NUR426 Comprehensive Final Exam

The nurse recalls which description as the most accurate regarding a deep partial-thickness burn? 1 Painful with weeping blisters 2 Minimal damage to the epidermis 3 Charring visible in the deepest areas 4 Necrotic tissue through all layers of the skin

1 A deep partial-thickness burn involves the epidermal and dermal layers of the skin. It is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch. Necrosis and charring are seen with a full-thickness burn. Redness and pain with minimal damage to the epidermis are characteristics of a superficial, or first-degree, burn.

A nurse is collecting health history information from a patient who states, "I had cancer in the cartilage of my leg." The nurse recalls that this type of malignancy found in connective tissue is known as: 1 Sarcoma 2 Osteoma 3 Adenoma 4 Myeloma

1 Cancer of the connective tissue is known as a sarcoma. Osteoma refers to cancer originating in bone. Adenoma refers to cancer originating in glandular tissue. Myeloma refers to cancer originating in blood-forming tissues such as bone marrow

To decrease the risk of medication-induced cardiovascular events, the nurse should instruct the patient to avoid which medication? 1 Celecoxib (Celebrex), a COX-2 inhibitor 2 Lisinopril, an ACE-inhibitor 3 Aspirin, an antiplatelet 4 Diazepam (Valium), a benzodiazepine

1 Celecoxib has been linked to increased cardiovascular events and should therefore be avoided. Lisinopril, an antihypertensive, is cardioprotective. Aspirin is recommended for heart health related to its antiplatelet effects. Diazepam does not have an impact on cardiovascular health.

The laboratory report reveals that the cells from the patient's tumor biopsy are Grade II. What should the nurse know about this histologic grading? 1 Cells are abnormal and moderately differentiated. 2 Cells are very abnormal and poorly differentiated. 3 Cells are immature, primitive, and undifferentiated. 4 Cells differ slightly from normal cells and are well differentiated.

1 Grade II cells are more abnormal than Grade I and moderately differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature, primitive, and undifferentiated; the cell origin is difficult to determine. Grade I cells differ slightly from normal cells and are well differentiated.

Following fluid resuscitation, which parameter indicates a stable condition? 1 Systolic blood pressure (BP) more than 90 mm Hg 2 Urine output < 0.5 mL/kg/hr 3 Heart rate more than 120 beats/minute 4 Mean arterial pressure (MAP) less than 65 mm Hg

1 Hourly assessments of the adequacy of fluid resuscitation are best made using clinical parameters. Urine and cardiac parameters are most commonly used. Urine output should be 0.5 to 1 mL/kg/hr and 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria or myoglobinuria. The MAP should be greater than 65 mm Hg, systolic BP greater than 90 mm Hg, and heart rate less than 120 beats/minute. MAP and BP are best measured by an arterial line.

A nurse is caring for an older adult patient with multiple myeloma. This patient has developed hypercalcemia. The primary health care provider advises hydration therapy for the patient and also prescribes diuretics. What is the reason for prescribing diuretics to the patient? 1 To prevent heart failure or edema 2 To inhibit the action of osteoclasts 3 To reduce serum calcium levels 4 To prevent bone complications

1 Hypercalcemia of high calcium levels is a metabolic emergency in patients with advanced cancers. Hydration therapy is the choice of treatment to prevent irreversible kidney failure. However, elderly patients may develop heart failure or edema if infused with 3L of fluids per day. Therefore, diuretics may need to be added with hydration therapy to prevent heart failure or edema as a result of fluid overload. Bisphosphonates are used to inhibit the action of osteoclasts, reduce serum calcium levels, and prevent bone complications.

The nurse is caring for a patient who underwent removal of the thyroid gland (thyroidectomy) 3 days ago. The patient's serum chemistries reveal calcium of 3.2 mg/dL, potassium of 3.9 mEq/L, and phosphorus of 4.0 mg/dL. What condition do these findings indicate? 1 Hypocalcemia 2 Hypercalcemia 3 Hyperkalemia 4 Hypophosphatemia

1 Hypocalcemia is a low serum calcium level. Surgical removal of the thyroid gland may also include removal of the parathyroid gland. This results in a deficiency of parathyroid hormone, which controls serum calcium by regulating absorption of calcium from the gastrointestinal tract, mobilizing calcium in bones, and excreting calcium in breast milk, feces, sweat, and urine. The normal serum calcium level ranges from 9.0 to 11.5 mg/dL. Potassium is within normal limits (3.5 to 5 mEq/L), and phosphorus is also within normal limits (2.8 to 4.5 mg/dL).

A patient's potassium level is 2.9 meq/L. Which prescription should the nurse expect? 1 Continuous ECG monitoring 2 Increase digoxin (Lanoxin) to 0.25 mg every day 3 40 meq KCL in 100 cc D5W intravenous piggyback (IVPB) to infuse over 30 minutes 4 Add 20 meq KCL to the present IV bag hanging and give over four hours

1 Hypokalemia can cause lethal ventricular rhythms. Therefore, continuous cardiac monitoring should be expected. Patients with hypokalemia are at risk for digoxin toxicity. The nurse should watch for signs of digoxin toxicity and question an increase in dosage. KCL infusion must be diluted and given at a rate not to exceed 10 meq/hour. 40 meq KCL in 100 cc of fluid is too concentrated and should be given over at least two hours. To prevent bolusing, KCL should never be added to an IV bag that already is hanging

Which statement by an 84-year-old patient with coronary artery disease (CAD) indicates understanding of discharge teaching about physical activity? 1 "I will use longer rest periods between exercise sessions." 2 "I can stop exercising as soon as my cardiac symptoms disappear." 3 "I should exercise outside all the time to achieve better results" 4 "I have to exercise for longer periods of time and more vigorously compared with younger people."

1 Older adults have to use longer rest periods between exercise sessions because of decreased endurance and ability to tolerate stress. The older adults have decreased sweating and therefore shouldn't exercise in extremes of temperature outside. The older adults have to perform low level activity exercise for longer periods of time. The elderly adults have to change their lifestyle to accommodate a physical activity program, even though they are more prone to make such changes during hospitalization or when experiencing symptoms of CAD.

During an assessment, the nurse finds that a patient who is HIV+ has whitish yellow patches in the mouth, GI tract, and esophagus. Which opportunistic infection is the patient likely experiencing? 1 Candida albicans 2 Coccidiodes immitis 3 Cryptosporidium muris 4 Cryptococcus neoformans

1 Opportunistic infections are caused by microorganisms that normally do not cause disease but which become pathogenic when the immune system is impaired and unable to fight off infection. AIDS patients are susceptible to opportunistic diseases. Whitish yellow patches in mouth, GI tract, and esophagus, and the presence of thrush indicate Candida albicans . Infection by Coccidiodes immitis manifests with symptoms like pneumonia, fever, weight loss, and cough. Cryptosporidium muris gastroenteritis is characterized by watery diarrhea, abdominal pain, and weight loss. Meningitis, cognitive impairment, motor dysfunction, fever, seizures, and headache are symptoms of Cryptococcus neoformans.

A patient has been treated successfully for dehydration. The nurse would expect 1 Oral intake balances output. 2 Oral intake is less than output. 3 Oral intake is greater than output. 4 No significant difference in fluid balance

1 Oral intake should equal output if fluid balance has been restored and dehydration has been corrected. Less intake than output would result in dehydration . Greater intake than output may indicate decreased renal function or impaired ability to excrete urine.

Which nursing diagnostic statement is the highest priority for a patient with myxedema? 1 Hypothermia 2 Excess fluid volume 3 Imbalanced nutrition: more than body requirements 4 Risk for activity intolerance

1 People with myxedema are at high risk for hypothermia. In myxedema severe hypothyroidism causes slower metabolism and subnormal body temperature. The nursing diagnoses in the other answer options are appropriate for a patient with myxedema, because edema, weight gain, and activity intolerance are likely a result of hypothyroidism.

A patient with pancreatic cancer is in the outpatient cancer center to receive radiation therapy. The nurse knows that radiation therapy for patients with pancreatic cancer is to: 1 Relieve pain 2 Reduce ascites 3 Increase survival time 4 Inhibit tumor metastasis

1 Radiation therapy alone for pancreatic cancer has little effect on survival, but may be effective for pain relief. Radiation therapy does not reduce ascites, increase survival time, or inhibit tumor metastasis to other areas of the body.

The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. The patient has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? 1 "The tube will help to drain the stomach contents and prevent further vomiting." 2 "The tube will push past the area that is blocked and thus help to stop the vomiting." 3 "The tube is just a standard procedure before many types of surgery to the abdomen." 4 "The tube will let us measure your stomach contents so that we can plan what type of intravenous (IV) fluid replacement would be best."

1 The NG tube is used to decompress the stomach by draining stomach contents, and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not indicated currently. The location of the obstruction will determine the type of fluid to use, not measuring the amount of stomach contents.

During the 48 hours after a myocardial infarction, a nurse should assign the highest priority to monitoring the patient for: 1 Dysrhythmias 2 Anxiety and fear 3 Metabolic acidosis 4 Medication side effects

1 The nurse must be most alert for dysrhythmias, which may signal another MI or impending complications. The nurse should also be alert for increased anxiety, which may cause pain and lead to a secondary infarction. Anxiety and fear are highly likely but secondary in importance to monitoring the patient for dysrhythmias. Metabolic acidosis and reactions to new medications are not likely but should still be included as part of overall assessment of the patient.

A patient is scheduled to undergo peritoneal dialysis. What is the highest-priority action that the nurse should perform before starting dialysis? 1 Obtain the patient's weight 2 Administer pain medication to the patient 3 Place the patient in a high Fowler's position 4 Place the patient in the Trendelenburg position

1 The nurse must check the patient's weight before and after peritoneal dialysis (PD) to determine how much fluid has been removed. The patient should assume a position of comfort, such as a low Fowler's, unless there is difficulty with removing the effluent, in which case the nurse will position the patient to facilitate drainage. Administering pain medication is not a priority in regard to PD. There is no indication that the patient is experiencing pain. Placing the patient in a high Fowler's or Trendelenburg position is not recommended for patients during PD.

A patient has been classified as having stage 2 hypertension on the basis of the blood pressure recorded. The primary goal of therapy for the patient is to normalize the blood pressure. What should be the target blood pressure for this patient? 1 120/80 mmHg 2 140/90 mmHg 3 130/80 mmHg 4 150/90mmHg

1 The nurse's goal is to normalize the blood pressure (BP) of this patient. Therefore, the target blood pressure would be 120/80mmHg, which is the normal BP. If the patient has a blood pressure within 140 to 159/90 to 99 mm Hg range, then the patient has stage 1 hypertension. This can be controlled by drugs and lifestyle modifications. If the BP of the patient is within 120 to 139/80 to 89 mmHg, then the patient has pre-hypertension. Lifestyle modifications are required for this patient to normalize the blood pressure. Blood pressure of 150/90 is indicative of stage 2 hypertension.

After synchronized cardioversion, a patient's electrocardiogram (ECG) tracing reveals the following. Which statement by a nurse is accurate? (normal rhythm) 1 "The cardioversion was successful." 2 "Cardioversion will need to be repeated." 3 "The patient is now in accelerated junctional rhythm." 4 "The ECG tracing indicates hyperkalemia."

1 The patient has converted to a normal sinus rhythm (NSR). The cardioversion was successful. Accelerated junctional rhythm is characterized by an absent P wave and inverted P wave before or following the QRS complex. Hyperkalemia is characterized by a peaked T wave. The T wave in this tracing is normal.

A patient has end-stage kidney disease and is receiving hemodialysis. During dialysis the patient complains of nausea and a headache and appears confused. On examination, the nurse finds that the blood pressure is very low. What should the nurse do? Select all that apply. 1 Decrease the volume of fluids being removed. 2 Infuse 0.9% saline solution. 3 Infuse hypertonic glucose solution. 4 Avoid excess coagulation. 5 Transfuse blood, as ordered

1, 2 Hypotension is a complication of hemodialysis and may manifest as headache and nausea. The nurse should try to keep the intravascular volume adequate by decreasing the volume of fluids being removed and infusing 0.9% saline solution. Hypertonic glucose solutions are infused if the patient gets muscle cramps. Excess coagulation is avoided if the patient has blood loss. Blood is transfused if the patient has blood loss.

A nurse is teaching a group of nursing students about cardiac conditions that could cause dysrhythmias. Which conditions should the nurse include? Select all that apply. 1 Valve disease 2 Emotional crisis 3 Conduction defects 4 Accessory pathways 5 Electrolyte imbalances

1, 3, 4 Dysrhythmia is a condition of abnormal heart rhythm caused by either abnormal conduction or abnormal formation of heart impulses. Several conditions are responsible for the development of dysrhythmia. The cardiac disorders that may lead to dysrhythmia involve valve disease, conduction defects, and accessory pathways. Emotional crisis and electrolyte imbalances are noncardiac conditions that may cause a dysrhythmia

A nurse reviewing the recent medical history of a patient with hypoparathyroidism expects to find a history of: 1 Hypertension 2 Thyroidectomy 3 Use of cocaine 4 Hypermagnesemia

2 Because of the location of the parathyroid glands within the thyroid gland, a thyroidectomy sometimes results in the accidental surgical removal of one or more of the parathyroid glands, which in turn causes hypoparathyroidism. Hypertension and cocaine use are important items to note in a medical history, but they are not directly related to hypoparathyroidism. Hypomagnesemia can lead to suppression of parathyroid hormone secretion, not hypermagnesemia.

A patient reports muscle weakness and swelling. The nurse notes that the patient has a low serum potassium level. The nurse identifies that hypersecretion of which hormone may be the cause of the assessment findings? 1 Insulin 2 Aldosterone 3 Thyroid hormone 4 Growth hormone

2 Hypersecretion of aldosterone, also called aldosteronism, may lead to fluid and electrolyte imbalance, resulting in muscle weakness and increased water retention due to loss of potassium from the body. Hypersecretion of insulin causes insulin shock, which is characterized by nervousness, sweating, chills, irritability, hunger, and pallor. Hypersecretion of thyroid hormone causes Grave's disease, which is characterized by exophthalmos. Hypersecretion of the growth hormone causes acromegaly, which is characterized by gradual enlargement or elongation of the facial bones and extremities.

The nurse reads the following prescription: "Infuse one unit of fresh frozen plasma before arrival to operating room (OR)." To complete this prescription safely, the nurse should take which action? 1 Infuse the fresh frozen plasma over four hours and then bring the patient to the OR. 2 Infuse the fresh frozen plasma as rapidly as the patient will tolerate. 3 Hang the fresh frozen plasma as a piggyback to the primary intravenous (IV) solution. 4 Hang the fresh frozen plasma as a piggyback to lactated Ringer's solution

2 The fresh frozen plasma should be administered as rapidly as possible and should be used within six hours. Fresh frozen plasma is infused with the use of any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infusing, unless a second IV line has been started for the transfusion.

A patient with angina pectoris asks the nurse about the cause of the pain. The nurse explains that the pain is primarily produced by: 1 Atherosclerosis 2 Myocardial ischemia 3 Movement of a thromboembolus 4 Coronary artery vasoconstriction

2 The pain of angina pectoris is caused by an inadequate oxygen supply to the myocardium, resulting in ischemia. The other answer options may lead to myocardial ischemia but are secondary causes.

A nurse is discussing the side effects of digoxin with another nurse. Which statements would the nurse make to demonstrate a correct knowledge about this medication? Select all that apply. 1 It increases the heart rate. 2 It may result in dysrhythmias. 3 It may cause toxicity. 4 It deteriorates myocardial contractility. 5 It increases the risk of thrombus formation

2, 3 In the case of a patient with myocarditis, the heart has increased sensitivity to dysrhythmias. Therefore, digoxin should be used with caution. Myocarditis also predisposes the patient to digoxin toxicity. Digoxin reduces the heart rate and improves myocardial contractility. It is not associated with thrombus formation.

A patient with chronic renal failure complains of severe itching all over the body. What should the nurse suspect as causes of itching? Select all that apply. 1 Edema 2 Excess urea in blood 3 Improper skin care 4 Imbalances in electrolyte levels 5 Abnormal liver function

2, 3 Pruritus could be caused by uremia and dry skin, both of which are features of kidney failure. Edema and electrolyte imbalances are a feature of renal failure but do not cause itching per se. Liver dysfunction may cause pruritus but may not be always associated with renal failure.

The nurse is evaluating the need for a radical cystectomy in a male patient with bladder cancer. What are the factors that the nurse should consider? Select all that apply. 1 The tumor is large. 2 The tumor is invasive. 3 The tumor involves the trigone. 4 There is no metastasis beyond the bladder area. 5 The tumor involves only one area of bladder.

2, 3, 4 A radical cystectomy involves removal of the bladder, prostate, and seminal vesicles in men and means that a new way needs to be created for urine to leave the body. Indications for a radical cystectomy include an invasive tumor that involves the trigone (the area where the ureters insert into the bladder) and is free from metastases. If the tumor is merely large, segmental or partial cystectomy, rather than radical cystectomy, is indicated. If the tumor involves only one area of bladder, segmental or partial cystectomy can be considered instead of radical cystectomy.

A patient with severe electric burns is admitted to the burn unit. When assessing the patient, what symptoms does the nurse know would indicate this patient is hyperkalemic? Select all that apply. 1 Palpitations 2 ECG changes 3 Muscle weakness 4 Decreased reflexes 5 Cardiac dysrhythmias

2, 3, 5 Electrical burns cause massive deep muscle injury, which leads to a release of large amounts of potassium into the blood stream. This can lead to hyperkalemia, which can be noted by related ECG changes. Muscle weakness can occur due to increased potassium levels. Cardiac dysrhythmias can be a result of elevated potassium levels. Palpitations and decreased reflexes are seen in hypokalemia.

A nurse is identifying obese women at risk of developing coronary artery disease in a community for health care research. What are the appropriate criteria for the selection of at-risk women? Select all that apply. 1 Age of less than 40 years 2 Apple-shaped obesity 3 Pear-shaped obesity 4 Body mass index greater than 30kg/m2 5 Waist circumference more than 30 inches

2, 4 Obesity is a major risk factor for the development of coronary artery diseases (CAD). Women below the age of 40 are generally premenopausal. The cardioprotective effects of estrogen make premenopausal women less susceptible for developing atherosclerosis, which can lead to CAD. Apple-shaped obesity is the type of obesity where there is more fat deposition around the abdomen. This condition is a major risk factor for development of coronary artery disease. Obesity in women is defined as having a body mass index of 30 or greater, which is a major risk factor for development of coronary artery disease. Evidence suggests that people having fat deposition around the thigh and hip regions (pear-shaped figure) are less susceptible to develop coronary artery disease than people having fat deposition around the abdomen (apple-shaped obesity). Obesity in women is defined as having a waist circumference more than 35 inches; therefore, the criterion should be "waist circumference greater than 35 inches."

The nurse is caring for a patient with severe burns in the emergency department. His laboratory values reveal serum creatinine level of 5 mg/dL, and the glomerular filtration rate (GFR) has decreased by 75%. What stage of acute kidney failure is this patient exhibiting? 1 Risk 2 Injury 3 Failure 4 Loss

3 As per the RIFLE (Risk, Injury, Failure, Loss, and End-stage) classification for staging acute kidney injury, this patient is at the Failure stage. When the GFR has decreased by 25%, the patient is at the Risk stage. The patient with a GFR that has decreased by 50% is at the Injury stage. The patient with persistent acute kidney failure experiences a complete loss of kidney function and is at the Loss stage.

The nurse monitoring the electrocardiogram (ECG) of a patient with hyperthyroidism observes regular, sawtooth-shaped flutter waves with an atrial rate 250 beats/minute. How should the nurse document this pattern? 1 Sinus bradycardia 2 Sinus tachycardia 3 Atrial flutter 4 Atrial fibrillation

3 Atrial flutter is an atrial tachydysrhythmia identified by flutter (F) waves, a sawtoothed pattern, with a 200-350 beats/minute atrial rate. In sinus bradycardia, the heart rate is less than 60 beats/minute, with regular rhythm and normal P waves. Sinus tachycardia is identified by 101-200 beats/minute, with regular rhythm and normal P waves. In atrial fibrillation, atrial rate is 350-600 beats/minute, with irregular rhythm, and fibrillatory (f) waves.

Shortly after having a central IV catheter inserted into the subclavian vein, the patient experiences shortness of breath, anxiety, and restlessness. What is the highest priority for the nurse? 1 Administering a sedative 2 Advising the patient to relax 3 Auscultating the breath sounds 4 Obtaining an arterial blood gas analysis

3 Because this is an acute episode, the nurse should first listen to the patient's lungs to see whether anything has changed. In this situation the probability is high that the patient sustained a pneumothorax during the subclavian IV catheter insertion procedure. The patient will need oxygen, and the doctor should be notified of the findings. Administering a sedative is not appropriate. Advising the patient to relax does provide reassurance, but the anxiety and restlessness are probably due to hypoxia. Obtaining an arterial blood gas analysis would likely be the next nursing action.

A patient had mitral valve replacement surgery two months ago, and has been receiving warfarin (Coumadin) therapy. The patient is in the clinic today to have blood work drawn, and the international normalized ratio (INR) results for today's visit are 3.1. The nurse anticipates taking which action? 1 Instruct the patient to stop taking the warfarin until INR levels are at a lower level. 2 Prepare to administer vitamin K injections because the INR level is elevated dangerously. 3 Inform the patient that there will be no changes in the warfarin dose because the INR is at a therapeutic level. 4 Instruct the patient regarding the new prescription for a higher dose of warfarin because the INR is not at a therapeutic level.

3 International normalized ratio (INR) values of 2.5 to 3.5 are therapeutic for patients with mechanical valves, so it is not necessary to change the dose. The patient should not stop taking the warfarin or take a higher dose. Vitamin K is the antidote for warfarin, and it is not necessary to take because the INR is in a therapeutic range.

A patient has the following arterial blood gas results: pH 7.32; PaCO2 56 mm Hg; HCO3- 24 mEq/L. The nurse determines that these results indicate 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 Respiratory acidosis (carbonic acid excess) occurs whenever a person experiences hyperventilation. Hypoventilation leads to a buildup of CO2, resulting in an accumulation of carbonic acid in the blood. Carbonic acid dissociates, liberating H+, and there is a decrease in pH. The patient is not experiencing metabolic acidosis. These results are not indicative of metabolic alkalosis or respiratory alkalosis (because the pH is high).

A patient has the following arterial blood gas results: pH 7.16, Paco2 80 mm Hg, Pao2 46 mm Hg, HCO3- 24 mEq/L, and Sao2 81%. The nurse recognizes that the results represent: 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 The pH is less than 7.35, indicating acidosis. This eliminates metabolic and respiratory alkalosis as possibilities. Because the Paco2 is high at 80 mm Hg (normal range is 35 to 45 mm Hg) and the metabolic measure of HCO3 - is normal (range is 22 to 28 mEq/L), the patient is in respiratory acidosis, not alkalosis

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? 1 Administer hypertonic saline 2 Administer a blood transfusion 3 Decrease the rate of fluid removal 4 Administer antiemetic medications

3 The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea, but would not help the hypovolemia.

Which instruction should the nurse provide when teaching a patient to exercise the pelvic floor? 1 Tighten both buttocks together 2 Squeeze thighs together tightly 3 Contract muscles around rectum 4 Lie on back and lift legs together

3 To teach pelvic floor, or Kegel, exercises, the nurse should instruct the patient (without contracting the legs, buttocks, or abdomen) to contract the muscles around the rectum (pelvic floor muscles) as if stopping a stool, which should result in a pelvic lifting sensation. Squeezing the thighs together, tightening buttocks together, and lying on the back and lifting legs do not strengthen the pelvic floor muscles.

The nurse is planning an educational course on risk factors for chronic kidney disease. Which factors should the nurse identify as nonmodifiable risk factors? Select all that apply. 1 Hypertension 2 Type II diabetes 3 Family history of chronic kidney disease (CKD) 4 Age > 60 5 Exposure to nephrotoxic drugs

3, 4 Family history of chronic kidney disease and age greater than 60 are risk factors out of the patient's control. The patient can make lifestyle changes to reduce high blood pressure and decrease blood glucose. The patient has a choice to take the drugs that are considered to be nephrotoxic.

When teaching patients and caregivers about the strategies to reduce burn injuries, what essential instructions does the nurse give? Select all that apply. 1 Store chemicals in the lowest shelves to avoid mixing up with other household chemicals. 2 Perform outdoor activities during lightning storms. 3 Ensure an electrical power source is shut off before beginning repairs. 4 Never leave burning candles unattended or near windows or curtains. 5 Check temperature of bath water with the back of hand or bath thermometer.

3, 4, 5 Ensure that the electrical power source is shut off before beginning any repairs to avoid electrical burn injury. Never leave candles unattended or near open windows or curtains to avoid fire. Check the temperature of the bath water using the back of the hand or use the bath thermometer to avoid scalding burns, which commonly occur due to hot bathing water. Chemicals should be stored safely, preferably out of reach of children, in clearly written labels. Performing outdoor activities during lightning storms increases the risk of electrical injury from the ongoing lightning.

A patient has recurrent episodes of fever and has a decreased neutrophil count (neutropenia). To prevent complications, which interventions should the nurse include in the patient's discharge teaching? Select all that apply. 1 Encourage the patient to eat raw eggs. 2 Encourage the patient to frequent crowded areas. 3 Encourage frequent hand washing. 4 Advise the patient to brush the teeth four times a day with a soft toothbrush. 5 Advise the patient to notify the health care provider if a fever develops.

3, 4, 5 Neutropenia, or decreased neutrophil count, increases the risk of developing infection. Therefore, measures should be taken to prevent infections. The self-care instructions provided by the nurse should include frequent hand washing to prevent transmission of germs. Brushing the teeth four times a day with a soft toothbrush prevents the risk of oral infections. Fever is an emergency situation in cases of neutropenia, and should be immediately reported to the healthcare provider. Eating raw eggs and staying in crowded areas increase the risk of acquiring infections, and should be avoided.

While planning physical therapy for a patient suffering from burns, which should be included? Select all that apply. 1 Practice physical therapy only occasionally. 2 Perform exercises before wound cleansing. 3 Perform passive and active ROM on all joints. 4 Provide pillows to sleep for patients with neck burns. 5 Perform exercises during and after wound cleansing.

3, 5 Perform passive and active ROM on all joints to avoid contractures and prevent compromising on patient's cardiopulmonary status. It is not a good habit to practice physical therapy only occasionally. This is because continuous physical therapy throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Performing exercises before wound cleansing is not appropriate. Patients with neck burns should continue to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension and avoid contractures.

A colectomy is scheduled for an 81-year-old man with an abdominal mass, suspected bowel obstruction, and a history of rectal polyps. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? 1 Rectal acetaminophen (Tylenol) to reduce postoperative pain 2 Administration of intravenous (IV) anticoagulants to prevent blood clots 3 Strict adherence to a liquid diet for three days before surgery 4 Administration of a cleansing enema

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A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? 1 Exercise almost every day 2 Avoid saturated fat intake 3 Limit calories to daily limit 4 Keep Hgb A1C less than 7%

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The nurse is providing care for a patient who has been admitted to the hospital for the treatment of nephrotic syndrome. What are priority nursing assessments in the care of this patient? 1 Assessment of pain and level of consciousness 2 Assessment of serum calcium and phosphorus levels 3 Blood pressure and assessment for orthostatic hypotension 4 Daily weights and measurement of the patient's abdominal girth

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When caring for the patient with cancer, the nurse understands that which of the following is the response of the immune system to antigens of the malignant cells? 1 Metastasis 2 Tumor angiogenesis 3 Immunologic escape 4 Immunologic surveillance

4 Immunologic surveillance is the process where lymphocytes check cell surface antigens, and detect and destroy cells with abnormal or altered antigenic determinants to prevent these cells from developing into clinically detectable tumors. Metastasis is increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site in the progression stage of cancer development. Tumor angiogenesis is the process of blood vessels forming within the tumor itself. Immunologic escape is the cancer cells evasion of immunologic surveillance that allows the cancer cells to reproduce

A male patient who has coronary artery disease (CAD) has serum lipid values of low-density lipoprotein (LDL) cholesterol 98 mg/dL, and high-density lipoprotein (HDL) cholesterol 47 mg/dL. What should the nurse include in the patient teaching? 1 Consume a diet low in fats 2 Reduce total caloric intake 3 Increase intake of olive oil 4 The lipid levels are normal

4 For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. The patient's normal lipid levels should be included in the patient teaching and the patient should be encouraged to continue taking care of himself. Assessing his need for teaching related to diet should be done also.

Which patient would the nurse identify being at higher risk for developing coronary artery disease (CAD)? 1 1.43-year-old nonsmoking African-American male 2 2.26-year-old Hispanic male smoking one pack of cigarettes per day 3 3.49-year-old Caucasian male with blood pressure 152/92mm Hg 4 4.72-year-old African-American female with a cholesterol level of 300 mg/dL

4 Multiple risk factors increase the risk of CAD, and this patient has three risk factors: age over 55, African-American ethnic background, and cholesterol level greater than 240 mg/dL. Middle-aged nonsmoking African-American male has only two risk factors: middle age and male gender: Caucasian middle-age males are more prone to develop CAD. The Hispanic patient has only two risk factors for CAD: male gender and smoking. Middle-aged white male has two risk factors only (age and gender) because systolic blood pressure is less than 160 mm Hg.

Which organ produces lymphocytes? 1 Spleen 2 Tonsils 3 Thymus 4 Bone marrow

4 Production of lymphocytes takes place in the bone marrow. The spleen is responsible for filtering foreign antigens that enter the bloodstream. Tonsils are lymphoid tissue that act as a first-line defense against ingested or inhaled pathogens. The thymus produces mature T-lymphocytes.

A burn patient has not received any active tetanua immunization within the previous 12 years. What is the primary nursing measure to help prevent the development of tetanus in the patient? 1 Administer tetanus toxoid 2 Provide musculoskeletal relaxants 3 Provide 100% oxygen to the patient 4 Administer tetanus immunoglobulin

4 Since the patient has not received any active immunization in the past 12 years, tetanus immunoglobulin administration is the primary measure. It would help in preventing development of tetanus. Tetanus toxoid administration would have been the primary measure if the patient had received active immunization within the past 10 years. Providing 100% oxygen does not ensure aerobic conditions at the burn area. Musculoskeletal relaxants will be helpful only after the patient develops tetanus.

Which item would be most beneficial when providing oral care to a patient with cancer who is at risk for oral-tissue injury? 1 Hydrogen peroxide rinses 2 Use of oral swabs only 3 Alcohol-based mouthwash 4 Soft-bristled toothbrush

4 Soft-bristled toothbrushes will prevent further irritation to oral tissue that is fragile. Alcohol-based mouthwash and hydrogen peroxide may further damage fragile oral tissue. Oral swabs may be used; however, these are not as effective in cleaning the oral cavity and teeth and reducing bacteria accumulation in the mouth.

The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which strategy would be most appropriate for the nurse to use to increase the patient's nutritional intake? 1 Increase intake of liquids at mealtime to stimulate the appetite. 2 Serve three large meals per day plus snacks between each meal. 3 Avoid the use of liquid protein supplements to encourage eating at mealtime. 4 Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.

4 The nurse can increase the nutritional density of foods by adding items high in protein or calories (such as peanut butter, skim milk powder, cheese, or honey) to foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid and decreases the desire to eat. Small frequent meals are tolerated best. Supplements can be helpful.

A nurse is providing preprocedural teaching to a patient who is scheduled for a bone marrow aspiration. Arrange the steps of performing a bone marrow aspiration in the correct order. 1. The stylet of the needle is then removed. 2. A bone marrow needle is inserted through the cortex of the bone. 3. The skin over the puncture site is cleansed with a bactericidal agent. 4. The hub is attached to a 10-mL syringe, and 0.2 to 0.5 mL of the fluid marrow is aspirated. 5. The skin, subcutaneous tissue, and periosteum are infiltrated with a local anesthetic agent.

A bone marrow aspiration involves obtaining bone marrow for cytological and chromosomal investigations. The bone marrow is usually aspirated from the posterior iliac crest. During a bone marrow aspiration, the skin over the puncture site is prepared by using a bactericidal agent. A local anesthetic agent is then infiltrated into the skin, subcutaneous tissue, and periosteum. Following this, a bone marrow needle is inserted into the bone through the cortex. The stylet of the needle is then removed and the hub is attached to 10-ml syringe. The bone marrow is then aspirated. A volume of 0.2 to 0.5 mL is sufficient for laboratory investigations.

The nurse reviews a plan of care for a patient with diagnosis of chronic kidney disease who is undergoing hemodialysis. Which part of the plan should the nurse question? 1 2-g sodium diet 2 Oxygen via nasal cannula at 4 L/min 3 Furosemide (Lasix) 40 mg PO twice a day 4 IV of 0.9% sodium chloride at 125 mL/hour

A patient with chronic kidney disease (CKD) should receive limited fluids because the kidneys are unable to remove excessive water. An IV solution of 0.9% sodium chloride at a rate of 125 mL/hr places this patient at high risk for complications such as fluid overload, electrolyte imbalance, and hypertension. A 2-g sodium diet, oxygen, and furosemide (Lasix) would be appropriate if prescribed for a patient with CKD.

What are the common causes of acute kidney injury? Select all that apply. A Hypovolemia B Interstitial nephritis C Increased cardiac output D Decreased renovascular blood flow E Increased peripheral vascular resistance

A, B, D Acute kidney injury is defined as rapid loss of kidney function. The common causes of acute kidney injury are prerenal, intrarenal, and postrenal. One cause of acute kidney injury is hypovolemia, which is associated with dehydration, diarrhea, burns, and hemorrhage. Interstitial nephritis, which is associated with allergies and infections, is another cause of acute kidney injury. Decreased renovascular blood flow, which is associated with embolism and renal artery thrombosis, is another cause of acute kidney injury. Decreased cardiac output, which is associated with cardiac dysrhythmias and cardiogenic shock, is also a cause of acute kidney injury. Decreased peripheral vascular resistance, which is associated with neurologic injury and septic shock, is another cause of acute kidney injury.

What are the complications of hemodialysis? Select all that apply. A Hepatitis B Hypertension C Muscle cramps D Lightheadedness E Excess coagulation of blood

A, C, D Hemodialysis is extracorporeal removal of waste products such as creatinine, urea, and free water from the blood during renal failure. The complications of hemodialysis include hepatitis, hypotension, muscle cramps, lightheadedness, and blood loss. Hepatitis is common in patients who are undergoing dialysis due to the transmission of infection-causing organisms. Hypotension occurs due to rapid removal of vascular volume and decreased cardiac output. Muscle cramps are caused by hypotension, hypovolemia, or high ultrafiltration rate. Lightheadedness is caused by a drop in blood pressure. Hemodialysis may cause hypotension and bleeding.

A nurse is assessing a patient's weight in order to evaluate fluid volume status. The patient's weight on the day of admission was 60 kg. On day 2, the weight is 62 kg. What is the quantity of fluid retention in the patient? Record your answer using a whole number and no punctuation. _______ mL

An increase in 1 kg is equal to 1000 mL of fluid retention. The patient has gained 2 kg, which is equal to 2000 mL of fluid retention.

A nurse is teaching about coronary artery disease to a group of nursing students. To evaluate their understanding, the nurse asks them to explain why pain is referred to the shoulder, neck, and jaw in a case of stable angina. Prioritize the pathophysiological events causing referred pain in stable angina. 1. Accumulation of lactic acid in the myocardium 2. Reduced blood supply to the myocardium 3. Inadequate aerobic metabolism in the myocardium 4. Transmission of pain impulses in the cardiac and upper thoracic posterior nerves 5. Irritation of nerve fibers of the myocardial tissue

Coronary occlusion causes a reduced blood supply to the heart, thereby leading to myocardial ischemia. As the blood supply is compromised, there is inadequate oxygen delivery to the myocardium for aerobic metabolism to take place. Anaerobic metabolism begins and leads to the accumulation of lactic acid. Lactic acid irritates the myocardial nerve fibers, and pain impulses are transmitted to the cardiac nerves and upper thoracic posterior nerve roots. This causes referred cardiac pain to the shoulder, neck, lower jaw, and arms.

A patient with chronic kidney disease is at risk for anemia. Arrange the events in the order in which they lead to anemia caused by chronic kidney disease. 1. Bone marrow fibrosis 2. Elevated levels of parathyroid hormone (PTH) 3. Inhibition of erythropoiesis 4. Shortened survival of red blood cells (RBCs)

Elevated levels of PTH, produced to compensate for low serum calcium levels, can inhibit erythropoiesis, shorten the survival of RBCs, and cause bone marrow fibrosis, which can result in a decrease in hematopoietic cells.

The patient has a prescription for levothyroxine (Synthroid) 37.5 mcg. Available are 0.075 mg tablets. How many tablets should the nurse administer? 1 0.25 tablet 2 0.5 tablet 3 0.75 tablet 4 1 tablets

First, convert 0.075 mg to mcg, which equals 75 mcg. Using ratio and proportion, multiply 37.5 by x and multiply 75 × 1 to yield 37.5x = 75. Divide 75 by 37.5 to yield 0.5 tablet.

The nurse is preparing to perform a head-up tilt-test for a patient who was brought to the health care facility with syncope. Arrange these steps in the order in which the nurse would execute them during the test. 1. Baseline electrocardiogram (ECG), blood pressure (BP), and heart rate (HR) are obtained in the horizontal position. 2. ECG and HR are recorded continuously. 3. Patient is placed on a table supported by belts. 4. BP is measured every 3 minutes. 5. The table is tilted 60 to 80 degrees for 20 to 60 minutes

In the head-up tilt-test the patient is placed on a table supported by a belt across the torso and feet. Baseline ECG, BP, and HR are obtained in the horizontal position. Next, the table is tilted 60 to 80 degrees and the patient is kept in this upright position for 20 to 60 minutes. ECG and HR are recorded continuously and BP is measured every 3 minutes throughout the test.

A patient is admitted with an acute myocardial infarction. An ECG tracing changes from a sinus tachycardia to the following tracing. In which order should a nurse perform these interventions?12676305 1. Begin cardiopulmonary resuscitation (CPR) 2. Call for assistance 3. Defibrillate when defibrillator arrives 4. Lower the head of the bed

The ECG tracing is ventricular fibrillation, a lethal rhythm requiring a team of health care providers to provide interventions. Therefore, the priority is to call for assistance and then lower the head of the bed and start CPR until the defibrillator arrives. Once the defibrillator is available, CPR should be stopped and the patient defibrillated. Text Reference - p. 801

A nurse is teaching a group of nursing students about nursing actions during an electrocardiographic (ECG) recording. Arrange the actions in their correct order. 1. Wipe the area 2. Remove excess hair 3. Monitor for artifact 4. Affix the electrodes

The first step during the measurement of an ECG is to remove excess hair on the skin. The presence of hair may not facilitate the proper adherence of electrodes to the skin. This could interfere with the recording of the cardiac impulses. It is followed by wiping the skin with alcohol to remove dirt and oil, and gently rubbing with gauze until the skin becomes pale pink. Wiping of the skin is followed by attaching the electrodes to the patient at the designated areas. Artifact may occur for various reasons. This indicates deformity of baseline and waveforms on electrocardiograph.

A nurse, while reading the ECG of a patient, finds that there are 8 R-R intervals in a span of 6 seconds. What would be the heart rate of this patient? Record your answer in a whole number. __ beats/minute.

The heart rate can be calculated from an ECG by counting the number of R-R intervals in 6 seconds and multiplying that number by 10. In this case, the patient's ECG has 8 R-R intervals. Therefore, 8 multiplied by 10 is 80.

A patient is suspected to have a smoke inhalation burn and carboxyhemoglobinemia. In what order should the nurse perform the treatment interventions? 1. Check for the adequacy of ventilation. 2. Check for the patient's pulse. 3. Elevate any burned limbs above the heart to decrease pain and swelling. 4. Check for a patent airway and soot around nares and tongue.

The most important intervention is to check that the airway is patent. Then evaluate the adequacy of appropriate ventilation, followed by a check of the patient's pulse. Finally, elevate any burned limbs above the heart to decrease pain and swelling.

A nurse has to determine the volume of fluid that must be administered to the patient with acute renal failure who is in the oliguric phase. The total urine output of the patient the previous day was 250 mL. What should be the fluid allocation for this patient on this day? Record your answer using a whole number. __ mL

The patient is at a risk of developing hypovolemia, and to prevent this, adequate fluid resuscitation should be done. To determine the volume for fluid resuscitation, the nurse adds together all losses during the previous 24 hours (e.g., urine, diarrhea, emesis, blood) and adds 600 mL for insensible losses (e.g., respiration, diaphoresis).

The nurse is caring for a patient with sepsis who was just initiated on continuous renal replacement therapy (CRRT). In which order should the nurse perform the following actions? (Place the options in the order in which they should be performed. All options must be used.) 1. Assess intake and output 2. Obtain vital signs 3. Document laboratory values 4. Obtain weight

The patient on CRRT is hemodynamically unstable. Therefore, frequent vital signs should be assessed. Intake and output should be next, followed by obtaining a weight with assistance from an unlicensed assistive personnel (UAP). Document all laboratory values after the patient has been determined to be stable.

The nurse is planning an education program on chronic kidney disease. Which ethnic group would the nurse target for promoting this event? 1 African Americans 2 Asian descent 3 Caucasian males 4 Hispanics

1 African Americans are at the greatest risk for develop kidney disease. Those of Asian descent, Caucasian males, and Hispanics are not at as great a risk.

The patient is receiving an intravenous (IV) vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? 1 Ask the patient if the site hurts 2 Turn off the chemotherapy infusion 3 Call the prescribing health care provider 4 Administer sterile saline to the reddened area

Because extravasation of vesicants may cause severe local tissue breakdown and necrosis, with any sign of extravasation the infusion first should be stopped, then the protocol for the drug-specific extravasation procedures should be followed to minimize further tissue damage. The site of extravasation usually hurts, but it may not. It is more important to stop the infusion immediately. The health care provider may be notified by another nurse while the patient's nurse starts the drug-specific extravasation procedures, which may or may not include sterile saline.

The nurse is preparing to perform a head-up tilt-test for a patient who was brought to the health care facility with syncope. Arrange these steps in the order in which the nurse would execute them during the test. 1. Baseline electrocardiogram (ECG), blood pressure (BP), and heart rate (HR) are obtained in the horizontal position. 2. ECG and HR are recorded continuously. 3. Patient is placed on a table supported by belts. 4. BP is measured every 3 minutes. 5. The table is tilted 60 to 80 degrees for 20 to 60 minutes.

In the head-up tilt-test the patient is placed on a table supported by a belt across the torso and feet. Baseline ECG, BP, and HR are obtained in the horizontal position. Next, the table is tilted 60 to 80 degrees and the patient is kept in this upright position for 20 to 60 minutes. ECG and HR are recorded continuously and BP is measured every 3 minutes throughout the test.

A nurse is teaching about the conduction system of the heart to a group of nursing students. Arrange the order in which the electrical impulses travel through the parts of the conduction system. 1. Bundle of His 2. Sinoatrial node 3. Purkinje fibers 4. Internodal pathways 5. Atrioventricular node

The conduction system of the heart consists of specialized neuromuscular tissue. The electrical impulse of the heart begins at the sinoatrial node in the upper right atrium. This impulse travels through the intermodal fibers and spreads over the atrial musculature. This causes atrial contraction. The impulse then reaches the atrioventricular (AV) node. From the AV node the impulse moves down through the bundle of His and ends at the Purkinje fibers. Impulses from the Purkinje fibers cause ventricular contractions.

A patient is undergoing treatment for partial-thickness burns on the legs. In what order should the nurse perform the given actions as a part of wound care? 1. Debride the loose necrotic tissue. 2. Protect the skin graft with dressing. 3. Cleanse wounds with soap and water. 4. Apply paraffin-based fine-meshed gauze dressing.

The nurse should first cleanse the wounds with soap and water or normal saline-moistened gauze. This is done to gently remove the old antimicrobial agent, any loosened necrotic tissue, scabs, or dried blood. Next, debridement should be carried out to gently remove loose necrotic tissue and make the wound ready for treatment. When partial-thickness burn wounds are fully debrided, protective, coarse or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied. This helps to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. If grafting is necessary, protect the skin graft with the same greasy gauze dressings next to the graft. This layer of dressing should be followed by a saline-moistened middle layer and dry gauze outer dressings.

The patient has multiple myeloma and will be treated with autologous hematopoietic stem cell transplantation because a suitable donor has not been found. In which order will the following procedures occur? Put a comma and space between each answer choice (1, 2, 3, 4, etc.). 1. Myeloablative chemotherapy is administered. 2. Stem cells are infused after chemotherapy has been eliminated from the body. 3. Peripheral stem cells are obtained from the peripheral blood in an outpatient procedure. 4. Filgrastim (Neupogen), a granulocyte colony-stimulating factor, is administered with plerixafor (Mozobil). 5. Stem cells are treated to remove undetected cancer cells, then cryopreserved and stored until needed.

When the patient donates the stem cells for the autologous hematopoietic stem cell transplantation, first filgrastim or another granulocyte colony-stimulating factor is given along with plerixafor to increase the number of stem cells released from the bone marrow into the bloodstream. Peripheral stem cells are collected at an outpatient center, treated to remove undetected cancer cells, and cryopreserved to be stored for later use. Then the patient is treated with myeloablative chemotherapy to destroy the bone marrow. The preserved stem cells are then infused after the chemotherapy has been eliminated from the patient's body, approximately 24 to 48 hours after the last dose of chemotherapy.

A patient is admitted to the hospital with a diagnosis of aortic valve stenosis. Which manifestation should the nurse expect when taking the health history? 1 Angina 2 Fatigue 3 Dyspnea 4 Weakness

1 Angina is one of the classic triad of manifestations that occurs on exertion in aortic valve stenosis. Angina occurs when the myocardial oxygen demand of the hypertrophied left ventricle exceeds oxygen supply. Fatigue, dyspnea, and weakness are clinical manifestations of chronic mitral valve regurgitation

The primary health care provider has prescribed parenteral nutrition for a patient. The nurse administers a 10% dextrose solution with amino acids, electrolytes, vitamins, and trace elements. Which statement is true about the 10% dextrose solution? 1 It is a hypertonic solution 2 It expands the extracellular compartment 3 It should be administered only through a central line 4 It is used as a plasma expander

1 A 10% dextrose solution with amino acids, electrolytes, vitamins, and trace elements is used in parenteral nutrition to provide additional calories. It is a hypertonic solution, which provides free water, expanding both the extracellular and intracellular compartments. Solutions with a dextrose concentration of 10% or more should be administered only through a peripheral line. Solutions with a higher dextrose concentration should be administered through a central line. Hypertonic solutions are not used as plasma expanders since they do not stay in the vascular space.

The nurse provides postoperative care 1 day after a patient undergoes colostomy surgery. The patient's stoma is moist and dark pink, with no obvious drainage. Which action should the nurse take? 1 Document the normal findings 2 Consult the enterostomal therapist 3 Irrigate the ostomy with normal saline 4 Palpate the abdomen around the stoma

1 A colostomy stoma that is moist and dark pink without any drainage on the first postoperative day is normal. These findings should be documented in the patient's medical record. Consulting the enterostomal therapist, irrigating the ostomy, and palpating the abdomen are not necessary because the colostomy stoma is normal.

