chest tube is accidentally pulled out of the chest, what is the next best nursing action? Auscultate breath sounds bilaterally. Cover the opening with sterile petroleum gauze or a three sided occlusive dressing Call the health care provider (HCP) and obtain a chest tube insertion tray. Immediately reintroduce the tube and attach it to water seal drainage.

Cover the opening with sterile petroleum gauze or a three sided occlusive dressing

The nurse receives the preoperative blood work report for a female patient who is scheduled to undergo surgery. Which of the following laboratory findings should be reported to the surgeon? INR, 1.1 Hemoglobin, 12.2 Creatinine, 4.2 Albumin, 3.5

Creatinine, 4.2

What would the nurse instruct nursing assistive personnel (NAP) to do to ensure safety when feeding Salisbury steak to a dependent patient? Cut the steak into small, bite-size pieces. Lower the head of the bed to a 30-degree angle. Ensure that the steak is steaming hot. Encourage the patient to drink all fluids first.

Cut the steak into small, bite-size pieces.

While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? Assess the patient's pulse oximetry reading to see if oxygenation is adequate. Interrupt suction to the catheter for at least 10 seconds. Encourage the patient to take several deep breaths. Discontinue suctioning by removing the suction catheter.

Discontinue suctioning by removing the suction catheter.

Which technique would the nurse use to change a patient's tracheostomy ties? Changing tracheostomy ties is not within the nurse's scope of practice. Use a slipknot. Do not remove the old ties until the new ties are securely attached. Ask the patient to hold his or her breath while the ties are changed.

Do not remove the old ties until the new ties are securely attached.

You are about to give the patient a dose of Carvedilol 25mg this morning. This drug is a beta-blocking agent for his hypertension. The patient's vitals are 128/82 and HR of 61. What should you do first? Have the patient exercise to raise BP before administration Give the medication Hold the medication Double check the parameters for HR and BP to see if there are specific instructions about holding the medication

Double check the parameters for HR and BP to see if there are specific instructions about holding the medication

How can you evaluate a patient for silent aspiration? A 5% increase in body fat. Elevation of less than or equal to 10% in O2 saturation. Drop in O2 Saturation of greater than or equal to 2% compared to their baseline. Unable to since it is silent.

Drop in O2 Saturation of greater than or equal to 2% compared to their baseline.

The client's ability to take PO medications will be hindered by: Lifestyle Dysphagia Age Dental Caries

Dysphagia

When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse position a patient who has leg ulcers that are venous in origin? Dangle the patient's legs over the side of the bed. Keep the patient's legs flat without the knees raised. Keep the patient's knees at a 45-degree angle. Elevate the patient's lower extremities.

Elevate the patient's lower extremities.

The patient is admitted with complications related to an ejection fraction of 25%. What is a nursing diagnosis that the nurse can anticipate? Excess fluid volume Acute pain Risk for infection Aspiration

Excess fluid volume

The patient who has just been diagnosed with Raynaud's phenomenon is placed on a calcium channel blocker. Which outcome criterion indicates to the nurse that the medication is having the desired effect for this patient? Fingers are warm to the touch BP is < 120/80 Oxygen saturation > 94% HR is < 100/min

Fingers are warm to the touch

The nurse is caring for a drowsy patient who returned from the PACU 10 minutes ago. Post-op orders include: IV of D5 NS with 20 meq KCL at 100 ml/hour, vital signs q1h, incentive spirometer q1h and continuous pulse oximetry. While taking the patient's vital signs, the nurse observes that the O2 sat has dropped to 91%. What is the next best nursing action? Call the provider Document the assessment finding Have the patient take deep breaths. Order a stat arterial blood gas (ABG)

Have the patient take deep breaths.

