Questions

A patient with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: A. Fluid intake and output B. Urine specific gravity C. VS D. Weight

D

A patient arrives in the ED with a HR of 210 bpm and the following pattern on the cardiac monitor. The nurse is correct to alert the health care provider that the patient has converted to: A. Premature atrial contractions B. Atrial flutter C. Sinus arrhythmia D. Supraventricular tachycardia

B

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

A

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

A

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A. arterial insufficiency B. Raynaud's phenomenon C. venous insufficiency D. coronary artery disease

A

A nurse is teaching the patient with a new diagnosis of stable angina about the side effects of sublingual nitroglycerin. Which symptoms would be included in the discussion? A. Dizziness and flushing B. Sedation and constipation C. Nausea and fatigue D. Pedal edema and decreased heart rate

A

A patient has been taking opioid analgesics for more than 2 weeks to control his post-surgical pain. While the surgeon is pleased with his healing process, he wants to change the analgesic to a non-opioid drug. He prescribes a gradually lower opioid dose and increasingly larger non-opioid drug doses. Why is the surgeon changing medications in this manner? A. To avoid withdrawal symptoms B. To avoid addiction C. To avoid tolerance D. To avoid respiratory depression

A

A patient is about to receive a transfusion of packed red blood cells (PRBC's). Prior to administration, what action should the nurse perform? A. Assess the patient's vital signs to establish baselines. B. Have the patient identify his or her blood type in writing. C. Ensure that the patient has granted verbal consent for transfusion. D. Facilitate insertion of a central venous catheter.

A

A patient is admitted for a surgical biopsy of a suspicious lump in her left breast. When the nurse arrives to take the patient to surgery, she is tearfully completing a letter to her 2 children. She tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic? A. "In case anything goes wrong? What are your thoughts and feelings right now?" B. "I can understand that you're nervous, but this really is a minor procedure. You'll be back in your room before you know it." C. "Try to take a few deep breaths and relax. I have some medication that will help." D. "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours."

A

A patient is recovering from a craniotomy with tumor debulking. Which comment by the patient indicates to the nurse to correct understanding of what the surgery entailed? A. "I guess the doctor could not remove the entire tumor." B. "I am so glad the doctor was able to remove the entire tumor." C. "I will be glad to finally be done with treatments for this thing." D. "Thank goodness the tumor is contained and curable."

A

A patient with a suspected dysrhythmia is to wear a holter monitor for 24 hours at home. What should the nurse instruct the patient to do? A. Keep a record of the day's activities B. Avoid going through laser-activated doors C. Record the pulse and BP every 4 hours D. Delay taking prescribed medications until the monitor is removed

A

A patient with advanced venous insufficiency is confined to bed rest following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities? A. Ensure that the client's heels are protected and supported B. Closely monitor the client's serum albumin and prealbumin levels C. Perform gentle massage of the client's lower legs, as tolerated D. Perform passive ROM exercises once per shift.

A

After receiving change of shift report about these postoperative patients, which patient should the nurse assess first? A. Obese patient who had abdominal surgeyr 3 days ago and whose wound edges are separating B. Patient who has 30 ml of sanguineous drainage in the wound drain 10 hours after hip replacement surgery C. Patient who has bibasilar crackles and a temperature of 100 degrees on the first postoperative day after chest surgery D. Patient who continues to have incisional pain 20 minutes after hydrocodone and acetaminophen (Vicodin) was given

A

The nurse has instructed the patient about the correct positioning of the leg and hip following a posterior-approach hip replacement surgery. Which of the following statements warrants correction by the nurse? A."I may cross my legs as long as I keep my knees extended." B. "I can sleep on my side only if I have pillows between the knees." C. "I should have my wife put my socks on me today." D. "It is ok touch my heels together and then point my toes away from each other."

