QUIZZES FOR THE FINAL!!!

22. After receiving IV heparin anticoagulant therapy, pts are generally not discharged from the hospital without a prescription and instructions for which drug? a. protamine sulfate b. prednisone (deltasone) c. warfarin (coumadin) d. oral heparin

c

23. A pt is following up on a post-op complication of PE. The pt must have blood drawn to determine the therapeutic range for coumadin. Which lab test determines this therapeutic range? a. PTT level b. Platelets c. PT and INR d. Coumadin peak and trough

c

23. A pt with a facemask at 5L/min is able to eat. Which nursing intervention is performed at mealtimes? a. change the mask to a nasal cannula of 6L/min or more b. have the pt work around the facemask as best as possible c. obtain a provider order for a nasal cannula at 5L/min d. obtain a provider order to remove the mask at meals

c

23. What test is used to differentiate a cholinergic crisis from a myasthenic crisis? a. EPS b. RNS c. tensilon testing d. CSF protein level

c

23. what is the total dosage of morphine that Natalie has received in the last 4 hours? (0.5mg/hour, and demand doses of 1mg/6min <hourly limit of 10mg>)(Natalie had 4 demand doses each hour for the last 4 hours) a) 6mg b) 10mg c) 18mg d) 40mg

c

25. What is a potential adverse outcome of autonomic dysreflexia in a pt with a spinal cord injury? a. heatstroke b. paralytic ileus c. hypertensive stroke d. aspiration and pneumonia

c

26. A pt recently received anticoagulant therapy for complications of PE after knee surgery. The pt is now in a rehab facility and is receiving warfarin. What is the nursing responsibility related to coumadin? a. having protamine sulfate available as an antidote b. administering NSAIDs or aspirin for pain related to the knee c. teaching the pt about foods high in vitamin k d. monitoring platelets for thrombocytopenia

c

26. A pt with MG has "bulbar involvement". what is the nurse's priority assessment for this pt? a. presence of pain in the extremities b. loss of bowel and bladder function c. ability to chew and swallow d. quality and volume of the voice

c

29. The nurse is planning activities for a pt with MG. which factor does the nurse consider to promote self-care, yet prevent excessive fatigue? a. time of day b. severity of symptoms c. medication times d. sleep schedule

c

29. Which class of antidiabetic medication should be given 1-30 min before meals? a. alpha-glucosanide inhibitors, which include miglitol (Glyset) b. biguanides, which include metformin (glucophage) c. meglitinides, which include natelinide d. sulfonylrueas, which include chlorpromadine (diabinese)

c

3. What is the most common cause of embolism? a. amniotic fluid b. air bolus c. blood clot d. arterial plaque

c

30. Which oral agent may cause lactic acidosis? a. nateglinide b. repaglinide c. metformin d. miglitol

c

31. The nurse is caring for a pt recently diagnosed and admitted with MG. during the morning assessment, the nurse notes some abnormal findings. Which symptom does the nurse report to the physician immediately? a. diarrhea b. fatigue c. inability to swallow d. difficulty opening eyelids

c

31. The pt with a spinal cord injury has a heart rate of 42/min. Which drug does the nurse expect to administer? a. methylprednisolone b. dextran c. atropine d. dopamine

c

33. Although an adverse reaction to tensilon is considered rare, which medication should be readily available to give as an antidote in case a pt should experience complications? a. protamine sulfate b. narcan c. atropine sulfate d. regitine

c

33. The pt is an adolescent who is quadriplegic as a result of diving accident. The nursing assistant reports that the pt started yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating "nobody is going to do anything else to me! I'm trying to get out of this place!" what is the best priority pt problem? a. noncompliance b. cognitive limitations c. inability to cope with the situation d. feelings of hopelessness

c

34. Which statement about insulin administration is correct? a. insulin may be given orally, IV, or subcut. b. insulin injections should be spaced no closer than 1/2 inch apart c. rotating injection sites improves absorption and prevents lipohypertrophy d. shake the bottle of intermediate-acting insulin and then draw it into the syringe

c

38. A 47 yr old pt with a history of type 2 DM and emphysema who reports smoking three packs of cigarettes per day is admitted to the hospital with a diagnosis of acute pneumonia. The pt is placed on the regular oral antidiabetic agents, sliding-scale insulin, and antibiotic medications. On day 2 of hospitalization, the health care provider orders prednisone therapy. What does the nurse expect the blood glucose to do? a. decrease b. stay the same c. increase d. return to normal

c

38. A patent's laboratory results show an elevated creatinine level. The patient's history reveals no risk factors for kidney disease. Which question does the nurse ask the patient to shed further light on the laboratory result? a. " How many hours of sleep did you get the night before the test?" b. " How much fluid did you drink before the test?" c. " Did you take any type of antibiotics before taking the test?" d. " When and how much did you last urinate before having the test?"

c

40. The nurse is caring for a pt receiving cholinesterase inhibitor drugs for MG. Which symptoms does the nurse immediately report to the physician? a. increasing loss of motor function b. ineffective cough c. dyspnea and difficulty swallowing d. GI side effects

c

41. The nurse is assessing a patient with kidney injury and notes a marked increase in the rate and depth of breathing. The nurse recognizes this as Kussmaul respiration, which is the body's attempt to compensate for which condition? a. Hypoxia b. Alkalosis c. Acidosis d. Hypoxemia

c

42. A patient is diagnosed with renal osteodystrophy. What does the nurse instruct the unlicensed assistive personnel (UAP) to do in relation to the patient's diagnosis? a. Assist the patient with toileting every 2 hours. b. Gently wash the patient's skin with mild soap and rinse well. c. Handle the patient gently because of risk for fractures d. Assist the patient with eating because of loss of coordination

c

43. The pt with MS states she is bothered by diplopia (double vision). Which intervention does the nurse expect to implement? a. consult for corrective lenses b. teach the pt scanning techniques moving her head from side to side c. application of an eye patch alternating from eye to eye every few hours d. prophylactic bilateral patches to both eyes at night

c

47. What type of breath odor is most likely to be noted in a patient with CKD? a. Fruity smell b. Fecal smell c. Smells like urine d. Smells like blood

c

49. a pt is receiving a cholinesterase (ChE) inhibitor drug for the treatment of MG. what is a nursing implication for the safe administration of this med? a. monitor for orthostatic hypotension b. take the pt's apical pulse prior to administration c. feed meals 45-60 min after administration d. drink at least 8 glasses of water each day

c

5. A pt in the hospital being treated for a PE is receiving a continuous infusion of heparin. When the nurse comes to take vs, the pt has blood on the front of his chest and nose and is holding a tissue saturated with blood to his nose. What is the first priority action the nurse must take? a. have the pt sit up and lean forward, pinching the nostrils b. have a pt care technician set up oral suctioning to suction excess blood from pts mouth c. stop the heparin IV infusion d. obtain lab results for prothrombin time and CBC

c

50. The nurse notes an abnormal laboratory test finding for a patient with CKD and alerts the health care provider. The nurse also consults with the registered dietitian because of excessive dietary protein intake is directly related to what factor? a. Elevated serum creatinine level b. Protein presence in the urine c. Elevated BUN level d. Elevated serum potassium level

c

50. The pt with diabetes has a foot that is warm, swollen, and painful. Walking causes the arch of the foot to collapse and gives the foot a "rocker bottom" shape. Which foot deformity does the nurse recognize? a. hallux valgus b. claw-toe deformity c. charcot foot d. diabetic foot ulcer

c

54. What is the recommended protocol for pts with type 2 DM who must lose weight? a. participate in aerobic program twice a week for 20 minutes each session b. slowly increase insulin dosage until mild hypoglycemia occurs c. reduce calorie intake moderately and increase exercise d. reduce daily calorie intake to 1000 calories and monitor urine for ketones

c

587. a client who had a total hip replacement asks the nurse about the continuous regional analgesia being used. What information should the nurse include when explaining the benefits of the treatment over conventional methods to control pain? a) adjusting the dose is easily done b) neuropathic pain can be relieved c) systemic side effects are minimal d) the need for parenteral medication is avoided

c

6. The nurses young neighbor who smokes is going on an overseas flight. The neighbor knows he is at risk for DVT and PE and asks the nurse for advice. What does the nurse suggest? a. exercise regularly and walk around before boarding the flight b. get a prescription for heparin therapy and take it before the flight c. drink water and get up every hour for at least 5 minutes during the flight d. Elevate the legs as much as possible during and after the flight

c

6. Which individual is at greatest risk for developing type 2 DM? a. 25 yr old african-american woman b. 36 yr old african-american man c. 56 yr old hispanic woman d. 40 yr old hispanic man

c

6. the pt has been on oxygen therapy at 70% for over 2 days. For which complication must the nurse monitor? a. oxygen induced hypoventilation b. hypercarbia c. oxygen toxicity d. absorptive atelectasis

c

60. Which statement about sexual intercourse for pts with diabetes is true? a. the incidence of sexual dysfunction is lower in men than women b. retrograde ejaculation does not interfere with male fertility c. impotence is associated with DM in male pts d. sexual dysfunction in female pts includes the inability to achieve pregnancy

c

61. Which behavior is the strongest indicator that a patient with ESKD is not coping well with the illness and may need a referral for a psychological counseling? a. Displays irritability when the meal tray arrives. b. Refuses to take one of the drugs because it causes nausea c. Repeatedly misses dialysis appointments d. Seems distracted when the health care provider takes about the prognosis

c

62. Which statement by a pt with DM indicates an understanding of the principles of self-care? a. "i dont like the idea of sticking myself so often to measure my sugar" b. "i plan to measure the sugar in my urine at least four times a day" c. "i plan to get my spouse to exercise with me to keep me company" d. "if i get a cold, i can take my regular cough medication until i feel better"

c

63. Which patient is the most likely candidate for CVVH? a. Patient with fluid volume overload b. Patient who needs long-term management c. Patient who is critically ill d. Patient who is ready for discharge to home

c

65. The nurse is caring for a patient with CKD. The family asks about when renal replacement therapy will begin. What is the nurse's best response? a. "As early as possible to prevent further damage in stage I." b. "When there is reduced kidney function and metabolic wastes accumulate." c. "When the kidneys are unable to maintain a balance in body functions." d. "It will be started with diuretic therapy to enhance the remaining function."

c

686. A nurse is caring for a client with acute kidney failure who is receiving a protein restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the clients questions? a. a high protein diet ensures an adequate daily supply of amino acids to compensate for losses b. essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis c. this supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys d. urea nitrogen can't be used to synthesize amino acids in the body so the nitrogen for amino acid synthesis must come from the dietary protein

c

7. An ambulatory pt has sought treatment of symptoms of GBS. IV immunoglobulin therapy has been prescribed. which precaution does the nurse expect with this therapy? a. it is given concurrently with plasmapheresis b. a shunt must be placed prior to beginning the therapy c. IV immunoglobulin is given slowly when started d. 3 or 4 treatments are given 1-2 days apart

c

775. a client receiving morphine by patient-controlled analgesia has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate? a) nasotracheal suction b) mechanical ventilation c) Naloxone administration d) cardiopulmonary resuscitation

c

789. a terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? a) add a placebo to the morphine to appease the spouse b) discuss with the spouse the risk for morphine addiction c) assess the client's pain before increasing the dose of the morphine d) check the client's heart rate before increasing the morphine tto the next level

c

8. The nurse is talking to a group of healthy young college students about maintaining good kidney health and preventing AKI. Which health promotion point is the nurse most likely to emphasize with this group? a. " Have your blood pressure checked regularly." b. " Find out if you have a family history of diabetes." c. " Avoid dehydration by drinking at least 2 to 3 L of water daily." d. " Have annual testing for microalbuminuria and urine protein."

c

8. what information should the nurse include in responding to Natalie? a) Aspirin comes in children's doses, which can be given safely to 4-year-olds b) buffered aspirin contains an ingredient that can be damaging to small children c) all aspirin products should be avoided unless specifically prescribed d) ibuprofen products should be used for children with a virus

c

83. The health care provider ordered intraperitoneal heparin for a patient with a new PD catheter to prevent clotting of the catheter by blood and fibrin formation. How does the nurse advise the patient? a. Watch for bruising or bleeding from the gums b. Make a follow-up appointment for coagulation studies c. Intraperitoneal heparin does not affect clotting times d. Heparin will be given with a small subcutaneous needle.

c

88. A patient has recently started PD therapy and reports some mild pain when the dialysate is flowing in. What does the nurse do next? a. Immediately report the pain to the health care provider. b. Try warming the dialysate in the microwave oven. c. Reassure that pain should subside after the first week or two. d. Assess the connection tubing for kinking or twisting.

c

9. which intervention should be implemented for a paralytic ileus? a. encourage ryan to eat a high-calorie, high-fiber diet b. turn ryan every 2 hours in kinetic bed c. obtain an order to insert a nasogastric tube and set the siphon drainage to a low, intermittent suction d. continue to reassess ryan, but take no action at this time

c

9. you are supervising a new nurse on orientation to the unit who is providing care for ms j after her return from surgery to create a left forearm access for dialysis. which action by the nurse requires that you intervene? a. monitoring the pts operative site dressing for evidence of bleeding b. obtaining a BP reading by placing the cuff on the right arm c. drawing blood for lab studies from the temp dialysis line d. administering oxycodone PO for moderate postop pain

c

90. The nurse is monitoring a patient's PD treatment. The Total output is slightly less than the inflow. What does the nurse do next? a. Instruct the patient to ambulate b. Notify the health care provider c. Record the difference as intake d. Put the patient on fluid restriction.

c

94. The intensive care nurse is caring for the kidney transplant patient who was just transferred from the recovery unit. Which finding is the most serious within the first 12 hours after surgery and warrants immediate notification of the transplant surgeon? a. Diuresis with increased output b. Pink and bloody urine c. Abrupt decrease in urine d. Small clots in bladder irrigation fluid

c

A 76 year old patient is having a bilateral cataract removal. What is the correct classification for this surgery? a. Major b. Cosmetic c. Elective d. Emergent

c

A client's family member says to you, "He needs more pain medicine. He is still having a lot of pain." What is your best response? a) "The physician ordered the medicine to be given every 4 hours." b) "If the medication is given too frequently, he could experience ill effects." c) "Please tell him that I will be right there to check on him." d) "Let's wait about 30 to 40 minutes. If there is no relief, I'll call the physician."

c

A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? a) Fever b) Nausea c) Diaphoresis d) Abdominal cramps

c

A male patient has a scar on his forehead from a third degree burn. What is the correct classification for this surgery? a. Major b. Restorative c. Cosmetic d. Curative

c

A nurse plans an evening snack of milk crackers, and cheese for a client who is receiving NPH insulin (Novolin N). What does this snack provide? a. encouragement to stay on the diet b. added calories to promote weight gain c. nourishment to counteract late insulin activity d. high-carbohydrate nourishment for immediate use

c

A pt is suspected for having PKD. which diagnostic study has minimal risks and can be reveal PKD? a. kidneys-ureters-bladder (KUB) x-ray b. urography c. renal sonography d. renal angiography

c

A pt with PKD reports a sever headache and is at risk for a berry aneurysm. What is the nurse's priority action? a.assess the pain and give a pro pain medication b. reassure the pt that this is an expected aspect of the disease c. assess for neurologic changes and check vital signs d. monitor for hematuria and decreased urinary output

c

A pt with a hx of PKD reports dull, aching flank pain and the UA is negative for infection. the HCP tells the nurse that the pain is chronic and related to enlarging kidneys compressing abdominal contents. what nursing intervention is best for this pt? a. administer trimethoprim/sulfamethoxazole (Bactrim) b. apply cool compress to the abdomen or flank c. Teach methods of relaxation such as deep-breathing d. administer around the clock NSAIDs

c

After Ms Jackson stops crying, she states "My father was in so much pain before he died. Talking about pain brings back so many memories. How should the nurse respond? a. We don't need to talk about pain control today if it makes you sad b. Perhaps you need to see a counselor to help you resolve your grief c. It sounds as if you went through a difficult time when your father died. d. You need to focus on your own needs now and not on past memories

c

An LPN/LVN's assessment for two diabetic patients reveals all of these findings. Which would you instruct the LPN/LVN to report immediately? a. Fingerstick glucose reading of 185 mg/dL b. Numbness and tingling in both feet c. profuse perspiration d. Bunion on the left great toe

c

An older adult male pt calls the clinic because he has "not passed any urine all day long". what is the nurse's best response? a. try drinking several large glasses of water and waiting a few more hours b. if you develop flank pain or fever, then you should probably come in c. You could have an obstruction, so you should come in to be checked out d. I am sorry, but I really can't comment about your problems over the phone

c

Based on description of ryan's limited physical mobility after the accident, the nurse suspects that ryan has experienced a SCI involving the lower cervical region. 3. which intervention has highest priority when assessing ryan? a. palpate the lower abdomen for any signs of urinary retention b. assess sensation by gently pinching the skin distal to proximal c. assess ryan's breathing pattern and ability to cough d. monitor client's vital signs, especially tympanic temperature

c

Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? a) "Where is the pain located, and does it radiate to other parts of your body?" b) "How would you describe the pain, and how is it affecting you?" c) "What do you believe about pain medication and drug addiction?" d) "How is the pain affecting your activity level and your ability to function?" e) "What information do you need about pain, healing, and addiction?"

c

In application of the principles of pain treatment, what is the first consideration? a) Treatment is based on client goals. b) A multidisciplinary approach is needed. c) The client's perception of pain must be accepted. d) Drug side effects must be prevented and managed.

c

In responding to Jess, the nurse recognizes that jess's remarks reflect which of eriksons developmental stages? ("my life is over. ill have to quit college and move home with my parents to let them take care of me. My bf won't want to spend time with someone who has diarrhea all the time") a. ego integrity vs despair b. generativity vs self absorption c. intimacy vs isolation d. identity vs inferiority

c

Mr.D says to you, Please don't call my mother. If she knows I'm back in the hospital, she'll make me quit school and move back home. I know I messed up, but I really don't want to move back in with my parents. what is the best therapeutic communications response? a. none of the staff will say anything, but you should tell her yourself b. Your mom loves you, and she is just concerned about your well-being c. It sounds like you want to be independent and responsible for yourself d. you are an adult and you have a right to make your own decisions

c

Ms Jackson is transferred to a stretcher and taken to the operating room. The nurse assists Ms. Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions Ms. Jackson for surgery. A. Ineffective protection B. Ineffective tissue perfusion C Risk for perioperative-positioning injury D. Risk for imbalanced body temperature

c

The ED nurse is preparing a pt with kidney trauma for emergency surgery. what is the best task to delegate to the UAP? A. set the automated blood pressure machine to cycle every 2 hours b. inform the family about surgery and assist them to the surgery waiting area c. go to the blood bank and pick up the units of packed red cells d. insert a urinary catheter if there is no gross bleeding at the urethra

c

The HCP advises the pt that diagnostic testing is needed to identify the possible presence of renal abscess. which test does the nurse prepare the pt for? a.renal arteriography b. cystourethrogram c. radionuclide renal scan d. urodynamic flow studies

c

The nurse I reviewing lab results for a pt with PKD. which lab abnormality indicates glomeruli involvement? a. low specific gravity of urine b. bacteria in urine c. proteinuria d. hematuria

c

The nurse begins discharge of Jess and self management of her ileostomy for the next 2 months until the next stage of surgery is performed. The stoma drainage is currently a dark green liquid. Jess asks if this is normal How should the nurse respond? a. yes this is the appearance of the drainage you will always experience b. your BMs will remain green but will become solid c. the drainage will become thicker and appear more yellow or yellow brown d. eventually you will experience normal looking soft brown bowel movements

c

The nurse is assessing a pt with glomerulonephritis and notes crackles in the lung fields and neck vein distention. the pt reports mild SOB. based on these findings, what does the nurse do next? a. check for CVA tenderness or flank pain b. obtain a urine sample to check for proteinuria c. assess for additional signs of fluids overload d. alert the HCP about the respiratory symptoms

c

The nurse is walking by the neuro-ICU waiting room and notices ryan's mother sitting and crying. there is no one else in the waiting room. 13. Which action should the nurse implement at this time? a. allow ryan's mother to cry and do not disturb her b. ask the hospital chaplain to come and see ryan's mother c. sit down beside ryan's mother d. discuss the situation with ryan as soon as possible

c

The nurse talks with Ms. Jackson about what to expect the day of surgery and during the immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. Ms. Jackson performs a return demonstration by breathing in deeply through her mouth and exhaling forcefully and rapidly through pursed lips. What action should the nurse implement? a. Advise the client to avoid pursing her lips when exhaling b. Remind the client to cough after taking 2-3 breaths c. Demonstrate the deep breathing and coughing technique again d. Document successful completion of the return demonstration

c

The patient is scheduled to have minimally invasive surgery for a laparoscopic cholecystectomy. Part of this surgery is the injection of air (insufflation) into the abdomen to separate and better see the organs. What patient teaching must the nurse do about the insufflation? a. Your surgeon will make several small incisions instead of a large one b. You will be able to go home once your surgery is completed and you are awake c. You may experience some abdominal discomfort from the air injected with the surgery d. You will have a tube for drainage for a few days after your surgery is completed

c

The patient received moderate sedation by IV prior to a bronchoscopy procedure. Before allowing the patient to have oral liquids, what must the nurse assess in this patient? a. The patient is arousable b. The patient is able to speak c. The patients gag reflex is working d. The patient is able to rotate his head.

c

To avoid electrical safety problems during surgery, what does the nurse do? a. Observes for breaks in sterile technique b. Continuously assists the anesthesia provider c. Ensures proper placement of the grounding pads d. Monitors the operating room with available cameras

c

To ensure jess remains free from infection, which responsibility is best to delegate to a UAP? a. teach jess about the signs of infection that should be reported b. observe the catheter insertion site for inflammation c. obtain and record vs every 4 hrs d. clean the catheter insertion site every 72 hrs

c

What action should the nurse take? a. verbally warn the other members of the nursing staff to avoid the alleged offender b. assist the uap to confront the offender with tape recorded proof of the harassment c. instruct the uap to document all of the alleged offenses in writing and submit a copy to the supervisor d. advise the uap to request a transfer to a different area of the hospital to avoid further confrontation

c

What is the priority nursing diagnosis for Mr. D? a. ineffective breathing pattern related to acidosis b. anxiety related to the uncertainty of the outcome c. deficient fluid volume related to hyperglycemia d. noncompliance related to medications and treatment

c

When the nurse begins teaching about the benefits of early mobilization following surgery, Ms. Jackson states, "Oh I know if i stay in bed very long I will get bedsores. How should the nurse respond? a. Getting a bedsore is very serious. Sometimes people die from infected bedsores b. The nurses will make sure you don't stay in bed long enough to get bedsores c. Bedsores are one of many problems that can occur from prolonged bedrest d. Those are now called pressure ulcers because they are caused by pressure

c

Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? a) Client who has sharp chest pain that increases with cough and shortness of breath b) Client who reports excruciating lower back pain with hematuria c) Client who is having an acute myocardial infarction with severe chest pain d) Client who is having a severe migraine with an elevated blood pressure

c

Which client is most likely to receive opioids for extended periods of time? a) A client with fibromyalgia b) A client with phantom limb pain in the leg c) A client with progressive pancreatic cancer d) A client with trigeminal neuralgia

c

Which communication is best for the nurse to use with the UAP? a. why didn't you obtain the stool specimen as you were assigned? b. you didn't complete your assignment with mrs. b today c. i've noticed that mrs b's stool specimen wasn't obtained d. i'll go get that stool specimen from mrs b for you

c

Which decision is most appropriate for the nurse to make regarding the administration of low dose morphine at this time? a. the dose shouldn't be given since morphine can cause respiratory depression b. the dose shouldn't be given because morphine causes side effects such as constipation c. the dose should be given because morphine reduces pain and anxiety d. the dose should be given because morphine will sedate the client

c

Which definition is appropriate for local anesthesia? a. Injection of anesthetic agent into or around a nerve or group of nerves resulting in blocked sensation and motor impulse transmission b. Injection of the anesthetic agent into the epidural space; the spinal cord areas are never entered c. Injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion d. Injection of anesthetic agent into or around a nerve or group of nerves, resulting in blocked sensation and motor impulse transmission

c

Which description best identifies the purpose of an adverse occurrence report? a. documentation that protects the nurse from a potential lawsuit by the client b. legal component of mrs. b's medical records c. hospital record that helps track patterns of risk to guide corrective action d. written report to the attending HCP describing the occurrence

c

Which description of the recessive form of PKD is correct? a. prognosis is better for the recessive form compared to the dominant form b. 100% of people with this form of PKD develop kidney failure around age 50 c. Most people with this form of PKD die in early childhood d. The recessive form only manifests fi other kidney problems occur

c

Which food should the nurse instruct mrs. b to avoid when on warfarin? a. apple products b. red meats c. green leafy veggies d. nuts

c

Which is the top priority for nurses during the perioperative period? a. Patient teaching b. Patient diagnostic testing c. Patient safety d. Patient care documentation

c

Which medical condition increases a patient's risk for surgical wound infection? a. Anxiety b. Hiatal hernia c. Diabetes mellitus d. Amnesia

c

Which statement best describes the collaborative roles of the nurse and surgeon when obtaining the informed consent? a. The nurse is responsible for having the informed consent form on the chart for the physician to witness b. The nurse may serve as a witness that the patient has been informed by the physician before surgery is performed c. The nurse may serve as witness to the patients signature after the physician has the consent form signed before preoperative sedation is given and before surgery is performed d. The nurse has no duties regarding the consent form if the patient has signed the informed consent form for the physician, even if the patient then asks additional questions about the surgery.

c

You are caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is an order to discontinue the PCA-delivered morphine and to start oral pain medication. The client begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." What is the best response? a) "Let me stop the pump and we can try oral pain medication to see if it relieves the pain." b) "I realize that you are scared of the pain, but we must try to wean you off the pump." c) "Show me where your pain is and describe how it feels compared to yesterday." d) "Let me take your vital signs, and then I will call the physician and explain your concerns."

c

You are supervising a nurse on orientation to the unit who is discharging a pt admitted with kidney stones who underwent lithotripsy. which statement by the nurse to the pt requires that you intervene? a. you should finish all your antibiotics to make sure that you don't get a UTI b. remember to drink at least 3 L of fluids every day to prevent another stone from forming c. report any signs of bruising to your physician immediately, since this indicated bleeding d. you can return to work in 2 days to 6 weeks, depending on what your physician prescribes

c

a pt has sustained a kidney injury. in order to assist the pt to undergo the best diagnostic test to determine the extend of injury, what does the nurse do? a. obtain a clean-catch urine specimen for urinalysis b. give an IV fluid bolus before renal arteriography c. give an explanation computer tomography d. obtain a blood sample for hemoglobin and hematocrit

c

a pt is diagnosed with acute pyelonephritis. what is the priority for nursing care for this pt? a. providing information about the disease process b. controlling hypertension c. managing pain d. preventing constipation

c

a pt is diagnosed with interstitial nephritis. which nursing action is relevant and specific for this pt's medical condition? a. avoid analgesic use b. use disposable gloves c. monitor for fever d. place the pt in isolation

c

a pt is newly admitted with nephrotic syndrome and has proteinuria, edema, hyperlipidemia, and hypertension. what is the priority for nursing care? a. consult the dietitian to provide adequate nutritional intake b. prevent urinary tract infection c. monitor fluid volume and the pt's hydration status d. prepare the pt for renal biopsy

c

a pt returning to the unit after a left radical nephrectomy for kidney cell carcinoma reports having some soreness on the right side. what does the nurse tell the pt? a. the right kidney was repositioned to take over the function of both kidneys b. ill call your doctor for an order to increase your pain medications c. the soreness is likely to be from being positioned on your right side during surgery d. would you like to talk with someone who had this surgery last year and now is fully recovered

c

a pt with PKD reports nocturne. what is the nocturne caused by? a. increased fluid intake in the evening b. increased hypertension c. decreased urine-concentrating ability d. detrusor irritability

c

a pt with chronic pyelnophritis returns to the clinic for follow-up. which behaviors indicates the pt is meeting the expected outcomes to conserve existing kidney function? a. drinks a liter of fluid every day b. considers buying a home blood pressure cuff c. reports taking antibiotics as prescribed d. takes pain medication on a regular basis

c

after a nephrectomy, a pt has a large urine output because of adrenal insufficiency. what does the nurse anticipate the priority intervention for this pt will be? a. ACE inhibitor to control the hypertension and decreased protein loss in urine b. straight catheterization or bedside bladder scan to measure residual urine c. IV fluid replacement because of subsequent hypotension and oliguria d. IV infusion of temsirolimus (torisel), to inhibit cell division

c

the clinic stocks a small number of scheduled medications, so the nurse obtains a dose of the prescribed medication for Natalie. At the end of the shift, the nurse counts the remaining medications with the oncoming nurse and notes that the count is not accurate. 15. what action should the nurse implement? a) request that the oncoming nurse investigate the inaccurate count, and leave a written report for the first nurse b) complete a variance report, documenting that the count was inaccurate, and submit the report to the pharmacist c) review prescriptions for any scheduled drugs with all nurses with access to the medications to determine why the count is inaccurate d) schedule a meeting with the medical director of the clinic to discuss methods to reduce drug errors by the nursing staff

c

the neuro-ICU nurse is developing the nursing care plan for Ryan. 10. which nursing diagnosis has priority at this time? a. self-care deficit b. disturbed sensory perception c. risk for impaired skin integrity d. risk for ineffective coping

c

the nurse is caring for a pt after a nephrectomy. the nurse notes the urine flow was 50 mL/hr at the beginning of the shift, but several ours later has dropped to 30 mL/ what would the nurse do first? a. notify the HCP for an order for an IV fluid bolus b. document the finding and continue to monitor for downward trend c. check the drainage system for kicks or obstructions to flow d. obtain the pt's weight and compare it to baseline

c

the nurse overhears two other nurses discussing Natalie's pain management in the hallway. One nurse states that Natalie is exhibiting drug-seeking behavior and is probably already addicted to her pain medications. 27. what is the priority nursing intervention? a) assess the client for signs of drug-seeking behavior b) ask the other nurses what behaviors they want observed c) arrange to continue the conversation in a more private location d) inform the other nurses that the client is not a drug addict

c

what changes in diabetic therapy may be needed for a pt who has diabetic nephropathy? a. fluid restriction b. decreased activity level c. decreased insulin dosages d. increased caloric intake

c

which description of the autosomal-dominant form of PKD is correct? a. 25% of its with this form of PKD develop acute kidney failure by the age 30 b. the dominant form is responsive to newer gene therapy treatment c. 50% of people with this form of PKD develop kidney disease by the age 50 d. Most people with this form of PKD die in the young childhood

c

which pt has the greatest risk for developing chronic pyelonephritis? a. 80-year-old women who takes diuretics for mild heart failure b. 80-year-old man who drinks four cans of beer per day c. 36-year-old women with diabetes mellitus who is pregnant d. 36-year-old man with diabetes insipidus

c

Which med is most likely to contribute to Jess's increased blood glucose level? a. azathioprine (imuran) b. diphenoxylate (lomotil) c. prednisone (deltasone) d. sulfasalazine (azulfidine)

c (its a glucocorticoid which can increase serum glucose)

The next day the nurse enters jess's room and notes that only 30ml of the tpn solution is remaining. The nurse contacts pharmacy and learns that the next bag of TPN will not be available for 2 hours a. apply a lock and flush the line with a heparin sodium flush solution b. hang a 500ml bag of NS at a KVO rate c. hang a liter of 10% dextrose in water at the same rate of infusion d. hang a liter of LR solution at the same rate of infusion

c (most similar to the TPN solution, which will help reduce the risk of hypoglycemia)

A patient was put in traction at 0800 hours. Hourly neurovascular checks were ordered for the first 24 hours and then every 4 hours there-after. At what time can the nursing staff start performing the 4 hour checks? a) 2000 hours the same day b) 0000 hours the next day c) 0800 hours the next day d)1200 hours the next day

c) 0800 hours the next day

A patient with a leg cast denies pain; toes are pink; capillary refill is brisk and toes move freely; the leg is elevated with an ice pack. Six hours later, the patient reports worsening pain unrelieved by medication. The patient's toes are cool and capillary refill is sluggish. What does the nurse suspect is occurring with this patient? a) Crush syndrome b) Fat embolism syndrome c) Acute compartment syndrome d) Fascitis

c) Acute compartment syndrome

The nurse is caring for a patient with a plaster splint applied to the ankle. The patient received oral pain medication at 0900. At 1100, the patient reports that the pain is getting worse, not better. What is the nurse's priority action? a) Give the patient IV pain medication. b) Reposition the extremity on a pillow and place an ice pack. c) Assess the pulses and skin temperature distal to the splint. d) Call the physician to report the patient's increasing pain.

c) Assess the pulses and skin temperature distal to the splint.

An older adult has been admitted with a hip fracture. Approximately 20 hours post injury, the patient develops a symptom recognized as an early sign of fat embolism syndrome. Which symptom is the patient displaying? a) Severe respiratory distress b) Significantly increased pulse rate c) Change in mental status d) Petechiae rash over the neck

c) Change in mental status

The nurse must adjust a pair of crutches to properly fit a patient. Which description illustrates correct crutch adjustment? a) Axilla rests lightly on the top of the crutch when the crutch is moved forward. b) Patient can easily use the crutch without subjective complaints. c) Elbow is flexed no more than 30 degrees when the palm is on the handle. d) Adult patient is of average height and the crutches are medium-sized.

c) Elbow is flexed no more than 30 degrees when the palm is on the handle.

The nurse case manager is making a home visit to help an older patient with a hip fracture. During the home visit, the nurse reviews home environment safety. Which observation indicates a need for additional teaching? a) Patient's bed has been moved to the ground floor level. b) There are handle bars around the toilet and tub. c) Floors are clean and shiny and covered with throw rugs. d) Patient's walker is close to the patient's beside.

c) Floors are clean and shiny and covered with throw rugs.

The older patient has a fracture that has failed to heal. Which fracture complication best describes this situation? a) Malunion b) Avascular necrosis c) Nonunion d) Crush syndrome

c) Nonunion

The nurse is assessing a patient with an injury to the shoulder and upper arm after being thrown from a horse. What is the best position for this patient's pain assessment? a) Supine so that the extremity can be elevated b) Low Fowler's on an exam table for patient comfort c) Sitting to observe for shoulder droop d) Slow ambulation to observe for natural arm movement

c) Sitting to observe for shoulder droop

The patient has a musculoskeletal injury that resulted from excessive stretching of a muscle or tendon. Which type best describes this patient's injury? a) Dislocation b) Sprain c) Strain d) Subluxation

c) Strain

The nurse is providing teaching for a patient with a forearm cast. What information does the nurse give to the patient? a) The hand should be elevated above the shoulder when resting. b) Use an ice pack for the first 6 to 8 hours, and cover the ice pack with a towel to absorb condensation. c) The sling should distribute the weight over a large area of the shoulders and trunk. d) Limit movement of the fingers or wrist joints to prevent pain.

c) The sling should distribute the weight over a large area of the shoulders and trunk.

The nursing student is assisting with the care of a patient with musculoskeletal pain related to soft tissue injury and bone disruption. The student sees that the patient has a prn (as needed) order for pain medication. What does the student do first in order to decide when to give the pain medication? a) Ask the physician to clarify the order for specific parameters. b) Check with the primary nurse or the charge nurse for advice. c). Ask the patient about types of activities that increase the pain. d) Ask the instructor for help interpreting the order.

c). Ask the patient about types of activities that increase the pain.

19. once the needle is inserted in the skin, what intervention should the nurse perform? (select all that apply) a) observe for a small bleb around the tip of the needle b) place a small sterile gauze pad close to the insertion site c) slowly inject the medication into the muscle mass d) follow the facility policy regarding aspiration of IM injection

c,d

48. Which statements about sensory alteration in pts with diabetes are accurate? (select all) a. healing of foot wounds is reduced because of impaired sensation b. very few patients with diabetic food ulcers have peripheral sensory neuropathy c. loss of pain, pressure, and temperature sensation in the foot increases the risk of injury d. sensory neuropathy causes loss of normal sweating and skin temperature regulation e. it can be delayed by keeping the blood glucose level as close to normal as possible

c,d,e

57. The nurse is teaching a pt with diabetes about proper foot care. Which instructions does the nurse include? (select all) a. use rubbing alcohol to toughen the skin on the soles of the feet b. wear open-toed shoes or sandals in warm weather to prevent perspiration c. apply moisturizing cream to feet after bathing but not between the toes d. use cold water for bathing the feet to prevent inadvertent thermal injury e. do not go barefoot f. inspect the feet daily

c,e,f

2. The daughter of a pt with cholelithiasis has heard that there is a genetic disposition for cholelithiasis. The daughter asks the nurse about the risk factors. How does the nurse respond? a. "There is no evidence that first-degree relatives have an increased risk of this disease." b. "Cholecystitis is seen more frequently in pts who are underweight." c. "Hormone replacement therapy has been associated with increased risk for cholecystitis." d. "Pts with DM are at increased risk for cholecystitis."

c. "Hormone replacement therapy has been associated with increased risk for cholecystitis."

25. The nurse has instructed a pt in the recovery phase of acute pancreatitis about diet therapy. Which statement by the pt indicates that teaching has been successful? a. "I will eat the usual three meals a day that I am used to." b. "I am eating tacos for my first meal back home." c. "I will avoid eating chocolate and drinking coffee." d. "I will limit the amount of protein in my diet."

c. "I will avoid eating chocolate and drinking coffee."

The nurse is instructing a patient about home care after an exploratory laparotomy for peritonitis. Which statement by the patient indicates that teaching has been effective? a. "It is normal for the incision site to be warm." b. " I will stop taking the antibiotics if diarrhea develops." c. "I will call the health care provider for a temperature greater than 101°F" d. "I will resume activity with my bowling league this week for exercise."

c. "I will call the healthcare provider for a temperature greater than 101°F"

What are the cardinal signs of peritonitis? a. Fever and headache b. Dizziness and nausea and vomiting c. Abdominal pain, distention, and tenderness d. Nausea and loss of appetite

c. Abdominal pain, distention, and tenderness

21. The pt comes to the ER with severe abdominal pain in the mid-epigastric area. The pt states that the pain began suddenly, is continuous, radiates to his back, and is worst when he lies flat on his back. What condition does the nurse suspect? a. acute cholecystitis b. Pancreatic cancer c. Acute pancreatitis d. Pancreatic pseudocyst

c. Acute pancreatitis

23. A pt with acute pancreatitis is at risk for the development of paralytic (adynamic) ileus. Which action provides the nurse with the best indication of bowel function? a. observing contents of the NG drainage b. Weighing the pt every day at the same time c. Asking the pt if he or she has passed flatus or had a stool d. Obtaining a computed tomography (CT) scan of the abdomen with contrast medium

c. Asking the pt if he or she has passed flatus or had a stool

30. What is the most common and serious complication after a Whipple procedure? a. DM b. wound infection c. Fistula development d. bowel obstruction

c. Fistula development

Which parasitic infection is manifested by diarrhea and occurs most commonly in immunosuppressed patients, especially those with human immunodeficiency virus? a. Entamoeba histolytica b. Cryptosporidium c. Giardia lamblia d. Escherichia coli

c. Giardia lamblia

Which test may be used in diagnosing IBS? a. erythrocyte sedimentation rate b. stool sample for ova and parasites c. hydrogen breath test d. blood cultures for infection

c. Hydrogen breath test

26. The nursing student is caring for a pt with chronic pancreatitis who is receiving pancreatic enzyme replacement therapy. Which statement by the student indicates the need for further study concerning this therapy? a. The enzymes will be administered with meals b. the pt will take the drugs with a glass of water c. If the pt has difficulty swallowing the enzyme preparation, i will crush it and mix it with foods d. The effectiveness of pancreatic enzyme treatment is monitored by the frequency and fat content of stools

c. If the pt has difficulty swallowing the enzyme preparation, i will crush it and mix it with foods

Which statement is true about drug therapy for crohn's disease? a. Budesonide (Entocort EC) is a rapid-release compound that delivers low local glucocorticoid concentrations to the terminal ileum for patients with crohn's disease b. Methrotrexate (Rheumatrex) is contraindicated in the treatment ofncrohn's disease c. Metronidazole (Flagyl) has been helpful in patients with fistulas and crohn's disease d. Adalimumab (Humira) is a glucocorticoid approved for the treatment of crohn's disease

c. Metronidazole (Flagyl) has been helpful in patients with fistulas and crohn's disease

6. The nurse is assessing a pt with acute cholecystitis whose abdominal pain is severe. The pt has a HR of 118, is pale, diaphoretic, and describes extreme fatigue. What is the nurse's priority action at this time? a. Instruct the UAP to check a complete set of VS b. Auscultate the pt's abdomen in all four quadrants c. Notify the pt's HCP d. Administer the ordered opioid analgesic

c. Notify the pt's HCP

3. Which pt is at low risk for the development of gallbladder disorders? a. Pt with sickle cell anemia b. Pt who is Mexican American c. Pt who is 20 years old and male d. Pt with a hx of prolonged parenteral nutrition

c. Pt who is 20 years old and male

Which is a preventative measure for diverticular disease? a. Excluding whole-grain breads from the diet b. Avoiding fresh apples, broccoli, and lettuce c. Taking bulk agents such as psyllium hydrophilic mucilloid (Metamucil) d. Taking routine anticholinergics to reduce bowel spasms

c. Taking bulk agents such as psyllium hydrophilic mucilloid (Metamucil)

The nurse observes that the word yes has been marked on Ms. Jackson's left hip and the word no has been written on her right hip. What action should the nurse implement? a. Use an antimicrobial agent to cleanse the operative site b. Take a photograph of the markings to place in the chart c. Confirm that the left hip is the site of the scheduled surgery d. Reassure the client that the surgeon will not make a mistake

c. The nurse should ensure that the markings on the hips are correct to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and right sides of the body, marking the site is a required component of the joint commission's universal protocol to prevent wrong site, wrong procedure, wrong person surgery

15. The female pt is to have her gallbladder removed by natural orifice transluminal endoscopic surgery. What does the nurse teach about the surgery? a. The surgeon will use powerful shock waves to break up the gallstones b. The surgeon will insert a trans-hepatic biliary catheter to open blocked bile ducts c. The surgeon will use a vaginal approach to remove your gallbladder d. The surgeon will inject ursodeoxycholic acid to dissolve any remaining gallstone fragments

c. The surgeon will use a vaginal approach to remove your gallbladder

Which are true statements about caring for a patient with a truss? Select all that apply a. a surgical binder holds the truss in place b. the truss is removed only for bathing c. the truss is only used after the hernia is reduced by the physician d. the truss is applied before the hernia is reduced to decrease the pain e. powder should be applied to the skin under the truss daily

c. The truss is only used after the hernia has been reduced by the physician e. Powder should be applied to the skin under the truss daily

What action should the nurse take during the time out? a. Ensure that sufficient surgical supplies are available b. check that all surgical personnel are properly attired c. review the scheduled procedure, site and client d. confirm that informed consent has been obtained

c. This is a protocol to prevent wrong site, wrong procedure and wrong person surgery

Which observation of a patient with an intestinal obstruction does the nurse report immediately? a. Urinary output of 1000 mL in an 8-hour period b. The patient's request for something to drink c. Abdominal pain changing from colicky to constant discomfort d. The patient is changing positions frequently

c. abdominal pain changing from colicky to constant discomfort

A patient is prescribed amitriptyline (Elavil) for the diagnosis of fibromyalgia. What kind of drug is the medication? a. antiinflammatory b. antiheumatic c. antidepressant d. antipsychotic

c. antidepressant

A nurse is caring for a client with rheumatoid arthritis. Based on the clients diagnosis, the nurse should review the result of which laboratory test? a. pancreatic lipase b. Bence Jones protein c. antinuclear antibody d. alkaline phosphatase

c. antinuclear antibody

The patient comes to the emergency department with lower right quadrant pain. What does the ED nurse suspect? a. Gastroenteritis b. Ulcerative colitis c. Appendicitis d. Crohn's disease

c. appendicitis

Aspirin is prescribed for a client with RA. Which clinical indicators of aspirin toxicity should the nurse teach the client to report? (select all that apply) a. nausea b. joint pain c. blood in the stool d. ringing in the ears e. increased urine output

c. blood in the stool d ringing in the ears

what is the most common area of involvement of RA in the spine? a. lumbar spine b. sacral spine c. cervical spine d. thoracic spine

c. cervical spine

Which test is definitive for the diagnosis of CRC? a. carcinoembryonic antigen (CEA) b. barium swallow c. colonoscopy with biopsy d fecal occult blood test (FOBT)

c. colonoscopy with biopsy

Which type of stoma will a patient with diverticulitis most likely have postoperatively? a. Ileostomy b. Jejunostomy c. Colostomy d. Cecostomy

c. colostomy

Which sign/symptom is a patient who had an AP resection instructed to report to healthcare provider immediately? a. Serosanguineous drainage from the wound b. Sensations of having a bowel movement c. Constant perineal odor and pain d. Occasional perineal pain and itching

c. constant perineal odor and pain

Which activity does the nurse tell the patient to avoid after surgery for a hernia repair? a. ambulating b. turning c. coughing d. deep-breathing

c. coughing

What should the nurse consider as the goal of therapy when administering allopurinol (Zyloprim) to a client with gout? a. increase bone density b. decrease synovial swelling c. decrease uric acid production d. prevent crystallization of uric acid

c. decrease uric acid production

The fluid shifts that occurs in peritonitis may result in which of the following? a. Intracellular fluid moving into the peritoneal cavity b. Significant increase in circulatory volume c. Decreased circulatory volume and hypovolemic shock d. Increased bowel motility caused by increased fluid volume

c. decreased circulatory volume and hypovolemic shock

A nurse is assessing a client with the diagnosis of scleroderma for the signs of CREST syndrome. What clinical indicators should the nurse expect to identify? select all that apply a. joint pain b. mask-like facies c. esophageal reflux d. spider-like hemangiomas e. episodic blanching of the fingers

c. esophageal reflux d. spider-like hemangiomas e. episodic blanching of the fingers

The nurse is teaching a patient about the common side effects of chronic salicylate and nonsteroidal antiinflammatory (NSAID) therapy. Which body system side effects does the nurse focus on in the teaching plan? a. central nervous system b. skin c. gastrointestinal d. cardiovascular

c. gastrointestinal

The patient with SLE is taking hydroxychloroquine (Plaquenil). What essential teaching point must the nurse include when teaching the patient about this drug? a. watch for signs of malaria as this is an antimalarial drug b. you are at risk for an increase in skin lesions while taking this drug. c. have eye examinations before and every 6 months after starting this drug. d. be sure to get lots of the sunlight while taking this drug.