The laboratory finding that is the best indicator of adequate protein intake in a client getting tube feeding is Low specific gravity Low serum albumin High serum albumin Low hemoglobin

High serum albumin

What will you do prior to suctioning, between passes and immediately after suctioning to help your patient stay oxygenated? Nothing they will be fine Hyperoxygenate with 100% O2 Encourage meditation Hypo-oxygenate with 100% O2

Hyperoxygenate with 100% O2

The patient is being admitted for suspected vascular compromise to his lower extremities. The APRN has ordered a Ankle Brachial Index study. Which of the following statements are true regarding this test? Select all that apply. When calculating, use the higher of the two upper extremity diastolic numbers If the result is 0.6 in both legs, the patient getting this exam likely has pain when walking and pallor of his lower extremities An ABI < 0.9 is abnormal This test assists in the diagnostics of arterial vascular problems When calculating, use the lower of the two upper extremity systolic BP numbers An ABI requires at least a 2+ pulse in each extremity to be accurate

If the result is 0.6 in both legs, the patient getting this exam likely has pain when walking and pallor of his lower extremities An ABI < 0.9 is abnormal This test assists in the diagnostics of arterial vascular problems When calculating, use the lower of the two upper extremity systolic BP numbers

The patient with intermittent claudication asks the nurse what is the reason for encouraging him to walk up to the point of pain, rest until the pain subsides and then resume walking. The nurse's reply is based on the understanding that the primary purpose of this exercise is to: Increase collateral circulation Enhance his range of motion Promote venous return Lower his resting heart rate

Increase collateral circulation

The nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the patient has an increased work of breathing due to copious, tenacious tracheobronchial secretions. What should the nurse encourage the patient to do? Increase activity to walking in the hallway. Call the nurse for oral suctioning, as needed. Maintain a low fowler's position as much as tolerated. Increase oral fluids unless contraindicated.

Increase oral fluids unless contraindicated.

When performing an assessment about medication, the drug history should include: Select all that apply Indication for the medication Does the client take OTC medications? Last physical therapy appointment Last set of vital signs

Indication for the medication Does the client take OTC medications? Last set of vital signs

A patient on the med-surg floor with pneumonia requires use of a non-rebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? It is ok for the nurse to switch out to O2 2L/min nasal cannula while the patient is eating. Oxygen concentration up to 50% can be obtained with this type of delivery device Intubation and mechanical ventilation may be required next for this patient. It is the nurse's responsibility to ensure the reservoir bag deflates completely with each exhalation.

Intubation and mechanical ventilation may be required next for this patient.

Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? Instructing the family to call immediately if the patient has difficulty breathing Reviewing the agency's policy regarding tracheostomy care Having a spare oxygen mask at the patient's bedside Keeping an obturator and a tracheostomy tube at the patient's bedside

Keeping an obturator and a tracheostomy tube at the patient's bedside

______ are hypertrophic scars that extend beyond the original wound margin. Keloids Ulcers Eschar Scabs

Keloids

The nurse is assessing a skin tear in an elderly patient that occurred from removal of tape that was applied to the skin. The edges of the wound are uneven and only the epidermis is involved. The nurse best classifies this wound as a(n): Puncture Wound Contusion Laceration Wound Penetrating Wound

Laceration Wound

The anesthetist is coming to the unit to see a patient prior to surgery that is scheduled for tomorrow morning. What information, obtained during the admission assessment, is most important for the nurse to ensure the anesthetist receives during the visit? Difficulty falling asleep Number of pregnancies Latex Allergy Last bowel movement

Latex Allergy

Which of the following landmarks is the correct one for obtaining an apical pulse? Left intercostal space, midaxillary line Left fifth intercostal space, midclavicular line Left second intercostal space, midclavicular line Left seventh intercostal space, midclavicular line

Left fifth intercostal space, midclavicular line

Of the following oxygen administration device choices, which has the advantage of providing highest oxygen concentration in an emergent situation? Face Tent Venturi Mask Non-Rebreather Face Mask

Non-Rebreather

A patient is scheduled for surgery at 8 a.m. While completing the preoperative checklist, the nurse sees that the surgical consent form isn't signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority of this situation? Giving the patient the preoperative analgesic at the scheduled time. Notifying the OR desk and canceling the surgery Notifying the surgeon that the patient hasn't signed the consent form. Insisting the patient sign the consent form.

Notifying the surgeon that the patient hasn't signed the consent form.