A

The nurse is assessing the patient who is immediately postoperative from a total knee replacement. Which assessment data would warrant immediate intervention? A. Complaints of left calf tenderness upon palpation B. T 99.4, HR 88, RR 20, BP 112/76 C. Bowel sounds heard intermittently in 4 quadrants D. Diffuse abdominal cramping and pain

A

The nurse is caring for a patient with a history of chronic angina. The patient states that after breakfast he usually takes a shower and shaves. It is at this time, the patient says, that he tends to experience chest pain. What should the nurse counsel the patient to do to decrease the likelihood of angina in the morning? A. Shower in the evening and shave before breakfast B. Skip breakfast and eat an early lunch C. Take a nitroglycerin tab prior to breakfast D. Shower once a week and shave prior to breakfast

A

The nurse is preparing to discontinue the patient's subclavian deepline. Which nursing intervention should have priority at this time? A. Place the patient in supine position B. Ensure that the patient has been NPO for 8 hours C. Give the patient an opioid analgesic D. Check to see if the patient has bowel sounds

A

The nurse on the surgical floor receives a new patient from PACU. initial assessment reveals that the patient has a patent airway. The nurse should next: A. Check the dressing for signs of bleeding B. Empty any peri-incisional drains C. Assess the patient's pain level D. Assess the patient's bladder

A

The patient admitted with unstable angina is on continuous telemetry monitoring. The nursing student asks the nurse what the T wave means on his telemetry rhythm. The nurse's response is based on the fact that the T wave represents: A. Ventricular repolarization B. Atrial repolarization C. Ventricular depolarization D. Atrial depolarization

A

When developing a plan of care to manage a patient's pain from cancer, what should the nurse plan to do? A. Individualize the pain medication regimen for the patient B. Select medications that are least likely to lead to addiction C. Administer pain medication as soon as the patient requests it. D. Change pain medications periodically to avoid drug tolerance

A

A patient is admitted to the telemetry floor following an MI. the following VS are seen: HR-45 bpm, BP-115/65. The patient is awake and alert when doing the physical exam. Which of the following interventions would be the highest priority for the nurse? A. Initiate CPR B. Insert an IV line C. Bring the defibrillator to the bedside D. Prepare for pacemaker insertion

B

A patient who is to receive external radiation for cancer says to the nurse, "my family and friends say that I will get a radiation burn." Which response by the nurse is best? A. "Daily application of an emollient will prevent the burn." B. "A localized skin reaction does usually occur." C. "It will be no worse than a sunburn." D. "They may be misinformed."

B

Where does bradycardia originate? A. AV node B. Left atrial wall C. SA node D. Purkinjie fibers

C

The nurse is preparing an in-service on the risk factors for coronary artery disease (CAD). which of the following should be included in the in-service? Select all that apply. A. A history of DM B. Elevated high-density lipoprotein (HDL) levels C. A history of ischemic heart disease D. Current cigarette and cigar smoking E. Alcohol twice weekly F. Hypertension and hyperlipidemi

A, D, F

A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? A. How to apply warm packs to the leg to reduce the pain B. How to monitor and care for a long term IV catheter C. The need for daily aerobic exercise to help maintain muscle strength D. The reason for taking oral antibiotics for 7-10 days after discharge

B

The nurse who is caring for a patient with severe osteomyelitis recognizes that the delayed ID and treatment of this disease can lead to which of the following? Select all that apply. A. Chronic pain B. Amputation C. Chronic discharge D. Death E. Generalized bleeding tendencies F. Bone cancer

A,B,C,D

The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? Select all that apply. A. Avoid constricting garments B. Elevate the legs about the heart level for 30 minutes every 2 hours C. Sit as much as possible to rest the valves in the legs D. Sleep with the foot of the bed elevated about 6 inches E.Sit on the side of the bed and dangle the feet

A,B,D

The OP nurse would anticipate being suspicious of malignant hyperthermia when the patient demonstrates which of the following during surgery? Select all that apply. A. Sustained muscle contraction B. Elevated CO2 C. Excessive pain upon arousal from anesthesia D.Reversal of signs/symptoms with dantrolene E. Tachycardia

A,B,D,E

A patient with laryngeal cancer has undergone a laryngectomy and is now receiving radiation therapy to the head and neck. The nurse would monitor the patient for which adverse effects of external radiation? Select all that apply. A. Xerostomia B. Stomatitis C. Thrombocytopenia D. Cystitis E. Mucositis F. Leukopenia

A,B,E

The nurse suspects a decrease in cardiac output from a dysrhythmia. Which of the following assessment findings best support the nurse's suspicion? Select all that apply. A. Weak pulse B. Urine output=40ml/2 hours C. Dry skin D. BP=128/64 E. Dizziness

