Questions Exam 1

A. Obtain vital signs

What is the nursing priority in the management of a patient with a newly active upper GI bleed? A. Obtain vital signs B. Notify the physician C. Apply oxygen by nasal cannula D. Type and cross match the patient for blood products

A. Potassium (K+)

What priority laboratory analysis should the nurse review when caring for a patient with Crohn's disease? A. Potassium (K+) B. Hemoglobin (Hgb) C. Serum Albumin D. C-reactive protein

10-20 mg/dL

Normal BUN levels

0.8-1.4 mg/dL

Normal Creatinine levels

Men: 13 to 18 g/dL Women: 12 to 16 g/dL

Normal Hgb levels

1.1 or below

Normal INR levels

1.7 to 2.2 mg/dL

Normal Magnesium (Mg2+) levels

25 to 35

Normal Partial Thromboplastin Time (PTT) levels

2.8 to 4.5 mg/dL

Normal Phosphorous (Phosph) levels

150,000 to 450,000

Normal Platelet levels

3.5-5.0 mEq/L

Normal Potassium (K+) levels

10 to 13 seconds

Normal Prothrombin Time (PT) levels

135-145 mEq/L

Normal Sodium (Na+) levels

4,500 to 11,000

Normal WBC levels

D. "Do you have a history of human papillomavirus (HPV)?"

A 23-year-old female patient reports having red, raised lesions at the base of her tongue and on the inside of her mouth for the past 3 weeks. What priority assessment question should the nurse ask? A. "Do you smoke cigarettes?" B. "What type of work do you do?" C. "Have you seen a dentist recently?" D. "Do you have a history of human papillomavirus (HPV)?"

D. Naproxen (Naprosyn) 500 mg twice daily

A 68-year-old patient with a history of arthritis and hypertension is admitted reporting progressive epigastric cramping, dyspepsia, nausea, and dark, sticky stools for 3 days. Which order will the nurse question? A. Guaiac stool sample x2 B. Stool sample for bacterial testing C. IV fluids, normal saline at 125 mL/hr D. Naproxen (Naprosyn) 500 mg twice daily

D. "What medications are you taking?"

A nurse assesses a patient who has multiple areas of ecchymosis on both arms. Which question will the nurse ask first? A. "Are you using lotion on your skin?" B. "Do you have a family history of this?" C. "Do your arms itch?" D. "What medications are you taking?"

D. "I take a lot of Tylenol for my arthritis pain."

A nurse obtains a patient's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this patient? A. "I drink two glasses of red wine each week." B. "I got a hepatitis vaccine before traveling." C. "I have a cousin who died of liver cancer." D. "I take a lot of Tylenol for my arthritis pain."

C. Place the patient in a high-Fowler's position.

A patient had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? A. Delegate oral care Q 4 hours. B. Monitor and record the patient's intake. C. Place the patient in a high-Fowler's position. D. Remove the inner cannula for cleaning.

A. Arrange a dietary consult

A patient has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? A. Arrange a dietary consult B. Increase fluid intake C. Limit the patient's foods D. Make the patient NPO

A. Assess the 24 hour fluid balance

A patient is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the patient's pulse is 128 beats/min., BP is 98/56, and skin turgor is dry. What action should the nurse perform next? A. Assess the 24 hour fluid balance B. Assess the patient's oral cavity. C. Prepare to hang a normal saline bolus. D. Turn up the infusion rate of the TPN.

B. "I will decrease the amount of fatty foods in my diet."

After teaching a patient who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the patient's understanding. Which statement made by the patient indicates a correct understanding of the teaching? A. "Drinking at least 2 L of water a day is suggested." B. "I will decrease the amount of fatty foods in my diet." C. "Drinking fluids with my meals will increase bloating." D. "I will avoid concentrated sweets and simple carbohydrates."

A. Dehydration

An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment? A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

C. "The stool will always be liquid with this type of colostomy."

A nurse cares for a patient who had a colostomy placed in the ascending colon 2 weeks ago. The patient states, " The stool in my pouch is still liquid." How would the nurse respond? A. "Your stool will become firmer over the next couple of weeks." B. "Eating additional fiber will bulk up your stool and decrease diarrhea." C. "The stool will always be liquid with this type of colostomy." D. "This is abnormal. I will contact your health care provider."

A. "Bile salts accumulate in the skin and cause the itching."

A nurse cares for a patient who has obstructive jaundice. The patient asks, "Why is my skin so itchy?" How would the nurse respond? A. "Bile salts accumulate in the skin and cause the itching." B. "Itching is caused by the release of calcium into the skin." C. "Toxins released from an inflamed gallbladder lead to itching." D. "Itching is caused by a hypersensitivity reaction."

B. Use pulse oximetry to assess the patient's oxygen saturation.

A nurse detects a bluish tinge to the patient's palms, soles, and mucous membranes. Which action will the nurse take next? A. Ask the patient about current medications he or she is taking. B. Use pulse oximetry to assess the patient's oxygen saturation. C. Auscultate the patient's lung fields for adventitious sounds. D. Palpate the patient's bilateral radial and pedal pulses.

A. "Changes in your liver cause drugs to be metabolized differently."

An older patient has had an instance of drug toxicity and asks why this happens, since the patient has been on this medication for years at the same dose. What response by the nurse is best? A. "Changes in your liver cause drugs to be metabolized differently." B. "Perhaps you don't need as high a dose of the drug as before." C. "Stomach muscles atrophy with age and you digest more slowly." D. "Your body probably can't tolerate as much medication anymore."

B. "Less protein in the diet will help prevent confusion associated with liver failure."

A nurse cares for a patient with hepatic portal-systemic encephalopathy (PSE). The patient is thin and cachectic in appearance, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? A. "A low-protein diet will help the liver rest and will restore liver function." B. "Less protein in the diet will help prevent confusion associated with liver failure." C. "Increasing dietary protein will help the patient gain weight and muscle mass." D. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

D. "I take ibuprofen 3 times daily for arthritis"

Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? A. "I don't like the taste of spicy foods" B. "I got dentures four years ago?" C. "I experience occasional constipation" D. "I take ibuprofen 3 times daily for arthritis"

C. Put on gloves

A nurse assesses a patient who has open lesions. Which action will the nurse take first? A. Assess the patient's pain B. Obtain vital signs C. Put on gloves D. Ask the patient about his or her occupation

A. Two 1 in. (2 cm) hyper pigmented patches.

A nurse assesses a patient who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the patient's skin. How will the nurse document these lesions? A. Two 1 in. (2 cm) hyper pigmented patches. B. "I need to wash this daily with antibacterial soap." C. "Two 0.8 in (2 mm) pigmented papules D. Two 1 in. (2.5 cm) moles

A. "Ambulating in the hallway twice a day will help."

A nurse cares for a patient who is recovering from laparoscopic cholecystectomy surgery. The patient reports pain in the shoulder blades. How would the nurse respond? A. "Ambulating in the hallway twice a day will help." B. "I will apply a cold compress to the painful area on your back." C. "Drinking a warm beverage can relieve this referred pain." D. "You should cough and deep breathe every hour."