The medical team orders a wound culture and antibiotic therapy on your newly admitted patient. Which of the following sequence of nursing interventions is correct? Obtain skin culture and then administer antibiotic therapy 6 hours from skin culture collection. Start antibiotic therapy and then immediately collect culture. Administer antibiotic therapy and then in 1 hour obtain skin culture. Obtain skin culture and then administer antibiotic therapy.

Obtain skin culture and then administer antibiotic therapy.

A provider admits a patient with a history of I.V. drug abuse to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this patient has: Retrosternal pain that worsens during supine positioning. A scratch pericardial friction rub. Osler's nodes and splinter hemorrhages. Pulsus paradoxus.

Osler's nodes and splinter hemorrhages.

A patient receiving parenteral nutrition is administered via the following routes except Subclavian line PICC (Peripherally inserted central catheter) line Central venous catheter PEG tube

PEG tube

When performing a wound assessment you also want to assess what? Patient's Pain Patient's Family History Patient's Address Patient's Therapy Performance

Patient's Pain

What position is ideal for a small bore feeding tube to prevent aspiration? Pre-gastric Pre-pyloric Gastric Post-pyloric

Post-pyloric

When healing occurs by the edges of the wound being pulled together and approximated with sutures, staples, or stripes of adhesive tape it is healing by what means? Atypical Healing Tertiary Intention Primary Intention Secondary Intention

Primary Intention

What may be an indicator that the wound has become infected? Serous Drainage Purulent Drainage Pink warm Periwound Area Normalized Vital Signs

Purulent Drainage

Which complication of tube feeding would be best associated with severely malnourished patients? Hyperglycemia Fluid overload Refeeding syndrome Abdominal cramping

Refeeding syndrome

A patient with a tracheostomy tube coughs violently during suctioning and the entire tracheostomy tube is dislodged from the stoma site. Which action should the nurse take first? Assess the patient's pulse, blood pressure, respirations and oxygen saturation. Remove the inner cannula, insert the obturator and reinsert the expelled trach tube. Position the patient in semi-fowler's position with the neck flexed at a 90-degree angle. Call for the code cart and emergency supplies in anticipation of cardiopulmonary arrest.

Remove the inner cannula, insert the obturator and reinsert the expelled trach tube.

As a knowledgeable nurse, you know that the following are part of the five rights except: Right drug Right Route Right room Right Person

Right room

A patient states they are having intense itching between their fingers with brown linear lines presenting. Based on your nursing knowledge this best describes what condition? Scabies Eczema Impetigo Psoriasis

Scabies

When healing occurs by the formation of granulation tissue and the wound edges contract healing quickly but leaving behind a more obvious scar this is healing by what means? Tertiary Intention Atypical Healing Secondary Intention Primary Intention

Secondary Intention

When removing the initial surgical dressing by order of the surgeon, the nurse assesses a moderate amount of watery pinkish-red bleeding at the site. The nurse accurately documents this drainage as: Sanguinous Serosanguinous Purulent Serous

Serosanguinous

You increase tube feed to 40mL/hr. The patient complains of cramping. What do you do? Stop the feeding Give laxative Change the formula Slow down the feeding

Slow down the feeding

A patient is admitted with possible active tuberculosis. To make a definitive diagnosis, the nurse expects which diagnostic test to be prescribed? Sputum for Acid Fast Bacilli Pulmonary Function Test IGRA Blood Test Mantoux Test

Sputum for Acid Fast Bacilli

Stage the pressure ulcer: -Full thickness tissue loss. -Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. -Slough may be present but does not obscure the depth of tissue loss. Stage II Stage III Stage I Stage IV

Stage III

Steroids and NSAIDs can interfere with wound healing by: Causing excessive bleeding Suppressing the inflammatory process Decreasing the oxygen carrying capacity of the blood cells Decreasing venous return

Suppressing the inflammatory process

When removing a nasogastric or enteral feeding tube the nurse should instruct the patient to do what to reduce the risk of aspiration? Hold their chin to their chest. Cough the entire time. Take a deep breath and hold it. Turn in three circles while counting to three.

Take a deep breath and hold it.