A,B,E

The patient is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse will look for potential causes. Which causes will the nurse look for in this patient? Select all that apply. A. Sympathomimetic drugs B. Anxiety C. Foods with vitamin k D. Hypothermia E. Anemia

A,B,E

A nurse who provides care in a busy postsurgical unit recognizes that patients are at particular risk of thromboembolism during their immediate postoperative recovery. Which of the following interventions best facilitates venous blood flow and the prevention of thrombosis? A. Correct application of compression stockings B. Use of intermittent pneumatic compression devices C. Early ambulation D. Prophylactic warfarin

A,C

An obese patient is having worsening SOA and chest pain. The provider feels it will be necessary to do a transesophageal echocardiogram (TEE), and explains the procedure to the patent. Which of the following statements by the patient would require follow up by the nurse? Select all that apply. A. "I am just so glad I won't have to skip breakfast, I need to eat every 4-6 hours around the clock." B. "I had no idea it was possible to see the function of my heart with a probe." C. "I am worried, I have such a sensitive gag reflex, I will never be able to hold still long enough." D. "I feel better that there is a special lab where this will take place." E. "I think the provider is going to be surprised that my arteries are pretty clogged."

A,C,E

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

B

A nurse is checking lab values on a patient who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which lab value does the nurse expect to be abnormal? A. Potassium B. BNP C. CRP D. ESR

B

A nurse is reviewing the medical record of a male patient with cancer. The HCP has prescribed filgrastim 400 mcg, subcutaneously once daily. The nurse reviews the laboratory report and determines treatment has been effective when: A. Hgb > 12g/dL B. WBC > 3,500/mm3 C. Platelets > 92,000/mm3 D. Hct > 35%

B

After undergoing surgery the previous day for a total knee replacement, a patient states that he doesn't feel ready to ambulate yet. What should the nurse do? A. Notify the provider of the patient's refusal to ambulate B. Discuss the complications that the patient may experience if he doesn't cooperate with the care plan C. Do nothing because the patient has the ultimate right to determine his degree of participation D. Document the patient's refusal to ambulate

B

As part of a large hospital's IV team, two nurses are responsible for inserting peripherally inserted central catheters (PICCs) at the bedside for patients who require this form of venous access. Which of the following patients would most likely require a PICC? A. A woman who recently suffered a pelvic fracture in a motor vehicle accident. B. A woman who has just been ordered total parenteral nutrition (TPN). C. A man whose low serum potassium requires a stat infusion of potassium chloride. D. An elderly man who has been admitted from the community with a fluid volume deficit.

B

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

B

Hickman and Groshong are examples of which central venous access device? A. Implanted ports B. Tunneled central catheters C. Peripherally inserted central catheters D. Non-tunneled central catheters

B

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

B

The nurse is caring for a patient with coronary artery disease. What is the nurse's priority goal for the patient? A. Decrease anxiety B. Enhance myocardial oxygenation C. Administer sublingual nitroglycerin D. Educate the client about his symptoms

B

The nurse is teaching the patient preoperatively, as he is scheduled for an open abdominal surgery tomorrow to remove his gallbladder. Which topic is most important for the nurse to discuss with this patient? A. Care for the surgical incision. B. Deep breathing and coughing. C. Medications to be used during surgery. D. Oral antibiotic therapy after discharge.

B

The nurse teaches the patient to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for this patient because they: A. Do not require specialized equipment B. Strengthen the muscles while keeping the joints stationary C. Involve patients in their own care and thus improve morale D. Prevent joint stiffness

B

The patient admitted with new onset of unstable angina is being prepared for a cardiac catheterization. In reviewing serum lab values, which lab in particular should the nurse monitor prior to this procedure? A. Glucose B. Creatinine C. LFT D. H&H

B

The patient arrived to the PACU postoperatively 4 hours ago. The nurse is monitoring the patient's urine output in the foley catheter and jackson pratt tube inserted intraoperatively. What would the nurse promptly report to the surgeon? A. Moderate pain around the jackson pratt site B. No drainage noted in the jackson pratt C. Increased urine output noted in foley catheter D. The color of the urine is light yellow