What is the clinical use of a multiple gated acquisition (MUGA) scan? 1 It helps determine ejection fraction. 2 It helps detect conduction disturbances. 3 It helps determine the effectiveness of dilated cardiomyopathy. 4 It helps detect infectious organisms in the heart tissue.

1 A multiple gated acquisition nuclear scan determines ejection fraction. Ejection fraction less than 20% is associated with a 50% mortality rate within a year. Conduction disorders like tachycardia, bradycardia, and dysrhythmias are diagnosed by electrocardiogram. Endomyocardial biopsy at the right side of the heart helps identify infectious organisms in heart tissue. Doppler echocardiography helps evaluate the effectiveness of dilated cardiomyopathy.

A patient is suspected of having leukemia. A nurse understands that investigating the shape and appearance of the blood cells may assist with the diagnosis. The nurse anticipates that which test will be prescribed? 1 Peripheral smear 2 Differential WBC count 3 Platelet count 4 Prothrombin time

1 A peripheral smear is used to look at the morphology of blood cells and helps to confirm the diagnosis. In leukemia a large number of immature blast WBCs may be present. Differential WBC count indicates the status of the immune system. The WBC count may be high or low in infections, inflammation, and malignancies. A platelet count indicates the status of clotting in the body. A high platelet count is associated with inflammation and malignancies. A low platelet count is associated with bleeding disorders. Prothrombin time reflects the adequacy of thrombin and the clotting mechanism.

A 32-year-old female patient is admitted to the emergency department (ED) with acute abdominal pain. In addition to a complete blood count, urinalysis, and abdominal x-ray, the nurse will expect to see a prescription for which diagnostic test? 1 Pregnancy test 2 Cardiac enzymes 3 Liver function studies 4 Renal function studies

1 A pregnancy test is performed in women of childbearing age with acute abdominal pain to rule out ectopic pregnancy. Cardiac enzymes are prescribed if a patient is experiencing chest pain or signs of a myocardial infarction. Liver function studies or renal function studies are not prescribed on a routine basis.

A patient's ECG tracing has a short QT interval and a high peaked T wave. Which prescription should the nurse question? 1 D5W with 20 meq KCL to run at 125 mL/hr 2 10 units regular insulin IVP and ½ ampule D50W IVP 3 2 grams calcium gluconate intravenous (IV) administered over two minutes 4 Sodium polystyrene sulfonate (Kayexalate) 30 grams by mouth

1 A short QT interval and a high peaked T wave are indicative of hyperkalemia. The prudent nurse should question any prescription that could increase the potassium level in the patient. IV insulin with D50W and calcium gluconate are given to force the potassium back into the cells, temporarily correcting the hyperkalemia. Polystyrene sulfonate binds with potassium in the gastrointestinal (GI) tract and excretes it via feces.

A human immunodeficiency virus (HIV)-infected patient tells the nurse that he or she is worried that he or she might have acquired immunodeficiency syndrome (AIDS). When is a diagnosis of AIDS in an HIV-infected patient confirmed? 1 The patient's CD4+ T cell count is below 200/μL. 2 The patient has flu-like symptoms. 3 Lipodystrophy with metabolic abnormalities is present. 4 Elevated platelet and white blood cell (WBC) counts are present.

1 AIDS is diagnosed when an individual with HIV meets one of several criteria; one criterion is a CD4+ T cell count below 200 cells/μL. Flu-like symptoms can be indicative of other diseases. Changes in WBC or platelet counts are not diagnostic criteria for AIDS (and WBC and platelet levels decrease, not increase). Changes in body shape because of lipodystrophy are not definitive diagnoses for AIDS.

Which symptoms should a nurse assess for when caring for a patient with heart failure who is at risk of developing fluid volume excess? 1 Full, bounding pulse 2 Flattened neck veins 3 Low blood pressure 4 Easily obliterated pulse

1 Any change in the fluid volume is reflected in changes in blood pressure, pulse rate force, and jugular venous distension. A fluid volume excess may cause a full bounding pulse, increased blood pressure, and distended neck veins. The pulse in this case is not easily obliterated. Flattened neck veins, low blood pressure, and a weak and thready pulse that can be easily obliterated indicate fluid volume deficit.

A patient reports shortness of breath one day after a cholecystectomy. On examination there is dullness on percussion on the right side of the chest, and breath sounds are also decreased in this region. The nurse recognizes that the most probable reason for the assessment findings is what? 1 Atelectasis 2 Pneumonia 3 Pneumothorax 4 Tension pneumothorax

1 Atelectasis is the most common complication seen after thoracic or abdominal surgery. In this condition the alveoli are collapsed, and there is no air in them. On examination the affected area is dull when percussion is done, and the breath sounds in the affected area are decreased. Therefore this patient most probably has atelectasis. Pneumonia can have similar findings, but it is highly unlikely to occur one day after surgery. In both pneumothorax and tension pneumothorax, the affected area is hyperresonant.

A nurse preparing a patient for cardiac catheterization should perform a baseline assessment of vital signs, pulse oximetry, and heart and lung sounds. What other vital assessment should the nurse include during a cardiac catheterization? 1 Allergies 2 Anemia 3 Dysrhythmia 4 Mental status

1 Before performing a cardiac catheterization, the nurse should assess the patient for an allergy to contrast medium, which would have an immediate adverse effect on the patient receiving this procedure. Anemia, dysrhythmia, and change in mental status present less immediate complications during a cardiac catheterization procedure.

A patient with chronic obstructive pulmonary disorder is considered for lung transplantation. The patient had melanoma and hepatitis A one year ago. The patient previously smoked three cigarettes per day but has not smoked in the past year. The nurse considers the patient's history and concludes what about the patient's eligibility for lung transplantation? 1 The patient is eligible for lung transplantation. 2 Because of the history of smoking, the patient is not eligible. 3 Because of the history of hepatitis A, the patient is not eligible. 4 Because of the history of cancer one year ago, the patient is not eligible.

1 Chronic obstructive pulmonary disease is one of the indications for lung transplantation. There are some absolute contraindications for lung transplantation, including but not limited to being a current smoker, chronic active hepatitis B or C, history of cancer except skin cancer, poor nutritional status, and HIV. This patient is eligible for lung transplantation. The patient is not a current smoker, has hepatitis A, and had melanoma, which is a skin cancer. Therefore there are no contraindications for lung cancer.

The nurse is presenting a class on the biology of cancer to a group of new graduate nurses, and is comparing cancer cells with normal cells. Which of these is a characteristic of cancer cells? 1 Cancer cells return to a previous undifferentiated state. 2 Proliferation of the cancer cells occurs at an intermittent rate. 3 Cancer cells will not invade the boundary of cells around them. 4 Undifferentiated cells, known as stem cells, become cancer cells.

1 Defective cell differentiation is a characteristic of cancer cells. Cancer cells revert to a previous undifferentiated state. Proliferation of the cancer cells is indiscriminate and continuous. Sometimes they produce more than two cells at the time of mitosis. In this way, there is continuous growth of a tumor mass. Normal cells respect the boundaries and territory of the cells surrounding them. They will not invade a territory that is not their own. Stem cells do not become cancer cells.

Which process involves movement of fluid and molecules across a semipermeable membrane from one compartment to another? 1 Dialysis 2 Osmosis 3 Diffusion 4 Ultrafiltration

1 Dialysis is the movement of fluid and molecules across a semipermeable membrane from one compartment to another. Substances move from the blood through a semipermeable membrane and into a dialysis solution in this process. Osmosis is the movement of fluid from an area of lesser concentration to an area of greater concentration of solutes. Diffusion is the movement of solutes from an area of greater concentration to an area of lesser concentration. Ultrafiltration occurs when there is a pressure gradient across the membrane.

A female patient who is HIV positive is prescribed Efavirenz (Sustiva) in large doses. What question should the nurse ask of the patient before administering the therapy to ensure drug safety? 1 "Are you pregnant?" 2 "Is your partner HIV positive?" 3 "Are you on your menses?" 4 "Have you ever had a blood transfusion?"

1 Efavirenz (Sustiva) is an antiretroviral drug. Large doses could cause fetal anomalies; therefore, it is important to know if the patient is pregnant. Asking about the HIV status of the partner is unrelated to administration of the drug. The information about the patient's menses does not impact the antiretroviral therapy. A history of blood transfusion helps ascertain the mode of infection, but does not impact the drug therapy.

Which action does flecainide have on the heart? 1 Decreases conduction 2 Decreases automaticity 3 Accelerates repolarization 4 Reduces myocardial contractility

1 Flecainide is a class IC sodium channel blocker; it decreases impulse conduction in the heart. Mexiletine is a class IB sodium channel blocker that accelerates repolarization. β-adrenergic blockers like esmolol decrease the automaticity of the sinoatrial node. Myocardial contractility is reduced with diltiazem, a calcium channel blocker.

A patient is prescribed levothyroxine (Synthroid). To promote optimal absorption, the nurse should instruct the patient to take the medication at which time? 1 0600 2 1200 3 1600 4 2100

1 For maximum absorption, levothyroxine should be taken first thing in the morning on an empty stomach 30 minutes before breakfast. 1200, 1600, and 2100 may not result in adequate absorption.

A patient is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which question is most important for the nurse to ask the patient? 1 "Have you recently had strep throat?" 2 "Do you have susceptibility to allergies?" 3 "How much fluid do you drink in a day?" 4 "Have you had any contact with anyone who has measles?"

1 Glomerulonephritis is an inflammatory process, usually resulting from antibodies reacting with group A hemolytic streptococcal antigens, the organism responsible for strep throat. Allergies, fluid intake, and measles exposure are not germane to the diagnosis of acute glomerulonephritis.

The nurse knows that the patient who is being treated conservatively for hyperparathyroidism understands the discharge teaching when the patient says 1 1."I should exercise regularly." 2 2."I should avoid excess dietary fiber." 3 3."I should restrict my fluids to 1000 mL daily." 4 4."I should report tingling in my hands and around my mouth."

1 Hyperparathyroidism is a condition of increased parathyroid hormone (PTH) secretion. PTH regulates serum calcium levels by stimulating bone resorption. When PTH levels are elevated, calcium resorption is accelerated. This loss of calcium from the bones causes hypercalcemia and puts the bones at risk for pathologic fractures. Patients with hyperparathyroidism can decrease bone loss through regular weight-bearing exercises. While high impact exercises put the patient at risk for pathologic fracture, walking is an important means of decreasing the rate of bone resorption. Hypercalcemia leads to constipation. The patient with hyperparathyroidism benefits from a high fiber diet. Hypercalcemia predisposes the patient to renal stones; adequate fluid intake decreases the risk of renal stones. Tingling in the hands and around the mouth is associated with tetany, a condition resulting from a sudden drop in serum calcium. Tetany is associated with hypocalcemia; it may occur postoperatively following parathyroidectomy. It is not associated with the state of hypercalcemia that is seen normally with untreated or undertreated hyperparathyroidism.

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? 1 "If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." 2 "I need to take good care of my belly and ankle skin where it is swollen." 3 "A scrotal support may be more comfortable when I have scrotal edema." 4 "I can use pillows to support my head to help me breathe when I am in bed."

1 If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. A scrotal support may improve comfort if there is scrotal edema. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency

A patient who is undergoing external beam radiation therapy for cancer asks, "Will I be radioactive after the treatment?" What is an appropriate nursing response? 1 The patient will not be radioactive at any time. 2 Only the patient's urine and stool will be radioactive. 3 The patient will be radioactive only during the treatment period. 4 Although the patient's blood is radioactive, it will not affect anyone else.

1 In external beam radiation therapy, gamma radiation is focused toward the treatment field. The patient does not absorb or retain any of the radiation particles during the treatment and is therefore not radioactive during or after the treatment period. A patient is only radioactive when there is some form of internal radiation, such as brachytherapy, as a sealed source, or an unsealed liquid radioactive source. These sources have short half-lives and are weak emitters. In these types of radiation treatments stool and urine and blood will emit some radiation. The principles of ALARA (as low as reasonably achievable) and TDS (time, distance, and shielding), should always be followed.

A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? 1 Preparing to assist with a head-up tilt-test 2 Preparing an intravenous (IV) dose of a b-adrenergic blocker 3 Assessing the patient's knowledge of pacemakers 4 Teaching the patient about the role of antiplatelet aggregators

1 In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV (-blockers are not indicated, although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.

A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? 1 Milk thistle may affect liver enzymes and thus alter drug metabolism. 2 Milk thistle generally is safe in recommended doses for up to 10 years. 3 There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. 4 Milk thistle may elevate the serum glucose levels and thus is contraindicated in diabetes.

1 Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.

A patient is receiving an infusion of monoclonal antibodies (MoAb) for non-Hodgkin's lymphoma. The nurse finds that the patient has developed an anaphylactic reaction. Which action should the nurse perform first? 1 Stop the infusion. 2 Reduce the rate of the infusion. 3 Stabilize the airway, breathing, and circulation. 4 Inform the health care provider

1 Monoclonal antibodies are a type of targeted therapy used for treating non-Hodgkin's lymphoma and chronic lymphocytic leukemia. Some patients may develop an anaphylactic reaction during the therapy, which can be life-threatening. If the patient develops such anaphylaxis, the infusion should immediately be stopped to prevent worsening of the anaphylactic reaction. Reducing the dose may also worsen the anaphylaxis. The airway, breathing, and circulation can be stabilized once the infusion is stopped. The primary health care provider can be informed once the infusion is stopped and the patient is stabilized

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient? 1 Multiple myeloma 2 Thrombocytopenia 3 Megaloblastic anemia 4 Myelodysplastic syndrome

1 Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia , megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.

A patient in asystole is likely to receive which drug treatment? 1 Epinephrine and atropine 2 Lidocaine and amiodarone 3 Digoxin and procainamide 4 β-Adrenergic blockers and dopamine

1 Normally the patient in asystole cannot be resuscitated successfully. However, administration of epinephrine and atropine may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for premature ventricular contractions (PVCs). Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate and dopamine is used to increase heart rate.

Which statement by the patient who is diagnosed recently with coronary artery disease (CAD) indicates that the patient understands dietary modifications that need to be implemented after discharge home? 1 "I will not eat bacon or any pork products." 2 "I will eat only fried eggs instead of boiled eggs." 3 "I may continue to enjoy French fries with hot dogs." 4 "I will drink no more than one glass of whole milk per day."

1 Nutritional therapy recommends for the patient with CAD a low cholesterol and low fat diet; therefore, the patient has to avoid bacon and any pork products. Egg yolk is high in cholesterol and the patient with CAD has to avoid fried food. French fries are high fat because of their preparation process. Low fat or nonfat milk is recommended for the patient with CAD

Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? 1 "It is essential that you maintain aseptic technique to prevent peritonitis." 2 "You will be allowed a more liberal protein diet once you complete CAPD." 3 "It is important for you to maintain a daily written record of blood pressure and weight." 4 "You will need to continue regular medical and nursing follow-up visits while performing CAPD."

1 Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring by use of aseptic technique. Although the nurse will teach a patient he or she may be allowed more liberal protein, the importance of maintaining a weight and blood pressure record, and keeping follow-up appointments, these statements do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority .

A patient is just returning to the surgical floor from the recovery room after undergoing a thyroidectomy. Identify the priority nursing intervention. 1 Have a tracheostomy tray at the bedside. 2 Closely monitor the patient's emotional state. 3 Avoid touching the patient's neck and shoulders. 4 Maintain hydration status with small sips of water.

1 Postoperative complications for a patient following a thyroidectomy include injury to the recurrent or superior laryngeal nerve, which can lead to vocal cord paralysis. If both cords are paralyzed, spastic airway obstruction will occur, requiring an immediate tracheostomy. Closely monitoring the patient's emotional status is important, especially because the appearance of the incision may be distressing to the patient. However, providing reassurance that the scar will fade in color and eventually look like a normal neck wrinkle is not the priority. Following surgery, patients are nothing by mouth status, and would not be taking small sips of water to maintain hydration. Hydration status is maintained via intravenous fluids. The nurse would not avoid touching the patient's neck and shoulders, as this would impede a thorough assessment.

The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? 1 Renal dialysis 2 Intravenous (IV) potassium chloride 3 IV furosemide (Lasix) 4 IV normal saline at 250 mL per hour

1 Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output, which is the major route of excretion for magnesium.

The nurse assesses a patient with diabetes who reports shortness of breath, neck pain, and hypoglycemic symptoms. The patient's blood pressure is 130/86 mm Hg, heart rate is 102 beats/min, respiratory rate is 24 breaths/min, and the fingerstick blood glucose is 136 mg/dL. The nurse recognizes that the patient may be experiencing: 1 Myocardial infarction 2 Late-stage diabetic ketoacidosis 3 Early-onset diabetic ketoacidosis 4 Hyperosmolar hyperglycemic nonketotic syndrome

1 Signs and symptoms of a myocardial infarction (MI) include shortness of breath, neck pain, and cool, clammy skin. Although cool, clammy skin may resemble a hypoglycemic reaction, when found along with shortness of breath and neck pain it is very specific for an MI. The patient is not experiencing a complication of diabetes (ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome). The blood glucose is close to normal, and further diagnostics would be required to determine a diabetic complication. Only cool, clammy skin is indicative of hypoglycemia.

Which continuous renal replacement therapy requires no fluid replacement? 1 Slow continuous ultrafiltration 2 Continuous venovenous hemodialysis 3 Continuous venovenous hemofiltration 4 Continuous venovenous hemodiafiltration

1 Slow continuous ultrafiltration is a simplified version of continuous venovenous hemofiltration. No fluid replacement is required in this process. Continuous venovenous hemodialysis removes both fluids and solutes and requires both dialysate and replacement fluid. Continuous venovenous hemofiltration removes both fluids and solutes and requires replacement fluid. Continuous venovenous hemodiafiltration removes both fluids and solutes and requires both dialysate and replacement fluid.

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? 1 Oxygen, nitroglycerin, aspirin, and morphine 2 Oxygen, furosemide (Lasix), nitroglycerin, and meperidine 3 Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen 4 Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

1 The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. Furosemide, meperidine, nitroprusside, dopamine, lorazepam, and warfarin may be used later in the patient's treatment.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? 1 Elevated D-dimers 2 Elevated fibrinogen 3 Reduced prothrombin time (PT) 4 Reduced fibrin degradation products (FDPs)

1 The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. Fibrinogen and platelets are reduced. PT, partial thromboplastin time (PTT), activated partial thromboplastin time (aPTT), and thrombin time are all prolonged. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed.

According to the Rule of Nines for calculating the percentage of burns, the nurse should assign what percentage to a burn in the genitalia? 1 1% 2 4.5% 3 9% 4 18%

1 The Rule of Nines is a formula used for calculating the percentage of burns during initial assessment of a burn patient. The genitals are assigned 1%. Burns in the head and arms are assigned 4.5% each. Burns on the lower extremities are assigned 9% each. Burns in the chest and back are assigned 18%.

When assessing the patient with a multilumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? 1 Administer oxygen 2 Notify the health care provider 3 Rapidly administer more intravenous (IV) fluid 4 Reposition the patient to the right side

1 The cap off the central line could allow entry of air into the circulation. For an air emboli, the priority is to administer oxygen; next, the catheter is clamped and the patient is positioned on the left side with the head down. Then the health care provider is notified.

The nurse receives a health care provider's prescription to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which procedure is most appropriate for infusing this blood product? 1 Infuse the fresh frozen plasma as rapidly as the patient will tolerate. 2 Hang the fresh frozen plasma as a piggyback to the primary intravenous (IV) solution. 3 Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. 4 Hand the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.

1 The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in Factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

A patient is brought to an emergency department in an unconscious condition. The hemoglobin level of the patient is 20 g/dl. How should the nurse interpret the lab result? 1 The patient is dehydrated. 2 The patient has anemia. 3 The patient has internal hemorrhage. 4 The patient has fluid volume excess.

1 The hemoglobin level in a normal healthy adult is 11 to 17 g/dl. The hemoglobin level may increase as a result of hemoconcentration as found in dehydration. A patient with anemia would have a low hemoglobin level due to decreased production of RBCs. A patient with internal hemorrhage would not have a high hemoglobin level of 20 g/dl; the patient would have a low hemoglobin level due to loss of intravascular volume. A patient with fluid volume excess would have a low hemoglobin level due to hemodilution.

When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? 1 "I will be able to regulate when I have stools." 2 "I will be able to wear the pouch 4 to 7 days, unless it leaks." 3 "Dried fruit and popcorn must be chewed very well." 4 "The drainage from my stoma can damage my skin."

1 The ileostomy is in the ileum and drains liquid stool frequently, unlike the colostomy, which has more formed stool the further distal the ostomy is in the colon. The ileostomy pouch is usually worn 4 to 7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

The nurse reviews laboratory test results for a patient with a diagnosis of acute infective endocarditis. Which test result is most significant in the patient with acute infective endocarditis? 1 Blood cultures 2 C- reactive protein 3 White blood cell count 4 Erythrocyte sedimentation rate

1 The most significant laboratory test for making the diagnosis of acute infective endocarditis is blood cultures. The collection of two blood cultures will be positive in more than 90% of patients. The C-reactive protein, white blood cell count, and erythrocyte sedimentation rate laboratory tests are more significant in monitoring the patient's response to antibiotic treatment.

A 76-year-old patient was admitted with exacerbation of chronic obstructive pulmonary disease (COPD). The arterial blood gas (ABG) reveals the following information: pH 7.34, PaCO2 46, PaO2 87, and oxygen saturation 94%. How does the nurse interpret these results? 1 Respiratory acidosis 2 Respiratory alkalosis 3 Metabolic acidosis 4 Normal

1 The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg, and normal PaO2 is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. With the low pH and high PaCO2 , the nurse can conclude that the patient's blood gas reveals respiratory acidosis, even without the bicarbonate level that usually is measured. This is not a normal ABG; the pH level is low, indicating acidosis. Because the patient is presenting with COPD and a slightly elevated PaCO2 , this indicates that this is respiratory-related.

Which serum potassium results best support the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over two hours? 1 3.1 mEq/L 2 3.9 mEq/L 3 4.6 mEq/L 4 5.3 mEq/L

1 The normal range for serum potassium is 3.5 to 5.0 mEq/L. This intravenous (IV) prescription provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L; 3.9 mEq/L, 4.6 mEq/L, and 5.3 mEq/L are not low values.

The nurse receives a health care provider's prescription to change a patient's intravenous (IV) from D5½ normal saline (NS) with 40 mEq KCl/L to D5 NS with 20 mEq KCl/L. Which serum laboratory value on this same patient best supports the rationale for this IV prescription change? 1 Sodium 136 mEq/L, potassium 4.5 mEq/L 2 Sodium 145 mEq/L, potassium 4.8 mEq/L 3 Sodium 135 mEq/L, potassium 3.6 mEq/L 4 Sodium 144 mEq/L, potassium 3.7 mEq/L

1 The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV prescription decreases the amount of potassium and increases the amount of sodium. For this prescription to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

What is the nurse's priority when changing the appliance of a patient with an ileal conduit? 1 Keep the skin free of urine 2 Inspect the peristomal area 3 Cleanse and dry the area gently 4 Affix the appliance to the faceplate

1 The nurse's priority is to keep the skin free of urine because the peristomal skin is at high risk for damage from the urine if it is alkaline. The peristomal area will be assessed, the area will be cleaned gently and dried, and the appliance will be affixed to the faceplate if one is being used, but these are not as much of a priority as keeping the skin free of urine to prevent skin damage.

The patient has a form of glomerular inflammation that is progressing rapidly. The patient is gaining weight and the urine output is declining steadily. What is the priority nursing intervention? 1 Monitor the patient's cardiac status 2 Teach the patient about hand washing 3 Obtain a serum specimen for electrolytes 4 Increase direct observation of the patient

1 The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions, but are not the priority . Electrolyte measurement is a collaborative intervention that will be done as prescribed by the health care provider.

The laboratory report of an elderly patient shows slight decrease in the mean corpuscular hemoglobin concentration. The nurse recognizes that what could be the reason for the decrease? 1 Aging 2 Microcytosis 3 Spherocytosis 4 Erythrocytosis

1 The red blood cell plasma membranes are more fragile in an older person. This may account for a slight decrease in the mean corpuscular hemoglobin concentration (MCHC) of the red blood cells. Microcytosis is a condition in which the mean corpuscular hemoglobin level is decreased. Spherocytosis is a condition in which the corpuscular hemoglobin concentration increases. Erythrocytosis is a disease state in which the proportion of blood volume occupied by red blood cells increases.

A patient has undergone a splenectomy. The nurse recalls that this surgery can cause what changes in the hematologic system? 1 Higher circulating levels of platelets 2 Reduced hemoglobin level 3 Compromised phagocytosis mechanism 4 Enhanced inflammation and allergic reactions

1 The spleen is an important component of the hematologic system and is involved in hematopoietic, filtration, immunologic, and storage functions. The platelets are stored in the spleen. If the spleen is removed, it may result in higher circulating levels of platelets than in a person with spleen. Removal of the spleen does not affect hemoglobin levels because the production of RBCs does not take place in the spleen. Also, it does not affect the phagocytosis mechanism. It does not evoke inflammation and allergic reactions; these are the function of the basophils which are not affected by the removal of the spleen.

The human immunodeficiency virus (HIV)-infected patient is taught health promotion activities, including good nutrition, avoiding alcohol, tobacco, drug use, and exposure to infectious agents, keeping up to date with vaccines, getting adequate rest, and stress management. The nurse knows that the rationale behind these interventions is best described as? 1 Delaying disease progression 2 Preventing disease transmission 3 Helping to cure the HIV infection 4 Enabling an increase in self-care activities

1 These health promotion activities , along with mental health counseling, support groups, and a therapeutic relationship with health care providers, will promote a healthy immune system which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities.

The nurse just received an urgent laboratory value on a patient in renal failure. The potassium level is 6.3. The telemetry monitor is showing peaked T waves. Which prescription from the primary health care provider should be implemented first? 1 Administer regular insulin intravenously (IV) 2 Restrict dietary potassium intake to 40 meq daily 3 Administer kayexalate enema 4 Educate the patient on dietary restriction of potassium

1 This patient is showing signs of hyperkalemia, which could be fatal and lead to myocardial damage. Regular insulin IV is needed to quickly force potassium into the cells. The kayexalate enema will take too long to excrete the potassium. Restricting oral intake and educating the patient will be needed when the crisis has resolved.

Thrombocytopenia develops in a patient being treated with chemotherapy for Hodgkin's disease. What is the goal of highest priority in the nursing plan of care? 1 Controlling bleeding 2 Controlling diarrhea 3 Controlling infection 4 Controlling hypotension

1 Thrombocytopenia is a low platelet count that leaves the patient at high risk for life-threatening spontaneous hemorrhage. Diarrhea and infection are not symptoms associated with thrombocytopenia. Hypotension may be seen if hemorrhagic or hypovolemic shock develops as a result of blood loss stemming from thrombocytopenia.

A nurse completes an assessment and notes that a patient's thyroid gland is enlarged. With which condition is this finding consistent? 1 Goiter 2 Fibroma 3 Thyrotoxicosis 4 Hyperthyroidism

1 Thyroid abnormalities consist of three basic forms: goiter (enlarged thyroid gland), hypothyroidism, and hyperthyroidism. Goiter may be present in hyper- or hypofunction of the gland. A fibroma is a fibrous encapsulated connective tissue tumor not usually occurring in the thyroid gland. Thyrotoxicosis results from extreme hyperthyroidism or increased secretion of T3 and T4. Thyrotoxicosis is also known as thyroid storm or thyroid crisis . Hyperthyroidism is a condition resulting from an increase in production of T3 and T4.

Which statement by the patient who is post operative following a transphenoidal hypophysectomy indicates a need for further education? 1 "It is important that I brush my teeth every day." 2 "I should refrain from vigorous coughing and sneezing" 3 "I should notify the nurse if I develop a severe headache." 4 "I may need to take a stool softener so that I do not strain with having a bowel movement."

1 Toothbrushing should be avoided for 10 days to protect the suture line. Vigorous coughing and sneezing should be avoided to prevent cerebrospinal leakage. A severe headache may indicate cerebrospinal leakage into the sinuses. Straining with bowel movements may cause cerebrospinal leakage. Text Reference - p. 1191

A nurse is caring for a patient with chest pain that began 10 days ago. Which serum cardiac marker should the nurse review to determine if a myocardial infarction occurred 10 days ago? 1 Troponin 2 Myoglobin 3 Homocysteine 4 Creatine kinase

1 Troponin is a serum cardiac marker that is detectable in the blood up to two weeks after myocardial injury and is used to diagnose a myocardial infarction. Troponin has two subtypes: cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI). Serum levels of cTnT and cTnI begin to increase 4 to 6 hours after the onset of myocardial injury, peak at 10 to 24 hours, and return to normal over 10 to 14 days. Myoglobin is a protein found in skeletal and cardiac muscle. It is a sensitive indicator of early myocardial injury but is not specific for cardiac muscle; therefore, it is not used to diagnose a myocardial infarction. Myoglobin peaks and returns to normal in 3 to 15 hours. Homocysteine is a protein amino acid. High levels of homocysteine may indicate an increased risk for coronary artery disease. It is not used to diagnose myocardial infarction. Creatine kinase is a serum cardiac marker for myocardial injury but lacks specificity for myocardial damage. Serum levels peak at about 18 hours and return to normal within 24 to 36 hours.

While taking a patient's blood pressure, a nurse notices that a carpal spasm occurs. To diagnose a possible cause for the carpal spasm, the nurse should expect the primary health care provider to prescribe which level? 1 Calcium 2 Sodium 3 Potassium 4 Magnesium

1 Trousseau's sign (carpal spasm when blood pressure cuff is inflated for a few minutes) is indicative of hypocalcemia. It does not occur with changes in sodium, potassium, or magnesium levels. The nurse should expect the primary health care provider to prescribe a calcium level be drawn.

Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of: 1 Impaired peristalsis 2 Irritation of the bowel 3 Nasogastric suctioning 4 Inflammation of the incision site

1 Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

A patient is being treated with radioactive iodine (131I) for thyroid cancer. With which major source of contamination from this patient should the nurse take precautions? 1 Urine 2 Feces 3 Blood 4 Sputum

1 Urine is the major source of contamination with this form of radioactive treatment. The nurse must be careful in handling bedpans, urinals, and linens and apply standard radiation precautions of time, distance, and shielding. Feces, blood, and sputum tend to contain lower levels of radiation contamination, but they should still be handled with the use of standard precautions.

A patient with suspected infective endocarditis (IE) is scheduled for cardiac catheterization. The nurse recognizes that the purpose of the test for this patient is what? 1 To evaluate valve function 2 To check for the presence of vegetations 3 To check for the presence of infection 4 To detect the presence of murmurs

1 Valve dysfunction is a common pathologic feature associated with infective endocarditis. Cardiac catheterization is an investigation required to evaluate the functioning of the heart valves. Echocardiography is an investigation used to detect the presence of vegetations. Blood cultures are done to determine the presence of an infection which can cause endocarditis. The presence of murmurs can be detected through auscultation.

A 78-year-old patient has Stage 3 chronic kidney disease (CKD) and is being taught about a low potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? 1 Apple, green beans, and a roast beef sandwich 2 Granola made with dried fruits, nuts, and seeds 3 Watermelon and ice cream with chocolate sauce 4 Bran cereal with ½ banana, milk, and orange juice

1 When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have elevated levels of potassium, at or above 200 mg per 1/2 cup.

The nurse is caring for a 49-year-old woman who had surgery one day ago for removal of a suspected malignant breast mass. The patient is awaiting the pathology report. She is tearful and says that she is afraid to die. Which of these is the most effective nursing intervention at this time? 1 Actively listen and allow her to talk about her fears. 2 Teach the patient about the seven warning signs of cancer. 3 Discuss the need to make changes in an unhealthy lifestyle. 4 Remind the patient that there is probably nothing to worry about.

1 While patients are waiting for the results of diagnostic studies, be available to actively listen to their concerns. It is not an appropriate time to teach about the warning signs of cancer, or to provide patient teaching regarding lifestyle changes. Do not provide false reassurances by telling her there is nothing to worry about.

Treatment for a patient diagnosed with rapidly progressive glomerulonephritis is directed towards: 1 Correction of fluid overload 2 Correction of hypotension 3 Correction of anemia and blood loss 4 Administration of parenteral antibiotics

1 With progressive renal failure, there is an increase in fluid retention. The patient will exhibit hypertension as a result of kidney damage. Patients will have anemia, but there will be no identification of acute blood loss, and this is not a priority in treatment at this point for this patient.

The nurse recalls that interferons may be used in the treatment of certain diseases. What is the clinical use of β-Interferon? 1 As a treatment for multiple sclerosis 2 As a treatment for multiple myeloma 3 As a treatment for hairy cell leukemia 4 As a treatment for renal cell carcinoma

1 β-Interferon is used in treating multiple sclerosis. Cytokines instruct cells to alter their proliferation, differentiation, secretion, or activity. Cytokines play an important role in hematopoiesis. α-interferon is used to treat multiple myeloma, hairy cell leukemia, and renal cell carcinoma.

A patient is given lymphocyte immune globulin (Atgam) as an induction therapy before a liver transplant. What is the importance of administering this medication to the patient? Select all that apply. 1 It helps to prevent early rejection. 2 It helps to reduce antibody production. 3 It stimulates leukocytosis. 4 It helps to provide passive immunity. 5 It prevents iatrogenic infection

1 & 2 Lymphocyte immune globulin is a polyclonal antibody used to severely immunosuppress an individual. This reduces the production of antibodies and thus helps in prevention of early organ rejection. Lymphocyte immune globulin inhibits leukocytosis. The drug does not provide passive immunity. Since it reduces antibody production, it increases the risk of an iatrogenic infection

A patient with multiple myeloma presents with sudden onset of depression, fatigue, muscle weakness, polyuria, nocturia, and vomiting. The serum calcium level is in excess of 12mg/dL. The nurse recognizes that which treatments could be helpful for the patient? Select all that apply. 1 Adequate hydration 2 Administration of mesna [Mesnex] 3 Infusion of bisphosphonate zoledronate (Zometa) 4 Administration of allopurinol (Zyloprim) 5 Administration of demeclocycline (Declomycin)

1 & 3 The clinical features of depression, fatigue, muscle weakness, polyuria, nocturia, and vomiting in a patient suffering from multiple myeloma are suggestive of hypercalcemia. Interventions for this condition involve adequate hydration and using bisphosphonate zoledronate (Zometa) to prevent formation of calcium stones in the kidney. Mesna [Mesnex] is used for the treatment of hemorrhagic cystitis. Allopurinol (Zyloprim) is useful for managing tumor lysis syndrome and not hypercalcemia. Demeclocycline (Declomycin) is used for treating syndrome of inappropriate antidiuretic hormone.

A patient with lung cancer develops headaches, facial edema, periorbital edema, and distention of the veins in the head, neck, and chest. The nurse expects that what will be included in the patient's treatment plan? Select all that apply. 1 Prepare the patient for radiation therapy. 2 Administer a narcotic and reassure the patient. 3 Administer a diuretic agent and reassure the patient. 4 Inform the patient that chemotherapy may be required. 5 Inform the patient that the symptoms are due to obstruction of the bronchus.

1 & 4 A lung cancer patient who presents with headaches, facial edema, periorbital edema, and distension of veins of the head, neck, and chest is indicative of superior vena cava syndrome. Management of this condition involves treating the patient with localized radiation therapy. If the cancer is sensitive to drugs, then the patient may also be treated with chemotherapy. Superior vena cava syndrome is a medical emergency, hence, just administering a pain killer and diuretic will only provide symptomatic relief without any effect on disease progression. Superior vena cava syndrome is due to obstruction of the superior vena cava and not the bronchus

A nurse is caring for a patient who is admitted for a kidney transplant. A crossmatch prior to the transplant is positive. What will the nurse tell the patient and his relatives? Select all that apply. 1 Transplantation cannot be done. 2 It is safe to proceed with the transplantation. 3 A renal scan needs to be done to confirm transplantation. 4 If transplanted, the organ would undergo a hyperacute rejection. 5 It is safe to proceed with the transplantation for now, but chronic rejection is anticipated.

1 & 4 A positive crossmatch indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation. If transplanted, the organ would undergo hyperacute rejection. It is not safe to proceed with transplantation if the crossmatch is positive. A renal scan will not help in this procedure.

A nurse is giving dietary advice to a patient who is on continuous ambulatory peritoneal dialysis for chronic renal failure. Which dietary instructions are appropriate for this patient? Select all that apply. 1 High-calorie foods 2 High-protein foods 3 High-potassium content 4 High-phosphorus content 5 High-fluid intake

1, 2 A chronic renal failure patient on continuous ambulatory peritoneal dialysis is encouraged to have a high-calorie diet to meet the increased demands of the body. A good amount of protein should be consumed to replace that lost during dialysis. Foods containing high amounts of potassium and phosphorus should be avoided in patients with chronic renal failure. High potassium can cause hyperkalemia and related complications, especially cardiac complications. High phosphorus may deteriorate bone health. Usually there is a modest restriction of fluids when the patient is on dialysis.

The nurse is caring for a patient who is at risk for a flail chest. The nurse knows which of the following? Select all that apply. 1 Palpation must be performed to check for crepitus. 2 Most patients with a flail chest require mechanical ventilation. 3 Splinting of the chest wall is seen only in the unconscious patient. 4 Paradoxical chest movements only occur if the sternum also is fractured. 5 Flail chest results from fracture of two or more nonconsecutive ribs on the same side. 6 Paradoxical chest movements involve the affected portion being sucked in during expiration and bulging out during inspiration

1, 2 Definitive therapy is based on ensuring adequate oxygenation. Most patients require mechanical ventilation, but not necessarily ALL patients. Splinting of the chest wall is seen in the conscious patient, while flail chest in the unconscious patient usually is visually apparent. Ribs 5 through 9 are the most frequently fractured because they are least protected by chest muscles. Flail chest can result if the sternum is fractured along with several consecutive ribs. Palpation must be performed for abnormal respiratory movements and crepitus. Flail chest results from fracture of two or more consecutive ribs on the same side. Paradoxical chest movements involve the affected portion bulging out during expiration and being sucked in during inspiration.

A nurse is attending to a patient admitted to the hospital with a diagnosis of chronic mitral valve regurgitation. Which heart sounds should the nurse expect to hear on auscultation? Select all that apply. 1 Third heart sound (S3) gallop 2 Holosystolic murmur 3 Absent S2 4 Prominent S4 5 Austin Flint murmur

1, 2 In patients with chronic mitral valve regurgitation, increased left ventricular volume leads to an audible S3, even with normal left ventricular function. A loud holosystolic murmur is heard at the apex radiating to left axilla. S2 is absent and S4 is prominent in aortic valve stenosis. Austin-flint murmur is heard in aortic valve regurgitation.

nurse is attending to a patient admitted to the hospital with a diagnosis of chronic mitral valve regurgitation. Which heart sounds should the nurse expect to hear on auscultation? Select all that apply. 1 Third heart sound (S3) gallop 2 Holosystolic murmur 3 Absent S2 4 Prominent S4 5 Austin Flint murmur

1, 2 In patients with chronic mitral valve regurgitation, increased left ventricular volume leads to an audible S3, even with normal left ventricular function. A loud holosystolic murmur is heard at the apex radiating to left axilla. S2 is absent and S4 is prominent in aortic valve stenosis. Austin-flint murmur is heard in aortic valve regurgitation.

A patient who has undergone valve replacement is on warfarin (Coumadin). He has been advised to check his international normalized ratio (INR) regularly. What explanation will the nurse give to emphasize the importance of this test? Select all that apply. 1 To determine proper dosage 2 To determine adequacy of therapy 3 To prevent endocarditis 4 To determine patency of valves 5 To prolong durability of valves

1, 2 The INR must be checked regularly if the patient is on anticoagulation therapy to determine the proper dosage. A high or low INR may require the dose to be adjusted. INR is also tested to determine the adequacy of anticoagulation. If the anticoagulant is not adequate, blood clots may form. If anticoagulation is more than adequate, there is an increased risk of bleeding. The test cannot indicate endocarditis or patency or durability of valves.

The nurse knows the patient with acute kidney injury (AKI) has entered the diuretic phase when what assessments occur? Select all that apply. 1 Dehydration 2 Hypokalemia 3 Hypernatremia 4 Blood urea nitrogen (BUN) increases 5 Serum creatinine increases

1, 2 ehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes, but not concentrate urine. Therefore, the serum BUN and serum creatinine levels also begin to decrease.

A patient with lung cancer has been treated with an anticancer drug that has a high propensity to cause myelosuppression. What nursing interventions would be helpful to this patient? Select all that apply. 1 Monitoring the red blood cell (RBC) count 2 Monitoring the platelet count 3 Monitoring the basophil count 4 Monitoring the neutrophil count 5 Monitoring the eosinophil count

1, 2, & 4 Monitoring the RBC count helps the nurse to detect the severity of anemia and assess the need for administering RBC growth factors or an RBC transfusion. Monitoring the platelet count helps to detect the risk of bleeding in the patient and the need for using platelet growth factors or a platelet transfusion. Monitoring the neutrophil count helps to detect the risk of infection and the need for using white blood cell (WBC) growth factors and measures to prevent infection. Eosinophil and basophil counts should be assessed only in patients who have an allergic predisposition or if the drug is known to produce allergic reactions.

The patient and the patient's family are upset that the patient is going through procedures to diagnose cancer. What nursing actions should the nurse use first to facilitate their coping with this situation? Select all that apply. 1 Maintain hope 2 Exhibit a caring attitude 3 Plan realistic long-term goals 4 Give them antianxiety medications 5 Be available to listen to fears and concerns 6 Teach them about all the types of cancer that could be diagnosed

1, 2, & 5 Maintaining hope, exhibiting a caring attitude, and being available to actively listen to fears and concerns would be the first nursing interventions to use, as well as assessing factors affecting coping during the diagnostic period. Providing relief from distressing symptoms for the patient and teaching the patient and family about the diagnostic procedures also would be important. Realistic long-term goals and teaching about the type of cancer cannot be done until the cancer is diagnosed. Giving the family ant-anxiety medications would not be appropriate.

A nurse is triaging a patient who has arrived in the emergency department with burns as a result of a fire. Which patient symptoms indicate an upper airway injury? Select all that apply. 1 Hoarseness 2 Difficulty swallowing 3 Copious secretions 4 Carbonaceous sputum 5 Dyspnea

1, 2, 3 An inhalation injury in the upper airways involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice due to the effect on the larynx. There may be difficulty in swallowing due to involvement of the mouth and oropharynx. There may be copious secretion in response to the injury to the airway. The injury to the lower airway involves trachea, bronchioles, and alveoli, and may cause carbonaceous sputum and dyspnea.

The nurse is attending to a patient who is undergoing peritoneal dialysis. The dialysate solution is being infused to the patient. The nurse finds that the patient is developing symptoms of respiratory distress. What nursing interventions are necessary to prevent further respiratory complications? Select all that apply. 1 Auscultate the lungs. 2 Frequently reposition the patient. 3 Promote deep-breathing exercises. 4 Increase the rate of infusion of the dialysate. 5 Place the patient in a low Fowler's position.

1, 2, 3 Auscultation is very important to find the cause of respiratory distress. Decreased areas of ventilation suggest the presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection. Frequent positioning will promote equal ventilation to all parts of the lungs. Deep-breathing exercises could help to promote proper expansion of lungs. Rapid infusion would cause more pressure on the diaphragm. The patient should be placed in the semi-Fowler's position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity.

A nurse is caring for a patient who reports diarrhea and vomiting for the past five days. As a result, the patient has developed severe hypokalemia. The primary health care provider prescribes IV potassium chloride (KCl) treatment. How can the nurse ensure the safety of the patient when administering IV KCl? Select all that apply. 1 Continuously monitor cardiac function 2 Check hourly for the presence of phlebitis at the IV site 3 Monitor the urine output 4 Assess for signs of tetany 5 Assess for laryngeal spasms

1, 2, 3 IV potassium chloride (KCl) is administered to treat hypokalemia. IV administration of KCl may cause rapid changes in potassium levels, which may adversely affect the heart. Therefore, the patient should be under continuous cardiac monitoring. KCl is an irritant and may cause phlebitis and infiltration, leading to necrosis and sloughing. So the nurse should frequently check the IV site for phlebitis and infiltration. KCl is administered when the urine output is at least 0.5 mL/kg of body weight per hour. The urine output should hence be monitored to check for its adequacy. Tetany and laryngeal spasms occur when there are low levels of calcium. They are not related to potassium levels.

The nurse makes a nursing diagnosis of "impaired gas exchange" for a patient with pneumonia based upon which physical-assessment findings? Select all that apply. 1 SpO2 of 85% 2 PaO2 65 mm Hg 3 Absent breath sounds in right lung lobes 4 Presence of thick yellow mucus 5 Respiratory rate 24 breaths/minute

1, 2, 3 Impaired gas exchange is evidenced by low oxygen saturation and elevated PaCO2 with absent breath sounds. Yellow mucus would indicate clearance of secretions. An increased respiratory rate does not imply impaired gas exchange.

A patient is in end-stage renal failure. What are the signs and symptoms that the nurse is likely to find while assessing neurologic function? Select all that apply. 1 Restless leg syndrome 2 Asterixis 3 Nocturnal leg cramps 4 Hypertonicity of muscles 5 Hyper exaggerated deep tendon reflexes

1, 2, 3 Individuals with advanced stage 5 chronic kidney disease may complain of restless legs syndrome, described as "bugs crawling inside the leg." Muscle twitching, jerking, asterixis (hand-flapping tremor), and nocturnal leg cramps also occur. Eventually, motor involvement may lead to bilateral footdrop, muscular weakness and atrophy, and loss of deep tendon reflexes. There is slowing down of conduction in the peripheral nerves; therefore, hyper exaggerated reflexes and hypertonicity will not be found.

A patient with burns needs permanent skin grafting. Which grafts should the nurse consider? Select all that apply. 1 Integra 2 AlloDerm 3 Autograft 4 Homograft 5 Heterograft

1, 2, 3 Integra is obtained from bovine collagen and glycosaminoglycan bonded to silicone and gives permanent coverage. AlloDerm is obtained from a cellular dermal matrix derived from donated human skin and can be used for permanent grafting. Autograft is from patient's own skin and can be used for permanent grafting. Homograft is obtained from cadaveric skin and can be used as temporary graft from 3 days to 2 weeks. Heterograft is obtained from porcine skin and can be used as temporary graft from 3 days to 2 weeks.

A patient with partial-thickness burns is being treated with zolpidem (Ambien). What is the appropriate nursing response to the patient's caregivers when they ask about the purpose of administering this drug? Select all that apply. 1 To promote sleep 2 To reduce anxiety 3 To promote wound healing 4 To prevent thromboembolism 5 To provide short-term amnesic effects

1, 2, 5 Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism.

A patient with a diagnosis of unstable angina is admitted to the intensive care unit. Which drug therapies would the nurse expect to be ordered for this patient? Select all that apply. 1 Nitrates 2 Antiplatelet therapy 3 Anticoagulant therapy 4 Beta-adrenergic blockers 5 Angiotensin-converting enzyme (ACE) inhibitors

1, 2, 3 Nitrates are the first line of drug therapy for angina because of their mechanisms of dilating peripheral blood vessels to reduce cardiac workload and dilating the coronary arteries and collateral vessels to increase blood flow to ischemic areas of the heart. Antiplatelet therapy works in different ways to inhibit platelet activation and aggregation. Anticoagulants have several different mechanisms of action to prevent the formation of fibrin and thrombin and interfere with formation of clotting factors. Beta-adrenergic blockers are commonly used in the treatment of chronic stable angina and acute coronary syndrome. ACE inhibitors are used for heart failure, tachycardia, myocardial infarction, hypertension, diabetes, and chronic kidney disease.