c. have eye examinations before and every 6 months after starting this drug

A regimen of rest, exercise, and physical therapy is ordered for a client with RA. What should the nurse explain is the intended purpose of the regimen? a. prevent arthritic pain b. halt the inflammatory process. c. help prevent the crippling effects of the disease d. provide for the return of joint motion after prolonged loss

c. help prevent the crippling effects of the disease

Which statement about intra-abdominal pressure (IAP) monitoring is correct? a. The normal IAP for adults is 15 to 20 mm Hg b. Patients with high IAP have bradycardia c. High IAP leads to increased afterload and decreased preload d. Patients with high IAP are hypertensive

c. high IAP leads to increased afterload and decreased preload

The nurse questions a client with RA about pain. When should the nurse expect the client to experience increased pain and limited movement of the joints? a. after assistive exercise b when the room is cool c. in the morning on awakening d. when the latex fixation test is positive

c. in the morning on awakening

Which statement best describes disoid lupus? a. it is most frequently diagnosed type of lupus b. it results in an increase in immune complexes within the joint cavity c. it is not a systemic condition and is limited to involvement of the skin. d. it is a lupus-like syndrome that occurs in patients taking certain medications.

c. it is not a systemic condition an dis limited to involvement of the skin

The nurse is performing an abdominal assessment on a patient suspected of having an abdominal hernia. The nurse auscultates the abdomen and determines the absence of bowel sounds. What does the nurse suspect in this patient? a. peritonitis b. IBS c. obstruction and strangulation d. low intraabdominal pressure

c. obstruction and strangulation

In patients with RA, where might Baker's cysts be located? a. ankles b. wrists c. popliteal bursae d. achilles tendon

c. popliteal bursae

A client with RA has severe pain and swelling of the joints in both hands. Range-of-motion exercises for this client should be: a. passively performed by the nurse b. avoided if the client reports discomfort c. preceded by the application of heat or cold d gradually increased to improve mobility and independence

c. preceded by the application of heat or cold

The nurse assesses a patient with a hernia and finds that the patient's symptoms include abdominal distention, nausea, vomiting, and pain. The patient's heart rate is 118 bpm and temperature is 101°F. Which type of hernia does the nurse suspect? a. incisional b. incarcerated c. strangulated d. umbilical

c. strangulated

Which description best defines intussusception of the intestine? a. Twisting of the intestine b. Fecal constipation or impaction c. Telescoping of a segment of the intestine within itself d. Adhesions forming scar tissue

c. telescoping of a segment of the intestine within itself

The nurses caring for a patient with gastroenteritis who has frequent stools. Which task is best to delegate to the UAP? a. Teach the patient to avoid toilet paper and harsh soaps b. Instruct the patient on how to take a sitz bath c. Use a warm washcloth to remove stool from the skin d. Dry the skin with absorbent cotton

c. use a warm washcloth to remove stool from the skin

676. A nurse is caring for a client with end stage renal disease. Which clinical indicators of end stage renal disease should the nurse expect? select all a. polyuria b. jaundice c. azotemia d. hypertension e. polycythemia

cd

as a charge nurse, you must rearrange room assignments to admit a new pt. which two pt would be best suited to be roommates? a. 58-year-old with urothelial cancer receiving multi agent chemotherapy b. 63-year-old with kidney stones who has just undergone open ureterolithotomy c. 24-year-old with acute pyelonephritis and severe flank pain d. 76-year-old with urge incontinence and a UTI

cd

which ethnic groups are mostly likely to develop end-stage kidney disease related to hypertension? Select all that apply. a. Caucasian Americans b. Asian Americans c. American Indians d. African Americans e. Hispanic Americans

cd

22. The nurse is providing discharge teaching for a pt with a spinal cord injury who will be performing intermittent self-catheterizations at home. Which signs and symptoms will the nurse instruct the pt to report immediately to the primary health care provider? (select all) a. dysuria b. retention c. fever d. urgency e. foul-smelling urine f. back pain

ce

3. A pt with GBS is identified as having poor dietary intake secondary to dysphagia. A feeding tube is prescribed. How does the nurse monitor this pt's nutritional status? (select all) a. checking the pt's skin turgor and urinary output b. giving the prescribed enteral feedings via feeding tube c. weighing the pt three times a week d. reviewing the pt's potassium and sodium levels e. monitoring weekly serum prealbumin level

ce

48. Which interventions are appropriate to protect a pt with MG from corneal abrasions? (select all) a. instruct the pt to keep the eyes closed b. apply an eye patch to both eyes after breakfast c. administer artificial tears to keep corneas moist d. place a clean moist washcloth over the pt's eyes e. apply lubricant gel and shield to the eyes at bedtime

ce

5. A pt is admitted for a probable diagnosis of GBS, but needs additional diagnostic testing for confirmation. Which tests does the nurse anticipate will be ordered for this pt? (select all) a. electroencephalography (EEG) b. cerebral blood flow (CBF) c. electrophysiologic studies (EPS) d. electrocardiogram (ECG) e. electromyography (EMG)

ce

9. A pt has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hours, the nurse is performing the change of shift assessment. Which postoperative findings are reported to the surgeon immediately? (select all) a. minimal serosanguineous drainage in the surgical drain b. pain at operative site c. swelling or bulging at the operative site d. reluctance or refusal to cough and deep breathe e. moderate clear drainage on the postoperative dressing

ce

In the initial emergency care for Mr.D, which orders would you question? Select all that apply. a. Start a peripheral IV line with a large-bore catheter b. Insert a Foley catheter with a urinometer c. Administer regular insulin subcutaneously d. Maintain the client in a semi-Fowler position. e. Initiate continuous electrocardiographic (ECG) monitoring f. Encourage intake of oral fluids as tolerated

cf

10. A pt with a PE asks for an explanation of heparin therapy. What is the nurses best response? a. it keeps the clot from getting larger by preventing platelets from sticking together to improve blood flow b. it will improve your breathing and decrease chest pain by dissolving the clot in your lung c. it promotes the absorption of the clot in your leg that originally caused the PE d. it increases the time it takes for blood to clot therefore preventing further clotting and improving blood flow

d

12. A pt has had an anterior cervical diskectomy with fusion and has returned from the recovery room. What is the priority assessment? a. assess for the gag reflex and ability to swallow own secretions b. check for bleeding and drainage at incision site c. monitor vital signs and check neurological status d. assess for patency of airway and respiratory effort

d

12. ms j is preparing for discharge. you are supervising a student nurse who is teaching the pt about her discharge meds. which statement by the SN will you intervene? a. sevelamer prevents your body from absorbing phosphorus b. take your folic acid after dialysis on dialysis days c. the docusate is to prevent constipation that may be caused by ferrous sulfate d. you must take the epoetin alfa 3 times a week by mouth to treat anemia

d

13. Upon diagnosis of a PE, the nurse expects to perform which therapeutic intervention for the pt? a. oral anticoagulant therapy b. bedrest in the supine position c. oxygen therapy via mechanical ventilator d. parenteral anticoagulant therapy

d

14. what intervention is required at this time? a. increased doses of immunosuppressive drugs b. IV antibiotics c. conservative management including dialysis d. immediate removal of the transplanted kidney

d

17. A patient has been diagnosed with AKI, but the cause is uncertain. The nurse prepares patient educational material about which diagnostic test? a. Flat plate of the abdomen b. Renal ultrasonography c. Computed tomography d. Kidney biopsy

d

18. A pt with a massive PE has hypotension and shock, and is receiving IV crystalloids. However, the pts cardiac output isn't improving. The nurse anticipates an order for which drug? a. Hydromorphone (dilaudid) b. alteplase (activase, tPA) c. Diltiazem (cardizem) d. Dobutamine (dobutrex)

d

19. What is the best description of the nurses role in the delivery of oxygen therapy? a. receiving the therapy report from the respiratory therapist b. evaluating the response to oxygen therapy c. contacting respiratory therapy fo the devices d. being familiar with the devices and techniques used in order to provide proper care

d

20. A pt with a PE is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform? a. measure abdominal girth because the med causes fluid retention b. check skin turgor because dehydration contributes to anticoagulation c. monitor for N/V, and diarrhea d. Examine skin every 2 hours for evidence of bleeding

d

25. A patient with AKI is ill and has a poor appetite. What would the health care team try first? a. Iv normal saline to prevent dehydration b. Familiar foods brought by the family c. Nasogastric tube for enteral feedings d. Oral supplements designed for kidney patients

d

25. Because the most common symptoms of MG are related to involvement of the levator palpebrae or extraocular muscles, which assessment technique does the nurse use? a. use a penlight and check for pupil size and response b. observe for protrusion of the eyeballs c. check accommodation by moving the finger toward the pt's nose d. face the pt and direct him or her to open and close the eyelids

d

25. you are caring for a pt admitted with dehydration secondary to deficient antidiuretic hormone (ADH). Which specific gravity value supports this dx? a. 1.010 b. 1.035 c. 1.020 d. 1.002

d

28. A patient has AKI related to nephrotoxins. In order to maintain cell integrity, improve GFR, and improve blood flow to the kidneys, which type of mediation does the nurse anticipate the health care provider will prescribe? a. Loop diuretics b. Alpha-adrenergic blockers c. Beta blockers d. Calcium channel blockers

d

28. Which class of antidiabetic medication is most likely to cause a hypoglycemic episode because of the long duration of action? a. alpha-glucosanide inhibitors, which include miglitol (Glyset) b. biguanides, which include metformin (glucophage) c. meglitinides, which include natelinide d. second-generation sulfonylureas, which include glipizide (glucotrol)

d

29. A pt with an SCI has paraplegia and paraparesis. The nurse has identified a priority pt problem of inability to ambulate. The nurse assesses the calf area of both legs for swelling, tenderness, redness, or possible complaints of pain. This assessment is specific to the pt's increased risk for which condition? a. contractures of joints b. bone fractures c. pressure ulcers d. deep vein thrombosis

d

3. Which behavior does Natalie exhibit , that the nurse documents as objective signs of acute pain? a) states pain level of 5 out of 10 b) complains of shortness of breath c) difficulty concentrating d) frequent grimacing

d

34. Which statement by the nursing student indicates an understanding of the purpose of administering oxygen by nasal cannula? a. with a nasal cannula, a wide range of oxygen flow rates and concentrations can be delivered b. a min. flow rate of 5L/min is needed to prevent the rebreathing of exhaled air c. it works by pulling in a proportional amount of room air for each liter flow of oxygen d. it is often used for chronic lung disease and for any pt needing long term oxygen therapy

d

36. The nurse is taking a history on a patient with diabetes and hypertension. Because of the patient's high risk for developing kidney problems, which early sign of chronic kidney disease (CKD) does the nurse assess for? a. Decreased output with subjective thirst b. Urinary frequency of very small amounts c. Pink or blood-tinged urine d. Increased output of very dilute urine

d

37. Increased BUN and creatinine, hyperkalemia, and hypernatremia are all characteristics of which stage of kidney disease? a. Stage 1 CKD b. Mild CKD c. Moderate CKD d. ESKD

d

4. A pt with GBS has been intubated for respiratory failure. The nurse must suction the pt. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the pt for? a. thick secretions b. atrial fibrillation c. cyanosis d. bradycardia

d

4. a patient has been talking to his physician about drugs that could potentially be used in the treatment of acute low back pain. Which statement by the patient indicates a need for additional teaching? a. "the doctor may prescribe an antiseizure drug such as oxcarbazepine; therefore, I would need to have blood tests to check my sodium level" b. "the doctor may suggest over-the-counter ibuprofen; therefore, I should watch for and report dark and tarry stools" c. "the doctor may prescribe an oral steroid such as prednisone; this would be short-term therapy and the dose would gradually taper off" d. "the doctor may prescribe hydromorphone and it may cause drowsiness; I should not drive or drink alcohol when I take it"

d

4. which med should you be prepared to administer to lower the pts potassium level? a. furosemide (lasix) 40mg IV push b. epoetin alfa (Epogen) 300 units/kg subQ c. calcium 1 tab PO d. sodium polystyrene sulfonate (Kayexalate) 15g PO

d

40. The pt is a woman in her early 30s who has recently been diagnosed with MS. The nurse has taught the pt's husband about the course of the illness and what problems might occur in the future. Which statement by her husband indicates the need for additional teaching? a. "she could fall because she may lose her balance and have poor coordination" b. "eventually she will not be able to drive because of vision problems" c. "she will probably have a decreased libido and diminished orgasm" d. "later on she could have intermittent short-term memory loss"

d

42. A pt with type 2 DM, usually controlled with a second-generation sulfonylurea, develops a urinary tract infection, the pt must be treated with insulin. What additional information about this treatment does the nurse relay to the pt? a. the sulfonylurea must be discontinued and insulin taken until the infection clears b. insulin will now be necessary to control the pt's diabetes for life c. the sulfonylurea dose must be reduced until the infection clears d. the insulin is necessary to supplement the second-generation sulfonylurea until the infeciton clears.

d

43. A pt with MG experienced a cholinergic crisis and is currently being maintained on a ventilator. The pt received several 1-mg doses of atropine. What does the nurse closely monitor this pt for? a. increasing muscle weakness b. increased salivation c. ventricular fibrillation d. development of mucus plugs

d

44. All patients with hypertension or diabetes should have yearly screenings for which factor? a. Creatinine b. BUN c. Glycosuria d. Microalbuminuria

d

44. The nurse is performing pt teaching about plasmapheresis. Which statement by the pt indicates understanding of the topic? a. "plasmapheresis causes immunosuppression, so i am at risk for infection" b. "i will have to be admitted to the hospital for this procedure" c. "two treatments are given over a 2-month period; then I must follow up on a monthly basis" d. "the goal of the treatment is to decrease symptoms, but it is not a cure"

d

49. The nurse is assessing the skin of a patient with ESKD. Which clinical manifestation is considered a sign of very late, premorbid, advanced uremic syndrome? a. Ecchymoses b. Sallowness c. Pallor d. Uremic frost

d

50. A pt with a thymoma had surgery to relieve symptoms of MG. A single chest tube has been inserted into the pt's anterior mediastinum. The nurse notes that the pt is restless with diminished breath sounds and decreased chest wall expansion. What is the nurse's first priority action? a. reposition the pt and perform chest physiotherapy b. activate the rapid response team c. suction the pt and tell him to breathe deeply d. provide oxygen and elevate the HOB

d

6. the nurse considers interventions to include in the plan of care. Before implementing any interventions, what action is most important for the nurse to take? a) place a copy of the plan of care in the client's chart b) evaluate the client's response to the interventions c) review interventions in a care plan manual d) discuss the plan of care with the client

d

688. a client with acute kidney failure becomes confused and irritable. Which does the nurse determine is the most likely cause of this behavior? a. hyperkalemia b. hypernatremia c. a limited fluid intake d. an increased BUN level

d

690. A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? a. it provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration b. it exchanges and cleanses blood by correction of electrolytes and excretion of creatinine c. it decreases the need for immobility because it clears toxins in short and intermittent periods d. it uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion

d

7. Which medication should the nurse suggest as a common NSAID? a) Diphenhydramine (Benadryl) b) Alprazolam (Xanax) c) Calcium Carbonate (Tums) d) Ibuprofen (Motrin)

d

71. The nursing student is explaining principles of hemodialysis to the nursing instructor. Which statement made by the student indicates a need for additional study and research on the topic? a. " Dialysis works as molecules from an area of higher concentration move to an area of lower concentration." b. " Blood and dialyzing solution flow in opposite directions across an enclosed semipermeable membrane." c. " Excess water, waste products, and excess electrolytes are removed from the blood." d. " Bacteria and other organisms can also pass through the membrane, so the dialysate must be kept sterile."

d

74. A pt with diabetes has signs and symptoms of hypoglycemia. The pt has blood glucose of 56 mg/dL, is alert but responds to voice, and is confused and is unable to swallow fluids. What does the nurse do next? a. give a glass of orange juice with two packets of sugar and continue to monitor the pt b. give a glass of orange or other type of juice and continue to monitor the pt c. give a complex carbohydrate and continue to monitor the pt d. administer D50 IV push

d

74. The nurse is caring for a patient with an arteriovenous fistula. What instructions are given to the UAP regarding the care of this patient? a. Palpate for thrills and auscultate for bruits every 4 hours. b. Check for bleeding at needle insertion sites c. Assess for patients distal pulses and circulation d. Do not the blood pressure reading in the arm with the fistula.

d

741. a nurse is taking the health history of a client who is to have surgery in one week. The nurse identifies that the client is taking ibuprofen (advil) for discomfort associated with osteoarthritis and notifies the health care provider. Which drug does the nurse expect with MOST likely be prescribed instead of the Advil? a) naproxen (aleve) b) ibuprofen (motrin) c) ketorolac (toradol) d) acetaminophen (tylenol)

d

77. The nurse is assessing a patient who has just returned from hemodialysis. Which assessment finding is cause for greatest concern? a. Feeling of malaise b. Headache c. Muscle cramps in the legs d. Bleeding at the access site

d

81. Which patient with kidney problems is the best candidate for peritoneal dialysis (PD)? a. Patient with peritoneal adhesions b. Patient with a history of extensive abdominal surgery. c. Patient with peritoneal membrane fibrosis d. Patient with a history of difficulty with anticoagulants

d

93. The nurse is caring for the kidney transplant patient in the immediate postoperative period. During the initial period, the nurse will assess the urine output at least every hour for how many hours? a. First 8 hours b. First 12 hours c. First 24 hours d. First 48 hours

d

A 47 year old patient is having surgery to remove kidney stones. What is the correct classification for this surgery? a. Restorative b. Emergent c. Palliative d. Urgent

d

A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced UAP states that she received training in Foley catheter insertion at a previous job. What task can be delegated to this UAP? a) Assessing the bladder distention and the pain associated with urinary retention b) Inserting the Foley catheter, once you ascertain that she knows sterile technique c) Evaluating the relief of pain and bladder distention after the catheter is inserted d) Measuring the urine output after the catheter is inserted and obtaining a urine specimen

d

A female patient is having a biopsy of a nodule found in the right breast. Which classification identifies this surgery? a. Urgent b. Minor c. Cosmetic d. Diagnostic

d

A patient experiences MH immediately after induction of anesthesia. What is the nurse anesthetist's first priority action? a. Administer IV dantrolene sodium (Dantrium) 2-3 mg/kg b. Apply a cooling blanket over the torso c. Assess arterial blood gases and serum chemistries d. Stop all inhalation anesthetic agents and succinylcholine e. Monitor cardiac rhythm by electrocardiography to assess for dysrhythmias

d

A pt has a family history of autosomal-dominant form of PKD and has therefore been advised to monitor for and report any symptoms. What is an early symptom of PKD? a. Headache b. Pruritus c. Edema d. Nocturia

d

A pt is very ill and is admitted to the intensive care unit with rapidly progressing glomerulonephritis. the nurse monitors the pt for manifestations of which organ system failure? a. immune system b. cardiovascular system c. neurological system d. renal system

d

As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? a) Make a note in the nurse's file and continue to observe clinical performance. b) Refer the new nurse to the in-service education department. c) Quiz the nurse about knowledge of pain management and pharmacology. d) Give praise for correctly charting the dose and time and discuss the deficits in charting.

d

In providing the care, which division of tasks is best for the nurse to assign? a. the lpn removes the subclavian catheter with the rn supervising to ensure that sterile procedure is followed b. after the hcp removes the subclavian catheter the lpn updates the plan of care and the rn starts the new iv and antibiotics c. after the rn removes the subclavian catheter the UAP applies pressure to the site and covers the area with a dressing d. after the rn removes the subclavian catheter the lpn obtains vs and the uap transports the tip to the lab

d

Jess's blood glucose level is 215. What action should the nurse take? a. slow down the rate of infusion to 30ml/hour b. call the lab to obtain a stat glucose via venipuncture c. add regular insulin to the infusing TPN solution d. administer insulin using a sliding scale protocol

d

Natalie has also been receiving docusate sodium, a stool softener. She asks the nurse if this needs to be continued. 26. how should the nurse respond? a) "you were receiving the docusate sodium because morphine is very constipating. You will no longer need to take it." b) "schedule III medications such as hydrocodone/acetaminophen tend to be more constipating than schedule II medications such as morphine" c) "the stool softener should have been discontinued as soon as your bowel sounds returned after surgery" d) "you may need to continue the docusate sodium because most opioid analgesics, including hydrocodone/acetaminophen, cause constipation"

d

Natalie states that she has also been applying a cold pack an hour at a time to help heal her back as quickly as possible. 10. Which instruction is most important for the nurse to provide? a) the cold pack provides pain relief but doesn't heal the injury b) the cold applications should be alternated with the heating pad c) cold reduces inflammation and prevents tissue swelling d) the cold pack should only be applied for approximately 20 minutes at a time

d

Natalie states that the guided imagery exercise was helpful, and she is interested in learning additional exercises. The nurse guides Natalie in a progressive relaxation activity. After first establishing a regular breathing pattern, the nurse tells Natalie to locate an area where she can feel muscle tension. 21. What instruction should the nurse provide next? a) apply gentle pressure over the opposing muscle b) apply firm pressure over the muscle c) relax the muscle completely d) tense the muscle fully

d

Natalie tells the nurse that she has an electric heating pad at home that she used when she sprained her ankle. 9. Which response by the nurse is accurate? a) "warm moist compresses are a better choice because there is less chance of injury to your skin" b) "a heating pad is more effective than moist compresses because it will penetrate more deeply into the muscles." c) "heating pads provide dry heat, which promotes vasoconstriction, reducing any muscle swelling that has occurred." d) "the dry heat provided by your heating pad will help relieve your pain by promoting muscle relaxation"

d

On the first day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the first action you should take? a) Deliver the bolus dose per standing order. b) Contact the physician to increase the dose. c) Try nonpharmacologic comfort measures. d) Assess the pain for location, quality, and intensity.

d

The HCP tells the nurse that the pt with PKD has salt wasting. which intervention is the nurse likely to use related to nutrition therapy? a. talk to the pt about seasoning that are alternative for salt b. help the pt select lunch tray with low-sodium items c. obtain an order for fluid restrictions to prevent loss of sodium during urination d. advise that a low-sodium diet is not currently necessary

d

The UAP submits a complaint to the supervisor who belittles her and refuses to take action. With whom should the nurse advise the UAP to collaborate? a. the local womens crisis center b. a hospital social worker c. the hospital medical director d. a legal aid clinic attorney

d

The patient in the OR holding area tells the nurse that his surgery is for the right foot. The patients chart states that the surgery is for his left foot. What is the nurses best action? a. Do nothing because the patient is confused after receiving premedications b. Make a note about this in the nursing notes of the patients chart c. Call the nurse anesthetist to check whether the chart or patient is correct d. Notify the surgeon immediately before the patient goes into the OR about this discrepancy

d

The physician has ordered a placebo for a client with chronic pain. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? a) Prepare the medication and hand it to the physician. b) Check the hospital policy regarding the use of a placebo. c) Follow a personal code of ethics and refuse to participate. d) Contact the charge nurse for advice.

d

The surgical team understands that time is crucial in recognizing and treating an MH crisis. Once recognized, what is the treatment of choice? a. Danazol gluconate (Danocrine) b. Phenytoin sodium (Dilantin) c. Diazepam sulfate (Valium) d. Dantrolene sodium (Dantrium)

d

The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? a) Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format b) Giving the ordered dose of Narcan and evaluating the response to therapy c) Monitoring the respiratory status for the first 30 minutes d) Applying oxygen per nasal cannula as ordered

d

To ensure the best skin protection around the stoma, the nurse should instruct jess to use what type of product? a. hydrogel dressing b. skin foam with vitamins a and E c. transparent film dressing d. pectin based solid skin barrier

d

What instruction is more important to include when teaching jess about the prednisone? a. urine may appear concentrated or red-orange in color b. take the daily dose at bedtime to avoid daytime drowsiness c. cover exposed skin when spending time in direct sunlight d. monitor mouth sores for white patches or increased discomfort

d

What instruction should the nurse provide to a client who just completed a barium enema? a. remain npo for 24 hours b. limit fluid intake c. resume normal fluid intake d. drink extra fluids

d

What is the best way to schedule medication for a client with constant pain? a) PRN at the client's request b) Before painful procedures c) IV bolus after pain assessment d) Around the clock

d

What is the common problem of hydronephrosis, hydroureter, and urethral stricture in kidney function? a. Dilute urine b. tubular cell damage c. dehydration d. obstruction

d

What is the legal concern involved in med errors? a. assault b. fraud c. defamation d. malpractice

d

Which assessment finding indicates that the diphenoxylate is having the desired effect? a. reported decrease in abdominal pain b. no evidence of blood in the stool c. increase in bowel sound activity d. decreased number of BMs

d

Which characteristics are appropriate to the anesthetic agent ketamine HCl? a. Can depress respiratory and cardiac functions b. May increase heart rate and lower BP during induction c. Short acting; patient becomes responsive quickly postoperatively d. Dissociative emergence reactions; can induce nausea and vomiting

d

Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? a) Elderly client with chronic pain who has a hip fracture b) Client with a heroin addiction and back pain c) Young female client with advanced multiple myeloma d) Child with an arm fracture and cystic fibrosis

d

Which duties are within the scope of practice of the circulating nurse in the operative setting? a. Manages the patient's care while the patient is in this area and initiates documentation on a perioperative nursing record b. Sets up the sterile field; assists with the draping of the patient; and hands sterile supplies, equipment and instruments to the surgeon c. Assumes responsibility for the surgical procedure and any surgical judgements about the patient d. Coordinates, oversees and participates in the patients nursing care while the patient is in the operating room

d

Which nursing intervention should the nurse implement to help reduce the risk for abnormal bleeding during heparin therapy? a. monitor for dysuria/diarrhea b. auscultate breath sounds regularly c. ensure that vitamin K is readily available d. maintain heparin on a continuous infusion pump

d

Which of mrs b's meds places her at increased risk for the development of DVT? a. antibiotics b. analgesics c. antiasthmatics d. oral contraceptives

d

Which pain management strategy does the nurse teach a to who has pain from infected kidney cysts if PKD? a. take nothing by mouth b. increase the does of NSAIDs c. assume a high-flower position d. apply dry heat to the abdomen or flank

d

Which route of administration should the nurse anticipate for heparin therapy? a. oral b. subQ c. IM d. IV

d

Which term should the nurse use to most accurately report that mrs. b may have developed a clot in her vein that is causing the pain and swelling in her leg? a. phlebitis b. thrombosis c. thrombitis d. thrombophlebitis

d

You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? a) Check the medication administration records (MARs) for the past several days. b) Ask the nurse educator to provide in-service training about pain management. c) Perform a complete pain assessment on the client and take a pain history. d) Have a conference with the nurses responsible for the care of this client.

d

You have completed the triage assessment and history taking. Now, what is your priority action? a. page the ED physician to come immediately to triage b. call the client's parents for permission to treat c. notify the client's primary care physician d. take the client immediately to a treatment room.

d

a nurse is caring for a pt with glomerulonephritis. what should the nurse instruct the pt to do to prevent recurrent attacks? a. take showers instead of tub baths b. continue the same restrictions on fluid intake c. avoid situations that involve physical activity d. seek early treatment for respiratory tract infections

d

a pt diagnosed with renal cel carcinoma that has metastasized to the lungs is considered to be in which stage of cancer? a. I b. II c. III d. IV

d

a pt with acute glomerulonephritis had edema of the face, the blood pressure is moderately elevate and the pt has gained 2 pounds within the past 24 hours. the pt reports fatigue and refuses to eat. what is the priority for nursing care? a. cluster care to allow rest periods for pt b. obtain a dietary consult to plan an adequate nutritional diet c. monitor urine output with accurate intake and output amounts d. assess for s/s of fluid volume overload

d

for a pt with acute glomerulonephritis, a 24-hour urine test was initiated and the glomerular filtration rate (GFR) results are pending. what are the clinical implications of the test results? a. GFR is normal; the therapy can be discontinued b. GFR is high; the pt is at risk for dehydration c. GRF is low; the pt is at risk for infection d. GFR is low; the pt is at risk for fluid overload

d

the night nurse finds ryan crying and asks ryan if he would like to talk. tonight, ryan tells the nurse, "i dont want to live if people will have to take care of me. Please tell my family and the doctors that I want to die. I don't want any medications or treatments. I have already told them, but they won't listen to me" 12. which intervention should the nurse implement? a. reassure ryan that everything will be fine and encourage him to not think like that b. encourage ryan to talk to the chaplain about his feelings as soon as possible c. request the hospital ethics committee to meet and discuss ryan's wishes d. arrange a meeting with ryan, his family, and the healthcare team to discuss ryan's concerns

d

the nurse is caring for a patient who had a nephrectomy yesterday. the manage the pt's pain, what is the best plain for analgesic therapy? a. limit narcotics because of respiratory depression b. give an oral analgesic when the pt can eat c. alternate parenteral and oral medications d. give parenteral medications on a schedule

d

the nurse is taking history in a pt with chronic glomerulonephritis. what is the pt mostly likely to report? a. hx of antibiotic allergy b. intense flank pain c. poor appetite and weight loss d. occasional edema and fatigue

d

the nursing diagnosis of constipation related to compression of the intestinal tract has been identified in a pt with polycystic kidney disease. which nursing care action should you delegate to a newly-trained LPN? a. instruction the pt about foods that are high in fiber b. teaching the pt about foods that assist in promoting bowel regularity c. assessing the pt for previous bowel problems and bowel routine d. administering decussate sodium (Colace) 100 mg by mouth twice a day

d

which nursing intervention is applicable for a pt with acute glomerulonephritis? a. restricting visitors who have infections b. assessing the incision site c. inspecting the vascular access d. measuring weight daily

d

To maintain jess's diet of low fiber, low lactose, which snack choice is best for jess? a. butter free popcorn and cola b. apple and flavored water c. nachos and light beer d. angel food cake and cranberry juice

d (popcorn, raw fruits, and chips are all high fiber foods)

Since the course of TPN treatment will last about 10 days, the nurse plans to prepare jess for the insertion of which access device? a. percutaneous endoscopic gastrostomy b. implanted port below the clavicle c. peripheral IV in the antecubital fossa d. multi lumen subclavian catheter

d (provides access to a large central vein, which will tolerate the hyperosmotic solution of TPN)

A patient is prescribed low-intensity ultrasound treatments for a very slow healing fracture of the right lower leg.What instructions does the nurse give this patient related to the treatment? a) Test for pregnancy before the therapy and use birth control until treatment is complete. b) the treatment is experimental, but there are no known adverse effects. c) The device is implanted directly into the fracture site and there is no external apparatus. d) Expect to dedicate approximately 20 minutes a day for one treatment.

d) Expect to dedicate approximately 20 minutes a day for one treatment.

The nurse is instructing a teenage patient with a tibia-fibula fracture that was treated with internal fixation and a long leg cast. He is anxious to know when the cast will be removed so that he can resume football practice. Which statement by the patient indicates a need for additional teaching? a) There's a possibility that the cast could be removed in 4 weeks. b) The plates and screws reduce the length of time I'll be in the cast. c) The cast could remain in place as long as 6 weeks. d) I'll use crutches for 2 weeks and then the cast will be removed.

d) I'll use crutches for 2 weeks and then the cast will be removed.

A patient comes to the ED after slipping on some chalk in her classroom. She did not fall far and was able to walk with the assistance of one of her students. What type of fracture does this patient likely have? a) Closed, non displaced b) Oblique c) Impacted d) Incomplete

d) Incomplete

A patient who tripped and fell down several stairs reports having heard a popping sound and fears that she has broken her ankle. How does the nurse initially assess for fracture in this patient? a) Measuring the circumference of the distal leg b) Gently moving the ankle through the full range of motion c) Inspecting for crepitus and skin color d) Observing for deformity or misalignment

d) Observing for deformity or misalignment

A patient with a lower extremity injury is being treated by external fixation. What nursing assessment is of particular concern in the care of this patient with this type of system? a) Maintaining a 30-degree flexed position of the knee. b) Measuring the weights used for counter-traction. c) Observing the patients ability to adjust the clickers. d) Observing the points of entry of the pins and wires.

d) Observing the points of entry of the pins and wires

A patient has a fracture of the right wrist. What is an early sign that indicates this patient may be having a complication? a) Patient loses ability to wiggle fingers without pain. b) Fingers are cold and pale; capillary refill is sluggish. c) Pain is severe and seems out of proportion to injury. d) Patient reports a subjective numbness and tingling.

d) Patient reports a subjective numbness and tingling.

An older patient with a lower leg fracture is having difficulty performing the weight-bearing exercises. Based on the fracture pathophysiology and the patient's abilities, which condition could the patient develop? a) Osteomyelitis b) Internal derangement c)Neuroma d) Pulmonary embolism

d) Pulmonary embolism

the student nurse is assessing a patient with a probable fractured tibia-fibula. What assessment technique used by the student nurse causes the supervising nurse to intervene? a) Inspects the fracture site for swelling or deformity b) Instructs the patient to wiggle the toes c) Assesses the bilateral dorsals pedis pulse d) Pushes on the leg to elicit pain response

d) Pushes on the leg to elicit pain response

Which term related to the fracture healing process is the process of bone building and resorption? a) Callus b) Granulation c) Hematoma d) Remodeling

d) Remodeling

The unlicensed assistive personnel (UAP) is assisting the orthopedic physician to cut a window in a patient's cast. What does the nurse instruct the UAP to do? a) Check the pulse that is assessed after the window is cut b) Clean up and dispose of all casting debris c) Inform the patient that the procedure is painless d) Save the plaster piece that was cut so it can be taped in place

d) Save the plaster piece that was cut so it can be taped in place

What potential adverse effect prevents meperidine (Demerol) from being used in older adults? a)Hypertension b) Angina c) Kidney failure d) Seizures

d) Seizures

22. Which are modifiable risk factors for type 2 DM? (select all ) a. age b. family history c. working in a low-stress environment d. maintaining ideal body weight e. maintaining adequate physical activity

d,e

The nurse discusses postoperative pain management with Ms. Jackson and explains the use of a patient controlled analgesia pump. Ms. Jackson expresses fear that she might accidentally overdose herself, since she will be sleepy after surgery. How should the nurse respond? a. You will only use the PCA pump for the first 24 hours after surgery b. The surgeon will prescribe the dose of medication that is correct for you c. I will tell the surgeon that you prefer that the nurses administer your pain medicine d. The pump has a control device that prevents you from taking too much medicine

d.

The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states she has been taking 2 medications; Hydrodiuril (hydrochlorothiazide) and Coumadin (warfarin) (a diuretic and an anticoagulant) every day for more than a year. What nursing action is most important? a. Observe the appearance of the client's oral mucosa b. Assess the client for any signs of excessive bruising c. Review common side effects of each of the medications d. Explain the need to withhold the warfarin prior to surgery.

d. Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to withhold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped

7. The HCP has assessed a pt's abdomen and found rebound tenderness on deep palpation. What does the nurse recognize? a. Steatorrhea b. Eructation c. Biliary colic d. Blumberg's sign

d. Blumberg's sign

9. Which type of drug is used to treat acute severe biliary pain? a. Acetaminophen (tylenol) b. NSAIDS (Ibuprofen) c. Antiemetics (Compazine) d. Opioids (Morphine)

d. Opioids (Morphine)

16. After removal of the gallbladder, a pt experiences abdominal pain with vomiting for several weeks. What does the nurse recognize? a. Chronic cholecystitis b. Recurrence of acute cholecystitis c. Unremoved gallstones d. Postcholecystectomy syndrome

d. Postcholecystectomy syndrome

The patient with IBS reports abdominal distention and feeling bloated to the nurse. The patient states she had a bowel movement that morning. What drug treatment does the nurse expect the healthcare provider to order? a. loperamide (Imodium) b. Psyllium hydrophilic mucilloid (Metamucil) c. Lubiprostone (amitiza) d. rifaximin (Xifaxan)

d. Rifaximin (Xifaxan)

14. Which statement about the care of a pt with a Jackson-Pratt (JP) drain after a traditional cholecystectomy is true? a. The pt is maintained in the prone position b. When the pt is allowed to eat, the JP drain is clamped continuously c. The JP drain is irrigated every hour for the first 24 hours d. Serosanguineous drainage stained with bile is expected for 24 hours

d. Serosanguineous drainage stained with bile is expected for 24 hours

24. Which condition is most likely to be treated with antibiotics? a. cancer of the gallbladder b. Acute cholelithiasis c. chronic pancreatitis d. acute necrotizing pancreatitis

d. acute necrotizing pancreatitis

A client with arthritis reports receiving the following dietary suggestions over the years. Which recommendation for a daily diet should the nurse reinforce? a. wheat germ and yeast b. yogurt and blakstrap molasses c. multiple vitamin supplements in large doses d. adequate foods in a variety of different food groups

d. adequate foods in a variety of different food groups

As part of the routine treatment plan for a patient with bacterial gastroenteritis, which drugs does the nurse anticipates the patient will most likely be prescribed? a. Anticholinergics b. Antiemetics c. Antiperistaltic drugs d. Antibiotics

d. antibiotics

The nurse is teaching a patient about colostomy care. Which information does the nurse include in the teaching plan? a. The stoma will enlarge within 6 to 8 weeks of surgery. b. Use a moisturizing soap to cleanse the area around the stoma. c. Place the colostomy bag on the skin when the skin sealant is still damp. d. An antifungal cream or powder can be used if a fungal rash develops.

d. antifungal cream or powder can be used if a fungal rash develops

Which intervention applies to the nursing care of an older patients with heart failure and hypovolemia related to an intestinal obstruction? a. Provide frequent mouth care with lemon glycerin swabs b. Offer ice chips to suck on before surgery c. Offer a small glass of water d. Assess for crackles in the lungs

d. assess for crackles in the lungs

What is the classic symptom of malabsorption syndrome? a. Unintentional weight loss b. Decreased libido c. Bloating with flatus d. Chronic diarrhea

d. chronic diarrhea

19. Disseminated intravascular coagulation (DIC) is a complication of pancreatitis. What pathophysiology leads to this complication? a. Hypovolemia b. Peritoneal irritation and seepage of pancreatic enzymes c. disruption of alveolar-capillary membrane d. consumption of clotting factors and microthrombi formation

d. consumption of clotting factors and microthrombi formation

Your patient with RA is taking prednisone (Deltasone) and naproxen (Aleve) to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider? a. RA symptoms are worst in the morning b. dry eyes c. round and movable nodules just under the skin d. dark-colored stools

d. dark-colored stools

A patient with Crohn's disease has a fistula. Which assessment findings indicates possible dehydration? a. Weight gain of 2 pounds in one day b. Abdominal pain c. Foul-smelling urine d. decreased urinary output

d. decreased urinary output

Which laboratory finding does the nurse expect may occur with a diagnosis of appendicitis? a. Decreased hematocrit and hemoglobin b. Increased coagulation time c. Decreased potassium d. Increased WBC count

d. increased white blood cell count

In RA, autoantibodies (rheumatoid factors [RFs]) are formed that attack healthy tissue, especially synovium, causing which condition? a. nerve pain b. bone porosity c. ischemia d. inflammation

d. inflammation

Which type of diet has been implicated in the formation of diverticula? a. High-fat diet b. Low-protein diet c. High-cholesterol diet d. Low-fiber diet

d. low-fiber diet

Which acid-base abnormality results from a bowel obstruction high in the small intestine? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

d. metabolic alkalosis

A client with type 2 diabetes develops gout, and allopurinol (Zyloprim) is prescribed. The client is also taking metformin (glucophage) and an over-the-counter nonsteroidal antiinflammatory drug (NSAID). When teaching about the administration of allopurinol, what should the nurse instruct the client to do? a. decrease the daily dose of NSAIDs. b. limit fluid intake to one quart a day c. take the medication on an empty stomach d. monitor blood glucose levels more frequently

d. monitor blood glucose levels more frequently

Which drug is often used in older patients for pain management of moderate to severe diverticulitis? a. Ibuprofen (Motrin) b. Acetaminophen (Tylenol) c. Aspirin (Anacin) d. Morphine sulfate (Duramorph)

d. morphine sulfate (Duramorph)

what common musculoskeletal health problem is often associated with RA? a. Paget's disease b. Fibromyalgia c. Marfan syndrome d. osteoporosis

d. osteoporosis

The nurse is assessing an older adult patient with abdominal pain. Assessment findings include generalized abdominal pain with ridigity, nausea, and vomiting, elevated temperature (101.2F), increased HR (122/min), and chills. The patient is also somewhat confused and does not know where he is. What does the nurse suspect with this patient? a. Crohn's disease b. Ulcerative colitis c. Diverticulitis d. Peritonitis

d. peritonitis

A nurse is caring for a client attending a community-based health center and reviews the client's medical record. What should the nurse encourage the client to do? "health care provider progress note" client has stage lll RA, which is progressively causing more joint deformity, stiffness, and pain. "Nurse's History and Physical Assessment" Client has ulnar drift of both hands and hallux valgus deformity of both feet. Client reports pain when walking and joint stiffness for several hours in the morning, particularly the small joints of the hands and feet. Joints of the hands reflect signs and symptoms of inflammation (heat, swelling, tenderness). "Laboratory Results" Rheumatoid factor (RF): 1:70 (positive for RA) Erythrocyte sedimentation rate (ESR): 40 mm/hour C-reactive protein (CRP): 20 mg/dL WBC 13,000ul a. Wring a sponge repeatedly when washing dishes b. install faucets that require turning rather than pushing c. engage in a sewing project several hours each morning. d. push with the palms rather than the fingers when rising from a chair

d. push with the palms rather than the fingers when rising from a chair

The nurse is assessing a patient with viral gastroenteritis. Which symptom is the nurse most concerned about? a. Orthostatic blood pressure changes b. Poor skin turgor c. Dry mucous membranes d. Rebound tenderness

d. rebound tenderness

The patient has an abdominal hernia with a sac that can be replaced into the abdominal cavity by gentle pressure. Which type of hernia does the nurse recognize? a. incisional b. irreducible c. indirect inguinal d. reducible

d. reducible

A client who has intermittently been having painful, swollen knee and wrist joints during the past 3 months is diagnosed with RA. What type of diet should the nurse expect the health care provider to order? a. salt-free, low-fiber diet b. high-calorie, low-cholesterol diet c. high-protein diet with minimal calcium d. regular diet with vitamins and minerals

d. regular diet with vitamins and minerals

What is the most common cause of death in patients with SLE? a. cardiac failure b. skin involvement c. central nervous system involvement d. renal failure

d. renal failure

Which laboratory test is the only significant test for diagnosing a patient with disoid lupus? a. antinuclear antibody b. serum complement c. CBC d. skin biopsy

d. skin biopsy

Which surgical procedure involves removal of the colon, rectum, and anus with surgical closure of the anus? a. Restorative proctolectomy with oleo pouch-anal anastomosis (RPC-IPAA) b. Natural orifice transluminal endoscopic surgery (NOTES) c. Sigmoid colostomy d. Total proctocolectomy with a permanent ileostomy

d. total proctocolectomy with a permanent ileostomy

35. The nurse is performing pt and family teaching about MG medication therapy. What important information does the nurse give during the teaching session? (select all) a. if a dose of cholinesterase is missed, a double dose is taken the next day b. antibiotics such as kanamycin synergize cholinesterase inhibitors c. medications must be taken on an empty stomach with a full glass of water d. administer with a small amount of food to decrease gastrointestinal upset e. if there is bulbar involvement, eat meals 45 min to 1 hour after taking the med f. drugs containing morphine or sedatives can increase muscle weakness

def

Side effects of sedatives/hypnotics

drowsiness, hypotension, dizziness, GI irritation, skin rash, blood disorders, drug dependence, barbiturates (photosensitivity, excitement)

You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3° F (38° C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR format. a) "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." b) "He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse." c) "I have tried to make him comfortable and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." d) "Would you like to give me an order for any laboratory tests or additional therapies at this time?" e) "Dr. S, this is Nurse J. I'm calling about Mr. D, who is reporting severe abdominal pain."

e,b,a,c,d

You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. a) Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. b) Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. c) Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. d) Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. e) Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today.

e,c,a,b,d

Surgery is classified as

elective, diagnostic, urgent, ablative, palliative, or curative

Side effects of inhalation anesthetics

excitement and restlessness during induction, nausea and vomiting, respiratory distress, affinity for adipose tissue regarding in prolonged effects, malignant hyperthermia, muscle rigidity, pyrexia, tachycardia

Side effects of depolarizing muscle relaxants

hypotension, respiratory depression, dysrhythmias

Neuromuscular blocking agents

inhibit transmission of nerve impulses by binding with cholinergic receptor sites, antagonizing action of acetylcholine

What should the nurse do if spinal anesthetic is administered to a patient

instruct them to keep flat for a specified period of time to prevent headaches, avoid pillows, monitor for hypotension

Advancements in surgical approaches have lead to

minimize tissue trauma, duration of anesthesia, and postoperative recovery time, and improved client outcomes

Ambulatory surgery

performed in hospital or private surgical facility, diagnostic workup is performed by hospital, health care provider or clinic before day of surgery, discharged same day as surgery; if complications occur client is admitted to hospital

Side effects of IV barbiturates

respiratory depression, hypotension and tachycardia, laryngospasm

Side effects of IV and IM nonbarbiturates

respiratory failure, changes in BP, hypertension, hypotension, rigidity, psychic disturbances

289. Where would you assess for appendicitis?

right lower quadrant

4 stages of anesthesia

stage 1- pt is drowsy and loses consciousness, stage 2-muscles become tense, breathing may be irregular, stage 3- VS and reflexes are depressed, operation begins, stage 4-respiratory depression is complete

Sedatives/hypnotics

used for short term treatment of clients with situational anxiety and insomnia, depress CNS, produce sedation in small dosages and sleep in larger dosages, available in oral, parenteral and rectal preparations

Robotic surgery

uses laparoscopic cameras that provide 3-D view and robotic equipment that is manipulated by health care provider at a surgical console; robotics improves precision and control

Laparoscopic surgery

uses small incisions and fiberoptic instruments that formerly required larger surgical incisions, depending on site, may require insufflation of cavity with carbon dioxide to enhance visualization of structures, particularly for abdominal surgery; after abdominal insufflation with carbon dioxide, client may experience right shoulder or scapular pain postoperatively because of migration of the carbon dioxide

128. A client states that the health care provider said the tidal volume is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume? 1. exhaled after there is a normal inspiration 2. exhaled forcibly after a regular expiration 3. inspired forcibly above a typical inspiration 4. trapped in the alveoli after a max expiration

1

129. A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction? 1. blowing vigorously into the mouthpiece 2. getting into a chair to use the spirometer 3. coughing deeply after using the spirometer 4. using lips to form a seal around the mouthpiece

1

130. A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions? 1. tidal volume 2. vital capacity 3. expiratory reserve 4. inspiratory reserve

1

14. Mr. A reluctantly discloses to you that his financial and social situations are problematic. Which aspect of his situation has the most impact on discharge teaching on wound care and other follow-up issues? 1. he is homeless and has no family in the city 2. he has no money for the prescribed medications 3. he has no transportation to the follow-up appointment 4. he cannot read or write very well

1

558. a client with myasthenia gravis experiences dysphagia. what is the PRIORITY risk associated with dysphagia that must be considered when planning nursing care? 1. aspiration 2. dehydration 3. nutritional imbalance 4. impaired communication

1

564. a client with myasthenia gravis continues to become weaker despite treatment with neostigmine (prostigmin). what reason should the nurse identify for the health care provider's prescription for edrophonium (enlon)? 1. rule out cholinergic crisis 2. promote synergistic effect 3. overcome neostigmine resistance 4. confirm the diagnosis of myasthenia

1

571. Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk? 1. Pain radiating to the hip and leg 2. Bowel and bladder incontinence 3. Paralysis of both lower extremities 4. Overgrowth of tissue on the lower back

1

575. What does the nurse do for a client with a cervical laminectomy that differs from the nursing care for a client with a laminectomy? 1. Assist with the removal of oral secretions 2. Maintain the client's head in a flexed position 3. Elevate the head of the client's bed to a 45-degree angle 4. Provide ROM exercise early during the postoperative period

1

576. A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. Which action should the nurse take FIRST? 1. Leave the individual lying on the back with instructions not to move, and seek additional help 2 Roll the individual onto the abdomen, place pad under the head, and cover with any material available 3. Gently raise the individual to a sitting position to see whether the pain either diminishes or increases in intensity 4. Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution

1

577. After a client is treated for a spinal cord injury, the health care provider informs the family that the client is a paraplegic. The family asks the nurse what this means. What explanation should the nurse provide? 1. Lower extremities are paralyzed 2. Upper extremities are paralyzed 3. One side of the body is paralyzed 4. Both lower and upper extremities are paralyzed

1

578. A client with a spinal cord injury has paraplegia. The nurse assesses for which major problem the client may experience early in the recovery period? 1. Bladder control 2. Nutritional intake 3. Quadriceps setting 4. Use of aids for ambulation

1

584. What should the nurse assess for when a client with a cervical injury reports a severe headache and nasal congestion? 1. Suprapubic distention 2. Increased spinal reflexes 3. Adventitious breath sounds 4. Imminent development of shock

1

586. A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? 1. They usually will never walk 2. It prepares them for wearing braces 3. It assists them in overcoming orthostatic hypotesion 4. They have the strength in the upper extremities for self-transfer

1

163. A nurse is caring for a group of clients on a medical surgical unit. Which client has the highest risk for developing a pulmonary embolism? 1. obese client with leg trauma 2. pregnant client with acute asthma 3. client with diabetes who has cholecystitis 4. client with pneumonia who is immunodeficient

1 -2 risk factors: obesity and leg trauma

19. You are admitting a pt for whom a dx of pulmonary embolus must be ruled out. The pts history and assessment reveal all of these findings. Which finding supports the dx of pulmonary embolus? 1. the pt was recently in a motor vehicle crash 2. the pt participated in an aerobic exercise program for 6 months 3. the pt gave birth to her youngest child 1 year ago 4. the pt was on bed rest for 6 hours after a diagnostic procedure

1 -at risk for DVT and pulmonary embolus

162. A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1. 59 yr old who had knee replacement 2. 60 yr old who has bacterial pneumonia 3. 68 yr old who had emergency dental surgery 4. 76 yr old who has history of thrombocytopenia

1 -decreased mobility

24. Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing physician before administration? 1. Warfarin 1.0mg PO 2. Morphine sulfate 2-4mg IV 3. Cephalexin 250mg PO 4. Heparin infusion at 900units/hr

1 -due to the trailing zero

3. The UAP tells you that a pt who is receiving oxygen at a flow rate of 6L/min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the pts comfort for this problem? 1. Humidify the pts oxygen 2. Use a simple face mask instead of a nasal cannula 3. Provide the pt with an extra pillow 4. Have the pt sit up in a chair at the bedside

1 -when the oxygen flow rate is higher than 4L/min the mucous membranes can be dried out

185.) A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level. 1. Cannula 2. Catheter 3. Venturi mask 4. Rebreather mask

1 Oxygen via nasal cannula is the most comfortable and least intrusive, because the cannula extends minimally into the nose.