B

The patient has undergone a posterior hip arthroplasty. Which of the following assessment findings should be reported to the provider? A. A total of 100 ml of red drainage in the auto-transfusion drainage system B. Urinary output of 60 ml of clear yellow urine in the past 3 hours C. Moderate pain relief after using the PCA D. Cool toes, distal pulses palpable, and pale nail beds bilaterally

B

The patient is undergoing a small bowel resection tomorrow. Which action by the nurse will be most helpful to the patient, since he will be expected to ambulate, deep breathe, and cough on the first postoperative day? A. Schedule the activity to begin after the patient has taken a nap B. Administer opioid analgesic medication before the activities C. Ask the patient to teach-back two possible complications of immobility D. Encourage the patient to state the purpose of splinting the incision

B

When the nurse observes the patient's HR increase during inspiration and decrease during expiration, the nurse reports that the patient is demonstrating: A. Normal sinus rhythm B. Sinus bradycardia C. Sinus arrhythmia D. Sinus tachycardia

B

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: A. Elevating the limb over the heart level B. Lowering the limb so that it is dependent C. Massaging the limb after application of cold compresses D. Placing the limb in a place horizontal to the body

B

Which of the following dysrhythmias is most likely to be associated with a reduction in cardiac output and loss of atrial kick? A. Sinus arrhythmia B. Premature atrial contractions C. Atrial fibrillation D. Sinus tachycardia

C

A med-surg nurse has admitted 4 patients over the course of a 12 hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A. A patient who has peripheral edema secondary to chronic heart failure B. An older patient who has a diagnosis of unstable angina C. A patient with poorly controlled type 1 diabetes who is a smoker D. A patient who has community-acquired pneumonia and a history of COPD

C

A nurse is caring for a patient who has developed dysphagia and is unable to swallow. The patient is receiving around the clock opioid pain medications for cancer pain, and hospice has recently begun caring for the patient. What is the best nursing intervention in preparing for the patient's discharge? A. Contact the patient's HCP to ask to substitute a liquid form of medications for the pill form B. Teach the patient and family members to crush the pills and administer them with applesauce C. Contact the patient's HCP to discuss use of transdermal medications for pain control D. Teach the patient and family members about addiction that may occur as a result of regular opioid use

C

A patient in the telemetry unit is on a cardiac monitor. The monitor technician notices there are no ECG complexes and the alarm sounds. What is the first action by the nurse? A. Begin CPR B. Call the rapid response team C. Assess the patient and check lead placement D. Press the record button to get an EKG strip

C

A patient is 5 hours s/p abdominal surgery. The oncoming nurse notes in report that there has been no drainage noted from the Hemovac since surgery. Which finding may explain the absence of drainage? A. The patient has been lying on his side for 2 hours with the drain positioned upward B. The patients has a nasogastric tube in place that drained 400 ml C. The hemovac drain isn't compressed; instead it's fully expanded D. There is a moderate amount of dry drainage on the outside of the dressing

C

A patient is about to receive a transfusion of PRBC's. Prior to the administration, what action should the nurse perform? A. Have the patient identify his or her blood type in writing B. Ensure that the patient has granted verbal consent for transfusion C. Assess the patient's VS to establish baseline D. Facilitate insertion of a central venous catheter

C

A patient is to receive IV antibiotics for osteomyelitis. Before the initial dose of antibiotics can be given, it is most important for the nurse to confirm that a blood sample of which test has been drawn? A. White blood cell (WBC) countu Answered B. Erythrocyte sedimentation rate (ESR) C. Culture D. Creatinine

C

A triage team is assessing a patient to determine if reported chest pain is a manifestation of angina or an MI. What is a primary distinction of angina? A. Described as crushing and substernal B. Associated with nausea and vomiting C. Relieved by rest and nitroglycerin D. Accompanied by diaphoresis and dyspnea

C

After a right total knee replacement, the patient's right leg is placed in a continuous passive motion (CPM) machine. Nursing responsibilities when caring for a patient with this apparatus should include: A. Adjusting the settings as needed to prevent patient discomfort B. Anticipate increasing the ROM settings at least every 8 hours C. Maintaining proper positioning of the leg on the CPM machine D. Discontinuing the CPM therapy if the patient complains of pain with movement

C

Hickman and Groshong are examples of which type of central venous access device? A. Implanted ports B. Non-tunneled central catheters C. Tunneled central catheters D. Peripherally inserted central catheters

C

On admission of a patient to the PACU, the BP: 122/72. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? A. Increase the IV fluid rate B. Notify the anesthesia care provider C. Continue to take VS every 15 minutes D. Administer O2 therapy at 100% per mask

C

The mother of a patient with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her daughter's pain management? A. Frequently, female patients and younger patients need higher doses of opioids to be comfortable. B. The dose range is higher with cancer patients, and the medical team will be very careful to prevent addiction. C. There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug. D. The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment.