A nursing assistive personnel (NAP) is preparing to weigh a resident in a skilled nursing facility. The patient is usually weighed in street clothing and socks, with his shoes off. The patient is currently wearing street clothing with shoes and socks. What will the NAP do to ensure that the patient's weight is correctly measured? Take off the patient's street clothing. Take off the patient's street clothing and put on a hospital gown and nonskid socks. Take off the patient's shoes, but leave his socks on. Take off the patient's shoes and socks, and put on slippers.

Take off the patient's shoes, but leave his socks on.

A patient is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the patient's shirt, and bleeding from the nose continues. The nurse intervenes by: Applying pressure to the tip of the nose for 1 to 2 minutes. Pinching the hard portion at the top of the nose. Instructing the patient to tilt the head back with ice applied to the nose. Telling the patient to sit upright with the head tilted forward.

Telling the patient to sit upright with the head tilted forward.

A surgical wound that has become infected is edematous with purulent drainage and debris. The nurse knows it must heal by: Primary Intention Tertiary Intention Surgical Closure Secondary Intention

Tertiary Intention

A patient who is seen at the outpatient clinic complains of pain of the right lower leg and foot. If the diagnosis of peripheral arterial occlusion is made, the nurse expects to see which of the following signs and symptoms? The patient has moderate swelling distal to the malleolus on the right foot. The patient cannot distinguish between sharp and dull pressure on the right leg. The patient says his right leg is more comfortable when elevated on pillows. The skin on the right lower leg appears flushed and diaphoretic.

The patient cannot distinguish between sharp and dull pressure on the right leg.

While feeding a patient, the nurse puts the fork down on the tray and turns on the suction machine. Why might the nurse perform this action? The patient is tilting the head backward while drinking. Food has dripped or spilled onto the patient's clothing. The patient is choking. The nurse determines that this is the wrong diet for the patient.

The patient is choking.

Why is it important to use gauze squares made for medical use to place around a patient's tracheostomy stoma instead of cutting your own? They may be allergic. It is just the correct way to do it. They could inhale the fibers. You need to support medical supply companies.

They could inhale the fibers.

If the patient's intake falls below 75% for any length of time, refer the patient to a RD (registered dietitian) for medical nutrition therapy. True False

True

Which of the following muscles is a possible site (by anatomical landmark standards) for IM injections? Shoulder Vastus Lateralis Outer edge of hip Vastus Gluteus

Vastus Lateralis

________ are small, clear, fluid-filled blisters < 10 mm in diameter and are commonly characteristic of herpes infections, acute allergic contact dermatitis, and some autoimmune blistering disorders. Plaques Papules Bullae Vesicles

Vesicles

If lubricant is needed to perform Nasotracheal or Nasopharyngeal Suctioning ensure to use what type of lubricant? Petroleum Based Vasoline Pectin-Based Water-Soluble

Water-Soluble

Which imaging study or diagnostic test would the nurse review to determine if the pressure injury on a patient's left heel is infected? X-ray of left foot White Blood Cell Count Culture & Sensitivity Complete blood count

White Blood Cell Count

The nurse on a progressive floor is caring for a patient diagnosed with bacterial endocarditis. The patient has a history of smoking and IV drug use. The nursing tech notifies the nurse during afternoon vitals that the patient's respiratory rate has increased from 20 (this AM) to 40 (currently) and the O2 saturation is 88% on room air. Of note, the patient has complained of SOB since admission. What are appropriate nursing actions? Select all that apply: a. Check the patient's vital signs b. Prepare for immediate intubation c. Notify the provider d. Provide supplemental oxygen e. Do nothing, since the patient has always complained of SOB

a. Check the patient's vital signs c. Notify the provider d. Provide supplemental oxygen

You are caring for a patient who was just admitted to the ED with SOB, chest pain radiating to the left arm, and nausea. Which of the following would you expect to be ordered given the symptoms noted above? Select all that apply: a. Troponin b. NG tube placement c. EKG d. MRI e. CK-MB

a. Troponin c. EKG e. CK-MB All these labs/tests deal with cardiac activity

A patient presents to the urgent care clinic with an anterior nosebleed. Which of the following would be important to discuss with a patient in terms of nursing management? Select all that apply: a. It is okay to use Tylenol and NSAID's for pain b. Avoid blowing the nose c. This is a medical emergency and requires hospitalization d. Loose packing is okay to use e. Remember to position upright, and lean forward

b. Avoid blowing the nose d. Loose packing is okay to use e. Remember to position upright, and lean forward