The nurse is caring for a patient being treated for acute thyrotoxicosis.What are the nursing interventions for this patient exhibiting exophthalmos? Select all that apply. 1 Apply artificial tears. 2 Tape the eyelids lightly for sleeping, if needed. 3 Ask the patient to exercise the intraocular muscles. 4 Place the patient in a supine position. 5 Avoid elevating the patient's head.

1, 2, 3 Nursing interventions for the patient exhibiting exophthalmos include application of artificial tears to soothe and moisten conjunctival membranes, to relieve eye discomfort, and to prevent corneal ulceration.If the eyelids cannot be closed, the nurse should lightly tape them shut to help the patient sleep.To maintain flexibility, the patient must be taught to exercise the intraocular muscles several times a day by turning the eyes in the complete range of motion. The patient should sit upright as much as possible. The head must be elevated to promote fluid drainage from the periorbital area.

When performing a physical examination of a patient suffering from infective endocarditis, what signs should the nurse look for? Select all that apply. 1 Osler's nodes 2 Janeway's lesions 3 Roth's spots 4 Aschoff's bodies 5 Sydenham's chorea

1, 2, 3 Osler's nodes are painful, tender, red or purple, pea-sized lesions found on the fingertips or toes in patients with infective endocarditis. Janeway's lesions are flat, painless, small, red spots that may be seen on the palms and soles of patients with infective endocarditis. Roth's spots are also seen in patients with infective endocarditis during fundoscopic examination of retinal lesions. Aschoff's bodies are nodules that are formed in patients with rheumatic heart disease. Sydenham's chorea is a central nervous system manifestation of rheumatic fever.

When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations? Select all that apply. 1 Osler's nodes 2 Janeway's lesions 3 Splinter hemorrhages 4 Subcutaneous nodules 5 Erythema marginatum lesions

1, 2, 3 Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Subcutaneous nodules and erythema marginatum lesions occur with rheumatic fever. Text Reference - p. 811

The nurse is caring for the patient with a pulmonary embolism. Which factor(s) are associated with a pulmonary embolism (PE)? Select all that apply. 1 Pregnancy 2 Pelvic surgery 3 Immobility 4 Herbal therapy

1, 2, 3 Pregnancy, pelvic surgery, and immobility are major risk factors associated with a pulmonary embolism. Risk factors among many for PE include immobility, pelvic surgery, pregnancy, oral contraceptives and hormone therapy. Herbal therapy is incorrect because herbal therapy is not associated with the development of a pulmonary embolism.

A patient with end-stage kidney disease is to begin continuous ambulatory peritoneal dialysis (CAPD). What are the preparations to be done by the nurse before starting the catheter insertion for this patient? Select all that apply. 1 Ask patient to empty the bladder and bowel. 2 Note the patient's weight. 3 Obtain a signed consent form. 4 Monitor for abnormal cardiac signs and symptoms. 5 Monitor for abnormal respiratory signs and symptoms.

1, 2, 3 Preparation of the patient for catheter insertion includes emptying the bladder and bowel, weighing the patient, and obtaining a signed consent form. The bladder should be emptied to prevent accidental puncture of the bladder by the needle. Weighing the patient before and after the procedure is important to determine the effectiveness of dialysis. Because it is an invasive procedure, the nurse should explain about the risks and benefits, and informed consent should be obtained. Other factors are not contraindications for CAPD. Monitoring of cardiac and respiratory signs is essential but does not directly affect the procedure.

The nurse is attending to a patient with tentative diagnosis of acute pancreatitis. Which diagnostic tests should the nurse anticipate for the health care provider to prescribe to confirm the diagnosis? Select all that apply. 1 Serum amylase 2 Serum lipase 3 Computed tomography (CT) scan 4 Liver biopsy 5 Serum alpha-fetoproteins

1, 2, 3 Serum amylase and lipase levels usually increase in acute pancreatitis due to pancreatic fibrosis. CT scan is used to confirm pancreatitis and its related complications. Liver biopsy is not indicated in pancreatitis, as it is not related to liver dysfunction. Serum alpha-fetoproteins are not related to pancreatitis; they are elevated in liver cancer.

A patient with hepatitis A is in the acute phase. The nurse plans care while anticipating that the patient may be experiencing which symptoms? Select all that apply. 1 Fatigue 2 Pruritus 3 Anorexia 4 Dizziness 5 Constipation

1, 2, 3 The acute phase of hepatitis usually lasts from one to four months. During the incubation period, symptoms may include malaise, anorexia and weight loss, fatigue, nausea, occasional vomiting, and abdominal (right upper quadrant) discomfort. The patient may find food repugnant, and smokers may have distaste for cigarettes. There is also a decreased sense of smell. Other symptoms may include headache, low-grade fever, arthralgias, and skin rashes. Pruritus (intense chronic itching) sometimes accompanies jaundice. The pruritus occurs as a result of the accumulation of bile salts beneath the skin. Dizziness and constipation are not symptoms of the acute phase of hepatitis A.

While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. What are the reasons behind this action? Select all that apply. 1 To decrease pain 2 To decrease itchiness 3 To prevent blistering 4 To reduce venous return 5 To enhance local immunity

1, 2, 3 The interim pressure due to tubular elastic gauze decreases pain and itchiness, and prevents blistering. It promotes venous return rather than reducing it. It does not enhance local immunity.

The nurse is attending to a patient who is planned to receive a kidney transplant. How should the nurse explain the postoperative care to the patient? Select all that apply. 1 The kidney may not function immediately postoperatively. 2 A urinary catheter will be present preoperatively in order to monitor urinary output postoperatively. 3 The patency of the vascular access must be maintained. 4 Dialysate will be reinfused into the peritoneal cavity before surgery. 5 Immunosuppressive drugs will be delivered before the procedure.

1, 2, 3 The transplanted kidney does not always function immediately; the patient should know that dialysis may have to be continued for several weeks. Just prior to surgery, a urinary catheter is inserted and an antibiotic is instilled into the bladder to decrease the risk of infection. The patency of the vascular access must be maintained because dialysis may be required after transplantation. A patient on peritoneal dialysis must empty the peritoneal cavity of all dialysate solution before going to surgery. Immunosuppressive therapy is started after, not before, surgery.

A patient is diagnosed with thrombocytopenia and a lymph node biopsy has been scheduled. Which primary nursing interventions should be performed after the procedure? Select all that apply. 1 Apply direct pressure to the area. 2 Observe the site for bleeding. 3 Monitor vital signs. 4 Change the dressing. 5 Inspect the site for healing

1, 2, 3 Thrombocytopenia refers to a low platelet count which can predispose to bleeding. Therefore, direct pressure should be applied to the biopsy site to ensure hemostasis. The site should be observed for bleeding because the patient has a high risk of bleeding. The vital signs should be monitored for early detection of complications. Changing the dressing and inspecting the site for healing are not primary interventions; they can be performed later once the patient is stable.

The nurse is caring for the patient with pulmonary hypertension. Which treatment(s) are appropriate? Select all that apply. 1 Vasodilators 2 Diuretics 3 Anticoagulants 4 Thrombolytics

1, 2, 3 Vasodilators, diuretics, and anticoagulants are correct because they are included in drug treatments for pulmonary hypertension. Vasodilators are especially important in the treatment of pulmonary hypertension as it will aid in reducing the right ventricular workload by dilating pulmonary vessels. Diuretics decrease plasma volume and thereby reduce myocardial workload. Anticoagulants also are used, especially if the case is severe, as it works to prevent in situ thrombus formation and venous thrombosis. Warfarin would be given to keep the international normalized ratio (INR) in the 2 to 3 range. Thrombolytic therapy is not an appropriate drug treatment and would be used if the condition causes right ventricle hypertrophy, resulting in cor pulmonale.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements? Select all that apply. 1 Vitamin A 2 Vitamin D 3 Vitamin E 4 Vitamin K 5 Vitamin B

1, 2, 3, 4 Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat soluble and thus would need to be supplemented in a patient with biliary obstruction. Vitamin B is water soluble and would not be recommended for a patient with biliary obstruction.

A patient suffering from supraventricular tachycardia reports a fluttering feeling in his chest. On assessment, the nurse finds that the heart rate of the patient is 150 beats per minute, and the blood pressure is 120/60 mm Hg. Which treatment should the nurse anticipate when planning care for this patient? Select all that apply. 1 Intravenous adenosine (Adenocard) 2 Intravenous beta-blockers 3 Intravenous calcium channel blockers 4 Intravenous amiodarone (Cordarone) 5 Emergent cardioversion

1, 2, 3, 4 Medications that may be used include adenosine, beta-blockers, calcium channel blockers, and amiodarone. These drugs have impact on various phases of action potential. Adenosine decreases conduction through the AV nodes. Beta-blockers decrease automaticity of the SA node. Amiodarone tends to delay depolarization. If the patient becomes hemodynamically unstable and symptomatic, emergent cardioversion is considered.

A patient is prescribed a statin drug to decrease levels of low-density lipoproteins and triglycerides. Which symptoms should the nurse teach the patient to be observant for? Select all that apply. 1 Rash 2 Myopathy 3 Rhabdomyolysis 4 Gastrointestinal disturbance 5 Flushing 6 Pruritus

1, 2, 3, 4 Statin drugs have been found to lower low-density lipoproteins and triglycerides.Common side effects of this class of drugs include rash, myopathy, rhabdomyolysis, and gastrointestinal disturbance, as well as elevated enzyme levels. Flushing and pruritus in the upper torso and facehave not been cited as a side effect of statins but may be seen with the use of niacin.

The patient with an acute kidney injury is being admitted. Which prescriptions by the primary health care provider should the nurse anticipate? Select all that apply. 1 Encourage fluid replacement 2 Potassium restriction 3 Sodium restriction 4 Phosphate binding agents 5 Intermittent straight catheterization

1, 2, 3, 4 The patient with acute kidney injury is at risk for kidney failure. Close monitoring of fluid and electrolyte balance is a key nursing assessment. There will be no prescription for intermittent straight catheterizations, as this places the patient at risk for a urinary tract infection (UTI).

A patient has been admitted with acute pericarditis. How should the nurse care for this patient? Select all that apply. 1 Provide an overbed table. 2 Ask the patient to avoid alcohol. 3 Keep the patient in a Trendelenberg position. 4 Allow the patient to be as active as possible. 5 Administer antiinflammatory medications

1, 2, 5 A sitting position with an overbed table helps in reducing the pain associated with acute pericarditis. The patient should be instructed to avoid alcohol to prevent gastrointestinal bleeding. Antiinflammatory medicines should be administered for pain relief. The patient should not be placed in a Trendelenberg position; instead, the head of the bed should be elevated to 45 degrees. The physical activities of the patient should be restricted, and he should be on complete bed rest to decrease cardiac workload.

A patient with burns of more than 5% of his total body surface area is intubated, and enteral feedings are ordered to meet his nutritional demands. Which nursing interventions are appropriate for the enteral feeding of this patient? Select all that apply. 1 Determine whether the nasogastric tube is in place. 2 Assess bowel sounds every 8 hours. 3 Increase the feeding to the goal rate within 24 to 48 hours. 4 Begin the feedings slowly at the rate of 10 to 20 mL/hr. 5 Check gastric residuals frequently.

1, 2, 3, 5 A patient that is intubated and has suffered burns to more than 5% of the body surface area may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every 8 hours. The enteral feedings should be started at 20-40 mL/hr and slowly increased to the goal rate within 24-48 hours. Gastric residuals should be checked to rule out delayed gastric emptying.

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome? Select all that apply. 1 Use smallest gauge needle possible when giving injections or drawing blood. 2 Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. 3 Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. 4 Apply gentle pressure for the shortest possible time period after performing venipuncture. 5 Instruct patient to avoid aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) to prevent hemorrhage when varices are present.

1, 2, 3, 5 Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. Aspirin and NSAIDS should be avoided because they can increase bleeding in ruptured varices. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

A patient with cancer develops sudden onset of chest heaviness, shortness of breath, tachycardia, hoarseness, and a reduced level of consciousness with muted heart sounds. The nurse expects that the immediate treatment plan for this patient will include what interventions? Select all that apply. 1 Administration of oxygen therapy 2 Administration of IV hydration 3 Administration of vasodilators 4 Placement of a pericardial catheter 5 Surgical establishment of a pericardial window

1, 2, 4, & 5 Sudden onset of heaviness in the chest, shortness of breath, tachycardia, hoarseness, and a reduced level of consciousness with muted heart sounds are suggestive of cardiac tamponade. The nurse manages this patient by administering oxygen to promote tissue oxygenation. A pericardial catheter or surgical establishment of a pericardial window is necessary to relieve pressure from the heart. The patient should be given IV hydration for maintaining fluid balance. The patient should be administered vasopressor therapy, not vasodilators, to avoid a fall in blood pressure.

A nurse works in an emergency department. Which patients are appropriate for the nurse to refer to the burn care unit? Select all that apply. 1 A patient with an inhalation injury 2 A patient with burns of the feet 3 A patient with burns involving minor joints 4 An elderly patient with third-degree burns 5 A patient with partial thickness burns involving 8% of total body surface area

1, 2, 4 A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. Inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. Burns of both feet is associated with complications like contractures, and needs to be referred to the burn care unit. Third-degree burns in any age-group require referral. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. Partial thickness burns require referral if they involve more than 10% of the body surface area.

A nurse is collecting data from a patient admitted with hepatitis A. Which information given by the patient may indicate the patient's susceptibility to contract hepatitis A? Select all that apply. 1 Living in slums 2 Working as local plumber 3 Working in a chemical factory 4 Working as a sewage cleaner 5 Working as a waiter and dishwasher

1, 2, 4 Hepatitis A spreads mainly through the fecal-oral route. People living in slums are also exposed to the virus, as food stuffs may be contaminated. Sewage may harbor this virus; hence sewage cleaners and plumbers may be exposed to it. Working as a waiter, dishwasher, or in a chemical factory does not expose the patient to the virus.

A patient with a chronic hepatitis C virus (HCV) infection is admitted to the hospital. What are the factors that contribute to a high risk for development of cirrhosis of the liver in this patient? Select all that apply. 1 Diabetes mellitus 2 Alcohol consumption 3 History of regular smoking 4 Elevated levels of cholesterol 5 Diet high in sodium and fatty foods

1, 2, 4 Hepatitis C virus (HCV) infection is more likely than hepatitis B virus (HBV) to become chronic. An infection with HCV can lead to development of cirrhosis of liver. People with diabetes mellitus have a compromised immune function and are at risk of developing cirrhosis. Alcohol consumption may further deteriorate the liver function and lead to development of cirrhosis of liver. Elevated cholesterol or triglycerides suppresses the liver function and may lead to progression of HCV to cirrhosis. Smoking and a high-sodium diet have no effect on hepatitis C progression, as they do not affect liver function.

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer? Select all that apply. 1 Asbestos exposure 2 Exposure to uranium 3 Chronic interstitial fibrosis 4 History of cigarette smoking 5 Geographic area in which the patient was born

1, 2, 4 Non-small-cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk, but not necessarily where the patient was born.

The nurse is examining the lymph nodes in a patient's neck. Which of these is an abnormal finding? Select all that apply. 1 Size 1.5 cm 2 Tender when palpated 3 Lymph nodes not palpable 4 Hard and fixed to palpation 5 Firm and mobile to palpation

1, 2, 4 Ordinarily, lymph nodes are not palpable in adults. If a node is palpable, it should be small (0.5 to 1 cm), mobile, firm, and nontender to be considered a normal finding. A node that is tender, hard, fixed, or enlarged (regardless if it is tender or not) is an abnormal finding and warrants further investigation. Tender nodes are usually a result of inflammation, whereas hard or fixed nodes suggest malignancy.

The nurse is caring for a patient with nephrotic syndrome. What nursing interventions are appropriate for this patient? Select all that apply. 1 Weighing the patient daily 2 Avoiding exposure to people with known infections 3 Ensuring the patient performs Kegel exercises regularly 4 Instructing the patient to consume a low-sodium, moderate-protein diet 5 Encouraging the intake of three big meals rather than small frequent meals

1, 2, 4 The patient suffering from nephrotic syndrome generally has edema as the main presenting symptom. Management of this edema is extremely essential in patient care. Accurate measurement of daily weight can indicate the severity of fluid gain or loss. People with nephrotic syndrome have a lowered immunity and should not be exposed to people with known infections. Sodium leads to the retention of fluids in the body and is not advised for a patient with edema. Kegel exercises are used to strengthen the pelvic floor muscles and are not of prime importance in nephrotic syndrome. Eating small meals is recommended because it makes it easier for patients to control the sodium and protein levels in their systems.

A patient with chronic kidney disease is advised to undergo peritoneal dialysis (PD). What advantages of PD over hemodialysis should the nurse explain to the patient? Select all that apply. 1 It is a simple procedure. 2 It is home-based. 3 It requires special water systems. 4 It needs a vascular access device. 5 Equipment setup is simple.

1, 2, 5 PD has many advantages over hemodialysis. The procedure is simple and home-based, with easy equipment setup. The patient can himself perform peritoneal dialysis. Because the dialysis is done through the peritoneal membrane, PD does not require a special water system or a vascular access device, as in hemodialysis.

The nurse is caring for a patient who survived sudden cardiac death (SCD) that was brought on by a lethal ventricular dysrhythmia. To reassure the patient, which tests should the nurse explain will be performed to monitor the effectiveness of drug treatment? Select all that apply. 1 Exercise stress testing 2 24-hour Holter monitoring 3 Magnetic resonance imaging 4 Signal-averaged electrocardiogram 5 Electrophysiological study under fluoroscopy

1, 2, 4, 5 Because most SCD patients have lethal ventricular dysrhythmias associated with a high recurrence rate, they are closely monitored to assess when they are most likely to have a recurrence and to determine which drug therapies are most effective for them. This monitoring includes exercise stress testing, 24-hour Holter monitoring, signal-averaged electrocardiogram, and electrophysiological study done under fluoroscopy. Magnetic resonance imaging is not used to monitor for lethal dysrhythmias.

A patient who has thrombocytopenia has undergone a bone marrow aspiration. Which interventions should the nurse perform to prevent complications in this patient? Select all that apply. 1 Administer analgesics 2 Monitor vital signs until the patient is stable 3 Administer antibiotics 4 Advise the patient to lie down on a rolled towel if the bed is too soft 5 Advise the patient to lie on the side for 30 to 60 minutes if bleeding is present

1, 2, 4, 5 Bone marrow examination is important in the evaluation of many hematologic disorders. After the marrow aspiration, analgesics are administered to reduce pain. The patient's vital signs should be monitored until the patient is stable. The aspiration site should be assessed for excess drainage or bleeding. If the bed is too soft, the patient should be advised to lie on a rolled towel. It would help to apply pressure on the site and control bleeding. If bleeding is present, the patient should be advised to lie on the side for 30 to 60 minutes to maintain pressure on the site. Antibiotics are not helpful in this case as the patient is not at risk of developing infection.

A patient has undergone a nephrectomy due to a renal tumor. What nursing interventions are appropriate for the postoperative care of this patient? Select all that apply. 1 Record urine output. 2 Monitor abdominal distention. 3 Allow oral intake immediately after operation. 4 Provide adequate pain relief through analgesics. 5 Weigh the patient daily. 6 Instruct the patient to minimize coughing.

1, 2, 4, 5 It is important to record hourly fluid intake and output to assess kidney function in the patient. Abdominal distension is commonly present in patients who have had abdominal surgery due to paralytic ileus caused by manipulation and compression of bowel during surgery. The patient may be reluctant to turn, cough, and deep breathe because of the incisional pain. Adequate pain medication should be given to ensure patient's comfort and ability to perform coughing and deep breathing exercises. It is important to weigh the patient daily, as a significant change in daily weight can indicate a retention of fluids. Oral intake is restricted until bowel sounds are present (usually 24 to 48 hours after surgery).

While observing the ECG characteristics of a patient with a third-degree heart block, what changes should the nurse expect to find? Select all that apply. 1 The PR interval is variable. 2 There are a greater number of P waves present. 3 The atrial rate is more than 100 beats per minute. 4 The ventricular rate is irregular. 5 The atrial and ventricular rhythms are regular but unrelated.

1, 2, 5 A third-degree block is often called a complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In such situations, the atria and ventricles beat independently because the AV node is completely blocked to the sinus impulse and, therefore, it is not conducted to the ventricles. One of the characteristics of a third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. The atrial and ventricular rhythms are regular, but these are not related to each other. The atrial rate is usually a sinus rate of 60 to 100 beats per minute.

A patient has undergone cholecystectomy. What postoperative care should the nurse perform for this patient? Select all that apply. 1 Maintain a low-fat diet. 2 Monitor for any bleeding. 3 Instruct not to do deep breathing. 4 Place patient in shock position. 5 Place the patient in Sims' position.

1, 2, 5 After cholecystectomy, it is important to follow dietary restrictions. A diet low in fat decreases the workload of the liver. Bleeding is a complication after the procedure; hence the nurse should monitor it. It is important to position the patient in Sims' position to facilitate gas pockets moving away from the diaphragm. Encourage deep breathing along with movement and ambulation to help expand the lungs and promote ventilation. The patient need not be put in shock position; it does not contribute to recovery.

The nurse is reviewing information about changes that occur during angina. Which of the following changes will the nurse review? Select all that apply. 1 Anaerobic metabolism begins, and lactic acid accumulates during hypoxia. 2 In ischemic conditions, cardiac cells are viable for approximately 20 minutes. 3 The coronary artery usually is blocked 50% or more when angina episodes occur. 4 Angina, or chest pain, is the clinical manifestation of irreversible myocardial ischemia. 5 Demand for myocardial oxygen exceeds the ability of the coronary arteries to supply the heart with oxygen.

1, 2, 5 Anaerobic metabolism begins, and lactic acid accumulates. On the cellular level, the myocardium becomes hypoxic within the first 10 seconds of coronary occlusion. Myocardial cells are deprived of oxygen and glucose needed for aerobic metabolism and contractility. When the demand for myocardial oxygen exceeds the ability of the coronary arteries to supply the heart with oxygen, myocardial ischemia occurs. The primary reason for insufficient blood flow is narrowing of coronary arteries by atherosclerosis . For ischemia secondary to atherosclerosis to occur, the artery usually is blocked (stenosed) 75% or more. Angina, or chest pain, is the clinical manifestation of reversible (not irreversible) myocardial ischemia.

A nurse is planning the discharge teaching for a patient with valvular heart disease. What instructions should the nurse include in the plan? Select all that apply. 1 Avoid cigarettes. 2 Take planned rest periods. 3 Continue with aerobic exercises. 4 Continue with daily activities as before. 5 Undergo regular cardiac assessments

1, 2, 5 Consumption of tobacco should be strictly avoided because it stimulates the heart. Rest periods should be planned to avoid exertion. Regular cardiac assessment helps to monitor the disease progress and effectiveness of the treatment provided. The patient should be advised to avoid strenuous physical activities because damaged valves may not be able to properly cope with the increased cardiac output demand. The patient should not continue aerobic exercises, as these are strenuous. It is necessary to conserve energy; therefore, modifications should be made in daily activities. Complex activities should be broken into simpler steps for easy execution.

A patient is being treated for burns on the face and ears due to a fire at home. What precautions should the nurse take to protect the ears from damage? Select all that apply. 1 Keep ears free from pressure. 2 Avoid using pillows. 3 Apply a heavy gauze dressing for fast healing. 4 Wrap ears with sterile gauze after applying ointment. 5 Elevate patient's head by placing rolled towel under shoulders.

1, 2, 5 Ears should be kept free from pressure because of their poor vascularization and tendency to become infected. Avoid using pillows, as the pressure on ear cartilage may cause chondritis, and the ear may adhere to the pillowcase, causing pain and bleeding. The patient's head is elevated by placing a rolled towel under shoulders to reduce pressure over the ears. It helps to prevent pressure necrosis. A heavy gauze dressing should not be applied, as it can put pressure on the ears and damage them. Ears are not to be wrapped with sterile gauze after applying ointment in order to avoid pressure over the ears.

Which strategies does the nurse use when caring for a patient recovering from a transsphenoidal hypophysectomy? Select all that apply. 1 Elevate the head of the bed 30 degrees 2 Monitor for and report clear nasal drainage 3 Encourage hourly coughing and deep breathing 4 Perform routine pin cares according to agency policy 5 Monitor for and report increased urinary output

1, 2, 5 Elevating the head of the bed 30 degrees decreases pressure on the sella turcica in the brain and decreases the patient's risk of headache. Clear nasal drainage may represent a cerebral spinal fluid leak. The primary health care provider should be notified and a sample of the drainage should be sent to the laboratory for analysis. The patient with cerebral spinal fluid leak is at risk for meningitis. Any insult to the posterior lobe of the pituitary gland puts the patient at risk for diabetes insipidus (DI). Transsphenoidal hypophysectomy induced pituitary insult may result in diabetes insipidus, either because of direct manipulation of the gland during surgery or as a result of postoperative edema. When diabetes insipidus occurs, there is a decrease in antidiuretic hormone (ADH), leading to a significant increase in urinary output. The increase in pressure created by vigorous coughing, sneezing, and straining to have a bowel movement can lead to cerebral spinal fluid leak in the patient recovering from transsphenoidal hypophysectomy. Deep breathing exercises are encouraged, but the patient should avoid coughing. Stereotactic radiosurgery may be a treatment option for some patients. Stereotactic radiosurgery is a form of radiation therapy that requires application of a stereotactic head frame to the patient's scalp. Patients with a stereotactic head frame require pin cares. Transphenoidal hypophysectomy is a surgical procedure that is accomplished via an endonasal (through the nose) approach or, less commonly, sublabially (under the lip at the upper gum line). Transshenoid hypophysectomy does not require attachment of a head frame and there are no pin cares.

A patient with chronic kidney disease is advised to undergo peritoneal dialysis (PD). What advantages of PD over hemodialysis should the nurse explain to the patient? Select all that apply. 1 It is a simple procedure. 2 It is home-based. 3 It requires special water systems. 4 It needs a vascular access device. 5 Equipment setup is simple

1, 2, 5 PD has many advantages over hemodialysis. The procedure is simple and home-based, with easy equipment setup. The patient can himself perform peritoneal dialysis. Because the dialysis is done through the peritoneal membrane, PD does not require a special water system or a vascular access device, as in hemodialysis.

A patient with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The patient has a fever and the nurse suspects that it is due to peritonitis. What are the other manifestations that the nurse should monitor the patient for? Select all that apply. 1 Vomiting 2 Abdominal pain 3 Bloody stools 4 Weight loss 5 Cloudy peritoneal effluent

1, 2, 5 Peritonitis may manifest as vomiting due to the inflammatory process in the peritoneum. The patient may have pain in the abdomen due to peritoneal irritation caused by the inflammatory process in the peritoneum. The primary clinical manifestations of peritonitis are abdominal pain and cloudy peritoneal effluent with a white blood cell (WBC) count greater than 100 cells/μL (more than 50% neutrophils). An activated immune response may attract WBCs, and an elevated level of WBC in the peritoneal fluid indicates peritonitis. Bloody stool or weight loss is not associated with peritonitis. Peritonitis may not cause hemorrhage; therefore, bloody stools may not be present. Weight loss is usually caused by malnutrition or fluid loss and therefore may not be seen in peritonitis; weight gain may occur due to fluid retention.

A nurse is caring for a patient experiencing sinus bradycardia. Which drugs are used to treat bradycardia? Select all that apply. 1 Atropine (AtroPen) 2 Dopamine (Intropin) 3 Adenosine (Adenocard) 4 Metoprolol (Lopressor) 5 Epinephrine (Adrenalin)

1, 2, 5 Sinus bradycardia is a condition in which the sinoatrial node elicits a heartbeat at a rate of less than 80 beats per minute. Sinus bradycardia is associated with hypotension, weakness, dizziness, and shortness of breath. It can be treated by the administration of atropine (AtroPen), an anticholinergic drug. Sympathomimetic drugs like dopamine (Intropin) and epinephrine (Adrenalin) are administered if atropine is ineffective. Beta blockers like adenosine (Adenocard) and metoprolol (Lopressor) are used in the treatment of sinus tachycardia.

A nurse is attending to a patient with burns. When considering the use of antibiotics, what factors does the nurse consider? Select all that apply. 1 It is essential to check the patient for allergies to sulfa. 2 Silver-impregnated dressings can be left in place from 3 to 14 days. 3 Systemic antibiotics are routinely used to control burn wound flora. 4 Silver sulfadiazine (Silvadene, Flamazine) or mafenide acetate (Sulfamylon) creams should never be used. 5 Topical antimicrobial agents may be applied after the wound cleansing.

1, 2, 5 The nurse should assess for a sulfa allergy, as some prescribed antibiotics may contain sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days, depending on the patient's clinical situation and the particular product. Topical antimicrobial agents may be applied after the wound cleansing to facilitate healing, and then the affected area should be covered with a light dressing. Systemic antibiotics are routinely not used to control burn wound flora because the burn eschar has little or no blood supply, and consequently, little antibiotic is delivered to the wound. Also, the routine use of systemic antibiotics increases the chance of developing multidrug-resistant organisms. Silver sulfadiazine and mafenide acetate creams are also used as burn antimicrobial creams.

A patient arrives at the burn unit with large burns on the chest and abdomen. While assessing the patient, the nurse suspects full-thickness burns. What findings are likely to be found in the patient with full-thickness burns? Select all that apply. 1 The patient has low blood pressure. 2 The patient is shivering. 3 The burned areas have blisters. 4 The burned areas are very painful. 5 The patient has absence of bowel sounds

1, 2, 5 The patient with severe burns is likely to be in shock from hypovolemia and may have low blood pressure. The patient experiences shivering as a result of chilling that is caused either by heat loss, anxiety, or pain. The patient with a larger burn area may develop a paralytic ileus, which may be accompanied with absent or decreased bowel sounds. The burned areas have blisters filled with fluid and protein in cases of partial-thickness burns. Superficial to moderate partial-thickness burns are very painful.

A patient with cancer of the head of the pancreas is admitted to the hospital. What are the manifestations that a nurse might expect to find in this patient? Select all that apply. Correct 1 Clay-colored stools Correct 2 Itching and irritation of the skin 3 Swelling of the face and extremities 4 Ulcers on the back and abdomen Correct 5 Extreme pain in the upper abdomen that may radiate to the back

1, 2, 5 Tumor of the head of the pancreas will obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The stools will be clay-colored when bile is not able to enter the duodenum. Pruritus is also a common symptom in cancer of the pancreas; hence the patient may complain of itching and irritation of the skin. Severe pain is also present. The pain generally depends on the part affected and severity. Edema and ulcers are not common manifestations of pancreatic cancer.

A patient with cancer of the head of the pancreas is admitted to the hospital. What are the manifestations that a nurse might expect to find in this patient? Select all that apply. 1 Clay-colored stools 2 Itching and irritation of the skin 3 Swelling of the face and extremities 4 Ulcers on the back and abdomen 5 Extreme pain in the upper abdomen that may radiate to the back

1, 2, 5 Tumor of the head of the pancreas will obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The stools will be clay-colored when bile is not able to enter the duodenum. Pruritus is also a common symptom in cancer of the pancreas; hence the patient may complain of itching and irritation of the skin. Severe pain is also present. The pain generally depends on the part affected and severity. Edema and ulcers are not common manifestations of pancreatic cancer.

A young patient who experienced burns on the neck and chest from a fire at the workplace 2 hours ago presents to the emergency department (ED). The patient is not intubated and on assessment, the nurse suspects inhalation injury. What appropriate actions should the nurse perform? Select all that apply. 1 Perform a fiberoptic bronchoscopy. 2 Reposition the patient every 1 to 2 hours. 3 Avoid administering 100% humidified oxygen. 4 Do not place the patient in a high Fowler's position. 5 Encourage deep breathing and coughing every hour.

1, 2, 5 Within 6 to 12 hours after the burn injury in which smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway. Reposition the patient every 1 to 2 hours, and provide suctioning and chest physiotherapy as prescribed to clear the airway. Encourage deep breathing and coughing every hour to clear the air passages and provide relief to the patient. When intubation is not performed, the treatment of inhalation injury includes administration of 100% humidified O2 as needed. Place the patient in a high Fowler's position, unless contraindicated as in spinal injury, and encourage deep breathing and coughing every hour.

A patient has been admitted with acute pericarditis. How should the nurse care for this patient? Select all that apply. 1 Provide an overbed table. 2 Ask the patient to avoid alcohol. 3 Keep the patient in a Trendelenberg position. 4 Allow the patient to be as active as possible. 5 Administer antiinflammatory medications.

1, 2, 5 A sitting position with an overbed table helps in reducing the pain associated with acute pericarditis. The patient should be instructed to avoid alcohol to prevent gastrointestinal bleeding. Antiinflammatory medicines should be administered for pain relief. The patient should not be placed in a Trendelenberg position; instead, the head of the bed should be elevated to 45 degrees. The physical activities of the patient should be restricted, and he should be on complete bed rest to decrease cardiac workload.

The nurse is caring for a patient receiving chemotherapy. The patient has developed chemotherapy-induced thrombocytopenia. Which instructions should the nurse provide to the patient and caregiver? Select all that apply. 1 Shave only with an electric shaver. 2 Avoid blowing the nose forcefully. 3 Reduce water intake. 4 Use a suppository if required. 5 Use an alcohol-based mouthwash. 6 Walk with sturdy shoes.

1, 2, 6 The nurse should instruct the patient to shave only with an electric shaver and avoid the use of blades. The patient should avoid blowing the nose forcefully; instead, gently pat it with a tissue. The patient should always walk with sturdy shoes for safety. The patient should drink plenty of fluids to prevent constipation. The patient should avoid using a suppository without the permission of the health care provider; the patient may be prescribed stool softeners. Alcohol-based mouthwashes should be avoided, as they can dry the gums and increase bleeding.

A nurse is monitoring a patient in the intensive care unit. Which are the choice of leads for continuous monitoring of the patient? Select all that apply. 1 Lead II 2 Lead III 3 Lead V1 4 Lead V6 5 Lead aVR

1, 3 An electrocardiogram is a graphical representation of the electrical impulses produced in the heart. It involves the use of 12 leads. Lead II and lead V1 are commonly used for continuous monitoring of the cardiac impulses. The use of lead III, lead V6, and lead aVR are also a part of the normal 12 lead electrocardiogram, but are not usually used for continuous monitoring.

The lipid profile of a patient is indicative of hyperlipidemia. A nurse advises the patient to consume a diet rich in high-density lipoproteins based on what rationale? Select all that apply. 1 High-density lipoproteins (HDLs) transport lipids to the liver. 2 High-density lipoproteins (HDLs) prevent stiffening of arterial walls. 3 High-density lipoproteins (HDLs) prevent deposition of lipids in the blood vessels. 4 High-density lipoproteins (HDLs) inhibit the production of low-density lipoproteins (LDLs). 5 High-density lipoproteins (HDLs) stimulate the liver to breakdown more low-density lipoproteins.

1, 3 High-density lipoproteins and low-density lipoproteins are vehicles for mobilization of fats. HDLs contain fewer lipids than proteins and mobilize lipids from the arteries to the liver for metabolism, thereby preventing the deposition of lipids on the vessel wall. LDLs have more lipid content than proteins and tend to deposit lipids in the arterial walls. HDLs prevent the deposition of lipids and do not directly alter the vessel wall or make it noncompliant. HDLs do not interfere with the production or breakdown of LDLs.

A nurse is caring for a patient experiencing severe side effects of chemotherapy. On examination, the nurse notices stomatitis. Which interventions should the nurse perform to relieve stomatitis? Select all that apply. 1 Apply topical anesthetics. 2 Give diuretics and laxatives regularly. 3 Encourage nutritional supplements. 4 Encourage oral application of alcohol. 5 Discourage the use of oral irritants like tobacco.

1, 3, & 5 Stomatitis is the inflammation of the mouth. It occurs when the epithelial cells get damaged due to chemotherapy or radiation therapy. Topical anesthetics such as viscous lidocaine may be used to provide local pain relief. Nutritional supplements helps to meet the nutritional demands when the food intake decreases due to stomatitis. Giving diuretics and laxatives regularly promotes bladder and bowel elimination, but does not help in relieving stomatitis. Oral application of alcohol may have a drying effect on the mucosa and may worsen stomatitis. Use of oral irritants like tobacco should be discouraged as they can worsen stomatitis and increase discomfort.

The nurse is providing discharge instructions to a patient and caregiver, following a laparoscopic cholecystectomy. Which of these measures will be included in the discharge counseling? Select all that apply. 1 Resume normal activities gradually. 2 Keep the bandages on the puncture sites for three days. 3 Eat a low-fat diet for several weeks after the surgery. 4 Report any bile-colored drainage or pus from any incision. 5 Empty and measure the contents of the bile bag from the T tube every day.

1, 3, 4 After a laparoscopic cholecystectomy, instruct the patient to have liquids for the rest of the day and eat light meals for a few days. The amount of fat in the postoperative diet depends on the patient's tolerance of fat. A low-fat diet may be helpful if the flow of bile is reduced (usually only in the early postoperative period) or if the patient is overweight. Sometimes the patient is instructed to restrict fats for four to six weeks. Otherwise, no special dietary instructions are needed other than to eat nutritious meals and avoid excessive fat intake. The bandages are to be removed the day after the surgery. Patients need to report any bile-colored drainage, or pus from any incision. Patients who undergo a laparoscopic cholecystectomy will not have a T tube present.

A patient underwent a lymph node biopsy. Which actions should the nurse perform after the procedure? Select all that apply. 1 Apply pressure to the site. 2 Discharge the patient. 3 Observe the site for bleeding. 4 Inspect the wound for infection. 5 Advise the patient to walk around.

1, 3, 4 After lymph node biopsy, the nurse should apply direct pressure to the affected area to achieve hemostasis, observe the site for bleeding, and monitor vital signs, especially if the platelet count is low. The nurse should also inspect the wound for healing and infection. Discharging the patient and advising the patient to walk around are not advisable.

A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply. 1 Antacids 2 Antidiarrheal 3 H2-histamine blockers 4 Proton pump inhibitors 5 Calcium channel blockers

1, 3, 4 Antacids are used prophylactically to neutralize the acids present in the stomach. H2-histamine blockers (e.g. ranitidine [Zantac]) are used to inhibit histamine, which causes increase in acid levels. Proton pump inhibitors (e.g. esomeprazole [Nexium]) help to inhibit the secretion of hydrochloric acid, which increases as a stress response to the decreased blood flow to the gastrointestinal tract after burns. Antidiarrheal is useful in providing symptomatic relief for diarrhea. It cannot prevent a Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on preventing development of Curling's ulcers.

A patient with cirrhosis of the liver is admitted to the hospital. What complications of cirrhosis is the nurse likely to find in the patient? Select all that apply. 1 Edema of the feet 2 Difficulty breathing 3 Blood in the stools or black stools 4 Disorientation and lethargy 5 Severe pain in the chest with a cold sweat

1, 3, 4 Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet. Gastric varices bleed easily. This bleeding can be presented as blood in vomiting or blood in the stool. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbances, and lethargy. Cirrhosis doesn't lead to pain in the chest with a cold sweat or difficulty in breathing.

A nurse is attending to a patient with partial-thickness burns on the face, including corneal burns. What should she do to protect the eyes of the patient? Select all that apply. 1 Use antibiotic ointments. 2 Wait for laboratory reports. 3 Arrange for ophthalmology examination. 4 Instill methylcellulose eye drops. 5 Inform the patient that periorbital edema is serious.

1, 3, 4 Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should be conducted on all patients who have sustained facial burns. The use of methylcellulose drops or artificial tears is recommended for moisture and additional comfort. Waiting for laboratory reports does not help the patient; rather, the nurse can start the basic examination and treatment in the process mentioned above. Avoid giving any misleading information, such as telling the patient that periorbital edema is serious. This can frighten the patient and prevent eye opening. The nurse should assure the patient that the swelling is not permanent.

A patient underwent pancreaticoduodenectomy (Whipple procedure) for pancreatic cancer. What are the instructions that the nurse should include when giving dietary advice to this patient? Select all that apply. 1 Consume a low-fat diet. 2 Consume a low-carbohydrate diet. 3 Consume a high-calorie diet. 4 Consume a diet high in proteins. 5 Patient may resume normal diet without any restrictions

1, 3, 4 Having a low-fat, high-carbohydrate, and high-protein diet is essential. The diet should be low in fat to decrease the work load of the liver and promote healing. A high-calorie diet should be provided, as more energy is required. High-calorie meals are needed for energy and to promote the use of protein for tissue repair. A high-protein diet is required for tissue building. The diet should be high in carbohydrates to provide the required energy. The patient should not resume a normal diet and should follow the restrictions as advised.

A patient underwent pancreaticoduodenectomy (Whipple procedure) for pancreatic cancer. What are the instructions that the nurse should include when giving dietary advice to this patient? Select all that apply. 1 Consume a low-fat diet. 2 Consume a low-carbohydrate diet. 3 Consume a high-calorie diet. 4 Consume a diet high in proteins. 5 Patient may resume normal diet without any restrictions.

1, 3, 4 Having a low-fat, high-carbohydrate, and high-protein diet is essential. The diet should be low in fat to decrease the work load of the liver and promote healing. A high-calorie diet should be provided, as more energy is required. High-calorie meals are needed for energy and to promote the use of protein for tissue repair. A high-protein diet is required for tissue building. The diet should be high in carbohydrates to provide the required energy. The patient should not resume a normal diet and should follow the restrictions as advised.

A patient suffering from ascites is admitted to the hospital. What are the factors that can lead to ascites development? Select all that apply. 1 Hyperaldosteronism 2 Diabetes mellitus 3 Portal hypertension 4 Decreased serum colloidal oncotic pressure 5 Decreased flow of hepatic lymph

1, 3, 4 Hyperaldosteronism or increased secretion of aldosterone causes ascites. Portal hypertension causes an increase in resistance to blood flow in the liver leading to ascites. When there is decreased serum colloidal oncotic pressure, there is impairment of synthesis of albumin and loss of albumin in the peritoneal cavity. It leads to ascites. Diabetes is a metabolic syndrome and does not cause ascites. Increased flow of hepatic lymph, not decreased flow, leads to ascites.

The nurse is caring for a patient admitted with diabetes mellitus, malnutrition, and massive gastrointestinal (GI) bleeding. In analyzing the morning laboratory results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? Select all that apply. 1 The potassium level may be increased if the patient has renal nephropathy. 2 The patient may be excreting extra sodium and retaining potassium because of malnutrition. 3 The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. 4 There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. 5 The patient has been overeating raisins, baked beans, and salt substitute that increases the potassium level.

1, 3, 4 Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. The patient with a massive GI bleed would have a nasogastric (NG) tube and not be eating.

A nurse is teaching a patient's caregivers about the immediate action to be taken in case of burns of more than 10% of body surface area. What reasons does the nurse provide for avoiding the use of ice on the burned body part? Select all that apply. 1 Ice can cause hypothermia. 2 Ice can stop further tissue damage. 3 Ice can cause vasoconstriction. 4 Ice can reduce blood flow to the burned area. 5 Ice can increase the blood flow to the burned area.

1, 3, 4 Ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasoconstriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen. Applying ice does not prevent further tissue damage; instead, it decreases the blood supply, causing delayed wound healing. Ice does not increase the blood flow to the burned area; rather it decreases the blood flow due to vasoconstriction.

A patient is diagnosed with a pneumothorax, and the health care provider has inserted a chest tube with chest drainage system. The nurse who is monitoring the system finds that there is no bubbling. The nurse checked all the connections and found no problems. What is the most probable reason for the absence of bubbling? Select all that apply. 1 Suctioning is not present. 2 Suction pressure is very high. 3 Suction pressure is very low. 4 Pleural air leak is too large to be drained. 5 There is collection of blood in pleural space.

1, 3, 4 It is important for a nurse to keep the water at the appropriate level in a suction chamber. If there is no bubbling seen, it indicates that there is no suction, or suction pressure is not enough, or the pleural leak is too large to be drained by the given suction pressure. The nurse should therefore revise the suction pressure. Collection of blood in pleural space would be evident by the type of drainage.

A patient is advised to undergo laparoscopic cholecystectomy. The patient asks the nurse what exactly this procedure means. What are the points that a nurse can include in this explanation? Select all that apply. 1 Gallbladder is removed through 1-4 small punctures on the abdominal wall. 2 Gallbladder is removed through an incision made on the right subcostal region. 3 The procedure is done with a laparoscope and grasping forceps under anesthesia. 4 The patient can be discharged on the day of operation or the next and resume his work after a week. 5 The gallbladder is removed through an incision on the abdomen, and a catheter is inserted to drain any fluids or effusion.

1, 3, 4 Laparoscopic cholecystectomy involves making 1-4 punctures on the abdominal wall, and the gall bladder is removed using laparoscope and grasping forceps. This procedure is done under anesthesia. The patient can be discharged in a day or two, as the recovery is fast. This procedure does not involve incisions.

The nurse teaches the patient receiving levothyroxine (Synthroid) that symptoms of drug toxicity include which of the following? Select all that apply. 1 Chest pain 2 Weight gain 3 Nervousness 4 Tachycardia 5 Cold intolerance 6 Mental sluggishness

1, 3, 4 Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. The signs of over treatment, or levothyroxine toxicity, are the same as the signs of hyperthyroidism, a state of increased metabolism and increased tissue sensitivity to sympathetic nervous system stimulation. Signs of overtreatment of hypothyroidism with levothyroxine include chest pain, nervousness, and tachycardia. Weight gain, cold intolerance, and mental sluggishness are signs of hypothyroidism.

The nurse performs a detailed health history for a patient with a possible bowel obstruction. Which of these are manifestations of an obstruction in the small intestine? Select all that apply. 1 Rapid onset 2 Absolute constipation 3 Frequent, copious vomiting 4 Colicky, cramplike, intermittent pain 5 Low-grade, cramping abdominal pain

1, 3, 4 Manifestations of an obstruction in the small intestine include rapid onset, frequent and copious vomiting, colicky, cramplike, intermittent pain, production of feces for a short time, and greatly increased abdominal distension. Absolute constipation and low-grade, cramping abdominal pain are manifestations of an obstruction of the large intestine.

The nurse is caring for a patient undergoing radioactive iodine (RAI) therapy in the outpatient setting. What instructions should the nurse provide to this patient? Select all that apply. 1 Avoid preparing food for others. 2 Gargle with warm water before meals. 3 Launder personal towels, bed linens, and clothes separately at home. 4 Avoid being close to pregnant women or children for 7 days after therapy. 5 Discontinue antithyroid drugs after RAI therapy.

1, 3, 4 The nurse should instruct the patient receiving RAI therapy to avoid preparing food for others, to launder personal towels, bed linens, and clothes separately at home, and to avoid being close to pregnant women or children for 7 days after therapy. These precautions are to limit radiation exposure to others.The patient is asked to use a salt and soda gargle three or four times per day to provide relief from dryness and irritation of the mouth and throat as a result of the therapy. RAI has a delayed response, and the maximum effect may not be seen for up to 3 months; therefore, the patient is usually treated with antithyroid drugs and propranolol before and for 3 months after the initiation of RAI therapy, until the effects of radiation become apparent.