C

The nurse has taken on a new role in the OR as circulating nurse. The nurse knows which patient would be most at risk for developing a latex allergy? A. The patient who is currently thrombocytopenic B. The patient with a family history of latex reactions C. The patient who has had repeated exposure to latex D. The patient who has had a history of a blood transfusion reaction

C

The nurse is assessing a patient in PACU, who is recovering postoperatively from general anesthesia. The patient can give his name but is not sure about where he is or the time of day. What should the nurse do next? A. Notify the surgeon B. Rub the patient's sternum to arouse the patient C. Tell the patient where he is and the time of day D. Take the patient's BP

C

The nurse is caring for a patient receiving a chemotherapy drug in a peripheral line that is a potential vesicant. The patient is currently not a candidate for a central line. The patient ℅ pain at the insertion site; redness noted. Which nursing action would be included in the follow-up care? A. Slow the infusion rate while notifying the HCP B. Restart the infusion distal to the dc'd IV site. C. Assess the patient for skin sloughing D. Hold the site below the level of the heart

C

The nurse is making patient rounds following shift report. Which patient should the nurse assess first? A. A 38 year old woman receiving internal radiation therapy for cervical cancer B. A 77 year old man with lung cancer hospitalized for induction of high-dose chemotherapy C. A 75 year old man with metastatic prostate cancer with a pathological fracture of the femur who is in pain D. A 33 year old woman with cancer undergoing surgery for placement of a central venous catheter

C

The nurse reads in the patient's progress notes that the HCP is contemplating performing a maze procedure on the patient admitted to the hospital yesterday. What is the most important criterion for a patient to have this procedure? A. Angina that is not responsive to other treatments B. Actively intolerance related to decreased cardiac output C. Atrial fibrillation that is not responsive to other treatments D. Sinus dysrhythmias that are not responsive to other treatments

C

The patient is receiving a unit of PRBC's. His baseline VS are: T-98.1, pulse-88, RR-16, BP-120/78. Fifteen minutes after the start of the administration, his temperature is 100.9. Which action should the nurse take first? A. Administer acetaminophen as ordered on MAR B. Notify the HCP of change in temperature C. Entirely disconnect the blood transfusion line and infuse normal saline D. Auscultate the breath sounds bilaterally

C

The patient who has undergone a total hip replacement and complains on the third postop day of SOA, chest pain, and notes that, "something is wrong." Temp-98.6, BP-168/98, Pulse-96, RR-32, O2-89% on room air. What is the priority nursing action? A. Administer the prescribed antihypertensive medication and reassess in 15 minutes B. Obtain an EKG and administer the ordered albuterol nebulizers C. Apply supplemental O2 and place the patient in high-fowlers position D. Notify the HCP and document the VS

C

When the nurse is screening patients with peripheral arterial disease (PAD), indicate where the posterior tibial artery will be palpated. A. 1 B. 2 C. 3 D. 4

C

You admit a patient to your med-surg floor with a suspected GI bleed and anemia and receive a list of HCP orders. Which HCP order should the nurse implement first? A. Explain to the patient NPO status B. Insert the nasogastric tube and hook to suction C. Take the vital signs D. Insert the IV and start IVFs

C

A patient had chemotherapy 2 weeks ago. Based on the understanding of the effects of chemotherapy, the nurse would expect which clinical finding? A. Decreased erythrocyte sedimentation (ESR) rate B. Increased WBC C. Desquamation marks D. Excessive ecchymosis

D

A patient hospitalized with osteomyelitis has a prescription for bed rest with bathroom privileges, with the affected foot elevated on 2 pillows. The nurse would place highest priority on which intervention? A. Ambulate the patient to the bathroom every one to two hours B. Ask the patient about preferred activities to relieve boredom C. Allow the patient to dangle legs at the bedside every one to two hours D. Perform frequent position changes and ROM exercises

D

A patient is recovering from a craniotomy with tumor debulking. Which comment by the patient indicates to the nurse a correct understanding of what the surgery entailed? A. "I will be glad to finally be done with treatments for this thing."u Answered B. "Thank goodness the tumor is contained and curable." C. "I am so glad the doctor was able to remove the entire tumor." D. "I guess the doctor could not remove the entire tumor."