A 74-year-old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following confirms your suspicions of heart failure? a. K+ = 5.6 b. BNP = 820 c. BUN = 10 d. Troponin = 0.02

b. BNP = 820 How hard the heart has to work, the higher the BNP, the harder the heart is working

With peripheral arterial insufficiency, leg pain can be reduced by? a. Elevating the limb above heart level b. Lowering the limb so it is independent c. Massaging the limb after application of cold compresses d. Placing the limb in a plane horizontal to the body

b. Lowering the limb so it is independent

A client comes into the outpatient clinic and tells the nurse that he has had leg pains that begin when he walks but cease when he stops walking. Which of the following conditions would then nurse assess for? a. An acute obstruction of the vessels of the legs b. Peripheral vascular problems in both legs c. Diabetes d. Calcium deficiency

b. Peripheral vascular problems in both legs Intermittent claudication

A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The most worrisome complication the nurse will constantly observe for is: a. Presence of a heart murmur b. Systemic emboli c. Fever d. CHF

b. Systemic emboli

Which patient should the nurse go see first? a. Patient who complains of burning at his peripheral IV site b. A patient who spikes an unexpected fever c. A patient who has a new onset of unexplained restlessness d. A patient who is having severe nausea

c. A patient who has a new onset of unexplained restlessness

You are caring for a patient following a bronchoscopy with the providers still at the patient's bedside. During the procedure, the patient was administered heavy doses of fentanyl. You note that the patient is excessively drowsy and is not responding to any commands, with an oxygenation status of 88 on 4L NC and a RR of 7. Which of the following would be the best nursing action to reverse the respiratory distress? a. Move the patient immediately to the ICU. b. Do nothing, as these vitals are normal. c. Give IV Narcan (naloxone). d. Intubate and prepare for chest tube insertion.

c. Give IV Narcan (naloxone)

Which type of assessment measures air flow in and out of the lungs, and is used to assess overall lung function? a. Chest x-ray b. CT scan c. Pulmonary function test d. Pulse oximetry

c. Pulmonary function test

The nurse is caring for a patient with a leg ulcer caused by arterial insufficiency. The nurse knows that a recommended treatment for arterial insufficiency of the leg is a. TED hose b. Sequential compression device (SCD) c. Vascular reconstruction by surgery d. Ace wrap bandaging

c. Vascular reconstruction by surgery Because it affects the arterial. TED hose, SCD, and ace wrap deals with venous

When listening to "normal" bowel sounds what do you expect to hear? clicks & gurgles cat & mouse slurps & giggles whistles & horns

clicks & gurgles

Your patient is admitted to the emergency department with shortness of breath and chest pain. The team suspects that a pulmonary embolus may be the cause. What test would you expect to be ordered for the patient given the suspected diagnosis? a. Pulmonary function test b. Troponin c. Lactic acid d. D-Dimer

d. D-Dimer

The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the? a. Aorta b. Right atrium c. Superior vena cava d. Pulmonary circulation

d. Pulmonary circulation Blood comes in through the mitral valve, if it can't flow it backs up into the lungs or pulmonary circulation

When irrigating a wound what do you want to use to your advantage to correctly irrigate the wound? gravitational flow the patients assistance limited volume of irrigating solution tap water

gravitational flow

The patient has been diagnosed with pericarditis. The nurse will anticipate giving which medication on the medication administration record (MAR) to this patient? acetaminophen (Tylenol) 650 mg PO prednisone 10 mg PO ibuprofen (Advil) 600 mg PO morphine 2 mg IV

ibuprofen (Advil) 600 mg PO

When palpating the skin what are some examples of the characteristics you are assessing for? turgor, turmoil and sweat bumps, bruises and scratches temperature, moisture and turgor moisture, texture and roughness

temperature, moisture and turgor

Where is the best place on the wound to obtain a sample for wound culture? always tissue from the 3 o'clock positoin tissue with the most necrosis viable granulation tissue near the center of the wound granulation tissue on the edge of the wound

viable granulation tissue near the center of the wound