170.) A client who is taking rifampin (Rifadin) tells the nurse, "My urine looks orange." What action should the nurse take? 1. Explain this is expected 2. Check the liver enzymes 3. Strain the urine for stones 4. Ask what foods were eaten

1 Rifampin (Rifadin) causes reddish orange discoloration of secretions such as urine, sweat, and tears.

407. A client with type 1 diabetes has an above the knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility 2 days after surgery when preparing the client to eat dinner? 1. checking the client's serum glucose level 2. assisting the client out of bed into a chair 3. placing the client in the high-fowler position 4. ensuring the client's residual limb is elevated

1 - because client has type 1 diabetes, it is essential that the blood glucose level be determined before meals to evaluate level of control of diabetes and possible need for insulin coverage

7. You are preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? 1. "i will avoid exercise because the pain gets worse" 2. "i will use the heat or ice to help control the pain" 3. "i will not wear the high-heeled shoes at home or work 4. "i will purchase a firm mattress to replace my old one

1 - exercises are used to strengthen the back, relieve pressure on compressed nerves, and protect the back from reinjury

287. A client who had surgery for a ruptured appendix develops peritonitis. What clinical finding related to peritonitis should the nurse expect the client to exhibit? SELECT ALL 1. Fever 2. Hyperactivity 3. Extreme hunger 4. Urinary retention 5. Abdominal muscle rigidity

1 Fever 5. Abdominal muscle rigidity

The nursing diagnosis for a patient with a fracture of the right ankle is Impaired Physical Mobility. As charge nurse, you observe a newly-graduated RN perform all of the interventions. For which action should you intervene? 1) Encouraging the patient to go from a lying to a standing position. 2) Administering pain medication before the patient begins exercises. 3) Explaining to the patient and family the purpose of the exercise program. 4) Reminding the patient about the correct use of crutches.

1) Encouraging the patient to go from a lying to a standing position.

During assessment of a patient with fractures of the medial ulna and radius, you find all of these data. Which assessment finding should you report to the health care provider immediately? 1) The patient reports pressure and pain. 2) The cast is in a place and is dry and intact. 3) The skin is pink and warm to the touch. 4) The patient can move all the fingers and the thumb.

1) The patient reports pressure and pain.

169.) A nurse assesses a newly admitted client with a diagnosis of pulmonary tuberculosis (TB). Which clinical findings support this diagnosis? select all that apply. 1. Fatigue 2. Polyphagia 3. Hemoptysis 4. Night sweats 5. Black tongue

1, 3, 4

572. A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? SELECT ALL THAT APPLY 1. Coughing or sneezing 2. Sitting on cold surfaces 3. Standing for extended periods 4. Lying supine while flexing the knees 5. Straining when having a bowel movement

1, 5

405. A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? (select all) 1. examining the feet daily 2. wearing well-fitting shoes 3. performing regular exercise 4. powdering the feet after showering 5. visiting the health care provider weekly 6. testing bathwater with the toes before bathing

1,2,3

21. A pt with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the pt with ADLs? select all that apply 1. use a life sheet when moving and positioning the pt in bed 2. use an electric razor when shaving the pt each day 3. use a soft bristled toothbrush or tooth sponge for oral care 4. use a rectal thermometer to obtain a more accurate body temp. 5. be sure the pts footwear has a firm sole when the pt ambulates

1,2,3,5 -avoid trauma to the rectal tissue which could cause bleeding

22. You are caring for an 81-year-old adult with type 2 diabetes, hypertension, and peripheral vascular disease. Which admission assessment findings increase the pt's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? (select all that apply) 1. hydrochlorothiazide (HCTZ) prescribed to control her diabetes 2. weight gain of 6 pounds over the past month 3. avoids consuming liquids in the evening 4. BP of 168/94 mmHg 5. urine output of 50-75 mL/hr

1,3

9. In care of a pt with type 2 diabetes, which actions can you delegate to the UAP? (select all that apply) 1. providing pt with extra packets of artificial sweetener for coffee 2. assessing how well the pt's shoes fit 3. recording the liquid intake from the pt's breakfast tray 4. teaching pt what to do if dizziness or lightheadedness occurs 5. checking and recording pt's BP

1,3,5

549. Which clinical findings does the nurse anticipate a client with an exacerbation of MS experience? (select all) 1. double vision 2. resting tremors 3. flaccid paralysis 4. scanning speech 5. mental retardation

1,4

557. a home care nurse is counseling with a client with ALS. what information should the nurse include in the discussion? (select all) 1. space activities throughout the day 2. engage in social interactions with large groups 3. request an opioid if leg pain becomes excessive 4. anticipate the use of alternate ways to communicate 5. use leg restraints to decrease the risk of physical injury

1,4

25. You are caring for a diabetic pt admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would you include in a teaching plan for the pt and family before discharge? (select all that apply) 1. signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL 2. treat hypoglycemia with 4-8 g of carbohydrate such as glucose tablets or 1/4 cup of fruit juice 3. retest blood glucose in 30 min 4. repeat the carbohydrate treatment if the symptoms do not resolve 5. eat a small snack of carbohydrate and protein if the next meal is more than an hour away

1,4,5

22. A client underwent an exploratory laparotomy 2 days ago. The physician should be called immediately for which physical assessment finding? 1. Abdominal distention and rigidity 2. Displacement of the NG tube by the client 3. Absent or hypoactive bowel sounds 4. Nausea and occasional vomiting

1. Abdominal distention and rigidity

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurses best interventions? 1. Attempt to identify the clients concerns 2. Reassure the client that the surgery is routine 3. Report the client anxiety to the health care provider 4. Provide privacy by pulling the curtain around the client

1. Assess the situation before planning an intervention

A self-help group of clients with irritable bowel syndrome have invited a nurse to present a program on nutrition. Which substance should the nurse teach the clients to minimize in the diet to decrease G.I. irritability? 1. Cola drinks 2. Amino acids 3. Rice products 4. Sugar products

1. Cola drinks

251. For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? SELECT ALL 1. Dark urine 2. Yellow skin 3. Pain on urination 4. Clay-colored stool 5. Coffee-ground vomitus

1. Dark urine 2. Yellow skin 4. Clay-colored stool

Place the steps for performing colostomy care in the correct order. 1. Fit the pouch snuggly around the stoma 2. Assess the color and appearance of the stoma 3. Wash the skin with mild soap and rinse with warm water 4. Apply a skin barrier to protect the peristomal skin 5. Dry the skin carefully 6. Don a pair of gloves and remove the old pouch

1. Don a pair of clean gloves and remove the old pouch 2. Assess the color and appearance of the stoma 3. Wash the skin with mild soap and rinse with warm water 4. Dry the skin carefully 5. Apply a skin barrier to protect the peristomal skin 6. Fit the pouch snugly around the stoma

250. A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indicators associated with these conditions? SELECT ALL 1. Ecchymosis 2. Yellow sclera 3. Dark brown stools 4. Straw-colored urine 5. Pain in right upper quadrant

1. Ecchymosis 2. Yellow sclera 5. Pain in right upper quadrant

When advising a college student about dietary choices the nurse should consider the caloric value of the most commonly ordered fast foods eaten by active young adults. List the following foods in order from the one with the least number of calories to the one with the most number of calories. 1._______Frech fries 2_______Garden salad 3_______Whooper with cheese 4._______One slice of French toast 5._______Six pieces of chicken tenders

1. Garden salad 2. French toast 3. Six pieces of chicken tenders 4. French fries 5. Whopper with cheese

Which food selections by a client with malabsorption syndrome indicate that the nurses dietary teaching was successful? Select all that apply 1. Green beans 2. Baked potato 3. Noodle pudding 4. Turkey sandwich 5. Whole wheat cereal

1. Green beans 2. Baked potato

A female client with the diagnosis of Crohn's disease tells the nurse that her boyfriend dates other women. She believes that this behavior causes an increase in her symptoms. What should the nurse do first when counseling this client? 1. Help the client explore attitudes about herself 2. Educate the client's boyfriend about her illness 3. Suggest the client should not see her new boyfriend for awhile 4. Schedule the client and her boyfriend for a counseling session

1. Help the client explore attitudes about herself

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure 1. dilation of blood vessels 2. decreased response of chemoreceptors 3. decreased strength of cardiac contractions 4. disruption of cardiac accelerator pathways

1. Paralysis of the sympathetic vasomotor nerves after administration of a spinal anesthetic results in dilation of blood vessels, which causes a subsequent decrease in blood pressure

You are caring for an obese post operative client who underwent surgery for bowel resection. As the client is moving in bed, he comments "something popped open". Upon examination you note wound evisceration. Place in order the steps for handling this complication. 1. Cover the intestine with sterile moistened gauze 2. Stay calm and stay with the client 3. Check the vital signs, especially blood pressure and pulse 4. Have a colleague gather supplies and contact the physician 5. Put the client into semi-Fowler position with knees slightly flexed 6. Prepare the client for surgery as ordered

1. Stay calm and stay with the patient 2. Put the clients into semi Fowler position with knees slightly flexed 3. Check the vital signs especially blood pressure and pulse 4. Have a colleague gather sterile supplies and contact the physician 5. Cover the intestine with sterile moisten gauze 6. Prepare the client for surgery as ordered

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1. Orient the client to the unit environment 2. Have a copy of hospital regulations available 3. Explain that there is no reason to be concerned 4. Reassure the client that the staff is available to answer questions

1. This may provide knowledge that may reduce the strangeness of the environment

A nurse is reviewing the laboratory results of and collecting a health history from client with a diagnosis of colitis. Which common clinical manifestation of colitis should the nurse expect? 1. Weight loss 2. Hemoptysis 3. Increased red blood cells 4. Decreased white blood cells

1. Weight loss

A client hospitalized with ulcerative colitis reports 10 to 20 small diarrhea stools per day, with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing diagnosis? 1. Diarrhea related to irritated bowel 2. Imbalanced Nutrition: Less than Body Requirements related to nutrition loss 3. Acute Pain related to increased GI motility 4. Ineffective Self-Health Management related to treatment plan

1. diarrhea related to irritated bowel

A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit? Select all that apply 1. Fever 2. Hyperactivity 3. Extreme hunger 4. Urinary retention 5. Abdominal muscle rigidity

1. fever 5. Abdominal muscle rigidity

An active adolescent is admitted to the hospital for surgery for an ileostomy. When planning a teaching session about self-care, the nurse includes sports that should be avoided by a client with an ileostomy. Which should be included on the list of sports to be avoided? Select all that apply 1. Football 2. Swimming 3. Ice hockey 4. Track events 5. Cross-country skiing

1. football 3. Ice hockey

A client is scheduled for a colonoscopy, and the healthcare provider orders a tap water enema. In which position should the nurse place the client during the enema? 1. Left sims 2. Back lying 3. Knee chest 4. Mid-Fowler

1. left sims

You are teaching the client and family how to perform colostomy irrigation. Place the following information in the correct order. 1. Hang the container at about shoulder height 2. Allow the solution to flow slowly and steadily for 5 to 10 minutes 3. Put 500 to 1000mL of lukewarm water in the container 4. Clip the irrigation sleeve and have the client walk for 30 to 45 minutes for secondary evacuation 5. Lubricate the stoma cone and gently inset the tubing tip into the stoma 6. Clean, rinse, and dry the skin, and apply a new drainage pouch 7. Put on a pair of clean gloves 8. Allow 15 to 20 minutes for the initial evacuation

1. put on a pair of clean gloves 2. Put 500 to 1000 mL of lukewarm water in the container 3. Hang the container at about shoulder height 4. Lubricate the stoma cone and gently insert the tubing tip into the stoma 5. Allow the solution to flow slowly and steadily for 5 to 10 minutes 6. Allowed 15 to 20 minutes for the initial evacuation 7. Clip the irrigation sleeve and have the client walk for about 30 to 45 minutes for a secondary evacuation 8. Clean, rinse, and dry the skin, and apply a new drainage pouch

You are preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? 1.) "I will avoid exercise because the pain gets worse." 2.) "I will use heat or ice to help control the pain." 3.) "I will not wear high-heeled shoes at home or work." 4.) "I will purchase a form mattress to replace my old one."

1.) "I will avoid exercise because the pain gets worse."

What does the nurse do for a client with a cervical laminectomy that differs from the nursing care for a client with a lumbar laminectomy? 1.) assist with the removal of oral secretions 2.) maintain the client's head in a flexed position 3.) elevate the head of the client's bed to a 45 degree angle 4.) provide range of motion exercise early during the post operative period

1.) assist with the removal of oral secretions

A client with a spinal cord injury has paraplegia. the nurse assesses for which major problem the client may experience early in the recovery period? 1.) bladder control 2.) nutritional intake 3.) quadriceps setting 4.) use of aid for ambulation

1.) bladder control

A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for the client, the nurse may delegate which actions to the LPN/LVN? select all that apply 1.) checking the patients skin for pressure from the device 2.) assessing the client's neurologic status for changes 3.) observing the halo insertion sites for signs of infection 4.) cleaning the halo insertion sites with hydrogen peroxide 5.) developing the nursing plan of care for the client

1.) checking the patients skin for pressure from the device 3.) observing the halo insertion sites for signs of infection 4.) cleaning the halo insertion sites with hydrogen peroxide

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? select all that apply 1.) coughing and sneezing 2.) sitting on cold surface 3.) standing for extended periods 4.) lying supine whole flexing the knees 5.) straining when having a bowel movement

1.) coughing and sneezing 5.) straining when having a bowel movement

A nurse finds a victim under the wreckage of a collapsed building. the individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. Which action should the nurse take first? 1.) leave individual lying on the back with instructions not to move, and seek additional help. 2.) roll the individual onto the abdomen, place a pad under the head, and cover with any material available 3.) gently raise the individual to a sitting position to see whether the pain either diminishes or increases in intensity 4.) gently lift the individual onto a flat piece of lumbar and , using any available transportation, rush to the closed medical institution

1.) leave individual lying on the back with instructions not to move, and seek additional help.

After a client is treated for a spinal cord injury, the health care provider informs the family that the client is paraplegic. the family asks the nurse what this means. what explanation should the nurse provide? 1.) lower extremities are paralyzed 2.) upper extremities are paralyzed 3.) one side of the body is paralyzed 4.) both lower and upper extremities are paralyzed

1.) lower extremities are paralyzed

What clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk? 1.) pain radiating to the hip and leg 2.) boweland bladder incontinence 3.) paralysis of both lower legs 4.) overgrowth of tissue on lower back

1.) pain radiating to the hip and leg

you are helping a client with an SCI to establish bladder retraining program. which strategies may simulate the client to void? select all that apply 1.) stroking the clients inner thigh 2.) pulling on the client's pubic hair 3.) initiating intermittent straight catheterization 4.) pouring warm water over the clients perineum 5.) tapping the bladder to stimulate the detrusor muscle

1.) stroking the clients inner thigh 2.) pulling on the client's pubic hair 4.) pouring warm water over the clients perineum 5.) tapping the bladder to stimulate the detrusor muscle

A nurse is a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. why is it important that the nurse provide this instruction? 1.) they usually will never walk 2.) it prepares them for wearing braces 3.) it assists them in overcoming orthostatic hypotension 4.) they have the strength in the upper extremities for self- transfer

1.) they usually will never walk

16. when Natalie is in the ED, the HCP prescribes an intramuscular injection of 30mg of ketorolac, a nonsteroidal antiinflammatory agent. The medication comes in a preloaded syringe labeled "20mg/mL." How many mL should the nurse expect to administer? ( round to the tenth)

1.5

17. While the nurse begins to assess the client, another nurse finds an infusion pump and prepares a prescribed "now" dose of an intravenous antibiotic. The prescription is for 2 grams of cefazolin (Ancef), which arrives from the pharmacy diluted in 50 ml of normal saline and is to be administered over 30 minutes. At what rate should the infusion pump be set? (mL/hr)

100 ml/hour

765. a nurse is caring for a client after a total knee replacement who is requesting Vicodin in addition to the patient-controlled analgesia (PCA). The client reports having taken 2 Vicodin tablets every 4 hours for several weeks before surgery. If each tablet contains 500mg of acetaminophen, how much acetaminophen had the client been ingesting per day? (round to the nearest whole number)

12 tablets (6,000mg)

20. What information regarding mr. r, who has acute pancreatitis, is appropriate to report to the physician? (select all) 1. hematocrit is decreased by more than 10% 2. calcium level is less than 9 mg/dL 3. partial oxygen pressure (PO2) is less than 60 mmHg. 4. pain is unrelieved by medication 5. blood type is O positive

1234

3. Which tasks will you delegate to the UAP? (select all) 1. assisting mr. t with perineal care after diarrheal episodes 2. measuring vital signs every 2 hours for mr. r 3. transporting ms. h off the unit for a procedure 4. gently cleansing the nares around ms. d's NG tube 5. removing mr. a's dressing

1234

772. an ambulatory female client with relapsing-remitting MS is to receive every-other-day injections of interferon beta-1a (avonex). what adverse effects should the nurse explain may occur when taking this medication? (select all) 1. depression 2. constipation 3. flulike symptoms 4. increased heart rate 5. decreased perspiration

1234

8. You are observing the nursing student perform an abdominal assessment on Ms. D. For which actions will you intervene? (select all) 1. palpating for abdominal distention with the index finger 2. auscultating for bowel sounds with the NG tube attached to low wall suction 3. performing the physical assessment before asking about pain 4. checking the NG collection canister for quantity and quality of drainage 5. inspecting for visible signs of peristaltic waves or abdominal distention 6. checking for skin turgor over the lower abdominal area

1236

2. Which clients would be best to assign to the new RN? (select all) 1. ms. h 2. ms. d 3. ms. t 4. mr. a 5. mr. k 6. mr. r

124

12. You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the client to void? (select all) 1. stroking the client's inner thigh 2. pulling on the client's pubic hair 3. initiating intermittent straight catheterization 4. pouring warm water over the client's perineum 5. tapping the bladder to stimulate the detrusor muscle

1245

13. A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? (select all) 1. checking the client's skin for pressure from the device 2. assessing the client's neurologic status for changes 3. observing the halo insertion sites for signs of infection 4. cleaning the halo insertion sites with hydrogen peroxide 5. developing the nursing plan of care for the client

134

17. Because of mr. k's advanced age, which complications of enteral feedings may occur? (select all) 1. hyperglycemia 2. hypotension 3. aspiration 4. diarrhea 5. fluid overload

1345

140. a hospitalized client is receiving pyridostigmine (mestinon) for control of myasthenia gravis. in the middle of the night, the nurse finds the client weak and barely able to move. which additional clinical findings support the conclusion that these responses are related to pyridostigmine? (select all) 1. respiratory depression 2. distention of the bladder 3. decreased BP 4. fine tremor of the fingers 5. high-pitched gurgling bowel sounds

135

23. What tasks should be accomplished toward the end of the shift before leaving for the day? (Select all) 1. complete documentation on all assigned clients 2. admit a new client from the ED 3. check all IV sites and total IV fluids 4. ask the UAP to obtain vital sign values for all clients 5. briefly check and assess every client 6. thank ancillary staff for their help 7. complete mr. r's transfer to the ICU

13567

26. the LPN/LVN whom you are supervising comes to you and says "i gave the client with myasthenia gravis 90 mg of neostigmine (prostigmin) instead of the ordered 45 mg!" in which order should you perform the following actions? 1. assess the client's heart rate 2. complete a medication error report 3. ask the LPN/LVN to explain how the error occurred 4. notify the physician of the incorrect medication dose

1432

The TPN is available in a 1000ml bag and is prescribed to run at 60ml per hour. The nurse will expect to hang a new bag in approx how many hrs?

17 (1000÷60=16.666=17hrs)

16. When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson's postoperative prescriptions indicates that 0.9% Normal Saline is to infuse at 75 ml/hour, alternating with Lactated Ringer's solution at 75 ml/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 15 drops/ml and resets the IV. At what rate should the IV infuse? (drops per minute)

19 75 ml/60 minutes × 15 gtts/1 ml =

11. You are floated from the ED to the neurologic floor. Which condition should you delegate to the UAP when providing nursing care for a client with an SCI? 1. assessing the client's respiratory status every 4 hours 2. taking the client's vital signs and recording every 4 hours 3. monitoring the client's nutritional status, including calorie counts 4. instructing the client how to turn, cough, and breathe deeply every 2 hours

2

127. A nurse uses abdominal thoracic thrusts when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx? 1. tidal 2. residual 3. vital capacity 4. inspiratory reserve

2

13. The UAP asks, "why can't ms. t get out of bed and do things for herself? she's only 29." what is your best response? 1. "the physician ordered bed rest for a few days" 2. "decreasing activity helps to decrease the diarrhea" 3. "acute exacerbations require decreased GI motility" 4. "she is too depressed and malnourished"

2

142. a client with MS is in remission. which diversional activity should the nurse encourage that BEST meets the client's needs while in remission? 1. hiking 2. swimming 3. computer classes 4. watching television

2

16. You are teaching the nursing student about enteral feedings for clients such as mr. k, who has a PEG tube. in the postoperative period, when can enteral feedings be started? 1. within 6-8 hours after the procedure 2. when bowel sounds are present, usually within 24 hours 3. when the client reports feeling hungry 4. on a schedule determined by pharmacy

2

18. While you are performing an admission assessment on a pt with type 2 diabetes, he tells you that he routinely drinks 3 beers a day. What is your priority follow-up question at this time? 1. "Do you have any days when you do not drink?" 2. "When during the day do you drink your beers?" 3. "Do you drink any other forms of alcohol?" 4. "Have you ever had a lipid profile completed?"

2

18. the UAP reports to you, the RN, that a client with myasthenia gravis has an elevated temperature (102.2 F), an increased heart rate (120 BPM), and a rise in BP (158/92 mmHg) and was incontinent of urine and stool. what is your best first action at this time? 1. administer the acetaminophen suppository 2. notify the physician immediately 3. recheck vital signs in 1 hour 4. reschedule the client's physical therapy

2

18.) When a patient with TB is being prepared for discharge, which statement by the patient indicates a need for further teaching? 1. "Everyone in my family needs to go and see the doctor for TB testing." 2. "I will continue to take my isoniazid until I am feeling completely well." 3. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." 4. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

2

5. The night nurse gives a brief and incomplete report. Which question do you pose to the night shift nurse to help determine the priority actions for ms. h (36, r. upper quadrant pain, "good night")? 1. "what are her vital signs?" 2. "is she going to surgery or radiology this morning?" 3. "is she still having pain?" 4. "does she need any morning medications?"

2

554. A nurse is caring for a client with the diagnosis of guillain-barre syndrome. the nurse identifies that the client is having difficulty expectorating respiratory secretions. what should be the nurse's FIRST intervention? 1. auscultate for breath sounds 2. suction the client's oropharynx 3. administer oxygen via nasal cannula 4. place the client in the orthopneic position

2

555. what nursing intervention is anticipated for a client with guillain-barre syndrome? 1. providing a straw to stimulate the facial muscles 2. maintaining ventilator settings to support ventilation 3. encouraging aerobic exercises to avoid muscle atrophy 4. administering antibiotic medication to prevent pneumonia

2

561. a nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. what should the nurse do FIRST? 1. administer oxygen 2. raise the HOB 3. perform tracheal suctioning 4. call the provider

2

563. a client with myasthenia gravis has been receiving neostigmine (prostigmin) and asks about its action. What information about its action should the nurse consider when formulating a response? 1. stimulates the cerebral cortex 2. blocks the action of cholinesterase 3. replaces deficient nuerotransmitters 4. accelerates transmission along neural sheaths

2

573. For which clinical indicator should the nurse assess a client who just had a microdiskectomy for a herniated lumbar disk? 1. Cerebral edema 2. Sensory loss in legs 3. Spasms of the bladder 4. Pain referred to the flanks

2

574. What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy? 1. Encourage the client to cough 2. Reposition the client by log rolling 3. Assess the client for indication of peritonitis 4. Instruct the client to bend the knees when turning

2

580. A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1-2 hours? 1. Maintain comfort 2. Prevent pressure ulcers 3. Prevent flexion contractures of the extremities 4. Improve venous circulation in the lower extremities

2

8. A client with a SCI reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased BP (164/94) and decreased heart rate (48 BPM), diaphoresis, and flushing of the face and neck. What action should you take first? 1. administer the ordered acetaminophen (tylenol) 2. check the foley tubing for kinks or obstruction 3. adjust the temperature in the client's room 4. notify the physician about the change in status.

2

While receiving a preoperative enema, a client starts to cry and says "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1. I don't mind it 2. You seem upset 3. This is part of my job 4. Nurses get used to it

2

133. A nurse assesses that several clients have low oxygen saturation levels. Which client would benefit the most from receiving oxygen via nasal cannula? 1. has an upper respiratory infection 2. receives many visitors while sitting in a chair 3. has a NG tube for gastric decompression 4. exhibits dry oral mucous membranes from mouth breathing

2 -client is more mobile and will benefit from a less restrictive form of oxygen administration

551. a recently hospitalized client with MS is concerned about generalized weakness and fluctuating physical status. What is the PRIORITY nursing intervention for this client? 1. encourage bed rest 2. space activities throughout the day 3. teach the limitations imposed by the disease 4. have one of the client's relatives stay at the bedside

2 - encourages maximum functioning within limits of strength and fatigue

550. Which statement by a client with MS indicates to the nurse that the client needs further teaching? 1. "i use a straw to drink liquids" 2. "I will take a hot bath to help relax my muscles" 3. "i plan to use an incontinence pad when i go out" 4. "i may be having a rough time now, but i hope tomorrow will be better"

2 - increases symptoms and may result in burns because of decreased sensation

180.) A nurse must administer streptomycin 1 g IM to a client with tuberculosis. The vial contains 500 mg/mL. How much solution must the nurse administer? Record your answer using a whole number answer_______mL

2 mL. First convert 1 g to its equivalent of 1000 mg and then use the "Desire over Have" formula of ratio and proportion to solve the problem. Desire 1000mg = x mL ________________________________ Have 500 mg 1 mL 500x = 1000 x= 1000/ 500 x= 2 mL

A nurse suspects the development of compartment syndrome for a client who has sustained blunt trauma to the forearm. For which early sign of compartment syndrome should the nurse assess the client? 1) Warm skin at the site of injury 2) Escalating pain in the fingers. 3) Rapid capillary refill in affected hand 4) Bounding radial pulse in the injured arm

2) Escalating pain in the fingers.

For what clinical findings of compromised circulation should the nurse assess in a client with a long leg cast? (Select all) 1) Foul odor 2) Swelling of the toes 3) Drainage on the cast 4) Increased temperature 5) Prolonged capillary refill

2) Swelling of the toes 5) Prolonged capillary refill

A patient has a fractured femur. Which finding would you instruct the UAP to report immediately? 1) The patient reports pain. 2) The patient appears confused. 3) The patient's blood pressure is 136/88 mm Hg. 4) The patient voided using the bed pan.

2) The patient appears confused.

168.) An older adult, who alternately lives in a homeless shelter on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and orders purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed. 1. Obtain a sputum specimen. 2. Institute airborne precautions. 3. Have a chest x-ray performed. 4. Notify the Department of Health. 5. Perform a PPD intradermal skin test.

2, 3, 5, 1, 4

155. A client is in the ICU after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's POC? SELECT ALL THAT APPLY 1. Minimizing environmental stimuli 2. Assessing for respiratory complications 3. Monitoring and maintaining BP 4. Initiating a bowel and bladder training program 5. Discussing long-term treatment plans with the family

2,3

5. You are supervising an RN who floated from the medical surgical unit to the emergency department. The nurse is providing care for a pt admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (select all that apply) 1. position the pt supine and turned on his side 2. apply direct lateral pressure to the nose for 5 minutes 3. maintain standard body substance precautions 4. apply ice or cool compresses to the nose 5. instruct the pt not to blow the nose for several hours

2,3,4,5 -to prevent blood from entering the stomach and to avoid aspiration

Neomycin 1g is prescribed preoperatively for a client with a diagnosis of cancer of the colon. The client asks why neomycin is being given. Which is the best response by the nurse? 1. "It will decrease your kidney function and lesson urine production during surgery." 2. It will kill the bacteria in your bowel and decrease the risk of infection after surgery." 3. "It is used to alter the body flora, which reduces the spread of the tumor to the adjacent organs." 4. "It is used to prevent you from getting an infection, particularly a bladder infection, before surgery."

2. "It will kill the bacteria in your bowel and decrease the risk of infection after surgery"

23. You must rearrange the room assignments for several clients. Which two clients would be best to put in the same room? 1. 35 year old woman with copious intractable diarrhea and vomiting 2. 43 year old woman who underwent cholecystectomy 2 days ago 3. 53 year old woman with pain related to alcohol-associated pancreatitis 4. 62 year old woman with colon cancer receiving chemotherapy and radiation

2. 43 year old woman who underwent cholecystectomy 2 days ago 3. 53 year old woman with pain related to alcohol-associated pancreatitis

257. A client is admitted with a tentative dx of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? SELECT ALL 1. Provide a low-fat diet 2. Administer analgesics 3. Teach relaxation exercises 4. Encourage walking in the hall 5. Monitor cardiac rate and rhythm 6. Observe for signs of hypercalcemia

2. Administer analgesics 3. Teach relaxation exercises 5. Monitor cardiac rate and rhythm

249. A nurse is preparing a teaching plan for a client with a hx of cholelithiasis. Which information about why the ingestion of fatty foods will cause discomfort should the nurse include in the teaching plan? 1. Fatty foods are hard to digest 2. Bile flow into the intestine is obstructed 3. The liver is manufacturing inadequate bile 4. There is inadequate closure of the ampulla of Vater

2. Bile flow into the intestine is obstructed

A CBC, urinalysis and xray of the chest are ordered for a client before surgery. The client asks why the these tests are done. What is the best reply by the nurse? 1. Don't worry; these tests are routine 2. They are done to identify other health risks 3. They determine whether surgery will be safe 4. I don't know; your health care provider ordered them

2. Certain diagnostic tests are done preoperatively to rule out the existence if health problems that may increase the risks involved with surgery

An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A nasogastric tube to suction is in place. What should the nurse expect regarding the clients nasogastric tube drainage during the first 24 hours after surgery? 1. Green and viscid 2. Contain some blood and clots 3. Contain large amounts of frank blood 4. Similar to coffee grounds in color and consistency

2. Contain some blood and clots

You are taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon before proceeding with additional history taking or physical assessment? 1. Obesity for approximately 5 years 2. History of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal for age, gender, and height

2. History of counseling for body dysmorphic disorder. Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment.

253. A client is returned to the surgical unit after an abdominal cholecystectomy. What is the MAIN reason why the nurse should assess for clinical indicators of respiratory complications? 1. Length of time required for surgery is prolonged 2. Incision is in close proximity to the client's diaphragm 3. Client's resistance is lowered because of bile in the blood 4. Bloodstream is invaded by microorganisms from the biliary tract

2. Incision is in close proximity to the client's diaphragm

A nurse teaches a client with G.I. irritability to minimize the intake of dietary irritants. Which products did the nurse teach the client to avoid? Select all that apply 1. Rice 2. Milk 3. Cheese 4. Table salt 5. Chocolate candy

2. Milk 3. Cheese 5. Chocolate candy

A nurse obtains daily's stool specimens for a client with chronic bowel inflammation. The nurse concludes that these stool examinations were ordered to determine: 1. Fat content 2. Occult blood 3. Ova and parasites 4. Culture and sensitivity

2. Occult blood

252. Before a cholecystectomy vit K is prescribed. Which element, formed in the presence of vit K, should the nurse determine is the purpose of administering this medication? 1. Bilirubin 2. Prothrombin 3. Thromboplastin 4. Cholecystokinin

2. Prothrombin

288. A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client? 1. Sims 2. Semi-fowlers 3. Trendelenburg 4. Dorsal recumbent

2. Semi-fowlers

After many years of coping with colitis, a patient makes a decision to have a colectomy as advised by the healthcare provider. Which is most likely the significant factor that impacted on the clients decision? 1. It is temporary until the colon heals 2. Surgical treatment cures ulcerative colitis 3. Ulcerative colitis can progress to Crohn's disease 4. Without surgery, eating table food is contraindicated

2. Surgical treatment cures ulcerative colitis

A nurse is teaching a client who has a full time job how to care for a new colostomy. At which time should the nurse suggest scheduling the colostomy irrigations? 1. When it is most convenient for the client 2. Approximately a half hour after breakfast 3. Halfway between the two largest meals of the day 4. At the time the client had bowel movements before surgery

2. approximately a half hour after breakfast

For clients coming to the ambulatory care G.I. clinic, which tasks would be most appropriate to assign to an LPN? 1. Teaching a client self-care measures for an ulcer 2. Assisting the physician in incision and drainage of a pilonidal cyst 3. Evaluating a client's response to sitz baths for an anorectal abscess 4. Describing the basic pathophysiology of an anal fistula to a client

2. assisting the physician in incision and drainage of a pilonidal cyst

247. Which clinical indicator should the nurse identify before scheduling a client for an endoscopic retrograde cholangiopanreatography (ERCP)? 1. Urine output 2. Bilirubin level 3. Blood pressure 4. Serum glucose

2. bilirubin level

A client is diagnosed as having colitis. Which clinical findings should the nurse expect the client to report? Select all that apply 1. Fever 2. Diarrhea 3. Gain in weight 4. Spitting up blood 5. Abdominal cramps

2. diarrhea 5. Abdominal cramps

A nurse is educating a client with a colostomy of the ascending colon about using a colostomy appliance. Which instruction should the nurse provide to help prevent leakage of stool from the appliance? 1. Irrigate the colostomy to establish an expected pattern of elimination 2. Empty the appliance when it is approximately one half full with feces 3. Use an antiseptic to clean the peristomal skin before applying the appliance 4. Select an appliance with a pouch opening of at least 5 cm larger than the stoma

2. empty the appliance when it is approximately one half full with feces

A nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy? 1. Mastery of techniques of colostomy care 2. Readiness to accept an altered body function 3. Awareness of available community resources 4. Knowledge of the necessary dietary modifications

2. readiness to accept an altered body function

When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to the UAP? 1. Explaining the need for clear liquid diet 1 to 2 days before the procedure. 2. Reinforcing "nothing by mouth" status 8 hours before the procedure 3. Administering laxatives 1 to 3 days before the procedure 4. Administering an enema the night before the procedure

2. reinforcing NPO status eight hours before the procedure

A nurse is teaching a client with an acute exacerbation of colitis about the most appropriate diet. Which food selected by the client indicates that the dietary teaching is effective? 1. Orange juice 2. Scrambled eggs 3. Vanilla milkshake 4. Creamed potato soup

2. scrambled eggs

A client had part of the ileum surgically removed. Why is it necessary for the nurse to monitor the client for clinical indicators of anemia? 1. Folic acid is absorbed in the ileum 2. The hemopoietic factor is absorbed in the ileum 3. Iron absorption is dependent on simultaneous bile salt absorption in the ileum 4. The trace elements copper, cobalt, and nickel, required for hemoglobin synthesis, are absorbed in the ileum

2. the hemopoietic factor is absorbed in the ileum

A client is in the intensive care unit after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? select all that apply 1.) minimizing environmental stimuli 2.) assessing for respiratory complications 3.) monitoring and maintaining blood pressure 4.) initiating a bowel and bladder training program 5.) discussing long-term treatment plans with the family

2.) assessing for respiratory complications 3.) monitoring and maintaining blood pressure

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment if the client reveals increased blood pressure (169.94mmhg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. what action should you take first? 1.) administer ordered acetaminophen (tylenol) 2.) check the foley tubing for kinks and obstructions 3.) adjust the temperature in the clients room 4.) notify the physician about the change in status

2.) check the foley tubing for kinks and obstructions

A client has paraplegia as a result of a motorcycle accident. what is the reason the nursing care plan should include turning the client ever 1 to 2 hours? 1.) maintain comfort 2.) prevent pressure ulcers 3.) prevent flexion contractures of the extremities 4.) improve venous circulation in the lower extremities

2.) prevent pressure ulcers

What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy? 1.) encourage the client to cough 2.) reposition the client by log rolling 3.) asses the client for indications of peritonitis 4.) instruct the client to bend the knees when turning

2.) reposition the client by log rolling

For which clinical indicator should the nurse assess a client who just had a microdiskectomy for a herniated lumbar disk? 1.) cerebral edema 2.) sensory loss in legs 3.) spasms of the bladder 4.) pain referred to the flanks

2.) sensory loss in legs

You are floated from the ED to the neurologic floor. which action should you delegate to the UAP when providing nursing care for a client with a SCI? 1.) assessing the clients's respiratory status every 4 hours 2.) taking the client's vital signs and recording every 4 hours 3.) monitoring the client's nutritional status, including calorie intake 4.) instructing the client how to turn, cough and breathe deeply every 4 hours

2.) taking the client's vital signs and recording every 4 hours

The patient has a continuous bladder irrigation via a three-way urinary catheter. At 7:00 am, the urine drainage bag was emptied and 1000 mL of irrigation fluid was started. at 11:00 am, 350 mL of irrigation fluid was administered through the catheter. The urinary drainage bag contains 600 mL. How many mL of urine has the patient produces in the past 4 hours?

250 mL

126. Levofloxacin (levaquin) 750mg IVPB is prescribed for a client with pneumonia. The dose is available in 150mL of 5% dextrose and is to infuse over 90min. The administration set has a drop factor of 15drops per ml. At how many drops per minute should the nurse regulate the IVPB to infuse?

25gtt/min -150x15/90=25gtt/min

1. You are preparing to review a teaching plan for a pt with type 2 diabetes mellitus. To determine the pt's level of compliance with his prescribed diabetic regimen, which value would you be sure to review? 1. fasting glucose level 2. oral glucose tolerance test 3. glycosylated hemoglobin (HbgA1C) level 4. fingerstick glucose findings for 24 hours

3

10. Ms. D reports feeling weak. she seems more confused compared with her baseline. you observe that the NG drainage container has a large amount of watery bile-colored fluid. which lab values will you check first? 1. blood urea nitrogen and creatinine levels 2. platelet count and wbc count 3. sodium level, potassium level, and pH of blood 4. bilirubin level, hematocrit, and hemoglobin level

3

12. Ms. t is receiving sulfasalazine (Azulfidine) 500 mg by mouth every 6 hours for treatment of ulcerative colitis. Which assessment finding concerns you the most? 1. urine discoloration 2. nausea and vomiting 3. decreased urine output 4. headache

3

131. A nurse identifies that a clients hemoglobin level is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test result indicates an acceleration in oxygen dissociation from hemoglobin? 1. pH 2. Po2 3. Pco2 4. HCO3

3

138. a client is admitted to the hospital with a diagnosis of myasthenia gravis. for which common early clinical finding should the nurse assess the client? 1. tearing 2. blurring 3. diplopia 4. nystagmus

3

14. A pt has a newly diagnosed type 2 diabetes. Which action should you assign to an LPN/LVN instead of a UAP? 1. measuring pt's vital signs every shift 2. checking pt's glucose level before each meal 3. administering subcutaneous insulin on a sliding scale as needed 4. assisting pt with morning care

3

14. You are preparing a nursing care plan for a client with an SCI for whom the nursing diagnoses of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. The client tells you "I don't know why we're doing all this. My life's over" Based on this statement, which additional nursing diagnosis takes priority? 1. risk for injury related to altered mobility 2. imbalanced nutrition: less than body requirements 3. impaired individual resilience related to spinal cord injury 4. disturbed body image related to immobilization

3

15. While you are teaching mr. a about dressing changes, he says, "when you live on the street, you can't do everything the way you nurses do in the hospital." what is the most important thing to emphasize in helping him to accomplish self-care? 1. "use new sterile field for supplies" 2. "maintain a sterile field for supplies" 3. "wash your hands before a dressing change" 4. "discard any opened packages of unused gauze"

3

16.) You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to the UAP? 1. Teaching the patient about the importance of adequate fluid intake and hydration. 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession

3

165. A nurse is caring for a client with a spinal cord injury during the immediate post-injury period. What is the PRIMARY focus of nursing care during this immediate phase? 1. Inhibiting UTIs 2. Preventing contractures and atrophy 3. Avoiding flexion or hyperextension of the spine 4. Preparing the client for vocational rehabilitation

3

22. The physician arrives while you are caring for mr. r. Based on mr. r's change of status (refer to questions 20 and 21), before the physician leaves, which order should you advocate for? 1. perform additional lab tests and continue monitoring 2. prepare mr. r for emergency surgery 3. prepare mr. r for transfer to the ICU 4. reestablish NG suction and apply restraints

3

553. what does the nurse understand that clients with myasthenia gravis, guillain-barre syndrome, and amyotrophic lateral sclerosis share in common? 1. progressive deterioration until death 2. deficiencies of essential neurotransmitters 3. increased risk for respiratory complications 4. involuntary twitching of small muscle groups

3

559. a client with myasthenia gravis asks the nurse why the disease has occurred. what pathology underlies the nurse's response? 1. a genetic defect in the production of acetylcholine 2. an inefficient use of the neurotransmitter acetylcholine 3. a decreased number of functioning acetylcholine receptor sites 4. an inhibition of the enzyme AChE, leaving the endplates folded

3

560. a client with myasthenia gravis asks the nurse, "what is going to happen to me and to my family?" what information about what the client can anticipate should be incorporated into the nurse's response? 1. high cure rate with proper treatment 2. slowly progressive course without remissions 3. chronic illness with exacerbations and remissions 4 poor prognosis, with death occurring in a few months

3

562. to what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? 1. narrowed airways 2. impaired immunity 3. ineffective coughing 4. viscosity of secretions

3

583. After a traumatic spinal cord severance, a young client is having difficulty accepting the paralysis. One day the client has severe leg spasms and says, "My strength is coming back, and I know I will walk again." The nurse's response should be based on what understanding? 1. The nerves are regenerating and motor function is returning 2. Motor function may be returning now that the edema is subsiding 3. Spinal shock has subsided and the client's reflexes are hyperactive 4. The client has developed thrombophlebitis and is experiencing pain

3

6. Ms. H's physician told her that she would probably need a laparoscopic cholecystectomy; however, the hepatobiliary iminodiacetic acid scan and laboratory results are still pending. Ms. H asks, "what should i expect?" What is the best intervention at this point? 1. describe the surgical procedure 2. call the physician to come and speak with her 3. provide some written material about gallbladder disease and options 4. explain general postoperative care, such as coughing and deep breathing exercises

3

9. You are unable to locate Ms. d's morning vital signs. The new nurse who is assigned to the client says she assumed that the UAP would take and record them. The UAP tells you she thought that the nursing student was supposed to do that. The nursing student says that no one told her to take ms. d's vital signs. what should you do first? 1. take ms. d's vital signs yourself, reassess the client, and write an incident report 2. talk to the nursing instructor and find out if the student was expected to take ms. d's morning vital signs 3. ask the UAP to take ms. d's vitals now, record them, and report the values to the new nurse 4. advise the new nurse to take ms. d's vital signs herself and remind her that the nurse is ultimately responsible

3

792. After surgery a client develops a DVT and a PE. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (vancocin) 500mg IV every 12 hours is prescribed. The client has 1 IV site: a peripheral line in left forearm. What action should the nurse take? 1. stop the heparin, flush line, administer vancomycin 2. use a piggyback setup to administer the vancomycin into the heparin 3. start another IV line for vancomycin and continue the heparin as prescribed 4. hold vancomycin and tell the health care provider that the drug is incompatible with heparin

3 -incompatible in the same IV

183.) A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client? 1. Assess frequently for nasal drying 2. Keep the mask tight against the face 3. Monitor oxygen saturation levels when eating. 4. Set the oxygen flow at the highest setting possible.