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors? Select all that apply. 1 Obesity 2 Pneumonia 3 Malignancy 4 Cigarette smoking 5 Prolonged air travel

1, 3, 4, 5 An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, surgery within the last three months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders. Pneumonia is not a risk factor

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care? Select all that apply. 1 Escharotomy 2 Administration of diuretics 3 Intravenous (IV) and oral pain medications 4 Daily cleansing and debridement 5 Application of topical antimicrobial agent

1, 3, 4, 5 Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

A patient with cirrhosis of the liver is on furosemide. The nurse should monitor the patient for which findings to prevent complications of diuretic therapy? Select all that apply. 1 Tachycardia 2 Hypertension 3 Hypotension 4 Muscle weakness 5 Cardiac arrhythmias 6 Lethargy

1, 3, 4, 5 When a patient is on diuretic therapy, it is important to monitor fluid and electrolyte status. The patient should be monitored carefully for signs of hypokalemia, including tachycardia, hypotension, muscle weakness, and cardiac arrhythmias. Hypertension and lethargy are not complications of diuretic therapy.

When examining a patient with glomerulonephritis, which clinical characteristics is the nurse likely to find? Select all that apply. 1 Hypertension 2 Nausea and vomiting 3 Dysuria, fever, and chills 4 Generalized body edema 5 Hematuria and smoky urine

1, 3, 5

The nurse is monitoring a patient following lung transplantation for manifestations of acute rejection, such as which of the following? Select all that apply. 1 Fatigue 2 High fever 3 Low-grade fever 4 Productive cough 5 Oxygen desaturation

1, 3, 5 Acute rejection is fairly common in lung transplantation, typically occurring in the first 5 to 10 days after surgery. Low-grade fever, fatigue, dyspnea, dry cough, and oxygen desaturation are signs of rejection. High fever and productive cough are not signs of acute rejection.

A nurse works in a critical care unit. When attending to a patient, the nurse finds that the patient has developed atrial fibrillation. What should be the treatment for this patient? Select all that apply. 1 Electrical cardioversion 2 Oxygen therapy 3 Anticoagulation therapy 4 Atropine injection 5 Prepare for radiofrequency catheter ablation

1, 3, 5 Electrical cardioversion converts the atrial fibrillation into normal sinus rhythm. If a patient is in atrial fibrillation for more than 48 hours, anticoagulation therapy with warfarin will be required for 3 to 4 weeks. This should commence before the cardioversion and has to be continued for several weeks after successful cardioversion. For patients with drug-refractory atrial fibrillation or those who do not respond to electrical conversion, radiofrequency catheter ablation may be done. Administering oxygen may not be required. Atropine injection is not required in atrial fibrillation. However, it may be required in cases of certain atrioventricular blocks.

A nurse is reviewing the laboratory reports of a patient with acute pericarditis. The electrocardiogram report shows an elevated ST segment. What laboratory abnormalities would the nurse expect to find in this patient? Select all that apply. 1 Elevated C-reactive protein (CRP) 2 Decreased erythrocyte sedimentation rate (ESR) 3 Elevated troponin levels 4 Decreased hemoglobin count 5 Elevated white blood cell count

1, 3, 5 Elevated CRP is a common laboratory finding in acute pericarditis. It is caused by the inflammation of the pericardial sac. Troponin levels are increased with the elevation of the ST segment, which indicates concurrent myocardial damage. Leukocytosis commonly occurs because of inflammation. The ESR is elevated due to inflammation of the pericardial sac. A decreased hemoglobin count is not associated with acute pericarditis.

A patient with cirrhosis of the liver is admitted to the hospital. What hematologic symptoms might be noted in this patient? Select all that apply. 1 Anemia 2 Leukemia 3 Leukopenia 4 Polycythemia vera 5 Thrombocytopenia

1, 3, 5 Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation disorders. Anemia, leukopenia, and thrombocytopenia are probably caused by the splenomegaly that results from the backup of blood from the portal vein into the spleen (portal hypertension). Overactivity of the enlarged spleen results in increased removal of blood cells from circulation. Anemia is also due to inadequate red blood cell (RBC) production and survival, poor diet, poor absorption of folic acid, and bleeding from varices. Leukemia and polycythemia vera are not caused by cirrhosis.

What points should a nurse emphasize while teaching a patient ways to protect oneself from exposure to hepatitis B infection? Select all that apply. 1 Use disposable needles and syringes. 2 Avoid eating food prepared in unhygienic ways. 3 Avoid sharing toothbrushes and razors. 4 Avoid touching or coming in contact with people with hepatitis B. 5 Avoid unsafe sex with multiple partners, and always use condoms.

1, 3, 5 Hepatitis B spreads through sexual contact and through blood. Sharing razors or toothbrushes with an infected person may introduce infection in another person's body. Similarly, a needle used by an infected person can spread the infection. Hepatitis B also spreads via sexual exposure with an infected person. Using a condom gives some protection against the spread of infection. Hepatitis B doesn't spread through water and food. Hepatitis B doesn't spread with general casual contact.

The nurse is monitoring a patient who is experiencing a hyperacute rejection following transplantation of an organ. Which of these statements is true about this type of rejection? Select all that apply. 1 It occurs minutes to hours after transplantation. 2 Hyperacute rejection can be treated with muromonab-CD3 (Orthoclone OKT3). 3 It is a rare event because a final cross-match is performed just before the transplant. 4 Hyperacute rejection is a process that occurs over months or years and is irreversible. 5 There is no treatment for hyperacute rejection, and the transplanted organ is removed.

1, 3, 5 Hyperacute rejection occurs minutes to hours after transplantation because the blood vessels are destroyed rapidly. There is no treatment for hyperacute rejection, and the transplanted organ is removed. Fortunately, hyperacute rejection is a rare event because the final cross-match just before transplant usually determines whether the recipient is sensitized to any of the donor HLAs. Muromonab-CD3 is used for short periods to prevent early rejection or reverse acute rejection. Chronic rejection is a process that occurs over months or years and is irreversible.

While assessing a patient with severe burns, the nurse suspects hypokalemia. What possible causes should the nurse evaluate? Select all that apply. 1 Vomiting 2 Renal failure 3 Prolonged gastrointestinal (GI) suction 4 Adrenal insufficiency 5 IV therapy without potassium

1, 3, 5 Hypokalemia occurs due to lack of potassium. Excessive vomiting causes loss of body fluids leading to a loss of potassium. Prolonged GI suction also causes fluid loss and decreases potassium levels. The IV therapy without potassium fails to compensate for the loss of potassium, and the deficiency persists, thus resulting in hypokalemia. Renal failure and adrenal insufficiency are the causes of hyperkalemia, which is marked by an increase in potassium levels.

The nursing care of a patient who had a parathyroidectomy should include which actions? Select all that apply. 1 Monitor intake and output 2 Monitor for Babinski's sign 3 Ensure that intravenous (IV) calcium is available 4 Instruct patient to maintain bed rest for 48 hours 5 Assess for numbness and tingling of the hands and mouth

1, 3, 5 Intake and output are assessed carefully because of the patient's risk for fluid imbalance. IV calcium gluconate or gluceptate should be readily available for administration because the postoperative parathyroidectomy patient is at risk for hypocalcemia, which can lead to life-threatening tetany. Numbness and tingling of the hands and mouth are signs of mild tetany. Babinski's sign is not assessed in postoperative parathyroidectomy patients. Chvostek's and Trousseau's signs are assessed to monitor for signs of tetany. Mobility should be encouraged to promote bone calcification.

A nurse is reviewing the laboratory reports of a patient with myocarditis. Which laboratory findings are likely to be in the reports? Select all that apply. 1 Elevated viral titers 2 Decreased level of troponin 3 Moderate leukocytosis 4 Decreased erythrocyte sedimentation ratio (ESR) 5 Elevated C-reactive protein (CRP) levels

1, 3, 5 Myocarditis refers to the focal or diffuse inflammation of the myocardium. Viral titers are elevated because of the presence of virus in the myocardial tissue causing cellular damage and necrosis of the myocardial tissue. Mild to moderate leukocytosis may be present due to the inflammation. CRP levels may be elevated because of the inflammation. Troponin is a myocardial marker; hence, the level of troponin will be elevated. The ESR is also elevated, as it is an inflammatory marker.

A nurse is attending to a patient who has been diagnosed with rheumatic fever. Which criteria aid in confirming the diagnosis? Select all that apply. 1 Positive throat culture for strep throat 2 Presence of albuminuria 3 Presence of polyarthralgia 4 Decreased hemoglobin count 5 Presence of subcutaneous nodules

1, 3, 5 Positive throat culture indicates evidence of group A streptococcal infection. Polyarthritis is also a common finding in rheumatic fever. Subcutaneous nodules are associated with severe carditis and are observed in patients with rheumatic fever. Albuminuria is a clinical sign of renal dysfunction and is not associated with rheumatic fever. Hemoglobin count may be unaffected in rheumatic fever.

A patient with severe inhalation burns has been receiving treatment for 24 hours. When assessing the patient, what findings would indicate respiratory distress? Select all that apply. 1 Restlessness 2 Increased sleep 3 Increased agitation 4 Increased water intake 5 Increased rate of breathing

1, 3, 5 Restlessness can result from respiratory distress, as the patient experiences disturbances in breathing. Increased agitation could result from the patient's attempts to compensate for an increasing oxygen demand and can be a sign of respiratory distress. An increased respiratory rate is a compensatory mechanism for the increased oxygen demands. It is a sign of impending respiratory distress and needs immediate attention. Increased sleep does not result from respiratory distress, as the patient becomes restless. Increased water intake is not specific to respiratory distress.

A nurse is caring for a patient experiencing severe side effects of chemotherapy. On examination, the nurse notices stomatitis. Which interventions should the nurse perform to relieve stomatitis? Select all that apply. 1 Apply topical anesthetics. 2 Give diuretics and laxatives regularly. 3 Encourage nutritional supplements. 4 Encourage oral application of alcohol. 5 Discourage the use of oral irritants like tobacco

1, 3, 5 Stomatitis is the inflammation of the mouth. It occurs when the epithelial cells get damaged due to chemotherapy or radiation therapy. Topical anesthetics such as viscous lidocaine may be used to provide local pain relief. Nutritional supplements helps to meet the nutritional demands when the food intake decreases due to stomatitis. Giving diuretics and laxatives regularly promotes bladder and bowel elimination, but does not help in relieving stomatitis. Oral application of alcohol may have a drying effect on the mucosa and may worsen stomatitis. Use of oral irritants like tobacco should be discouraged as they can worsen stomatitis and increase discomfort.

Hemodialysis is planned for a patient who has end-stage kidney disease. The patient is scheduled for the creation of an internal arteriovenous fistula and the placement of an external arteriovenous shunt to be used until the fistula heals. What postoperative nursing care is appropriate for this patient? Select all that apply. 1 Regularly check the positioning of the external shunt. 2 Check for signs and symptoms of respiratory complications. 3 Ensure that intravenous fluids are not infused in the arm with the shunt. 4 Cover the ends of the shunt cannula with a dressing. 5 Do not take blood pressure on the extremity with the shunt.

1, 3, 5 The external shunt may come apart, external temperatures make clotting a potential hazard, and frequent handling increases the risk of infection. Infusions should not be in the extremity with the shunt or the fistula to avoid pressure from the tourniquet and to lessen the chance of phlebitis. Blood pressure readings should not be obtained in the extremity that has a shunt or fistula because of the pressure exerted on the circulatory system during the procedure. There are no respiratory complications of this procedure. The ends of the shunt cannula should be left exposed for rapid reconnection in the event of disruption.

A patient who underwent a cardioverter-defibrillator implant (ICD) is being discharged from the health care facility. Which instructions should the nurse give the patient and caregiver? Select all that apply. 1 Keep the incision dry as instructed and report any signs and symptoms of infection. 2 Exercise the arm on the incision side as soon as the incision heals and discomfort decreases. 3 Avoid large magnets and strong electromagnetic fields. 4 Avoid air travel until the cardiologist provides official clearance. 5 Inform the cardiologist if the implanted ICD fires.

1, 3, 5 The incision should be kept dry for as many days as instructed by the cardiologist. The patient should avoid metal detectors, large magnets, and strong electromagnetic fields. If the ICD fires, the patient should inform the cardiologist or contact emergency medical service. The patient should not lift the arm on the side of the ICD until approved by the cardiologist. Air travel is not restricted; however, the patient should not drive unless cleared by the cardiologist. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency.

A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition? Select all that apply. 1 Ask caregivers to get the patient's favorite food. 2 Suggest low-calorie food. 3 Suggest a high-protein diet. 4 Suggest reduced fluid intake. 5 Suggest a high-carbohydrate diet

1, 3, 5 The patient may have a reduced appetite and may not like the food from the hospital. Therefore, the caregivers can get the patient's favorite food. A swallowing assessment should be done by a speech pathologist before beginning with oral feeds. The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. A low-calorie food may not meet the calorie requirements of the patient and leads to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing.

Following a laparoscopic cholecystectomy, a patient without pre- or postoperative complications is being discharged from the hospital. What instructions should the nurse include in the discharge teaching? Select all that apply. 1 Take a shower. 2 Take complete bed rest for at least 2 weeks. 3 Wait 1 week after surgery to return to work. 4 Increase fat in the diet during recovery. 5 Notify the surgeon of any redness and swelling at the incision site.

1, 3, 5 The patient who undergoes a laparoscopic cholecystectomy without complications may be discharged shortly after surgery. Therefore, it is important to teach the patient about care following discharge. The patient should be informed that he or she may take a shower. Normal activities can be resumed the next day, and the patient may return to work within 1 week of surgery. A normal diet can also be resumed, but a low-fat diet is recommended for several weeks after surgery. The patient should immediately notify the surgeon if there is redness, swelling, bile-colored drainage, or pus from any incision; severe abdominal pain; nausea; vomiting; and/or fever and chills.

A patient with chronic kidney disease is on hemodialysis. Which should the nurse teach the patient and his or her caregiver? Select all that apply. 1 Space out the amount of fluid intake throughout the day. 2 Avoid cheese, yogurt, and pudding. 3 Include gelatin and ice cream as part of the fluid intake. 4 Ensure interdialytic weight gain is not more than 5 kg. 5 Avoid frequent use of NSAIDS such as ibuprofen.

1, 3, 5 The patient with chronic kidney disease on hemodialysis should space their limited fluid allotment throughout the day. Foods that are liquid at room temperature, such as gelatin and ice cream, should be included in the total fluid intake. The patient should avoid frequent use of NSAIDS, as they can cause further damage to the kidneys. If NSAIDS are taken as prescribed for short periods, they are usually considered safe. Patients do not need to avoid cheese, yogurt, or pudding unless their kidney disease progresses into end-stage kidney disease. Patients are advised to limit fluid intake so that interdialytic weight gain is no more than 1 to 3 kg.

A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply. 1 Touch sensation is impaired. 2 Blanching with pressure is observed. 3 Lack of blanching with pressure is observed. 4 Wounds appear mottled white, pink to cherry-red. 5 Wounds appear waxy white, dark brown, or charred.

1, 3, 5 Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, as all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, as all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. Blanching with pressure is observed in partial-thickness burns because varying degrees of both the epidermis and dermis are involved, and skin elements of regeneration are viable. Wounds appear mottled white, pink to cherry-red in a partial-thickness burn.

A nurse is reviewing a drug therapy regimen for a postmenopausal, obese female for prevention of coronary artery disease. The regimen includes low-dose aspirin. Which specific assessments should the nurse perform to ensure that it is safe for the client to take the aspirin? Select all that apply. 1 Check the blood pressure 2 Obtain the history of chest pain 3 Check liver function test reports 4 Obtain the history of gastrointestinal bleeding 5 Check for the presence of autonomic symptoms like flushing

1, 4 Aspirin is an antiplatelet drug that can be used to prevent the development of coronary artery disease. It prevents the aggregation of platelets, which can prevent plaque from increasing in size. If blood pressure is high, aspirin can cause bleeding. People with a history of gastrointestinal bleeding are more susceptible to bleeding with aspirin administration. Therefore, before prescribing aspirin, the nurse should assess whether the patient is hypertensive and whether the patient has a history of gastrointestinal bleeding. Aspirin is used as a premedication for the prevention of autonomic symptoms like flushing associated with the use of niacin (Nicobid). Aspirin is also used as an analgesic for treating pain. Unlike statin drugs, low-dose aspirin does not alter liver function.

A nurse is teaching a patient with coronary artery disease to decrease saturated and increase polyunsaturated dietary fat. Which major sources of polyunsaturated fats should the nurse include? Select all that apply. 1 Walnuts 2 Palm oil 3 Egg yolk 4 Margarine 5 Sour cream

1, 4 Walnuts and margarine are major sources of polyunsaturated dietary fat. Palm oil, egg yolk, and sour cream are major sources of saturated dietary fat.

A patient is advised to have radiotherapy for ovarian cancer. Applying radiation to which body areas or regions may increase the patient's risk of developing myelosuppression? Select all that apply. 1 Pelvis 2 Sternum 3 Cervical vertebrae 4 Thoracic vertebrae 5 Lumbar vertebrae

1, 4, & 5 Myelosuppression is a side effect of radiation therapy to specific treatment fields. Radiation to large marrow-containing regions of the body produces the most clinically significant myelosuppression. Therefore, radiation therapy to the pelvis, thoracic, and lumbar vertebrae may cause myelosuppression. The sternum and cervical vertebrae do not contain as much bone marrow and are therefore not as prone to myelosuppression.

A nurse is delivering a lecture on organ donation. She is explaining about the selection criteria for kidney donors. What are the donor characteristics that the nurse should discuss with the group? Select all that apply. 1 Donors should not have diabetes. 2 Donors should be a first-degree relative of a recipient. 3 Donors should be approximately the same body size as the recipient. 4 Donors must have ABO compatibility with the recipient. 5 The donor and recipient should have matching leukocyte antigen complexes.

1, 4, 5 Diabetes is a major predisposing factor for development of kidney disease; hence, the donor should not be a diabetic. ABO compatibility is necessary for being a donor, although the exact blood type is not necessary. Human leukocyte antigen compatibility provides the most specific predictions of the body's tendency to accept or reject foreign tissue. Being a member of the same family is unsafe unless the family member has matching leukocyte antigen complexes. Being a member of the same family may increase the possibility of a match, but there is no guarantee that a family member will match. Differences in body size do not cause problems.

While giving instructions to a group of caregivers working at the organ transplantation unit, what instructions should the nurse give? Select all that apply. 1 Two organs can be transplanted together. 2 Living donors can donate only a part of the organ. 3 Patients are matched to the available donors according to their age. 4 Segments of organs can be transplanted instead of the complete organ. 5 On imminent death of a donor or patient, organs can be donated with the consent of the legal next of kin.

1, 4, & 5 Some organs are transplanted individually, and others can be transplanted together, such as kidney and pancreas, kidney and liver, and kidney and heart. For instance, some diabetic patients undergoing pancreas transplant might also end up having a kidney transplant. This is mainly because they suffered from renal failure due to diabetes. Living donors can donate a part of an organ as well as certain complete organs such as their kidneys. In cases of organs like the liver and intestine, only their segments can be transplanted. Patients are matched to available donors based on blood group, human leukocyte antigen (HLA) typing, medical urgency, geographical location, etc. On imminent death of a person, legal next of kin gives consent for donation. It is therefore important to inform the next of kin if one desires to donate organs.

A nurse is caring for a patient with lung cancer. The patient's laboratory reports reveal a platelet level of 19,000/μL. What nursing actions will help prevent bleeding complications associated with this lab finding? Select all that apply. 1 Avoid invasive procedures. 2 Ensure proper hand washing. 3 Include iron-rich food in the diet. 4 Obtain a prescription for a platelet transfusion. 5 Instruct the patient to avoid activities that increase the risk of injury.

1, 4, & 5 The patient is at increased risk of bleeding since the platelet levels are below 20,000/μL. The nurse should avoid any invasive procedures as they can cause bleeding. Platelet transfusion should be performed to increase the platelet levels. The patient should avoid all activities that increase the risk of injury and bleeding because even a minor injury can result in huge blood loss. Proper hand washing should be performed before and after handling any patient; however, it does not help to decrease the bleeding risk. Including iron-rich food in the diet helps to manage anemia, but may not be helpful in decreasing the risk of bleeding.

A nurse is teaching a group of nursing students about cancer cell proliferation. Which are the tissues in the human body where cell proliferation is rapid? Select all that apply. 1 Bone marrow 2 Cartilage 3 Myocardium 4 Hair follicles 5 Epithelial lining of the GI tract

1, 4, & 5 The tissues in the human body that proliferate very rapidly include bone marrow, hair follicles, and epithelial lining of the gastrointestinal (GI) tract. The rapid rate of proliferation of these tissues makes them susceptible to developing cancers. Cartilage and myocardial cells do not proliferate or proliferate very slowly. Therefore, these cells are less prone to developing cancers.

A patient with pharyngitis is suspected to have rheumatic fever. Which interventions are appropriate for this patient? Select all that apply. 1 Adequate treatment for streptococcal pharyngitis 2 Discontinuation of antibiotics if there is symptomatic relief 3 Cold fomentation for painful joints 4 Administering nonsteroidal antiinflammatory drugs (NSAIDs) for joint pain 5 Monitoring fluid intake

1, 4, 5 Adequate treatment of streptococcal pharyngitis prevents the initial attack of rheumatic fever. NSAIDs can be given to relieve pain in the joints. It is important to monitor fluid intake to prevent dehydration. Completing the full course of antibiotics is important for successful treatment. Heat needs to be applied to painful joints, as cold fomentation may lead to stiffness.

The nurse is reviewing statistics regarding the incidence and death rates of cancer. Which of these statements are true? Select all that apply. 1 Thyroid cancer is more prevalent in women than in men. 2 Colon cancer is the most common type of cancer in men. 3 A higher percentage of women than men have lung cancer. 4 More men than women die from cancer-related deaths each year. 5 African Americans have a higher death rate from cancer than whites.

1, 4, 5 Cancer-related deaths are higher in men than in women; African Americans have a higher death rate from cancer than whites. Thyroid cancer is more prevalent in women. Prostate cancer is the most common type of cancer in men. The incidence of lung cancer is the same for men and women.

A patient is brought to the emergency department (ED) with a history of inhalation injury from hot air in a manufacturing unit. The patient has also sustained burns on his face, neck, and hands. What actions should the nurse perform immediately? Select all that apply. 1 Check for evidence of inhalation of smoke. 2 Observe for the next 2 hours. 3 Wait for laboratory reports. 4 Observe for signs of respiratory distress. 5 Perform early endotracheal intubation.

1, 4, 5 Checking for smoke inhalation is an important step to evaluate burn victims. Also, looking out for signs of respiratory distress like increased agitation, anxiety, restlessness, or a change in the rate or character of breathing is important. Early treatment includes airway management that involves early endotracheal (preferably orotracheal) intubation, as it eliminates the need for an emergency tracheostomy. Observing the patient for the next 2 hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within 1 to 2 hours after the injury.

The nurse is caring for a patient with hepatitis C. What steps regarding nutrition can the nurse take to ensure that the patient gets the best nutrition possible? Select all that apply. 1 Avoid very hot or very cold foods. 2 Provide the patient with more liquid foods such as soups. 3 Provide the patient with only raw foods such as fruits and salads until healthy. 4 Ensure that the patient drinks at least 2500-3000 mL of water every day. 5 Ensure that the patient has a good breakfast and small or moderate dinner.

1, 4, 5 Drinking very hot or very cold foods may cause anorexia; therefore, the patient should be encouraged to avoid hot and cold foods. The nurse should maintain adequate fluid intake of 2500 to 3000 mL/day to maintain hydration. The patient experiences less nausea in the mornings; therefore, the breakfast should be the most nutritious meal. Small, frequent meals may be preferable to three large ones and may also help prevent nausea. Liquids may not be able to meet the nutritional requirements of the patient due to nausea and vomiting. The patient may not be able to have raw foods due to nausea and anorexia.

The health care provider informs the nurse that the patient who had been admitted a week ago is in the diuretic phase of acute kidney injury, and the interventions have to be changed accordingly. The nurse explains the present condition of the patient to the caregivers. Which information is appropriate regarding the condition of the patient? Select all that apply. 1 Urine output of the patient is increased. 2 The kidney has become fully functional. 3 The electrolyte imbalance will be normalized. 4 The patient will be in this phase for no more than 3 weeks. 5 There is a possibility that the fluid volume will be reduced in the body.

1, 4, 5 During the diuretic phase of acute kidney injury, daily urine output is usually around 1 to 3 L but may reach 5 L or more. Hypovolemia and hypotension can occur from massive fluid losses. The diuretic phase may last 1 to 3 weeks. Near the end of this phase, the patient's acid-base, electrolyte, and waste product (blood urea nitrogen, creatinine) values begin to normalize. Although urine output is increasing, the nephrons are still not fully functional. The high urine volume is caused by osmotic diuresis from the high urea concentration in the glomerular filtrate and the inability of the tubules to concentrate the urine. In this phase the kidneys have recovered their ability to excrete wastes, but not to concentrate the urine. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration.

On assessment, the nurse finds that a patient has a headache, increased blood pressure, peripheral edema, dyspnea, and jugular venous distention. The symptoms indicate excess fluid volume. Which causes of excess fluid volume might the nurse find in the patient? Select all that apply. 1 Heart failure 2 Hemorrhage 3 Diabetic insipidus 4 Long-term use of corticosteroids 5 Syndrome of inappropriate antidiuretic hormone (SIADH)

1, 4, 5 Excess volume of fluid can accumulate in illnesses such as heart failure and SIADH, or due to long-term use of corticosteroids. In heart failure, the heart is unable to pump adequate blood to the body, resulting in pooling of blood in the periphery. In SIADH, abnormal levels of ADH cause reabsorption of water from the kidneys, leading to water retention in the body. Long-term use of corticosteroids causes altered homeostatic regulation of sodium and water, resulting in excess fluid volume. Hemorrhage and diabetic insipidus cause a deficit in fluid volume.

When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply. 1 Increasing hoarseness 2 Location of contact points 3 Leathery white charred skin 4 Darkened oral or nasal membranes 5 Productive cough with black sputum

1, 4, 5 In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury. Some other signs include darkened oral or nasal membranes and productive cough with black sputum, which are evident due to charring of the membranes of the respiratory tract. Location of contact points is done in case of electrical burns. In this case, the skin may appear leathery white and charred.

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion in the acute care setting. What nursing interventions are important for this patient? Select all that apply. 1 Restrict fluid intake to no more than 1000 mL/day. 2 Elevate the head of the bed to an angle of 30 degrees. 3 Avoid frequent repositioning of the patient. 4 Implement seizure precautions and set the bed alarm. 5 Provide the patient with ice chips to decrease thirst.

1, 4, 5 In the acute care setting the patient's total fluid intake is restricted to no more than 1000 mL/day, including that taken with medications. The nurse should implement seizure precautions and set the bed alarm to protect the patient from injury, because of the potential for an alteration in mental status. The nurse should provide the patient with frequent oral care and ice chips to decrease discomfort related to thirst from the fluid restrictions. The head of the bed should be flat or elevated no more than 10 degrees to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of antidiuretic hormone. Frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility. Text Reference - p. 1193

A patient with ascites is admitted to the hospital. What should be the primary nursing actions in this case? Select all that apply. 1 Monitor fluid and electrolytes. 2 Provide a high-sodium diet. 3 Encourage high-fluid intake. 4 Administer an albumin infusion. 5 Anticipate paracentesis.

1, 4, 5 Management of ascites focuses on sodium restriction, diuretics, and fluid removal. The fluid and electrolytes should be closely monitored; an imbalance may lead to an increase in ascites. An albumin infusion may be used to help maintain intravascular volume and adequate urine output by increasing plasma colloid osmotic pressure. Paracentesis can be done to remove the ascitic fluid from the peritoneum. The amount of sodium restriction is based on the degree of ascites. The patient is usually not on restricted fluids unless severe ascites develops; however, high-fluid intake should be avoided.

A nurse is involved in the wound care of patients on the burn management unit. What precautions should the nurse take while performing wound care? 1 The nurse wears personal protective equipment. 2 The nurse wears the same gown and masks for all patients. 3 The nurse uses nonsterile gloves when applying ointments. 4 The nurse uses sterile gloves when applying sterile dressings. 5 The nurse uses nonsterile gloves when removing contaminated dressings.

1, 4, 5 The nurse wears personal protective equipment like a disposable gown, mask, and gloves to prevent the spread of infection. The nurse uses sterile gloves when applying sterile dressings to prevent infection. The nurse uses nonsterile gloves when removing contaminated dressings for self-protection. The nurse should not wear the same gown and masks for all patients to avoid cross-contamination. It is necessary to wear new equipment before treating a new patient. The nurse should not use nonsterile gloves when applying ointments. Since the wound is open, sterile gloves should be used to prevent contamination.

A patient with the following ECG tracing is preparing for discharge from the hospital. The discharge medications are warfarin (Coumadin) and digoxin (Lanoxin). The patient education should include which of the following? Select all that apply.12676328 1 Avoid foods containing Vitamin K 2 Take warfarin twice a day 3 Importance of monitoring partial thromboplastin time (PTT) levels 4 Warfarin reduces risk of strokes 5 Notify the primary health care provider of epistaxis 6 Check the pulse before taking warfari

1, 4, 5 Vitamin K can counteract the effects of warfarin. Therefore, the patient needs to be taught which foods contain Vitamin K. Because warfarin is prescribed for patients in atrial fibrillation because of the risk for clot development in the heart resulting in stroke, heart attack, or pulmonary embolism, it should be included in the patient education. A major side effect of warfarin is bleeding. Therefore, the patient should be taught to notify the primary health care provider if he or she develops nosebleeds. Taking warfarin twice a day is incorrect because this medication is given once a day. Outpatient international normalized ratio (INR), not PTT levels, are required to determine correct dosage of warfarin. It is not necessary for the patient to check his or her pulse before taking warfarin. Text Reference - p. 796

A nurse plans to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which are antioxidants and therefore should be included in the protocol? Select all that apply. 1 Zinc 2 Water 3 Calcium 4 Selenium 5 Multivitamins

1, 4, 5 Zinc is an antioxidant and also a part of the antioxidant protocol because it supports cell growth and development. Selenium is used in the antioxidant protocol, as it helps to prevent cell damage. Multivitamins are a part of the antioxidant protocol because they help to compensate for the nutritional deficiencies of essential vitamins and minerals. Water is useful for the patient but does not form a part of the antioxidant protocol. Calcium is important to maintain strong bones and teeth, but it is not included in the antioxidant protocol.

A patient is suspected of having acromegaly. When gathering a health history, what questions would be important for the nurse to ask? Select all that apply. 1 Do you snore? 2 Do you crave salty foods? 3 Have you experienced a recent weight loss? 4 Have you noticed an increase in your shoe size? 5 Have you experienced unusual thirst or excessive urination? 6 Have you experienced numbness or tingling in your fingers or hands?

1, 4, 5, 6 The patient with acromegaly experiences excess secretion of growth hormone from the anterior pituitary. Growth hormone excess results in enlargement and thickening of bones and soft tissues. Sleep apnea can occur because of narrowing of the airway caused by enlargement of the soft tissues of the upper airway. Increased snoring is suggestive of sleep apnea. Bones and tissues of the face, feet, and hands are particularly susceptible to the effects of excess growth hormone. Patients may notice that their rings no longer fit and that their shoe size is increasing. Because growth hormone antagonizes insulin, patients with acromegaly often experience hyperglycemia. Hyperglycemia causes an osmotic diuresis, resulting in increased thirst and excessive urination. As soft tissues and bony structures enlarge, patients may experience nerve impingement syndromes. Numbness or tingling of the fingers or hands may be caused by carpal tunnel syndrome. There is no association between acromegaly and a craving for salty foods. Acromegaly occurs when there is excess secretion of growth hormone after the epiphyses of the long bones have closed. While the patient will not gain additional height, thickening of the bones leads to an increase, rather than a decrease, in body weight.

The patient is brought to the emergency department following a car accident and is wearing medical identification that says the patient has Addison's disease. What should the nurse expect to be included in the collaborative care of this patient? 1 Low sodium diet 2 Increased glucocorticoid replacement 3 Suppression of pituitary adrenocorticotropic hormone (ACTH) synthesis 4 Elimination of mineralocorticoid replacement

2

A patient's T3 and T4 levels are decreased, and the TSH (thyroid-stimulating hormone) level is increased. The nurse suspects what condition? 1 Hypoparathyroidism 2 Hypothyroidism 3 Hyperthyroidism 4 Hyperparathyroidism

2 A decrease in the level of thyroid hormone, evidenced by below-normal T3 and T4 levels and increased TSH, indicates hypothyroidism. TSH increases as the body attempts to compensate for decreased thyroid production by trying to stimulate more T3 and T4 production. Hypoparathyroidism is a decrease in parathormone that in turn causes a decrease in serum calcium. In hyperthyroidism T3 and T4 production are increased and TSH is decreased. Hyperparathyroidism is an increase in parathormone that causes an increase in serum calcium.

Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures? 1 Sunburn 2 Full thickness burn 3 Deep partial thickness burn 4 Superficial partial thickness burn

2 A full thickness burn is a burn of the layers of subcutaneous fat, muscle, or deeper structures. A superficial partial thickness burn is a burn of the epidermis layer; a sunburn is a type of superficial partial thickness burn. A deep partial thickness burn involves the dermis layer, between the epidermis and subcutaneous layers.

A nurse is performing a physical assessment of a patient and finds that the lymph nodes are hard and fixed. How should the nurse interpret the finding? 1 It is a normal finding. 2 It suggests malignancy. 3 It indicates inflammation. 4 It signifies vitamin deficiency

2 A hard and fixed lymph node is an abnormal finding and warrants further investigation. Hard or fixed nodes suggest malignancy. Palpated nodes which are mobile, firm, and nontender are considered normal. Tender nodes usually indicate inflammation. Vitamin deficiency does not affect lymph nodes.

A 68-year-old patient has been admitted with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history places the patient at greatest risk for colorectal cancer? 1 Osteoarthritis 2 Recurrent rectal polyps 3 Gastroesophageal reflux disease (GERD) 4 Daily use of nonsteroidal antiinflammatory drugs (NSAIDs)

2 A history of rectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Daily use of NSAIDS, GERD, and osteoarthritis do not place the patient at risk for colorectal cancer.

While teaching care guidelines to a family member of a patient with burns, the nurse instructs the family member to include foods rich in omega-3 fatty acids in the patient's diet. What is the rationale behind the nurse's instruction? 1 To improve sleep 2 To prevent blood clots 3 To promote weight gain 4 To decrease stomach acid

2 A patient with severe burns is at greater risk of venous thromboembolism. Omega-3 fatty acids are natural anticoagulants that decrease platelet aggregation. Eating foods rich in tryptophan, not omega-3 fatty acids, improves the patient's sleeping pattern. Tryptophan is an amino acid that blocks body wakeup cycles and promotes sleep. Foods rich in protein and fats, like peanut butter and red meat, help the patient gain weight. Avoiding spicy foods and drinking plenty of pure water helps decrease stomach acid.

A patient has a prescription to receive 0.9% sodium chloride (normal saline) intravenously (IV) at a rate of 100 mL per hour. The current bag of 1000 mL was hung at 1000. When making rounds at 1300, the nurse notes that the IV bag contains 900 mL of normal saline. How would the nurse document this incident report? 1 Wrong solution 2 Wrong rate 3 Wrong route 4 Wrong documentation

2 After three hours of infusion time, 300 mL of IV solution should have infused, but the patient has received 100 mL. Therefore, the patient has received the wrong rate. The solution, route, and documentation are correct.

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? 1 Gastrointestinal (GI) distress 2 Tachycardia 3 Restlessness 4 Hypokalemia

2 Albuterol stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a noncardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur, but will decrease with use. Hypokalemia does not occur with albuterol.

The nurse assesses a patient who has been administered the tissue-type plasminogen activator alteplase (Activase) for an acute myocardial infarction. Which assessment finding is the highest priority and should be reported to the primary health care provider immediately? 1 Anorexia 2 Hematuria 3 Oral temperature of 100.4° F (38° C) 4 Occasional premature ventricular contractions

2 Alteplase (Activase) has a proteolytic enzyme that digests threads and other substances in the blood, including clotting factors, thereby causing hypercoagulability of the blood and possibly bleeding, which is evidenced by blood in the urine. Anorexia and increased temperature are not issues directly related to this drug. Alteplase (Activase) may cause premature ventricular contractions, which should be monitored, but this is usually not a problem because the drug has a short half-life.

During the admission assessment, the nurse discovers that the patient has used illicit drugs. Related to the hematologic system, what question should the nurse next ask the patient? 1 "Do you have any blood in your stools?" 2 "What agent and when did you last use it?" 3 "Have you had any surgeries causing pain?" 4 "Do you have shortness of breath with activity?"

2 Although asking about blood in the stools, painful surgeries, or shortness of breath with activity are appropriate questions related to the hematologic system, the only one related specifically to illicit drug use is asking about what agent and when it was last used. The route and frequency also should be assessed

A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for the scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after the treatment? 1 Level of consciousness 2 Blood pressure and fluid balance 3 Temperature, heart rate, and blood pressure 4 Assessment for signs and symptoms of infection

2 Although monitoring level of consciousness, temperature, heart rate, and blood pressure and assessing for signs of infection are relevant to the care of a patient receiving hemodialysis , the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance.

The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). How should resumption of sexual activity be discussed? 1 Delegated to the health care provider 2 Discussed along with other physical activities 3 Avoided because it is embarrassing to the patient 4 Accomplished by providing the patient with written material

2 Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. The discussion of sexual activity should not be delegated to the health care provider or avoided because of embarrassment. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse should recognize that this diagnostic finding most likely suggests which problem? 1 Hypoxemia 2 An infection 3 A risk of hypocoagulation 4 An acute thrombotic event

2 An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not affect directly neutrophil production.

The nurse is providing postoperative care to a patient who underwent open cholecystectomy 3 days ago. Which finding during the nurse's assessment should prompt the nurse to notify the primary health care provider? 1 Tolerance of a full-liquid diet 2 Oral temperature of 101.8° F 3 Report of pain at a level 5 on a scale of 0 to 10 4 An 8-hour fluid intake of 680 mL and an output of 660 mL

2 An oral temperature of 101. 8º F on the third postoperative day indicates a possible infection and requires further evaluation and modification of the nursing plan of care. Tolerating a full liquid diet and pain at level of 5 on a 0 to 10 scale are appropriate outcomes at this time. Although fluid intake is low, it is in balance with the output; therefore it would not be as high a priority as the increased temperature.

Which category of medication helps reduce afterload in patients with heart failure? 1 Nitrates 2 ACE inhibitors 3 Antidysrhythmic drugs 4 β-adrenergic blocker

2 Angiotensin-converting enzyme (ACE) inhibitors block angiotensin II and dilate both arteries and veins. ACE inhibitors reduce arterial pressure and afterload in patients with heart failure by causing vasodilatation. Nitrates dilate both arteries and veins. At the normal therapeutic dose, venous dilation predominates and reduces venous pressure. The decreased venous pressure helps decrease venous preload in patients with heart failure. Antidysrythmics are used to suppress abnormal rhythms such as atrial fibrillation and atrial flutter. β-adrenergic blockers suppress the neurohumoral stimulation that occurs in patients with heart failure.

Which category of medication helps reduce afterload in patients with heart failure? 1 Nitrates 2 ACE inhibitors 3 Antidysrhythmic drugs 4 β-adrenergic blockers

2 Angiotensin-converting enzyme (ACE) inhibitors block angiotensin II and dilate both arteries and veins. ACE inhibitors reduce arterial pressure and afterload in patients with heart failure by causing vasodilatation. Nitrates dilate both arteries and veins. At the normal therapeutic dose, venous dilation predominates and reduces venous pressure. The decreased venous pressure helps decrease venous preload in patients with heart failure. Antidysrythmics are used to suppress abnormal rhythms such as atrial fibrillation and atrial flutter. β-adrenergic blockers suppress the neurohumoral stimulation that occurs in patients with heart failure.

A nurse is caring for a patient with a history of chronic stable angina who complains of chest pain. Which factor is true of ischemia related to angina? 1 It generally lasts longer than 15 to 20 minutes. 2 It will be relieved by rest, nitroglycerin, or both. 3 It indicates that irreversible myocardial damage is occurring. 4 It is frequently associated with vomiting and extreme fatigue.

2 Chronic stable angina is characterized by intermittent chest pain, often described as pressure or tightness that occurs over a period of time in the same pattern, onset, and intensity. It commonly subsides when precipitating factors have stopped and the patient is at rest or with the use of nitroglycerin.The pain usually lasts just 5 to 15 minutes and does not always indicate irreversible myocardial damage. Vomiting and extreme fatigue are symptoms of myocardial infarction and are not commonly seen in chronic stable angina.

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets this rhythm as what? 1 Sinus tachycardia 2 Atrial fibrillation 3 Ventricular fibrillation 4 Ventricular tachycardia

2 Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not contracting truly, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave, an unmeasureable heart rate, PR, or QRS, and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm; the P wave usually is buried in the QRS complex without a measureable PR interval.

A 57-year-old patient has been diagnosed with acute myelogenous leukemia (AML). The nurse explains to the patient that collaborative care will focus on what? 1 Leukapheresis 2 Attaining remission 3 One chemotherapy agent 4 Waiting with active supportive care

2 Attaining remission is the initial goal of collaborative care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the white blood cell (WBC) count and risk of leukemia-cell induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia (CLL), waiting may be done to attain remission, but not with AML.

The blood bank notifies the nurse that the two units of blood prescribed for an anemic patient are ready for pick up. The nurse should take which action to prevent an adverse effect during this procedure? 1 Immediately pick up both units of blood from the blood bank. 2 Infuse the blood slowly for the first 15 minutes of the transfusion. 3 Regulate the flow rate so that each unit takes at least four hours to transfuse. 4 Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

2 Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse initially should infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging a unit of blood. Only one unit of blood can be picked up at a time, must be infused within four hours, and cannot be hung with dextrose.

A 24-year-old female donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is experiencing a lot of pain and refuses to get up to walk. How should the nurse handle this situation? 1 Have the transplant psychologist convince her to walk. 2 Encourage even a short walk to avoid complications of surgery. 3 Tell the patient that no other patients have ever refused to walk. 4 Tell the patient she is lucky she did not have an open nephrectomy.

2 Because ambulating will improve bowel, lung, and kidney function with improved circulation, even a short walk with assistance should be encouraged after pain medication. The transplant psychologist or social worker's role is to determine if the patient is emotionally stable enough to handle donating a kidney, while postoperative care is the nurse's role. Trying to shame the patient into walking by telling her that other patients have not refused and telling the patient she is lucky she did not have an open nephrectomy (implying how much more pain she would be having if it had been open) will not be beneficial to the patient or her postoperative recovery.

A 71-year-old patient with dyspnea secondary to metastatic lung cancer is admitted to the hospital. What should the nurse assess first? 1 Temperature 2 Lung sounds 3 Oxygen saturation 4 Capillary refill

2 Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. The priority assessment is lung sounds to evaluate for the presence of adverse reactions secondary to tumors, including pneumothorax, pneumonia, and obstruction. Temperature, oxygen saturation, and capillary refill should be assessed after assessment of the lungs.

A patient is brought to the emergency department with penetrating renal trauma due to a motor vehicle accident. What should be the immediate nursing action? 1 Monitor intake and output of fluid. 2 Assess the cardiovascular system and monitor for signs of shock. 3 Provide pain relief and comfort measures. 4 Assess for hematuria and myoglobinuria.

2 Because the patient may have suffered significant blood loss following this accident, assessment of the cardiovascular system and monitoring the patient for signs of shock are the most urgent actions that the nurse should perform. Other interventions can be performed once the patient is stable.

The nurse is providing education to a patient who is in the rehabilitation phase of burn recovery after burning the arm with scalding water. Which of these statements by the patient indicates a need for further instruction? 1 "If the area itches, I can apply a water-based moisturizer." 2 "After a month, I will be able to go to the beach to get a tan." 3 "I will need to wear the pressure garment for 24 hours a day." 4 "I will continue the range-of-motion exercises on a regular schedule."

2 Burn patients must protect healed burn areas from direct sunlight for about three months to prevent hyperpigmentation and sunburn injury. They should always wear sunscreen when they are outside. Water-based moisturizers are appropriate for itching. Pressure garments and masks should never be worn over unhealed wounds and, once a wearing schedule has been established, are removed only for short periods while bathing. Pressure garments are worn up to 24 hours a day for as long as 12 to 18 months. The range-of-motion exercises are important to prevent contractures that may develop as new tissue shortens.

A nurse is attending a seminar on the causes of death in the United States. Which disease is considered the second most common cause of death in the United States? 1 Heart disease 2 Cancer 3 HIV infection 4 Tuberculosis

2 Cancer is the second most common cause of death in the United States. Heart disease is the primary cause of death in the United States. HIV infection, which can lead to acquired immunodeficiency syndrome, is not among the leading causes of death in the United States. Tuberculosis is an infection of the lungs, and is not among the most common causes of death.

A patient's arterial blood gas results are: pH 7.48; PaCO2 38; HCO3¯ 30. The patient is in: 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

2 Normal pH is 7.35-7.45. Values greater than 7.45 indicate alkalosis. Normal value for HCO3¯ is 22--26 mEq/L. Because the PaCO2 is normal and the HCO3¯ is elevated, the source of the alkalosis is metabolic. The patient is in metabolic alkalosis

A patient is about to receive an infusion of α-interferon (Roferon-A). The nurse will premedicate the patient with which of these drugs to prevent fever and shivering during this infusion? 1 Aspirin 2 Acetaminophen 3 Morphine sulfate 4 Ondansetron (Zofran)

2 Common side effects of interferons include constitutional flu-like symptoms, including headache, fever, chills, myalgias, fatigue, malaise, weakness, photosensitivity, anorexia, and nausea. Acetaminophen administered every four hours, as prescribed, often reduces the severity of the flu-like syndrome. The patient is commonly premedicated with acetaminophen in an attempt to prevent or decrease the intensity of these symptoms. In addition, large amounts of fluids help decrease the symptoms. Aspirin would not be appropriate because of its platelet aggregation inhibiting effect. Morphine is an opioid analgesic. Ondasetron is for prevention and treatment of nausea.

The nurse reviews lab tests that have been prescribed for a patient in acute renal failure. Which is the best indicator of renal function? 1 Potassium 2 Creatinine 3 BUN (blood urea nitrogen) 4 ALT (alanine aminotransferase)

2 Creatinine is the best indicator of renal function. Creatinine is a waste product of the skeletal muscles and is excreted through the kidneys. In renal failure, the kidneys are unable to excrete creatinine, leading to a serum level greater than the normal range of 0.2 to 1. 0 ml/dL. Potassium excretion and regulation is impaired in acute renal failure, and potassium may therefore be increased. However, potassium may be increased for reasons other than renal disease, whereas increased creatinine is specific to renal disease. Blood urea nitrogen (BUN) is also used to measure kidney function, but other disorders such as dehydration may cause an increase in BUN. Alanine aminotransferase (ALT) is related to liver dysfunction, not renal dysfunction.