D

A patient is undergoing brachytherapy of the cervix and tells the nurse, "I feel like i'll be alone in this room forever!" What is the best response by the nurse? A. "The staff is trying to provide privacy for you as much as possible" B. "Is there a family member we can call to stay with you during the treatment?" C. "Let me call your primary HCP to see if the therapy can be removed early." D. "We have to limit how much time we are in your room, but the treatment will be finished soon."

D

A patient tells the nurse, "My heart is skipping beats again yesterday and I was feeling palpitations." After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). What nursing action would be appropriate for this patient? A. Instruct the patient to lie down and elevate the feet. B. Request an order for sublingual nitroglycerin. C. Apply supplemental oxygen. D. Teach the patient to avoid caffeinated beverages.

D

A patient with atherosclerosis is admitted with atrial fibrillation and is started on continuous heparin drip. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? A. An elevated prothrombin time B. An absence of eccyhmotic areas C. A decreased viscosity of the blood D. An activated partial thromboplastin twice the usual value

D

An obese, malnourished patient has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? A. Splint the abdomen with a pillow and call the surgeon B. Administer oxygen per nasal cannula C. Reinforce the existing dressing with another dressing D. Lift the dressing to assess the would

D

As part of a large hospital's IV team, 2 nurses are responsible for inserting PICCs at the bedside for patients who require this form of venous access. Which of the following patients would most likely require a PICC? A. A woman who recently suffered a pelvic fracture in a motor vehicle accent B. An elderly man who has been admitted from the community with a fluid volume deficit C. A man whose low serum potassium requires a stat infusion of potassium chloride D. A woman who has just been ordered TPN

D

The mother of a patient with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about which aspect of her daughter's pain management? A. The dose range is higher with cancer patients, and the medical team will be very careful to prevent addiction B. Frequently, female patients and younger patients need higher doses of opioids to be comfortable C. The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment D. There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

D

The nurse is caring for a patient with HF who is unable to answer multiple questions in a row. The spouse is present and trying to describe some of the symptoms. The nurse knows that this patient has orthopnea based on which of the following statements? A. "We don't even go out to eat anymore, he has such anxiety that he won't have enough O2." B. "He usually wakes up 2-3 times a night and can't catch his breath." C. "We could never take a trip out west, he has such terrible dependent edema." D. "He doesn't even come to bed anymore, he just sleeps in his chair."

D

The nurse is caring for an elderly patient with a history of chronic osteomyelitis of the left hip. The nurse knows that the most appropriate way to identify the causative microorganism is: A. Blood culture B. Wound culture C. MRI of hip D. Bone or soft tissue biopsy

D

The nurse is preparing to infuse a unit of PRBC's to the patient. It is noted that the patient is B+ and the unit of blood is O+. What is the next best nursing action? A. Notify the HCP B. Ask the patient if he has ever had incompatible blood before C. Return the blood to the blood bank D. Spike the packed RBC bag with the Y-tubing

D

The patient has a history of atrial fibrillation with rapid ventricular response. Which statement is true about this dysrhythmia? A. This dysrhythmia is typically irreversible and fatal. B. The atrial activity mimics a saw-tooth appearance. C. Atropine is sometimes used to treat this dysrhythmia. D. This dysrhythmia does not originate in the sino-atrial (SA) node.

D

The patient who had major surgery five days ago comes to the emergency department with complaints of a suspected wound infection. Which of the following would be the nurse's priority action? A. Ask the patient to rate his pain on a scale of 0-10. B. Assess the patient's white blood cell (WBC) count. C. Take the patient's oral temperature. D. Assess the patient's wound drainage.

D

Which statement by a patient undergoing external radiation therapy indicates the need for further teaching? A. "I'll wash my skin with mild soap and water only." B. "I'll not use my heating pad during my treatment." C. "I'll wear protective clothing when outside." D. "I'm worried I'll expose my family members to radiation."

D