3 Because the mask cannot be worn when eating, the client may become hypoxic. A nasal cannula may be needed to deliver oxygen while the client is eating.

167.) A client who is to be admitted for minor surgery has a chest radiograph as part of the presurgical physical. The nurse is notified that the radiograph reveals that the client has pulmonary tuberculosis. What evidence of tuberculosis is provided by the radiograph? 1. Sensitized T cells 2. Presence of acid-fast bacilli 3. Cavities caused by caseation 4. Microscopic primary infection

3 Cavities are evident on radiograph. Necrotic lung tissue may liquefy, leaving a cavity (cavitation), or granulose tissue can surround the lesion, become fibrous, and form a collagenous scar around the tubercle (Ghon tubercle).

171.) What must the nurse determine before discontinuing airborne precautions for a client with pulmonary tuberculosis? 1. Client no longer is infected 2. Tuberculin skin test is negative 3. Sputum is free of acid-fast bacteria 4. Client's temperature has returned to normal

3 The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne routine.

368. Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1. Providing oxygen 2. encouraging carbohydrates 3. administering fluid replacement 4. teaching facts about dietary principles

3 - as a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated

377. A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? 1. fluid loss 2. glycosuria 3. kussmaul respirations 4. increased blood glucose level

3 - kussmaul resp occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones; HHNS affects people with type 2 diabetes who still have some insulin production; insulin prevents the breakdown of fats into ketones

344. A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other client has type 2 diabetes. The nurse determines that the main difference between the newly diagnosed type 1 and type 2 diabetes is that the in type 1 diabetes: 1. The onset of the disease is slow 2. excessive weight is a contributing factor 3. complications are not present at the time of diagnosis 4. treatment involves diet, exercise, and oral medications

3 - type 1 has an acute onset which causes no time to develop long-term complications

What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh? 1) Palpate the femoral artery. 2) Assess for a Homan sign. 3) Compress and release the client's toenails. 4) Instruct the client to flex and extend the knee.

3) Compress and release the client's toenails.

A nurse is teaching crutch walking to a client who had arthroscopic surgery of the knee. On which part of the body should the nurse instruct the client to place weight? 1) The upper arms 2) The axillary region 3) Palms of the hands 4) Both lower extremities

3) Palms of the hands

A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would you instruct the UAP to report immediately? 1) The patient wants to change position in bed. 2) There is a small amount of clear fluid at the pin sites. 3) The traction weights are resting on the floor. 4)The patient reports pain and muscle spasm.

3) The traction weights are resting on the floor.

A client is ready to walk with crutches after knee surgery. Which crutch walking technique will the nurse most likely have to reinforce after the client returns from physical therapy? 1) Two-point 2) Four-point 3) Three-point 4) Swing-through

3) Three-point

179.) The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all the apply. 1. Vomiting 2. Chest pain 3. Hemoptysis 4. Night Sweats 5. Bilateral crackles

3, 4

790.) Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active TB. What statements by the client indicate that there is a need for further teaching? select all that apply. 1. "I plan to start taking vitamin B6 with breakfast." 2. "I'll still be taking this drug six months from now." 3. "I sometimes allow our children to sleep in our bed at night." 4. "I know I also have tuberculosis because the skin test was positive." 5. "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

3, 4, 5

184.) A nurse is caring for a client with a Venturi mask who is receiving 40 % oxygen. What nursing actions are indicated? select all that apply. 1. Keep the oxygen source higher than the client's airway. 2. Adjust the liter flow according to the oxygen saturation. 3. Prevent the client's blanket from covering the adaptor's orifices. 4. Ensure that the bag does not deflate completely during inspiration. 5. Check that the appropriate adaptor to deliver the prescribed Fio2 its attached to the mask.

3, 5

582. A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? SELECT ALL THAT APPLY 1. Spasticity 2. Incontinence 3. Flaccid paralysis 4. Respiratory failure 5. Lack of reflexes blow the injury

3, 5

254. A client with a hx of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "what is a pseudocyst?" what information should the nurse include in a response to this question? 1. Malignant growth 2. Pocket of undigested food particles 3. Dilated space of necrotic tissue and blood 4. Sack filled with fluid and pancreatic enzymes

3. Dilated space of necrotic tissue and blood

A nurse is teaching a client with a permanent colostomy about self-care in preparation for discharge from the hospital. Which intervention should the nurse discuss with the client? 1. Limiting activity 2. Wearing special clothing 3. Dilating the stoma periodically 4. Maintaining a low-residue diet

3. Dilating the stoma periodically

For which classic clinical findings should the nurse assess the stool of clients with malabsorption syndrome? 1. Melena 2. Frank blood 3. Fat globules 4. Currant jelly consistency

3. Fat globules

A nurse is evaluating a client who has been receiving medical intervention for the diagnosis of Crohn's disease. Which expected outcome is most important for this client? 1. Does skin care 2. Takes oral fluids 3. Gains a half pound per week 4. Experiences less abdominal cramping

3. Gains a half pound per week

A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply 1. Corn 2. Cheese 3. Oatmeal 4. Rye bread 5. Fruit juice

3. Oatmeal 4. Rye bread

286. An 18 year old is admitted with an acute onset of right lower quadrant pain at McBurney's point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1. Urinary retention 2. Gastric hyperacidity 3. Rebound tenderness 4. Increased lower bowel motility

3. Rebound tenderness

18. You are providing postoperative care for a client who underwent laparoscopic cholecystectomy. What should be reported immediately to the physician? 1. The client cannot void 5 hours postoperatively 2. The client reports shoulder pain 3. The client reports RUQ pain 4. Output does not equal input for the first few hours

3. The client reports RUQ pain

A client with cancer of the colon had surgery for a resection of the tumor and the creation of a colostomy. During the six week post operative check up, the nurse teaches the client about nutrition. The nurse evaluates that learning has taken place when the client states, "I should follow a diet that is: 1. Rich in protein." 2. Low in fiver content." 3. As close to usual as possible." 4. Higher in calories that before."

3. as close to usual as possible"

You are planning a treatment intervention program for chronic fecal incontinence for an elderly client. Which intervention should you try first? 1. Administer a glycerin suppository 15 minutes before evacuation time 2. Insert a rectal tube at specified intervals each day 3. Assist the client to the bedpan or toilet 30 minutes after meals 4. Use incontinence briefs or adult-sized diapers

3. assist the client to the bedpan or toilet 30 minutes after meals

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the clients nasogastric tube is bright red. What should the nurse do first? 1. Notify the health care provider 2. Clamp the nasogastric tube for one hour 3. Determine that this is an expected finding 4. Irrigate the nasogastric tube with iced saline

3. determine that this is an expected finding

You are caring for a client with a nasal gastric tube. Which task can be delegated to an experienced UAP? 1. Removing the NG tube per physician order 2. Securing the tape if the client accidentally dislodges the tube 3. Disconnecting the suction to allow ambulation to the toilet 4. Reconnecting the suction after the client has ambulated

3. disconnecting the suction to allow ambulation to the toilet

An 18-year-old is admitted with an acute onset of right lower quadrant pain at McBurney's point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1. Urinary retention 2. Gastric hyperacidity 3. Rebound tenderness 4. Increased lower bowel motility

3. rebound tenderness

A client with ulcerative colitis has experienced frequent severe exacerbations over the past several years. The client is admitted to the hospital with intense pain, severe diarrhea, and cachexia. Which therapeutic course should the nurse expect the healthcare provider to explore with this client? 1. Intensive psychotherapy 2. Continued medical therapy 3. Surgical therapy (colectomy) 4. Diet therapy (low-residue, high-protein diet)

3. surgical therapy (colectomy)

Which explanation is most accurate when the nurse teaches a client about intussusception of the bowel? 1. Kinking of the bowel onto itself 2. A band of connective tissue compressing the bowel 3. Telescoping of a proximal loop of bowel into a distal loop 4. A protrusion of an organ or part of an organ through the wall that contains it

3. telescoping of a proximal loop of bowel into a distal loop

A nurse is caring for a client with a spinal cord injury during the immediate post injury period. what is the primary focus of nursing care during this immediate phase? 1.) inhibiting urinary tract infections 2.) preventing contractures and atrophy 3.) avoiding flexion or hyperflexion of the spine 4.) preparing the client for vocational rehabilitation

3.) avoiding flexion or hyperflexion of the spine

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? select all that apply 1.) spasticity 2.) incontinence 3.) flaccid paralysis 4.) respiratory failure 5.) lack of reflexes below the injury

3.) flaccid paralysis 5.) lack of reflexes below the injury

You are preparing a nursing care plan for a client with an SCI for whom the nursing diagnoses of impaired physical mobility and toileting self care deficit have been identifies. the client tells you " I don't know why we're doing all this. My life's over." based on this statement, which additional nursing diagnosis takes priority? 1.) risk for injury related to altered mobility 2.) imbalanced nutrition: less than body requirement 3.) impaired individual resilience related to spinal cord injury 4.) disturbed body image related to immobilization

3.) impaired individual resilience related to spinal cord injury

after having a traumatic spinal cord severance, a young client is having difficulty accepting paralysis. one day the client has severe leg spasms and says, "my strength is coming back, and I know I will walk again." The nurse's response should be based on what understanding? 1.) the nerves are regenerating and motor function is returning 2.) motor function may be returning now that the edema is subsiding 3.) spinal shock has subsided and the client's reflexes are hyperactive 4.) the client has developed thrombophlebitis and is experiencing pain

3.) spinal shock has subsided and the client's reflexes are hyperactive

4. Which reporting tasks are appropriate to delegate to the UAP? (select all) 1. reporting on the condition of ms. t's perineal area after application of ointment 2. reporting of the quality and color of NG drainage for ms. d 3. reporting whether mr. r's blood pressure is below 100/60 mmHg 4. reporting if any of the clients indicate pain 5. reporting if mr. a is seen leaving the unit to smoke a cigarette

345

21. The physician has been paged and is en route to see mr. r with acute pancreatitis. The client is increasingly agitated and confused. He pulls out his IV line and NG tube and removes the oxygen nasal cannula. His skin is pale and clammy. Pulse rate is 140 BPM and BP is 140/60 mmHg. List in order of priority the following steps in caring for mr. r. 1. restart IV line 2. reinsert NG tube 3. stay with client 4. replace nasal cannula for supplemental oxygen 5. have a colleague gather equipment, including a pulse oximeter and nonrebreather mask 6. check the blood glucose level 7. continuously monitor vital signs

3451672

33. The nurse and the dietitian are planning dietary intake for a patient with AKI who is currently not on dialysis therapy. The dietitian informs the nurse that 0.6 g/kg of body weight of protein are needed. The patient weighs 130 pounds. How many grams of protein should the patient receive? (Round grams to the nearest whole number.)___________grams

35

At what rate should the IV pump be set to deliver the prescribed rate of infusion?

37

11. Ms. t is discouraged and dispirited about her ulcerative colitis. She is resistant to TPN because "i'm being kept alive with tubes." which explanation will encourage ms. t to continue with the TPN therapy? 1. "it will help you regain your weight" 2. "it will create a positive nitrogen balance" 3. "your physician has ordered this important therapy for you" 4. "your bowel can rest and the diarrhea will increase"

4

135. A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? 1. slow deep respirations 2. normal oral temp 3. dry unproductive cough 4. diminished breath sounds

4

16. a client with MS tells the UAP after physical therapy that she is too tired to take a bath. what is the priority nursing diagnosis at this time? 1. fatigue related to disease state 2. activity intolerance due to generalized weakness 3. impaired physical mobility related to neuromuscular impairment 4. bathing self-care deficit related to fatigue and neuromuscular weakness

4

17. an LPN/LVN, under your supervision, is providing the nursing care for a client with GBS. what observation should you instruct the LPN/LVN to report immediately? 1. reports of numbness and tingling 2. facial weakness and difficulty speaking 3. rapid heart rate of 102 BPM 4. shallow respirations and decreased breath sounds

4

19. You find the new RN in the bathroom crying. She tells you, "i'm a terrible nurse. I'm so disorganized and so far behind. I'm going to quit. I hate this job." what is the best thing to do? 1. send her on a break off the unit 2. offer to take one of her clients 3. ask the UAP to help her out 4. calm her down and help her prioritize

4

2. A patient has newly-diagnosed type 2 diabetes. Which task should you delegate to the UAP? 1. arranging a consult with the dietitian 2. assessing the pt's insulin injection technique 3. teaching the pt to use a glucometer to monitor glucose at home 4. reminding the pt to check glucose level before each meal

4

20. Which intervention for a pt with a pulmonary embolus could be delegated to the LPN/LVN on your pt care team? 1. evaluating the pts reports of chest pain 2. monitoring lab values for changes in oxygenation 3. assessing for symptoms of respiratory failure 4. auscultating the lungs for crackles

4

556. a nurse is caring for a client in the home who has the diagnosis of amyotrophic lateral sclerosis (ALS). which position should the nurse recommend that the client assume after eating? 1. sims 2. sitting 3. side-lying 4. semi-fowler

4

579. A nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities. What should the nurse include in the plan of care for this client to prevent the development of lower extremity contractures? 1. Deep massage 2. Active exercise 3. Use of a tilt board 4. Proper positioning

4

581. What problem is the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake? 1. Dehydration 2. Skin breakdown 3. Electrolyte imbalances 4. Urinary tract infections

4

585. A client with quadriplegia is placed on a tilt table daily. Each day the angle of the head of the table gradually is increased. What should the nurse identify as its purpose when the client asks the reason for the tilt table? 1. Facilitates turning 2. Prevents pressure ulcers 3. Promotes hyperextension of the spine 4. Limits loss of calcium from the bones

4

7. A UAP tells you that, while assisting with the morning care of a postoperative pt with type 2 diabetes who has been given insulin, the pt asked if she will always need to take insulin now. What is your priority for teaching the pt? 1. explain to the pt that she is now considered to have type 1 diabetes 2. tell the pt to monitor fingerstick glucose level every 4 hours after discharge 3. teach the pt that a person with type 2 diabetes does not always need insulin 4. talk with the pt about the relationship between illness and increased glucose levels

4

760. the nurse explains to the family of a client suspected of having myasthenia gravis that edrophonium (enlon) is used to establish the diagnosis. an increase in which factor will confirm the diagnosis? 1. symptoms 2. consciousness 3. blood pressure 4. muscle strength

4

What principle must a nurse consider when caring for a client with a closed wound drainage system? 1. Gravity causes fluids to flow down a pressure gradient 2. Fluid flow rate is determined by the diameter of the lumen 3. Siphoning causes fluids to flow from one level to a lower level 4. Fluids flow from an area of higher pressure to one of lower pressure

4

What should the nurse do initially when obtaining consent for surgery? 1. Describe the risks involved in the surgery 2. Explain that obtaining the signature is routine for any surgery 3. Witness the clients signature, which the nurse's signature will document 4. Determine whether the clients knowledge level is sufficient to give consent

4

72. A nurse is caring for a client in respiratory distress. The health care provider orders oxygen via a nonrebreather mask. Which mask should the nurse obtain to implement the oxygen order?

4 -can accurately deliver high concentrations of oxygen (>90%), can't be used with a high degree of humidity

397. A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, "I will: 1. cut my toenails before bathing" 2. soak my feet daily for one hour" 3. examine my feet using a mirror at least once a week" 4. break in my new shoes over the course of several weeks"

4 - a slower, longer period of time to break in new, stiff shoes will help prevent blisters and skin breakdown

552. a client with Guillain-Barre syndrome has been hospitalized for 3 days. Which assessment finding indicates a need for more frequent monitoring? 1. localized seizures 2. skin desquamation 3. hyperactive reflexes 4. ascending weakness

4 - begins in lower extremities and moves upward

10. A client with a new SCI at the level C3-C4 is being cared for in the ED. what is the priority assessment? 1. determine the level at which the client has intact sensation 2. assess the level at which the client has retained mobility 3. check BP and pulse for signs of spinal shock 4. monitor respiratory effort and oxygen saturation level

4 - first priority = respiratory pattern and ensuring adequate airway

370. A client tells the nurse during the admission history that an oral hypoglycemic agent is taken daily. For which condition does the nurse conclude that an oral hypoglycemic agent may be prescribed by the health care provider? 1. ketosis 2. obesity 3. type 1 diabetes 4. reduced insulin production

4 - oral hypoglycemics may be helpful when some functioning of the beta cells exists, as in type 2 diabetes

248. A client is discharged the same day after ambulatory surgery for a laparoscopic cholecystectomy. The nurse is providing discharge teaching about how many days the client should wait to engage in certain activities. Place in order the activities from the first to the last in which the client may engage. 1 _________ Showering 2 _________Driving a car 3 ________ Performing light exercise 4 ________ Getting out of bed in a chair 5 ________ Lifting objects of more than ten pounds

4 3 1 2 5

376. Metformin (Glucophage) 2g by mouth is prescribed for a client with type 2 diabetes. Each tablet contains 500 mg. How many tablets should the nurse administer?

4 tablets

A client has a long leg cast. What instructions should the nurse give the client in preparation for crutch walking? 1) Use the trapeze to straighten the biceps 2) Keep the affected limb in extension and abduction 3) Sit up straight in a chair to develop the back muscles 4) Do exercises in bed to strengthen the the upper extremities

4) Do exercises in bed to strengthen the the upper extremities

Which nursing action is contraindicated when caring for a client with a newly applied long leg cast? 1) Elevating the cast on a pillow 2) Drying the cast by using a fan 3) Leaving the cast exposed to air 4) Handling the cast with fingertips

4) Handling the cast with fingertips

255. A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "what does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? 1. Promotes the formation of calculi in the cystic duct 2. Stimulates the pancreas to secrete more insulin than it can immediately produce 3. Alters the composition of enzymes so they are capable of damaging the pancreas 4. Increases enzyme secretion and pancreatic duct pressure that causes back-flow of enzymes into the pancreas

4. Increases enzyme secretion and pancreatic duct pressure that causes back-flow of enzymes into the pancreas

A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely? 1. Sodium 2. Calcium 3. Chloride 4. Potassium

4. Release of adrenocortical steroids (cortisol) by the stress of surgery causes renal retention of sodium and excretion of potassium

What should the nurse do when caring for a client with an ileostomy? 1. Teach the client to eat foods high in residue 2. Explain that drainage can be controlled with daily irrigations 3. Expect the stoma to start draining on the third postoperative day 4. Anticipate that any emotional stress can increase intestinal peristalsis

4. anticipate that any emotional stress can increase intestinal peristalsis

A nurse is admitting a client with the diagnosis of malabsorption syndrome to the medical unit at lunchtime. Which foods can be included on the clients ordered diet? 1. Breaded veal cutlet with cheese 2. Roast beef sandwiches with pickles 3. Chicken noodle soup with crackers 4. Cheese omelet with chopped spinach

4. cheese omelet with chopped spinach

A nurse is assessing two clients. One client has ulcerative colitis and the other client has Crohn's disease. Which is more likely to be identified in the client with ulcerative colitis than the client with Crohn's disease? 1. Inclusion of transmural involvement of the small bowel wall 2. Correlation with increased malignancy because of malabsorption syndrome 3. Pathology beginning proximally with intermittent plaques found along the colon 4. Involvement starting distally with rectal bleeding that spreads continuously up the colon

4. involvement starting distally with rectal bleeding that spreads continuously up the colon

You are caring for a client who was recently admitted for severe diverticulitis. Which task is appropriate to delegate for the care of this client? 1. Tell the unit secretary to call radiology and schedule a barium enema 2. Instruct the LPN/LVN to give PRN laxatives when the client reports constipation 3. Advise the nursing student to help the client ambulate up and down the hall 4. Tell the UAP that a stool specimens must be saved to test for occult blood

4. tell the UAP that a stool specimen must be saved to test for occult blood

A client with quadriplegia is placed on a tilt table daily. each day the angle of the head of the table gradually is increased. what should the nurse identify as its purpose when the client asks the reason for the tilt table? 1.) facilitates turning 2.) prevents pressure ulcers 3.) promotes hyperextension of the spine 4.) limits loss of calcium from the bones

4.) limits loss of calcium from the bones

A client with an SCI at level C3-C4 is being cared for in the ED. What is the priority assessment? 1.)determine the level at which the client has intact sensation 2.) assess the level at which the client has retained mobility 3.) check blood pressure and pulse for signs of spinal shock 4.) monitor respiratory effort and oxygen saturation

4.) monitor respiratory effort and oxygen saturation

A nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities. what should the nurse include in the plan of care for this client to prevent the development of lower extremity contractures? 1.) deep massage 2.) active exercise 3.) uses of tilt board 4.) proper positioning

4.) proper positioning

What problems the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake? 1.) dehydration 2.) skin breakdown 3.) electrolyte imbalance 4.) urinary tract infection

4.) urinary tract infection

18. During the shift, the following events happen at the same time. Indicate the order in which you will attend to these situations. 1. ms. h calls for an antiemetic after vomiting bile 2. mr. a wants to know when he will be discharged 3. mr. k's family wants to speak to the physician 4. mr. r is walking down the hall, threatening to leave

4132

23. The HCP is notified of Raymond's physical exam findings indicating possible dehydration and vital signs, including BP of 100/50. It is determined Raymond could use a bolus of IV fluids. HCP prescribes 1000 mL of normal saline to run over 6 hours. Drop factor is 15 drops/mL. How many gtt/min will the IV run? (round to whole number)

42

7. All of these clients must receive their routine morning medications. Which client should receive his or her medication last? 1. ms. h (36, r. upper quadrant pain, "good night") 2. ms. d (60, vomiting & mid-abd. pain, NG, IV, NPO) 3. ms. t (29, wasted & malnourished, diarrhea, TPN through central line) 4. mr. a (26, discharging in afternoon) 5. mr. k (85, A&O x 2, PEG, family asks a lot of questions and argues) 6. mr. r (57, periumbilical pain, no pain relief, NPO, NG, IV, belligerent & confused, elevated WBC & glucose)

5

125. A client is admitted to the hospital with a dx of pneumonia. List the following nursing actions in the order they should be accomplished. 1. check peak and trough levels of the antibiotic 2. insert an IV catheter to establish venous access 3. collect a sputum sample for culture and sensitivity 4. administer prescribed antibiotic IV piggyback 5. obtain data about the client's history and physical status

5,2,3,4,1

Case Study: 6 clients Ms. H - 36, r. upper quadrant pain that radiates to r. shoulder, hx of gallstones, acute cholecystitis, "had a good night" Ms. D - 60, vomiting & pain in midabdomen related to bowel obstruction, abd. pain has improved since NG tube, has IV fluids and on NPO status Ms. T - 29, wasted and malnourished, severe diarrhea, predefecation abd. pain and generalized tenderness to palpation, TPN through central line Mr. A - 26, discharged in afternoon, wants review of wound care instructions before he leaves Mr. K - 85, frail but A&O x 2, transferred from extended care to receive a percutaneous endoscopic gastrostomy (PEG) tube that was placed 5 days ago, large family that ask a lot of questions and argue continuously with each other and staff, he has stable vitals Mr. R - 57, periumbilical pain, pain is severe despite meds and radiates to back, admitted w/ acute pancreatitis, NPO w/ NG tube and IV line, he is belligerent and confused, WBC & blood glucose levels increased 1. The night shift nurse has just finished giving you report on the 6 clients. Which client has the highest acuity level and is at greatest risk for shock during your shift? 1. ms. h (36, r. upper quadrant pain, "good night") 2. ms. d (60, vomiting & mid-abd. pain, NG, IV, NPO) 3. ms. t (29, wasted & malnourished, diarrhea, TPN through central line) 4. mr. a (26, discharging in afternoon) 5. mr. k (85, A&O x 2, PEG, family asks a lot of questions and argues) 6. mr. r (57, periumbilical pain, no pain relief, NPO, NG, IV, belligerent & confused, elevated WBC & glucose)

6

Admin IV bolus dose of heparin 80U per kg of body weight. Initiate IV infusion of 500ml of 5% dextrose in water with 25000U of heparin at a rate of 22 units of heparin per kg per hour. The heparin bolus is available in a 1000 unit/ml concentration. Mrs B weighs 187lbs. What is the correct IV bolus dose of heparin that the nurse should administer?

6.8

The HCP prescribes an infusion of aminocarproic acid (Amicar). The prescription is for a loading dose of animocarpoic acid (Amicar) IV 5 g to be infused in 250 mL of D5W over 1 hour. The tubing drop factor is 15 drops/mL. How many drops per minutes would the nurse set the IV rate?

63 drops/min

1. Which nursing intervention is most appropriate for the patient in the operative setting? a. provide a climate of privacy, comfort, and confidentiality when caring for the patient. b. instruct the patient that after the preoperative medication has taken effect, he or she will be drowsy c. avoid discussing the actives taking place around the patient while in the holding area d. assist members of the surgical team readying the operating room suite.

A

13. A patient arrives in the PACU. Which action does the nurse perform first? a. Assess for a patent airway and adequate gas exchange b. Rate the patient's pain using the 0-10 pain assessment scale c. Position the patient in a supine position to prevent aspiration d. Calculate the patient-controlled analgesia (PCA) pump maximum dose per hour to avoid an overdose

A

14. Following surgery, Ms. Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson had a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 97.6° F, P 88, R 14, and BP 130/70. What action should the nurse implement first? A) Position the client on her side. B) Observe the surgical dressing. C) Place the call bell within reach. D) Remove the oral airway.

A

14. What is the priority nursing diagnosis for Raymond at this time? A. Risk for new opportunistic infections related to decreased immune function B. Social isolation related to worsening of condition C. Imbalanced nutrition, less than body requirements related to medication side effects D. Fatigue related to altered body chemistry

A

152. Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure? a. dilation of blood vessels b. decreased response of chemoreceptors c. decreased strength of cardiac contraction d. distribution of cardiac accelerator pathways.

A

17. The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first? a. The nurse calls for help and stays with the patient. b. The nurse leaves the patient to immediately call the surgeon. c. The nurse covers the wound with a non-adherent dressing moistened with normal saline. d. The nurse takes the patient's vital signs

A

17.) A pt is diagnosed with pneumonia. During auscultation of the lower lung fields, the nurse hears coarse crackles and identifies the pt problem of impaired oxygenation. What is the underlying physiologic condition associated with the pt's condition? a. Hypoxemia b. Hyperemia c. Hypocapnia d. Hypercapnia

A

177. A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? a. Keeps the area free of microorganisms b. Confines microorganisms to the surgical site c. Protects self from microorganisms in the wound d. Reduces the risk for growing opportunistic microorganisms

A

18. What action should the nurse take to assess atelectasis? a. Auscultate the client's breath sounds. b. Observe the appearance of the sputum. c. Determine the client's temperature. d. Measure the client's blood pressure.

A

19. The nurse determines that Ms. Jackson's bowel sounds are hypoactive. What action should the nurse implement in response to this finding? a. Document the assessment finding in the chart. b. Notify the surgeon of the assessment finding. d. Review the client's serum electrolyte values. d. Administer a laxative prescribed for PRN use.

A

19. The nurse is caring for a patient who had a hysteroscopic surgery. The patient reports severe lower abdominal pain, she appears pale, and has trouble focusing on the nurses questions about pain. Vital signs show: T 98.6 F, P 120/min, R 24/min, BP 103/60. Which complication does the nurse suspect? a. Hemorrhage b. Embolism c. Fluid overload d. Incomplete suppression of menstruation

A

19. You are working in the ED when a client with possible toxic shock syndrome is admitted. Which prescribed intervention will you implement first? a. Remove the client's tampon b. Obtain blood specimens for culture c. Give acetaminophen (Tylenol) 650 mg. d. Infuse nafcillin (Unipen) 1000 mg IV

A

19.) A pt is admitted to the hospital with pneumonia. What does the nurse expect the chest x-ray results to reveal? a. Patchy areas of increased density b. Tension pneumothorax c. Thick secretions causing airway obstruction d. Large hyperinflated airways

A

20. The patient reports itching, change in vaginal discharge, and an odor. The nurse suspects that the patient has vulvovaginitis. Based on knowledge about the common causes of vulvovaginitis, which question would the nurse ask? a. "Have you recently been taking antibiotics?" b. "Have you been swimming in a lake or pond?" c. "Do you consistently wipe from front to back?" d. "Do you use tampons or menstrual pads?"

A

21.) The nurse is conducting an in-service for the hospital staff about practices that help prevent pneumonia among at-risk patients. Which nursing interventions is encouraged as standard practice? a. Administering vaccines to patients at risk b. Implementing isolations for debilitated patients c. Restricting foods from home in immunosuppressed patients d. Decontaminating respiratory therapy equipment weekly

A

22. A client who underwent an abdominal hysterectomy 3 days ago reports burning with urination. Her urine output during the previous shift was 210 mL, and her temperature is 101.3 F (38.5 C) Which of these actions prescribed by the health care provider will you implement first? a. Insert a straight catheter PRN for output of less than 300 mL/8 hr. b. Administer acetaminophen (Tylenol) 650 mg orally. c. Send a urine specimen to the laboratory for culture and sensitivity testing. d. Administer ceftizoxime (Cefizox) 1 g IV every 12 hours

A

22. A patient with a fever, myalgia, sore throat, and sunburn-like rash is admitted with the diagnosis of toxic shock syndrome. What additional clinical manifestation should the nurse assess for? a. Hypotension b. Vaginal bleeding c. Bradycardia d. Polyuria

A

220. On which concern should the nurse focus when caring for a client after abdominal surgery? a. Identifying signs of bleeding b. Preventing pressure on the suture site c. Encouraging use of an incentive spirometer d. Detecting clinical manifestations of inflammation

A

24. Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 ml/hour. In transfusing the 250 ml unit of packed red blood cells, what action should the nurse implement? a. Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. b. Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75 mL/hour. c. Flush the IV tubing with a 5 mL bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour. d. Replace the Lactated Ringer's solution with the unit of packed red blood cells and administer through the tubing at 75 mL/hour.

A

24. Which patient is most at risk for postoperative nausea and vomiting (PONV)? a. The patient with a history of motion sickness b. The patient with a nasogastric tube c. The patient who recently experienced weight loss of 50 pounds d. The patient who had minimally invasive surgery (MIS)

A

25. A patient reports the sensation of feeling as if "something is falling out" along with painful intercourse, backache, and a feeling of heaviness or pressure in the pelvis. Which question does the nurse ask to assess for a cystocele?" a. "Are you having urinary frequency or urgency?" b. "Do you feel constipated?" c. "Have you had problems with hemorrhoids?" d. "Have you had any heavy vaginal bleeding?"

A

28.) The nurse is providing discharge instructions about pneumonia to a patient and family which discharge information must the nurse be sure to include? a. Complete antibiotics as prescribed, rest, drink fluids, and minimize contact with crowds b. Take all antibiotics as ordered, resume diet and all activities as before hospitalization c. No restrictions regarding activates, diet, and rest because the patient is fully recovered when discharged d. Continue antibiotics only until no further signs of pneumonia are present avoid exposing immunosuppressed individuals

A

29.) A pt is admitted to the hospital with cough, purulent sputum production, temperature of 37.9 C (100.3 F), and reports of shortness of breath. Which intervention does the nurse provide first? a. Set up oxygen equipment and administer oxygen b. Instruct the patient about the importance of keeping the oxygen delivery device on. c. Monitor the effectiveness of oxygen therapy (pulse oximetry, ABG's) as appropriate d. Monitor the patient's anxiety related to the need for oxygen delivery

A

3. After undergoing a modified radical mastectomy, a client is transferred to the post anesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/LVN? a. Monitoring the client's dressing for any signs of bleeding b. Documenting the initial assessment on the client's chart c. Communicating the client's status report to the charge nurse on the surgical unit d. Teaching the client about the importance of using pain medication as needed

A

31. A patient has had a pelvic examination and needs an additional diagnostic test for possible uterine leiomyomas. The nurse prepares the patient for which first-choice diagnostic test? a. Transvaginal ultrasound b. Laparoscopy c. Hysterectomy d. Endometrial biopsy

A

31.) Which complications of pneumonia creates pain that increased on inspiration because of inflammation of the parietal pleura? a. Pleuritic chest pain b. Pulmonary emboli c. Pleural effusion d. Meningitis

A

32. A client is extubated in the post anesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? a. Restlessness b. Bradycardia c. Constricted pupils d. Clubbing of the fingers

A

38. A client past menopause undergoes an anterior-posterior colporrhaphy. What should the discharge teaching include? a. Eating a high fiber diet b. Limiting daily activities c. Reporting signs of urinary retention d. Observing for signs of a rectovaginal fistula

A

38. A patient with swelling in the perineal area is diagnosed with a Bartholin cyst. Nonsurgical management is recommended. What does the nurse instruct the patient to do? a. Apply moist heat (ex: sitz baths or hot wet packs) to the vulva b. Return immediately to the clinic of the cyst ruptures c. Contact all sexual partners about the need for treatment d. Change the dressing at least three times a day

A

4. The nurse notices the UAP about to enter Raymond's room to deliver a meal tray without wearing any protective apparel. What information should the nurse provide to the UAP? A. A mask is required for healthcare workers entering the room of someone suspected of having active TB B. Wearing a mask, gown, and gloves is required for healthcare workers entering Raymond's room for any reason C. The UAP will only be in the room for a brief moment to deliver the tray so no intervention is needed by the nurse D. Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB

A

41. The nurse is caring for a patient with radioactive implant in the uterus. Which instruction will the nurse give to unlicensed assistive personnel (UAP)? a. Patient is on bedrest and excessive movement is restricted b. Assist the patient to ambulate in the hall at least three times per shift c. Assist the patient to get up to the toilet or the commode chair d. Linens and patient gown should be frequently changed for drainage

A

41.) Which test results indicates a patient has clinically active TB? a. Induration of 12mm and positive sputum b. Positive chest x-ray for TB c. Positive chest x-ray and clinical symptoms d. Sputum tests positive for blood

A

47.) The nurse is teaching a pt about the combination drug therapy that is used in the treatment of TB. Which patient statement indicated the nurse's instruction was effective? a. I will take three drugs; isoniazid, rifampin, and pyrazinamide, then ethambutol may be added later b. Combining the drugs in one pill is a convenient way for me to take all the medications c. The isoniazid combines with TB bacteria. I can take the rifampin and pyrazinamide if I continue to have symptoms d. Combining the medications means to take the isoniazid, rifampin, and pyrazinamide all at the same time

A

48. A patient had loop electrosurgical excision procedure (LEEP) for treatment and diagnosis of cervial cancer. In the discharge instruction, what does the nurse tell the patient to expect after the procedure? a. Spotting b. Menses-like vaginal bleeding c. Cramps lasting 24 hours d. Watery discharge

A

5. A patient has an MH incident during surgery. To whom does the nurse report this incident? a. North American Malignant Hyperthermia Registry b. The Joint Commission c. Centers for Disease Control Occupational Safety and Heath Administration

A

51. The home health nurse is reviewing the patients medication list and sees that the patient was given doxorubicin (Adriamycin) at the hospital. What gynecologic diagnosis would the nurse expect to see as part of the patients history? a. Endometrial cancer b. Cervical polyps c. Endometriosis d. Bartholin cyst

A

52. After an abdominal hysterectomy the client returns to the unit with an indwelling catheter. The nurse identifies that the urine in the client's collection bag has become increasingly sanguineous. What complication does a nurse suspect? a. An incisional nick in the bladder b. A urinary infection from the catheter c. Disseminated inravascular coagulopathy d. Uterine relaxation with increased bleeding

A

52. The nurse is preparing patient teaching for several young women who will undergo surgical procedures for gynecologic problems. Which surgical procedure is most likely to induce menopausal symptoms? a. Bilateral salpingo-oophorectomy b. Endometrial ablation c. Uterine artery embolization d. Hysteroscopic myomectomy

A

6. A current treatment of nonemergent dysfunctional uterine bleeding includes which medication? a. Oral or patch contraceptives b. Tamoxifen (Nolvadex) c. Magnesium supplement d. Cisplatin (Platinol)

A

A client had a suprapubic prostatectomy. Which type of tube can the nurse expect the client to have when he returns to his room from the PACU? A. Cystostomy B. Nasogastric C. Nephrostomy D. Ureterostomy

A

A nurse is caring for a client with an indwelling urinary catheter. What is the most important action for the nurse to implement when irrigating the bladder? A. Use sterile equipment B. Instill the fluid under high pressure C. Warm the solution to body temperature D. Aspirate immediately to ensure return flow

A

A patient had a transrectal ultrasound with biopsy earlier in the day. What urine characteristics does the nurse expect to see? A. Light pink urine B. Bright red urine C. Dark urine with small clots D. Very pale yellow urine

A

A patient has an enlarged prostate. which procedure does the nurse anticipate that the health care provider will order to test for bladder Obstruction? A.) Urodynamic pressure-flow study B.) Bladder scan C.) Transrectal ultrasound D.) Computer tomography scan

A

A patient is undergoing large-volume bladder irrigation. During and after the procedure, the nurse observes the patient for confusion, muscle weakness, and increased gastrointestinal motility related to which potentially adverse effect of large-volume irrigation? A. Hyponatremia B. Hypovolemia C. Hypokalemia D. Hypotension

A

A patient needs surgical interventions for an enlarged prostate, but also needs to maintain his anticoagulant therapy. Which brochure would be the most appropriate to prepare for the patient? A. Talking to your doctor about Holmium laser enucleation of the prostate (HO-LEP) B. Transurethral resection of the prostate (TURP), the gold standard treatment C. Is laparoscopic radical prostatectomy (LRP) with robotic assistance right for you? D. Common questions about the open surgical technique for radical prostatectomy

A

A young patient has been diagnosed with testicular cancer. He and his wife had been trying to conceive a child for several months. What information does the nurse give the couple about sperm storage? A. Arrangements for sperm storage should be made as soon as possible after diagnosis B. Sperm collection should be completed after radiation therapy or chemotherapy C. Two or three samples should be collected 6 days apart D. Saving sperm prevents fears related to ED.

A

After a radical prostatectomy, a client is ready to be discharged. Which nursing action included in the discharge plan should be delegated to an experienced LPN/LVN? A. Reinforcing the client's need to check his temperature daily B. Teaching the client how to care for his retention catheter C. Documenting a discharge assessment in the client's chart D. Instructing the client about the prescribed narcotic analgesic

A

An older adult patient is scheduled for an annual physical including a PSA and a digital rectal examination (DRE). How are these two test scheduled for the patient? A. PSA is drawn before the DRE is performed B. DRE is one severe weeks before PSA C. PSA is reviewed first because DRE may be unnecessary D. Both tests can be done at the convenience of the patient

A

An older patient's wife is very upset because "my husband was just told that he had prostate cancer. he feels fine now, but the doctor told him to watch and wait. Why are we just watching? What are we waiting for?" What is the nurse's best response? A. Prostate cancer is slow-growing. Your husband needs regular DRE and PSA testing and here is a list of symptoms to watch for." B. "This is very upsetting news. Let's sit down and talk about how you feel and then I will have the doctor talk to you again.: C. "It is okay , don't be upset. This is very common was to handle prostate cancer for men who are your husband's age." D. "I can get you some information about prostate cancer. This will help you understand why the doctor said this to your husband."

A

During the first 24 hours after prostatectomy, what is the priority assessment in the nursing care plan? A. Hemorrhage B. Infection C. Hydronephrosis D. Confusion

A

The advanced-practice nurse is performing a testicular exam on a young caucasian male patient. The practitioner find a lump, which the patient reports id painless, This findings is considered the most common manifestation of which disease or disorder? A. Testicular cancer B. ED C. Prostate cancer D. Epididymitis

A

The nurse is caring for a patient who had minimally invasive surgery (MIS) for testicular cancer. The nurse is also caring for a patient who had an open radical retroperitoneal lymph node dissection for testicular cancer. The nurse anticipates that the second patient had more of a risk for which condition? A. Paralytic ileus B. urinary incontinence C. Metastatic disease D. Fluid overload

A

The nurse is giving discharge instructions to a patent who had a TURP. What does the nurse include in the instructions? A. Reassurance that loss of control or urination or dribbling of urine is temporary B. Instructions about how to apply a condo, catheter and monitor for skin breakdown C. Advice about how to control bleeding and passage of blood clots D. Information about the side effects related to aminocaproic acid (Amicar)

A

The nurses sees that the patient is taking tamsulosin (Flomax). Which question would the nurse ask to determine if the medication is achieving there desired effect? A.) Are you having trouble passing urine? B.) Does your urine have a strong odor or appear cloudy? C.) Are you have any problems with achieving an erection? D.) Have you had problems with fatigue or feeling sleepy?

A

The patient had a TURP several days ago and the urinary catheter case removed 6 hours ago. Which S/S must be resolved before the patient is discharged? A. patient has not voided since the catheter was removed B. patient reports a burning sensation with urination C. Patient reports dribbling and leakage since catheter was removed D. Patient reports anxiety related to sexual function because of TURP

A

The patient is prescribed trimethoprim/sulfamethoxazole (Bactrim, septa) for prostatitis. Which laboratory results indicates that the medication is having the desired therapeutic effect? A. Normalization of white cell count B. Decreased blood urea nitrogen level C. Increased red blood cell count D. Prostate-specific antigen within normal limits

A

What instructions should the nurse relate to Mr. H? A. Do no try to void around the catheter B. Drink more fluid to relieve pressure C. Start pelvic floor muscle exercises D. Ask for your pain medication sooner

A

What is the best response by the nurse? A. I wil be glad to andere any questions you may have B. Do you want me to stay here with you for awhile? C. I can see you are comfortable, but call if I can help you D. Take Mrs. H's hand and offer silent support

A

What lab value would the nurse question? A. Hemoglobin 15.0g/dL B. Hematocrit 35% C. PO2 70.0 mm/Hg D. WBC 6,000 mm

A

What nursing diagnosis has the highest priority when implementing care? A. altered cardiac output B. Altered body temperature C. Altered urinary patterns D. Altered thought process

A

Which action should the nurse implement first? A. assess Mr. H for additional symptoms B. Administer a prescribed PRN analgesic C. Ask the UAP to obtain Mr. H's vital signs D. Notify the HCP immediately

A

Which postoperative intervention should the nurse perform first? A. Observe the urinary drainage B. Palpate the bladder C. Assess the level of pain D. Encourage oral fluid intake

A

which data set indicates that the pt with diabetes is achieving the goals of care to prevent the development of microalbuminuria and delay the progression to end-stage kidney disease? a. A1C <7%, BP is 125/75 mm Hg, LDL cholesterol is 90 mg/dL b. A1C >7%, BP is 140/80 mm Hg, LDL cholesterol is 200 mg/dL c. A1C <7%, BP is 130/80 mm Hg,with proteinuria 2.0 g/24hours d. A1C >7%, BP is 120/70 mm Hg, LDL cholesterol is 300 mg/dL

A

Jess is a 21 yr old college student who reports that she has been in good health until the last few months when she started to experience increasing abdominal pain and diarrhea. Jess is evaluated for possible ulcerative colitis an inflammatory bowel disease. The nurse anticipates that Jess will describe her diarrhea as a. Bloody B. green and frothy c. gray with observable fat d. clay colored

A (c would indicate pancreatitis d would indicate cirrhosis or cholecystitis)

20. Raymond develops severe diarrhea with occasional incontinence that could be caused by an opportunistic gastrointestinal infection or by one of his meds. While stool cultures are pending, other interventions can be initiated. Which tasks can be delegated to the UAP? (select all that apply) A. weigh Raymond each morning before breakfast B. Measure urine output C. Count and record number of watery stools D. assess Raymond's peri-rectal skin during incontinent care E. Check Raymond's skin turgor to determine if he is dehydrated

A, B, C

13. Raymond's HCP has also prescribes the anti-TB regiment of rifabutin/isoniazid/pyrazinamide/ethambutol. What information is important to teach Raymond about the use of rifabutin/isoniazid/pyrazinamide/ethambutol? (select all that apply) A. Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange B. Liver function tests should be routinely conducted and monitored C. There is no need to wear sunscreen when exposed to sunlight while taking rifabutin/isoniazid/pyrazinamide D. Visual disturbances related to ethambutol therapy may develop during therapy, but may resolve once treatment is discontinued E. Rifampin/isoniazid/pyrazinamide has been known to cure HIV within a few months of taking it

A, B, D

5. An acid-fast bacilli (AFB) stain is part of the initial admission prescriptions. Early morning sputum specimens will be collected for 3 consecutive days and sent to the lab. Which tasks may the nurse delegate to the UAP? (Select all that apply) A. have UAP tell Raymond that the specimen must be collected in the early morning B. Provide Raymond with three sterile specimen cups at his bedside. C. Allow the UAP to teach the client how to cough to obtain sputum from deep in the bronchi D. Document the time and date that each sputum specimen was collected E. Instruct the UAP to assess Raymond's ability to expectorate the sputum specimen

A, B, D

18. To achieve the goal of improving Raymond's nutrition, the nurse should perform which nursing intervention? (select all that apply) A. request a dietary consultation for Raymond to better assess Raymond's nutritional status and food preferences B. Request a prescription for total parenteral nutrition C. Monitor for oral thrush and diarrhea D. Instruct Raymond to focus on breakfast, the most important meal of the day E. Weigh daily and record signs of wasting syndrome

A, C, E

9. The nurse creates a plan of care for Raymond. The nursing diagnosis of Knowledge Deficit is used to describe what is needed during client education sessions with Raymond. Which statements by Raymond indicates he understands why he is at risk for TB? (select all that apply) A. "I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB" B. "I may get TB because my viral load count is diminished" C. "I am at risk for developing TB because I was born with a low number of helper T cells" D. "I realize I am at risk for acquiring TB because I used intravenous drugs in the past" E. "I guess living in that homeless shelter increased my chances of getting TB"

A, E

10. Which clinical features are found in an MH crisis? (select all that apply.) a. Sinus tachycardia b. Tightness and rigidity of the patient's jaw area c. Lowering of the blood pressure d. A decrease in the end-tidal carbon dioxide level e. Skin mottling and cyanosis f. An extremely elevated temperature at onset g. Tachypnea

A,B,C,E,G

21. What criteria guide the handoff report when a patient is transferred from the OR to the PACU (Select all that apply) a. It is a two way verbal interaction b. The language is clear c. Reporting nurse asks questions about PACU procedures d. Standardized reports help avoid omissions e. Receiving nurse repeats information to verify what she said

A,B,D,E

26. The PACU nurse is assessing an older adult postoperative patient of pain. Which nonverbal manifestations by the patient suggest pain to the nurse? (Select all that apply) a. Restlessness b. Profuse sweating c. Difficult to arouse d. Confusion e. Increased blood pressure

A,B,D,E

10. A patient cared for in the PACU has had a colostomy placed for treatment of Crohn's disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguineous drainage and notes that the incision is intact. An IV is infusing with D5/lactated Ringer's at 100 mL/hr through a 20-g peripheral IV access. Auscultation of abdomen reveals hypoactive bowel sounds in all four quadrants, abdomen soft, and no distention. Foley catheter is in place and draining yellow urine with sediment, 375 mL output in Foley bag. Which body systems have been assessed by the nurse? (Select all that apply) a. Renal/urinary b. Gastrointestinal c. Respiratory d. Musculoskeletal e. Integumentary

A,B,E

9. A postoperative patient in the PACU has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49 mm Hg, heart rate 100/min sinus rhythm, respirations 22/min, temperature 98.3 degrees fahrenheit. The foley catheter has a total of 110 mL of clear, yellow urine in the last 4 hours. Which body systems have been assessed by the nurse? (Select all that apply) a. Respiratory b. Cardiovascular c. Neurovascular d. Integumentary e. Renal/urinary

A,B,E

169. A client experiences abdominal distention following surgery. Which nursing actions are appropriate? Select all that apply. a. Encouraging ambulation b. Giving sips of ginger ale c. Auscultating bowel sounds d. Providing a straw for drinking e. Offering the prescribed opioid analgesic

A,C

2. Which intervention must the operating room nurse provide for a patient's physiological integrity during the intraoperative period? (Select all that apply) a. apply padding to the OR bed to protect skin integrity b. communicate patients fears about anesthesia to the nurse anesthetist c. monitor patient airway, vital signs, electrocardiogram, and oxygen saturation during and after sedation d. assess and document skin condition before transferring patient to the postanesthesia care unit e. ensure that patient wishes with regard to advance directives are respected

A,C,D

28. Which are interventions for the medical-surgical nurse to use in preventing hypoxemia for the postoperative patient? (Select all that apply). a. Monitor the patient's oxygen saturation b. Position the patient supine c. Encourage the patient to cough and breathe deeply d. Get the patient up ambulating as soon as possible e. Instruct the patient to rest as much as possible

A,C,D

4. To reduce the incidence of patients with a known history or risk of malignant hyperthermia (MH) what best practices are put in place in the operating room? (Select all that apply) a. list of medications available for emergency treatment of MH b. genetic counseling after each episode of MH c. dedicated MH cart with treatment medications d. treatment before, during, and after surgery if the patient has a known history or risk e. additional nursing support on call if MH develops f. Available MH hotline number

A,C,D,E,F

7. During surgery, what things do anesthesia personnel monitor, measure, and assess (select all that apply.) a. Intake and Output b. Room temperature c. Cardiopulmonary function d. Level of anesthesia e. Family concerns f. Vital signs

A,C,D,F

21. Which patient would be a candidate for moderate sedation? (select all that apply.) a. Endoscopy b. Cesarean section delivery c. Closed fracture reduction d. Cardiac catheterization e. Suturing a laceration f. Abdominal surgery g. Cardioversion

A,C,D,G

29. The health care provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home on daily dressing changes. Which actions does the nurse take for this patient's discharge teaching? (Select all that apply) a. Ask the patient's family or significant other to observe the dressing change b. Ask the UAP to get dressing supplies for the patient c. Instruct that the drainage will appear serosanguineous d. Instruct the patient to go to the emergency department (ED) for problems related to dressing changes e. Have the case manager arrive for a home health nurse to ensure that dressing changes are done and there are no complications or infections

A,C,E

14. What techniques are essential to performing a proper surgical scrub of the hands by the surgeon, assistants, and scrub nurse? (select all that apply.) a. Use a broad-spectrum, surgical antimicrobial solution. b. Scrub for 2 minutes, followed by a rinse with water. c. Use an alcohol-based antimicrobial solution d. Hold hands higher than elbows during scrub and rinse. e. Scrub for 3-5 minutes, followed by a rinse with water. f. Hold hands below the elbows during the scrub and rinse.