A patient has a prescription to receive D5W with 20 mEq KCl/L at 100 mL/hour. The nurse should select which solution from the intravenous supply cart? 1 5% dextrose lactated Ringer's solution with 20 mEq of KCl 2 5% dextrose in water with 20 mEq of KCl 3 5% dextrose in 0.45% sodium chloride with 20 mEq of KCl 4 5% dextrose in 0.9% sodium chloride with 20 mEq of KCl

2 D5W stands for 5% dextrose in water, which is different than normal saline, half normal saline, or lactated Ringer's.

The nurse prepares to deliver an electrical shock to a patient in a cardiac crisis. The nurse knows that defibrillation differs from synchronized cardioversion in which of these aspects? 1 The patient will be sedated before defibrillation is initiated. 2 Defibrillation is the treatment of choice to end ventricular fibrillation. 3 Synchronized cardioversion is indicated to treat atrial bradydysrhythmias. 4 Defibrillation is synchronized to deliver a shock during the QRS complex.

2 Defibrillation is the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia. Synchronized cardioversion is the therapy of choice for the patient with hemodynamically unstable ventricular or supraventricular tachydysrhythmias. Defibrillation is not synchronized to deliver a shock during the QRS complex, nor is the patient sedated for defibrillation (a patient in ventricular tachycardia [VT] or pulseless VT will generally be unconscious).

The nurse assesses a patient with diabetes insipidus. The most important assessment finding is an increase in: 1 Temperature 2 Urine output 3 Serum glucose 4 Blood pressure

2 Diabetes insipidus is a disorder of the posterior pituitary gland that results in a deficiency of antidiuretic hormone, which in turn causes the kidneys to be unable to reabsorb water. This deficiency leads to increased urine output as a primary clinical manifestation of the disorder. Without treatment, an affected individual can become severely dehydrated and experience hypovolemic shock. As diabetes insipidus progresses, the individual may experience hypotension; however, temperature and serum glucose level are usually not affected.

The nurse is caring for a patient newly diagnosed with human immunodeficiency virus (HIV). The patient asks what would determine the actual development of acquired immunodeficiency syndrome (AIDS). The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? 1 Presence of HIV antibodies 2 CD4+ T cell count below 200/µL 3 Presence of oral hairy leukoplakia 4 White blood cell (WBC) count below 5000/µL

2 Diagnostic criteria for AIDS include a CD4+ T cell count below 200/µL or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The presence of HIV antibodies or oral hairy leukoplakia or WBC count below 5000/µL may be found in patients with HIV disease, but do not define the advancement of HIV infection to AIDS.

The nurse is explaining the stages of cancer development to a support group of cancer survivor families. Which of these is a characteristic of the promotion stage in the development of cancer? 1 Mutation of the cell's genetic structure. 2 A period of latency before clinical detection of cancer. 3 An irreversible steady growth facilitated by carcinogens. 4 Proliferation of cancer cells in spite of host control mechanisms.

2 During the promotion stage, a period of time known as the latent period, ranging from 1 to 40 years elapses between the initial genetic alteration and the actual clinical evidence of cancer. During the promotion stage, development of cancer is characterized by the reversible proliferation of the altered cells. The initiation stage of cancer development is characterized by mutation of the cell's genetic structure. Proliferation of cancer cells occurs during the third stage of cancer development, known as the progression stage.

The nurse provides discharge instructions to a patient with newly diagnosed cirrhosis. Which statement made by the patient indicates the need for further teaching? 1 "I should take frequent rest periods." 2 "I can eat anything that appeals to me." 3 "I can do without my glass of wine with dinner." 4 "I should take only medications that have been prescribed."

2 Even though a low-protein diet has been questioned in the treatment of patients with cirrhosis, it remains in use. In light of this, it is incorrect for the patient to say that he may eat anything. Patients with cirrhosis must also avoid alcohol. Frequent rest and limitation of medications to those that have been prescribed are appropriate resolutions in a newly diagnosed case of cirrhosis and therefore do not indicate the need for further teaching.

Which nursing intervention is most important for a patient with diabetes insipidus? 1 Providing dietary education 2 Monitoring fluid intake and output 3 Assessing for constipation every day 4 Obtaining a fingerstick blood glucose level

2 Polyuria and polydipsia are the major clinical manifestations of diabetes insipidus. Therefore strict monitoring of fluid intake and output is a priority nursing intervention. Diet education and fingerstick blood glucose measurements are not high-priority interventions for diabetes insipidus. Constipation can be a secondary problem as a result of dehydration.

Fluid resuscitation is an important intervention in burn patients. The nurse recognizes that what fluid is recommended for the first 24 hours after a burn? 1 1 to 2 mL lactated Ringer's/kg/%TBSA burned 2 2 to 4 mL lactated Ringer's/kg/%TBSA burned 3 6 to 8 mL lactated Ringer's/kg/%TBSA burned 4 8 to 10 mL lactated Ringer's/kg/%TBSA burned

2 Fluid resuscitation is an important intervention in burn management. It helps to replenish the fluid loss caused by burns and maintain the fluid and electrolyte balance. The fluid recommendation for the first 24 hours is 2-4 mL lactated Ringer's/kg/%TBSA burned. A fluid volume of 1-2 mL lactated Ringer's/kg/%TBSA burned would be inadequate to meet the patient's requirement. Volumes of 6-8 mL lactated Ringer's/kg/%TBSA burned and 8-10 mL lactated Ringer's/kg/%TBSA burned may cause fluid overload.

After a successful organ transplant, a patient began receiving immunosuppressive therapy, specifically tacrolimus (Prograf), methylprednisolone (Solu-Medrol), and mycophenolate mofetil (CellCept). Which food should the nurse instruct the patient to avoid during this therapy? 1 Jackfruit 2 Grapefruit 3 Dragon fruit 4 Passion fruit

2 Grapefruit contains a chemical substance that interferes with the metabolism of tacrolimus, causing drug toxicity events. Jackfruit, dragon fruit, and passion fruit do not interfere with the metabolism of these medications.

A 75-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, has no energy or appetite, and does not seem to care about anything. He also has been getting up more at night to urinate. Which complication of cancer is this most likely caused by? 1 Hypokalemia 2 Hypercalcemia 3 Tumor lysis syndrome 4 Spinal cord compression

2 Hypercalcemia can occur with multiple myeloma. The primary manifestations of hypercalcemia include apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea, and vomiting. Serum levels of calcium in excess of 12 mg/dL (3 mmol/L) often produce symptoms, and significant calcium elevations can be life threatening. The symptoms are not indicative of tumor lysis syndrome, spinal cord compression, or hypokalemia.

A patient with anemia presents with a heart rate of 120 beats per minute. What should the nurse document the heart rate as? 1 Bradycardic 2 Tachycardic 3 Hypertensive 4 Hypotensive

2 If a patient is tachycardic, the heart rate is above 100 beats per minute, which may occur in anemic patients as a compensatory mechanism to increase cardiac output. If a patient is bradycardic, the heart rate is below 60 beats per minute. Hypertensive and hypotensive refer to blood pressure readings, not the heart rate

A patient has been admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse. Laboratory results are significant for an alanine aminotransferase (ALT) of 198 IU/L and aspartate transaminase (AST) of 224 IU/L. Which diagnosis does the nurse attribute these findings to? 1 Diabetes mellitus 2 Alcohol abuse 3 Malnutrition 4 Osteomyelitis

2 In the patient with alcohol abuse, liver disease could develop as a complication, increasing the liver function tests above the normal levels. Normal ALT range is 7--56 IU/L and normal AST range is 5--40 IU/L. Diabetes would result in elevated blood sugar levels. Malnutrition would be evidenced by low protein levels. Osteomyelitis is an infection of the bone, which would result in an elevated white blood cell count.

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention should the nurse expect to include in the patient's plan of care? 1 Immediately start enteral feeding to prevent malnutrition 2 Insert a nasogastric (NG) tube and maintain nothing by mouth (NPO) status to allow the pancreas to rest 3 Initiate early prophylactic antibiotic therapy to prevent infection 4 Administer acetaminophen (Tylenol) every four hours for pain relief

2 Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. Enteral feedings will be used only for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is needed only with acute necrotizing pancreatitis and signs of infection. The pain will be treated with IV morphine because of the NPO status.

The nurse anticipates that the typical fluid replacement for the patient experiencing hypovolemic shock to be which of the following? 1 Dextran 2 0.9% NaCl 3 0.45% saline 4 5% dextrose in 0.45% saline

2 Isotonic saline (0.9% NaCl) may be used when a patient has experienced both fluid and sodium losses or as vascular fluid replacement in hypovolemic shock. The nurse would not administer 0.45% saline, 5% dextrose in 0.45% saline, or dextran, as these are not appropriate for fluid replacement in hypovolemic shock.

A nurse is teaching a patient newly diagnosed with Addison's disease about safety related to the disease. What should the nurse include in the teaching? 1 Maintaining an active lifestyle. 2 Wearing a Medic Alert bracelet. 3 Avoiding stressors, such as infection. 4 Keeping excess weight to a minimum.

2 It is critical that the patient wear an identification bracelet (Medic Alert) and carry a wallet card stating the patient has Addison's disease so that appropriate therapy can be initiated in case of an emergency. Maintaining an active lifestyle would not promote safety. Avoiding stressors would not be a reasonable expectation, but teaching the patient how to manage his or her disease during times of stress would be. The patient with Addison's disease is unable to tolerate physical or emotional stress without additional exogenous corticosteroids. Patients with Addison's disease are usually thin, not with excess weight.

Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse? 1 A 50-year-old white female with hypertension 2 A 61-year-old Native-American male with diabetes 3 A 40-year-old Hispanic female with cardiovascular disease 4 A 28-year-old African-American female with a urinary tract infection

2 It is especially important that the nurse should teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest and Native Americans with diabetes develop CKD six times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. African Americans have the highest rate of CKD because hypertension is increased significantly in African Americans. A urinary tract infection (UTI) will not cause CKD unless it is not treated or occurs recurrently.

The nurse is administering a vesicant chemotherapy agent to a patient who has colon cancer. During rounds, the nurse notes that the intravenous site is reddened and swollen, and the patient complains that it is painful. What is the first action the nurse will take? 1 Slow the infusion rate. 2 Turn off the infusion. 3 Check the patient's vital signs. 4 Notify the primary health care provider.

2 It is extremely important to monitor for and promptly recognize symptoms associated with extravasation of a vesicant and to take immediate action if it occurs. Immediately turn off the infusion and follow protocols for drug-specific extravasation procedures to minimize further tissue damage. It is not appropriate to slow the infusion rate. The health care provider should be notified, and vital signs checked, but they are not the first action that should be taken.

The nurse has the following tasks to perform. Which is an appropriate task to delegate to the unlicensed assistive personnel (UAP)? 1 Document intake and output on the patient performing bedside peritoneal dialysis 2 Obtain a finger stick blood sugar on the patient receiving hemodialysis 3 Ambulate the patient who is postoperative day one following a right-sided nephrectomy 4 Report the patient's potassium level of 5.2 to the primary health care provider

2 It is within the scope of practice of the UAP to obtain a finger stick blood glucose level. It is not within the UAP scope of practice to assess the intake and output during a peritoneal dialysis exchange. The patient postoperative day one will need a nursing assessment on his or her ability to ambulate, as well as a pain assessment. UAP do not report any results to health care providers.

Which strategy is most important for a nurse to include when planning care for a patient who has leukopenia? 1 Restricting all visitors 2 Placing the patient in a private room 3 Advising the patient to use only an electric shaver 4 Wearing a gown and gloves when in direct contact with the patient

2 Leukopenia is the reduction in the number of leukocytes in the blood. This leaves a patient prone to infection. The risk of infection can be reduced by placing a patient in a private room. Restriction of all visitors is not necessary; however, visitors with signs and symptoms of infections, such as a cough or fever, should be restricted. Use of an electric shaver would be recommended for a patient taking anticoagulants but is not required for this condition. Wearing a gown and gloves when in direct contact with the patient is not necessary; however, meticulous hand hygiene is a must. If the patient is in protective isolation, a mask will need to be worn.

The nurse is caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should be withheld until consulting with the health care provider? 1 Antibiotics 2 Loop diuretics 3 Bronchodilators 4 Antihypertensives

2 Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus, administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing health care provider should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

Which nursing intervention is most appropriate when caring for a patient with dehydration? 1 Auscultate lung sounds every two hours. 2 Monitor daily weight and intake and output. 3 Monitor diastolic blood pressure for increases. 4 Encourage the patient to reduce sodium intake.

2 Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water.

The patient who is two days postoperative ileal conduit loop informs the nurse that there is mucus in the urine. Which is the correct response by the nurse? 1 "This is because of your lack of fluid intake; you will need to increase your fluids." 2 "This is a normal occurrence." 3 "Let me call the health care provider to check on the outflow of your stoma." 4 "We will need to catheterize your stoma to remove the mucus."

2 Mucus is a normal production of the intestinal liner. This will not cause any disruption in flow of the urine. Mucus in the urine is not caused by a decrease in fluid intake. It is not necessary for the health care provider to assess the stoma, as this is a normal finding. Catheterizing the stoma will not remove the mucus.

Which cytokine is used in the treatment of multiple sclerosis? 1 Interferon-alpha 2 Interferon-beta 3 Interleukin-2 4 Interleukin-11

2 Multiple sclerosis is associated with inflammation and demyelination of the neurons in the brain and the spinal cord. Interferon-beta prevents inflammation and demyelination of neurons and used in the treatment of multiple sclerosis. Interferon-alpha is used in the treatment of hepatitis B and C, malignant melanoma, and renal cell carcinoma. Interleukin-2 is used in the treatment of metastatic melanoma and metastatic renal cell carcinoma. Interleukin-11 prevents thrombocytopenia after chemotherapy.

Upon taking a lipid-lowering medication for hyperlipidemia, a patient reports muscle pain. The nurse notes the patient has elevated liver enzymes and creatine kinase levels. It is most likely that which lipid-lowering medication was taken by the patient? 1 Niacin (Nicobid) 2 Simvastatin (Zocor) 3 Gemfibrozil (Lopid) 4 Colestipol (Colestid)

2 Muscle pain and elevated creatine kinase levels are manifestations of rhabdomyolysis. Elevated liver enzymes and rhabdomyolysis are adverse effects of statin drugs like Simvastatin (Zocor). Side effects of Niacin (Nicobid) include pruritus and flushing. High doses of this drug may cause decreased liver function. Gemfibrozil (Lopid) is a fibric acid derivative that can cause rhabdomyolysis when given with a statin drug. Colestipol (Colestid) is a bile-acid sequestrant drug. This drug does not have any major adverse effects except that it lowers the absorption of drugs such as warfarin, digoxin, and thiazide diuretics. Colestipol is not related to rhabdomyolysis.

A nurse reviews the laboratory results of a patient. The arterial blood gas (ABG) values are: pH 7.30; PaCO2 25 mm Hg, and bicarbonate (HCO3-) 16mEq/L. What is the correct interpretation of the values given? 1 Respiratory acidosis 2 Metabolic acidosis 3 Metabolic alkalosis 4 Respiratory alkalosis

2 Normal ABG values fall in the range of pH 7.35-7.45, PaCO2 35-45 mm Hg, and HCO3-22-26 mEq/L. Bicarbonate and pH values are less than the normal values and indicate metabolic acidosis. A pH value less than 7.35 and low PaCO2 indicates respiratory acidosis. Metabolic acidosis is indicated by a low pH and low bicarbonate levels. Respiratory alkalosis is indicated by decreased PaCO2. In Metabolic conditions, the pH and the HCO3 go in the same direction. The PaCO2 may also go in the same direction.

Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect? 1 Decreased hematocrit and diuresis 2 Decreased serum creatinine and weight loss 3 Increased potassium level and improved appetite 4 Decreased white blood cell count and diaphoresis

2 One of the main purposes of hemodialysis is removal of creatinine, other waste products, and water. Fluid loss may be measured by weighing the patient before and after the dialysis treatment and also by measuring the serum creatinine. The other answer options are inaccurate and/or incomplete. Hemodialysis will decrease potassium. It may also increase hematocrit and improve appetite. Hemodialysis will not produce diuresis, and has no direct effect on WBC count or diaphoresis.

The nurse providing care for a patient with suspected cancer recalls that the only diagnostic procedure that is definitive for a diagnosis of cancer is: 1 MRI 2 Biopsy 3 CT scan 4 Tumor marker

2 Only a biopsy is a definitive means of diagnosing cancer, because it actually identifies the pathological cells. Many tests, such as MRI, CT scan, and tumor markers, are indicative of cancer, but they do not confirm the presence of cancer cells as examination of a specimen obtained by biopsy does.

he nurse is performing an assessment on a newly admitted patient who was brought to the emergency department with complaints of chest pain. Which assessment data would indicate that the patient has a stable angina? 1 The patient developed chest pain while sitting and watching television 2 Pain developed when the patient was jogging and subsided now 3 The patient developed chest pain shortly after going to bed 4 Pain starts approximately the same time every day without regard to activity level

2 Pain of stable angina is precipitated by increased demand of myocardial muscle for oxygen that is happening with exercising or other activity and subsides with rest in 5 to 15 minutes. Prinzmetal's angina (variant angina) occurs at rest. Nocturnal angina occurs when patient is supine in bed. Prinzmetal's angina (variant angina) is characterized by a pain at the same time of the day

The nurse is performing an assessment on a newly admitted patient who was brought to the emergency department with complaints of chest pain. Which assessment data would indicate that the patient has a stable angina? 1 The patient developed chest pain while sitting and watching television 2 Pain developed when the patient was jogging and subsided now 3 The patient developed chest pain shortly after going to bed 4 Pain starts approximately the same time every day without regard to activity level

2 Pain of stable angina is precipitated by increased demand of myocardial muscle for oxygen that is happening with exercising or other activity and subsides with rest in 5 to 15 minutes. Prinzmetal's angina (variant angina) occurs at rest. Nocturnal angina occurs when patient is supine in bed. Prinzmetal's angina (variant angina) is characterized by a pain at the same time of the day.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? 1 Prevent all oral intake 2 Control abdominal pain 3 Provide enteral feedings 4 Avoid dietary cholesterol

2 Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. Nothing by mouth status may be needed if the patient will have surgery, but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed and avoiding dietary cholesterol is not used to treat cholelithiasis.

The nurse is caring for a patient with chronic kidney disease who is undergoing hemodialysis. What is an appropriate diet for this patient? 1 High protein and low calcium 2 Low protein and low potassium 3 High protein and high potassium 4 Low protein and high phosphorus

2 Patients with chronic kidney disease undergoing hemodialysis should consume a diet low in protein and potassium. Calcium needs to be maintained in the diet to help prevent hyperphosphatemia. High protein should be avoided because it causes uremic toxicity. High potassium in the diet needs to be avoided because the increased serum potassium level can result in cardiac disturbances.

The nurse is caring for a patient admitted with heart failure (HF) secondary to dilated cardiomyopathy. In addition to drug therapy, the nurse will anticipate which intervention? 1 Atrioventricular pacemaker 2 Ventricular assist device (VAD) 3 Ventriculomyotomy and myectomy surgery 4 Percutaneous transluminal septal myocardial ablation

2 Patients with dilated cardiomyopathy may benefit from nondrug therapies. A VAD allows the heart to rest and recover from acute HF. It also may serve as a bridge to heart transplantation. Additionally, cardiac resynchronization therapy and an implantable cardioverter-defibrillator are used in appropriate patients. Atrioventricular pacemaker, ventriculomyotomy and myectomy surgery, and percutaneous transluminal septal myocardial ablation are appropriate for hypertrophy cardiomyopathy.

A nurse is caring for a patient with pericardial effusion. Which clinical sign is associated with phrenic nerve compression due to pericardial effusion? 1 Cough 2 Hiccups 3 Dyspnea 4 Hoarseness of voice

2 Pericardial effusion can cause compression of nearby structures. Phrenic nerve compression causes hiccups. In pericardial effusion, cough and dyspnea occur due to compression of the pulmonary tissue. Hoarseness of the voice is due to compression of the laryngeal nerve.

The nurse was stuck accidently with a needle used on a human immunodeficiency virus (HIV)-positive patient. After reporting this, what care should this nurse first receive? 1 Personal protective equipment 2 Combination antiretroviral therapy 3 Counseling to report blood exposures 4 A negative evaluation by the manager

2 Postexposure prophylaxis with combination antiretroviral therapy can decrease significantly the risk of infection. Personal protective equipment should be available, although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed, but would not occur first.

The nurse notes that a patient with a serum potassium of 2. 8 mEq/L is at highest risk for: 1 Metabolic alkalosis 2 Dysrhythmias 3 Acute renal failure 4 Malignant hypertension

2 Potassium exerts a direct effect on the excitability of cardiac muscle tissue. Therefore an increased or low serum level of potassium can alter cardiac function and heart rhythm, resulting in dysrhythmias. Acute renal failure is not a complication of hypokalemia, but it may be seen with hyperkalemia. Metabolic alkalosis and malignant hypertension are not associated with hypokalemia.

A patient has renal failure. The nurse, reviewing the lab results, recognizes which finding as indicative of the diminished renal function associated with the diagnosis? 1 Hypokalemia 2 Increased serum urea and serum creatinine 3 Anemia and decreased blood urea nitrogen 4 Increased serum albumin and hyperkalemia

2 Renal failure, whether acute or chronic, causes an increase in serum urea, creatinine, and blood urea nitrogen. Renal failure may also cause hyperkalemia and anemia and decrease serum albumin. However, it does not cause decreased blood urea nitrogen or increased serum albumin.

A nurse has identified a group of people who are at risk for developing coronary artery disease. To prevent atherosclerosis, the nurse advises a reduction in salt consumption. How does salt consumption increase the risk of developing atherosclerosis? 1 It causes hormonal imbalances 2 It causes water retention 3 It increases the fat levels in the body 4 It increases homocysteine levels in the body

2 Salt contains sodium, which causes water retention in the body and thus hypertension. The shearing stress due to elevated blood pressure causes endothelial injury. This makes the blood vessels more susceptible to develop atherosclerosis. Hormonal changes, hyperlipidemia, and high homocysteine levels also contribute to atherosclerosis but are not caused by increased salt intake. Changes in the hormonal levels like a decrease in estrogen levels can increase the risk of atherosclerosis. Hyperlipidemia is a major predisposing factor for the development of atherosclerosis. Homocysteine contributes to atherosclerosis by damaging the inner lining of blood vessels, promoting plaque buildup, and altering the clotting mechanism to make clots more likely to occur.

A nurse is assessing a patient diagnosed with Hodgkin's lymphoma. The patient reports fever, night sweats, and weight loss. On examination, the nurse finds that the lymph nodes above and below the diaphragm are involved. What clinical stage of the patient's disease do these symptoms indicate in this patient? 1 Stage IIIA 2 Stage IIIB 3 Stage IVA 4 Stage IVB

2 Since lymph nodes both above and below the diaphragm are involved, the patient is in Stage III of the disease. Letter A indicates the absence of systemic symptoms and letter B indicates their presence. As the patient presents with systemic symptoms such as fever, night sweats, and weight loss, the patient is in Stage IIIB. If the patient did not have any systemic symptoms, the stage of the disease would have been Stage IIIA. In Stage IV, other internal organs also get involved apart from the diaphragm. Stages IVA and IVB indicate the absence and presence of systemic symptoms respectively.

A 33-year-old patient recently has been diagnosed with stage II cervical cancer. The nurse should understand what about the patient's cancer? 1 It is in situ 2 It has metastasized 3 It has spread locally 4 It has spread extensively

2 Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ. Stage I denotes tumor limited to the tissue of origin with localized tumor growth. Stage III denotes extensive local and regional spread and stage IV denotes metastasis.

A primary health care provider has prescribed nonemergent synchronized cardioversion for a patient. When teaching the patient, which statement by a nurse indicates an understanding of the procedure? 1 "A shock will be delivered on the P wave." 2 "Cardioversion is designed to stop the heart momentarily." 3 "We will give a medicine called adenosine before the procedure to sedate you." 4 "After cardioversion, medications to regulate the heart rhythm are no longer needed."

2 Synchronized cardioversion is designed to send an electrical shock through the heart on the R wave. This stops the heart momentarily, allowing it to convert back to a normal sinus rhythm. In a nonemergent situation, sedation medicine is given before the procedure because of the pain of the electrical current passing through the chest wall. Postcardioversion, the patient will most likely be placed on cardiac medications to prevent recurrence of the tachyarrhythmia. In nonemergent cases, sedation is given for the patient's comfort. Adenosine is an intravenous medication designed to treat paroxysmal supraventricular tachycardia (PSVT) by slowing the conduction through the AV node, allowing the heart to return to a normal rhythm, but it has no sedative effects.

When teaching a patient about physical activity guidelines following acute coronary syndrome, the nurse recommends isotonic (static) activities. What should isotonic activities require according to the FITT (frequency, intensity, type, and time) formula? 1 An increase in heart rate of at least 20 beats/minute over the resting heart rate 2 A steady load on the heart and gradual increase in time and intensity 3 A rapid increase in heart rate and blood pressure 4 A stretching of muscles but no increase in heart rate and blood pressure

2 The FITT formula recommends isotonic activities that require a steady load on the heart, with careful attention not to increase the heart rate by more than 20 beats/minute over the resting heart rate, and that gradually increase in time and intensity. The FITT formula recommends limited isometric (dynamic) activities that rapidly increase the heart and blood pressure, but there is no FITT guideline that limits patients to stretching exercises only.

The patient is admitted with metabolic acidosis. Which system is not functioning normally? 1 Buffer system 2 Kidney system 3 Hormone system 4 Respiratory system

2 When the patient has metabolic acidosis , the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes hydrochloric acid by forming a weak acid. The hormone system is not related directly to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen then is buffered by the hemoglobin.

A nurse assessing a patient with pancreatitis suspects the presence of Grey Turner sign when the patient exhibits: 1 Jaundice of the sclera 2 Bluish discoloration of the flank area 3 Bluish discoloration of the periumbilical area 4 Left abdominal pain that occurs with movement

2 The Grey Turner sign includes a bluish discoloration, or ecchymosis, on the left or right flank area, the result of internal bleeding caused by pancreatitis. Jaundice of the sclera is associated with liver disorders and with increased serum bilirubin. Bluish discoloration of the periumbilical area is also seen in bleeding associated with pancreatitis and is known as the Cullen sign. Left abdominal pain that occurs with movement may be seen with pancreatitis but is not associated with the Grey Turner sign

A nurse is teaching a patient about strategies to prevent angina caused by coronary artery disease. The nurse tells the patient to avoid heavy meals as they can further compromise the blood supply to the heart. What is the most likely reason for the nurse to give such advice? 1 Eating a heavy meal can cause physical inactivity, which could precipitate angina. 2 Eating a heavy meal would divert more blood to the gastrointestinal system. 3 Heavy meals cause obesity and increase the susceptibility to myocardial ischemia. 4 Heavy meals cause excessive heat production, which leads to peripheral vasodilation.

2 The digestive system requires more blood supply for a longer period of time to digest heavy meals. Therefore blood is diverted to the gastrointestinal system, which causes reduced blood supply to the myocardium. Physical inactivity does not cause an anginal attack; angina can be precipitated by physical exertion. Eating heavy meals causes obesity in due course of time, and this increases the susceptibility of an individual to have coronary artery disease. This is not a valid reason here, as the patient already has coronary artery disease. Eating heavy meals does not cause peripheral pooling of blood.

A patient returns to the unit after having a stent inserted into the coronary artery. What should the nurse do first to assess patency of the femoral artery? 1 Palpate the insertion site for induration 2 Assess peripheral pulses in the right leg 3 Inspect the patient's right side and back 4 Compare the color of the left and right legs

2 The first action the nurse should take is to assess peripheral pulses in the right leg. If a pulse is absent, the artery is not patent, meaning there is minimal or no blood flow to the artery. Inspecting the patient's right side and back can be used to assess an intact artery, but the blood may take a long time to pool into the tissues. Palpating the insertion site for induration and comparing the color of the legs does is not the best method to assess patency of the artery.

A nurse is caring for a neutropenic patient admitted to the health care facility with a febrile episode. Which priority intervention would the nurse perform first? 1 Obtain blood cultures from two sites. 2 Administer a broad spectrum IV antibiotic. 3 Administer an oral antibiotic. 4 Obtain cultures of the throat.

2 The first nursing intervention for a febrile neutropenic patient is to administer a broad spectrum antibiotic by IV route within one hour. Because of the rapid lethal effects of infection, this should be done even before obtaining cultures to determine a specific causative organism. Administration of a broad spectrum antibiotic by the IV route is preferred to oral antibiotic for initial management because it is the faster administration method.

A human immunodeficiency virus (HIV)-infected patient is about to receive treatment with antiretroviral drugs. Which statement by the nurse reflects a correct understanding of the purpose of these drugs? 1 "Antiretroviral drugs can cure HIV infection." 2 "These drugs work by decreasing the viral load." 3 "Antiretroviral drugs will prevent opportunistic diseases." 4 "These drugs only work in the initial replication stage of the virus."

2 The goals of drug therapy in HIV infection are to decrease the viral load, maintain or raise CD4+ T cell counts, and delay onset of HIV-related symptoms and opportunistic diseases. Antiretroviral drugs do not cure HIV infection nor do they prevent opportunistic diseases. Drugs used to treat HIV work at various points in the HIV replication cycle.

A nurse planning care for a patient with acute renal failure recognizes that the interventions of highest priority are directly related to: 1 Ineffective coping 2 Excess fluid volume 3 Impaired gas exchange 4 Imbalanced nutrition: less than body requirements

2 The issue of excess fluid volume is the primary problem of acute renal failure and the highest priority for the nurse in this situation. The major problem with acute renal failure is altered fluid and electrolyte balance, which, if not managed, can lead to permanent renal damage, cardiac complications, and death. The nursing diagnosis of Ineffective Coping is due to the acute severity of the illness. The nursing diagnosis of Impaired Gas Exchange is related to Excess Fluid Volume, such as in the development of pulmonary edema. The nursing diagnosis of Imbalanced Nutrition, less than body requirements, is due to a decrease in appetite as a result of the acute renal failure.

The patient recently diagnosed with coronary artery disease (CAD) asks the nurse: "What caused my problem?" Which response by the nurse is the most appropriate? 1 "The heart is not able to pump effectively." 2 "Fatty deposits on the walls of coronary arteries." 3 "Low oxygen saturation of your blood." 4 "Orthostatic hypotension caused this problem."

2 The major cause of CAD is an atherosclerosis that is manifested by fatty deposits on the walls of coronary arteries. Decrease in pumping action of the heart will result in congestive heart failure (CHF). Low oxygen saturation of the blood is a result of respiratory problems. Hypertension, not orthostatic hypotension, will predispose a patient to development of CAD.

The nurse assessing a patient with mitral valve stenosis finds symptoms primarily associated with what cardiac change? 1 Diminished cardiac output 2 Improper emptying of the left atrium 3 Increased pressure in the left ventricle 4 Inadequate filling of the right ventricle

2 The mitral valve prevents backward flow into the pulmonary vein. If the valve does not close, pulmonary circulation is compromised and the left atrium will not empty. Decreased cardiac output may be influenced by mitral valve stenosis; however, it would be more related to mitral valve regurgitation. Increased left ventricular pressure may be seen with aortic stenosis. Inadequate filling of the right ventricle may be due to atrial fibrillation or atrial flutter.

The nurse is caring for a patient who underwent a transsphenoidal hypophysectomy. What is the most important nursing intervention for this patient? 1 Place the patient in a supine position at all times. 2 Monitor pupillary response and speech patterns. 3 Perform mouth care every 12 hours. 4 Test any clear nasal drainage for potassium.

2 The nurse should monitor the pupillary response, speech patterns, and extremity strength to detect neurologic complications. The nurse should ensure the head of the bed is elevated at all times to a 30-degree angle to avoid pressure on the sellaturcica and to decrease headaches, a frequent postoperative problem. The nurse must perform mouth care for the patient every 4 hours to keep the surgical area clean and free of debris.The nurse must notify the surgeon and send any clear nasal fluid to the laboratory to test for glucose.

The patient comes to the emergency department with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerostic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? 1 Unstable angina 2 Acute coronary syndrome (ACS) 3 ST segment elevation myocardial infarction (STEMI) 4 Non-ST segment elevation myocardial infarction (NSTEMI)

2 The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as STEMI.

The patient with end stage renal disease (ESRD) has decided to terminate dialysis treatments. Which is the best response by the nurse? 1 "I respect your decision. Would you like me to ask the health care provider for a palliative care consult?" 2 "I respect your decision, but believe you need to discuss options with your health care provider. Would you like me to page the health care provider to come speak with you?" 3 "You cannot stop now, you have so much to live for." 4 "Are you sure this is the right decision? How about if I ask a psychiatrist to come speak with you."

2 The patient has the right to end treatment. This decision must be made with the health care provider. Telling the patient he or she has too much to live for may be giving false reassurance. The nurse has no right questioning the decision or calling a psychiatrist at this point.

A nurse is admitting a patient with heart failure. The patient has the following electrocardiogram (ECG) tracing, is experiencing chest pain, shortness of breath, and has a blood pressure of 70/40. What would be an appropriate intervention for this patient? (two p waves after QRS) 1 Start a lidocaine drip 2 Transcutaneous pacing 3 Place in Trendelenburg position 4 Administer a 500 mL bolus of normal saline

2 The patient is in a third degree atrioventricular (AV) block and is requiring some type of pacemaker. Lidocaine is contraindicated because it further decreases ventricular conduction. Placing the patient in a Trendelenburg position would increase the work of breathing and increase venous return, which could worsen the patient's condition. Administration of fluid boluses in heart failure patients would cause worsening symptoms.

The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side of the chest. Which statement by the patient indicates to the nurse that the patient needs more teaching? 1 "I will call the cardiologist if my ICD fires." 2 "I cannot fly because it will damage the ICD." 3 "I cannot move my left arm until it is approved." 4 "I cannot drive until my cardiologist says it is okay."

2 The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that the Transportation Security Administration should be informed about the ICD because it may set off the metal detector, and if a hand-held screening wand is used it should not be placed directly over the ICD. "I will call the cardiologist if my ICD fires," "I cannot move my left arm until it is approved," and "I cannot drive until my cardiologist says it is okay" indicate the patient understands the teaching.

A patient with chronic kidney disease is prescribed regular peritoneal dialysis (PD). What should the nurse inform the patient while teaching about PD? 1 Avoid high-protein diets. 2 Take potassium supplements. 3 Restrict fluid intake, as in hemodialysis. 4 Avoid powdered breakfast drinks

2 The patient undergoing regular peritoneal dialysis (PD) does not need to restrict potassium intake; instead, this patient may be prescribed oral potassium supplementation because of hypokalemia caused by dialysis. The patient need not restrict protein diet or fluid intake. The patient should include enough protein in diet to compensate for loss of protein in dialysate. The patient may even take liquid or powdered breakfast drinks in case of inadequate protein intake. Patients on hemodialysis have a more restricted fluid

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What should the nurse place highest priority on initiating interventions to reduce? 1 Thirst 2 Fatigue 3 Headache 4 Abdominal pain

2 The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia

A 22-year-old female patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? 1 Brentuximab vedotin (Adcetris) 2 Two to four cycles of doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine (ABVD) 3 Four to six cycles of ABVD 4 Bleomycin, etoposide, dosorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone (BEACOPP)

2 The patient with stage-favorable prognosis early-stage Hodgkin's lymphoma will receive two to four cycles of ABVD. Brentuximab vedotin is a newer agent that will be used to treat patients who have relapsed or refractory disease. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP.

A patient complains of suddenly feeling dizzy. The ECG tracing is the following. A nurse understands the dizziness is most likely a result of:12676323 1 Inner ear infection 2 Decreased cardiac output 3 Digoxin (Lanoxin) toxicity 4 Rapid metoprolol (Lopressor) administration

2 The patient's ECG tracing is a paroxysmal supraventricular tachycardia (PSVT). Depending on the rate and duration of PSVT, the patient often experiences symptoms related to decreased cardiac output. The cardiac output drops because of decreased ventricular filling time. Although an inner ear infection can cause dizziness, the ECG tracing is more likely to be the source of the dizziness. Digoxin toxicity can cause dizziness, but most often in the presence of bradycardia. Metoprolol is given to treat hypertension and to decrease the heart rate. Text Reference - p. 795

The nurse is examining the ECG of a patient who has just been admitted with a suspected myocardial infarction (MI). Which ECG change is most indicative of prolonged or complete coronary occlusion? 1 Sinus tachycardia 2 Pathologic Q wave 3 Fibrillatory P waves 4 Prolonged PR interval

2 The presence of a pathologic Q wave, as often accompanies ST segment elevation myocardial infarction (STEMI), is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

What can the nurse do to facilitate cancer prevention for the patient in the promotion stage of cancer development? 1 Teach the patient to exercise daily 2 Teach the patient promoting factors to avoid 3 Tell the patient to have the cancer surgically removed now 4 Teach the patient which vitamins will improve the immune system

2 The promotion stage of cancer is characterized by the reversible proliferation of the altered cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity, cigarette smoking, and alcohol consumption) can reduce the chance of cancer development. Daily exercise and vitamins alone will not prevent cancer . Surgery at this stage may not be possible without a critical mass of cells, and this advice would not be the nurse's role.

The nurse is performing medication teaching to a patient who has been prescribed sublingual (SL) nitroglycerin (NTG) tablets. Which statement by the patient indicates a need for further education? 1 "When I put the tablet under my tongue, I should feel a tingling sensation." 2 "I can take as many tablets as needed until the pain goes away, five minutes apart." 3 "I will need to be careful when I stand up because nitroglycerin can cause dizziness." 4 "If chest pain occurs, I will stop what I'm doing and take one tablet under my tongue."

2 The recommended dose for the patient for whom NTG has been prescribed is one tablet taken SL or one metered spray for symptoms of angina. If symptoms are unchanged or worse after five minutes, the patient should contact the emergency medical services (EMS) system before taking additional NTG. Tell the patient to place an NTG tablet under the tongue and allow it to dissolve. NTG should cause a tingling sensation when administered; otherwise it may be outdated. Warn the patient that a headache, dizziness, or flushing may occur. Caution the patient to change positions slowly after NTG use because orthostatic hypotension may occur.

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What nursing care is the priority for this patient after this procedure? 1 Position the patient prone 2 Apply a pressure dressing 3 Administer analgesic for pain 4 Return metal objects to the patient

2 The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure; thus, this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for a magnetic resonance imaging (MRI), not a bone marrow biopsy.

A nurse is admitting a patient with the diagnosis of advanced renal carcinoma. Based upon this diagnosis, the nurse will expect to find what clinical manifestations as the "classic triad" occurring in patients with renal cancer? 1 Fever, chills, flank pain 2 Hematuria, flank pain, palpable mass 3 Hematuria, proteinuria, palpable mass 4 Flank pain, palpable abdominal mass, and proteinuria

2 There are no characteristic early symptoms of renal carcinoma . The classic manifestations of gross hematuria, flank pain, and a palpable mass are those of advanced disease. Fever, chills, and flank pain, and proteinuria are not signs of renal carcinoma.

A nurse reviews a patient's blood gas results: pH 7.15, Pao2 40 mm Hg, Paco2 70 mm Hg, and HCO3 25 mEq/L. The nurse suspects hypoxia and what other condition? 1 Metabolic acidosis 2 Respiratory acidosis 3 Respiratory alkalosis 4 Compensating respiratory acidosis

2 This patient is not breathing effectively and therefore has a buildup of carbon dioxide in the form of carbonic acid. This places the patient in an acidotic state, because the pH is less than 7.35. Metabolic and respiratory alkalosis are therefore eliminated as possibilities. Because the Paco2 is high at 70 mm Hg (normal range is 35 to 45 mm Hg) and the metabolic measure of HCO3 - is normal at 25 mEq/L (normal range is 22 to 28 mEq/L), the patient is in respiratory acidosis. The patient is not compensated, because the HCO3 - is still within normal range. If the HCO3 - were increased, this would be an indication of compensation.

The nurse is caring for a patient with a nephrostomy tube. The tube has stopped draining. After receiving prescriptions, what should the nurse do? 1 Keep the patient on bed rest 2 Use 5 mL of sterile saline to irrigate 3 Use 30 mL of water to gently irrigate 4 Have the patient turn from side to side

2 With a nephrostomy tube, if the tube is occluded and irrigation is prescribed, the nurse should use 5 mL or less of sterile saline to irrigate it gently. The patient with a ureteral catheter may be kept on bed rest after insertion, but this is unrelated to obstruction. Only sterile solutions are used to irrigate any type of urinary catheter. With a suprapubic catheter, the patient should be instructed to turn from side to side to ensure patency.

The nurse is teaching care guidelines to the parent of a child with hypothyroidism. During the follow-up visit, the nurse suspects that the child may be receiving ineffective treatment. Which action of the parent supports the nurse's suspicion? 1 The parent is giving the child fiber-rich food. 2 The parent gives the child a thyroid supplement after meals. 3 The mother gives the child a thyroid supplement each morning. 4 The mother encourages the child to increase activity and exercise.

2 Thyroid supplements should be given on an empty stomach in order to enhance absorption. Therefore, giving thyroid supplements after meals reduces the concentration of medication in the blood. Thyroid supplements may cause constipation, so the nurse recommends that the parent give the child fiber-rich food. Thyroid supplements should be given in the morning for effective treatment. Hypothyroidism causes low metabolic activity, so a gradual increase in activity and exercise will be beneficial for the child.

A nurse finds that a patient has severe diarrhea and may be at risk of fluid volume deficit. After the appropriate prescription by the health care provider, what is the most appropriate nursing intervention to treat fluid deficit in the patient? 1 Administer isotonic sodium chloride 2 Administer lactated Ringer's solution 3 Transfuse blood and blood products 4 Restrict sodium intake in the patient

2 To correct fluid deficit in the patient the nurse would administer lactated Ringer's solution to replace both water and any needed electrolytes. Isotonic normal saline is used when rapid volume replacement is needed. If the fluid deficit has been identified as due to blood loss, then blood can be transfused. Sodium intake should be restricted in case of fluid excess

Which nursing intervention is most important for a patient during the first several days after a myocardial infarction? 1 Determining the patient's ability to tolerate a regular diet 2 Instructing the patient in how to utilize a bedside commode 3 Assisting the patient in turning, coughing, and deep-breathing 4 Encouraging the patient to perform active range-of-motion exercises

2 To prevent complications, such as cardiac rupture and reinfarction, it is important for the patient to cease any unnecessary activity, thereby decreasing cardiac demands. Straining while having a bowel movement on a bedpan causes an unnecessary increase in cardiac workload. Therefore allowing a patient to assume a normal elimination position on a bedside commode will facilitate an easy bowel movement and conservation of energy. Within the first several days after myocardial infarction (MI), patients may usually return to a regular diet with the addition of a stool softener to ease the passage of stool. Breathing exercises are important in preventing pneumonia while activity is diminished; however, this is still not as important as the bedside commode. Activity is minimized for the first several days after an MI; this includes avoiding active range-of-motion exercises

Certain types of tumor cells secrete substances that may be detected in the blood. When their concentrations in the serum are increased, these substances may be used to diagnose certain types of cancer. The nurse recalls that these substances are known as: 1 Carcinogens 2 Tumor markers 3 Malignant viruses 4 Neoplastic oncogenes

2 Tumor markers are substances secreted by cancerous cells that serve as indicators of malignant cell presence and activity. Carcinogens are cancer-causing agents. Some cancers are linked to viral agents, such as those seen in HIV disease. Neoplastic oncogenes are genes in certain viruses that have the ability to induce a cell to become malignant.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 1 18% 2 22.5% 3 27% 4 36%

2 Using the rule of nines , for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area. Eighteen percent, 27%, and 36% are incorrect calculations.

A patient who has undergone a modified radical mastectomy sees the surgical site for the first time. The patient appears shocked and exclaims, "I look horrible! Will it ever look better?" Which response by the nurse is most appropriate? 1 "Would you like to meet another patient who's had a mastectomy?" 2 "You're shocked by the change in your appearance from the surgery?" 3 "After it heals and you're dressed, you won't even know you've had surgery." 4 "Don't worry. You know that the tumor is gone, and the area will heal very soon."

2 When a patient appears shocked by her appearance after a mastectomy, the nurse should help her express her feelings and offer supportive care. Reflecting the patient's statement will allow her to expand and discuss her feelings. "After it heals" and "Don't worry" diminish the patient's distress regarding having undergone a modified radical mastectomy. "Would you like me to?" is an appropriate statement but does not allow the patient to verbalize her fears and concerns.

A nurse is caring for a patient who is undergoing plasmapheresis for glomerulonephritis. The nurse should be observant for which symptoms indicating citrate toxicity? 1 Sneezing 2 Headache 3 Hypertension 4 Conjunctivitis

2 When caring for a patient undergoing plasmapheresis, the nurse should be observant for headache. Citrate toxicity is a common complication of plasmapheresis because citrate is used as an anticoagulant and may cause hypocalcemia, which in turn manifests as headache, paresthesias, and dizziness. Another common complication of plasmapheresis is hypotension caused by a vasovagal reaction or transient volume changes. Sneezing and conjunctivitis are not manifestations of citrate toxicity but are common symptoms of allergy.

A patient has 20% total body surface area (TBSA) burns from a brush fire. For the past week, the patient's wounds have been debrided and covered with a silver-impregnated dressing. Today the nurse noticed that the partial-thickness burn wounds have been fully debrided. The nurse's priority intervention for wound care at this time would be to 1 Reapply a new dressing without disturbing the wound bed 2 Apply fine-meshed petroleum gauze to the debrided areas 3 Wash the wound aggressively with sterile saline three times a day 4 Apply cool compresses for pain relief in between dressing changes

2 When the partial-thickness burn wounds have been fully debrided, a protective, coarse or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.

The nurse is attending to a patient who will receive a kidney transplant. What information or instruction should the nurse share with the patient to prepare the patient for the transplant? Select all that apply. 1 Production of urine will be delayed after surgery. 2 Lifelong immunosuppressive drugs daily will be required. 3 Symptoms of rejection include a decrease in temperature and blood pressure. 4 Avoid all exercise, work, and sports activities. 5 Transplantation will be performed only if the crossmatching is negative.

2 & 5 Immunosuppressive agents are administered to reduce the immune system's tendency to reject the transplanted organ. A crossmatch uses serum from the recipient mixed with donor lymphocytes to test for any preformed anti-HLA antibodies to the potential donor organ. A negative crossmatch indicates that no preformed antibodies are present, and it is safe to proceed with transplantation. Urine production occurs almost immediately. If the transplant is rejected, the patient may experience a rise in temperature and blood pressure due to fluid retention. Although recreation and exercise are encouraged, strenuous sports activities should be strictly avoided.

Which signs and symptoms would the nurse expect to assess in a patient who is diagnosed with acromegaly? Select all that apply. 1 Fragile skin 2 Increased shoe size 3 Elevated blood glucose 4 Complaint of headaches 5 Increased height and weight

2, 3, 4 Acromegaly is a disorder in which there is increased secretion of growth hormone (GH). Enlargement of the feet and hands occurs as a result of overgrowth of bones and tissue. GH antagonizes the action of insulin, and therefore blood glucose is elevated. Headaches also are common if the increased secretion of GH is caused by a pituitary adenoma, which increases pressure on the optic nerve. The skin becomes thick and leathery. The patient's weight may increase, but there is no change in height because acromegaly occurs after epiphyseal closure.