A,D,E

The nurse reviews the discharge and home care instructions with a patient who has back surgery. Which statement by the patient indicates further teaching is needed? A.) " I will drive myself to my doctor's office next week." B.) "I will put a piece of plywood under my mattress." C.) "I will try to increase fruits and vegetables and decrease fat intake." D.) "I plan to get a new ergonomic chair at work."

A.) " I will drive myself to my doctor's office next week."

A patient has just undergone spinal fusion surgery and returned from the operating room 12 hours ago. Which risk is best to delegate to the unlicensed assistive personal (UAP)? A.) Log-roll the patient every 2 hours B.) Help the patient dangle the legs on the evening of surgery C.) Assist the patient to put on a brace so he can get out of bed D.) Help the patient ambulate to the bathroom as needed

A.) Log-roll the patient every 2 hours

Which position is therapeutic and comfortable for a patient with lower back pain? A.) Semi-Fowler's position with a pillow under the knees to keep them flexed B.) Supine position with arms and legs in a correct anatomical position C.) Orthopneic position; sitting with trunk slightly forward; arms supported on a pillow D.) Modified Sim's position with upper arm and leg support by pillows

A.) Semi-Fowler's position with a pillow under the knees to keep them flexed

A patient has just undergone a spinal fusion and laminectomy and has returned from the operating room. Which assessment are done in the 24 hours? select all that apply A.) Take vital signs every 4 hours and assess for fever and hypotension B.) Perform a neurologic assessment every 4 hours with attention to movement and sensation C.) Monitor intake and output and assess for urinary retention D.) Assess for ability and independence in ambulating and moving in bed E.) Observe for clear fluid on or around the dressing

A.) Take vital signs every 4 hours and assess for fever and hypotension B.) Perform a neurologic assessment every 4 hours with attention to movement and sensation C.) Monitor intake and output and assess for urinary retention E.) Observe for clear fluid on or around the dressing

A patient is scheduled for lumbar surgery. Which key points must the nurse include in a preoperative teaching plan for this patient? select all that apply A.) Techniques for getting in and out of bed B.) Expectation for turning and moving in bed C.) Limitations and restrictions for home activities D.) Restriction of bedrest for at least 48 hours E.) Report any numbness and tingling to the nurse immediately

A.) Techniques for getting in and out of bed B.) Expectation for turning and moving in bed C.) Limitations and restrictions for home activities E.) Report any numbness and tingling to the nurse immediately

Which neurologic assessment technique does the nurse use to test a patient for sensory function? A.) Touch the skin with a clean paper clip and ask whether it is a sharp or dull sensation B.) Ask the patient to elevate both arms off the bed and extend wrists and fingers C.) Have the patient close the eyes and move the toes up or down; the patient identifies the position D.) Have the patient sit with the legs dangling use a reflex hammer to test reflex responses

A.) Touch the skin with a clean paper clip and ask whether it is a sharp or dull sensation

Because the patient is at risk for spinal shock, what does the nurse monitor for? A.) decreased blood pressure, bradycardia, and decreased bowel sounds B.) Tachycardia and a change in the level of consciousness C.) Decreased respiratory rate and loss of sensation to pain and touch D.) Paralytic ileus and loss of bowel and bladder function

A.) decreased blood pressure, bradycardia, and decreased bowel sounds

The nurse is caring for a patient who has been in a long-term care facility for several months following an SCI. The patient has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. which are expected outcomes of the training program? select all that apply A.) demonstrates a predictable pattern of voiding B.) is able to independently catheterize himself C.) pours warm water over perineum to stimulate voiding D.) takes bethanechol chloride (urecholine)1 hour before voiding E.) is able to empty the bladder completely F.) does not experience a urinary tract infection

A.) demonstrates a predictable pattern of voiding E.) is able to empty the bladder completely F.) does not experience a urinary tract infection

What key point does the nurse include in teaching an SCI patient about bowel and bladder retraining? select all that apply A.) ensure the patient gets a sufficient quantity of fluid each day B.) instruct the patient about the purpose of stool softeners C.) teach the patient about high fiber foods D.) teach the patient that continence is dependent upon spinal cord healing E.) digital rectal stimulation is essential for regular bowel movement

A.) ensure the patient gets a sufficient quantity of fluid each day B.) instruct the patient about the purpose of stool softeners C.) teach the patient about high fiber foods

Which statements about spinal shock are accurate? select all that apply A.) it lasts for from less than 48 hours up to a few weeks B.) There is temporary loss of motor and sensory function C.) Theere is permanent loss of motor and sensory function D.) There is temporary loss of reflex and autonomic function E.) There is permanent loss of reflex and autonomic function

A.) it lasts for from less than 48 hours up to a few weeks B.) There is temporary loss of motor and sensory function D.) There is temporary loss of reflex and autonomic function

After suffering an SCI, a patient develops autonomic dysfunction, including a neurogenic bladder. What is the priority patient problem for this condition? A.) risk for urinary tract infection B.) risk for dehydration C.) risk for urinary retention D.) risk for urinary incontinence

A.) risk for urinary tract infection

What should the nurse asses for when a client with a cervical injury reports a severe headache and nasal congestion? A.) suprapubic distention 2.) increased penal reflexes 3.) adventitious breath sounds 4.) imminent development of shock

A.) suprapubic distention

A patient had a transrectal ultrasound with biopsy. After this procedure, what does the nurse instruct the patient to do? Select all that apply. A. report fever, chills, bloody urine, and any difficulty voiding B. Avoid strenuous physical activity C. Limit fluid intake for several hours after the procedure D. Expect decreased urine output for 24 hours after procedure E. Expect some mild perineal and abdominal pain

AB

23. The nurse is teaching a group of women about prevention of toxic shock syndrome. What preventative measures does the nurse include? (Select all that apply) a. "Avoid the use of superabsorbent tampons" b. "Use sanitary napkins at night" c. "Avoid using internal contraceptives" d. "Void immediately after intercourse" e. "Change your tampon every 8 hours."

ABC

4. A 22 year old patient reports abdominal pain that seems to start several days before her menstrual period. What questions does the nurse ask in order to obtain a thorough menstrual history? (Select all that apply) a. "How old were you when you started menstruation?" b. "Typically, how long does your period last?" c. "How would you describe your menstrual flow?" d. "When did you last have sexual intercourse?" e. "Would you like information about contraception?"

ABC

10.) The nurse is giving discharge instructions to an adult patient diagnosed with the flu. The patient says, I am generally pretty healthy, but I am concerned because my wife has several serious chronic health problems. What can I do to protect her from getting my flu? What does the nurse instruct the patient to do? Select all that apply a. Wash hands thoroughly after sneezing, cough, or blowing nose b. Avoid kissing, hugging, close face-to-face proximity, or hand-holding c. If there is no tissue immediately available, cough of sneeze into upper sleeve d. Have the wife wear a respiratory filter mask until coughing stops e. Use disposable tissues rather than cloth handkerchiefs, and immediately dispose of tissues

ABCE

8. What types of examinations are done to reveal the presence of uterine enlargement related to fibroids? (Select all that apply) a. Abdominal examination b. Vaginal examination c. Rectal examination d. Excretory urography e. Transvaginal ultrasound with saline infusion

ABCE

The nurse is teaching a patient diagnoses with ED about common treatments and therapies. Which topics does the nurse include? Select all that apply. A. Phosphodiesterace-5 (PDE-5) inhibitors B. Intraurethral applications C. Vacuum devices D. Active surveillance E. Penile implants

ABCE

The patient is diagnosed with acute bacterial prostatitis. What assessment findings does the nurse expect to find? Select all the apply. A. Fever B. Chills C. Dysuria D. Urinary incontinence E. Urethral discharge

ABCE

49.) The pt is receiving isoniazid (INH) to treat TB. Which nursing intervention points are essential when giving this drug? Select all that apply. a. Teach the patient not to take medications such as Maalox with this medication b. Avoid drinking alcoholic beverages c. Teach the patient that urine will be orange in color d. Take a multivitamin with B complex e. If going out in the sun, be sure to wear protective clothing and sunscreen f. Teach women that this drug reduces the effectiveness of oral contraceptives

ABD

27. A patient has had a posterior colporrhaphy. What is included in the nursing care of this patient? (Select all that apply.) a. Administer pain medication before a bowel movement b. Instruct to avoid straining during a bowel movement c. Resume regular activities after discharge from the hospital d. Provide sit baths e. Promote a low-residue (low fiber) diet

ABDE

32.) Which conditions may cause patients to be at risk for aspirations pneumonia? Select all that apply. a. Continuous tube feedings b. Bronchoscopy procedure c. Magnetic resonance imaging (MRI) procedure d. Decreased level of consciousness e. Stroke f. Chest tube

ABDE

33.) An older adult pt often coughs and chokes while eating or trying to take medication. The pt insists that he is okay, but the nurse identifies the priority patient problem of risk for aspiration. Which nursing interventions are used to prevent aspiration pneumonia? Select all that apply. a. Head of the bed should always be elevated during feeding b. Monitor the patient's ability to swallow small bites c. Give thin liquids to drink in small, frequent amounts d. Consult a nutritionist and obtain swallow studies e. Monitor the patient's ability to swallow saliva f. Place the patient on NPO status until swallowing is normal

ABDE

The nurse is preparing a teaching plan for the pt and family on how to care for an automatic epinephrine injector? Which essential points must the nurse include? Select all that apply? a. Keep the device with you at all timed b. You can inject the drug right through you pants c. Whenever you use the device, call your doctor and rest in bed for the next 24 to 48 hours d. Protect the device from light and avoid temperature extremes e. Keep safety cap in place until you are ready to use the device

ABDE

The nurse is teaching a patient about self-care following a radical prostatectomy. What does the nurse include in the health teaching? Select all that apply. A. Teach how to care for the indwelling catheter and manifestations of infection B.Walk short distances C. PSA blood tests are taken 12 weeks after surgery and then once a year D. Maintain an upright position and do not walk bent or flexed E. Shower rather than soak in a bathtub for the first 2 to 3 weeks

ABDE

What does Mr. H need to know about taking finasteride (Proscar)? Select all that apply. A. Liver function studies (LFT's) need to be monitored frequently B. Most clients see significant change in BPH symptoms in 4 months C. Clients should see increases in their libido as symptoms resolve D. Protect the medication from light E. Clients can experience breast enlargement

ABDE

1.) For a pt who is having an anaphylactic reaction, which common symptoms will manifest almost immediately after being exposed to an allergen? Select all that apply. a. Angioedema b. Apprehension c. Chills d. Fever e. Urticarial

ABE

Patients with which condition meet the criteria for having a TURP? Select all that apply. A.) Acute urinary retention B.) Hydronephrosis C.) Acute urninary tract infection D.) Kidney stone E.) Hematuria

ABE

Which additional manifestations would the nurse expect in clients with BPH? Select all that apply. A. Hesitancy when starting the urine stream B. Decrease in the size and force of urine stream C. Sharp pain when starting to void D. Unusual scrotal tenderness with swelling E. Frequent urination, including nocturia

ABE

2.) A pt in anaphylaxis who is going into respiratory failure will demonstrate which symptoms? Select all that apply? a. Laryngeal edema b. Hypoxemia c. Hypocapnia d. Dehydration e. Crackles f. Wheezing

ABEF

35. A nurse is assessing a client who is being admitted for surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? Select all that apply. a. Painful intercourse b. Crampy abdominal pain c. Bearing-down sensations d. Urinary stress incontinence e. Recurrent urinary tract infections

AC

37. A client has an anterior and posterior surgical repair of a cystocele and rectocele and returns form the PACU with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? Select all that apply. a. Discomfort is minimized b. Bladder tone is maintained c. Urinary retention is prevented d. Pressure on the suture line is relieved e. Hourly urine outputs can be easily measured

ACD

49. The nurse is teaching a patient who is being discharged after having a total abdominal hysterectomy. Which conditions does the nurse tell the patient to immediately report to the surgeon? (Select all that apply) a. Vaginal drainage that becomes thicker or foul-smelling b. Hot flashes and night sweats c. Temperature over 100 F d. Burning during urination e. Feeling more tired and sleeping longer

ACD

The nurse is performing an assessment on a patient with organic ED. What are possible causes of this condition? Select all that apply. A. meditations for hypertension B. Obesity C. Thyroid disorders D. Diabetes Mellitus E.Diverticulitis

ACD

15. What signs/symptoms does the nurse assess in a patient with dysfunctional uterine bleeding? (Select all that apply) a. Male hair pattern b. Gastric ulcers c. Thyroid enlargement d. Abdominal pain e. Abdominal masses

ACDE

The nurse teaches a patient with BPH to follow which instructions? Select all that apply. A.) Avoid diuretics B.) Avoid sexual intercourse C.) Avoid antihistamines D.) Avoid caffeine E.) Avoid drinking large amounts of fluid in a short time

ACDE

The nurse is interviewing a patient to determine the presence of lower urinary tract symptoms (LUTS) associated with BPH. Which questions would the nurse ask? Select all that apply. A.) "Do you hace difficultly starting and continuing urination?" B.) "Do you have ever had a kidney infection?" C.) "Have you have reduced force and size of urinary stream?" D.) "Have you noticed postpaid dribbling or leaking?" E.) "How many times do you have to get up during the night to urinate?" F.) "Have you noticed blood at the start of at the end of voiding?"

ACDEF

39.) Which people are at greatest risk for developing TB in the US? Select all that apply a. An alcoholic homeless man who occasionally stays in a shelter b. A college student sharing a room in the dormitory c. A person with immune dysfunction or HIV d. A homemaker who does volunteer work at a homeless shelter e. Foreign immigrants (especially from the Philippines and Mexico)

ACE

40. The surgical procedure for stage I disease of endometrial cancer involves removal of which components? (Select all that apply) a. Uterus b. Vagina c. Fallopian tubes d. Rectum e. Ovaries

ACE

40.) After several weeks of "not feeling well", a pt is seen in the provider's office for possible TB. If TB is present, which assessment findings does the nurse expect to observe? Select all that apply. a. Fatigue b. Weight gain c. Night sweats d. Chest soreness e. Low-grade level

ACE

6.) Which pt are at risk for developing health-care acquired pneumonia Select all that apply a. Confused patient b. Patient with atrial fibrillation who is alert and oriented c. Patient with gram-negative colonization of the mouth d. Patient with hyperthyroidism e. Malnourished patient

ACE

11. Following a uterine embolization using a vascular closure device., what patient care would the nurse provide? (Select all that apply) a. Assist the patient to ambulate 2 hours after the procedure b. Keep the patient on bedrest with the leg immobilized for 4 hours before ambulating c. Encourage the patient to drink a lot of fluids d. Assess the patients pain level and administer analgesics as needed e. Raise the HOB

ADE

14.) A patient is seen in the health care provider's office and is diagnosed with community-acquired pneumonia. What are the most common symptoms that pt will have? Select all that apply? a. Dyspnea b. Abdominal pain c. Back pain d. Hypoxemia e. Chest discomfort

ADE

What are common serum tumor markers that confirm a diagnosis of testicular cancer? Select all that apply. A. Lactate Dehydrogenase (LDH) B. Early prostate cancer antigen (EPCA-2) C. Glutathione S-transferase (GST P1) D. Alpha-fetoprotein (AFP) E. Beta human chorionic gonadotropin (hCG)

ADE

15.) Which diagnostic test are most likely to be done for a pt suspected of having community-acquired pneumonia? Select all that apply. a. Sputum gram stain b. Pulmonary function test c. Fluorescein bronchoscopy d. Peak flowmeter measurement e. Chest x-ray

AE

39. Which diagnostic tests are considered the gold standard tests for determining the presence of endometrial thickening and cancer? (Select all that apply) a. Transvaginal ultrasound b. Abdominal ultrasound c. MRI d. Computed tomography of the pelvis (CT) e. Endometrial biopsy

AE

10. Which woman is at greatest risk for dysfunctional uterine bleeding? a. 20 year old housewife who has one child b. 45 year old attorney with a stressful life c. 30 year old nurse who smoked for 10 years d. a 25 year old teacher who rarely exercises

B

12.) Which pt is at highest risk for developing pneumonia? a. Any hospitalized pt between the ages of 18-65 years old b. 32-yeard-old patient on a mechanical ventilator c. disabled 54-years-old with osteoporosis; discharged to home d. any patient who had not received the vaccine for pneumonia

B

13. A 36 year old patient is diagnosed with dysfunctional uterine bleeding. During the pelvic exam, the health care provider determines that the bleeding is acute and heavy. What is the nurses priority action? a. Prepare the patient for immediate transport to the operating room b. Prepare to administer combination hormonal therapy c. Anticipate an order for a hormonal contraceptive patch d. Prepare to administer injectable medroxy-progesterone acetate (Depo-Provera)

B

13. You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the nursing diagnosis of Activity Intolerance. Which action should you delegate to the UAP? a. Instructing the patient to alternate rest and cavity periods. b. Encouraging, monitoring, and recording nutritional intake. c. Monitoring cardiorespiratory response to activity d. Planning activities for periods when the patient has the most energy.

B

13.) Which statement best described pneumonia? a. An infection of just the "windpipe" because the lungs are "clear" of any problems b. A serious inflammation of the bronchioles from various causes c. Only an infection of the lungs with mild to severe effects on breathing d. An inflammation resulting from lung damage by long-term smoking

B

14. A patient who is very upset asks the nurse, "My doctor says I have endometriosis. What does it mean?" What is the nurses best response? a. "It is an early warning sign of endometrial cancer, but you still need more testing." b. "A special type of tissue, called endometrial tissue, is outside of your uterus." c. "Its a special tissue which grows rapidly, but it is not dangerous." d. "It is a type of infection and inflammation of the endometrial tissue."

B

15. The nurse is teaching incisional care to a patient who has been discharged after abdominal surgery. Which priority instruction must the nurse include? a. Do not rub or touch the incision site b. Practice proper hand washing c. Clean the incision site two times a day with soap and water d. Splint the incisional site as often as needed for comfort

B

15. Which nursing interventions will prevent the potential intraoperative complication of radial joint stiffness, pain, and inflammation? a. Support the wrist with padding; do not over tighten wrist straps. b. Place pillow or foam padding under bony prominences; maintain good body alignment; slightly flex joints and support with pillows, trochanter rolls, and pads. c. Pad the elbow, avoid excessive abduction, secure the arm firmly on an arm board positioned at shoulder level. d. Place a safety strap above or below the area. Place a pillow or padding under the knees.

B

15. While assessing Ms. Jackson, the nurse observes that the surgical dressing is in place on the left hip, with no visible drainage. How should the nurse document this finding? A) No problems with dressing on left hip. B) Left hip dressing clean, dry, and intact. C) Dressing present over hip incision. D) Incision well-approximated with no drainage.

B

16. What is the primary treatment for dysfunctional uterine bleeding in perimenopausal women? a. Intravaginal estrogen therapy b. Progestin or combination hormone therapy c. Laparoscopic myomectomy d. Magnetic resonance-guided focused ultrasound

B

167. A nurse in the post anesthesia care unit (PACU) observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action? a. Change the dressing b. Reinforce the dressing c. Replace the tape with Montgomery ties d. Support the incision with an abdominal binder

B

168. Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? a. Decreased blood supply b. Impaired neural functioning c. Perforation of the bowel wall d. Obstruction of the bowel lumen

B

18. A patient has undergone a total hysterectomy with vaginal repair. The nurse advises about careful intercourse and which over the counter product to decrease sexual discomfort related to intercourse? a. Hydrocortisone cream b. Water-based lubricants c. Petroleum jelly d. Vit A & D ointment

B

189. A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain? a. Encourage rest b. Obtain the vital signs c. Administer the prn analgesic d. Document the client's pain response

B

19. Since Raymond now has thrush, in addition to fatigue and anorexia, which food best contributes to improving Raymond's nutrition? A. Broiled steak B. milk shake C. tomato soup D. lettuce salad with raw vegetables

B

19. The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing? a. Remove the dressing and puts on a dry, sterile dressing b. Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing c. Applies dry, sterile dressing material directly to the wound, then retapes the original dressing d. Does nothing to the dressing but calls the surgeon to evaluate the patient immediately

B

2. Raymond's significant other arrives. Raymond wants to know why a mask is necessary for people entering his room. What teaching should the nurse implement? A. explain use of private room and mobile high-efficiency particle filters placed in the room B. explain that the TB organism is most often spread through the air C. tell Raymond that TB will not spread to others and everything will be okay if the mask is worn D. tell Raymond that masks are required for those persons who do not agree to be vaccinated with BCG vaccine.

B

2. What is the primary purpose of a PACU? a. Follow-through on the surgeons postoperative orders b. Ongoing critical evaluation and stabilization of the patient c. Prevention of lengthened hospital stay d. Arousal of patient following the use of conscious sedation

B

20. When assessing a client with cervical cancer who had a total abdominal hysterectomy yesterday, you obtain the following data. Which information has the most immediate implications for planning of the client's care? a. Fine crackles are audible at the lung bases b. The client's right calf is swollen, and she reports calf tenderness c. The client uses the patient-controlled analgesia pump every 30 minutes d. Urine in the collection bag is amber and clear

B

21. The nurse observes that the Hemovac drain is full of sanguineous drainage. What action should the nurse implement first? a. Compress the drain and re-establish suction. b. Empty the drain and measure the amount of drainage. c. Page the surgeon to report the finding. d. Document the appearance of the drainage

B

22. A patient is requesting moderate sedation for repair of a torn meniscus and has no medical contraindications. How does the nurse respond to this patient's request? a. "Your surgeon will decide if you will receive moderate sedation or general anesthesia." b. "You can discuss your request for moderate sedation with your surgeon and anesthesiologist." c. Most patients prefer general anesthesia. Can you tell me why you want moderate sedation?" d. "It can be frightening to see surgery done on yourself. You need to think about that."

B

22. The nurse notifies the surgeon of the wound drainage. What lab data is important for the nurse to report to the surgeon? a. White blood cell count. b. Hemoglobin and hematocrit. c. Culture and sensitivity. d. Type and cross match.

B

23. An 86 year old woman had an anterior and posterior colporrhaphy (A & P repair) several days ago. Her retention catheter was removed 8 hours ago. Which assessment finding requires that you act most rapidly? a. The oral temperature is 100.7 F (38.2 C) b. The abdomen is firm and tender to palpation above the symphysis pubis. c. Breath sounds are decreased, with fine crackles audible at both bases d. The apical pulse is 86 beats/min and slightly irregular

B

23. Based on the lab data provided by the nurse, the healthcare provider prescribes the transfusion of two units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells is ready, the nurse obtains the blood from the blood bank. When the nurse enters Ms. Jackson's room to begin the transfusion, the UAP is giving Ms. Jackson a partial bath. What action should the nurse take? a. Place the unit of blood in the medication refrigerator until the client's personal care is completed. b. Hang the transfusion of packed cells while the UAP continues to complete the client's personal care. c. Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care. d. Return the blood to blood bank and send the UAP to obtain the blood when the personal care is completed.

B

24. A patient is admitted with toxic shock syndrome. What organism is frequently associated with this syndrome when it occurs as a menstrually related infection? a. E. coli b. Staphylococcus aureus c. Haemophilus influenzae d. Beta-hemolytic streptococcus

B

25. The 2 units of packed RBCs are transfused without complication. The drainage begins to decrease, and Ms. Jackson's hemoglobin and hematocrit remain stable. The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis? a. Disturbed body image. b. Situational low self-esteem. c. Anticipatory grieving. d. Impaired physical mobility.

B

26. A patient had an anterior colporrhaphy and is returning to the clinic for the follow up appointment. Which patient statement indicates that the procedure has achieved the desired therapeutic outcome? a. "The abdominal pain is almost gone." b. "I have good control over my urination." c. "I am no longer having that constipated feeling." d. "My vaginal bleeding has resolved."

B

26. Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. You find that the wound edges are open and loops of intestine are protruding. Which action should you take first? a. Notify the surgeon that wound evisceration has occurred b. Cover the wound with saline-soaked dressings c. Use swabs to obtain aerobic and anaerobic wound cultures d. Call for assistance from the Rapid Response Team

B

26.) The nurse has identified the priority patient problem of ineffective airway clearance with bronchospasms for a patient with pneumonia. The pt has no previous history of chronic respiratory disorders. The nurse obtains an order for which nursing intervention? a. Increased liters of humidified oxygen via facemask b. Scheduled and prn aerosol nebulizer bronchodilator treatments c. Handheld bronchodilator inhaler as needed d. Corticosteroid via inhaler or IV to reduce inflammation

B

28. The nurse is giving discharge teaching to a patient who had a transvaginal repair for pelvic organ prolapse using a surgical mesh. What does the nurse include? a. Avoid cigarette smoking for at least one month b. Abstain from sexual intercourse for 6 weeks c. Reduce calories to lose 2 pounds a month d. Avoid tub baths to prevent soaking the mesh

B

29. A patient is diagnosed with uterine leiomyomas. What does the nurse expect to see in the documentation for this patient as the chief presenting problem? a. Foul-smelling vaginal discharge b. Heavy vaginal bleeding c. Intermittent abdominal pain d. Urinary incontinence

B

3. A patient tells the nurse that she was told that she had a "chocolate" cyst. Which assessment is the nurse likely to perform? a. Ask for description of the vaginal discharge b. Assess onset and description of pain c. Assess for family history of cervical cancer d. Ask about personal or family history of renal disease

B

3. The UAP asks why Raymond could not be in an empty semiprivate room closer to the nurse's station so the staff would not have to walk so far to provide care. What information should the nurse provide to the UAP on infection control practices? A. The client needs to be at the end of the hall because he requires privacy B. The implementation of airborne precautions for possibly TB requires a private, negative pressure room assignment C. A private room is required to implement contact precautions for possible TB D. The client needs to be at the end of the hall for confidentiality

B

30. A client who has a diagnosis of endometriosis is concerned about the side effect of hot flashes from her prescribed medication. She tells the nurse that her mother found them very uncomfortable during her menopause. Which medication causes this side effect? a. Estrogen (Premarin) b. Leuprolide (Lupron) c. Diclofenac (Voltaren) d. Ergonovine (Ergotrate)

B

30. A patient with uterine leiomyomas reports feeling of pelvic pressure, constipation, and urinary retention. She says, "I can't button my pants anymore." What doe the nurse assess for to further evaluate the patients symptoms? a. Check the lower extremities for fluid retention. b. Assess the abdomen for distention or enlargement c. Measure the fluid intake and urine output d. Inspect the perineal area for bleeding or discharge

B

30.) A pt has been treated for pneumonia and the nurse is preparing discharge instructions. The pt is capable of performing self-care and is anxious to return to his job at the construction site. Which instructions does the nurse give to this patient? a. You are not contagious to others, so you can return to work as soon as you like b. You will continue to feel tired and will fatigue easily for the next several weeks c. Try and drink 4 quarts of water per day especially if you are very physically active d. You should be able to return to work full-time in 2 weeks when your energy returns

B

32. A 15 year-old adolescent tells a school nurse "I have persistent pain during my periods" What should the nurse encourage her to do? a. Continue daily activities b. Have a gynecologic examination c. Eat a nutritious diet containing iron d. Practice relaxation of abdominal muscles

B

34. A patient with cancer has also been diagnosed with uterine leiomyomas. Which procedure does the nurse prepare the patient for? a. Myomectomy b. Hysterectomy c. Endometrial ablation d. Magnetic resonance-guided focused ultra sound surgery

B

34.) Which condition causes a pt to have the greatest risk for community-acquired pneumonia? a. Tube feedings b. History of tobacco use c. Poor nutritional status d. Altered mental status

B

43. A patient receiving chemo treatments reports fatigue, loss of energy, and experiencing an "emotional crisis every day and my hair is falling out" What does the nurse do first to help the patient adapt to body changes? a. Suggest participation in self-management b. Encourage the patient to ventilate feelings c. Help the patient to select a wig or a scarf d. Encourage the patient to talk to her family

B

44. The nurse encourages a teenage patient to receive the human papillomavirus (HPV) vaccine (Gardasil) because it protects against which type of cancer? a. Endometrial cancer b. Cervical cancer c. Ovarian cancer d. Uterine cancer

B

45. What information would the nurse give to sexually active 22 year old woman about conventional Papanicolaou (Pap) smear testing? a. Every 2 to 3 years is sufficient b. Annual screening is recommended c. Testing can stop after three consecutive normal Pap smears d. If there are no risk factors, testing is not necessary

B

46.) A pt has an HIV infection, but the TB skin test shows an induration of less than 10 mm and no clinical symptoms of TB are present. Which medication does the patient receive for a period of 12 months to prevent TB? a. Bacille Calmette- Guerin (BCG) vaccine b. Isoniazid (INH) c. Ethambutol d. Streptomycin

B

48.) A pt diagnosed with TB has been receiving treatment for 3 weeks and had clinically shown improvement. The family asks the nurse if the pt is still infectious. What is the nurse's reply? a. The patient is still infectious until the entire treatment is completed b. The patient is not infectious but needs to continue treatment for at least 6 months c. The patient is infectious until there is a negative chest x-ray d. The patient may or may not be infectious; a purified protein derivative test (PPD) must be done

B

50.) A pt with suspected TB is admitted to the hospital. Along with private room, which nursing intervention is appropriate related to isolation procedures? a. Respiratory isolation and contact isolation for sputum only b. Strict respiratory isolation and use specifically designed facemasks c. Respiratory isolation with surgical masks until diagnoses is confirmed d. No respiratory isolation necessary until diagnosis is confirmed

B

54.) The nurse is making home visits to an older adult recovering from a hip fracture and identifies the priority patient problem of risk of respiratory infection. Which condition represents a factor of normal aging that would contribute to this increased risk? a. Inability to force a cough b. Decreased strength of respiratory muscles c. Increased elastic recoil of alveoli d. Increased macrophages in alveoli

B

55. Young women who have intercourse as teenagers and/or have multiple sex partners are at high risk for which disease? a. Endometriosis b. Cervical cancer c. Amenorrhea d. Ovarian cancer

B

6. Raymond is scheduled for several activities the following morning. What activity should Raymond perform first upon wakening? A. Eat nutritionally dense, early morning snack sent from food services department B. Obtain the first of three sputum specimens for laboratory testing C. Take a shower and get ready to go to radiology for a chest X-ray. D. Weigh to determine if weight loss from the disease is continuing

B

7. In the PACU, the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurse's best fist action? a. Notify the surgeon b. Apply pressure to the wound dressing c. Instruct the UAP to get additional dressing supplies d. Request and draw a complete blood count

B

7. The nurse is teaching self-care management to a 39 year old woman who had an abdominal hysterectomy Which point would be emphasized to avoid complications of this surgery? a. Bathe and douche daily to prevent infection b. Take temperature twice a day for the first 3 days after surgery c. Resume typical exercise routines as soon as possible d. Gently massage calves if tenderness or swelling occurs

B

8. Which nursing interventions are appropriate during stage 2 of anesthesia? a. Prepare for and assist in treatment of cardiovascular and/or pulmonary arrest. Document in record b. Shield patient from extra noise and physical stimuli. Protect the patient's extremities. Assist anesthesia personnel as needed. Stay with the patient. c. Close operating room doors and control traffic in and out of room. Position patient securely with safety belts. Maintain minimum discussion in operating room. d. Assist anesthesia personnel with intubation of patient. Place the patient in position for surgery. Prep the patient's skin in area of operative site.

B

9. The acute, life-threatening complication of MH results from use of which agents? a. Hypnotics and neuromuscular blocking agents b. Succinylcholine and inhalation agents c. Nitrous oxide and pancuronium for muscle relaxation d. Fentanyl and regional anesthesia for spinal block

B

A client who had a suprapubic prostatectomy returns from the PACU and accidentally pulls out the urethral catheter. What should the nurse do first? A. Reinsert a new catheter B. Notify the health care provide C. Check for bleeding by irrigating the suprapubic tube D. Take no immediate action if the suprapubic tube is draining

B

A nurse is caring for a client with continuous bladder irrigation. Which is the most important nursing action? A. Monitor urinary specific gravity to determine hydration B. Subtracting irritant for output to determine urine volume C. Record urinary output every hour to determine kidney function D. Obtain a twenty-four hour urine specimen to determine urine concentration

B

A patient has undergone external beam radiation therapy (EBRT) for palliative treatment of prostate cancer. What suggestions does the nurse make to help the patient manage acute radiation cystitis secondary to EBRT? A. Limit intake of water and other fluids B. Avoid consumption of caffeinated drinks C. Increase consumption of dairy products D. Wash genitals with mild soap and water

B

A patient reports having ED and is seeking a prescription for Sildenafil (Viagra). Because of the potential for dangerous drug-drug interactions, the nurse asks the patent specifically if he takes which type of drug? A. NSAIDs B. Nitrates C. Opioids D. Antilipemics

B

A patient tells the nurse that he was diagnosed with benign prostatic hyperplasia (BPH). Based on this medical diagnosis, which symptom is the patient most likely to report? A.) Pain in the scrotum B.) Trouble passing urine C.) Erectile Dysfucntion (ED) D.) Constipation

B

After 3 days, nurse receives results from Raymond's TB skin test that was administered at his HCP's office. Even though Raymond's reaction to the TB test measures only 5mm in diameter, the HCP documents a positive test result. A new graduate nurse finds this confusing. New grad thought that a 10mm induration was the minimum size for a positive reading and asks the nurse preceptor for clarification. How should the nurse preceptor respond? A. "This confuses me too. I think we need to consult with the HCP" B. "That is not always true. A 5mm induration is considered positive for TB in a person with HIV" C. "It may be that you are confusing induration with inflammation in skin testing results" D. "Let's ask the nurse practitioner who specializes in caring for clients who are HIV positive"

B

How can the nurse best interpret Mrs. H's minimal eye contact in light of Mrs. H's cultural background? A. A cultural practice reflecting unease in the healthcare environment B. A cultural practiced based on recognition of someone's social status C. A nonverbal sign of lack of respect for the other person D. A nonverbal cue that the person is not being completely truthful

B

Jess has no other GI s/s at the present time. She does report that her body is stiff and aching when she rises in the morning for which she takes a non-steroidal med to help relieve the pain. What is the nurses best response to this info? a. that may indicate that the colitis has spread throughout the GI tract b. Ulcerative colitis can cause problems in areas other than the colon c. it is probably related to the stress you are experiencing not the colitis d. that has no bearing on your current problems related to the colitis

B

The nurse is caring for a patient who had an open radical prostatectomy. During the assessment, the nurse notes that the penis and scrotum are swollen. What does the nurse do next? A. Notify the health care provider and monitor for an inability to void or increasing pain B. Elevate the scrotum and penis; intermittently apply ice to the area for 24-48 hours C. Assist the patient to increase mobility, especially early ambulation D. Observe the urethral meatus for redness and discharge and monitor urine output

B

The nurse is designing a teaching plan for a patient with an enlarged prostate and obstructive symptoms. What does the nurse teach the patient to avoid? A.) Sexual intercourse B.) Diuretics C.) Straining to urinate D.) masturbation

B

The nurse is giving instructions to the unlicensed assistive personnel (AUP) about hygienic care for an older adult patient who is uncircumcised. What does the nurse instruct the UAP to do? A. Defer cleaning the penis because of patient embarrassment B. Replace the foreskin over the penis after bathing C. Observe the penis and foreskin for redness or odor D. Avoid touching the foreskin because of hypersensitivity

B

The nurse is reviewing the laboratory results from a patient being evaluated for LUTS. What does the elected prostate-specific antigen (PSA) level and serum acid phosphatase level in this patient indicate? A.) Infection B.) Prostate cancer C.) BPH D.) Infertility

B

The nurse is talking to a 35-year old African-American man about PSA testing. The patient tells the nurse that his father and older brother were diagnosed with prostate cancer in their 50's. What should the nurse tell the patient? A. Although authorities do not always agree, PSA testing usually starts at age 50 B. Your genetic and racial risk factors suggest testing should begin at age 40 C. Because your African-American heritage, you should start your testing at age 45 D. PSA testing can be started at anytime for all males at any age

B

The nurse is teaching a patient at risk for prostate cancer about food sources of omega-3 fatty acids. Which foods does the nurse suggest? A. red meat B. Fish C. Watermelon D. Oatmeal

B

The nurse notes that the patient has just started taking an alpha blocker medication to treat BPH. What instruction, related to the medication side effects, will the nurse give to the UAP who will assist the patient with activities of daily living (ADLs)? A. Frequently offer the patient the urinal B. Have him sit up slowly and pause before standing C. Remind the patient to drink plenty of extra fluids D. Frequently check the linens for soiling and moisture

B

The patient had several diagnostic test to evaluate reports of LUTS. Which findings suggests that the patient may have kidney disease? A. Elevated white blood cell count B. Elevated serum creatinine C. Elevated red blood cell count D. Elevated prostate-specific antigen

B

What action should the nurse take next after stopping the transfusion? A. Administer a dose of prescribed PRN antipyretic medication B. Infuse normal saline solution through separate IV tubing C. Obtain a urinalysis and send it to the lab with blood bag and tubing D. Reassess Mr. H's vital sings anf oxygen saturation level

B

What assessment data would indicate the onset of thrombotic complication? A. Frothy pink sputum B. Chest pain and dyspnea C. Wheezing and stridor D. Sudden high fever

B

What is most important for the nurse to do when providing care to a client who has had a transurethral resection of the prostate? A. Maintain patience off the cystostomy tube B. Ensure latency of the indwelling catheter C. Keep the abdominal dressing clean and dry D. Observe the wound for hemorrhage and infection

B

What statement best described this term? A. An act performed by a nurse that results in harm to a client B. A nurse's actions do no meet established standards C. A nurse's actions that requires adverse occurrence documentation D. A client reports that a nurse's care was unsatisfactory

B

Which instruction should the nurse provide Mr. H before starting the procedure? A. You will receive medications for sedation prior to the procedure B. Empty your bladder completely C. Drink at least 16 ounces of water 2 hours before the procedure D. Remain NPO following the procedure

B

Which sign or symptom is associated with advanced prostate cancer? A. Difficulty starting urination B. Swollen groin lymph nodes C. Frequent bladder infections D. ED

B

Which statement about dietary concepts for a patient with diabetes is true? a. Alcoholic beverage consumption is unrestricted b. Carbohydrate counting is emphasized when adjusting dietary intake of nutrients c. sweeteners should be avoided because of the side effects d. both soluble and insoluble fiber foods should be limited

B

While cleansing the incision, the nurse observes that the staples are intact, but a 2 cm gap has opened at the bottom of the incision. How should the nurse document this finding? a. Bottom edges of incision approximated. b. Small area of dehiscence at bottom of incision. c. Evisceration of incision noted at bottom edge. d. Wound healing via secondary intention.

B

While the nurse I monitoring Mr. H closely, which additional responsibility is best to assign to the LPN? A. Initiate a blood transfusion for a post-abdominal hysterectomy client B. Prepare a client with renal failure for a scheduled dialysis treatment C. Complete the admission assessment for a client with renal calculi D. Teach a client with cancer how to administer bolus tube feedings

B

You are caring for a 21-year-old client who had a left orchiectomy for testicular cancer on the previous day. Which nursing activity will you delegate to an LPN/LVN? A. educating the client about post-orchiectomy chemotherapy and radiation B. Administering the prescribed "as needed" (PRN) oxycodone (Roxicodone) to the client C. Teaching the client how to perform testicular self-examination on the remaining testicle D. Assessing the client's knowledge level about post-orchiectomy fertility

B

You are caring for a client who have just returned to the surgical unit after a TURP. Which assessment finding will require the most immediate action? A. Blood pressure reading of 153/88 mmHg B. Catheter that is draining deep red blood C. Client not wearing anti embolism hose D. Client reports of abdominal cramping

B

Because rectal bleeding is a common finding in ulcerative colitis, which additional question is important for the nurse to ask jess? a. do you ever hear ringing in your ears? b. do you feel fatigued or light headed? c. do you experience tremors or headaches? d. do you have trouble remembering recent events?

B (A would mean aspirin toxicity)

A 79-yerar-old whop has just returned to the surgical unit following s TURP reports acute bladder spasms. In which order will you perform the following prescribed actions? A. Administer acetaminophen/oxycodone 325 mg/5 mg (Percocet) 2 tabs B. irrigate the retention catheter with 30 to 50 mL of sterile normal salne C. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours D. Offer the client oral fluids to at least 2500 to 3000 mL daily.

B, A, C, D

3. A patient with breast cancer is scheduled for a left mastectomy. The patient has informed the surgeon and nurse that she is a jehovah witness and does not want any blood transfusions. in preparation for intraoperative care of this patient, what measures does the nurse take? (Select all that apply) a. obtain 2 units of packed red blood cells typed and crossmatched b. make provider aware of patients request for no blood transfusion c. ensure auto transfusion decide is in place intraoperatively d. ensure patient has medical necessity order for emergency blood transfusion e. inform the patient of potential risks if blood transfusion is not given

B,C

11. A 49-year-old patient is in the PACU following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses that the patients eyes open on verbal stimulation. Pupils are equal, reactive to light, and diameter is 3 mm. The patients hand grasps are equal and strong. When the nurse asks the patient to state name, the patient states name correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished per auscultation and the nurse observes the patient is using abdominal accessory muscles to breathe. Which body systems has the nurse assessed? (Select all that apply) a. Cardiovascular b. Gastrointestinal c. Neurologic d. Integumentary e. Respiratory

B,C,D,E

16. In which situations is regional anesthesia used instead of general anesthesia? (Select all that apply.) a. For an endoscopy or cardiac catheterization. b. In patients who have had an adverse reaction to general anesthesia c. In some cases when pain management after surgery is enhanced by regional anesthesia d. In patients with serious medical problems e. When the patient has a preference and a choice is possible

B,C,D,E

12. Which factors may lead to an anesthetic overdose in a patient? (select all that apply.) a. Amount of anesthesia retained by fat cells b. Patient who is older c. Slowed metabolism and drug elimination d. An uncooperative patient e. Liver or kidney disease

B,C,E

22. The nurse on the medical-surgical unit is caring for a postoperative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty? (Select all that apply) a. The patients oxygen saturation drops from 98% to 94% b. The patient is using accessory muscles to breathe c. The patient makes a high-pitched crowing sound when breathing d. The patient's blood pressure drops from 120/80 to 110/78 mm Hg. e. The patient's respiratory rate is 26/min

B,C,E

6. A patient who is 2 days postoperative for abdominal surgery states, "I coughed and heard something pop." The nurse's immediate assessment reveals an open incision with a portion of large intestine protruding. Which statements apply to this clinical situation? (Select all that apply). a. Incision dehiscence has occurred b. This is an emergency situation c. The wound must be kept moist with normal saline-soaked sterile dressings d. This is an urgent situation e. Incision evisceration has occurred

B,C,E

23. When assessing the older postoperative patient for hydration status, where must the nurse assess for tenting of the skin? (Select all that apply) a. On the back of the hand b. On the forehead c. On the forearm d. On the sternum e. On the abdomen

B,D

12. The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? (Select all that apply) a. Open eyes on command b. Absent dorsalis pedis pulse left foot c. Foley catheter in place with clear yellow drainage d. Monitor shows normal sinus rhythm e. States name correctly when asked f. Apical pulse 85 beats/minute

B,D,F

17. You are caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." Upon examination you note wound evisceration. Place in order the steps for handling this complication. a. Cover the intestine with sterile moistened gauze. b. Stay calm and stay with the client. c. Check the vital signs, especially blood pressure and pulse d. Have a colleague gather sterile supplies and contact the physician e. Put the client into Semi-Fowler position through knees slightly flexed f. Prepare the client for surgery as ordered.

B,E,C,D,A,F

When preparing an individualized teaching plan for a client with rheumatoid arthritis, which topic should the nurse omit from the generalized teaching plan for clients with arthritis? a. ulnar drift b. Heberden nodes c. Swan neck deformity d Boutonniere deformity

B. Heberden nodes

The nurse is taking a history on an older adult patient who reports chronic back pain. The nurse seeks to identify factors that are contributing to the pain. Which question is the most useful in eliciting information? A.) "Have you had any recent falls or have you been in an accident?" B.) "Do you have a history of osteoarthritis?" C.) "Do you have a history of diabetes mellitus?" D.) "Are you having pain that radiates down your leg or into the buttocks?"

B.) "Do you have a history of osteoarthritis?"

The nurse is preparing to physically assess a patient's subjective report of paresthesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the nurse use? A.) Use a doppler to locate the pedal pulse, the dorsals pedis pulse or the popliteal pulse. B.) Ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball C.) Use a reflex hammer to test for deep tendon patellar or achilles reflexes D.) Ask the patient to walk across the room and observe his gait and equilibrium

B.) Ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball

Which symptoms indicate that patient with a spinal cord injury is experiencing autonomic dysreflexia? select all that apply A.) Flaccid paralysis B.) Hypertension C.) Hypotension D.) severe headache E.) Blurred vision F.) Loss of reflexes below the injury

B.) Hypertension D.) severe headache E.) Blurred vision

The patient with chronic back pain is receiving ziconotide (Prialt) by intrathecal (spinal) infusion with a surgically implanted pump. The patient develops hallucinations. What is the nurse's best first action? A.) Request a psychiatric evaluation B.) Notify the health care provider C.) Perform an assessment of level of consciousness D.) Decrease the dose of the medication

B.) Notify the health care provider

Assessment of a patient with a lower spinal cord injury conforms that the patient has paralysis of the bilateral lower extremities. How does the nurse document this finding? A.) Paraparesis B.) Paraplegia C.) Quadriparesis D. Quadriplegia

B.) Paraplegia

The nurse is assessing a patient who presented to the emergency department (ED) reporting acute onset of numbness and tingling in the right leg. How does the nurse document this subjective finding? A.) Paraparesis B.) Paresthesia C.) Ataxia D.) Quadriparesis

B.) Paresthesia

The nurse is assessing a patient with spinal cord injury and recognizes the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? A.) Check for bladder distention B.) Raise the head of the bed C.) administer an antihypertensive medication D.) Notify the primary health care provider

B.) Raise the head of the bed

A patient has a long history of chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending a surgical procedure for spine stabilization. Which procedure does the nurse anticipate this patient will need? A.) Laparoscopic diskectomy B.) Spinal fusion C.) Laminectomy D.) Traditional diskectomy

B.) Spinal fusion

A patient involved in a high-speed motor vehicle accident with sustained multiple injuries and active bleeding is transported to the emergency department by ambulance with immobilization devices in place. There is a high probability of cervical spine and extremities are flaccid. What is the priority assessment for this patient? A.) Check the mental status using the glasgow coma scale B.) assess the respiratory pattern and ensure a patent airway C.) Observe for intraabdominal bleeding and hemorrhage D.) Assess for loss of motor functioning sensation

B.) assess the respiratory pattern and ensure a patent airway

The nurse is caring for several patients with SCI's. Which task is best to delegate to the UAP? A.) encourage use of incentive spirometry; evaluate the patient's ability to use is correctly B.) log-roll the patient; maintain proper body alignment and place a bedpan for tolieting C.) check for skin breakdown under the immobilization device during bathing D.) Insert a foley catheter and report the amount and color of the urine

B.) log-roll the patient; maintain proper body alignment and place a bedpan for tolieting

The nurse is caring for a patient with a recent spinal cord injury (SCI). Which intervention does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? select all that apply A.) frequently perform passive ROM exercises B.) loosen or remove any tight clothing C.) Monitor stool output and maintain a bowel program D.) keep the patient immobilized with neck or back brace E.) monitor urinary output and check for bladder distention

B.) loosen or remove any tight clothing C.) Monitor stool output and maintain a bowel program E.) monitor urinary output and check for bladder distention

The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? select all that apply A.) going out in the cold B.) swimming or contact sports C.) sexual activity D.) bathing in the bathtub E.) driving

B.) swimming or contact sports E.) driving

The nurse is preparing a quadriplegic patient for discharge and has taught the patient's spouse to assist the patient with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught? A.) the spouse assists the patient to the side of the bed to encourage deep breaths B.) the spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales C.) The spouse places her hands above the patient's diaphragm and pushes upward as the patient inhales D.) The spouse places the patient in an upright sitting position to encourage deep breaths

B.) the spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales

The nurse and the nursing student are working together to bathe and reposition a patient who is in a halo fixator device. Which action by the nursing student causes the supervising nurse to intervene? A.) uses the log-roll technique to clean the patient's back and buttocks B.) turns the patient by pulling on the top of the halo device C.) position the patient with the head and neck in alignment D.) supports the head and neck area during the repositioning

B.) turns the patient by pulling on the top of the halo device

38.) Which statements about the precautions of caring for a hospitalized patient with TB are true? Select all that apply. a. Health care workers must wear a mask that covers the face and mouth b. Negative airflow rooms are required for these patients c. Health care workers must wear an N95 or high efficiency particulate air (HEPA) mask d. Gown and gloves are included in appropriate barrier protection e. Strict contact precautions must be maintained

BCD

8.) A patient with COPD needs instruction in measures to prevent pneumonia. What information does the nurse include? Select all that apply a. Avoid going outside b. Clean all respiratory equipment you have at home c. Avoid indoor pollutants such as dust and aerosols d. Get plenty of rest and sleep daily e. Limit alcoholic beverages to 4-5 per week

BCD

36.) The nurse is preparing a community information pack about "bird flu". What information does the nurse include for public dissemination? Select all that apply. a. In the event of an outbreak, do not eat any cooked or uncooked poultry products b. Prepare a minimum of 2 weeks supply of food, water, and routine prescription drugs c. Listen to public health announcements and early warning signs for disease outbreaks d. Avoid traveling to areas where there has been a suspected outbreak of disease e. Obtain a supply of antivirals drugs such as oseltamivir (Tamiflu) f. In the event of an outbreak, avoid going to public areas such as churched and schools

BCDF

35. A patient who had a total abdominal hysterectomy is anxious to resume her activities because she has young children at home. What post procedure information does the nurse provide to the patient? (Select all that apply) a. Climb stairs to build strength and endurance b. Avoid sitting for prolonged periods c. Do not lift anything heavier than 5 to 10 lbs d. Walk or jog at least 1-2 miles every day e. When sitting, do not cross legs

BCE

53. The nurse is giving instructions to a patient who is undergoing brachytherapy for cervical cancer. What information does the nurse include? (Select all that apply) a. "Limit interactions with others between treatments for their protection." b. "You are not radioactive between treatments." c. "Report any blood in the urine or severe diarrhea immediately." d. "Expect heavy vaginal bleeding during this time." e. "You will be on bedrest during the treatment session."

BCE

53.) Pt who are at high risk for TB would be asked which questions upon assessment? Select all that apply. a. What does your diet normally consist of? b. Do you have an immune dysfunction or HIV c. Do you use alcohol or inject recreational drugs? d. Do you live in the United States? e. Do you work in a crowded area such as a prison or mental health facility?

BCE

The nurse is providing discharge teaching to a patient about self-monitoring of blood glucose (SMBG). What information does the nurse include? Select all that apply. a. Only perform SMBG before breakfast b. Wash hands before using the meter c. Do a retest if the result seem unusual. d. It is okay to reuse lancets in the home setting e. Do not share the meter

BCE

The nurse is teaching a patient who is taking finesteride (Proscar), an 5-alpha reductase inhibitor (5-ARI). What medication side effects does the nurse include in the teaching? Select all the apps. A. Urinary incontinence B. ED C. Dizziness D. Headaches E. Decreased libido

BCE

What are common sites of metastasis for prostate cancer? Select all that apply. A. Pancreas B. Bone of the pelvis C. Liver D. Bones of the lower extremities E. Lungs

BCE

1. Nurse admits Raymond to private room. Nurse puts on mask before admission process. Raymond tells the nurse that his significant other is downstairs and he would like for him to stay in the room with him. How should the nurse respond? A. "your HCP wants you to get some rest" B. "he may stay, but only after we have the results of his tuberculin skin test" C. "He may stay, but he needs to wear a mask" D. "you dont want to risk infecting your significant other with TB, do you?"

C

10. The postoperative care of a morbidly obese client is being planned. Which task best utilizes the expertise of the LPN/LVN? a. Obtaining an oversized blood pressure cuff and a large-size bed b. Setting up a reinforced trapeze bar. c. Assisting in the planning of toileting, turning, and ambulation d. Assigning tasks to UAPs and other ancillary staff

C

11.) The pt developed flu symptoms less than 24 hours ago. Which drug therapy does the nurse expect the health care provider to order at this time? a. Penicillin therapy b. Amantadine (Symmetrel) c. Oseltamivir (Tamiflu) d. IV steroid therapy

C

12. Ms. Jackson is transferred to a stretcher and taken to the operating room. The nurse assists Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions jackson for surgery.Which nursing diagnosis has the highest priority at this time? a. ineffective protection b. ineffective tissue perfusion c. risk for perioperative-positioning injury d. risk for imbalanced body temperature

C

13. Once the OR team has assembled in the room, the circulating nurse calls for a time out. What action should the nurse take during the time out? a. ensure that sufficient surgical supplies are available b. check that all surgical personnel are properly attired c. review the scheduled procedure, site, and client. d. confirm that informed consent has been obtained

C

165. What is the priority nursing intervention for a client during the immediate postoperative period? a. Monitoring vital signs b. Observing for hemorrhage c. Maintaining a patent airway d. Recording the intake and output

C

17. What instruction should the nurse give Raymond about the use of liquid nystatin (Nyamyc)? A. place all of the suspension in the mouth, then swish and swallow immediately B. sip the suspension over 5 minutes, swishing and swallowing after each sip C. place the suspension in the mouth, then swish for several minutes before swallowing D. use the applicator to paint the medication on the infected sites and swallow the remaining dose

C

170. In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? a. 1 to 2 hours b. 3 to 4 hours c. 10 to 12 hours d. 24 to 48 hours

C

18. To avoid electrical safety problems during surgery, what does the nurse do? a. Observes for breaks in sterile technique b. Continuously assists the anesthesia provider c. Ensures proper placement of grounding pads d. Monitors the operating room with available cameras

C

18.) Which pt is the least likely to be at risk for developing pneumonia? a. Patient with a 5-year history of smoking b. Renal transplant patient c. Postoperative patient with a beside commode d. Postoperative patient with a hip replacement

C

19. Which medical condition increases a patient's risk for surgical wound infection? a. Anxiety b. Hiatal hernia c. Diabetes mellitus d. Amnesia

C

20. The PACU nurse is caring for postoperative patient. The patient's oxygen saturation drops from 98% to 88%. What is the nurse's priority action? a. Call the anesthesia provider b. Call the surgeon c. Call the rapid response team d. Call the respiratory therapist

C

20. Which definition is appropriate for local anesthesia? a. Injection of anesthetic agent into or around a nerve or group of nerves, resulting in blocked sensation and motor impulse transmission. b. Injection of anesthetic agent into the epidural space; the spinal cord areas are never entered. c. Injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion. d. Injection of anesthetic agent into or around a nerve or group of nerves, resulting in blocked sensation and motor impulse transmission.

C

20.) What nursing intervention may help to prevent the complication of pneumonia for a surgical patient? a. Monitoring chest x-rays and WBC counts for early signs of infection b. Monitoring lung sounds every shift and encouraging fluids c. Teaching coughing, deep-breathing exercising, and use of incentive spirometer d. Encouraging hand hygiene among all care-givers, patients, and visitors

C

21. The nurse sees that a patient has been advised by the health care provider to apply lindane (Kwell) to the affected area. What is a self-care measure for this patient to ensure that the symptoms do not return after using the medication? a. Wash the area daily with hydrogen peroxide b. Take a sit bath for 30 minutes several times a day c. Wash clothes, linens, and disinfect the home environment. d. Remove any irritants or allergens (change detergents)

C

21. When performing morning physical assessment, nurse discovers he has weak, rapid pulse, decreased skin turgor, and dry, sticky, oral mucous membranes. Weight is 2 lbs (0.91 kg) less than yesterday. What is highest priority nursing diagnosis for Raymond? A. fatigue B. disturbed sleep pattern C. deficit fluid volume D. situational low self-esteem

C

21. You observe a student nurse who is caring for a client who has an intracavitary radioactive implant in place to treat cervical cancer. Which action by the student requires that you intervene immediately? a. Standing next to the client for 5 minutes while assisting with her bath b. Asking the client how she feels about losing her childbearing ability c. Assisting the client to the bedside commode for a bowel movement d. Offering to get the client whatever she would like to eat or drink

C

22. Which action should the nurse take first? A. hold Raymond's breakfast tray to provide bowel rest. B. perform oral care and moisten mucous membranes C. take Raymond's BP to assess for postural hypotension D. notify HCP of Raymond's weak, rapid pulse

C

22.) A pt hospitalized for pneumonia has the priority patient problem of ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness. What nursing intervention helps to correct this problem? a. Administer oxygen to prevent hypoxemia and atelectasis b. Push fluids to greater than 3000mL/day to ensure adequate hydration c. Administer bronchodilator therapy in a timely manner to decrease bronchospasms d. Maintain semi-fowlers position to facilitate breathing and prevent further fatigue

C

23. The patient is scheduled to have minimally invasive surgery (MIS) for a laparoscopic cholecystectomy. Part of this surgery is the injection of air (insufflation) into the abdomen to separate and better see the organs. What patient teaching must the nurse do about the insufflation? a. "Your surgeon will make several small incisions instead of a large one." b. You will be able to go home once your surgery is completed and you are awake." c. "You may experience some abdominal discomfort from the air injected with the surgery." d. "You will have a tube for drainage for a few days after your surgery is completed."

C

23.) A pt is admitted to the hospital for treatment of pneumonia. Which nursing assessment finding best indicates that the patient is responding to antibiotics? a. Wheezing, oxygen at 2 L/min, respiratory rate 26, no shortness of breath or chills b. Temperature 99 F, lung sounds clear, pulse oximetry on 2 L/min at 98%, cough with yellow sputum c. Cough, clear sputum, temperature 99 F, pulse oximetry at 96% on room air d. Feeling tired, respiratory rate at 28 on 2 L/min of oxygen, audible breath sounds

C

237. After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information? a. The T-tube may have to be irrigated b. The bile is now draining into the duodenum c. Mechanical problems may have developed with the T-tube d. Suction must be reestablished in the portable drainage system

C

25. The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has returned? a. Presence of bowel sounds b. Patient states he is hungry c. Passing of flatus or stool d. The presence of abdominal cramping

C

25. The patient received moderate sedation (conscious sedation) by IV prior to a bronchoscopy procedure. Before allowing the patient to have oral liquids, what must the nurse assess in this patient? a. The patient is arousable. b. The patient is able to speak. c. The patient's gag reflex is working. d. The patient is able to rotate his head.

C

27. After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves? a. Prior to removing the dressing on the client's hip. b. Before opening the new sterile dressing package. c. Before cleansing the client's hip incision. d. After cleansing the client's hip incision.

C

27. The medical-surgical nurse is caring for a postoperative patient whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value? a. The patient may need a transfusion b. The patient is using up clotting factors c. The patient is developing an infection d. The patient's result is expected postoperatively

C

27.) An older adult patient asks the nurse how often one should receive the pneumococcal vaccine for pneumonia prevention. What is the nurse's best response a. Every year when the patient is receiving the "flu shot" b. The standard is vaccination every 3 years c. It is usually given once, but some older adults may need a second vaccination after 5 years d. There is no set schedule; it depends on the patient's history and risk factors

C

32. What is the priority nursing care most commonly seen preoperatively and postoperatively in a patient with leiomyomas? a. Preventing infection b. Managing severe pain c. Monitoring for bleeding d. Assessing for and managing anxiety

C

35.) In the event of new severe acute respiratory syndrome (SARS) outbreak, what is the nurse's primary role? a. Immediately report new cases of SARS to the Centers for Disease Control and Prevention (CDC) b. Administer oxygen, standard antibiotics, and supportive therapies to patients c. Prevent the spread of infection to other employees and patients d. Initiate and strictly enforce contact isolation procedures

C

36. The nurse is caring for several patients who had total abdominal hysterectomies. All patients are coming to the clinic for their six week follow up appointment. Which patient demeanor is the strongest indicator that there is a need for psychological referral? a. Quiet and withdrawn but asks appropriate questions b. Tense and impatient but answers questions correctly c. Disheveled and lackluster and displays a lack of interest in questions d. Cheerful and distractible and answers questions with excessive detail

C

37.) A pt reports experiencing mild fatigue and a dry, harsh cough, there is a possibility of exposure to inhalation anthrax, but the pt currently reports feeling much better. What does the nurse advise the patient to do? a. Have a complete blood count to rule out the disease b. Monitor for and immediately seek attention for respiratory symptoms c. Consult a provider for diagnostic testing and antibiotic therapy

C

4.) The nurse is caring for a pt and suspects anaphylaxis. What first priority action does the nurse take at this time? a. Place the pt on a cardiac monitor b. Insert a large-bore IV line c. Call the rapid response team d. Apply oxygen by nasal cannula

C

40. A client with a third degree uterine prolapse is scheduled for vaginoplasty. What should the nurse anticipate the surgeon will order? a. Encourage ambulation b. Elevate the foot of the bed c. Apply moist compress to the uterus d. Support the prolapsed uterus with a sanitary pad

C

42. A patient is receiving external radiation therapy for treatment of endometrial cancer. What task does the nurse delegate to the UAP? a. Gently wash the markings outlining the treatment site b. Monitor for signs of skin breakdown, especially in the perineal area c. Assist the patient to ambulate if she feels fatigue or tiredness d. Clean the urinary catheter and meatus with mild soap and water

C

43.) A pt has a positive skin test result for TB. What explanation does the nurse give to the patient? a. There is active disease, but you are not yet infectious to others b. There is active disease and you need immediate treatment c. You have been infected but this does not mean active disease is present d. A repeat skin test is necessary because the test could give a false positive result

C

46. Which classic symptom is indicative of invasive gynecologic cancer in an older patient? a. Swelling of one leg b. Dark and foul smelling discharge c. Painless vaginal bleeding d. Flank pain

C

5. If a patient experiences a wound dehiscence, which description illustrates what is happening with the wound? a. Purulent drainage is present at incision site because of infection b. Extreme pain is present at incision site c. A partial or complete separation of outer layers is present at incision site d. The inner and outer layers of the incision are separated

C

50. A patient had a total abdominal hysterectomy. Which patient behavior is the best indicator that she is coping and adapting successfully? a. Refuses to look at the wound, but encourages the nursing students to look b. Sits quietly and passively while the nurse performs wound care c. Asks questions about the wound care, but seems reluctant to do self-care d. Frequently stares at the wound site, but refuses to touch the area

C

51.) A pt is admitted to the hospital to rule out TB. What type of mask does the nurse wear when caring for this patient? a. Surgical facemask b. Surgical facemask with eye shield c. HEPA respirator mask d. Any type of mask that covers the nose and mouth

C

52.) After being discharged from the hospital, a patient is diagnosed with TB at the outpatient clinic. What is the correct procedure regarding public health policy in this case? a. Contact the infection control nurse at the hospital because the hospital is responsible for the follow-up of this case b. There are no regulations because the patient was diagnosed at the clinic and not during the hospitalization c. Contact the public health nurse so that all individuals who have came in contact with the patient can be screened d. Have the patient sign a waiver regarding the hospital and clinic's liability for treatment

C

54. What is the primary factor for the low survival rates for patients who are diagnosed with ovarian cancer? a. Ovarian cancer develops in patients with underlying immunosuppression and poor health b. Ovarian cancer does not respond well to conventional radiation and chemo treatments c. Symptoms are mild and vague, therefore the cancer is often not detected until its late stage d. There are no specific diagnostic tests that can confirm or rule out ovarian cancer

C

7.) A 35-year-old male pt with no health problem states that he had a flu shot last year and asks if it is necessary to have it again this year. What is the best response by the nurse? a. No, because once you get a flu shot, it lats for several years. b. Yes, because the immunity against the virus wears off, increasing your chances of getting the flu c. Yes, because the vaccine guards against a specific virus and reduces your chances of acquiring flu and is only effective for one year d. No, flu shots are only for high-risk patients and you are not considered to be high risk

C

8. The nurse transfers a patient to the PACU with an incision and drainage of an abscess in the right groin under general anesthesia. Blood pressure is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L nasal cannula, temp is 38.5 degrees Celcius. The Jackson-Pratt drain has 70 mL of a cream-colored output. Normal saline is infusing at 150 mL/hr. The surgeon orders a bolus of 500 mL IV over 1 hour of normal saline, two sets of blood cultures, and culture drainage from the Jackson-Pratt drain. The patient's history includes vulvar cancer with a needle biopsy of the right groin, hypertension treated with lisinopril (Zestful) 5 mg PO daily, and no known drug allergies. The patient is a full code. Using the SBAR charting format, which information should be included in the assessment? a. Nurse transfers patient to the PACU with an incision and drainage of an abscess in the right groin with general anesthesia. b. Surgeon sending orders to bolus the patient with 500 mL normal saline over an hour, draw two sets of blood cultures and send a culture of drainage from the Jackson-Pratt drain. c. Blood pressure 80/47 mm Hg, heart rate 117/min, sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L nasal cannula, temperature 38.5 degrees Celcius, Jackson-Pratt drain with 70 mL cream-colored output. d. Patient had a right groin abscess. History of vulvar cancer. Needle biopsy of right groin completed 1 week ago. History of hypertension treated with lisinopril (Zestril) 5 mg. No known drug allergies. Full code.

C

9.) In a long-term care facility for older adults and immunocompromised patients, one employee and several patients have been diagnosed with influenza. What does the supervising nurse do to decrease risk of infection to other patient? a. Ask employees who have flu to stay at home for at least 24 hours b. Place any patients with a sore throat, cough, and rhinorrhea into isolation for 1 to 2 weeks c. Ask employees with flu symptoms to stay at home for up to 5 days after onset of symptoms d. Recommend that all patients and employees be immediately vaccinated for flu

C

A client had had a needle biopsy of the prostate gland using the transrectal approach. Which statement is most important to include in the client teaching plan? A. the doctor will call you about the test results in a day or two B. Serious infections may occur as a complication of this test C. You will need to call the doctor if you develop a fever or chills D. It it normal to have a small amount of recital bleeding after the test

C

A client with cancer of the prostate request the urinal at frequent intervals but either does not void or voids in ver small amounts. what does the nurse conclude is most likely the causative factor? A. Edema B. Dysuria C. Retention D. Suppression

C

A nurse is caring for a client with a diagnosis of benign prostatic hyupoerplasia (BPH). Which information about this condition is important for the nurse to consider when caring for this client? A. It is a congenital abnormality B. A malignancy usually results C. It predisposes to hydronephrosis D. An increase in the acid phosphatase level occurs

C

A patient is diagnosed with prostatitis. Which intervention does the nurse use to alleviate the discomfort associated with this condition? A. Apply ice packs intermittently to reduce swelling B. Restrict fluid intake, especially in the late evening C. Assist with comfort measures such as sitz bath for pain D. Suggest scrotal support during the day and elevating testes at night

C

A patient reports having uncomfortable and unsettling episodes of "hot flashes" after receiving hormonal therapy for a prostate tumor. To alleviate this symptoms, which prescription medication does the nurse assist the patient in obtaining? A. Biphosphonate drugs such as pamidronate (Aredia) B. Antiandrogen drug such as bicalutamide (Casodex) C. Hormonal inhibitor drug such as megestrol acetate (Megace) D. Antimuscarinic agents such as tolterodine (Detrol)

C

A patient who has testicular cancer is likely to have which common problem? A. Priapism B. ED C. Azoospermia D. Cryptorchidism

C

An older patient reports that he has an enlarged prostate with chronic urinary retention, but declines to seek treatment because "It's been that way for a long time." The nurse would encourage a follow-up appointment to prevent which complication of this chronic condition? A. Prostate caner B. ED C. Hydronephrosis D. Testicular cancer

C

The nurse hears in shift report that the patient had a transurethral needle ablation. Which question would the nurse ask the patient to determine if the procedure achieved the intended therapeutic goal? A. Did the pain resolve completely after the procedure? B. Are you able to achieve and sustain an erection? C. Have your problems with urination been resolved? D. Have you had a PSA level to see if the cancer is in remission?

C

The nurse is reviewing the laboratory results for a totient who prostate cancer. Which laboratory results suggests metastasis to the bone>=? A. Decreased alpha fetoprotein B. Increased blood urea nitrogen C. Elevated serum alkaline phosphatase D. Decreased serum creatinine

C

The nurse is teaching a patient who had an open radical prostatectomy about how to manage the common potential long-term complications. What does the nurse teach the patient? A. how to perform testicular self-examination B. How to manage a permanent suprapubic catheter C. How to perform Kegel Perineal exercises D. How to use dietary modifications to acidify the urine

C

The nurse its reviewing PSA results for a patient who had a prostatectomy for prostate caber several weeks ago. The PSA level is 40 ng/mL. How does the nurse interpret this data? A. At this stage, PSA level of 40 ng/mL is expected B. The cancer was completely removed C. The cancer is mostly likely recurring D. Prostate irritation and infection are present

C

The patient has an indwelling catheter in place following a TURP. What instructions will the nurse give to the UAP with regards to the catheter? A. Secure the catheter so there is no tension B. Irrigate the catheter to prevent clotting C. Maintain traction on the catheter D. Defer catheter care until the patient is discharged

C

The patient with DM had a pancreas transplant and takes daily doses of cyclosporine (Neoral). For which key lab assessment does the nurse monitor? a. Serum electrolytes b. CBC with differential count c. Serum creatinine d. Clotting studies

C

What action should the nurse take? A. Apply gentle pressure over the bladder B. Continue the CBI, and notify the HCP C. Stop the CBI, and irrigate the catheter D. Gradually increase the flow rate of the CBI

C

What information should be included when teaching Mr. H about terazosin (Hytrin)? A. Avoid caffeine within 2 hours of taking medication B. Take this medication on an empty stomach C. This medication can cause dizziness so it should be taken at night D. Symptoms subside within 2 weeks

C

What is the best initial response by the charge nurse? A. Do you have your own malpractice insurance? B. No, you did not do anything indicates malpractice C. Describe everything you did that is related to the transfusion D. Many people experience febrile reactions; don't be concerned

C

What should the nurse do to obtain an accurate urine output for a client with continuous bladder irrigation (CBI)? A. measure the contents of the bedside drainage bag B. Stop the irrigation and determine the urine output C. Subtract the volume of irrigant from the total drainage D. Ensure the urine and irrigant drain into two separate bags

C

Which action by the nurse is most helpful? A. Inform Mr. H that this information is very complicated for a layperson to understand B. Give the client a web site resource that may help C. Explain that PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed. D. Notify the healthcare provider to discuss the results with Mr. H

C

Which catheter should the nurse select to perform the procedure? A. 8Fr with 5 mL balloon B. 16 Fr with 5 mL balloon C. 12 Fr straight Catheter D. 12 F metal Catheter

C

While Mr. H is awaiting transport to the Operating Room, which nursing staff member should be assigned to his care? A. A graduate nurse who is of Korean descent B. An LPN who formerly worked in the OR C. An RN who has worked on the unit for 3 years D. An RN from an agency who has 10 years of long-term care experience

C

You are assessing a long-term-cre client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? A. The client states that he always has trouble starting his urinary stream B. The chart shows an elevated level of prostate-specific antigen C. The bladder is palpable about the symphysis pubis and the client is restless D. The client says he has not voided since having a glass of juice 4 hours ago

C

a 22-year-old pt comes to the clinic for a wellness check-up. Hx reveals that the pt's parents has the autosomal-dominant form of polycystic kidney disease (PKD). Which vital sign suggests that the pt should be evaluated for PKD? a. Pulse of 90 beats/min b. temperature of 99.6 F c. Blood pressure of 136/88 mmHg d. Respiratory rate of 22/min

C

4. Which signs/symptoms are considered postoperative complications? (Select all that apply) a. Sedation b. Pain at the surgical site c. Pulmonary embolism d. Hypothermia e. Wound evisceration

C,D,E

20. During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate amount of sanguineous drainage. What action should the nurse implement? (select all that apply) a. Apply pressure to the site. b. Elevate the leg on a pillow. c. Observe the linens under the hip. d. Use sterile technique to replace the dressing. e. Mark the amount of drainage on the dressing.

C,E

The nurse is caring for a patient with a spinal cord injury which is experiencing neurogenic shock. The patient's systolic blood pressure is 88 mm/hg despite starting a dopamine drip 2 hours earlier. There is a new order to infuse 500ml of Dextran-40 over 4 hours. At what rate does the nurse set infusion pump? A.) 75ml/hr B.) 100ml/hr C.) 125ml/hr D.) 150ml/hr

C.) 125ml/hr

A patient has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hours, the nurse is performing the change of shift assessment. Which postoperative findings are reported to the surgeon immediately? select all that apply A.) Minimal serosanguineous drainage in the surgical drain B.) Pain at the operative site C.) Swelling or bulging at the operative site D.) Reluctance or refusal to cough and deep-breathe E.) Moderate clear drainage on the postoperative dressing

C.) Swelling or bulging at the operative site E.) Moderate clear drainage on the postoperative dressing

The patient with a spinal cord injury has a heart rate of 42/minute. Which drug does the nurse expect to administer? A.) methylprednisolone B.) dextran C.) atropine D.) dopamine

C.) atropine

The nurse is providing discharge teaching for a patient with a spinal cord injury who will be performing intermittent self-catheterizations at home. Which signs and symptoms will the nurse instruct the patient to report immediately to the primary health care provider? select all that apply A.) dysuria B.) retention C.) fever D.) urgency E.) foul-smelling urine F.) back pain

C.) fever E.) foul-smelling urine

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury? A.) heatstroke B.) paralytic ileus C.) hypertensive stroke D.) aspiration and pneumonia

C.) hypertensive stroke

The patient is an adolescent who is quadriplegic as a result of a diving accident. The nursing assistant reports that the patient started yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating "nobody is going to do anything else to me! I'm going to get out of this place!" what is the priority patient problem? A.) noncompliance B.) cognitive limitations C.) inability to cope with the situation D.) feelings of hopelessness

C.) inability to cope with the situation

33. A client at the women's health clinic tells the nurse she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report? (Select all that apply). a. Insomnia b. Ecchymoses c. Rectal pressure d. Abdominal pain e. Skipped periods f. Pelvic infections

CD

The nurse initiates a physical examination to further investigate Mr. Perry Hamilton's symptoms. Which assessment finding would indicate that Mr. Hamilton is experiencing urinary retention? A. Presence of a bruit auscultated over the renal artery B. Complaints of flank pain gently palpation C. observance of bladder distention D. Dullness heard on percussion below there umbilicus E. Observance of dribbling after voiding

CD

What information should be included in the nurse's explanation? Select all that apply. A. If the kidney test result are normal, then your symptoms are probably not due to prostate enlargement B. IF these kidney test are elevated, dehydration, not prostate enlargement, may be the cause of these symptoms C. Prostate enlargement may result in renal damage, causing a decrease of urine production in the kidneys, which these test will evaluate D. When the prostate gland is blocking the flow of urine, some degree of kidney damage that can be detected with these test E. advise the client that the prescription will be rechecked to make sure the healthcare provider really intended to prescribe those test

CD

37. The nurse is giving discharge teaching to a woman who had a local cervical ablation. What information would be included? (Select all that apply) a. Sexual activity may be resumed usually in 1 week b. Change tampons every 4 hours c. Report heavy vaginal bleeding or foul smelling drainage d. Showering is permitted, but no tub baths e. Avoid lifting heavy objects for 3 weeks

CDE

The nurse is teaching a patient how had open retroperitoneal node dissection. What instructions does the nurse give to the patient? Select all that apply. A. Do not lift anything over 45lbs B. Limit intake of fluids to 1000 mL per day C. Do not drive a car for several weeks D. Perform monthly testicular self-examination on the remaining testis E. Have follow-up diagnostic testing for at least 3 years after the surgery

CDE

What actions should the nurse take? A. Ask Mr. H to apply pressure by bearing down B. Release the tape traction on the catheter C. Increase the flow rate of the CBI D. Notify the HCP of the findings E. Perform manual irrigation

CDE

1. For a patient with endometriosis, which supplement might offer relief of the muscle cramping? a. Vit C b. Vit D c. Potassium d. Magnesium

D

1. Which description illustrates the beginning of the postoperative period? a. Completion of the surgical procedure and arousal of the patient from anesthesia in the OR b. Discharge planning initiated in the preoperative setting c. Closure of the patients surgical incision with sutures. d. Completion of the surgical procedure and transfer of the patient to the post anesthesia care unit (PACU)

D

11. The surgical team understands that time is crucial in recognizing and treating an MH crisis. Once recognized, what is the treatment of choice? a. Danazol gluconate (Danocrine) b. Phenytoin sodium (Dilantin) c. Diazepam sulfate (Valium) d. Dantrolene sodium (Dantrium)

D

12. An obese 57 year old patient describes excessive menstrual bleeding that occurs approximately every 10 days. The nurse educates the patient for which diagnostic test that is used to evaluate for endometrial cancer? a. Bimanual pelvic examination b. Transvaginal ultrasound c. Sonohysterography d. Endometrial biopsy

D

13. A patient experiences MH immediately after induction of anesthesia. What is the nurse anesthetist's first priority action? a. Administer IV dantrolene sodium (Dantrium) 2 to 3 mg/kg. b. Apply a cooling blanket over the torso. c. Assess arterial blood gases (ABGs) and serum chemistries. d. Stop all inhalation anesthetic agents and succinylcholine e. Monitor cardiac rhythm by electrocardiography to assess for dysrhythmias.

D

14. A patient arrives at the PACU and the nurse notes a respiratory rate of 10 with sternal retractions. The report from anesthesia personnel indicates that the patient had received fentanyl during surgery. What is the nurses best priority first action? a. Monitor the patient for effects of anesthetic for at least 1 hour b. Closely monitor vital signs and pulse oximetry readings until the patient is responsive c. Administer oxygen as ordered, monitoring pulse oximetry d. Maintain an open airway through positioning and suction if needed

D

16. The health care team determines a patient's readiness for discharge from the PACU by noting a post anesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profiles after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first? a. 10-year-old girl, tonsillectomy, general anesthesia. Duration of surgery 30 minutes. Immediate response to voice. Alert to place and person. Able to move all extremities. Respirations even, deep, rate of 20. Vital signs are within normal limits. IV solution is D5RL. Has voided on bedpan. Eating ice chips, Complaining of sore throat. b. 55-year-old man, repair of fractured lower left leg. General anesthesia. Duration of surgery 1 hour, 30 minutes. Drowsy, but responds to voice. Nausea and vomiting twice in PACU. No urge to void at this time. IV infusing D5NS. Pedal pulses noted in both lower extremities. VS: Temperature 98.6 degrees F; pulse 130 beats/min; respiratory rate 24.min; blood pressure 124/76 mm Hg. c. 24 year old man, reconstruction of facial scar. General anesthesia. Duration of surgery 2 hours. Sleeping, groans to voice command. VS are within normal limits. Respirations 10 breaths/min. No urge to void. IV of D5Rl infusing. Complains of pain in surgical area. d. 42 year old woman, colonoscopy, IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS are within normal limits.

D

16. Which assessment finding by the nurse would be indicative of oral candidiasis, a common secondary infection in persons with compromised immune systems? A. blisters on tongue or oral mucosa B. inflammation of gums C. painless white lesions on lateral surface of the tongue D. white-yellow patches on the tongue or oral mucosa

D

16.) The nurse is reviewing laboratory results for a patient who has pneumonia. Which laboratory value does the nurse expect to see for this patient? a. Decreased hemoglobin b. Increased red blood cells c. Decreased neutrophils d. Increased white blood cells

D

163. A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? a. Postural drainage b. Cupping the chest c. Nasotracheal suctioning d. Frequent changes of position

D

17. A patient has excessive bleeding from uterine fibroids. Which therapy stops the blood flow to the fibroids? a. An infusion of conjugated estrogens b. Dilation and curettage c. Topical vaginal estrogen therapy d. Endometrial ablation

D

17. Which characteristics are appropriate to the anesthetic agent ketamine HCI? a. Can depress respiratory and cardiac functions b. May increase heart rate and lower blood pressure (BP) during induction c. Short-acting; patient becomes responsive quickly and postoperatively d. Dissociative emergence reactions; can induce nausea and vomiting

D

17. You are working on the PACU caring for a 32-year old client who has just arrived after undergoing dilation and curettage to evaluate infertility. Which assessment finding should be immediately communicated to the surgeon? a. Blood pressure of 162/90 mmHg b. Saturation of the perineal pad after the first 30 minutes c. Oxygen saturation of 91% to 95% d. Sharp, continuous, level 8 (out of 10) abdominal pain

D

176. A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? a. Dialysis b. Osmosis c. Diffusion d. Capillary

D

178. A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? a. Productive cough b. Clubbing of the fingertips c. Crackles at the height of inhalation d. Diminished breath sounds on auscultation

D

178. When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? a. Obtain the vital signs b. Notify the health care provider c. Reinsert the protruding organs using aseptic technique d. Cover the wound with a sterile towel moistened with a normal saline

D

179. While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention? a. Encircle the drainage on the dressing b. Irrigate the suction tube with sterile saline c. Clean the drainage port with an alcohol wipe d. Compress the container before closing the port

D

18. Which intervention for post surgical care of the patient is correct? a. When positioning the patient, use the knee gatch of the bed to bend the knees and relieve pressure. b. Gentle massage on the lower legs and calves helps promote venous blood return to the heart. c. Encourage bedrest for 3 days after surgery to prevent complications. d. The patient should splint the surgical wound for support and comfort when getting out of bed.

D

180. A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? a. Vitamin A (Aquasol A) b. Cyanocobalamin (Cobex) c. Phytonadione (Mephyton) d. Ascorbic acid (Ascorbicap)

D

191. After abdominal surgery a client reports pain. What action should the nurse take first? a. Reposition the client b. Obtain the client's vital signs c. Administer the prescribed analgesic d. Determine the characteristics of the pain

D

2. A 20 year old woman is being evaluated for possible toxic shock syndrome. What question would the nurse ask? a. "How many pads do you use on heavy flow days?" b. "Have you ever used intravaginal estrogen therapy?" c. "Do you have a history of multiple sexual partners?" d. "Do you use internal contraceptives?"

D

24. The patient in the OR holding area tells the nurse that his surgery is for the right foot. The patient's chart states that the surgery is for the left foot. What is the nurse's best action? a. Do nothing because the patient is confused after receiving premedications. b. Make a note about this in the nursing notes of the patient's chart c. Call the nurse anesthetist to check whether the chart or the patient are correct. d. Notify the surgeon immediately before the patient goes into the OR about this discrepancy.

D

24.) The nurse is reviewing the laboratory results for an older adult patient with pneumonia. Which laboratory value frequently seen in patient with pneumonia may not be seen in this patient? a. RBC 4.0 to 5.0 b. HgB 12 to 16 c. Hct 36 to 48 d. WBC 12 to 18

D

25.) A patient is admitted to the hospital to rule out pneumonia. Which infection control technique does the nurse maintain? a. Strict respiratory isolation and use of a specially designated facemask b. respiratory isolation and contact isolation for sputum c. respiratory isolation with a stock surgical mask d. standard precautions and no respiratory isolation

D

26. The nurse teaches Ms. Jackson safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. What is the rationale for the inclusion of these actions in Ms. Jackson's plan of care? a. Frequent activity will distract the client from her concerns. b. Maintaining a safe environment reduces client depression. c. The client should depend on the therapist rather than the nurse. d. Increased mobility will promote an improved sense of control.

D

3. A patient develops respiratory distress after having a left total hip replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Assess change in patients respiratory status b. Order necessary medications to be administered c. Intubate the patient for maintenance of airway and assisted breathing d. Check the patients vital signs

D

3.) The pt has documented allergy to bananas and avocados. What specific priority precaution must the nurse take when providing care for this patient? Ask the pt about: a. Other food allergies b. Antibiotic drug allergies c. Allergies to pets d. Latex allergies

D

33. What disease is strongly associated with prolonged exposure to estrogen without the protective effects of progesterone? a. Endometriosis b. Uterine cancer c. Leiomyomas d. Endometrial cancer

D

34. What does a nurse expect to be the priority concern of a 28 year old woman who is to undergo a laparoscopic bilateral slapping-oophorectomy? a. Acute pain b. Risk for hemorrhage c. Fear of chronic illness d. Loss of childbearing potential

D

36. When taking the health history of a client who is admitted for repair of a cystocele and rectocele, the nurse should expect the client to report the occurrence of: a. white vaginal itching and discharge b. sporadic bleeding and abdominal pain c. elevated temperature and intractable diarrhea d. stress incontinence and low abdominal pressure

D

39. What potential complication does a nurse anticipate when admitting a client with the diagnosis of severe procidentia (prolapse of the uterus)? a. Edema b. Fistulas c. Exudate d. Ulcerations

D

42.) After receiving the subcutaneous Mantoux skin test, a pt with no risk factors returnd to the clinic in required 48 to 72 hours for the test results. Which assessment finding indicted a positive test result? a. Test are is red, warm, and tender to touch b. Induration or a hard nodule of any size at the site c. Infuration/hardened area measures 5 mm or greater d. Induration/hardened area measures 10 mm or greater

D

44.) A pt has been compliant with drug therapy for TB and had returned as instructed for follow-up. Which results indicates that the patient is no longer infections/communicable? a. Negative chest x-ray b. No clinical symptoms c. Negative skin test d. Three negative sputum cultures

D

45.) A pt diagnosed with TB agrees to take the medication as instructed and to complete the therapy. When does the nurse tell the pt is the best time to take the medication? a. Before breakfast b. After breakfast c. Midday d. Bedtime

D

47. The nurse is taking a history on a patient with probable gynecologic cancer. Which clinical manifestation is a sign of metastasis? a. Watery vaginal discharge b. Constipation c. Dyspareunia d. Dysuria

D

5. What self-management strategy would the nurse recommend to a patient to prevent vulvovaginitis? a. Wear nylon underwear b. Douche daily to remove vaginal secretions c. Apply antiseptic cream daily to perineal area d. Avoid wearing tight-fitting clothing

D

50. A client is diagnosed with uterine fibroids, and the health care provider advises a hysterectomy. The client expresses concern about having a hysterectomy at age 45 because she has heard form friends that she will undergo severe symptoms of menopause after surgery. What is the nurse's most appropriate response? a. "You are correct, but there are medicines you can take that will ease the symptoms." b. "This sometimes occurs in women of your age, but you needn't worry about it at this time." c. "Perhaps you should talk to your surgeon because I am not allowed to discuss this with you." d. "Some women may experience symptoms of menopause if their ovaries are removed with their uterus"

D

51. After a hysterosalpingo-oophorectomy, a client wants to know whether it would be wise for her to take hormones right away to prevent symptoms of menopause. What is the nurses most appropriate response? a. "It is best to wait because you may not have any symptoms." b. "It is comforting to know that hormones are available if you should ever need them." c. "You have to wait until symptoms are severe; otherwise, hormones will have no effect." d. "Discuss this with your health care provider, because it is important to know your concerns."

D

56. In recalling dietary intake for a recent 24 hour period, a female patient describes eating eggs, whole milk, and bacon for breakfast; fried chicken and french fries for lunch; three cheese pizza and ice cream for dinner. This type of diet places her at increased risk for which disorder? a. Dysfunctional uterine bleeding b. Dyspareunia c. Early menopause d. Cancer of the ovaries

D

6. Which duties are within the scope of practice of the circulating nurse in the operative setting? a. Manages the patient's care while the patient is in this area and initiates documentation on a preoperative nurse record. b. Sets up the sterile filed; assists with the draping of the patient; and hands sterile supplies, equipment, and instruments to the surgeon. c. Assumes responsibility for the surgical procedure and any surgical judgments about the patient. d. Coordinates, oversees, and participates in the patient's nursing care while the patient is in the operating room.