A nurse is attending to a post renal transplant patient. The nurse finds that the patient's urine output is very high. What are the reasons for this diuresis? Select all that apply. 1 Rejection of the transplanted kidney 2 The new kidney's ability to filter blood urea nitrogen (BUN) 3 The abundance of fluids administered 4 Initial renal tubular dysfunction 5 High blood sugar levels of the patient

2, 3, 4 Diuresis is common after transplantation of the kidneys. The new kidney has an improved ability to filter BUN, which acts as an osmotic diuretic, thus increasing urine output. The fluids given during the surgery may also cause an increase in urine output. Initial renal tubular dysfunction may inhibit the kidney from concentrating the urine normally, which may also lead to increased urine output. Rejection of the kidney leads to decreased or no urine output. High blood sugar levels may increase the urine output, but not drastically.

A nurse is assessing a patient with mitral stenosis. Which findings are likely during the nursing examination? Select all that apply. 1 Syncope 2 Exertional dyspnea 3 Fatigue and palpitations 4 Diastolic murmur at the apex 5 Nausea and vomiting

2, 3, 4 Exertional dyspnea is caused by reduced lung compliance in mitral stenosis. Fatigue and palpitations are present because of atrial fibrillation. A low-pitched diastolic murmur is heard in mitral stenosis; however, it is best heard at the apex using the stethoscope. Syncope, nausea, and vomiting are not seen in patients with mitral stenosis.

When administering intravenous (IV) potassium chloride (KCl) to a patient to correct hypokalemia, which interventions are important? Select all that apply. 1 IV KCl can be added to a hanging IV bag. 2 KCl should never be given via IV push or bolus. 3 KCl must always be diluted before administering. 4 IV site should be regularly assessed for infiltration. 5 IV KCl should be administered at a rate of 50 mEq/h.

2, 3, 4 IV KCl is given to correct hypokalemia. IV KCl should never be given via IV push or as a bolus. IV KCl must never be given in a concentrated form; it should always be diluted before administration. The nurse should check the IV site regularly as KCl can irritate the veins, causing phlebitis and infiltration. The solution should not be added to a hanging IV bag; following this rule lowers the risk of a bolus dose being given. The rate of IV administration of KCl should not exceed 10 to 20 mEq/h. The solution should be administered by infusion pump so that correct doses are administered at the correct rate.

A patient is admitted to the burns ward with deep partial-thickness burns on the hands. What characteristics is the nurse likely to find when performing examination of the wound? Select all that apply. 1 Wounds are painless. 2 Wounds are wet and shiny. 3 Wounds are painful to touch. 4 Wounds appear pink to cherry-red. 5 Wounds appear black and leathery

2, 3, 4 Partial-thickness wounds are wet and shiny due to serous exudates. These wounds are painful to touch due to nerve injury. Wounds appear pink to cherry-red. Wounds are painless in full-thickness burns due to nerve destruction. Wounds appear black and leathery in full-thickness burns, as all skin elements and local nerve endings are destroyed, and coagulation necrosis is present.

The nurse is caring for a patient admitted to the health care facility with acute pericarditis. Which interventions should the nurse perform? Select all that apply. 1 Ensure the patient is supine at all times. 2 Administer antiinflammatory drugs with milk or food. 3 Ensure patient has complete bed rest. 4 Instruct the patient to avoid alcohol. 5 Elevate the head of the bed at meal time only.

2, 3, 4 The nurse should administer antiinflammatory drugs with milk or food. The nurse should ensure complete bed rest for the patient. The nurse should instruct the patient to avoid alcohol to prevent gastrointestinal bleeding. Patients with acute pericarditis experience severe pain when lying supine; hence the head of the bed should be elevated to 45 degrees, and the patient should be provided an overbed table for support when leaning forward.

A patient with cancer of the esophagus presents with weight gain without edema, anorexia, and oliguria. Which nursing measures would help to relieve the patient's symptoms? Select all that apply. 1 Encourage fluid intake. 2 Administer furosemide (Lasix). 3 Administer 0.9% saline solution. 4 Administer 3% sodium chloride solution. 5 Withhold demeclocycline (Declomycin)

2, 3, 4 The presence of weight gain without edema, anorexia, and oliguria in a patient with cancer of the esophagus is suggestive of syndrome of inappropriate antidiuretic hormone (SIADH). It involves increased secretion of antidiuretic hormone (ADH). The management involves administering furosemide in the initial stages to facilitate excretion of excess fluid. Isotonic solutions like 0.9% saline solution are administered in mild cases to prevent dehydration; 3% saline solution is administered in severe cases. Patients should have fluid restrictions. Demeclocycline (Declomycin) is helpful in moderate cases of SIADH.

The nurse is providing education about transmission of human immunodeficiency virus (HIV) for a patient who is infected with the virus to another person. Which of these is a potential method of HIV transmission? Select all that apply. 1 Shaking hands and sharing eating utensils. 2 Unprotected anal or vaginal sexual intercourse. 3 Exposure to HIV-infected blood through needle stick. 4 Sharing of needles, syringes, pipes, and straws during drug use. 5 Transmission from mother to infant during labor and delivery and breastfeeding.

2, 3, 4, & 5 HIV can be transmitted as a result of contact with infected blood, semen, vaginal secretions, or breast milk. Transmission of HIV occurs through sexual intercourse with an infected partner, type of exposure to HIV-infected blood or blood products, and perinatal transmission during pregnancy, at delivery, or through breastfeeding. HIV is not spread through casual contact, such as shaking hands, hugging, or sharing utensils.

The nurse is monitoring a patient who is receiving a transfusion of packed red blood cells (PRBCs). Which of these interventions are appropriate? Select all that apply. 1 Start the infusion at a rate of 5 mL/minute. 2 Check the patient's vital signs after the first 15 minutes. 3 Infuse the blood over two hours, but no longer than four hours. 4 Remain with the patient during the first 15 minutes of blood infusion. 5 Stop the infusion if the patient develops chills, fever, or low back pain.

2, 3, 4, 5 During the first 15 minutes or 50 mL of blood infusion, remain with the patient. If there are any untoward reactions, they are most likely to occur at this time. The rate of infusion during this period should be no more than 2 mL/minute. Most patients not in danger of fluid overload can tolerate the infusion of 1 unit of PRBCs over two hours. The transfusion should not take more than four hours to administer because of the increased risk of bacterial growth in the product once it is out of refrigeration. Chills, fever, low back pain, flushing, tachycardia, dyspnea, tachypnea, and hypotension are some manifestations of an acute hemolytic reaction. The nurse needs to stop the transfusion immediately if signs of a reaction are noted.

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI)? Select all that apply. 1 Flushing 2 Ashen skin 3 Diaphoresis 4 Nausea and vomiting 5 S3 or S4 heart sounds

2, 3, 4, 5 During the initial phase of an MI , catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds

A patient has been prescribed IV potassium chloride (KCl) for the treatment of hypokalemia. What precautions should the nurse take to prevent severe complications related to KCl administration? Select all that apply. 1 Administer KCl as an IV push or as a bolus 2 Turn IV bags containing KCl upside down and upright several times prior to administration 3 Never add KCl to an existing IV bag 4 Dilute KCl before administering 5 Ascertain an adequate urine output prior to administration

2, 3, 4, 5 Severe hypokalemia can be treated by administering KCl. IV bags containing KCl should be inverted several times to ensure dilution of the drug and prevent accidental bolus delivery. Adding KCl to a hanging IV bag may cause accidental bolus delivery and lead to cardiac complications. It can cause severe cardiac complications and so should not be given undiluted. KCl is given to patients who have a urine output of at least 0.5 mL/kg of body weight per hour. This ensures timely clearance of unused potassium. KCl should never be administered as IV bolus or push because it can affect the cardiac function.

The nurse is attending to a patient who is recovering from a full-thickness burn. The nurse understands that the patient is in a hypermetabolic state and needs nutritional support to promote wound healing and prevent malnutrition. What types of food and drinks should the nurse provide to the patient? Select all that apply. 1 Tea 2 Milkshakes 3 Protein powder 4 Low-protein food 5 High-calorie food

2, 3, 5 A patient with burns needs a high-calorie diet to compensate for the energy loss and increased protein intake to avoid malnutrition and delayed healing. Milkshakes have high calories. Protein powder provides high protein. High-caloric food contains calories in large quantities and will help in the patient's recovery. Tea does not provide adequate quantities of calories and proteins. Low-protein food is not advised for a patient with burns, as the demand for proteins is high to promote healing and a faster recovery.

The nurse is planning discharge teaching for a patient after a laser laparoscopic cholecystectomy. The nurse explains to the patient about self-care at home. Which statements of the patient indicate that the patient has understood the discharge teachings? Select all that apply. 1 I cannot bathe or shower for 10 days. 2 I can have normal food that is low in fat. 3 I may have mild shoulder pain for a week. 4 I should have only a liquid diet for the first week. 5 I should not lift heavy weights for a few days.

2, 3, 5 After the procedure, high fiber and low fat should be consumed. Having mild shoulder pain after cholecystectomy is common due to diaphragmatic irritation. After cholecystectomy, it is essential that the patient doesn't lift heavy weights so that abdominal pressure doesn't increase. The patient can bathe and shower normally after a couple of days. The patient doesn't need to follow a liquid diet.

The patient's glomerular filtration rate (GFR) is 15 mL/min. What are the treatment options the nurse would expect the health care provider to discuss with the patient? Select all that apply. 1 Nephrectomy 2 Hemodialysis 3 Peritoneal dialysis 4 Kidney transplant in place of dialysis 5 Continuous ambulatory peritoneal dialysis

2, 3, 5 Any dialysis option would be appropriate for the patient. A nephrectomy is not going to cure the chronic kidney disease, and it is unknown whether the kidney has a tumor or cancer with this question. Kidney placement in place of dialysis at this point is too late. Dialysis needs to begin while awaiting a kidney transplant. Text Reference - p. 1117

A patient with acute kidney injury has been admitted to the hospital, and the nurse is notified that the electrocardiogram (ECG) reading shows tall peaked T waves, ST depression, and QRS widening. What nursing interventions should the nurse perform for this patient to treat hyperkalemia? Select all that apply. 1 Ensure potassium intake of 50mEq/day. 2 Administer regular insulin intravenously. 3 Administer sodium bicarbonate. 4 Administer diuretics as ordered. 5 Administer calcium gluconate intravenously.

2, 3, 5 ECG readings for this patient are indicative of cardiac changes due to hyperkalemia induced by acute kidney injury. Regular insulin, administered intravenously, helps the potassium to move into the cells. Sodium bicarbonate corrects the acidosis and causes the potassium to shift into the cells. Calcium gluconate raises the threshold for excitation, protecting the heart. The potassium intake should be limited to 40mEq/day. Diuretics are not effective in hyperkalemia. Text Reference - p. 1105

A nurse identifies a group of patients who have a high risk of developing infective endocarditis. What instructions should be included when teaching the patients about the prevention of infective endocarditis? Select all that apply. 1 Remain on complete bed rest. 2 Avoid overexertion. 3 Avoid people with cold and flu symptoms. 4 Undergo immunotherapy. 5 Visit a dentist regularly

2, 3, 5 Patients who have a high risk of developing infective endocarditis should not overexert themselves, as this can increase cardiac workload. Such patients should plan rest periods before and after activities to avoid excessive fatigue. Contact with people having cold or flulike symptoms should be avoided to prevent infection. Dental hygiene is very important in preventing infective endocarditis. Regular visits to the dentist would help in maintaining good oral hygiene, thus preventing infection. Bed rest is not recommended unless the patient has fever or heart damage. Modulating the immune response contributes little to the development of endocarditis. Therefore, immunotherapy is not the treatment of choice.

A nurse identifies a group of patients who have a high risk of developing infective endocarditis. What instructions should be included when teaching the patients about the prevention of infective endocarditis? Select all that apply. 1 Remain on complete bed rest. 2 Avoid overexertion. 3 Avoid people with cold and flu symptoms. 4 Undergo immunotherapy. 5 Visit a dentist regularly.

2, 3, 5 Patients who have a high risk of developing infective endocarditis should not overexert themselves, as this can increase cardiac workload. Such patients should plan rest periods before and after activities to avoid excessive fatigue. Contact with people having cold or flulike symptoms should be avoided to prevent infection. Dental hygiene is very important in preventing infective endocarditis. Regular visits to the dentist would help in maintaining good oral hygiene, thus preventing infection. Bed rest is not recommended unless the patient has fever or heart damage. Modulating the immune response contributes little to the development of endocarditis. Therefore, immunotherapy is not the treatment of choice.

A patient is treated with radiation therapy for lung cancer. The nurse finds that the patient has dry desquamation of the skin due to the radiation therapy. How should the nurse prevent infection and facilitate healing of the skin? Select all that apply. 1 Apply ice packs. 2 Avoid the use of heating pads. 3 Avoid constricting garments. 4 Suggest the use of deodorants. 5 Avoid rubbing the affected area.

2, 3, 5 Radiation therapy may cause skin changes due to desquamation, and the skin is prone to infection. The nurse should avoid extreme temperatures on the affected area. Heating pads may cause burns and should be avoided. Constricting garments may traumatize the skin and should be avoided. Rubbing the affected area may also traumatize the skin and should be avoided. Ice packs may cause damage to the affected skin. Deodorants are chemicals and may irritate and traumatize the affected area, and should be avoided.

A patient undergoing treatment for dysrhythmia is provided with a Holter monitor. Which information or instructions should the nurse provide to the patient using the Holter monitor? Select all that apply. 1 The patient should activate the monitor when experiencing symptoms. 2 The monitor records electrocardiogram (ECG) when the patient is ambulatory. 3 The patient should record activities and symptoms in a diary. 4 The monitor evaluates heart rhythm during exercise. 5 The monitor records ECG when the patient performs daily activities.

2, 3, 5 The Holter monitor continuously records the ECG while the patient is ambulatory and performing daily activities. The patient should keep a diary and record activities and any symptoms. Event monitors are recorders that the patient activates only when experiencing symptoms. Exercise treadmill testing evaluates the patient's heart rhythm during exercise.

For which antilipemic medications should the nurse question a prescription for in a patient with cirrhosis of the liver? Select all that apply. 1 Niacin (Nicobid) 2 Ezetimibe (Zetia) 3 Gemfibrozil (Lopid) 4 Atorvastatin (Lipitor) 5 Cholestyramine (Questran)

2, 4 Ezetimibe should not be used by patients with liver impairment. Adverse effects of atorvastatin, a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

A patient will have a positron emission tomography (PET) scan for diagnostic studies. Which actions should the nurse perform prior to the scan? Select all that apply. 1 Give IV fluids containing glucose. 2 Ensure IV access is available for injection. 3 Avoid water and stop medications. 4 Stop oral intake of food 4 hours before the test. 5 Administer the test directly after a meal.

2, 4 In PET scan, a nuclear tracer substance is injected and is taken up by metabolically active cells. Before the test, the nurse should ensure that IV access is available, as it is required for injection of the tracer substance. Patients should have nothing by mouth except water and medications for at least 4 hours before the test, and IV solutions containing glucose can be held. Avoiding water, stopping medications, and feeding the patient before the test are not recommended.

A patient with lung cancer presents with intense, localized, and persistent back pain. The patient also has motor and sensory disturbances. What nursing interventions would be helpful to this patient? Select all that apply. 1 Withhold narcotics. 2 Administer corticosteroids. 3 Encourage a graded increase in patient activity. 4 Prepare the patient for a laminectomy. 5 Prepare the patient for radiation therapy

2, 4, & 5 A lung cancer patient with symptoms of intense, persistent, and localized back pain associated with motor and sensory disturbances is suggestive of spinal cord compression. Therefore, this patient would require administration of corticosteroids, radiation therapy, and surgical decompression (laminectomy). Corticosteroids help to prevent inflammation related to the spinal cord compression. Radiation therapy helps to control metastasis. Surgical decompression helps to relieve the pressure from the nerves and provide relief from symptoms. To provide symptomatic relief, the patient needs to be immobilized and administered pain killers.

The patient with systemic lupus erythematosus has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What should the nurse expect to include in this patient's plan of care? Select all that apply. 1 Obtain weekly weights 2 Limit fluids to 1000 mL per day 3 Monitor for signs of hypernatremia 4 Minimize turning and range of motion 5 Keep the head of the bed at 10 degrees or less elevation

2, 5 The care for the patient with SIADH will include limiting fluids to 1000 mL per day or less to decrease weight, increase osmolality, and improve symptoms. The head of the bed should be kept elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. The weights should be done daily along with intake and output. Signs of hyponatremia should be monitored and frequent turning, positioning, and range of motion exercises are important to maintain skin integrity and joint mobility.

A senior nurse, when teaching a group of novice nurses, informs them about temporary pacemakers. What are the indications of a temporary pacemaker? Select all that apply. 1 Heart failure 2 Prophylaxis after open heart surgery 3 Atrial fibrillation with slow ventricular response 4 Acute anterior myocardial infarction (MI) with second- or third- degree heart block 5 Bundle branch block

2, 4, 5 A temporary pacemaker helps to maintain the normal pace of the heart when its electrical pathways are damaged. The power source of this device is placed outside the body. Temporary pacemakers are used after open heart surgery as prophylaxis and during acute anterior MI with second- or third-degree heart block or bundle branch block. Permanent pacemakers are used in cases of heart failure or atrial fibrillation

A nurse is advising a 24-year-old obese female about smoking cessation, since smoking can lead to coronary artery disease. Why does the nurse discourage cigarette smoking? Select all that apply. 1 Tobacco decreases blood pressure 2 Tobacco causes release of catecholamines 3 Tobacco increases the estrogen levels in the body 4 Smoking decreases the oxygen levels in the blood 5 Tobacco increases the low-density lipoproteins levels

2, 4, 5 Nicotine present in tobacco smoke stimulates the release of catecholamines. Catecholamines have a stimulatory effect on the sympathetic nervous system that causes an increase in heart rate and blood pressure. Carbon monoxide present in tobacco smoke has a greater affinity to hemoglobin than oxygen. Therefore carbon monoxide reduces the oxygen carrying capacity of blood. Tobacco smoke is known to increase the level of low-density lipoproteins and subsequently decrease in high-density lipoproteins. All these factors can lead to atherosclerosis. Tobacco smoke is known to decrease estrogen levels in premenopausal women thereby increasing their susceptibility to get coronary artery disease.

The nurse is managing a patient who has undergone a nephrectomy. Which actions should the nurse perform during the postoperative period? Select all that apply. 1 Clamp the catheter. 2 Observe color and consistency of urine. 3 Attend to care for the stoma and collecting device. 4 Measure urine output at least every 1 or 2 hours. 5 Measure the drainage from the catheters and on the dressing.

2, 4, 5 Observing the color and consistency of urine is important, as urine with increased amounts of mucus, blood, or sediment may occlude the drainage tubing or catheter. Measuring and recording urine output is important, as the total urine output should be at least 0.5 mL/kg/hr. It is important to assess for urine drainage from the catheters and on the dressings to estimate the minimum amount of urine output of 0.5 mL/kg/hr. Never clamp the catheter unless ordered to do so by a health care provider. There is no stoma after a nephrectomy; stoma and its care are integral part of procedures such asileal conduit.

The nurse caring for a patient with a central venous access device is unable to infuse fluids into the catheter. Which nursing interventions are appropriate for the patient's treatment plan to address the issue of the catheter occlusion? Select all that apply. 1 Instruct the patient to remain supine in bed and not to move. 2 Assess the catheter for clamping and kinking, and alleviate the cause. 3 Force-flush the device with normal saline using a 10-mL syringe. 4 Perform fluoroscopy to determine the cause and evaluate the site. 5 Administer anticoagulant or thrombolytic agents.

2, 4, 5 Occlusion is a common problem with central venous catheters. If occlusion is suspected, the nurse should instruct the patient to change position, raise the arm, and cough, which helps move any blockage. The nurse must assess the catheter for clamping and kinking and undo it if found. The nurse should inform the health care provider about the catheter occlusion so that fluoroscopy can be performed if needed to determine the cause and site of occlusion. In addition, anticoagulants or antithrombolytic agents can be administered. Having the patient lie supine and motionless is not appropriate when assessing possible occlusion. Flushing is a very important step in maintaining the patency of the catheter. Flushing should be done with normal saline in a 10-mL syringe to avoid pressure on the catheter. Force should not be applied if resistance is felt.

It is especially important for the nurse to assess for which clinical manifestation(s) in a patient with primary hypoparathyroidism? Select all that apply. 1 Anorexia 2 Easy fatigability 3 Depressed reflexes 4 Circumoral numbness 5 Positive Trousseau's sign

2, 4, 5 Primary hypoparathyroidism can result in a lack of parathyroid hormone, leading to hypocalcemia. Manifestations of low serum calcium levels include easy fatigability, depression, anxiety, confusion, numbness and tingling in extremities and the region around the mouth, hyperreflexia, muscle cramps, positive Chvostek's and Trousseau's signs, and others. Anorexia and depressed reflexes are manifestations of hypercalcemia

The nurse is attending to a patient with second degree atrioventricular (AV) block. The patient is scheduled for pacemaker implantation. What instructions should a nurse give to the patient? Select all that apply. 1 Bathe after the implantation. 2 Avoid direct blows to the incision site. 3 Perform shoulder exercises. 4 Monitor pulse and inform the cardiologist if it drops. 5 Use microwave ovens when required.

2, 4, 5 The patient should avoid direct blows to the incision site for safety reasons. The patient should monitor pulse and inform the cardiologist if it drops below the predetermined rate. Microwave ovens are safe to use and do not interfere with the functioning of the pacemaker. Also, the incision site should be kept dry for 4 days after implantation, so bathing should be avoided. The patient should avoid lifting the arm above the shoulder until approved by the cardiologist, as it might affect the functioning of the pacemaker.

A patient in a coronary care unit has a reduced heart rate resulting in decreased cardiac output. The nurse observes that the ECG characteristics of the patient indicate second-degree atrioventricular (AV) block Type I. What can be the possible results of this change? Select all that apply. 1 Cardiac rhythm is regular. 2 QRS complexes are missing after some P waves. 3 PR interval is same throughout the lead. 4 Each successive PR interval becomes longer. 5 Atrial rate is normal.

2, 4, 5 The second-degree AV block type I is also called Mobitz I or Wenckebach phenomenon. It is depicted by the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. Once a ventricular beat is blocked, the cycle repeats itself with progressive lengthening of the PR intervals until another QRS complex is blocked. The QRS complex is usually greater than 0.12 seconds due to bundle branch block. The atrial rate remains normal, but ventricular rate may be slower, due to blocked QRS complex. This results in bradycardia. The cardiac rhythm is irregular. The PR intervals are not of same length; they are progressively lengthened.

A nurse is attending to a patient with jaundice. The health care provider instructs the nurse to prepare the patient for percutaneous liver biopsy. The nurse understands that presence of certain conditions may need the procedure to be rescheduled. Which conditions may require percutaneous liver biopsy to be rescheduled? Select all that apply. 1 Chronic hepatitis 2 Marked ascites 3 Hepatic cirrhosis 4 Low hemoglobin levels 5 Bleeding disorder

2, 4, 5 To do a liver biopsy when a patient has marked ascites increases the risk of leakage of ascitic fluid. The liver biopsy should be postponed. A patient with low hemoglobin levels should not have a liver biopsy because the patient cannot take the risk of the puncture of a hepatic blood vessel. A patient with bleeding disorder may not be an appropriate candidate for liver biopsy due to the increased risk of bleeding. Chronic hepatitis is not a reason to postpone a liver biopsy; in fact, it is an indication for liver biopsy. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy because it is done to detect the presence of hepatic cirrhosis

A nurse is attending to a patient with second-degree atrioventricular (AV) block, Type I. Which statements about the disease condition are true? Select all that apply. 1 A pacemaker is the only viable treatment. 2 Some P waves are conducted to the ventricles. 3 The P waves are not conducted to the ventricles. 4 The treatment includes the use of atropine or a pacemaker. 5 It may result from drugs such as digoxin (Lanoxin). 6 It is generally transient and well tolerated

2, 4, 5, 6 Second-degree heart block type I refers to AV conduction that is intermittently blocked. Therefore, some P waves are conducted to the ventricle while some are not. Some patients may require administration of atropine and transcutaneous or transvenous pacing for emergent treatment. This type of heart block may result from drugs such as digoxin, and the condition is transient and well tolerated. Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. Treatments include transcutaneous or transvenous pacing and implanting a permanent pacemaker.

The nurse is performing an assessment of a patient whose older brother recently had a myocardial infarction (MI). Which assessment data indicates to the nurse that the patient has additional risk factors for coronary artery disease (CAD)? Select all that apply. 1 Smoking cessation three years ago 2 Serum cholesterol level of 260 mg/dL 3 Fasting triglyceride level of 110 mg/dL 4 Multiple family problems over last two years 5 Living together with son who smokes two packs of cigarettes per day 6 Clerk job in an accounting firm and not exercising

2, 4, 5, 6 Serum cholesterol level greater than 200 mg/dL is a risk factor for CAD. Stress is an additional risk factor for developing CAD. Second hand smoking increases the risk of CAD. Sedentary job and lack of exercising are risk factors for CAD. Smoking cessation will lead to a reduced mortality rate in a period of 12 months. Fasting triglyceride level above 150 mg/dL is a risk factor for CAD.

A patient who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. What substances should the nurse tell the patient are passing through the membrane during hemodialysis? Select all that apply. 1 Red blood cells (RBCs) 2 Creatinine 3 Glucose 4 Bacteria 5 Sodium

2, 5 Creatinine, urea, uric acid, and electrolytes such as sodium and potassium are filtered by the semipermeable membrane during hemodialysis. RBCs do not pass through the semipermeable membrane during hemodialysis because of their molecular weight. Glucose does not pass through the semipermeable membrane during hemodialysis due to the osmotic difference of the dialysate. Bacteria do not pass through the semipermeable membrane during hemodialysis due to their high molecular weight.

What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? 1 Providing a dark, low-stimulation environment 2 Closely monitoring the patient's intake and output 3 Patient teaching related to levothyroxine (Synthroid) 4 Patient teaching related to radioactive iodine therapy

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

The nurse recalls that hepatic coma results primarily from accumulation of which substance in the blood? 1 Sodium 2 Calcium 3 Ammonia 4 Potassium

3 A high ammonia level in the blood is a late manifestation of liver failure, which results in hepatic coma, causing neurological dysfunction and brain damage. Sodium, calcium, and potassium are not directly affected by liver dysfunction or hepatic coma.

A nurse is reviewing the laboratory reports of a patient. Which parameter would require further investigation? 1 Hemoglobin level of 13.0 g/dl 2 Hematocrit of 38% 3 Total WBC count of 3000/µL 4 Platelet count of 200,000/ µL

3 A normal WBC count is 4,000-11,000/µL. A count less than 4000/µL indicates bone marrow depression and severe or chronic illness, and needs further investigation. A hemoglobin level of 13.0 g/dl is a normal value. A hematocrit of 38% is a normal range. A normal platelet count ranges from 150,000 to 400,000/µL, and a platelet count of 200,000/µL is under normal limits.

The nurse is caring for a patient who is postoperative following a thyroidectomy. A priority of the patient's nursing care includes which action? 1 Assessment of hoarseness 2 Assessment of Babinski reflex 3 Assessment of Chvostek's sign 4 Assessment of neck full range of motion

3 A positive Cvostek's sign is a sign of life-threatening tetany, which could be caused by hypocalcemia because of accidental removal of the parathyroid glands. Hoarseness for three to four weeks postoperatively is an expected outcome of a thyroidectomy. A Babinski reflex is not related to thyroid removal. Although it is advisable that the postoperative thyroidectomy patient exercise the neck muscles, neck flexion is contraindicated because it places tension on the suture line.

The electrocardiogram of a patient indicates hidden P waves in preceding T waves and a normal QRS complex. The nurse recognizes that the patient is most likely experiencing what condition? 1 Ventricular fibrillation 2 Junctional dysrhythmia 3 Premature atrial contraction 4 Premature ventricular contraction

3 A premature atrial contraction occurs at the atrium and occurs before the next sinus beat occurs. A premature atrial contraction occurs in either the left atrium or right atrium and travels along the atria. The electrocardiogram of a premature atrial contraction usually shows hidden P waves in preceding T waves with prolonged PR interval. The QRS complex remains normal. The electrocardiogram of ventricular fibrillation has absent P waves and an undetectable PR interval and QRS complex. The electrocardiogram of junctional dysrhythmia shows a distorted P wave and reduced PR interval. The QRS complex remains normal. The electrocardiogram of premature ventricular contractions shows a rare occurrence of P waves. The PR interval cannot be measured with a disturbed and elongated QRS complex and T wave.

The nurse assesses a patient with recently diagnosed human immunodeficiency virus disease who has been admitted to the hospital with a new diagnosis of acquired immunodeficiency syndrome (AIDS). What assessment finding is most diagnostic of AIDS? 1 Sleeping 6 to 8 hours per night 2 Feelings of fatigue in the evening 3 Steady weight loss over the past several months 4 Feelings of profound helplessness and hopelessness

3 A very common complaint of patients with acquired immunodeficiency syndrome (AIDS) is steady weight loss regardless of attempts to maintain or gain weight. Other common findings include anorexia, decreased sleep, constipation, and anxiety. Sleeping 6 to 8 hours per night, fatigue in the evening, and feelings of helplessness and hopelessness may be seen with human immunodeficiency virus/AIDS, but they are not as diagnostic as unexplained steady weight loss.

A patient presents with acute upper quadrant pain radiating to the back that the patient rates as a 10 on a 1-to-10 pain scale. The patient says, "I'm nauseated, and I've vomited several times." The diagnosis is cholecystitis with cholelithiasis. Which collaborative nursing diagnosis does the nurse recognize as the highest priority? 1 Impaired Skin Integrity related to the surgical incision 2 Anxiety related to knowledge deficit of diagnostic studies 3 Acute Pain related to inflammation and blockage of the biliary tract 4 Risk for Fluid Volume Deficit related to nausea and vomiting

3 Acute pain is the priority problem at the moment. Acute pain can and should be managed immediately before other nursing care activities are carried out. Managing the patient's pain help the nurse achieving other care goals. Impaired skin integrity is not currently a problem because the patient has not yet had surgery. Anxiety related to deficient knowledge of diagnostic studies is a lower priority and may be addressed after pain is managed. After the patient's pain is managed, nausea, vomiting, and decreased fluid intake should be the next problems addressed.

The patient admitted with sepsis is at risk of developing what renal pathology? 1 Nephritis 2 Glomerular nephritis 3 Acute tubular necrosis 4 Chronic kidney disease

3 Acute tubular necrosis is a result of an acute shock on the renal system and is recoverable, but the patient is likely to develop acute kidney impairment (AKI). Nephritis is an acute infection of the nephrons. Glomerular nephritis develops into chronic kidney disease and is not a result of sepsis.

The nurse is caring for a patient who is 24 hours post-pacemaker insertion. Which nursing intervention is most appropriate at this time? 1 Reinforcing the pressure dressing as needed 2 Encouraging range-of-motion exercises of the involved arm 3 Assessing the incision for any redness, swelling, or discharge 4 Applying wet-to-dry dressings every four hours to the insertion site

3 After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.

A patient comes to the emergency department complaining of dizziness and shortness of breath. The ECG tracing reveals the following. Which prescription should a nurse question?12676331 1 12-Lead ECG 2 Transcutaneous pacing 3 Amiodarone (Cordarone) bolus 4 2 L oxygen vía nasal cannula

3 Amiodarone is an antiarrhythmic medication that decreases ventricular irritability. Amiodarone is contraindicated in patients with third degree atrioventricular (AV) heart block. The nurse would expect to receive prescriptions for oxygen and a 12-lead ECG. Transcutaneous pacing is used to increase the heart rate until a transvenous or permanent pacemaker can be placed. Text Reference - p. 799

A nurse is learning about the different types of cancers. Which cancer has the highest incidence among men? 1 Lung cancer 2 Colon cancer 3 Prostate cancer 4 Thyroid cancer

3 Among all the cancers in men, prostate cancer has the highest incidence (29%). Lung cancer has the highest death rate among men (29%). The incidence of colon cancer in males is 9%. Thyroid cancer is more common in women than men.

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? 1 Low-grade fever of 100 degrees F and dehydration 2 Abscess in the right upper quadrant of the abdomen 3 Activated partial thromboplastin time (aPTT) of 54 seconds 4 Multiple obstructions in the cystic and common bile duct

3 An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration, the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy .

The patient with breast cancer is having teletherapy radiation treatments after surgery. What should the nurse teach the patient about the care of the skin? 1 Use Dial soap to feel clean and fresh 2 Scented lotion can be used on the area 3 Avoid heat and cold to the treatment area 4 Wear the new bra to comfort and support the area

3 Avoiding heat and cold in the treatment area will protect it. Only mild soap and unscented, non-medicated lotions may be used to prevent skin damage . The patient will want to avoid wearing tight-fitting clothing, such as a bra, over the treatment field and will want to expose the area to air as often as possible.

What is the highest priority information to include in preoperative teaching for a patient scheduled for a colectomy? 1 How to care for the colostomy 2 Activity restrictions and bed rest requirements 3 Postoperative activities and pain management 4 Medications planned for use during the procedure

3 Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of highest priority to teach the patient to cough and deep-breathe and use pain medication. Otherwise, atelectasis and pneumonia could develop, delaying recovery from surgery and, as a result, hospital discharge. Caring for a colostomy and activity restrictions also can be discussed postoperatively. Medications for discharge should be discussed before discharge, not surgery. To reduce the risk of adverse outcomes, the highest priority is pain control and early ambulation and activity.

The nurse, reviewing a patient's laboratory results, recognizes what result as most indicative of myocardial infarction? 1 Increased myoglobin 2 Decreased C-reactive protein 3 Increased creatine phosphokinase 4 Increased white blood cell count

3 Biochemical markers such as creatine phosphokinase (CPK), CPK-MB, and troponin are released specifically by myocardial cells when injured and are detectable in the blood. Myoglobin, although one of the first markers to increase after a myocardial infarction (MI), does not have as high of a cardiac specificity as others. C-reactive protein is increased after an MI as a result of the inflammation caused by tissue damage; however it is also not as highly specific to cardiac tissue. An increased white blood cell count may be present after an MI but is due to a generalized inflammatory response.

The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? 1 Hemodialysis (HD) three times per week 2 Automated peritoneal dialysis (APD) 3 Continuous venovenous hemofiltration (CVVH) 4 Continuous ambulatory peritoneal dialysis (CAPD)

3 CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD three times per week would not be used for this patient because fluid and solutes build up and then are removed rapidly. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not remove as rapidly large amounts of fluid as CVVH can do.

A patient with cancer that has metastasized to the liver manifests symptoms of fluid retention, including edema and ascites. To determine the effectiveness of the diuretic therapy that has been prescribed, what should the nurse assess? 1 Breath sounds 2 Bowel sounds 3 Abdominal girth 4 Recent blood work

3 Daily measurement of the abdominal girth provides a direct indication of ascitic fluid increase or decrease. Breath and bowel sounds are usually not affected by liver metastasis until the late stages, when fluid overload and multisystem organ involvement occur. Reviewing the results of the most recent blood work will not show direct measurement of the effectiveness of diuretic therapy.

Which cellular dysfunction in the process of cancer development allows defective cell proliferation? 1 Protooncogenes 2 Cell differentiation 3 Dynamic equilibrium 4 Activation of oncogenes

3 Dynamic equilibrium is the regulation of proliferation that usually only occurs to equal cell degeneration or death or when the body has a physiologic need for more cells. Cell differentiation is the orderly process that progresses a cell from a state of immaturity to a state of differentiated maturity. Mutations that alter the expression of protooncogenes can activate them to function as oncogenes, which are tumor-inducing genes and alter their differentiation.

An elderly patient has low hemoglobin levels. The patient is otherwise healthy and has no signs of gastrointestinal bleeding. The nurse recognizes that what could be the reason for the low hemoglobin level? 1 Low level of hepicidin 2 Increase in iron-binding capacity 3 Decrease in intestinal absorption of iron 4 Decrease in erythropoietin secretion from the kidneys

3 Elderly patients may have low normal levels of hemoglobin. Aging leads to a decreased absorption of iron from the intestines. A low iron level leads to lower levels of hemoglobin in the elderly patients. Hepcidin is produced by the liver and is a key regulator of iron balance. Its production is not affected by aging. Elderly patients usually have a decreased iron-binding capacity, which also leads to low hemoglobin levels. Erythropoeitin secreted from the kidneys helps in the synthesis of hemoglobin; however, aging does not affect erythropoietin secretion

When caring for a patient with an electrical burn injury, which prescription from the health care provider should the nurse question? 1 Mannitol 75 gm intravenous (IV) 2 Urine for myoglobulin 3 Lactated Ringer's at 25 mL/hr 4 Sodium bicarbonate 24 mEq every four hours

3 Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2--4 mL/kg/% total body surface area (TBSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. Mannitol also can be used to maintain urine output. The urine would be monitored also for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine.

The nurse is reviewing the patient's serum cholesterol results. Which of the following serum cholesterol levels increases the risk of coronary artery disease (CAD)? 1 Decreased triglycerides 2 Elevated high density lipoproteins (HDL) 3 Elevated low density lipoproteins (LDL) 4 Decreased very low density lipoproteins (VLDL)

3 Elevated LDLs contain more cholesterol than any of the other lipoproteins and have an affinity for arterial walls. Elevated LDL levels correlate most closely with increased incidence of atherosclerosis and CAD. Elevated HDL, decreased triglycerides, and VLDL are all negative risk factors for CAD.

The female patient is having whole brain radiation for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? 1 "When your hair grows back it will be patchy." 2 "Don't use your curling iron and that will slow down the loss." 3 "You can get a wig now to match your hair so you will not look different." 4 "You should contact 'Look Good, Feel Better' to figure out what to do about this."

3 Hair loss with radiation usually is permanent. The best response by the nurse is to suggest getting a wig before the patient loses her hair so she will not look or feel so different. When hair grows back after chemotherapy it is frequently a different color or texture. Avoiding use of electric hair dryers, curlers, and curling irons may slow the hair loss, but will not answer the patient's concern. The American Cancer Society's "Look Good, Feel Better" program will be helpful, but this response is avoiding the patient's immediate concern.

A nurse recalls that which factor is responsible for maintaining acid-base balance in the body? 1 White blood cells 2 Prothrombin 3 Hemoglobin 4 Platelets

3 Hemoglobin acts as a buffer and plays a role in maintaining acid-base balance. White blood cells help in immune function. Prothrombin is a coagulation factor and helps in clotting. Platelets help in clotting.

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? 1 Serum α-fetoprotein level 2 Ventilation/perfusion scan 3 Hepatic structure ultrasound 4 Abdominal girth measurement

3 Hepatic structure ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

A patient with hepatitis A asks whether other family members are at risk for "catching" the disease. The nurse's response will be based on the knowledge that hepatitis A is transmitted primarily: 1 During sexual intercourse 2 By contact with infected body secretions 3 Through fecal contamination of food or water 4 Through kissing that involves contact with mucous membranes

3 Hepatitis A is primarily transmitted through ingestion of organisms on fecally contaminated hands, food, or water. Care should be taken in the handling of food and water, as well as contaminated items such as bed linens, bedpans, and toilets. Hand hygiene and personal protective equipment such as gloves are important in preventing the spread of infection for hospital personnel. In the home, hand hygiene and good personal hygiene are important in decreasing the risk of transmission. Sexual intercourse, contact with infected body secretions, and contact through mucous membranes all present higher risk for hepatitis B and C than for hepatitis A.

A patient is admitted with suspected myocarditis. Which test is considered most diagnostic for this illness? 1 Echocardiogram 2 Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels 3 Endomyocardial biopsy 4 Electrocardiogram (ECG)

3 Histologic confirmation of myocarditis is through an endomyocardial biopsy. A biopsy done during the first six weeks of acute illness is most diagnostic. This is the period in which lymphocytic infiltration and myocyte damage are present. The ECG changes for a patient with myocarditis are often nonspecific but may reflect associated pericardial involvement (e.g., diffuse ST segment changes). Dysrhythmias and conduction disturbances may be present. Laboratory findings are often inconclusive. They may include mild to moderate leukocytosis and atypical lymphocytes, increased ESR and CRP levels, elevated levels of myocardial markers such as troponin, and elevated viral titers. The virus is generally present in tissue and pericardial fluid samples only during the initial 8 to 10 days of illness. Nuclear scans, echocardiography, and magnetic resonance imaging (MRI) are used to assess cardiac function.

The laboratory findings for a patient indicate acute myelogenous leukemia (AML). The nurse caring for the patient recognizes which symptom as indicative of AML? 1 Hypercellular bone marrow with lymphoblasts 2 Presence of lymphoblasts in cerebrospinal fluid 3 Hypercellular bone marrow with myeloblasts 4 Increased peripheral lymphocytes and lymphocytes in the bone marrow

3 Hypercellular bone marrow with myeloblasts indicates AML. Hypercellular bone marrow with lymphoblasts and presence of lymphoblasts in cerebrospinal fluid are observed in acute lymphocytic leukemia (ALL). An increase in peripheral lymphocytes and lymphocytes in the bone marrow are noted in chronic lymphocytic leukemia (CLL).

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Because of the potential effects of this disease on electrolyte balance, the nurse should assess this patient for what manifestation? 1 Neurologic irritability 2 Declining urine output 3 Lethargy and weakness 4 Hyperactive bowel sounds

3 Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability, declining urine output, and hyperactive bowel sounds do not occur with hypercalcemia.

A patient has glomerulonephritis. The nurse recalls that which common complications of the disorder tend to recur frequently? 1 Fever and edema 2 Urinary tract infections 3 Hypertension and edema 4 Upper respiratory infections

3 Hypertension and edema, along with headaches and oliguria, are common complications of glomerulonephritis and tend to recur. Fever, UTI, and upper respiratory infections are not primarily associated with glomerulonephritis.

The patient has scleroderma and is experiencing hypertension. The nurse should know that this could be related to which renal problem? 1 Obstructive uropathy 2 Goodpasture's syndrome 3 Chronic glomerulonephritis 4 Calcium oxalate urinary calculi

3 Hypertension occurs with chronic glomerulonephritis, which may be found in patients with scleroderma. Obstructive uropathy, Goodpasture's syndrome, and calcium oxalate urinary calculi are not related to scleroderma and do not cause hypertension.

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage? 1 Epidermis only 2 Muscle and bone 3 Epidermis and dermis 4 Epidermis, dermis, and subcutaneous tissue

3 In a second-degree or partial-thickness burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree deep partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue.

Which dysrhythmia is associated with a heart rate of 60 to 100 beats per minute and irregular cardiac rhythm? 1 Sinus tachycardia 2 Junctional dysrhythmias 3 Premature atrial contraction 4 Paroxysmal supraventricular tachycardia

3 In premature atrial contraction, the heart rate is usually 60 to 100 beats per minute and has irregular rhythm. In sinus tachycardia, the patient's heart rate is 101 to 200 beats per minute, and the cardiac rhythm is regular. A heart rate of 40 to 180 beats per minute with regular cardiac rhythm is observed in patients with junctional dysrhythmias. A heart rate of 150 to 220 beats per minute with regular cardiac rhythm is observed in patients with paroxysmal supraventricular tachycardia.

When assessing the mental status of a patient in acute renal failure, the nurse recognizes that abnormal findings are most likely caused by: 1 Anger related to denial of chronic illness 2 Delirium related to hypoxia of brain cells 3 Confusion related to an increased urea level 4 Aggression related to possible underlying comorbidities

3 In renal disease, urea is not filtered out of the blood by the kidneys and therefore accumulates in the blood. This results in toxicity to brain tissue, causing confusion. Anger is a possible emotional reaction, but it does not manifest as a change of mental status. Delirium related to hypoxia of brain cells is not a complication seen with acute renal failure. Aggression is not necessarily related to acute renal failure.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? 1 Sit or lie in a position of comfort 2 Wear a pressure garment for eight hours each day 3 Refer the patient to a counselor for psychosocial support 4 Use the sun to increase the skin color on the healed areas

3 In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the body looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury and sunscreen should always be worn when the patient is outside.

A patient undergoes ABO compatibility tests. When administering the patient a prescribed blood transfusion, the nurse monitors for what type of hypersensitivity reaction? 1 Type I: IgE-mediated 2 Type III: Immune-complex 3 Type II: Cytotoxic and cytolytic 4 Type IV: Delayed hypersensitivity

3 In type II hypersensitivity reactions, cellular structures are destroyed. These reactions mostly involve the destruction of red blood cells, platelets, and leukocytes. When incompatible blood types are mixed, agglutination occurs. As a result, hemoglobin may be released into the urine and plasma, causing acute kidney failure. Type I, III, and IV are not responsible for ABO incompatibility reactions. Type I hypersensitivity reactions occur during allergic rhinitis and asthma. Type III hypersensitivity reactions occur in disease conditions like rheumatoid arthritis. Type IV reactions occur in contact dermatitis.

A patient admitted to the hospital with cirrhosis of the liver suddenly starts vomiting blood. What is the priority action that the nurse should take in this situation? 1 Send for endoscopic variceal ligation. 2 Give propronalol orally. 3 Stabilize the patient and manage airway. 4 Check for signs of cirrhosis

3 Individuals with cirrhosis of the liver are at risk of bleeding from esophageal and gastric varices. Hematemesis in the patient with cirrhosis of the liver is likely to be variceal bleeding. In this case, the nurse should first stabilize the patient and manage the airway. Once the patient is stable, other steps in treatment can be initiated, such as assessing further and administering necessary medications.

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in the new home? 1 Cook for the patient 2 Stop the patient from smoking 3 Install tap water anti-scald devices 4 Be sure the patient uses an open space heater

3 Installing tap water antiscald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for the patient may be needed at times of illness or in the future, but the patient is moving to an independent living facility, so at this time should not need this assistance. Stopping the patient from smoking may be helpful to prevent burns, but may not be possible without the requirement by the facility. Using an open space heater would increase the patient's risk of being burned and would not be encouraged.

The patient was told that he or she would have intraperitoneal chemotherapy. The patient asks the nurse when the IV will be started for the chemotherapy. What should the nurse teach the patient about this type of chemotherapy delivery? 1 It is delivered via an Ommaya reservoir and extension catheter. 2 It is instilled in the bladder via a urinary catheter and retained for one to three hours. 3 A Silastic catheter will be placed percutaneously into the peritoneal cavity for chemotherapy administration. 4 The arteries supplying the tumor are accessed with surgical placement of a catheter connected to an infusion pump.

3 Intraperitoneal chemotherapy is delivered to the peritoneal cavity via a temporary percutaneously inserted Silastic catheter, and drained from this catheter after the dwell time in the peritoneum. The Ommaya reservoir is used for intraventricular chemotherapy. Intravesical bladder chemotherapy is delivered via a urinary catheter. Intraarterial chemotherapy is delivered via a surgically placed catheter that delivers chemotherapy via an external or internal infusion pump.

While ambulating a patient, the ECG tracing changes from a normal sinus rhythm, with a ventricular rate of 90 impulses per minute, to the following tracing. Which action should the nurse take?12676315 1 Notify the primary health care provider 2 Administer digoxin (Lanoxin) 3 Continue ambulating the patient 4 Place the patient back into bed

3 It is a normal phenomenon for the heart rate to increase slightly during ambulation because of an increased demand for oxygen. Therefore, the correct answer is to continue ambulating the patient. There is no need to notify the primary health care provider unless other symptoms occur. Digoxin does decrease the heart rate, but is not given if the heart rate only increases with exertion. Ambulation is to be encouraged to promote health. Placing the patient back into bed would not be appropriate in this situation. Text Reference - p. 793

Which statement by a patient diagnosed with stable angina indicates understanding of the disease process? 1 "Decreased oxygen level in blood is causing my chest pain." 2 "Angina is causing an irreversible damage to cardiac muscles by cardiac ischemia." 3 "Anginal pain is caused by increased demand for oxygen or decreased supply of oxygen." 4 "Symptoms of angina start when the process of atherosclerosis completely occludes coronary artery."