D

9. Which woman is at greatest risk for developing pelvic organ prolapse? a. 16 year old adolescent caring for her first child b. 25 year old who became sexually active at 15 c. 34 year old who has a history of endometriosis d. 48 year old obese mother of four children

D

A 67-year-old client with BPH has a new prescription for tamsulosin (Flomax). Which statement about tamsulosin is most important to include when teaching this client? A. This medication will improve your symptoms by shrinking the prostate B. The forst of your urinary stream will probably increase C. You blood pressure will decrease as rest of taking this medication D. You should avoid string up or standing up too quickly

D

A client is admitted to the hospital with a tentative diagnosis or urinary retention related to benign prostatic hyperplasia. There is a secondary diagnosis of delirium related to urosepsis. The health care provider prescribes the insertion of an indwelling urinary retention catheter. What nursing action is most important for this client's safety? A. Secure an order for wrist restraints B. Orient the client to time, place and person C. Involve family members in the client's care D. Determine if any unsafe behavior patterns exist

D

A nurse is caring for a client with a diagnosis of cancer of the prostate. What serum level should the nurse teach the client to have monitored to follow the course of the disease? A. Serum creatinine B. Blood urea nitrogen C. Nonprotein nitrogen D. Prostate-specific antigen

D

A patient had a TURP and has a three-way urinary catheter taped to the left thigh. What does the nurse instruct about the position of the left leg? A. Maintain slight abduction B. Maintain slight flexion of the hip C. Keep the legs elevated D. Keep the leg straight

D

A patient is prescribed the luteinizing hormone-releasing hormone (LH-RH) agonist leuprolide (Lupron) for treatment of a prostate tumor. What possible side effects of this medication does he nurse advise the patient about? A. Nipple discharge B. Scrotal enlargement C. Fragility of the skin D. ED

D

A patient is receiving internal radiation therapy (Brachytherapy) and has had a low dose radiation seed implanted directly into the prostate gland. What nursing implications us related to this therapy? A. Ensure that any staff member or visitor who its pregnant is not exposed to the patiet B. Organize the nursing care so that exposure to the patient is limited to a few minutes C. instruct the UAP that all urine specimens should be immediately discarded D. Teach the patient that fatigue is common, but it should pass after several months

D

An older adult patient had a TURP at 8:00am. At 3:00pm, the nurse assesses the patient. Which finding does the nurse report to the health care provider? A. Patient reports a continuous urge to void B. Patient keeps attempting to void around catheter C. Patient wants to get out of bed D. Patient keeps moving and ketchup-like out is noted

D

How should the nurse respond? A. You will no longer need rectal exams or PSA screening B. Yearly PSA screenings need to be done but not rectal exams C. You will only need recta exams but not PSA screenings D. You will still need yearly rectal exams and PSA screenings

D

Mr. H tell the nurse that he has cut back on drinking fluids to reduce his symptoms. Which instructions is most important for the nurse to provide to Mr. H? A. Restrict fluid intake until results are back B. Increase the intake of diuretic-type fluids, such a coffee or tea, to increase urine flow, C. Consider taking an over the counter (OTC) herb supplement D. Decrease fluid to increase the risk of developing a urinary tract infection

D

The advanced-practice nurse is preparing to examine a patient's prostate gland. Before the exam, what does the nurse tell the patient? A.) He mat feel the urge to defecate or faint as the prostate is palpated B.) He should lie supine with knees bent in a fully flexed position C.) The examination is very painful, but it lasts just a few seconds D.) The gland will be massaged to obtain a fluid sample for possible prostatitis

D

The day after a radical prostatectomy, your client had blood clots in the urinary catheter and reports bladder spasms. The client says that his right calf is sore and that he feels short of breath. Which action will you take first? A. Irrigate the catheter with 50 mL of sterile saline B. Administer oxybutynin (Ditropan) 5 mg orally C. Apply warm packs to the client's right calf D. Measure oxygen saturation using a pulse oximetry

D

The male diabetic patient asks the nurse for advice about alcohol consumption. what is the nurse's best response? a. "it is best to have alcohol near bedtime." b. "As long as your diabetes is under control you can drink as much as you like?" C. "You should drink only one alcoholic beverage with each meal." d. " Avoid more than two drinks a day and have then with or shortly after meals."

D

The nurse is caring for an older patient who had a urinary catheter inserted after a TURP. The patient is intermittently confused, and picks at the IV tubing and catheter. What should the nurse try first? A. Obtain an order to restrain the patient's hands and forearms B. Sedate the patient until the IV tube and catheter can be removed C. Inform the family that a family member will have to sit by the patient D. Give the patient a familiar object to hold, such as a family picture

D

The nurse is preparing to assess an obese patient who reports subjective symptoms and urinary patterns associated with BPH. Which techniques foes the nurse use to perform the physical assessment? A.) Instruct the patient to undress from the waist down, then inspect and palpate the bladder B.) Have the patient drink several large glass of water and percuss the bladder C.) Apply gentle pressure to the bladder to elicit urgency; then instruct the patient to void D.) Instruct the patient to void and then use the bedside ultrasound bladder scanner

D

What action should the nurse implement to reduce the risk for a hemolytic transfusion reaction? A. Observe the IV site for signs of infiltration B. Hang the blood as soon as it arrives on the unit C. Gently rotate the unit of blood being spiking D. Verify the blood type and Rh factor with another nurse

D

What action should the nurse take? A. Notify the HCP of the drainage B. stop the CBI and irrigate the catheter C. Increase the rate of flow of the CBI D. Document that the CBO is infusing correctly

D

What is the basic principle of meal planning for a patient with type 1 DM? a. Five small meals per day plus a bedtime snack b. taking extra insulin when okaying to eat sweet foods c. High-protein, low-carbohydrates, and low-fiber foods d. Considering the effects and peak action times of the patient's insulin

D

What man had the highest risk for prostate cancer? A. A 65-year-old Again-American man with a history of BPH B. A 45-year-old Caucasin-American man who has several cousins with prostate cancer C. A 55-year-old Hispanic-American man who has poor dietary practices D. A 75-year-old African-American man whose brother had prostate cancer

D

What position should the nurse place Mr. H? A. High-Fowler's position with feet lowered B. Semi-Fowler's position with feet flat C. Trandelenburg portion with feet elevated D. Supine with feet elevate at a 45 degree angle

D

Which assessment tool is most commonly used to ask patient about the effect of urinary symptoms on their quality of life? A.) American Urological Assessment Scale B.) International Urological Assessment Tool C.) American Prostate Symptom Tool D.) International Prostate Symptom Score

D

Which nursing action can best prevent infection from a urinary retention catheter? A. cleansing the perineum B. Encouraging adequate fluids C. Irrigating the catheter once daily D. Cleansing around the meatus routinely

D

Which type of surgery is most commonly used to treat BPH? A.) Contact laser prostatectomy B.) Radical prostatectomy C.) open prostatectomy D.) Transurethral resection of the prostate (TURP)

D

You obtain the following assessment data about your client who has had a TURP and has continuous bladder irrigation. Which finding indicates the most immediate need for nursing intervention? A. the client states that he feels a continuous urge to void B. The catheter drainage is light pink with occasional clots C. the catheter is taped to the client's thigh D. The client reports painful bladder spams

D

what analogy can the nurse use to describe how to contract the pelvic floor muscles? A. bear down as if having a bowel movement B. Pull the abdominal muscles toward the spine C. Tilt both the hips and the pelvis forward D. Squeeze as if stopping the flow of urine

D

A patient has been talking to his physician about drugs that could potentially be used in the treatment of acute low back pain. Which statement by the patient indicates a need for additional teaching? A.) "The doctor may prescribe an antiseizure drug such as oxcarbazepine; therefore, I would need to have blood tests to check my sodium levels." B.) "The doctor may suggest over the counter ibuprofen; therefore, I should watch for and report dark or tarry stools." C.) "The doctor may prescribe an oral steroid such as prednisone; this would be short-term therapy and the dose would gradually taper off." D.) "The doctor may prescribe hydromorphone and it may cause drowsiness; I should not drive or drink alcohol when I take it."

D.) "The doctor may prescribe hydromorphone and it may cause drowsiness; I should not drive or drink alcohol when I take it."

A patient has had an anterior cervical discectomy with fusion and has returned from the recovery room. What is the priority assessment? A.) Assess for the gag reflex and ability to swallow own secretions B.) check for bleeding and drainage at the incision site C.) Monitor vital signs and check neurologic status D.) Assess for potency of airway and respiratory effort

D.) Assess for potency of airway and respiratory effort

A patient with an SCI has paraplegia and paraparesis. the nurse has identified a priority patient problem of inability to ambulate. the nurse assesses the calf area of both legs for swelling, tenderness, redness or possible complaints of pain. The assessment id specific to the patient's increased risk for which condition? A.) contractures of joints B.) bone fractures C.) pressure ulcers D.) deep vein thrombosis

D.) deep vein thrombosis

1. which information obtained by the nurse is most likely to influence Natalie's perception of her pain? a) Natalie's younger child is an infant who feeds every three hours b) Natalie's 4-year-old enjoys being the "big brother" to his baby sister c) Natalie was a first grade teacher before having children but now stays home d) Natalie's parents live in the same neighborhood and often help with the children

a

10. A pt has just undergone spinal fusion surgery and returned from the operating room 12 hours ago. Which task is best to delegate to the UAP? a. log-roll the pt every 2 hours b. help the pt dangle the legs on the evening of surgery c. assist the pt to put on a brace so he can get out of bed d. help the pt ambulate to the bathroom as needed

a

11. 6 months later ms j is readmitted to the unit. she has just returned from HD. Which nursing care action should you delegate to the UAP? a. measuring vs and postdialysis weight b. assessing the HD access site for bruit and thrill c. checking the access site dressing for bleeding d. instructing the pt to request assistance getting out of bed

a

11. The nurse is monitoring a pt with GBS undergoing plasmapheresis. The pt reports dizziness and has a heart rate that has dropped to 48 BPM. The nurse notifies the primary care provider. Which order does the nurse anticipate? a. atropine IV push b. epinephrine IV push c. continue to monitor pt d. defibrillate the pt

a

11. The nurse reviews the discharge and home care instructions with a patient who had back surgery. Which statement by the pt indicates further teaching is needed? a. "i will drive myself to my doctor's office next week" b. "i will put a piece of plywood under my mattress" c. "i will try to increase fruits and vegetables and decrease fat intake" d. "i plan to get a new ergonomic chair at work"

a

11. how should the nurse explain the mechanism that causes the skin to become reddened from prolonged exposure to cold? a) reflex vasodilation occurs following the initial vasoconstricting effects of the cold b) cold causes a numbing sensation, which interferes with circulation at the site c) debris from necrotic tissue collects at the site of vasoconstriction, causing inflammation d) intradermal tissue blisters occur as the result of the damage caused by exposure to cold

a

118 pulse, 36 RR, weak pulse, cyanotic nailbeds, chest pain, has developed a pulmonary embolus. Which action should the nurse implement first? a. administer oxygen b.stop the heparin infusion c. perform oral pharyngeal suctioning d. position the client on right side

a

12. The nurse is caring for a pt receiving humidified oxygen. Which precaution does the nurse take to prevent bacterial contamination and infection? a. never drain fluid from the water trap back into the nebulizer b. always wear gloves when cleaning the pts nasal cannula c. don't allow live or cut flowers into the pts room d. administer routinely ordered antibiotic therapy

a

12. The nurse is caring for several patients on a medical-surgical unit. None of the patients currently has any acute or chronic kidney problems. Which patient has the greatest risk to develop AKI? a. 73-year-old male who has hypertension and peripheral vascular disease b. 32-year-old female who is pregnant and has gestational diabetes c. 49-year-old male who is obese and has a history of skin cancer d. 23-year-old female who has been treated for urinary tract infection

a

13. you are caring for ms j 1 day postop. On assessment her temp is 100.4F, bp is 168/92, and the pt tells you she has pain around the transplant site. what is the best interpretation of these findings? a. hyperacute rejection b. acute rejection c. chronic rejection d. transplant site infection

a

14. The nurse is caring for a postoperative patient and is evaluating the patient's intake and output as a measure to prevent AKI. The patient weighs 60 kilograms and has produced 180 mL of urine in the past 4 hours. What should the nurse do? a. Perform other assessments related to fluid status and record the output. b. Call the health care provider and obtain an order for a fluid bolus. c. Encourage the patient to drink more fluid, so that the output is increased. d. Compare the patient's weight to baseline to determine fluid retention.

a

14. What is the priority expected outcome in a pt with GBS? a. maintain airway patency and gas exchange b. promote communication c. manage pain d. prevent complications of immobility

a

16. According to the RIFLE classification (Risk. Injury, Failure, Loss, End-stage kidney failure). How would the nurse interpret the following date? Serum creatine increased x 1.5 or glomerular filtration rate (GFR) decrease > 25%; Urine output is < 0.5mL/kg/hr for ≥ 6 hours. a Risk stage b. Injury stage c. Failure stage d. End-stage kidney disease (ESKD)

a

16. The pt with GBS describes a chronological progression of motor weakness that starrted in the legs and then spread to the arms and upper body. Which type of GBS do these symptoms indicate? a. ascending b. pure motor c. descending d. miller-fisher variant

a

17. Because the pt is at risk for spinal shock, what does the nurse monitor for? a. decreased BP, bradycardia, and decreased bowel sounds b. tachycardia and a change in the level of consciousness c. decreased respiratory rate and loss of sensation to pain and touch d. paralytic ileus and loss of bowel and bladder function

a

17. The pt with GBS is in the plateau period. Which intervention is best for the nurse to delegate to the UAP? a. perform passive ROM every 2-4 hours b. turn the pt every 2 hours and assess for skin breakdown c. remove the antiembolism stockings every 24-48 hours and perform skin care d. make a communication board for the pt with a list of common requests

a

18. Which neurologic assessment technique does the nurse use to test a pt for sensory function? a. touch the skin with a clean paper clip and as whether it is a sharp or dull sensation b. ask the pt to elevate both arms off the bed and extend wrists and fingers c. have the pt close the eyes and move the toes up or down; the pt identifies positions d. have the pt sit with the legs dangling; use a reflex hammer to test reflex responses

a

18. a pt is receiving warmed and humidified oxygen. In discarding the moisture formed by condensation, why does the nurse minimize the time that the tubing is disconnected? a. to prevent the pt from desaturating b. to reduce the pts risk of infection c. to minimize the disturbance to the pt d. to facilitate overall time management

a

2. The community health nurse is designing programs to reduce kidney problems and kidney injury among the general public. In order to do so, the nurse targets health promotion and compliance with therapy for people with which conditions? a. Diabetes mellitus and hypertension b. Frequent episodes of sexually transmitted disease c. Osteoporosis and other bone diseases d. Gastroenteritis and poor eating habits

a

20. A UAP reports to you that a pt with acute kidney failure has had a urine output of 350ml over the past 24 hrs after receiving furosemide 40mg IV push. The UAP asks you how this can happen. What is your best response? a. during the oliguric phase of acute kidney failure, pts often don't respond well to either fluid challenges or diuretics b. there must be some sort of error. Someone must have failed to record the urine output c. a pt with acute kidney failure retains sodium and water, which counteracts the action of the furosemide d. the gradual accumulation of nitrogenous waste products results in the retention of water and sodium

a

20. The nurse is caring for a patient with AKI and notes a trend of increasingly elevated BUN levels. How does the nurse interpret this information? a. Breakdown of muscle for protein which leads to an increase in azotemia. b. Sign of urinary retention and decreased urinary output. c. Expected trend that can be reversed by increasing dietary protein. d. Ominous sign of impending irreversible kidney failure.

a

22. A patient sustained extensive burns and depletion of vascular volume. The nurse expects which changes in vital signs and urinary function? a. Decreased urine output, hypotension, tachycardia b. Increased urine output, hypertension, tachycardia c. Bradycardia, hypotension, polyuria d. Dysrhythmias, hypertension, oliguria

a

22. when is the best time to teach Natalie about the use of the PCA? a)the day before the surgery is scheduled b) while she is in the post-anesthesia care unit c) when she is in pain and wants to learn how to obtain relief d) after receiving a dose of medication from the PCA pump

a

22. your pt is receiving IV piggyback doses of gentamicin every 12 hrs. Which would be your priority for monitoring during the period that the pt is receiving this drug? a. serum creatinine and BUN levels b. pt weight every morning c. I and O every shift d. temperature

a

23. A diabetic pt is scheduled to have a blood glucose test the next morning. What does the nurse tell the pt to do before coming in for the test? a. eat the usual diet but have nothing after midnight b. take the usual oral hypoglycemic tablet in the morning c. eat a clear liquid breakfast in the morning d. follow the usual diet and medication regimen

a

232. A client is admitted to a medical unit with the dx of acute kidney failure. The nurse reviews the client's lab data, performs a physical assessment, and obtains the client's vital signs. What should the nurse conclude the client is most likely experiencing? a. hyperkalemia b. hyponatremia c. hypouricemia d. hypercalcemia

a

24. The nurse is reviewing the biographic data and history for a pt with MG. what does the nurse expect to see included in the pt's records? a. muscle weakness that increases with exertion or as the day wears on b. difficulty sleeping with early morning waking and restlessness c. confusion and disorientation in the late afternoon d. muscle pain and cramps that interfere with ADLs

a

24. The provider orders transtracheal oxygen therapy for a pt with respiratory difficulty. What does the nurse tell the pts family is the purpose of this type of oxygen delivery syste,? a. delivers oxygen directly into the lungs b. keeps the small air sacs open to improve gas exchange c. prevents the need for an endotracheal tube d. provides high humidity with oxygen delivery

a

24. Which disorder could be a complication of AKI? a. Heart failure b. Diabetes mellitus c. Kidney cancer d. Compartment syndrome

a

24. a pt on the med-surg unit with acute kidney failure is to begin continuous arteriovenous hemofiltration (CAVH) asap. What is the priority action at this time? a. call the charge nurse and transfer the pt to the ICU b. develop a teaching plan for the pt that focuses on CAVH c. assist the pt with morning bath and mouth care before transfer d. notify the physician that the pts mean arterial pressure is 68 mm Hg

a

26. After suffering an SCI, a pt develops autonomic dysfunction, including a neurogenic bladder. What is the priority pt problem for this condition? a. risk for urinary tract infection b. risk for dehydration c. risk for urinary retention d. risk for urinary incontinence

a

26. The nurse is caring for a patient with AKI who does not have signs or symptoms of fluid overload. A fluid challenge is performed to promote kidney perfusion by doing what? a. Administering normal saline 500 to 1000 mL infused over 1 hour b. Administering drugs to suppress aldosterone release c. Instilling warm, sterile normal saline into the bladder d. Having the patient drink several large glasses of water

a

26. Which class of antidiabetic medication should be taken with the first bite of a meal to be fully effective? a. alpha-glucosanide inhibitors, which include miglitol (Glyset) b. biguanides, which include metformin (glucophage) c. meglitinides, which include natelinide d. second-generation sulfonylureas, which include glipizide (glucotrol)

a

26. a pt requires long term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure and mechanism that are associated with this long term therapy. Which piece of equipment does the nurse most likely use for this pt teaching session? a. trach tube b. nasal trumpet c. endotracheal tube d. nasal cannula

a

26. you are supervising a senior nursing student who is caring for a 78yr old scheduled for an IV pyelography. What info would you be sure to stress about this procedure to the nursing student? a. after the procedure, monitor urine output because the contrast dye increases the risk for kidney failure in older adults b. the purpose of this procedure is to measure kidney size c. because this procedure assesses kidney function, there is no need for a bowel prep d. keep the pt NPO after the procedure because during the procedure the pt will receive drugs that affect the gag reflex

a

28. A pt with MG reports having difficulty climbing stairs, lifting heavy objects, and raising arms over the head. What is the pathophysiology of this pt's symptoms due to? a.limb weakness is more often proximal b. spinal nerves are affected c. large muscle atrophy is occurring d. demyelination of neurons is occurring

a

29. A patient with AKI has a high rate of catabolism. What is this related to? a. Increased levels of catecholamines, cortisol, and glucagon b. Inability to excrete excess electrolytes c. Conversion of body fat into glucose d. Presence of retained nitrogenous wastes

a

3. Which position is therapeutic and comfortable for a patient with lower back pain? a. semi-fowler's position with a pillow under the knees to keep them flexed b. supine position with arms and legs in a correct anatomical position c. orthopneic position; sitting with trunk slightly forward; arms supported on a pillow d. modified sims' position with upper arm and leg supported by pillows

a

3. you review ms js lab results. which finding is of most concern? a. serum potassium level of 7.1 b. serum creatinine of 15 c. BUN of 180 d. serum calcium of 7.8

a

30. A pt is suspected of having MG and a tensilon test has been ordered. What does the nurse do to prepare the pt for the test? a. ensure that the pt has a patent IV access b. draw a blood sample and send it for baseline analysis c. keep the pt NPO after midnight d. have the pt void before the beginning of the test

a

31. For which pt should the health care provider avoid prescribing rosiglitazone (avandia)? a. pt with symptomatic heart failure b. pt with new-onset asthma c. pt with kidney disease d. pt with hyperthyroidism

a

32. A patient with AKI is receiving total parenteral nutrition (TPN). What is the therapeutic goal of using TPN? a. Preserve a lean body mass b. Promote tubular reabsorption c. Create a nitrogen balance d. Prevent infection

a

36. A pt asks the nurse how insulin injection site rotation should be accomplished. What is the nurse's best response? a. "rotation within one site is preferred to avoid changes in insulin absorption" b. "change rotation sites after a week or two to avoid lipohypertrophy" c. "rotation from site to site each day is best for the best insulin absorption" d. "always rotate insulin injection sites within 4-5 inches from the umbilicus"

a

38. A pt with MG has generalized weakness and fatigue and is limited in the ability to perform ADLs. Which nursing action is best to help this pt avoid excessive fatigue? a. schedule activities after med admin b. schedule activities during the lat afternoon or early morning c. during periods of maximal strength, provide assistnace for ambulation d. instruct UAP to assist with all ADLs and feedings

a

39. The nurse is reviewing med orders for a pt with MG. The pt is scheduled to receive pyridostigmine (mestinon) on a daily basis. What does the nurse expect regarding this drug? a. daily dosage change related to pt symptoms b. administration 30 min after antacids such as milk of magnesia c. immediate monitoring for decreased muscle strength d. gradual tapering and weaning off the drug

a

40. A patent with CKD has a potassium level of 8 mEq/L. The nurse notifies the health care provider after assessing for which signs/symptom? a. Cardiac dysrhythmias b. Respiratory depression c. Tremors or seizures d. Decreased urine output

a

41. During shift report, the nurse learns that a pt with MG deteriorated toward the end of the shift and the physician was called. A tensilon test indicated the pt was having a myasthenic crisis. What is the priority problem for this pt? a. potential for inadequate oxygenation b. potential for decreased ability to perform ADLs c. potential for aspiration d. potential for increase in BP, pulse, and respirations

a

43. A patient with CKD develops severe chest pain, an increased pulse, low-grade fever, and a pericardial friction rub wth a cardiac dysrhythmia and muffled heart tones. The nurse immediately alerts the health care provider and prepares for which emergency procedure? a. Pericardiocentesis b. CVVH c. Kidney dialysis d. Endotracheal intubation

a

45. The nurse is reviewing urinalysis results for which patient who is in the early stages of CKD. What results might the nurse expect to see? a. Excessive protein, glucose, red blood cells, and white blood cells b. Increased specific gravity with a dark amber discoloration c. Dramatically increased urine osmolarity d. Pink-tinged urine with obvious small blood clots

a

47. A pt with MG is having difficulty maintaining an adequate intake of food and fluid because of difficutly chewing and swallowing. Which task for this pt is best to delegate to the UAP? a. weigh the pt daily b. monitor calorie counts c. ask the pt about food preferences d. evaluate intake and output

a

48. The patient with CKD reports chronic fatigue and lethargy with weakness and mild shortness of breath with dizziness when rising to a standing position. In addition, the nurse notes pale mucous membranes. Based on the patient's illness and the presenting symptoms, which laboratory result does the nurse expect to see? a. Low hemoglobin and hematocrit b. Low white cell count c. Low blood glucose d. Low oxygen saturation

a

5. which is the best goal for the nurse to include in the plan of care related to the problem statement of "acute pain related to strain on muscles with movement?" a) client reports pain of less than 1 on a 0-10 scale b) client will verbalize pain control methods c) client will learn alternative methods for pain control d) client will learn to live with long-term pain

a

5. you are the team leader supervising an lpn/lvn. which nursing care action for ms j should you delegate to the lpn/lvn? a. inserting a catheter intermittently to assess for residual urine b. planning restricted fluid amounts to be given with meals c. assessing breath sounds and noting increased presence of crackles d. discussing renal replacement therapies with the pt

a

53. In order to assist a patient in the prevention of osteodystrophy, which intervention does the nurse perform? a. Administer phosphate binders with meals b. Encourage high-quality protein foods c. Administer iron supplements d. Encourage extra milk at mealtimes

a

56. The nurse monitors a CKD patient's daily weights because of the risk for fluid retention. What instructions does the nurse give to the UAP? a. Weigh the a patient daily at the same time each day, same scale, with the same amount of clothing. b. Weigh the patient daily and add 1 kilogram for the intake of each liter of fluid c. Weight the patient in the morning before breakfast and weigh the patin at night just before bedtime d. Ask the patient what his or her normal weight is and then weigh the patient before and after each voiding

a

56. What type of exercise does the nurse recommend for the pt with diabetic retinopathy? a. non-weight-bearing activities such as swimming b. weight-bearing activities such as jogging c. vigorous aerobic and resistance exercises d. weight training and heavy lifting

a

59. The nurse is evaluating a patient's treatment response to erythropoietin (Epogen). Which hemoglobin reading indicates that the goal is being met? a. Around 10 g/dL b. Greater than 20 g/dL c. Upward trend d. At baseline for gender

a

6. The nurse is reviewing the cerebral spinal fluid (CSF) results for a pt with probable GBS. Which abnormal finding is common in GBS? a. increase in CSF protein level b. increase in CSF glucose level c. cloudy appearance of CSF d. elevation of lymphocyte count in CSF

a

60. A patient has been receiving erythropoietin (Epogen). Which statement by the patient indicates that the therapy is producing the desired effect? a. "I can do my housework with less fatique" b. " I have been passing more urine that I was before." c. " I have less pain and discomfort now." d. " I can swallow and eat much better than before."

a

70. The home health nurse is evaluating the home setting for a patient who wishes to have income hemodialysis. What is important to have in the home setting to support this therapy? a. Specialized water treatment system to provide a safe, purified water supply b. Large dust-free space to accommodate and store dialysis equipment c. Modified electrical system to provide high voltage to power the equipment d. Specialized cooling system to maintain strict temperature control

a

72. Which diabetic pt is at greatest risk for diabetic foot ulcer formation? a. 75 yr old african-american male with history of cardiovascular disease b. 53 yr old caucasian female with history of renal insufficiency c. 38 yr old american indian with history of gastric ulcers d. 28 yr old caucasian male with history of chronic kidney disease

a

73. A patient is undergoing a dialysis treatment and exhibits a progression of symptoms which include headache, nausea, and vomiting, and fatigue. How does the nurse interpret these symptoms? a. Mild dialysis disequilibrium syndrome b. Expected manifestations of ESKD c. Transcient symptoms in a new dialysis patient d. Adverse reaction to dialysis

a

76. The nurse is providing post dialysis care for a patient. In comparing vital signs and weight measurements to the predialysis data, what does the nurse expect to find? a. Blood pressure and weight are reduced b. Blood pressure is increased and weight is reduced c. Blood pressure and weight are slightly increased d. Blood pressure is low and weight is the same

a

79. A patient has returned to the medical-surgical unit after having a dialysis treatment. The nurse notes that the patient is also scheduled for an invasive procedure on the same day. What is the primary rationale for delaying the procedure for 4 to 6 hours? a. The patient was heparinized during dialysis b. The patient will have cardiac dysrhythmias c. The patient will be incoherent and unable to give consent d. The patient needs routine medicine that were delayed

a

8. which nursing intervention is included in the care plan when managing a client w/ Gardner-wells tongs? a. do not remove the traction weights and ensure they hang freely b. ensure that an extra set of drill bits are available in case a new set of predrilled holes must be made in ryan's skull c. place the velcro binders securely around ryan's head d. apply a halo vest when ryan is in the upright position

a

80. The nurse is talking to a patient with ESKD. The Patient frequently displays weight gain and increased blood pressure beyond the baseline of measurements. Which question is the nurse most likely to ask to determine if the patient is doing something that is contributing to these assessment findings? a. "Are you controlling your salt intake?" b. "Are you following the protein restrictions?" c. "Have you been eating a lot of sweets?" d. "Have you been exercising regularly.

a

84. What is the best action for the CAPD? a. Daily infusion of four 2 L exchanges of dialysate every 4 to 6 hours while awake b. Is a form of automated dialysis the uses an automated cycling machine c. Functions of the cycling machine are programmed to the patient's needs d. This form decreases the risk of peritonitis and poor dialysate flow.

a

85. The home health nurse is visiting a patient who independently performs PD. Which question does the nurse ask the patient to assess for the major complication associated with PD? a. "Have you noticed any signs or symptoms of infection." b. "Are you having any patin during the dialysis treatment." c. "Is the dialysis fluid slow or sluggish." d. "Have you noticed any leakage around the catheter."

a

89. The nurse is caring for a patient requiring PD. In order to monitor the patient's weight, what does the nurse do? a. Check the weight after a drain and before the next fill to monitor the patient's "dry weight." b. Calculate the "dry weight" by weighing the patient every day and comparing the measurements to baseline. c. Determine "dry weight" by comparing the patient's weight to a standard weight chart based on height and age. d. Weigh the patient each day and count fluid intake and dialysate volume to determine the patient's "dry weight"

a

9. The nurse is caring for a patient who had hypovolemic shock secondary to trauma in the emergency department (ED) 2 days ago. Based on the pathophysiology of hypovolemia and prerenal azotemia, what does the nurse assess at least every hour? a. Urinary output b. Presence of edema c. Urine color d. Presence of pain

a

A client is crying and grimacing but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." What is the priority intervention for this client? a) Encourage expression of fears and past experiences. b) Provide accurate information about the use of pain medication. c) Explain that addiction is unlikely among acute care clients. d) Seek family assistance in resolving this problem.

a

A client with diabetes stats, " I cannot eat big meals I prefer to snack throughout the day,: What information should the nurse include in a response to this client's statement? a. Regulated food intake is basic to control. b. salt and sugar restriction us the main concern. c. small, frequent meals are better for digestion d. large meals can contribute to a weight problem.

a

A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? a) Gabapentin (Neurontin) b) Corticosteroids c) Hydromorphone (Dilaudid) d) Lorazepam (Ativan)

a

A colostomy is scheduled to be done on a patient who has severe crohn's disease. What is the correct classification for this surgery? a. Palliative b. Minor c. Restorative d. Curative

a

A patient has an MH incident during surgery. To whom does the nurse report this incident? a. North American Malignant Hyperthermia Registry b. The Joint Commission c. Centers for Disease Control d. Occupational Safety and Health Administration

a

A pt reprots straining to pass ver small amounts of urine today, despite a normal fluid intake, and reports having the urge to urinate. the nurse placates the bladder and finds that it is distended. which conditions is mostly likely to be associated with these findings? a. urethral stricture b. hydroureter c. hydronephrosis d. PKD

a

A pt with PKD had nocturne. what does the nurse encourage the pt to do? a. drink at least 2 liters of fluid daily b. restrict fluid in the evening c. drink 1000ml early in the morning d. add a pinch of salt to water in the evenings

a

After a heparin drip is discontinued and the APTT is prescribed, what is the most important order the nurse would expect next? a. platelet count b. WBC count c. renal function tests d. monitor the clients fluid intake and output

a

An appendectomy is being performed on a patient with appendicitis. What is the correct classification for this surgery? a. Curative b. Diagnostic c. Urgent d. Radical

a

During heparin therapy, mrs b's APTT was monitored every 6 hours. The midnight results were APTT 120 seconds, control 35 seconds. What action should the nurse expect to initiate? a. increase the rate of infusion b. continue the rate of infusion c. decrease the rate of infusion d. recalculate the rate of infusion

a

During preoperative screening, the nurse discovers that the patient is allergic to shellfish. What is the nurse's best first action? a. Notify the surgeon b. Develop a plan to keep the patient safe c. Obtain an order for shellfish free diet d. Ask the patient if any other family members have the same allergy

a

In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? a) Assisting the client with preparation of a sitz bath b) Monitoring the client for signs of discomfort while ambulating c) Coaching the client to deep breathe during painful procedures d) Evaluating relief after applying a cold compress

a

Jess gets a ng tube and urinary catheter. The current iv fluid D5 1/4 NS is increased to 125ml/hr through the peripheral iv. Jess next dose of IV antibiotic which is compatible with the current iv solution is now due to be administered. What action should the nurse take? a. administer the dose as scheduled concurrently with the IV fluids b. stop the iv fluids until the dose of antibiotics is administered c. give the dose after the first liter of IV fluids is infused d. hold the dose until the HCP arrives to evaluate jess

a

Jess is scheduled for a flexible sigmoidoscopy and a barium enema. Which explanation of the procedure for the barium enema should the nurse provide jess? a. xray is used to visualized the large intestine after barium is instilled b. movement of barium in the colon is observed through a scope c. a barium based dye is injected IV, followed by abdominal scanning d. a digital exam is performed after the barium is removed by an enema

a

Natalie's nurse believes that the other nurses are incorrect in their understanding of Natalie's pain management. The nurse explains this to the other nurses, providing the nurses with accurate information about the pain management and addiction. 28. the nurse's response demonstrates what ethical principle? a) veracity b) fidelity c) teleology d) confidentiality

a

The female UAP assisting with Jess's care confides to the nurse on the unit that another hospital employee has made numerous sexual advances to her despite being asked to stop. The nurse recognizes that the UAP is protected under what legal statute? a. civil rights legislation b. state nurse practice act c. joint commission accreditation standards d. HIPPA

a

The nurse is caring for a pt with kidney cell carcinoma. what does the nurse expect to find documented about the pt;s initial assessment? a. flank pain, gross hematuria, palpable, kidney mass, and renal bruit b. gross hematuria, hypertension, diabetes, and oliguria c. dysuria, polyuria, dehydration, and palpable kidney masses d. nocturia and urinary retention with difficult starting stream

a

The nurse is reviewing the lab results of a pt with chronic glomerulonephritis. the phosphorus level of 5.3 mg/dL. what else does the nurse expect to see? a. serum calcium level below the normal range b. serum potassium level below the normal range c. falsely elevated serum sodium level d. elevated serum levels for all other electrolytes

a

The nurse notes bright-red blood with numbers clots int he urinary drainage bag for a patient who had a TURP. After notifying the surgeon, what does the nurse do next? A. Irrigate the catheter with normal saline per protocol B. Remove the urinary catheter and save the tip for culture C. Start an IV infusion and draw blood for type and cross D. Empty the drainage bag and record the appearance of output

a

The plan of are or a diabetic patient includes all o these interventions. Which intervention should you delegate to a UAP? a. Checking to make sure that the patient's bath water is not too hot b. Discussing community resources for diabetic outpatient care c. teaching the patient to perform daily foot inspection d. assessing the patient's technique for drawing insulin into a syringe

a

What do you anticipate the physician will order for initial fluid replacement>? a. Normal saline (0.9% sodium chloride) b. Half-strength saline (0.45% sodium chloride) c. Dextrose 5% in water and half-strength saline d. Normal saline with potassium chloride

a

What is the nurses best response to jess? a. this all seems very overwhelming right now b. i know you are feeling very angry about this c. you wont have to quit college or move home d. you are beginning to cope with a new situation

a

What physical assessment should the nurse perform to assist in the dx of suspected DVT? a. measure calf circumference bilaterally b. observe for excessive bruising c. perform test for homans sign d. auscultate for bruits

a

What should the nurse tell mrs. b to avoid while on warfarin a. alcohol b. TV c. coffee d. soda

a

When an analgesic is titrated to manage pain, what is the priority goal? a) Titrate to the smallest dose that provides relief with the fewest side effects. b) Titrate upward until the client is pain free. c) Titrate downward to prevent toxicity. d) Titrate to a dosage that is adequate to meet the client's subjective needs.

a

Which action can be delegated by the nurse to a UAP who is assigned to the nurse caring for mrs. B a. obtain a stool specimen for guaiac b. assess skin for bruising c. teach the client to use a soft toothbrush d. review the side effects of anticoagulants

a

Which additional serum lab values best reflects nutritional malabsorption? a. albumin 1.5g/dl b. calcium 8.5mg/dl c. BUN 20 d. sodium 148

a

Which nursing intervention is most appropriate for the patient in the operative setting? a. Provide a climate of privacy, comfort, and confidentiality when caring for the patient b. Instruct the patient after the preoperative medication has taken effect, he or she will be drowsy c. Avoid discussing the activities taking place around the patient while in the holding area d. Assist members of the surgical team readying the operating room suite

a

Which statement is true regarding the patient who has given consent for a surgical procedure? a. Information necessary to understand the nature of and reason for the surgery has been provided b. The length of stay in the hospital has been preapproved by the managed care provider c. Information about the surgeons experience has been provided d. The nurse has provided detailed information about the surgical procedure

a

Which vital sign requires follow up by the nurse? a. BP of 160/88 b. Pulse of 68 beats/min c. Respirations of 14 breaths/min d. Temperature of 97F

a

Why may a pt with PKD experience constipation? a. polycystic kidneys enlarge and put pressure on the large intestine b. pt becomes dehydrated because the kidneys are dysfunctional c. constipation is a side effect from the medications given to treat PKD d. pt's with PKD have special dietary restrictions that cause constipation

a

You overhear one of the UAP talking to someone on the phone. The UAP says, "Yes, Mr. D is doing much better than when he first got here. I will tell him that you called and I will give him your message." What will you do first? a. ask the UAP about the phone conversion that you just overheard b. remind the UAP that release of information is outside of her scope of practice c. Report the UAP to the nurse manager for HIPAA violation d. Give the positive feedback for trying to help the client and the caller.

a

a 53-year-old pt is newly diagnosed with renal artery stenosis. what clinical manifestation is the nurse most likely to observe when the pt first seeks health care? a. sudden onset of hypertension b. urinary frequency and dysuria c. nausea and vomiting d. flank pain and hematuria

a

a pt had a nephrostomy and a nephrostomy tube is in place. what is included in the postop care of this pt? a. assess the amount of drainage in the collection bag b. irrigate the time to ensure patency c. keep the pt NPO for 6 to 8 hours d. review the results of the clotting studies

a

a pt has come to the clinic for follow-up of acute pyelonephritis. which action does the nurse reinforce to the pt? a. complete all antibiotics regimens b. report episodes of nocturia c. stop taking the antibiotics when pain is relieved d. avoid taking any over-the-counter drugs

a

a pt has had one kidney removed as a treatment for kidney cancer. the pt's spouse ask, "Does the good kidney take over immediately? I know a person can live with just one kidney." what is the nurse's best response? a. the other kidney will provide adequate function, but this may take days or weeks. b. the other kidney alone isn't able to provide adequate function, so supplemental therapies will be needed c. thats a gapped question. remember to ask your doctor next time he or she comes in d. it caries a lot, but within a few days we expect everything to normalize

a

a pt is admitted for acute glomerulonephritis. in reviewing the pt's past medical hx, which systemic condition does the nurse suspect ma have caused acute glomerulonephritis and will include in the overall plan of care? a. systemic lupus erythematous and diabetic nephropathy b. myocardial infarction and atrial fibrillation c. ischemic stroke and hemiparesis d. blunt trauma to the kidney with hematuria

a

a pt is diagnosed with hydronephrosis. what is a complication that could result from this condition? a. damage to the nephrons b. kidney cancer c. kidney stone d, structural defects

a

a pt is newly diagnosed with type 2 diabetes mellitus. which screening recommendation does the nurse give to the pt regarding the early detection of diabetic kidney disease? a. urine should be tested annually for protein and mircoalbuminuria b. blood urea nitrogen and serum creatinine should tested within 5 years c. urine should be tested within 5 years for protein and microalbuminuria d. urine should be tested annually for protein, glucose, and blood

a

a pt with PKD usually experiences constipation. what does the nurse recommend? a. increased dietary fiber and increased fluids b. decreased dietary fiber and laxatives c. daily laxatives and increased exercise d. tap-water enemas and fiber supplements

a

a pt with acute glomerulonephritis is required to provide a 240hour urine specimen. what does the nurse expect to see when looking at the specimen? a. smoky or cola-colored urine b. clear and very dilute urine c. urine that is fun of pus and very thick d. bright orange-colored urine

a

as charge nurse, you would assign the nursing care of which pt to an LPN, working under the supervision of an RN? a. 48-year-old with cystitis who is taking oral antibiotics b. 64-year-old with kidney stones who has a new order for lithotripsy c. 72-year-old with urinary incontinence who needs bladder training d. 52-year-old with pyelonephritis who has severe acute flank pain

a

for a pt with PKD, which antihypertensive medication may be used because it helps control the cell growth aspects of PKD and reduce microalbuminuria? a. angiotensin-converting enzyme inhibitors b. beta blockers c. calcium channel blockers d. vasodilators

a

on the second postop day, the nurse observes that Natalie is no longer self-administering demand doses of the morphine. 24. what is the most likely reason for this change? a) she is receiving adequate pain control without the additional doses b) she has developed tolerance to the effects of the medication c) she is addicted to the dose of morphine that is still infusing d) the IV line is infiltrated and she no longer obtains any pain relief

a

the health care team is using a collaborative and interdisciplinary approach to design a treatment plan for a pt with PKD. what is the top priority? A. Controlling hypertension b. preventing rupture cysts c. providing genetic counseling d. identifying community resources

a

the nurse is caring for a pt with a nephrostomy. the nurse notifies the health care provider about which assessment findings? a. urine drainage is red-tinged 4 hours post surgery b. amount of drainage decreased and the pt has back pain c. there is a small steady drainage for the first 4 hours postsurgery d. the nephrostomy site looks dry and intact

a

the nurse is reviewing arterial blood gas results of a pt with acute glomerulonephritis. the pH of the sample is 7.35. As acidosis is likely to be present because of the hydrogen ion retention and loss of bicarbonate, how does the nurse interpret this data? a. normal pH with respiratory compensation b. acidosis with failure of respiratory compensation c. alkalosis with failure of respiratory compensation d. normal pH with metabolic compensation

a

the nurse is reviewing the lab results for a pt with chronic glomerulonephritis. the serum albumin level is low. what else does the nurse expect to see? a. proteinuria b. elevated hematocrit c. high specific gravity d. low white blood cell count

a

the off-going nurse is giving shift report to the oncoming nurse about the care of a pt who has nepohrostomy tube placed 3 days ago and it is to remain in place until the urinary obstruction is resolved. what is the most important point to clearly communicate about the urine drainage? a. urine is draining only into the collection bag, not the bladder, therefore the minimum expected drainage is 30mL/hour b. for the first 24 hours postoperatively, the amount of urinary drainage was assessed every hour c. the surgeon placed ureteral tubes so al the urine may pass through the blaster or all the urine might go directly into the collection bag d. the nephrostomy site has not been leaking any blood or urine and you should continue to monitor the site for leakage

a

which clinical manifestation in a pt with an instruction in the urinary system is associated specifically with a hydronephrosis? a. flank asymmetry b. chills and fever c. urge incontinence d. decreased urine volume

a

which pt has the greatest risk of developing a kidney abscess? a. pt is diagnosed with acute pyelonephritis b. pt had flank asymmetry related to hydronephrosis c. pt developed a urinary tract infection secondary to urinary catheter d. pt is diagnosed with hypertension and nephrosclerosis

a

you are the admitting nurse for a pt with nephrotic syndrome. which assessment finding supports this diagnosis? a. edema formation b. hypotension c. increased urine output d. flank pain

a

The nurse expects to alter jess's oral intake in what way? a. Jess should be NPO b. Jess should be given clear liquids only c. jess should be given full liquids only d. jess should be encouraged to eat any foods she can tolerate

a (toxic megacolon can result in bowel obstruction and intestinal perforation; jess needs a NG tube)

A patient in traction reports severe pain from a muscle spasm. What is the nurse's priority action? a) Assess the patient's body alignment. b) Give the patient prn pain medication. c) Notify the heath care provider. d) Remove some of the weights.

a) Assess the patient's body alignment.

The nurse is caring for a patient with skeletal pins that have been placed for traction. What does the nurse expect to see in the first 48 hours? a) Clear fluid drainage weeping from the pin insertion site b) Some bloody drainage, but very minimal c) Swelling at the site with tenderness to gentle touch d)Dressings around the pin sites to be dry and intact

a) Clear fluid drainage weeping from the pin insertion site

A chronic complication of bone healing is called avascular necrosis. Which statements about this complication are true? (Select all) a) It involves disrupting the blood supply to the bone. b) It occurs when fat globules disrupt blood supply to the bone. c) It involves disrupting the nerve supply to the bone. d) It results in the death of bone tissue. e) It is most often a complication of hip fractures.

a) It involves disrupting the blood supply to the bone. d) It results in the death of bone tissue. e) It is most often a complication of hip fractures.

The nurse is caring for a patient with a external fixation of a bone fracture. What are the advantages of this type of treatment? (Select all) a) It is less painful than other treatments. b) It allows for earlier ambulation. c) It decreases the risk for infection. d) It maintains bone alignment. e) It stabilizes commuted fractures that require bone grafting.

a) It is less painful than other treatments. b) It allows for earlier ambulation. d) It maintains bone alignment. e) It stabilizes commuted fractures that require bone grafting.

The nurse is caring for several patients on an orthopedic trauma unit. Which conditions have a high risk for development of acute compartment syndrome? (select all) a) Lower legs caught between the bumpers of two cars b) Massive infiltration of IV fluid into forearm c) Bivalve cast on lower leg d) Multiple insect bites to lower legs e) Daily use of oral contraceptives f) Severe burns to upper extremities

a) Lower legs caught between the bumpers of two cars b) Massive infiltration of IV fluid into forearm d) Multiple insect bites to lower legs f) Severe burns to upper extremities

the nurse is caring for a patient who had a kyphoplasty. What does postoperative care for this patient include? (Select all) a) Monitor and record vital signs b) Perform frequent neurologic assessments. c) Apply a warm pack to the puncture site if needed to relieve pain. d) Assess the patient's pain level and compare it to the preoperative level. e) Give opioid analgesics as needed. f) Monitor for bleeding at the puncture site.

a) Monitor and record vital signs b) Perform frequent neurologic assessments. d) Assess the patient's pain level and compare it to the preoperative level. f) Monitor for bleeding at the puncture site.

Which is a potentially fatal complication of acute compartment syndrome? a) Myoglobinuric renal failure b) Ischemic heart failure c) Acute liver failure d) Hypovolemic shock

a) Myoglobinuric renal failure

A patient with a long leg cast that was applied in the ED is being admitted to the orthopedic unit. Which task is the best for the nurse to delegate to the UAP? a) Obtain a fracture pan and use caution to prevent spilage on the cast. b) Obtain several plastic-covered pillows for elevation of the leg. c) Check flexion/extension and color of the toes. d) Turn the patient every 4 to 6 hours to allow the cast to dry.

a) Obtain a fracture pan and use caution to prevent spilage on the cast.