3 Mismatch between oxygen demand of cardiac muscles and supply of oxygen leads to myocardial ischemia that is represented by pain. Decreased oxygenation level of blood indicates respiratory problems. Myocardial ischemia is completely reversible. The patient will start to experience symptoms of ischemia when the coronary artery is blocked by 75% or more.

A patient with type 2 diabetes mellitus has been diagnosed with nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include which of the following? 1 Having genetic testing done. 2 Eliminating carbohydrates from the diet. 3 Following measures to gain tighter glucose control. 4 Avoiding alcohol until liver enzymes return to normal.

3 NAFLD can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For those who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. NAFLD does not show up positive on a genetic test. It is not recommended to completely eliminate carbohydrates from the diet. NAFLD is not caused by alcohol, and the question does not imply the patient drinks.

A patient's arterial blood gas results are: pH 7.32; PaCO2 52; HCO3¯ 24. The patient is in: 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 Normal pH is 7.35--7.45. Values less than 7.35 indicate acidosis. Normal value for PaCO2 is 35--45 mm Hg. Because the HCO3¯ 24 is normal and the PaCO2 is elevated, the source of the acidosis is respiratory. The patient is in respiratory acidosis.

A pregnant woman who was tested and diagnosed with human immunodeficiency virus (HIV) infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? 1 "The baby probably will be infected with HIV." 2 "Only an abortion will keep your baby from having HIV." 3 "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." 4 "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."

3 On average, 25% of infants born to women with untreated HIV will be born with HIV. The risk of transmission is reduced to less than 2% if the infected pregnant woman is treated with antiretroviral therapy. Duration and frequency of contact with the HIV organism is one variable that influences whether transmission of HIV occurs. Volume, virulence, and concentration of the organism, as well as host immune status, are variables related to transmission via blood, semen, vaginal secretions, or breast milk.

A nurse discusses chemotherapy treatment with a patient with colon cancer. Which body system does the nurse tell the patient is most susceptible to the side effects of commonly used antineoplastic drugs? 1 Lymphatic 2 Respiratory 3 Bone marrow 4 Cardiovascular

3 One of the most common side effects of chemotherapeutic drugs is bone marrow suppression, which decreases the production of blood cells. Bone marrow is susceptible to chemotherapy because of the rapid cell cycles and replacement of blood-forming tissue in bone marrow. The lymphatic, respiratory, and cardiovascular systems may be affected by chemotherapy drugs but vary in their levels of severity and involvement, whereas bone marrow suppression is common in all forms of antineoplastic therapy.

The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? 1 Cardiac output 2 Blood pressure 3 Abdominal girth 4 Intake and output

3 Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the healthcare provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continues to be monitored to account for the paracentesis fluid but is not as informative as abdominal girth.

A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? 1 Hypokalemia 2 Hyponatremia 3 Large urine output 4 Leukocytosis with cloudy urine output

3 Patients frequently experience diuresis (a large volume of urine output) in the hours and days immediately following a kidney transplant. Hypokalemia, hyponatremia, and signs of infection are unexpected findings that warrant prompt intervention.

The nurse has finished a teaching session with a patient who has acute rheumatic fever (RF). Which statement by the patient indicates a need for further education? 1 "I will receive ibuprofen for my joint pain." 2 "I will need to take antibiotics to stop the infection." 3 "Exercise is important to help me get back my strength." 4 "I can have a heating pad placed on my painful knees if needed."

3 Promoting optimal rest (not promoting exercise) is essential to reduce cardiac workload and the body's metabolic needs. The primary goals of managing a patient with RF are to (1) control and remove the infecting organism; (2) prevent cardiac complications; and (3) relieve joint pain, fever, and other symptoms. Administer salicylates, nonsteroidal antiinflammatory drugs (NSAIDs), and corticosteroids as prescribed, and monitor fluid intake as appropriate. Administer antibiotics as prescribed to treat the streptococcal infection. Teach the patient that completing the full course of antibiotics is vital to successful treatment. Another priority nursing goal is relief of joint pain. Position painful joints for comfort and in proper alignment. Heat may be applied and salicylates or NSAIDs administered for joint pain.

A patient diagnosed with hyperthyroidism received radioactive iodine (RAI) one week ago. The patient tells the nurse, "I don't think the medication is working, I don't feel any different." Identify the best nursing response. 1 "You should notify your primary health care provider immediately." 2 "You may need to have your thyroid removed sooner than anticipated." 3 "It may take several weeks to see the full benefits of the treatment." 4 "You don't feel any different? Would you like to sit down and talk about it?"

3 RAI has a delayed response, and the maximum effect may not be seen for up to three months. For this reason, it would not be necessary to contact the primary health care provider immediately, or for the patient to have the thyroid gland removed sooner. Asking the patient to sit and talk about it demonstrates that the nurse is being responsive to psychosocial/emotional needs, but is not the best nursing response at this time.

A patient is recovering from second- and third-degree burns over 30% of the body and is now ready for discharge. Just before leaving, the patient states, "What's going to happen to me? Will I ever look normal again?" The nurse recognizes that this patient is exhibiting which emotional response to the patient's type of injury? 1 Fear 2 Guilt 3 Anxiety 4 Depression

3 Recovery from a 30% total body surface area (TBSA) burn injury takes time and is exhausting, both physically and emotionally for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. While fear, anger, guilt, and depression are all common emotions experienced by a burn patient, this patient's statements reflect feelings of anxiety.

A patient with acute myelogenous leukemia has completed the prescribed cycles of cytotoxic chemotherapy. The nurse reviews the patient's medical record and notes documentation that the patient is in partial remission. How should the nurse interpret this documentation? 1 There are no physical symptoms or bone marrow abnormalities, and molecular studies are negative for residual leukemia. 2 No tumor cells were detected by morphologic examination, but can be identified by molecular testing. 3 Symptoms are absent and there is a normal peripheral blood smear, but there is evidence of the disease in the bone marrow. 4 Physical examination reveals no evidence of the disease, and the bone marrow and peripheral blood appear normal.

3 Remission is a phase in which the patient does not exhibit any cancer symptoms. In partial remission, symptoms are absent and the blood smear is normal, but the disease may be evident in the bone marrow. If a patient is in molecular remission, there are no signs of residual leukemia in molecular studies. In minimal residue disease, tumor cells are not detected by morphologic examination, but can be identified by molecular testing. A complete remission means that there is no evidence of the disease on physical examination, and the bone marrow and peripheral blood appear normal

The nurse provides education to a patient who has expressed concern about HIV infection. Which statement indicates that the patient understands the teaching? 1 "I can't contract HIV unless there's an opportunistic infection present." 2 "Using a condom with a spermicide will give 100% protection from HIV." 3 "Using a condom with a spermicide will reduce my risk of contracting HIV." 4 "Kaposi's sarcoma is one of the first opportunistic infections to show up in someone with HIV."

3 Research indicates that using a condom with a spermicidal jelly containing nonoxynol-9 provides the greatest reduction of risk of contracting HIV during sexual intercourse. An opportunistic infection does not have to be present, a condom with spermicide does not provide 100% protection, and Kaposi's sarcoma is not one of the first opportunistic infections to appear in someone infected with HIV.

A patient's ECG tracing has changed from sinus tachycardia (ST) to the following rhythm. The nurse should notify the primary health care provider because the patient is ___.12676344 1 At risk for a pulmonary embolism 2 At risk of ventricular tachycardia 3 Experiencing a myocardial infarction 4 Showing signs of an elevated potassium level

3 ST elevation is a manifestation of a myocardial infarction (MI). ST elevation does not increase a patient's risk of a pulmonary embolism. A patient can go into ventricular tachycardia because of an MI, but it is not the main reason the nurse would notify the primary health care provider in this situation. Hyperkalemia is evidenced by a peaked T wave, not ST elevation. Text Reference - p. 807

The nurse reviews a patient's laboratory values and recognizes which finding as an indication of resolution of acute pancreatitis? 1 Increasing hemoglobin level 2 Falling serum bilirubin level 3 Decreasing serum amylase level 4 Increasing serum alkaline phosphatase level

3 Serum amylase is a major indicator of pancreatic function and will be increased during acute pancreatitis. A decreasing serum amylase level indicates resolution of pancreatic inflammation. The nurse would evaluate the hemoglobin level if the acute pancreatitis were hemorrhagic in nature. Although serum bilirubin and serum alkaline phosphatase levels may be increased in acute pancreatitis, they are not most indicative of recovery from acute pancreatitis.

A nurse is caring for a patient with metastatic breast cancer. The nurse finds that the patient has developed facial and periorbital edema, and has distention of veins of the face, neck, and chest. What condition do these findings indicate to the nurse? 1 Spinal cord compression 2 Third space syndrome 3 Superior vena cava syndrome 4 Tumor lysis syndrome

3 Superior vena cava syndrome (SVCS) is an obstructive emergency. There can be many causes, including lung cancer, metastatic breast cancer, and non-Hodgkin's lymphoma. In these instances, SVCS results due to the obstruction of the superior vena cava by a tumor or thrombosis. Spinal cord compression is also an obstructive emergency caused by a malignant tumor in the epidural space of the spinal cord. It can be caused by breast, lung, prostate, GI, and renal tumors and melanomas. Third space syndrome is an obstructive emergency caused by the shifting of fluid from the vascular space to the interstitial space. It may occur due to extensive surgical procedures, biologic therapy, or septic shock. Tumor lysis syndrome is a metabolic emergency caused by rapid release of intracellular components in response to chemotherapy.

A nurse is caring for a patient who has sustained burns over the entire surfaces of both arms, the anterior trunk, and the right leg. The nurse uses the rule of nines to estimate the percentage of the burn surface area as: 1 27% 2 36% 3 54% 4 72%

3 The "rule of nines" is a method used to determine the body surface area (BSA) of a burn injury. It assigns 9% to each arm, 9% to the head, 18% to the anterior torso, 18% to the posterior torso, 18% to each leg, and 1% to the genitals. The other answer options are incorrect applications of the rule of nines BSA estimate.

While a nurse is administering Lasix via intravenous push (IVP), a patient becomes unresponsive. The electrocardiogram (ECG) tracing shows the following. Which of these actions should the nurse do first? (extreme tachycardia with no qrs wave) 1 Cardiovert 2 Defibrillate 3 Feel for a pulse 4 Administer oxygen

3 The ECG tracing is ventricular tachycardia (VT). Ventricular tachycardia can either be with a pulse or pulseless. The treatment algorithm depends on whether the patient has a pulse or not. Therefore, checking for a pulse is a priority. If the patient does not have a pulse, cardiopulmonary resuscitation (CPR) should be performed until a defibrillator is available. Oxygen may be administered, but it is not a priority.

A patient has sustained thermal injuries amounting to approximately 30% of his total body surface area. What action should the nurse take first? 1 Cover the burned body area with ice. 2 Immerse the burned body area in cool water. 3 Check for a patent airway, breathing, and circulation. 4 Cover the burned area with a clean, cool, tap water-dampened towel.

3 The first step in the management of a person who has sustained thermal injuries on 10% or more of his or her body surface is to assess the airway, breathing, and circulation. If the injury is less than 10% of total body surface area, then it would be appropriate to cover the burned area with a clean, cool, damp towel, but only after the airway, breathing, and circulation have been checked. It is not appropriate to cover the patient's afflicted area with ice because this can cause hypothermia and vasoconstriction, which would further reduce the blood flow to the injury site. Immersing the patient or the patient's afflicted area in cool water may cause extensive heat loss.

The nurse is discussing the effects of chemotherapy with a patient who has a new diagnosis of cancer. Which statement by the patient reflects an adequate understanding of the teaching? 1 "I will need to use effective birth control methods for the rest of my life." 2 "My doctor will stop the chemotherapy if nausea and vomiting occur during treatment." 3 "I will join a support group after my therapy is finished to help me get back on my feet." 4 "I probably won't be able to do anything I used to do anymore now that I have cancer."

3 The impact of a cancer diagnosis can affect many aspects of a patient's life, with cancer survivors commonly reporting financial, vocational, marital, and emotional concerns even long after treatment is over. These psychosocial effects can play a profound role in a patient's life after cancer, with issues related to living in uncertainty being encountered frequently. Participation in appropriate supportive care and community resources would benefit the patient in recovery or ongoing care. It will not be necessary for the patient to use birth control for the rest of the patient's life; nausea and vomiting are expected effects of chemotherapy and treatment will continue unless the vomiting becomes severe.

The nurse determines that the patient who is receiving radioactive iodine (RAI) therapy for the treatment of hyperthyroidism needs additional instructions when the patient makes which statement? 1 "I will need to flush the toilet twice after I use it." 2 "I should launder my laundry separately from those in my household." 3 "I will need to take antithyroid drugs for two weeks after I begin RAI therapy." 4 "If I develop a dry mouth I may gargle with a salt and soda mixture for relief."

3 The maximum effect of RAI therapy may not occur for three months, and therefore the patient usually continues to be treated wtih antithyroid drugs for three months after the initiation of RAI therapy. Flushing the toilet twice and laundering clothes separately will help to limit radiation exposure to household members. Radiation parotiditis may cause dryness and irritation of the mouth, and a salt and soda gargle may provide relief.

A nurse is administering mycophenolate mofetil (CellCept) as a part of triple immunosuppressive therapy for a posttransplant patient. Which is the most important nursing intervention? 1 Give large doses as intravenous (IV) bolus. 2 Reconstitute the drug in normal saline. 3 Administer the drug over 2 or more hours. 4 Educate the patient about gastrointestinal side effects.

3 The most important nursing intervention when administering mycophenolate mofetil is to infuse this medication over 2 or more hours. Giving the drug slowly helps to decrease the side effects. The drug should never be given as an IV bolus and should always be reconstituted in D5W. Thereafter, the nurse may educate the patient about the gastrointestinal side effects.

The nurse is teaching the patient with adrenocortical insufficiency and her caregiver about management of corticosteroid therapy. What should the nurse tell the patient and the caregiver? 1 Assess for cataracts every 2 years. 2 Decrease the dose of corticosteroids when stressed. 3 Recognize edema and ways to restrict sodium intake. 4 Plan a diet high in concentrated simple carbohydrates.

3 The nurse should teach the patient to recognize edema and ways to restrict sodium intake to less than 2000 mg/day if edema occurs.The nurse should ask the patient to see an eye specialist yearly to assess for cataracts. The patient should recognize the need for an increased dose of corticosteroids when stressed. The nurse should teach the patient and caregiver to plan a diet high in protein, calcium, and potassium but low in fat and concentrated simple carbohydrates such as sugar, honey, syrups, and candy.

Which clinical manifestation of pain does the nurse expect to identify in a patient who has cholecystitis? 1 Left flank pain with intermittent exacerbations 2 Right lower quadrant pain with rebound tenderness 3 Right upper quadrant pain radiating to the patient's back 4 Epigastric pain that intensifies when the patient is lying down

3 The pain of cholecystitis is in the region of the gallbladder (right upper quadrant), which is inflamed as a result of infection and irritation from bile. The pain may be referred to the right shoulder and scapula. Left flank pain with intermittent exacerbations may be caused by renal calculi. Right lower quadrant pain with rebound tenderness may be related to acute appendicitis, Crohn's disease, or peritonitis. Epigastric pain that intensifies when the patient is lying down may be related to gastroesophageal reflux disease or hiatal hernia.

The nurse is preparing a patient for a water deprivation test for central diabetes insipidus in the hospital. What intervention is required for this patient? 1 Deprive the patient of water for 6 hours. 2 Administer intravenous hypotonic saline or dextrose 5% in water. 3 Administer desmopressin acetate (DDAVP) subcutaneously. 4 Provide the patient with a diluted solution of sodium.

3 The patient is given DDAVP subcutaneously or nasally. The patient is deprived of water for 8 to 12 hours before administration of DDAVP. In acute diabetes insipidus, intravenous hypotonic saline or dextrose 5% in water is given and titrated to replace urine output. The patient with chronic syndrome of inappropriate antidiuretic hormone is given a diluted solution of sodium electrolyte to prevent gastrointestinal irritation or damage.

The priority focus of care in the patient with central diabetes insipidus (DI) is on: 1 Pacing activities and minimizing fatigue 2 Preventing treatment-related hypoglycemia 3 Avoiding dehydration and fluid volume deficit 4 Decreasing renal responsiveness to antidiuretic hormone (ADH)

3 The patient with diabetes insipidus may experience massive diuresis of up to 20 L per day. Severe dehydration and hypovolemic shock may occur if the patient does not consume or receive sufficient fluids to address the urinary losses. The patient may experience nocturia- related weakness and fatigue, but this is of lower priority than preventing dehydration and fluid volume deficit. Diabetes insipidus is a condition of too little ADH. Glucose-lowering agents are not used to treat diabetes insipidus. While diabetes insipidus and diabetes mellitus both result in polydipsia and polyphagia, the mechanism driving these symptoms is entirely different between the two disorders, and treatment is not the same. Diabetes insipidus is a disorder of too little antidiuretic hormone. Decreasing renal responsiveness to a hormone that is already insufficiently present would be deleterious.

A patient's complete blood count is RBC 1.8 × 106/μL, WBC 2 × 109/L, platelets 90 × 109/L. How should the nurse interpret the test results? 1 Leukopenia 2 Neutropenia 3 Pancytopenia 4 Thrombocytopenia

3 The patient's complete blood count is suppressed. There is a marked decrease in the number of RBCs, WBCs, and platelets. This condition is called pancytopenia. Leukopenia is a condition in which white blood cells count less than 4000/μL. Neutropenia is a condition in which the absolute neutrophil count (ANC) is less than 1000 cells/μL. Thrombocytopenia is condition in which platelet counts falls below 100,000/μL

The nurse is reviewing the genetic testing results of a patient, and sees that the patient has a human leukocyte antigen (HLA) allele that is positive for ankylosing spondylitis. Which of these statements is true about the HLA antigens and disease conditions? 1 This patient already has developed ankylosing spondylitis. 2 This patient will develop ankylosing spondylitis at some point in his or her lifetime. 3 This patient has a higher risk than the general population for developing ankylosing spondylitis. 4 Further testing is needed to discover the degree of risk the patient has for developing ankylosing spondylitis.

3 The possession of a particular HLA allele does not mean that the person will necessarily develop the associated disease—only that the relative risk is greater than in the general population. The patient has not developed ankylosing spondylitis already and may not ever develop it. The patient already has had genetic testing for ankylosing spondylitis.

A nurse finds that the patient undergoing radiotherapy has developed erythema and desquamation. Which measure should the nurse include when teaching the patient about skin care in the radiation treatment area? 1 Wear fabrics such as wool and corduroy to prevent exposure to cold. 2 Use perfumes and cosmetics on the treatment area as desired. 3 Gently cleanse the skin using a mild soap, tepid water, and a soft cloth. 4 Allow brief periods of direct exposure to sunlight for good bone health.

3 The skin should be gently cleansed using a mild soap, tepid water, and a soft cloth. Fabrics such as wool and corduroy should not be worn, as they can traumatize the skin. Chemicals like perfumes, cosmetics, and powders should not be used on the treatment area, as they are harsh on skin and can increase the irritation of the skin. The skin should not be exposed to direct sunlight. Protective clothing should be worn, if exposure to sun is expected.

A patient who was in a motor vehicle accident is brought to the emergency department unconscious, and cardiopulmonary resuscitation (CPR) is performed. The patient responds well, and the condition improves. After several hours, the patient experiences dyspnea and becomes cyanotic. On examination the neck veins are distended, and the patient is tachycardic. The nurse expects that the immediate plan for treatment will include what intervention? 1 Oxygen administration 2 Pericardiocentesis 3 Needle decompression 4 Placing the patient in a side-lying position

3 The symptoms and signs indicate that the patient has tension pneumothorax. This is a medical emergency in which air enters into the pleural space and does not come out. This leads to compression of the surrounding organs like the lung, heart, and large vessels. If not treated promptly, the patient may die. Therefore the patient requires immediate needle decompression followed by chest tube insertion with chest drainage system. Oxygen administration will not help this patient. Pericardiocentesis is done for patients with cardiac tamponade. Repositioning the patient to his side is not required in this case.

A patient sustained injuries to the chest and extremities during a street fight. The patient reports shortness of breath. The patient's breath sounds are decreased on the right side, the right lung is dull on percussion, and the blood pressure is 80/50 mm of Hg. The primary health care provider is preparing to insert a chest tube for drainage. The nurse is aware that what size chest tube will be used? 1 28F 2 12F 3 38F 4 24F

3 The symptoms indicate that the patient has hemothorax, which means accumulation of blood in the pleural space. Therefore it is important to drain the blood immediately by chest tube drainage. The size of the tube to be used is determined by the patient's condition. Large tubes 36F to 40F are used to drain the blood. Therefore in this case, the 38F tube should be used. Size 12F to 24F tubes are used to drain air, and size 24F to 36F tubes are used to drain clear fluid.

A nurse is assessing an older adult patient who is diagnosed with coronary artery disease. An angiogram reveals that the patient has 80% block in the left circumflex artery and 70% block in the right coronary artery. The patient does not show any symptoms of coronary ischemia. What is the most appropriate reason for this finding? 1 Lowering of low-density lipoprotein (LDL) levels in the body 2 Pulmonary artery supplies oxygenated blood to the heart 3 Formation of collaterals in the coronary circulation 4 Increased production of C-reactive proteins in the liver

3 This patient is an older adult and, therefore, the occlusion may have occurred slowly over a long period of time. Collateral circulation may have developed which provides adequate blood supply to the myocardium, thereby preventing ischemia. Lowering LDL does not prevent coronary ischemia in the patient whose myocardial blood supply is already compromised. The pulmonary artery consists of deoxygenated blood and does not supply blood to the coronary arteries unless there is a congenital anatomic variation. C-reactive proteins are inflammatory markers that are increased in patients with coronary artery disease. These are not associated with reducing coronary ischemia.

What does the nurse include in the teaching plan for the client who is receiving radioactive iodine (RAI)? 1 Private bathroom facilities are not necessary unless the patient is incontinent 2 Radioactive iodine therapy is contraindicated in women of childbearing age 3 Towels that are used by the patient should not be used by other family members 4 The patient should avoid being around pregnant women and children for 48 hours after treatment

3 To decrease risk of radiation exposure to household contacts, towels and bed linens used by the patient should not be handled by other members of the household and should be washed daily, separate from other household laundry. The patient who has been treated with RAI should use separate bathroom facilities and should flush two to three times after each use. Radioactive iodine may not be given to a pregnant woman. A pregnancy test must be administered to women of childbearing age, to rule out pregnancy, before initiation of therapy. The patient who has received RAI should avoid close proximity to pregnant woman or children for seven days following treatment.

A patient is undergoing transsphenoidal hypophysectomy. The nurse is aware that the procedure involves surgical resection of what gland? 1 Thyroid 2 Adrenal 3 Pituitary 4 Parathyroid

3 Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland. The surgical approach to the pituitary gland is made through an incision through the upper gum and nare into the base of the skull. Transsphenoidal hypophysectomy does not involve removal of the thyroid, adrenal, or parathyroid gland. Text Reference - p. 1190

A patient has been admitted to the emergency department after an automobile accident. The patient had been bleeding from a leg laceration, but the bleeding has stopped. While checking the patient's vital signs, the nurse notes that the patient has normal blood pressure and pulse while at rest, but when getting up to use the bathroom, the patient almost passed out. The nurse rechecked the patient's vital signs and found that the patient's blood pressure had dropped by 20 mm Hg and the pulse had become tachycardic. Based on these findings, the nurse suspects that the patient may have lost what percentage of blood volume? 1 10% 2 20% 3 30% 4 40%

3 Manifestations of loss of 30% of blood volume include normal supine blood pressure and pulse at rest, but postural hypotension and tachycardia with exercise.

A patient with breast cancer who recently had extensive surgical procedures develops hypotension, tachycardia, and decreased urinary output. Which nursing actions would be useful for management of this patient? Select all that apply. 1 Administer fibrinolytic agents. 2 Discourage fluid intake. 3 Replace fluids and electrolytes. 4 Administer plasma protein replacement. 5 Prepare the patient for radiation therapy

3, 4 Extensive surgical procedures in a cancer patient can lead to third space syndrome which involves a shift of fluid from the vascular space to the interstitial space. Its management involves replacement of plasma proteins and fluid and electrolytes. The use of fibrinolytic agents further aggravates the patient's condition. Fluid intake should be encouraged, not discouraged. Use of radiation therapy does not prevent the shifting of fluids

When advising an obese patient about ways to prevent coronary artery disease, the nurse suggests using tofu instead of chicken when making food dishes. Which reasons would have led the nurse to make this suggestion? Select all that apply. 1 Tofu has a high salt content. 2 Tofu has very low-fiber content. 3 Tofu is a good source of alpha-linolenic acid. 4 Tofu increases omega-3 fatty acid in the body. 5 Tofu increases the triglyceride levels in the body.

3, 4 The American Heart Association recommends consuming tofu and other soybean products since they are rich sources of alpha-linolenic acid. Alpha-linolenic acid is converted to omega-3 fatty acid, which reduces the risk of coronary artery disease by lowering the triglyceride levels in the body. A diet high in salt may increase blood pressure, which could make an individual more susceptible to developing coronary artery disease. A high-fiber diet is preferred to prevent coronary artery disease, as fiber is known to reduce total cholesterol and low-density lipoprotein levels. Increased triglyceride levels make an individual more susceptible to atherosclerosis.

A nurse is attending to a patient suffering from cirrhosis of the liver. What clinical manifestations should the nurse expect to find upon physical examination? Select all that apply. 1 White patches on skin 2 Deposits of dark pigments 3 Small areas of bleeding into the skin 4 Vascular lesions formed by small blood vessels 5 Small dilated blood vessels with spiderlike branches

3, 4, 5 Ecchymoses are small areas of bleeding into the skin or mucous membrane forming blue or purple patches. Because there is decreased synthesis of prothrombin in the liver, the bleeding and clotting time may be deranged. Telangiectasia is a vascular lesion formed by a group of small blood vessels. Spider angioma is also seen in cirrhosis of the liver. Vitiligo (white patches of skin) develops from destruction of melanocytes and is not related to cirrhosis. Melanosis is the deposit of dark pigment unrelated to cirrhosis.

A nurse is explaining the warning signs of organ rejection to a patient who had a kidney transplant. What are the signs of rejection that the nurse should explain to the patient? Select all that apply. 1 Weight loss 2 Subnormal temperature 3 Elevated blood pressure 4 Reduction in the amount of urine 5 Pain over the transplant site

3, 4, 5 Hypertension is caused by hypervolemia because of the failure of the new kidney. A reduction in the amount of urine produced indicates ineffective functioning of the kidney. Pain in the site of transplant could be caused by any underlying kidney pathology, which could be a result of rejection. Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. The patient will have an elevated temperature exceeding 100°F with kidney rejection.

The nurse is attending to a patient who receives regular hemodialysis. When teaching the patient about nutritional therapy during hemodialysis, which food items should the nurse tell the patient to avoid? Select all that apply. 1 Pasta 2 Cereal 3 Bananas 4 Pickled tuna 5 Barbecued red meat

3, 4, 5 Pasta and cereal have a good amount of carbohydrates and hence should be encouraged. Bananas are high in potassium, pickled tuna is high in protein and sodium, and barbecued red meat is high in protein, sodium, and potassium. Therefore, these foods are to be avoided in this patient.

When caring for older patients, the nurse should watch for signs of dehydration due to decreased fluid intake. Which factors contribute to dehydration in older patients? Select all that apply. 1 Fear of stomach bloating and discomfort 2 Decreased taste sensation 3 Disorientation and confusion 4 Inability to hold a cup or glass 5 Decrease in thirst mechanisms

3, 4, 5 Some older adults experience mental changes including confusion and disorientation, which may lead to a decrease in fluid intake. In addition, older adults may also have musculoskeletal disabilities, such as stiffness of the hands, which make it difficult for them to hold a cup or glass. Older adults may have decreased thirst mechanisms; therefore they may not feel like drinking water even if they are dehydrated and have increased osmolality and serum sodium levels. Fear of bloating and decreased taste sensation do not affect intake of fluid.

The nurse is caring for a patient who had a recent lung transplant. The nurse knows which of the following? Select all that apply. 1 Acute rejection can occur 2 to 3 weeks after surgery. 2 Immunosupressive therapy is usually a two-drug regimen. 3 Accurate diagnosis of rejection is by transtracheal biopsy. 4 Cytomegalovirus (CMV) pneumonia is the most common opportunistic infection. 5 During the first year, viral pneumonia is the most common postoperative infection. 6 Lung transplant recipients usually receive higher levels of immunosuppressive therapy than other organ recipients.

3, 4, 6 Cytomegalovirus (CMV) is the most common opportunistic infection. Because acute rejection is common, higher levels of immunosuppressive therapy than what other organ recipients receive are given. Diagnosis of rejection is confirmed by transtracheal biopsy. Immunosuppressive therapy is usually a three-drug regimen and acute rejection can occur in the first 5 to 10 postoperative days. If acute rejection is diagnosed, then high doses of corticosteroids are given for three days, followed by high doses of oral prednisone. If this does not work and rejection occurs, then antilymphocytic therapy may be useful. Bacterial pneumonia is the most common postoperative infection.

The nurse is caring for a patient who had a recent lung transplant. The nurse knows which of the following? Select all that apply. 1 Acute rejection can occur 2 to 3 weeks after surgery. 2 Immunosupressive therapy is usually a two-drug regimen. 3 Accurate diagnosis of rejection is by transtracheal biopsy. 4 Cytomegalovirus (CMV) pneumonia is the most common opportunistic infection. 5 During the first year, viral pneumonia is the most common postoperative infection. 6 Lung transplant recipients usually receive higher levels of immunosuppressive therapy than other organ recipients.

3, 4, 6 Cytomegalovirus (CMV) is the most common opportunistic infection. Because acute rejection is common, higher levels of immunosuppressive therapy than what other organ recipients receive are given. Diagnosis of rejection is confirmed by transtracheal biopsy. Immunosuppressive therapy is usually a three-drug regimen and acute rejection can occur in the first 5 to 10 postoperative days. If acute rejection is diagnosed, then high doses of corticosteroids are given for three days, followed by high doses of oral prednisone. If this does not work and rejection occurs, then antilymphocytic therapy may be useful. Bacterial pneumonia is the most common postoperative infection.

A 55-year-old patient with suspected bowel obstruction has had a nasogastric tube inserted at 0800. The tube should be checked routinely at which times? 1 0900, 1000, and 1200 2 08300 and 1430 3 0900, 1200, and 1500 4 1200 and 1600

4 A nasogastric tube should be checked routinely at four-hour intervals. Therefore, if the tube were inserted at 0400, it would be due to be checked at 0800 and 1200. The other time intervals are not consistent with appropriate times to monitor the nasogastric tube.

A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement regarding the nutritional status of this patient is true? 1 Decreased protein intake will decrease the chance of renal complications. 2 Maintaining a hypermetabolic state reduces the patient's risk for infection. 3 Controlling the temperature of the environment reduces caloric requirements. 4 A hypermetabolic state results in poor healing and increased protein and lipid needs.

4 A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism that can inhibit wound healing. Therefore the patient with a burn injury requires increased calories and protein to enable the healing process. Protein intake in the burn patient should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased. A hypermetabolic state is not desired and is a complication of a burn injury. Controlling the temperature of the environment has no effect on caloric requirements.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? 1 Full liquids only 2 Whatever the patient requests 3 High-protein and low-sodium foods 4 High-calorie and high-protein foods

4 A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing

Which clinical action plan is most appropriate for a patient in stage 3 of chronic kidney disease? 1 Diagnosis and treatment 2 Estimation of progression 3 Renal replacement therapy 4 Evaluation and treatment of complications

4 A patient in stage 3 of chronic kidney disease has a moderate decrease in the glomerular filtration rate (GFR). The most appropriate clinical action plan for this patient is evaluation and treatment of complications. Diagnosis and treatment is the clinical action plan for patients in stage 1 of chronic kidney disease. Estimation of progression is the clinical action plan for patients in stage 2 of chronic kidney disease, as this stage is associated with kidney damage with mild decrease in GFR. Renal replacement therapy is the clinical action plan for patients in stage 5, which is associated with kidney failure.

A patient is seen in the emergency department with nausea and vomiting. Which nursing diagnosis has the highest priority? 1 Infection as evidenced by nausea and vomiting 2 Aspiration related to emesis 3 Dehydration related to emesis 4 Hypovolemia related to nausea and vomiting

4 A patient with nausea and vomiting is at risk for hypovolemia and electrolyte imbalance because of the massive amount of fluids that can be lost via emesis. Infection may be the cause of the nausea and vomiting, but the first priority is to assess for fluid and electrolyte imbalance. Aspiration is a potential risk for the patient with altered mental status, but is not mentioned in this scenario. Dehydration related to emesis is incorrect, because dehydration is a loss of water only. A patient who is vomiting is at risk for losing fluid and electrolytes.

A nurse is caring for a patient who is diagnosed with AIDS. The nurse should inform the patient that the virus can be spread through which method? 1 Shaking hands 2 Sharing a toilet seat 3 Eating from the same utensils 4 Having unprotected sex

4 AIDS can be transmitted from one individual to another by unprotected anal or vaginal sexual intercourse. Any sexual activity that involves contact with body fluids, such as semen, vaginal secretions, or blood, can spread the infection. Shaking hands, using common toilet seats, and sharing utensils do not involve contact with body fluids. Therefore, the HIV infection cannot be transmitted through these modes.

The patient is receiving biologic and targeted therapy for ovarian cancer. What medication should the nurse expect to administer before therapy to combat the most common side effects of these medications? 1 Morphine sulfate 2 Ibuprofen (Advil) 3 Ondansetron (Zofran) 4 Acetaminophen (Tylenol)

4 Acetaminophen is administered before therapy and every four hours after to prevent or decrease the intensity of the severe flu-like symptoms, especially with interferon, which frequently is used for ovarian cancer. Morphine sulfate and ibuprofen will not decrease flu-like symptoms. Ondansetron is an antiemetic, but not used first to combat flu-like symptoms such as headache, fever, chills, and myalgias.

A patient is to receive adenosine (Adenocard). It is essential for the nurse to consider which aspect of this patient's care? 1 Renal function 2 Neurological status 3 Presence of an indwelling catheter 4 Proximity of the intravenous (IV) site to the heart

4 Adenosine has a very short half life (less than 10 seconds). Therefore, it is imperative that it be given rapidly, within one to two seconds, followed immediately by 20 mL of Normal saline bolus flush, and be given via an IV site as close as possible to the heart. Renal function, neurological status, and presence of an indwelling catheter are not relevant to the administration of adenosine.

Adrenocortical insufficiency develops secondary to inadequate secretion of which pituitary hormone? 1 Antidiuretic hormone (ADH) 2 Follicle-stimulating hormone (FSH) 3 Thyroid-stimulating hormone (TSH) 4 Adrenocorticotropic hormone (ACTH)

4 Adrenocortical insufficiency occurs as a result of an inadequate amount of serum cortisol, which occurs as a result of undersecretion of ACTH by the anterior pituitary. ADH and FSH are both secreted by the posterior pituitary, not the anterior pituitary. TSH is secreted by the anterior pituitary, but it acts on the thyroid gland to secrete thyroid hormones.

A patient who has undergone bone marrow aspiration is being monitored by the nurse. The nurse observes that bleeding is present at the needle aspiration site. Which action should the nurse advise the patient to perform? 1 Walking for 10 to 15 minutes 2 Sitting for 30 to 40 minutes 3 Standing for 30 to 40 minutes 4 Lying on the side for 30 to 60 minutes

4 After bone marrow aspiration, if bleeding is present at the site, the patient should be advised to lie on the affected side for 30 to 60 minutes to maintain pressure on the site. If the bed is too soft, the patient can lie on a rolled towel to provide additional pressure. Walking, sitting, and standing do not help to maintain pressure on the site.

The nurse is caring for an older patient who is receiving intravenous (IV) fluids postoperatively. During the 8 am assessment of this patient, the nurse notes that the IV solution, which was prescribed to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4 am. What is the priority nursing intervention? 1 Notify the health care provider and complete an incident report. 2 Slow the rate to keep the vein open until the next bag is due at noon. 3 Obtain a new bag of IV solution to maintain patency of the site. 4 Listen to the patient's lung sounds and assess respiratory status.

4 After four hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and the nurse should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further prescriptions.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? 1 Impaired skin integrity related to edema, ascites, and pruritus 2 Imbalanced nutrition: less than body requirements related to anorexia 3 Excess fluid volume related to portal hypertension and hyperaldosteronism 4 Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

4 Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priority. Impaired skin integrity, imbalanced nutrition, and excess fluid volume are all seen in patients with cirrhosis, but they are not priorities at this time.

A patient experienced sudden cardiac death (SCD) while hospitalized and survived. What should the nurse expect to be used as a preventive treatment for this patient while at home? 1 External pacemaker 2 An electrophysiologic study (EPS) 3 Medications to prevent dysrhythmias 4 Implantable cardioverter-defibrillator (ICD)

4 An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital, but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used, but are not the best prevention of SCD.

The nurse recalls that excessive secretion of the hormone vasopressin characterizes: 1 Thyrotoxicosis 2 Diabetes insipidus 3 Hyperosmolar hyperglycemic nonketotic syndrome 4 Syndrome of inappropriate antidiuretic hormone secretion

4 Another term for antidiuretic hormone (ADH) is vasopressin. Syndrome of inappropriate antidiuretic hormone secretion is characterized by excessive release of ADH from the posterior pituitary gland, resulting in the inability of the kidneys to dilute urine. The patient retains water and experiences increased extracellular fluid volume and hyponatremia. The disorder can cause cardiopulmonary overload and neurological problems as a result of water intoxication. Thyrotoxicosis, also known as thyroid storm or thyroid crisis, results from an abrupt increase in T3 and T4 thyroid hormones. Diabetes insipidus results from a decrease in ADH. Hyperosmolar hyperglycemic nonketotic syndrome results from hyperglycemia in type 2 non-insulin-dependent diabetes mellitus.

A nurse, creating a plan of care for a patient with Addison's disease, expects that primary treatment will include: 1 Blood transfusions 2 Ablation of the thyroid 3 Oral calcium supplementation 4 Adrenocorticosteroid replacement therapy

4 Because Addison's disease results from a deficiency of adrenocorticosteroid hormones, steroid therapy is the primary treatment. Blood transfusions, thyroid ablation, and oral calcium supplements are not primary treatments for Addison's disease.

The nurse performs an admission assessment of a patient with acute renal failure. For which common complication does the nurse assess the patient? 1 Polyphagia 2 Hypernatremia 3 Hypotensive shock 4 Cardiac dysrhythmias

4 Because the kidneys are not effectively removing waste products, including electrolytes, an increased potassium level (hyperkalemia) of more than 5.0 mEq/L is common in acute renal failure and places the patient at risk for cardiac arrhythmias. Patients usually experience anorexia, not an increase in hunger. Acute renal failure will likely manifest as hyponatremia. Hypotensive shock may be the result of a severe cardiac arrhythmia that is not treated.

The nurse is assessing a patient who was admitted to the emergency room after an anaphylactic reaction to an antibiotic. Which of these assessment findings may be indicative of the development of disseminated intravascular coagulation (DIC)? 1 Scattered wheezes 2 Increasing dyspnea 3 Bradycardia and hypertension 4 Blood oozing from venipuncture sites

4 Bleeding in a person with no previous history or obvious cause should be questioned because it may be one of the first manifestations of acute DIC. The patient will not have dyspnea or wheezing. Tachycardia and hypotension are found in patients with DIC (not bradycardia and hypertension).

A patient has been advised to undergo an autologous bone marrow transplant. A nurse explains the procedure to the patient. Which patient statement indicates that the teaching has been understood? 1 "It involves transfusing stem cells from an identical twin." 2 "It involves transfusing stem cells from a family member." 3 "It involves transfusing stem cells from a donor from a bone marrow registry." 4 "It involves transfusing stem cells harvested from myself."

4 Bone marrow transplants are very effective in treating malignancies of the bone marrow. There are three types of bone marrow transplantation. An autologous stem cell transplant requires harvesting the stem cells from the patient, and transfusing it back to the patient after myeloablative therapy. Syngeneic transplantation involves obtaining stem cells from one identical twin and infusing them into the other. An allogeneic transplantation involves obtaining stem cells from a donor who is human leukocyte antigen (HLA) matched to the patient. It can be a family member or a donor from a bone marrow registry.

A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage of cancer, the cells' genetic structure is mutated. Exposure to what may have had the greatest impact as a carcinogen for this patient? 1 Bacteria 2 Sun exposure 3 Most chemicals 4 Epstein-Barr virus

4 Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr virus in vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations leading to melanoma and squamous and basal cell skin carcinoma. Long-term exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known to initiate cancer.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? 1 Baked flounder 2 Angel food cake 3 Baked potato with margarine 4 Canned chicken noodle soup

4 Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content. Baked flounder, angel food cake, and baked potato with margarine are all low-sodium and low-fat and would be appropriate for this diet.

The nurse is providing care to a patient with chronic stable angina that is scheduled for a cardiac catheterization. What finding associated with myocardial ischemia could be obtained by this diagnostic procedure? 1 ST segment depression 2 Cardiac enlargement 3 Abnormal cardiac wall motion 4 70% block in right coronary artery

4 Cardiac catheterization is an invasive diagnostic procedure to find out the location and severity of blockages in the coronary circulation. ST segment depression is an important diagnostic finding for the presence of myocardial ischemia, which is obtained by electrocardiography (ECG). Cardiac enlargement is a sign of heart failure that can be seen on an x-ray. Echocardiography is used to detect the presence of abnormal wall motion due to myocardial ischemia.

A nurse caring for a patient with hyperparathyroidism should monitor the patient for which complication? 1 Seizures 2 Cataracts 3 Constipation 4 Cardiac dysrhythmias

4 Cardiac dysrhythmias may result because of the increased serum calcium level in hyperparathyroidism. Seizures and cataracts are complications seen in hypoparathyroidism. Constipation is not directly associated with parathyroid disorders.

The nurse recognizes that a patient is demonstrating signs of a transplant rejection after a renal transplant. Which phenomenon is responsible for the rejection of donor organs and tissue? 1 Innate immunity 2 Passive immunity 3 Humoral immunity 4 Cell-mediated immunity

4 Cell-mediated immunity involves various cells, including natural killer cells. The natural killer cells are responsible for identifying "self" and "non-self" tissues, which sometimes results in rejection of grafts and transplants. Innate immunity is present after birth. It involves a non-specific response through neutrophils and monocytes and is not responsible for graft rejections. Passive immunity results when antibodies are acquired by the body and not produced within. Humoral immunity involves immunoglobulin production and is responsible for allergic reactions

The nurse caring for a patient undergoing chemotherapy finds that the patient has a low white blood cell (WBC) count. Which is an appropriate intervention? 1 Request that the chemotherapy dose be reduced. 2 Monitor the respiratory rate of the patient. 3 Allow the patient to visit with family and friends. 4 Administer white blood cell growth factors.

4 Chemotherapy may suppress the proliferation of bone marrow resulting in neutropenia or low white blood cell counts. Low WBC count makes the patient prone for developing infection; therefore, the nurse should consult the health care provider and get WBC growth factors administered. In addition, the nurse should monitor the temperature of the patient, as it can indicate fever. The number of visitors should be limited to prevent risk of infection. The chemotherapy dose need not be reduced, as neutropenia is a common side effect. Respiratory rate is routinely monitored, but in this case it is not directly related to the patient's WBC.

While assessing a patient's medical history, the nurse notices loss of elasticity of the pericardial sac. Which condition does the nurse suspect in this patient? 1 Pericarditis 2 Pericardiectomy 3 Pericardiocentesis 4 Chronic constrictive pericarditis

4 Chronic constrictive pericarditis results from scarring, with fibrin deposition and loss of elasticity of the pericardial sac. Inflammation of the pericardial sac is termed pericarditis. A pericardiectomy is a procedure that involves complete resection of the pericardium through median sternotomy with the use of cardiopulmonary bypass. Pericardiocentesis is a procedure usually performed for pericardial effusion with acute cardiac tamponade, purulent pericarditis, and suspected neoplasm.

The nurse is admitting a patient with cirrhosis. The nurse checks the patient's history for which most frequent risk factor associated with cirrhosis? 1 Polypharmacy 2 Intravenous drug abuse 3 Hepatitis A 4 Alcohol abuse

4 Cirrhosis is highly correlated with alcohol abuse. Polypharmacy, drug abuse, and hepatitis A are not linked to cirrhosis

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? 1 The patient has completed a college education. 2 The patient has been able to stop smoking cigarettes. 3 The patient has well controlled type 1 diabetes mellitus. 4 The chest x-ray showed another lung cancer lesion.

4 Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course. It does not matter if the patient has a college education. The fact that the patient has quit smoking is not a contraindication for liver transplant. The patient is a well-controlled diabetic, which is not a contraindication.

A patient has impaired intracranial regulation and hypoxemia. The primary health care provider prescribes red blood cell indices for the patient, and the patient later asks the nurse to explain the purpose of the test. What should the nurse tell the patient? 1 To measure the packed cell volume in the blood 2 To test the size and shape of the red blood cells 3 To measure the number of circulating red blood cells 4 To measure the gas-carrying capacity of the red blood cells

4 Decreased hemoglobin saturation results in hypoxemia and compromises brain function, causing the patient to experience difficulty with intracranial regulation. Red blood cell indices are special indicators that reflect red blood cell volume, color, and hemoglobin saturation. Hematocrit value gives the measure of packed cell volume of red blood cells. Hematocrit value is generally three times the hemoglobin value. Red blood cell morphology provides information regarding the size and shape of the patient's red blood cells. Total red blood cell count gives the number of circulating red blood cells.

A patient has a newly formed ileostomy and asks the nurse, "When can I start training my ostomy to only produce stool at certain times?" What is the nurse's appropriate response? 1 "We will start training when the stoma heals." 2 "When your stools transition from liquid to semisolid." 3 "Because you have an ileostomy and not a colostomy, we can start any time." 4 "We will not be able to train your ileostomy because of the frequent drainage from the site."

4 Drainage from the ileostomy is frequent, of liquid consistency, and irritating to the skin, preventing regularity from being established. Not all colostomies can be trained. A colostomy formed in the sigmoid or descending colon produces semiformed or formed stools and can be regulated by the irrigation method.

A patient who is undergoing a diagnostic workup for cancer expresses anxiety about the results. Which is the best nursing response? 1 "It is probably nothing." 2 "Let's discuss that later." 3 "Everyone feels that way." 4 "Let's talk about your concerns."

4 During the diagnostic workup of cancer, it is common for patients to be anxious. The nurse should actively listen to all concerns expressed. The nurse should not use communication patterns that may hinder exploration of feelings and meanings. "It is probably nothing" may indicate that the nurse is giving false reassurances. "Let's discuss that later" may mean that the nurse is delaying the discussion, and "Everyone feels this way" means that the nurse is generalizing the patient's concern. By using these strategies, the nurse may deny patients the opportunity to share the meaning of their experience.

What is the primary function of interferon-beta? 1 Proliferation and differentiation of monocytes 2 Proliferation and differentiation of neutrophils 3 Production of red blood cells in the bone marrow 4 Activation of natural killer cells and macrophages

4 Interferon-beta activates natural killer cells, inhibits viral replication, and has antiproliferative effects on tumor cells. Granulocyte-macrophage colony-stimulating factor (GM-CSF) is responsible for the proliferation and differentiation of monocytes. GM-CSF stimulates the proliferation and differentiation of neutrophils. Production of red blood cells in the bone marrow is the function of erythropoietin.

The nurse reviews lab values for a patient who underwent thyroidectomy 48 hours ago. Which finding is of most concern? 1 Increased thyroxine 2 Decreased phosphorus 3 Increased serum calcium 4 Decreased serum calcium

4 During thyroid surgery the parathyroid glands are often unavoidably removed. The result is an inability to regulate serum calcium stemming from a lack of parathyroid hormone. In hypoparathyroidism there is a decrease in parathyroid hormone, which results in decreased serum calcium and increased phosphorus levels. An increase in thyroxine is not seen after thyroidectomy; the thyroxine level may actually drop below normal. Decreased phosphorus and increased serum calcium levels may occur initially after a thyroidectomy because of manipulation of the thyroid gland during surgery. This causes a surge of parathormone, but the level does decrease if the parathyroid glands are removed.

The patient is wondering why anesthesia is needed when the lithotripsy being done is noninvasive. The nurse explains that the anesthesia is required to ensure the patient's position is maintained during the procedure. The nurse knows that this type of lithotripsy is called: 1 Laser lithotripsy 2 Electrohydraulic lithotripsy 3 Percutaneous ultrasonic lithotripsy 4 Extracorporeal shock-wave lithotripsy (ESWL)

4 ESWL is noninvasive, but anesthesia is used to maintain the patient's position. The other types of lithotripsy are invasive. Laser lithotripsy uses an ureteroscope and small fiber to reach the stone. Electrohydraulic lithotripsy positions a probe directly on the stone then continuous saline irrigation flushes are used to rinse the stone out. Percutaneous ultrasonic lithotripsy places an ultrasonic probe in the renal pelvis via a percutaneous nephroscope inserted through an incision in the flank.

The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? 1 Low pitched and rumbling above the area of obstruction 2 High pitched and hypoactive below the area of obstruction 3 Low pitched and hyperactive below the area of obstruction 4 High pitched and hyperactive above the area of obstruction

4 Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

The nurse is providing patient education for a newly diagnosed human immunodeficiency virus (HIV)-infected patient. Which of these statements by the patient reflects a need for further teaching? 1 "I need to keep my appointments for follow-up laboratory work." 2 "I will call my health care provider if I am too sick to take these drugs." 3 "I won't take any new drugs or herbal products without checking with my health care provider first." 4 "Once my tests show that the virus has decreased, I cannot give HIV to another person."

4 Even at the point when the viral load is undetectable, HIV still can be transmitted to others and the patient will need to continue protection measures. It is important to keep the appointments for follow-up laboratory work to monitor the effectiveness of the antiretroviral therapy (ART). Patients should be instructed to take all medications as prescribed without stopping any of them. If the patient is unable to tolerate even one of the drugs, then the health care provider needs to be notified immediately. Instruct patients not to take any other medications, including over-the-counter and herbal products, without checking with the health care provider first.

A nurse is assessing a 53-year-old obese female patient who has been postmenopausal for three years. The nurse suspects that the patient may have coronary artery disease and asks the patient to test her lipid profile. What abnormality in the lipid profile would the nurse expect to find? 1 Increased high-density lipoprotein and low-density lipoprotein levels 2 Decreased high-density lipoprotein and low-density lipoprotein levels 3 Decreased low-density lipoprotein and increased high-density lipoprotein levels 4 Decreased high-density lipoproteins and increased low-density lipoprotein levels

4 Following menopause, there is a significant increase in the low-density lipoprotein levels and a consequent reduction in the high-density lipoprotein levels. This occurs due to hormonal changes in the body. This makes postmenopausal women more susceptible to developing coronary artery disease. Obese postmenopausal women may have increased levels of both high-density lipoproteins and low-density lipoproteins (HDLs and LDLs). As the patient is obese, the low-density lipoproteins (LDL) levels would be high and as she is postmenopausal, there is a marked reduction in high-density lipoprotein levels (HDLs). Before menopause, high estrogen levels cause an increase in high-density lipoproteins and lowering of low-density lipoprotein levels

The nurse has been teaching a patient about ways to decrease risk factors for coronary artery disease (CAD). Which statement by the patient indicates an adequate understanding? 1 "I will add weightlifting to my exercise program." 2 "I will change my diet to increase my intake of saturated fats." 3 "I need to switch to smokeless tobacco instead of smoking cigarettes." 4 "I will change my lifestyle to reduce activities that increase my stress."

4 Health-promoting behaviors for those at risk for CAD include: improving physical activity such as brisk walking (three to four miles/hour for at least 30 minutes five or more times a week); reducing total fat and saturated fat intake; stopping all tobacco use, and altering patterns that are conducive to stress.

The health care provider prescribes lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? 1 Relief of constipation 2 Relief of abdominal pain 3 Decreased liver enzymes 4 Decreased ammonia levels

4 Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. Lactulose does not relieve constipation or abdominal pain or decrease liver enzymes.

A patient has an undetectable level of plasma human immunodeficiency virus (HIV) RNA after 6 months of antiretroviral therapy. The patient exclaims, "I'm so glad to be cured!" Which response by the nurse is most therapeutic and accurate? 1 "Oh, that is wonderful. I'm glad everything worked out so well for you." 2 "No, you're wrong. You're never going to be cured— this is a lifelong illness." 3 "You should be very pleased, and I think you should celebrate the good news." 4 "An undetectable level means that your therapy was successful but not that you were cured."

4 Human immunodeficiency virus antiretroviral therapy can reduce viral load, resulting in an undetectable serum level. This does not indicate a cure; rather, it indicates that the therapy is working and that the patient must continue to take the medication. Congratulating the patient, or telling her to celebrate, is inaccurate and incorrect; telling her that she is wrong and will never be cured is nontherapeutic.

The nurse should monitor for increases in which patient's laboratory value as a result of being treated with dexamethasone (Decadron)? 1 Sodium 2 Calcium 3 Potassium 4 Blood glucose

4 Hyperglycemia or increased blood glucose level is an adverse effect of corticosteroid therapy. Sodium, calcium, and potassium levels are not affected directly by dexamethasone.

A patient has just been admitted to the intensive care unit with a suspected diagnosis of pulmonary embolism (PE). The patient's condition is stable. The nurse will prepare for which intervention? 1 Oral administration of warfarin (Coumadin) 2 Thrombolytic therapy with alteplase (Activase) 3 Intravenous administration of unfractionated heparin 4 Subcutaneous administration of enoxaparin (Lovenox)

4 Immediate anticoagulation is required for patients with PE. Subcutaneous administration of low-molecular-weight heparin (LMWH; e.g., enoxaparin) has been found to be safer and more effective than use of unfractionated heparin. It is the recommended choice of treatment for patients with nonmassive PE. Warfarin should be initiated within the first three days of heparinization and typically is administered for three to six months. Thrombolytic therapy in PE is done in cases of hemodynamic instability and right ventricular dysfunction.

The nurse is reviewing the pathophysiology of human immunodeficiency virus (HIV) infection. Which of these statements about HIV infection is true? 1 HIV is able to replicate outside a living cell. 2 The virus replicates going from DNA to RNA. 3 Infection of monocytes may occur, but antibodies quickly destroy these cells. 4 The immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells.

4 Immune dysfunction in HIV infection is predominantly the result of damage to and destruction of CD4+ T cells (also known as T helper cells or CD4+ T lymphocytes). HIV cannot replicate unless it is inside a living cell. HIV replicates in a "backward" manner (going from RNA to DNA). Antibodies do not destroy the infected monocytes.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? 1 "The hepatitis vaccine will provide immunity from this exposure and future exposures." 2 "I am afraid there is nothing you can do because the patient was infectious before admission." 3 "You will need to be tested first to make sure you don't have the virus before we can treat you." 4 "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."

4 Immunoglobulin provides temporary (one to two months) passive immunity and is effective for preventing hepatitis A if given within two weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is used only for preexposure prophylaxis.

A patient with liver cancer is scheduled to receive radiofrequency ablation (RFA) therapy. The nurse knows that this treatment is appropriate for which of these? 1 Metastatic liver cancer 2 Large tumors over 6 cm in size 3 Tumors that are less than 3 cm in size 4 Tumors that are less than 5 cm in size

4 In RFA, a thin needle is inserted into the core of the tumor. The electrical energy is used to create heat in a specific location for a limited time. The end result is destruction of tumor cells. This procedure can be done percutaneously, laparoscopically, or through an open incision. RFA can be used to treat tumors that are less than 5 cm in size and for palliative purposes. RFA is not effective in tumors over 6 cm or metastatic cancer. Alcohol injection is used for tumors that are less than 3 cm in size.

After receiving chemotherapy treatments for leukemia, a patient is declared to be in partial remission. Which statement does the nurse identify as being true about partial remission? 1 All molecular studies for residual leukemia are negative. 2 No evidence of overt disease on examination, and normal bone marrow and peripheral blood. 3 Tumor cells cannot be detected by morphologic examination, but are present in molecular testing. 4 A lack of symptoms and a normal peripheral blood smear, but evidence of the disease is still present in bone marrow.

4 In complete remission there is no evidence of overt disease on physical examination, and the bone marrow and peripheral blood appear normal. A lesser state of control is known as partial remission. Minimal residual disease is defined as tumor cells that cannot be detected by morphologic examination, but can be identified by molecular testing. Partial remission is characterized by a lack of symptoms and a normal peripheral blood smear, but still evidence of disease in the bone marrow. Molecular remission indicates that all molecular studies are negative for residual leukemia.

A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next? 1 Insert a Foley catheter and monitor output. 2 Obtain vital signs and a stat arterial blood gas (ABG). 3 Obtain a sputum specimen and send it to the lab stat. 4 Anticipate the need for endotracheal intubation and notify the health care provider.

4 Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for endotracheal intubation and mechanical ventilation as this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time.

The nurse is reviewing the role of the immune system in cancer development. Which of these statements explains the primary protective role of the immune system related to malignant cells? 1 Immune cells bind with free antigen released by malignant cells. 2 Immune cells produce blocking factors that immobilize cancer cells. 3 The immune system produces antibodies that attack the cancer cells. 4 The immune system provides surveillance for cells with tumor-associated antigens (TAAs).

4 It is believed that one of the functions of the immune system is to respond to TAAs, which are altered cell-surface antigens that occur on a cancer cell as a result of malignant transformation. This immune function is known as immunologic surveillance. Immune cells do not bind with free antigens released by malignant cells, nor do they produce blocking factors that immobilize cancer cells. The immune system does not produce antibodies to attack cancer cells.

When teaching a patient about modifying risk related to serum lipid levels, what action should the nurse teach to help lower the risk of coronary artery disease? 1 Decrease low-density and high-density lipoprotein levels. 2 Increase low-density and high-density lipoprotein levels. 3 Increase low-density lipoproteins and decrease high-density lipoprotein levels. 4 Increase high-density lipoproteins and decrease low-density lipoprotein levels

4 Low-densitylipoproteins contain more cholesterol than any other lipoprotein and have an attraction to arterial walls, whereas high-density lipoproteins carry lipids away from the arteries to the liver for metabolism and prevent lipid accumulation within the arterial walls. Therefore, increasing high-density lipoprotein levels and decreasing low-density lipoprotein levels are most helpful in lowering the patient's risk of coronary artery disease. The nurse should not advise the patient to decrease high-density lipoproteins or increase low-density lipoprotein levels, because these actions would be counterproductive.

The nurse provides instructions regarding markings on the skin to a patient who is undergoing radiation therapy. What explanation should the nurse provide regarding the markings? 1 They are permanent effects of radiation therapy. 2 They indicate that previous treatments have been unsuccessful. 3 They are a warning of potentially serious side effects of radiation. 4 They should be protected, because they are landmarks for the radiation therapy.

4 Markings should be protected from being washed or removed because they are landmarks for the radiation therapy treatment field. They are not permanent; nor are they an indication that previous treatment has been unsuccessful or a warning about the side effects of radiation.

Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? 1 Acute pain 2 Hypothermia 3 Powerlessness 4 Risk for infection

4 Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain also are possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount.

What is the therapeutic role of digoxin in treating myocarditis? 1 To decrease preload 2 To treat an enlarged heart 3 To improve cardiac output 4 To improve myocardial contractility

4 Myocarditis is the diffuse inflammation of myocardium. Digoxin improves myocardial contractility and reduces the heart rate. Diuretics reduce the fluid volume and decrease the preload. ACE inhibitors reduce afterload and treat anenlarged heart associated with myocarditis. Intravenous medications like nitroprusside reduce afterload and improve cardiac output by decreasing systemic vascular resistance

The patient with pericarditis is complaining of chest pain. After assessment, which intervention should the nurse expect to implement to provide pain relief? 1 Corticosteroids 2 Morphine sulfate 3 Proton pump inhibitor 4 Nonsteroidal antiinflammatory drugs (NSAIDs)

4 NSAIDs will control pain and inflammation. Corticosteroids are reserved for patients already taking them for autoimmune conditions or those who do not respond to NSAIDs. Morphine is not necessary. Proton pump inhibitors are used to decrease stomach acid to avoid the risk of gastrointestinal bleeding from the NSAIDs.

A human immunodeficiency virus (HIV)-infected patient asks the nurse, "I've heard about opportunistic diseases in HIV-infected people. What does that mean? I already have the HIV infection." Which response by the nurse is correct? 1 "These diseases are usually benign." 2 "Opportunistic diseases only occur at the end-stages of HIV infection." 3 "Unfortunately, opportunistic diseases are not treatable if they occur." 4 "These are caused by organisms that do not cause severe disease in those with functioning immune systems."

4 Opportunistic diseases generally do not occur in the presence of a functioning immune system. Organisms that do not cause severe disease in people with functioning immune systems can cause debilitating, disseminated, and life-threatening infections during this stage. Several opportunistic diseases may occur at the same time, compounding the difficulties of diagnosis and treatment. Advances in HIV treatment have decreased the occurrence of opportunistic diseases. These diseases can occur early in the process of HIV infection and sometimes are used to diagnose the presence of HIV.

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? 1 Chronic stable angina 2 Left-sided heart failure 3 Coronary artery disease (CAD) 4 Acute myocardial infarction

4 PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD normally are treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

The nurse notes that a patient has a history of paroxysmal supraventricular tachycardia. What heart rate characterizes this dysrhythmia? 1 Slower than 60 beats/min 2 Between 60 and 100 beats/min 3 Between 100 and 150 beats/min 4 Between 150 and 220 beats/min

4 Paroxysmal supraventricular tachycardia (PSVT) is characterized by a heart rate of 150 to 220 beats/min. A heart rate of fewer than 60 beats/min is considered bradycardia. A rate of 100 beats/min is the upper limit for a normal heart rate, and a rate of 100 to 150 beats/min is the range for a sinus tachycardia.

The nurse is caring for a patient with a diagnosis of idiopathic pulmonary arterial hypertension (IAPH). The nurse knows that: 1 IAPH occurs more often in males than females. 2 The mean diagnosis time between onset of symptoms and diagnosis is 5 to 10 years. 3 IAPH increases the work of the left ventricle and causes left-ventricular hypertrophy. 4 Functional classification of IAPH is measured by using the New York Heart Association Scale.

4 Patients are classified using the New York Heart Association functional classification. IAPH occurs more often in females than in males. The time between onset of symptoms and diagnosis is about two years and usually by the time the patient becomes symptomatic, the disease is in the advanced stages. IAPH increases the work of the right ventricle and causes right-ventricular hypertrophy (cor pulmonale).

When caring for a patient during the oliguric phase of acute kidney injury (AKI), what is an appropriate nursing intervention? 1 Weigh patient three times weekly 2 Increase dietary sodium and potassium 3 Provide a low-protein, high-carbohydrate diet 4 Restrict fluids according to previous daily loss

4 Patients in the oliguric phase of acute kidney injury will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted. The patient also should be weighed daily, not just three times each week. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism.

A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in management of this patient? 1 Administration of β-blocker medications 2 Abdominal palpation to search for a tumor 3 Administration of potassium-sparing diuretics 4 A 24-hour urine collection for fractionated metanephrines

4 Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable, with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma preoperatively an α-adrenergic receptor blocker is used to reduce blood pressure. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed; most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

The nurse preparing to administer a dose of potassium phosphate (Neutra-phos) would hold the medication after noting which laboratory value? 1 Sodium 133 mEq/L 2 Magnesium 1.8 mEq/L 3 Potassium 5.2 mEq/L 4 Calcium 6.4 mg/dL

4 Phosphorus and calcium have inverse or reciprocal relationships, meaning that when calcium levels are high, phosphorus levels tend to be low. Therefore, administration of phosphorus will reduce a patient's already abnormally low calcium level, which can result in life-threatening complications. Potassium phosphate will not have any effect on sodium, magnesium, or potassium levels.

The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? 1 Sodium 2 Potassium 3 Magnesium 4 Phosphorus

4 Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore, administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. PhosLo will not have an effect on sodium, potassium, or magnesium levels.

A patient is scheduled for pelvic radiation therapy. The patient asks why the instructions state to go for radiation therapy with a full bladder. What explanation should the nurse give? 1 A full bladder indicates adequate fluid intake. 2 A full bladder improves effectiveness of the treatment. 3 A full bladder prevents harmful effects of radiation therapy on the bladder. 4 A full bladder moves the bowels out of the treatment field.

4 Radiation therapy may compromise the gastrointestinal function, leading to diarrhea. The small bowel is highly sensitive to radiation therapy and may not tolerate significant doses. A full bladder helps to move the bowels out of the treatment field and minimizes the radiation effects on it. An adequate urine output indicates an adequate fluid intake. A full bladder does not improve the effectiveness of the therapy, and does not prevent harmful effects of radiation therapy on the bladder.

A patient is experiencing atrial flutter. The nurse anticipates that what treatment will most likely be included in the patient's plan of care? 1 Anticholinergic drugs 2 Carotid massage 3 The Maze procedure 4 Radiofrequency catheter ablation

4 Radiofrequency catheter ablation is the most effective technique for the treatment of atrial flutter. It is performed in the electrophysiology study laboratory, and involves the introduction of a catheter in the right atrium. The tissue is targeted and destroyed by the application of low-voltage, high-frequency electrical impulses. The destruction of the tissue results in a normal sinus rhythm. Anticholinergic drugs would increase the heart rate and are thus not appropriate to treat atrial flutter. Carotid massage is a maneuver for vagal stimulation and is generally used for treating paroxysmal supraventricular tachycardia. The Maze procedure is performed to treat atrial fibrillations that are refractory to drugs, electrical conversion, and radiofrequency catheter ablation.

The nurse is caring for a patient who has had a left pneumonectomy. An appropriate nursing intervention for a patient postpneumonectomy is 1 Monitoring chest tube drainage and functioning 2 Positioning the patient on the nonoperative side 3 Auscultating frequently for lung sounds on the operative side 4 Encouraging range-of-motion exercises on the affected upper extremity

4 Range of motion exercises performed on the affected upper extremity will prevent edema and encourage circulation to the lung space to promote healing. A patient who has had a pneumonectomy may have a clamped chest tube postoperatively, so there will not be any drainage. Fluid will gradually fill space where the lung has been removed. Position patient on operative side to facilitate expansion of remaining lung. There will not be lung sounds on the operative side as the entire lung has been removed.

When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume? 1 Polyuria 2 Decreased pulse 3 Difficulty breathing 4 General restlessness

4 Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma

A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient? 1 Decrease fluid intake to avoid ascites. 2 Eat foods quickly so they do not get cold and cause distress. 3 Avoid exercise because it may cause bleeding of the varices. 4 Avoid straining during defecation to keep venous pressure low.

4 Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation.

The patient has been diagnosed with non-small cell lung cancer. Which type of targeted therapy most likely will be used for this patient to suppress cell proliferation and promote programmed tumor cell death? 1 Proteasome inhibitors 2 BCR-ABL tyrosine kinase inhibitors 3 CD20 monoclonal antibodies (MoAb) 4 Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TK)

4 Targeted therapies are more selective for specific molecular targets. Thus they are able to kill cancer cells with less damage to normal cells than with chemotherapy. Epidermal growth factor receptor (EGFR) is a transmembrane molecule that works through activation of intracellular tyrosine kinase (TK) to suppress cell proliferation and promote apoptosis of non-small cell lung cancer, and some colorectal, head and neck, and metastatic breast cancers. Proteasome inhibitors promote accumulation of proteins that promote tumor cell death for multiple myeloma. BCR-ABL tyrosine kinase inhibitors target specific oncogenes for chronic myeloid leukemia and some gastrointestinal stromal tumors. CD20 monoclonal antibodies (MoAb) bind with CD20 antigen, causing cytotoxicity in non-Hodgkin's lymphoma and chronic lymphocytic leukemia

An 80-year-old patient with uncontrolled type 1 diabetes mellitus is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to consider what procedure? 1 Aortic valve replacement 2 Nitroglycerin for chest pain 3 Open commissurotomy (valvulotomy) procedure 4 Percutaneous transluminal balloon valvuloplast (PTBV) procedure

4 The PTBV procedure is best for this older adult patient who is a poor surgery candidate related to the uncontrolled type 1 diabetes mellitus. Aortic valve replacement probably would not be tolerated well by this patient, although it may be done if the PTBV fails and the diabetes is controlled in the future. Nitroglycerin is used cautiously for chest pain because it can reduce blood pressure and worsen chest pain in patients with aortic stenosis. Open commissurotomy procedure is used for mitral stenosis.

A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication prescription should the nurse question because it is most likely to cause hepatic complications? 1 Tramadol (Ultram) 2 Hydromorphone (Dilaudid) 3 Oxycodone with aspirin (Percodan) 4 Hydrocodone with acetaminophen (Vicodin)

4 The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage. Tramadol, hydromorphone, and oxycodone with aspirin are less likely to cause complications than acetaminophen.

A patient undergoes modified radical mastectomy with axillary node dissection. After the surgical incision is sufficiently healed, the patient is to undergo radiation therapy. What instruction should the nurse give the patient regarding care of the skin at the site of radiation therapy? 1 Expose the area to sunlight twice a week 2 Apply an ointment to the area to prevent irritation 3 Apply talcum powder to the area to promote comfort 4 Wash the area gently with lukewarm water and lightly pat it dry

4 The area undergoing radiation therapy may safely be washed with lukewarm water if it is done gently and if care is taken not to injure the skin. A patient undergoing radiation therapy should avoid anything that may be irritating to the skin, such as sunlight, lotions, ointments, or talcum powder.

A patient with chronic kidney disease has an arteriovenous (AV) graft in the right forearm. What is the nurse's priority in determining the patency of the graft? 1 Determine the range of motion of the right arm and shoulder 2 Observe for clubbing of the fingers on the right hand of the AV graft site 3 Compare radial pulses by checking the right and left pulses simultaneously 4 Check for a bruit by listening over the right arm AV graft site with a stethoscope

4 The arteriovenous (AV) graft is an artificial connection between an artery and vein to provide access for hemodialysis. Thrombosis may occur; therefore the need to determine patency is an essential assessment. Palpation of the site should indicate a thrill, which also indicates that the graft is patent. Listening over the AV graft should reveal a bruit sound, indicating patency. A bruit sounds similar to the impulse beat heard when measuring blood pressure. The arm that has the AV graft site should not be put through range-of-motion movements or exercises. Clubbing is not a complication observed in the fingers of a patient with an AV graft. Comparing the left radial pulse with the pulse on the AV graft site is not an accurate patency assessment procedure.

The patient has had type 1 diabetes mellitus for 25 years and now is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? 1 Serum creatinine 2 Serum potassium 3 Microalbuminuria 4 Calculated glomerular filtration rate (GFR)

4 The best study to determine kidney function or CKD that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for three months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

A patient is scheduled for surgery to have a permanent ostomy created. What does the nurse remember is the preferred site for the ostomy? 1 Terminal ileum 2 Ascending colon 3 Transverse colon 4 Descending colon

4 The descending colon is the preferred site for a permanent ostomy. Because the colon absorbs water in large quantities, the preferred site is as close to the end of the colon as possible, where stools will be of a more normal consistency. A permanent ostomy may be required in the terminal ileum or the ascending or transverse colon. However, the farther down in the colon that the ostomy is performed, the better the possibility of regulating the stools. An ostomy located at the terminal ileum is known as an ileostomy. An ostomy in the large intestine is known as a colostomy.

The nurse cares for a patient with advanced cirrhosis. What indicates that the patient is experiencing a serious complication? 1 Urine retention 2 Increased blood glucose 3 No bowel movement in 3 days 4 Frequent nosebleeds and bruising

4 The liver produces clotting factors. As cirrhosis becomes more advanced, the production of clotting factors is disrupted and thereby decreased, making the patient more susceptible to bleeding. Increasing frequency and severity of nosebleeds and bruising would indicate a deterioration in liver function. Urine retention, abnormal blood glucose, and constipation are not directly associated with advanced cirrhosis.

When teaching the male patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? 1 "I will use care when kissing my wife to prevent giving it to her." 2 "I will need to take adofevir (Hepsera) to prevent chronic HCV." 3 "Now that I have had HCV, I will have immunity and not get it again." 4 "I will need to be checked for chronic HCV and other liver problems."

4 The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with hepatitis A virus (HAV) and HBV, so the patient may be reinfected with another type of HCV.

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report? 1 60 mL urine output in 90 minutes 2 1200 mL urine output in 24 hours 3 300 mL urine output per eight-hour shift 4 20 mL urine output for two consecutive hours

4 The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that subsequently were attributed to ST segment elevation myocardial infarction (STEMI). What complication of myocardial infarction (MI) should the nurse anticipate? 1 Unstable angina 2 Cardiac tamponade 3 Sudden cardiac death 4 Cardiac dysrhythmias

4 The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

While assessing a patient with suspected Cushing's syndrome, of what most prominent clinical manifestation is the nurse aware? 1 Dehydration and hypotension 2 "Bulking up" of skeletal muscle 3 Hypoglycemia with intense hunger 4 Weight gain, including truncal obesity

4 The most prominent clinical manifestation in Cushing's syndrome is weight gain leading to truncal obesity, with a characteristic rounded "moon face" and fat deposits in the neck and upper back, also known as a "buffalo hump." Cushing syndrome's results from an overproduction of adrenocorticosteroids or large doses of steroid medication. Dehydration and hypotension, bulking of skeletal muscle, and hypoglycemia with intense hunger are not directly associated with Cushing's syndrome.

A 49-year-old patient with an abdominal mass and suspected bowel obstruction asks the nurse why a nasogastric tube is going to be inserted. Which response by the nurse is most appropriate? 1 "The tube will push past the area that is blocked and help stop the vomiting." 2 "The tube will let us measure your stomach contents so we can rehydrate you properly." 3 "The tube is just a standard procedure before surgery to the abdomen." 4 "The tube will help to drain the stomach contents and prevent further vomiting."

4 The nasogastric tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The tube will not remove the blockage; is not standard for abdominal surgery. Although the nasogastric tube will measure stomach contents, it is not the priority reason for insertion in the patient with bowel obstruction.

The patient has a one-time prescription for potassium chloride 20 mEq in 250 mL of normal saline intravenous (IV) to be given immediately. The nurse would seek clarification for this prescription if the patient's more recent potassium level is: 1 1.7 mEq/L 2 2.9 mEq/L 3 3.6 mEq/L 4 4.5 mEq/L

4 The normal range for serum potassium is 3.5 to 5 mEq/L. The IV prescription provides a substantial amount of potassium, so the patient's potassium level must be low. A level of 4.5 mEq/L would not warrant this medication.

A patient is receiving tacrolimus (Prograf, FK506) as a part of triple immunosuppressant therapy after a kidney transplant. Which instruction is most important when teaching the patient about this particular medicine? 1 Wear a mask when going out. 2 Eat a healthy and nutritious diet. 3 Avoid meeting people who have a cold. 4 Avoid consuming grapefruit or its juice

4 The nurse should educate the patient to avoid consuming grapefruit or grapefruit juice, as it can interact with tacrolimus and prevent its metabolism. This decreased metabolism can lead to toxicity of the drug through accumulation. Wearing a mask when going out, eating a healthy diet, and avoiding people who have an infection are general measures to prevent contracting infections when on immunosuppressive therapy but are not specifically related to consuming this medication.

A patient newly diagnosed with HIV wishes to know the ways to prevent transmission of HIV to others. Which instruction should the nurse include in her teachings? 1 Do not hug or kiss other people. 2 Do not shake hands with people. 3 Avoid sharing utensils with others. 4 Avoid sexual contact with noninfected partners

4 The nurse should inform the patient that HIV can be transmitted through sexual contact, and the patient should abstain from any kind of sexual activity that involves contact with body fluids. In addition, HIV can also be transmitted through exposure to HIV-infected blood or blood products; and perinatal transmission during pregnancy, at delivery, or through breastfeeding. However, HIV cannot be transmitted through hugging or kissing, shaking hands with people, or sharing utensil

A patient with cirrhosis of the liver has ascites and is being prepared for a paracentesis. What instructions should the nurse give the patient? 1 The patient should fast overnight. 2 The patient should not pass urine until the procedure. 3 The patient should not take any fluids before the procedure. 4 The patient should void urine immediately before the paracentesis.

4 The nurse should instruct the patient to void prior to the paracentesis to prevent accidental puncture of the bladder. During the procedure, the patient sits on the side of the bed or is placed in high Fowler's position. There is no need to keep the patient on NPO status (taking nothing by mouth) or to restrict fluid intake.

A patient is being administered 15 g sodium polystyrene sulfonate (Kayexalate) orally for hyperkalemia. Which intervention should the nurse perform? 1 Observe the patient for iron overload. 2 Inform the patient that constipation is an expected side effect. 3 Provide magnesium-containing antacids. 4 Report peaked T waves in electrocardiogram (ECG).

4 The nurse should report changes to the health care provider in the ECG, such as peaked T waves and widened QRS complexes; dialysis may be required to remove excess potassium. Monitoring for iron overload is a consideration for blood transfusions, but not for administration of sodium polystyrene sulfonate. The nurse should warn the patient that this treatment will often cause diarrhea because the preparation contains sorbitol, a sugar alcohol that has an osmotic laxative action. Magnesium-containing antacids should not be prescribed for patients with chronic kidney disease because magnesium is excreted by the kidneys.

he nurse finds that the patient's platelet count is below 10,000/μL. To avoid complications associated with the patient's condition, what should the nurse include in the patient's teaching? 1 Avoid people who have infections. 2 Include iron-rich food in the diet. 3 Anticipate further testing to determine the cause of the abnormally high number. 4 Look for signs of hemorrhage such as visual abnormalities.

4 The patient has thrombocytopenia. As the platelet count falls below 10,000/μL, it produces the risk of hemorrhage. The patient should be advised to look for signs of hemorrhage such as visual abnormalities, or bleeding from the gingival and mucus membrane. People with low WBC counts have an increased risk of infection and should be advised to avoid crowds. A low RBC count may require the patient to include iron-rich food items in the diet. A high WBC count may require further investigation for lymphoma.

The nurse provides care for a patient with respiratory alkalosis. What arterial blood gas results correspond to this condition? 1 pH 7.46, pco2 44 mm Hg, po2 95 mm Hg, and HCO3- 36 mEq/L 2 pH 7.27, pco2 70 mm Hg, po2 80 mm Hg, and HCO3- 26 mEq/L 3 pH 7.30, pco2 35 mm Hg, po2 70 mm Hg, and HCO3- 20 mEq/L 4 pH 7.52, pco2 24 mm Hg, po2 85 mm Hg, and HCO3- 24 mEq/L

4 The patient is experiencing alkalosis because the pH is greater than 7.45. The alkalosis is of a respiratory origin because the carbon dioxide is below normal (reflecting that there is not enough acid) and the HCO3 - is within normal range. Normal arterial blood gas values include pH 7.35 to 7.45, PCO2 35 to 45, HCO3 - 22 to 26. A pH of 7.46, pco2 of 44 mm Hg, po2 of 95 mm Hg, and HCO3 - of 36 mEq/L indicate metabolic alkalosis, because pH is increased, the Pco2 is normal, and the HCO3 - is increased. A pH of 7.27, pco2 of 70 mm Hg, po2 of 80 mm Hg, and HCO3 - of 26 mEq/L indicate respiratory acidosis, because pH is low, pco2 is increased, and HCO3 - is normal. A pH of 7.30, pco2 of 35 mm Hg, po2 of 70 mm Hg, and HCO3 - of 20 mEq/L indicate metabolic acidosis, because the pH is low, pco2 is normal, and HCO3 - is low.

The nurse is preparing education regarding ostomy self-care for a patient with a new colostomy. What statement by the patient is most indicative that the patient is ready to learn? 1 "I'm ready for discharge and have no questions." 2 "I'd like for my wife to be taught about ostomy care first." 3 "I'd like to arrange for a visiting nurse at home for a little while." 4 "I need more information about the procedure for changing the bag."

4 The patient is expressing indirect but definite interest when the nurse is providing colostomy care. He indicates that he is willing to watch, which is the first step in self-care. Indicating that he has no questions, asking for the wife to be taught first, and asking for a visiting nurse reflect difficulty accepting and providing self-care for the new colostomy.

In developing a teaching plan for the patient with Addison's disease, the nurse understands that the highest priority is placed on 1 Avoiding infection 2 Following a low salt diet 3 Practicing stress management techniques 4 Managing lifelong corticosteroid replacement

4 The patient with Addison's disease experiences hypofunctioning of the adrenal cortex, resulting in decreased production of glucocorticoids, mineral corticoids, and androgens. Patients with Addison's disease require lifelong glucocorticoid and mineral corticoid replacement therapy to avoid Addisonian crisis. Addisonian crisis is characterized by profound hypotension, dehydration, fever, tachycardia, hyponatremia, and hyperkalemia. Circulatory collapse may occur if the patient is treated inadequately. Although Addisonian crisis often is triggered by illness-related physiological stress, and although avoiding infection is important, avoiding infection is of lower priority than managing lifelong corticosteroid replacement. Corticosteroid replacement must be increased during times of stress to prevent Addisonian crisis. Patients taking a mineral corticoid should increase their salt intake. Emotional stress may contribute to the need for increased corticosteriod replacement. Stress management techniques are important. Practicing stress management techniques, however, is of lower priority than managing lifelong corticosteroid replacement.

The nurse suspects that a patient has hepatitis A. Which symptom will the patient most likely report developed first? 1 Ascites 2 Itching 3 Jaundice 4 Anorexia

4 The preicteric phase of hepatitis is usually marked by severe anorexia, malaise, and fever. Itching and jaundice appear later in the hepatitis disease process in a stage known as the icteric phase. Ascites may develop as a long-term effect of diffuse liver damage.

The patient is being treated with brachytherapy for cervical cancer. What factors of protection must the nurse be aware of when caring for this patient? 1 The medications the patient is taking 2 The nutritional supplements that will help the patient 3 How much time is needed to provide the patient's cares 4 The time the nurse spends with the patient and at what distance

4 The principles of ALARA (as low as reasonably achievable) and time, distance, and shielding are essential to maintain the nurse's safety when the patient is a source of internal radiation. The patient's medications, nutritional supplements, and time needed to complete care will not protect the nurse caring for a patient with brachytherapy for cervical cancer.

The patient with an adrenal hyperplasia is returning from surgery for an adrenalectomy. What immediate postoperative risk should the nurse plan to monitor the patient for? 1 Vomiting 2 Infection 3 Thomboembolism 4 Rapid blood pressure changes

4 The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

The nurse is assessing a colostomy in a patient who had a colectomy 24 hours ago. Which of these assessment findings is considered normal for a new stoma? 1 Pale pink color 2 Dusky blue color 3 Brown or black color 4 Dark pink to red color

4 The stoma should be dark pink to red. The stoma should not be pale and pink. A dusky blue stoma indicates ischemia, and a brown-black stoma indicates necrosis. Assess and document stoma color every four hours and ensure that there is no excessive bleeding.

The nurse understands that a pacemaker is used most often for which type of dysrhythmia? 1 Atrial fibrillation 2 Ventricular fibrillation 3 Ventricular tachycardia 4 Third-degree heart block

4 The use of a pacemaker (temporary or permanent) is considered a lifesaving measure for patients who have experienced heart block, particularly third-degree or complete heart block. A temporary pacemaker may be used until the block is resolved through medical interventions or a permanent pacemaker is inserted. In special situations, a pacemaker may be used for ventricular fibrillation or ventricular tachycardia; however, this is more an exception rather than routine. Atrial fibrillation is treated with medication such as diltiazem (Cardizem) or synchronized electrical cardioversion. In special situations a ventricular pacemaker may be used for ventricular fibrillation or ventricular tachycardia; however, this is more an exception rather than routine.

A patient is scheduled for a total thyroidectomy. What information does the nurse include when teaching this patient about recovery after the procedure? 1 Exercise will be restricted for up to six months. 2 A low- or no-sodium diet will be prescribed. 3 Physical therapy will need to be continued. 4 Life-long hormone replacement will be needed.

4 This patient will need life-long thyroid hormone replacement with levothyroxine (Synthroid) because the entire thyroid gland will be missing after surgery. Exercise will not be restricted for six months. Lengthy exercise restriction or physical therapy generally is not indicated following a thyroidectomy. A sodium-restricted diet would not ordinarily be necessary.

The patient experiencing thyrotoxicosis asks the nurse why he or she is being given propranolol (Inderal). The most accurate answer to the patient's question is 1 To suppress thyroid hormone secretion 2 To prevent thyroid hormone induced hypotension 3 To decrease thyroid gland vascularity in preparation for surgery 4 To block the sympathetic nervous system response to excess thyroid hormone

4 Thyrotoxicosis is an acute crisis state of hyperthyroidism often precipitated by a physiologic stressor in the patient with hyperthyroidism. Thyrotoxicosis, is an extreme state of hypermetabolism. Excessive amounts of thyroid hormone are present and tissue sensitivity to sympathetic nervous system stimulation is increased, resulting in a number of signs and symptoms, including severe tachycardia leading to heart failure. Propanolol is a beta-adrenergic antagonist that blocks the thyroid-hormone-induced sympathetic nervous system stimulation, resulting in a lowered heart rate and a decreased risk of heart failure. One of the priority treatment goals in the patient with thyrotoxicosis is to decrease thyroid hormone secretion. A decrease in thyroid hormone secretion is primarily accomplished through the use of either methimazole (Tapazole) or propylthiourical (PTU). Propranolol does not suppress thyroid hormone secretion. In addition to slowing heart rate, propranolol decreases blood pressure; it is not used to prevent hypotension. Nonradioactive strong iodine solution, either in the form of saturated solution of potassium iodine (SSKI) or Lugol's solution, may be used to decrease size and vascularity of the thyroid gland in preparation for surgery. SSKI or Lugol's solution also may inhibit thyroid hormone synthesis. Propranolol does not decrease size or vascularity of the thyroid gland.

Which diagnostic study helps detect the presence of vegetation on the heart valves in a patient with endocarditis? 1 Chest x-ray 2 Echocardiography 3 Cardiac catheterization 4 Transesophageal echocardiogram

4 Transesophageal echocardiogram and two- or three-dimensional transthoracic echocardiograms help detect vegetation on the heart valves of a patient with infectious endocarditis. A chest x-ray helps identify changes in the heart; it cannot detect the presence of vegetation on the heart valves. Cardiac catheterization is used to examine the blood vessels; it cannot detect the presence of vegetation on the heart valves. An electrocardiogram may be used to identify first- or second-degree atrioventricular heart block in the patient; it cannot detect the presence of vegetation on the heart valves.

A nurse is caring for a patient with breast cancer. The primary health care provider has prescribed trastuzumab (Herceptin) for the patient. How does this drug control cell growth in breast cancer? 1 The drug prevents the mechanisms and pathways necessary for vascularization of tumors. 2 The drug prevents blood vessel growth by binding with vascular endothelial growth factor. 3 The drug inhibits BCR-ABL tyrosine kinase that suppresses proliferation of cancer cells and promotes apoptosis. 4 The drug inhibits the abnormal growth of cells by targeting the human epidermal growth factor receptor2 (HER-2) protein.

4 Trastuzumab (Herceptin) targets the human epidermal growth factor receptor 2 (HER-2). HER-2 is over-expressed in certain cells, especially in breast cancer cells. Trastuzumab acts by binding to HER-2 receptors and inhibits the growth of cells. Angiogenesis inhibitors prevent the mechanisms and pathways necessary for vascularization of tumors. Bevacizumab (Avastin) prevents blood vessel growth by binding with vascular endothelial growth factor. Imatinib (Gleevec) inhibits BCR-ABL tyrosine kinase that suppresses proliferation of cancer cells and promotes apoptosis.

The nurse recognizes which cardiac dysrhythmia as life-threatening and necessitating immediate intervention? 1 Sinus tachycardia 2 Atrial fibrillation 3 Junctional tachycardia 4 Ventricular fibrillation

4 Ventricular fibrillation is a life-threatening dysrhythmia that requires immediate intervention. During ventricular fibrillation, the ventricles are quivering and are no longer able to contract to produce effective cardiac output. Because there is no cardiac output, the body is left without oxygenation. Rhythm strip 1 shows sinus tachycardia, which requires treatment to slow the rate to 60 to 100 beats/min. Rhythm strip 2 shows atrial fibrillation, which requires treatment to convert the rhythm back to a normal sinus rhythm with one atrial contraction for every ventricular contraction. Rhythm strip 3 shows normal sinus rhythm, in which the rate is 60 to 100 beats/min, which requires no treatment.

When assessing laboratory values on a patient admitted with septicemia, what should the nurse expect to find? 1 Increased platelets 2 Decreased red blood cells 3 Decreased erythrocyte sedimentation rate (ESR) 4 Increased bands in the white blood cell (WBC) differential (shift to the left)

4 When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs usually are reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Decreased red blood cells indicate anemia. Decreased ESR is not indicative of septicemia.

The ambulance reports that it is transporting a patient to the emergency department who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? 1 Severe pain, blisters, and blanching with pressure 2 Pain, minimal edema, and blanching with pressure 3 Redness, evidence of inhalation injury, and charred skin 4 No pain, waxy white skin, and no blanching with pressure

4 With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

The nurse is caring for a patient admitted with dehydration because of nausea and vomiting. The nurse anticipates which acid-base imbalance based on this information? 1 Respiratory acidosis 2 Respiratory alkalosis 3 Metabolic acidosis 4 Metabolic alkalosis

4 With nausea and vomiting, acid is lost from the gastrointestinal system, elevating the pH, causing metabolic alkalosis . There is not a respiratory component of this imbalance caused by nausea and vomiting. The pH would be low, resulting in an acidosis if the patient had diarrhea, not vomiting.

A patient's laboratory report reveals that the patient's CD4+ T-cell count has dropped below 200 cells/μL. The patient is diagnosed with Burkitt's lymphoma and has herpes simplex with chronic ulcers. The nurse weighs the patient and finds that there is a loss of 10% of body mass. Which infection is likely to be found in this patient? 1 Parvovirus 2 Varicella-zoster 3 Adenoviruses infection 4 Human immunodeficiency virus infection

4 n human immunodeficiency virus infection, the CD4+ T-cell count drops below 200 cells/μL due to the destruction of the white blood cells. As a result, immunity decreases. Due to the decreased immunity, opportunistic infections such as herpes simplex and Burkitt's lymphoma may occur. Due to the ongoing infectious process, the body goes into a state of catabolism, resulting in significant weight loss. Parvovirus produces gastroenteritis. Varicella-zoster virus causes chickenpox and shingles. Adenoviruses cause upper respiratory tract infections and pneumonia.

The nurse must prepare the correct intravenous (IV) solution before administration. The prescription reads for the patient to receive D5½ NS with 40 mEq KCl/L at 125 mL/hr. The nurse must add KCl to the IV because no premixed solutions are available. The unit medication supply has a stock of KCl 3 mEq/mL in multidose vials. What amount of KCl should be added to a liter of D5½ NS to obtain the correct solution? Fill in the blank using one decimal place. ___ mL

40 mEq/L (dose desired) ÷ 3 mEq/ml (dose available) = 13.3 mL.

A patient with atrial fibrillation has been scheduled to undergo a biologic valve replacement. What should the nurse tell the patient about the benefits of a biologic valve versus a mechanical valve? Select all that apply. 1 Biologic valves do not leak. 2 Biologic valves do not cause endocarditis. 3 Biologic valves are more durable. 4 Biologic valves lower the risk of tissue rejection. 5 Biologic valves do not require anticoagulation therapy.

4, 5 Biologic valves are made from bovine, porcine, or human tissues. Therefore, they have a low risk of eliciting an immune response and tissue rejection. As these have low thrombogenicity, they do not require anticoagulation therapy, unlike mechanical valves. However, these may tend to leak or cause endocarditis, similar to mechanical valves. Biologic valves are less durable than mechanical valves.

A patient who underwent a cholecystectomy is now complaining of pain referred to his right shoulder. What is the most probable cause for this pain? Select all that apply. 1 Myocardial infarction 2 Pericarditis after surgery 3 Gallstone left accidentally 4 Carbon dioxide that was used in surgery 5 Irritation of the phrenic nerve

4, 5 The carbon dioxide that is used to inflate the abdomen during surgery may not be released or absorbed by the body and can irritate the phrenic nerve and diaphragm. This is the reason for breathing difficulty and the most common cause of shoulder pain following a cholecystectomy. Other conditions, such as myocardial infarction, pericarditis after surgery, and a gallstone left in the gall bladder, may also cause shoulder pain but are less common causes of right shoulder pain in this situation.

A patient with cancer is receiving massive doses of chemotherapeutic agents. The nurse reviews the patient's laboratory results to assess for which findings that suggest the development of tumor lysis syndrome (TLS)? Select all that apply. 1 Hypokalemia 2 Hyponatremia 3 Hypercalcemia 4 Hyperuricemia 5 Hyperphosphatemia

4, 5 Tumor lysis syndrome is a metabolic change which occurs whenever a tumor sensitive to chemotherapy is subjected to chemotherapeutic agents. It is characterized by hyperuricemia and hyperphosphatemia. Hyperkalemia is associated with tumor lysis syndrome, but not hypokalemia. Tumor lysis syndrome is not associated with hyponatremia. In tumor lysis syndrome there is hypocalcemia, but not hypercalcemia

The patient has hypokalemia and the nurse obtains the following measurements on the rhythm strip: heart rate of 86 with a regular rhythm, P wave of 0.06 seconds and normal shape, PR interval of 0.24 seconds, and QRS of 0.09 seconds. How should the nurse document this rhythm? 1 First-degree atrioventricular (AV) block 2 Second-degree AV block 3 Premature atrial contraction (PAC) 4 Premature ventricular contraction (PVC)

In first degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 seconds. In type I second-degree AV block the PR interval continues to increase in duration until a QRS complex is blocked. In Type II the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS usually is greater than 0.12 seconds. PACs cause an irregular rhythm with a different shaped P wave than the rest of the beats and the PR interval may be shorter or longer. PVCs cause an irregular rhythm and the QRS complex is wide and distorted in shape.