An older patient's family is trying to find an appropriate cane for the patient to use because of chronic pain in the right ankle. The nurse instructs the family to purchase which type of cane? a) One with the top being parallel to the greater trochanter of the femur b) One that creates about 45 degrees of flexion of the elbow c) One that is based on the patient's weight to provide adequate support d) One that has padding on the handle grip to ensure safety

a) One with the top being parallel to the greater trochanter of the femur

A female patient with osteoporosis comes to the ED after falling suddenly while opening her car door. She said it felt as though her "leg gave away" and caused her to fall. What type of fracture does this patient likely have? a) Pathologic (spontaneous) b) Spiral c) Impacted d) Incomplete

a) Pathologic (spontaneous)

Which factors affect bone healing after a fracture has occurred? (Select all) a) Patient's age b) Patient's Occupation c) Type of bone injured d) How the fracture is managed e) Presence of infection at the fracture site

a) Patient's age c) Type of bone injured d) How the fracture is managed e) Presence of infection at the fracture site

An older adult sustained injury to the lower legs after being trapped underneath a fallen bookcase. Because the patient is at high risk for crush syndrome, which laboratory values will the nurse specifically monitor? a) Serum potassium level and myoglobin in urine b) White cell count and red cells in the urine c) Prothrombin level and serum lipase level d) Platelet count and serum calcium level

a) Serum potassium level and myoglobin in urine

The nurse is caring for a patient in Buck's (skin) traction. Which task is best to delegate to the UAP (with supervision)? a) Turning and repositioning b) Inspecting heels and sacral area c) Asking the patient about muscle spasms d) Adjusting the weights on the apparatus

a) Turning and repositioning

The nurse is caring for a patient with an open fracture. Which intervention does the nurse preform to prevent infection of the fracture? a) Use clean or aseptic technique for dressing changes and wound irrigations. b) Use clean technique for dressing changes and wound irrigations. c) Place the patient in contact isolation and wear sterile gloves. d) Place the patient in reverse isolation and wear sterile gloves.

a) Use clean or aseptic technique for dressing changes and wound irrigations.

The nurse is educating a patient who will have external fixation for treatment of a compound tibial fracture. What information does the nurse include in the teaching session? a) the device allows for early ambulation b) There is some danger of blood loss, but no danger of infection c) The device is a substitute therapy for a cast d) The advantage of the device is rapid bone healing

a) the device allows for early ambulation

The nurse has received a patient in the holding area who is scheduled for a left femoral-popliteal bypass. What are the priority safety measures for this patient before surgery? (select all that apply) a. The operative limb is marked by the surgeon. b. The patient is positively identified by checking the name and date of birth c. The patient is asked to confirm the marked operative limb. d. The patient is identified by checking the name and room number. e. The patient is instructed to verify any family members waiting.

a, b, c

Which clinical features are found in an MH crisis? (select all that apply) a. Sinus tachycardia b. Tightness and rigidity of the patient's jaw area c. Lowering of the BP d. A decrease in the end tidal carbon dioxide level e. Skin mottling and cyanosis f. An extremely elevated temperature at onset g. Tachypnea

a, b, c, e, g

A patient with type 1 diabetes mellitus is scheduled for surgery at 0700. Which actions must the nurse perform for this patient before he goes to the operating room? (select based on priority order) a. Modify the dose of insulin given based on the patients blood glucose b. Complete the preoperative checklist before transfer to surgical suite c. Teach the patient about foot care and properly fitted shoes d. Delegate obtaining the patient's accucheck and vital signs to the unlicensed assistive personnel e. Check if the patient has any jewelry on and call security to secure valuables

a, b, d, e

The 79 year old patient with type 2 diabetes is scheduled for surgery to remove his left great toe. Which risk factors for complications of surgery does the nurse assess for in this patient? (select all that apply) a. Presence of chronic illnesses b. Problems with healing c. Absence of smoking history d. Dehydration e. Electrolyte imbalances f. Daily exercise routine

a, b, d, e

The nurse has given the ordered preoperative medications to the patient. What actions must the nurse take after administering these drugs? (select all that apply) a. Raise the side rails b. Place the call light in the patients reach c. Ask the patient to sign the consent form d. Instruct the patient not to get out of bed e. Place the bed in lowest position

a, b, d, e

Which are the focus areas for the surgical care improvement project? (select all that apply) a. Prevention of infection b. Prevention of respiratory complications c. Prevention of serious cardiac events d. Prevention of venous thromboembolism e. Prevention of acute kidney injury

a, c, d

Which interventions must the operating room nurse provide for patient physiological integrity during the intraoperative period? (select all that apply) a. Apply padding to the OR bed to protect skin integrity b. Communicate patients fears about anesthesia to the nurse anesthetist c. Monitor patient's airway, VS, ECG, and oxygen saturation during and after sedation d. Assess and document skin condition before transferring patient to the postanesthesia care unit e. Ensure that patients wishes with regard to advance directives are respected

a, c, d

To reduce the incidence of patients with a known history or risk of malignant hyperthermia, what best practices are put in place in the OR? (select all that apply) a. List of medications available for emergency treatment of MH b. Genetic counseling after each episode of MH c. Dedicated MH cart with treatment medications d. Treatment before, during and after surgery if the patient has a known history or risk e. Additional nursing support on call if MH develops f. Available MH hotline number

a, c, d, e, f

During surgery, what things do anesthesia personnel monitor, measure and assess? (select all that apply) a. Intake and output b. Room temperature c. Cardiopulmonary function d. Level of anesthesia e. Family concerns f. VS

a, c, d, f

Which patient would be a candidate for moderate sedation? (select all that apply) a. Endoscopy b. C-section delivery c. Closed fracture reduction d. Cardiac catheterization e. Suturing a laceration f. Abdominal surgery g. Cardioversion

a, c, d, g

What other steps can the nurse take to reduce post-op risk of embolization formation? select all that apply a. provide adequate hydration b. increase the use of sedation c. use elastic stockings or sequential compression devices when indicated d. mobilize and ambulate the client as early as possible e. perform routine administration of weight based heparin IV or give low molecular weight heparin when indicated

a, c,d,e`

What techniques are essential to performing a proper surgical scrub of the hands by the surgeon, assistants, and scrub nurse? (select all that apply) a. Use a broad spectrum surgical antimicrobial solution b. Scrub for 2 minutes, followed by a rinse with water c. Use an alcohol based antimicrobial solution d. Hold hands higher than the elbows during the scrub and rinse e. Scrub for 3-5 minutes followed by a rinse with water f. Hold hands below the elbows during the scrub and rinse

a, d, e

Which postoperative interventions will the nurse typically teach a patient to prevent complications following surgery? (select all that apply) a. ROM exercises b. Massaging of lower extremities c. Taking pain medication only when experiencing severe pain d. Incision splinting e. Deep breathing exercises

a, d, e

172. a client with arthritis increases the dose of ibuprofen (motrin, advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The health care provider determines that the client is severely anemic and admits the client to the hospital. What clinical indicators does the nurse expect to identify when performing an admission assessment? (select all that apply) a) melena b) tachycardia c) constipation d) clay-colored stools e) painful bowel movements

a,b

15. The nurse is caring for a patient receiving gentamicin. Because this drug has potential for nephrotoxicity. which laboratory results does the nurse monitor? (select all that apply) a. Blood urea nitrogen (BUN) b. Creatine c. Drug peak and trough levels d. Prothrombin time (PT) e. Platelet count f. Hemoglobin and hematocrit

a,b,c

66. Which are the most accurate ways to monitor kidney function in the patient with CKD? (select all that apply) a. Monitoring intake and output b. Checking urine specific gravity c. Reviewing BUN and serum creatinine levels d. Reviewing x-ray reports e. Consulting dietitian's notes

a,b,c

Which interventions are preventative measures for at home? a. use a soft bristled toothbrush and avoid flossing b. shave with an electric razor instead of a blade razor c. inspect the legs and feet daily d. run a dehumidifier day and night e. continue warfarin prior to any invasive procedure f. briskly massage any red, tender areas in calf

a,b,c

15. Increased risk for oxygen toxicity is related to which factors? select all that apply a. continuous delivery of oxygen at greater than 50% concentration b. delivery of a high concentration of oxygen over 24-48 hrs c. the severity and extent of lung disease d. neglecting to monitor the pts status and reducing oxygen concentration asap e. adding continuous positive airway pressure or positive end expiratory pressure

a,b,c,d

68. The nurse is assessing a patient with uremia. Which gastrointestinal changes does the nurse expect to find? (select all that apply) a. Halitosis b. Hiccups c. Anorexia d. Nausea e. Vomiting f. Salivation

a,b,c,d,e

1. Which problems occur with acute kidney injury (AKI)? (select all that apply) a. Decreased peristalsis b. Anemia c. Metabolic acidosis d. Hypokalemia e. Peripheral edema

a,b,c,e

51. In collaboration with the registered dietitian, the nurse teaches the patient about which diet recommendations for management of CKD? (select all that apply) a. Controlling protein intake b. Limiting fluid intake c. Restricting potassium d. Increasing sodium e. Restricting phosphorus f. Reducing calories

a,b,c,e

7. The nurse is caring for several post-op pts at risk for developing PE. Which interventions does the nurse use to help prevent the development of PE in these pts? select all that apply a. start passive and active ROM exercises for the extremities b. ambulate post-op pts soon after surgery c. use antiembolism devices postop d. elevate legs in an extended position e. change pt position every 4-6 hrs f. administer drugs to prevent episodes of valsalva maneuver

a,b,c,f

11. Which complications of DM are considered emergencies? (select all that apply) a. DKA b. hypoglycemia c. diabetic retinopathy d. hyperglycemic-hyperosmolar state (HHS) e. diabetic neuropathy

a,b,d

32. what is a nurse's responsibility when administering prescribed opioid analgesics? (select all that apply) a) count the client's respirations b) document the intensity of the client's pain c) withhold the medication if the client reports pruritus d) verify the number of doses in the locked cabinet before administering the prescribed dose e) discard the medication in the client's toilet before leaving the room if the medication is refused

a,b,d

4. A patient can develop intrarenal kidney injury from which causes? (select all that apply.) a. Vasculitis b. Pyelonephritits c. Strenuous exercise d. Exposure to nephrotoxins e. Bladder cancer

a,b,d

5. Which parameters does the nurse monitor to ensure that a pts response to oxygen therapy gas exchange is adequate? select all that apply a. LOC b. respiratory pattern c. oxygen flow rate d. pulse oximetry e. respiratory rate

a,b,d

21. A pt requires oxygen therapy with a nasal cannula. Which interventions will the nurse teach the student nurse providing care for this pt? select all that apply a. make sure that the prongs on the nasal cannula are properly positioned in the nares b. apply a water soluble gel to the nares as needed c. adjust the flow rate between 1 and 8l/min based on how the pt is feeling d. be sure to assess that both nares are patent e. assess the pt for any changes in respiratory rate and pattern

a,b,d,e

21. Which statements about type 2 DM are accurate? (select all) a. it peaks at about the age of 50 b. most people with type 2 DM are obese c. it typically has an abrupt onset d. people with type 2 DM have insulin resistance e. it can be treated with oral antidiabetic medications and insulin

a,b,d,e

25. A pt is at risk for aspiration. Which instructions must the nurse provide to the UAP prior to feeding the pt? select all that apply a. position the pt in the most upright position possible b. provide adequate time; don't hurry the pt c. provide sips of water or milk between bites of food to help with swallowing d. encourage the pt to tuck their chin down and move the forehead forward while swallowing e. if the pt coughs, stop the feeding until he/she indicates that the airway has been cleared

a,b,d,e

35. Which characteristics are associated with ESKD? (select all that apply) a. Severe fluid overload b. Renal osteodystrophy c. Nephrons compensate d. Dialysis or transplant needed to maintain homeostasis e. Excessive water products

a,b,d,e

49. Intensive therapy with good glucose control results in delays in which diabetic complications? (select all) a. macrovascular disease b. cardiovascular disease c. stroke d. retinopathy e. nephropathy f. neuropathy

a,b,d,e,f

57. A patient with CKD is taking digoxin (Lanoxin). Which symptoms of digoxin toxicity does the nurse vigilantly monitor for? (select all that apply) a. Nausea and vomiting b. Visual changes c. Respiratory depression d. Restlessness or confusing e. Headache or fatigue f. Tachycardia

a,b,d,e,f

6. When shock or other problems cause an acute reduction in blood flow to the kidneys, how do the kidneys compensate? (select all that apply) a. Constrict blood vessels in the kidneys. b. Activate the renin-angiotensin-aldosterone pathway. c. Release beta blockers. d. Dilate blood vessels throughout the body. e. Release antidiuretic hormones.

a,b,e

96. What might the nurse notice if the patient is experiencing reduced perfusion and altered urinary elimination related to AKI? (select all that apply) a. Hemodynamic instability, especially persistent hypotension and tachycardia b. Urine output of less than 0.5 mL/kg/hour for 6 or more hours c. Serum creatinine below baseline or admission values d. Urine may be clear or have a pale yellow color e. Abnormal serum and urine potassium and sodium values

a,b,e

27. Which signs/symptoms does the nurse expect to see in the patient with AKI that has progressed in severity? (select all that apply) a. Oliguria b. Hypotension c. Shortness of breath d. Pulmonary crackles e. Weight loss

a,c,d

31. The nurse is caring for a patient in the intensive care unit who sustained a blood loss during a traumatic accident. For early identification of sings and symptoms would suggest the development of kidney dysfunction, what does the nurse observe for? (select all that apply) a. Hypotension b. Bradycardia c. Decreased urine output d. Decreased cardiac output e. Increased central venous pressure

a,c,d

17. Which factors are considered hazards associated with oxygen therapy? select all that apply a. increased combustion b. oxygen narcosis c. oxygen toxicity d. absorption atelectasis e. oxygen induced hypoventilation

a,c,d,e

69. Which patients with CKD are candidates for intermittent hemodialysis? (select all that apply) a. Patient with fluid overload who does not respond to diuretics b. Patient with injury stage according to RIFLE classification c. Patient with symptomatic toxin ingestion d. Patient with uremic manifestations. such as decreased cognition e. Patient with symptomatic hyperkalemia and calciphylaxis

a,c,d,e

78. The nurse is preparing to teach a diabetic pt how to select appropriate shoes. Which points must be included in the teaching plan? (select all) a. "it is best to have the shoes fitted by an experienced shoe fitter such as a podiatrist" b. "the shoes should be 1-1.5 inches longer than your longest toe" c. "the heels of the shoes should be less than 2 inches high d. "avoid tight-fitting shoes, which can cause tissue damage to your feet" e. "you should get at least two pairs of shoes so you can change them at midday and in the evening"

a,c,d,e

Which clients must be assigned to an experienced RN? (Select all that apply.) a) Client who was in an automobile crash and sustained multiple injuries b) Client with chronic back pain related to a workplace injury c) Client who has returned from surgery and has a chest tube in place d) Client with abdominal cramps related to food poisoning e) Client with a severe headache of unknown origin f) Client with chest pain who has a history of arteriosclerosis

a,c,d,e

23. The nurse is taking a history of a patient at risk for kidney failure. What does the nurse ask the patient about during the interview? (select all that apply) a. Exposure to nephrotoxic chemicals b. Increased appetite c. History of diabetes mellitus, hypertension, systemic lupus erythematous d. Recent surgery, trauma, or transfusions e. Leakage of urine when coughing or laughing f. Recent or prolonged use of antibiotics and NSAIDS

a,c,d,f

1. At what times is oxygen therapy needed for a pt? select all that apply a. to treat hypoxia b. to treat hypothermia c. to treat hypoxemia d. When the normal 35% oxygen level in the air is inadequate e. When the normal 21% oxygen level in the air is inadequate

a,c,e

1. Which are the risk factors for pulmonary embolism and DVT? select all that apply a. trauma b. swimming activity c. heart failure d. COPD e. cancer (particularly lung/prostate)

a,c,e

32. The pt with type 2 diabetes is prescribed sitagliptin (Januvia) for glucose regulation. Which key changes does the nurse teach a pt to report to the health care provider immediately? (select all) a. report any signs of jaundice b. report any signs of bleeding c. report any blue-grey discoloration of the abdomen d. report any cough or flu symptoms e. report any sudden onset of abdominal pain

a,c,e

14. The nurse is caring for a pt with a post-op complication of PE. The pt has been receiving treatment for several days. Which factors are indicators of adequate perfusion in the pt? select all that apply a. pulse oximetry of 95% b. ABG, pH of 7.28 c. pts subjective desire to go home d. absence of pallor or cyanosis e. mental status at pts baseline

a,d,e

4. What are the hazards of administering oxygen therapy? select all that apply a. oxygen supports and enhances combustion b. oxygen can burn c. each electrical outlet in the room must be covered if not in use d. all electrical equipment in the room must be grounded to prevent fires e. solutions with high concentrations of alcohol or oil can't be used in the room

a,d,e

54. The home health nurse is reviewing the medication list of a patient with CKD. The nurse calls the health care provider as a reminder that the patient might need which nutritional supplements? (select all that apply) a. Iron b. Magnesium c. Phosphorus d. Calcium e. Vitamin D f. Water-soluble vitamins

a,d,e,f

Which information does the nurse include when teaching a patient with new onset hemorrhoids about prevention of hemorrhoid flare-up? Select all that apply a. "Increase the fiber in your diet to prevent constipation." b. "Do not participate in any physical exercise." c. "Maintain a healthy weight." d. "Increase your amount of fluid intake." e. "Prolonged sitting or standing will not affect the development of hemorrhoids."

a. " increase the fiber in your diet to prevent constipation" c. "Maintain a healthy weight" d. "Increase your amount of fluid intake"

A patient is prescribed sulfasalazine (Azulfidine) for the treatment of ulcerative colitis. Which patient statement indicates the patient is experiencing a side effect of this drug? a. "My skin is covered with a rash" b. "My knees hurt." c. "My appetite has increased." d. "I wake up at night sweating sometimes."

a. " my skin is covered with a rash"

Which statements does the nurse include while providing discharge instructions for a patient with giardiasis? Select all that apply a. "Avoid contact with stool from dogs and beavers" b. "All household and sexual partners should have stool examinations for parasites" c. "Treatment will most likely consist of metronidazole (Flagyl)" d. "Infection can't be transmitted to others until the amebicides kill the parasites" e. "Stools are examined 6 days after treatment to asses for eradication."

a. "Avoid contact with stool from dogs and beavers" b. "All household and sexual partners should have stool examinations for parasites" c. "Treatment will most likely consist of metronidazole (Flagyl)" d. "Infection can't be transmitted to others until the amebicides kill the parasites"

A patient with ulcerative colitis who has had an ileostomy is being discharged home. The nurse has provided discharge teaching. Which statements by the patient indicate the teaching has been effective? Select all that apply a. "I will avoid foods that cause gas" b. "I will call the health care provider if I have a fever over 101°F" c. "I will change the adhesive for the appliance daily." d. "I know the pouch needs emptying when I feel pain in that area." e. "I will call the healthcare provider if I feel like my heart is beating fast"

a. "I will avoid foods that cause gas" b. "I will call the health care provider if I have a fever over 101°F" e. "I will call the healthcare provider if I feel like my heart is beating fast"

Which discharge instructions does the nurse include for a patient after abdominoperitoneal resection? a. use a soft pillow to sit on whenever you sit down b. Lie on your back when you are resting in bed c. use a rubber doughnut device for sitting on when in the car d. sit in a chair for at least 4 consecutive hours a day

a. "use a soft pillow to sit on whenever you sit down"

10. The nurse is administering ketorolac (toradol) to a 78 yo pt for mild to moderate pain management. Which assessment finding indicates the pt is experiencing a side effect of this drug? a. Abdominal bloating and cramping b. Ventricular cardiac dysrhythmias c. Decreased urinary output d. Jaundice

a. Abdominal bloating and cramping

Which drug is the drug of choice for the treatment of IBS when pain is the predominant symptom? a. Amitriptlyine (Elavil) b. Fesoterodine (Toviaz) c. Loperamide (Imodium) d. psyllium hydrophilic mucilloid (Metamucil)

a. Amitriptyline (Elavil)

5. Which are common manifestations of acute cholecystitis? SELECT ALL a. Anorexia b. ascites c. Eructation d. Steatorrhea e. Jaundice f. Rebound tenderness

a. Anorexia c. Eructation e. Jaundice f. Rebound tenderness

The patient has a diagnosis of irritable bowel syndrome. What forms can IBS take? select all that apply a. diarrhea (IBS-D) b. constipation (IBS-c) c. Bloating (IBS-B) d. alternating diarrhea and constipation (IBS-A) e. mix of constipation and diarrhea (IBS-M)

a. Diarrhea (IBS-D) b. Constipation (IBS-C) d. Alternating diarrhea and constipation (IBS-A) e. Mix of constipation and diarrhea (IBS-M)

Which question is most important for the nurse to ask Ms Jackson during the admission interview? a. Have you had anything to eat or drink since midnight? b. Are any of your family members or friends here with you? c. Do you understand you will be admitted to the hospital following surgery? d. Did you bring any valuables with you that needs to be stored during surgery?

a. Ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery

Which are potential complications of polyps? Select all that apply a. Gross rectal bleeding b. Colorectal cancer c. Intestinal obstruction d. Septic shock e. Intussusception

a. Gross rectal bleeding c. Intestinal obstruction e. Intussusception

20. The pt with acute pancreatitis experiences abdominal pain. What is the best intervention to begin management of this pain? a. IV opioids by means of PCA b. Oral opioids such as morphine sulfate given as needed c. Intramuscular opioids given every 6 hours d. Oral hydromorphone (dilaudid) given twice a day

a. IV opioids by means of PCA

The nurse is to administer alvimopan (Entereg) to a patient with postoperative ileus (POI). What is the action of this drug? a. Increases gastrointestinal (GI) motility b. Laxative for bowel movement c. Antibiotic to prevent infection d. Prevents nausea and vomiting

a. Increases gastrointestinal (GI) motility

Darifenacin (Enablex) is an example of a new group of drugs that may be used to manage IBS. What action of this drug would make it suitable for treatment of IBS? a. inhibits intestinal motility b. decreases abdominal distention c. Eliminates constipation d. increases fluid in the intestines

a. Inhibits intestinal motility

Which statements regarding rheumatoid arthritis (RA) are true? (Select all that apply.) a. It is a chronic, progressive, systemic, inflammatory process. b. It primarily affects the synovial joints c. It is known to have periods of remission d. It occurs most often in older men and women e. It often involves an inflamed, red rash.

a. It is a chronic, progressive, systemic, inflammatory process. b. It primarily affects the synovial joints c. It is known to have periods of remission

13. Which statements are true regarding laparoscopic cholecystectomy? SELECT ALL a. Laparoscopic cholecystectomy is considered the gold standard and is performed far more often than the traditional open approach. b. Pts with chronic lung disease or HF who are unable to tolerate the oxygen used in the laparoscopic procedure are examples of pts who have the open approach (Abdominal laparotomy) c. Removing the gallbladder with the laparoscopic technique reduces the risk of wound complications d. Pts who have their gallbladders removed by the laparoscopic technique should be taught the importance of early ambulation to promote absorption of CO2 e. Use of laparoscopic cholecystectomy puts the pt at increased risk for bile duct injuries

a. Laparoscopic cholecystectomy is considered the gold standard and is performed far more often than the traditional open approach. c. Removing the gallbladder with the laparoscopic technique reduces the risk of wound complications d. Pts who have their gallbladders removed by the laparoscopic technique should be taught the importance of early ambulation to promote absorption of CO2

Which laboratory results are expected with malabsorption syndrome resulting in hypochromic microcytic anemia? Select all that apply a. Low mean corpuscular hemoglobin (MCH) b. High serum vitamin A level c. Elevated fecal fat content d. Increased mean corpuscular volume (MCV) e. Decreased serum cholesterol level f. Low mean corpuscular hemoglobin concentration (MCHC)

a. Low mean corpuscular hemoglobin (MCH) f. Low mean corpuscular hemoglobin concentration (MCHC)

The nurse is caring for the patient with acute appendicitis. Which interventions will the nurse perform? Select all that apply a. Maintain the patient on NPO status b. Administer IV fluids as prescribed c. Apply warm compresses to the right lower abdominal quadrant d. Maintain the patient in supine position e. Administer laxatives

a. Maintain the patient on NPO status b. Administer IV fluids as prescribed

Which intervention does the nurse delegate to the unlicensed assistive personnel (UAP) when caring for a post operative patients with peritonitis? a. Measure intake and output b. Assess wound drainage c. Administer antibiotics d. Teach patient about wound care

a. Measure intake and output

Which statement about diverticular disease is true? a. Most diverticula occur in the sigmoid colon b. Diverticula are uncomfortable even when not inflamed c. High-fiber diets contribute to diverticula d. Diverticula form where intestinal wall muscles are weak

a. Most diverticula occur in the sigmoid colon

4. The nurse on a med-surg unit is caring for several pts with acute cholecystitis. Which task is best to delegate to the UAP? a. Obtain pt's VS b. Determine if any foods are not tolerated c. Assess what measures relieve the abdominal pain d. Ask the pts to describe their daily activity or exercise routines

a. Obtain pt's VS

In caring for patients with Crohn's disease, the nurse observes for which complications? Select all that apply a. Peritonitis b. Small bowel obstruction c. Nutritional and fluid imbalances d. Presence of fistulas e. Appendicitis f. Severe nausea and vomiting

a. Peritonitis b. Small bowel obstruction c. Nutritional and fluid imbalances d. Presence of fistulas

1. A pt is admitted to the patient care unit with obstructive jaundice. Which S&S does the nurse expect to find upon assessment of the pt? a. Pruritus b. Pale urine in increased amounts c. Pink discoloration of sclera d. Dark, tarry stools

a. Pruritus

Which NG tube can be connected to low continuous suction? a. Salem sump b. Levin c. Anderson d. Carney

a. Salem sump

After completing the admission interview, the nurse reviews Ms Jacksons medical record and notes that the surgical consent form is filled out but isn't signed by the client. What action should the nurse take? a. Ask Ms. Jackson if she has received sufficient information to sign the consent form b. Call the operating room and notify the staff that the surgery needs to be cancelled c. Notify the surgeon of the need to come to the clients room so the consent can be signed d. Inform a family member of the need to serve as a witness to the client's signature

a. The nurse may witness the client's signature if the nurse is able to determine that the client has been sufficiently informed of the necessary information

While discussing postoperative pain management strategies with Ms. Jackson, the nurse observes Ms Jackson begin to cry. What action should the nurse take? a. Quietly sit with the client b. Offer reassurance about the surgery c. Calmly continue the preoperative instructions d. Leave the room until the client has composed herself

a. This action is caring and therapeutic

27. Which statements about pancreatic cancer are accurate? SELECT ALL a. VTE is a common complication of pancreatic cancer b. Pancreatic cancer often presents in a slow and vague manner c. The most common concern of the patient with pancreatic cancer is pain d. There are no specific blood tests to dx pancreatic cancer e. Chemotherapy is the treatment of choice for pancreatic cancer f. Chronic pancreatitis predisposes a pt to pancreatic cancer

a. VTE is a common complication of pancreatic cancer b. Pancreatic cancer often presents in a slow and vague manner d. There are no specific blood tests to dx pancreatic cancer f. Chronic pancreatitis predisposes a pt to pancreatic cancer

Which findings for a patient with a new colostomy will the nurse report to the surgeon? Select all that apply a. a dark-red, dry stoma b. Stoma protruding about 2 cm from the abdominal wall c. Mucocutaneous seperation d. A slight amount of edema in the initial postoperative period e. Large amount of bleeding

a. a dark-red, dry stoma c. mucocutaneous separation e. large amount of bleeding

A nurse plans care to prevent deformities in a client with RA. which intervention should be alternated with periods of rest? a. active exercise b. passive massage c. bracing of joints d. isometric exercises

a. active exercise

You are checking medication orders that were received by telephone for a client with RA who was admitted with methotrexate toxicity. Which order is most important to clarify with the physician? a. administer chlorambucil (Leukeran) 4mg PO daily b. infuse normal saline at 250 mL/hr for 4 hours c. administer folic acid (Folacin) 2000 mcg PO daily d. give cyanocobalamin (vitamin B12) 10,000 mcg PO

a. administer chlorambucil (Leukeran) 4mg PO daily

although the etiology of RA is unknown, it is considered to be what type of disorder? a. an autoimmune disease b. associated with aging c. genetic d. the result of joint misuse

a. an autoimmune disease

Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with RA? a. aspirin b. codeine c. meperidine d. alprazolam

a. aspirin

The respiratory problems that may accompany peritonitis are a result of which factor? a. Associated pain interfering with ventilation b. Decreased pressure against the diaphragm c. Fluid shifts to the thoracic cavity d. Decreased oxygen demands related to the infectious process

a. associated pain interfering with ventilation

A client newly diagnose with scleroderma states, "where did I get this from?" the nurse's best response is "although no cause has been determined for scleroderma, it is thought to be the result of: a. autoimmunity b. ocular motility c. increased amino acid metabolism d. defective sebaceous gland formation

a. autoimmunity

What are the major focus areas for interventions aimed at treating malabsorption syndromes? Select all that apply a. Avoiding substances that aggravate malabsorption b. Use of complementary and alternative therapies c. Supplementation of nutrients d. Assessment and supplementation of coping strategies e. Curative radiation therapy

a. avoiding substances that aggravate malabsorption c. Supplementation of nutrients

A nurse is interviewing a client who is diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply a. butterfly facial rash b. firm skin fixed to tissue c. inflammation of the joints d. muscle mass degeneration e. inflammation of small arteries

a. butterfly facial rash c. inflammation of the joints

Which interventions are useful in preventing the spread of gastroenteritis? Select all that apply a. Careful handwashing b. Sanitize all surfaces that may be contaminated c. Prophylactic use of antibiotics d. Easily accessible hand sanitizers e. Test all food preparation employees

a. careful handwashing b. Sanitize all surfaces that may be contaminated d. Easily accessible hand sanitizers

Which are the most common signs of colorectal cancer (CRC)? Select all that apply a. change in stool consistency b. absent bowel sounds c. abdominal cramping d. anemia e. rectal bleeding

a. change in stool consistency d. anemia e. rectal bleeding

A patient is suspected to have ulcerative colitis. Which definitive diagnostic test does the nurse expect the patient to undergo in order to confirm the diagnosis? a. Colonoscopy b. C-reactive protein c. Albumin levels d. Erythrocyte sedimentation rate

a. colonoscopy

The nurse is assessing a patient newly admitted with constipation and failure to pass flatus. Which condition is the most likely cause of this patient's symptoms? a. Complete bowel obstruction b. Partial obstruction c. Colorectal cancer d. Crohn's disease

a. complete bowel obstruction

Complications of spinal involvement in RA may be seen as which signs/symptoms? (select all that apply). A. compression of the phrenic nerve that controls the diaphragm b. resulting subluxation of the first and second vertebrae c. becoming quadriplegic or quadriparetic d. bilateral sciatic pain in the legs e. numbness of the hands and feet

a. compression of the phrenic nerve that controls the diaphragm b. resulting subluxation of the first and second vertebrae c. becoming quadriplegic or quadriparetic

A client with RA has been taking a steroid medication for the past year. For which complication of prolonged use of the medication should the nurse assess the client? a. decreased white blood cells b. increased C-reactive protein c. increased sedimentation rate d. decreased serum glucose levels

a. decreased white blood cells

Which intervention is contraindicated in the nonsurgical management of hemorrhoids? a. Diets low in fiber and fluids b. Dibucaine (Nupercainal) ointment c. Warm sitz baths three or four times a day d. Cleansing the anal area with moistened cleaning tissues

a. diets low in fiber and fluids

Raynaud's phenomenon in a patient with scleroderma may present as which signs/symptoms? (select all that apply) a. digit necrosis b. excruciating pain c. autoamputations of digits d. periungual lesions e. peripheral neuropathy

a. digit necrosis b. excruciating pain c. autoamputations of digits d periungul lesions

The nurse is teaching a patient about how to control gas in odor from a colostomy. Which information does the nurse include? a. Do not chew gum b. Place an aspirin in the colostomy c. Do not consume buttermilk d. Do not eat parsley

a. do not chew gum

A patient with scleroderma may have which problems? (select all that apply) a. dysphagia b. smooth tongue c. malabsorption problems causing malodorous diarrhea stools d. butterfly lesions on the face and nose e. spider-like hemangiomas

a. dysphagia b. smooth tongue e. spider-like hemangiomas

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply a. eat foods high in vitamin C b. take your temperature daily c. balance periods of rest and activity d. use a strong soap when washing the skin e. expose the skin to the sun as often as possible

a. eat foods high in vitamin C b. take your temperature daily c. balance periods of res and activity

A patient with SLE is admitted to the hospital for evaluation and management of acute joint inflammation. Which information obtained in the admission laboratory testing concerns you most? a. elevated blood urea nitrogen level b. increased C-reactive protein level c. positive antinuclear antibody test result d. positive lupus erythematosus.

a. elevated blood urea nitrogen level

35. Which abnormal laboratory findings are cardinal findings in acute pancreatitis? SELECT ALL a. elevated serum lipase b. increased serum amylase c. decreased serum trypsin d. elevated serum elastase e. elevated serum glucose

a. elevated serum lipase b. increased serum amylase d. elevated serum elastase

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? (select all that apply). a. encourage motion of the joint b. maintain a knee brace on the leg c. keep the client on a regimen of bed rest. d. maintain joints in functional alignment when resting e immobilize the joint with pillows until pain subsides.

a. encourage motion of the joint d. maintain joints in functional alignment when resting

Which discharge information does the nurse include for the patient who has had an intestinal obstruction caused by fecal impaction? a. Encourage the patient to report abdominal distention, nausea, or vomiting, and constipation b. Provide the patient a written description of a low-fiber diet c. Remind the patient to limit activity d. Remind the patient to decrease fluid intake

a. encourage the patient to report abdominal distention, nausea, or vomiting, and constipation

The nurse's plan of care for a patient with RA includes which interventions? (select all that apply) a. ensure optimal pain relief b. utilize the prone position c. encourage frequent rest periods d. decrease exercise to every other day. e. recommend liberal used of arthritic creams

a. ensure optimal pain relief c. encourage frequent rest periods

12. Which factor renders a pt the least likely to benefit from Extracorporeal Shock Wave Lithotripsy for the treatment of gallstones? a. height 5 ft 10 inches, 325 lbs b. Cholesterol-based stones c. Height 5 ft 7 inches, 138 lbs d. Small gallstones

a. height 5 ft 10 inches, 325 lbs

What CBC laboratory values does the nurse expect to be low for a patient with RA? (select all that apply) a. hemoglobin b. hematocrit c. red blood cell count (RBC) d. white blood cell count (WBC) e. platelets

a. hemoglobin b. hematocrit c. red blood cell count (RBC)

The emergency department nurse is assessing a patient with abdominal trauma after a motor vehicle accident. The patient has become somewhat confused, his skin is pale, cool, and moist and he has had only 20 mL of urine output during the past hour. What does the nurse suspect? a. Hypovolemic shock b. Head injury c. Liver laceration d. Large bowel injury

a. hypovolemic shock

What is the nature of pain associated with diverticulitis? a. Intermittent becoming progressively steady b. Sharp and continuous c. Localized to the right upper quadrant d. Severe and incapacitating

a. intermittent becoming progressively steady

The nurse is assessing a patient admitted with RA. Which manifestations indicate to the nurse that the patient is experiencing late RA? a. joint deformities b. joint inflammation c. vasculitis d. subcutaneous nodules e. paresthesis f. low-grade fever g. anemia

a. joint deformities c. vasculitis d. subcutaneous nodules g. anemia

The nurse is providing teaching about ways to reduce the risk for colorectal cancer. Which dietary suggestions will the nurse be sure to include? Select all that apply a. low fat b. low protein c high fiber d. high in red meat e. low in refined carbohydrates

a. low fat c. high fiber e. low in refined carbohydrates

In late RA, the patient may have systemic involvement called "flareups." How are these characterized? (select all that apply) a. moderate to severe weight loss b. fever and fatigue c. muscle atrophy d. joint contractures e. complete loss of mobility

a. moderate to severe weight loss b. fever and fatigue

A patient was prescribed the combination drug of probenicid (Lannett's Probalan) adn colchicine (Colcrys) for the treatment of gout. How does the health care team evaluate the effectiveness of the therapy? a. monitor the serum uric acid level. b. check the results of urinalysis c. review the patient's compliance with a low-purine diet d. assess the mobility of affected joints.

a. monitor the serum uric acid level

which patient-reported symptoms are typical of RA? (select all that apply). a. my hands are stiff, swollen, and tender. b. my right hand is weak. c. my pain and stiffness is worse in the morning. d. my knees are swollen and stiff. e. I am weak and fatigued

a. my hands are stiff, swollen, and tender. c. my pain and stiffness is worse in the morning. d. my knees are swollen and stiff. e. I am weak and fatigued

The nurse assessing a patient with fibromyalgia identifies the trigger points by palpation. In which specific areas does the nurse expect to elicit pain and tenderness? (select all that apply) a. neck b. lips c. trunk d. lower back e. upper back

a. neck c. trunk d. lower back

When a patient has RA of the temporomandibular joint, what is the major complaint? a. pain on chewing and opening the mouth b. headache at the temple c toothache d. earache

a. pain on chewing and opening the mouth

Which description best defines an anal fissure? a. Perianal tear that can be very painful b. Duct obstruction and infection c. Communicating tract d. Localized area of induration with pus

a. perianal tear that can be very painful

Which statements about peritonitis are true? Select all that apply a. Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals b. Continuous ambulatory peritoneal dialysis (CAPD) can cause peritonitis c. White blood cell counts are often decreased with peritonitis d. Abdominal wall rigidity is a classic finding in patients with peritonitis e. Chemical peritonitis is caused by leakage of pancreatic enzymes or gastric acids

a. peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals b. continuous ambulatory peritoneal dialysis (CAPD) can cause peritonitis d. abdominal wall rigidity is a classic finding in patients with peritonitis

29. The nurse is caring for a pt with pancreatic cancer who had a Whipple procedure. Which interventions or assessments does the nurse implement? SELECT ALL a. place the pt in the semi-fowlers position b. place the NG tube on intermittent suction c. monitor NG drainage, which should be bile-tinged and contain blood d. keep the pt NPO e. check blood glucose often

a. place the pt in the semi-fowlers position b. place the NG tube on intermittent suction d. keep the pt NPO e. check blood glucose often

Which findings does the nurse expect for a post operative colostomy patient? Select all that apply a. Reddish-pink, moist stoma b. Small amount of bleeding c. Large amount of stoma swelling d. Mucocutaneous separation e. Smooth, intact peristomal skin

a. reddish-pink, moist stoma b. small amount of bleeding e. smooth, intact peristomal skin

What might a psychosocial examination of a patient with advanced RA reveal? (select all that apply) a. role changes b. poor self-esteem and body image c. grieving and depression d. loss of control and independence e. inability to perform relaxation techniques

a. role changes b. poor self-esteem and body image c. grieving and depression d. loss of control and independence

The emergency department nurse is assessing a patient admitted with frequent, liquid, foul-smelling stools containing mucus and blood. Assessment findings include a temperature of the 103.8°F, tenesmus, abdominal tenderness, and vomiting. Which additional laboratory tests does the nurse expect to collect? a. Serial stool samples b. Urine culture c. Throat culture d. Sputum culture

a. serial stool samples

The nurse is teaching a patient about what to expect after a descending colon colostomy. The nurse tells the patient to expect this stool to have what kind of form? a. Similar to that of stool expelled from the rectum b. Think and paste-like c. Thin and gelatin-like d. Watery

a. similar to that of stool expelled from the rectum

the nurse is providing teaching for a patient with RA who is receiving methotrexate (Rheumatrex). Which teaching points must the nurse include? (select all that apply) a. the medication is given in a low dose once a week. b. methotrexate is an immunosuppressant medication c. expect some increase in swelling while taking this medication. d. avoid crowds of people and people who are ill e. report any mouth sores to the health care provider immediately.

a. the medication is given in a low dose once a week. b. methotrexate is an immunosuppressant medication. d. avoid all crowds of people and people who are ill. e. report any mouth sores to the health care provider immediately.

34. Which are potential cardiovascular complications for a pt after surgery for a Whipple procedure? SELECT ALL a. thrombophlebitis b. PE c. MI d. HF e. renal failure

a. thrombophlebitis c. MI d. HF

Why does the nurse place a patient with a bowel obstruction in semi Fowler's position? Select all that apply a. To promote increased peristalsis b. To alleviate the pressure of abdominal distention on the chest c. To decrease the likelihood of nausea and vomiting d. To facilitate breathing e. To prevent aspiration

a. to promote increased peristalsis b. To alleviate the pressure of abdominal distention on the chest d. to facilitate breathing

Which key features does the nurse most likely find when performing a physical assessment on a patient with a small bowel obstruction? a. Visible peristaltic waves in the upper and middle abdomen b. Minimal or no vomiting c. No major fluid and electrolyte imbalances d. Metabolic acidosis

a. visible peristaltic waves in the upper and middle abdomen

82. Place the sequence of steps of continuous ambulatory peritoneal dialysis (CAPD) in the correct order using the numbers 1 through 4. _______a. Fluid stays in the cavity for a specific time prescribed by the health care provider. _______b. 1 to 2 L of dialysate is infused by gravity over a 10-to 20-mintue period _______c. Fluid flows out of the body by gravity into a drainage bag. _______d. Warm the dialysate bags before instillation by using a heating pad to wrap the bag.

a.3; b.2; c.4; d.1

32. What key points does the nurse include in teaching an SCI pt about bowel and bladder retraining? (select all) a. ensure the pt gets a sufficient quantity of fluid each day b. instruct the pt about the purpose of stool softeners c. teach the pt about high-fiber foods d. teach the pt that continence is dependent upon spinal cord healing e. digital rectal stimulation is essential for regular bowel movements

abc

which diagnostic test and results does the nurse expect to see with acute glomerulonephritis? select all that apply. a. UA revealing hematuria b. UA revealing proteinuria c. Microscopic red blood cell casts d. serum albumin levels increased e. serum potassium decreased

abc

a pt is brought to the ED after being involved I a fight in which the pt was kicked and punched repeatedly in the back. what does the nurse include in the initial physical assessment? select all that apply. a. take complete vital signs b. check apical and peripheral pulses c. inspect both flanks for asymmetry or penetrating injuries of the lower chest or back d. inspect the abdomen for bruising or penetrating wounds e. deeply palpate the abdomen for signs of rigidity f. inspect the urethra for gross bleeding

abcdf

5. A patient is scheduled for lumbar surgery. Which key points must the nurse include in a preoperative teaching plan for this patient? (select all) a. techniques for getting in and out of bed b. expectations for turning and moving in bed c. limitations and restrictions for home activities d. restriction of bedrest for at least 48 hours e. report any numbness and tingling to the nurse immediately

abce

7. A patient has just undergone a spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hours? (select all) a. take vital signs every 4 hours and assess for fever and hypotension b. perform a neurological assessment every 4 hours with attention to movement and sensation c. monitor intake and output and assess for urinary retention d. assess for ability and independence in ambulating and moving in bed e. observe for clear fluid on or around the dressing

abce

7. ms j's nursing care plan includes the nursing dx excess fluid volume. What interventions are appropriate for this nursing dx? select all a. measure weight daily b. review daily I and O c. restrict sodium intake with meals d. restrict fluid to 1500ml plus urine output e. assess for crackles and edema every shift

abce

Ryan is transferred to the rehab unit. He is tetraplegic at the C6 level. He has some movement in his hands, but is still unable to move his arms and legs independently. he is able to sit up in a wheelchair and advances to a regular diet. the nurse discusses autonomic dysreflexia and reflexic bowel program with ryan, his girlfriend, and his mother. 14. to evaluate the teaching, the nurse asks ryan to explain his understanding of all intructions give. Which statements indicate ryan's understanding? (select all) a. "it is important to drink hot fluids prior to defecation" b. "i will plan bowel evacuation at the same time everyday" c. "i should try to empty my bladder at least every 2-3 hours" d. "daily enemas will be needed to help achieve a bowel movement" e. "if i have a pounding headache, i should move to a sitting position"

abce

Which tasks are appropriate to assign to an experienced UAP? Select all that apply. a. measuring and reporting Mr. D's vital signs every 15 minutes b. checking and reporting Mr. D's blood glucose level c Bagging and labeling Mr.D's belongings d. Updating the roommate regarding Mr.D's status e. Measuring and recording the volume of Mr.D's vomitus

abce

You are teaching a pt how best to prevent renal trauma after an injury that required a left nephrectomy. which points would you include in your teaching plan? select all that apply a. always wear a seat belt b. avoid all contact sports c. practice safe walking habits d. wear protective clothing to participate in contact sports e. use cation when riding a bicycle

abce

14. Which statements about spinal shock are accurate? (select all) a. it lasts for from less than 48 hrs up to a few weeks b. there is temporary loss of motor and sensory function c. there is permanent loss of motor and sensory function d. there is temporary loss of reflex and autonomic function e. there is permanent loss of reflex and autonomic function

abd

19. The nurse is assessing a pt with myasthenia gravis (MG). Which manifestations can the nurse expect to observe? (select all) a. ptosis b. diplopia c. delayed puipllary responses to light d. incomplete eye closure e. decreased pupillary accomodation

abd

8. The pt with GBS is at risk for aspiration. Which precautions must the nurse initiate to prevent aspiration? (select all) a. elevate HOB at least 45 degrees b. have pt assessed for dysphagia before administering oral fluids or medications c. teach the pt coughing or deep breathing exercises d. have suctioning equipment available at the bedside e. turn the pt from side to side at least every 2 hours

abd

The nurse is developing a teaching plan for a pt with PKD. Which topics does the nurse include? Select all that apply. a. teach how to measure and record blood pressure b. assist to develop a schedule for self-administering drugs c. Instruct to take and record weight twice a month d. explains the potential side effects of the drug e. review high-protein, low-fat diet plan

abd

9. Which interventions are appropriate for pain management in an older adult with GBS? (select all) a. IV opiates b. gabapentin (neurontin) c. tricyclic antidepressants d. massage e. music therapy

abde

In developing an individualized meal plan for a patient with diabetes, which goals will be focal points of the plan? Select all that apply. a. Maintaining blood glucose levels at or as close to normal range as possible b. patient food preferences c. allowing patients to eat as much as they desire d. Patient cultural preferences e. Limiting food choices only when guided by scientific evidence

abde

19. You are providing nursing care for a patient with acute kidney failure for whom a nursing dx of excess fluid volume related to compromised regulatory mechanisms has been identified. Which actions should you delegate to an experienced UAP? select all a. measuring and recording vital sign values every 4 hours b. weighing the pt every morning using a standing scale c. administering furosemide (lasix) 40 mg orally twice a day d. reminding the pt to save all urine for intake and output measurement e. assessing breath sounds every 4 hours f. ensuring that the pts urinal is within reach

abdf

44. The pt and family are referred to the nurse for education about amyotrophic lateral sclerosis (ALS). What information does the nurse include in the educational session? (select all) a. it is a progressive disease involving the motor system b. the cause of ALS is unknown c. memory loss will occur but it will be very gradual d. death typically will occur several decades after diagnosis e. there is no known cure for ALS

abe

a 58-year-old with type 2 diabetes was admitted to your unit with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbating. when you prepare a care plan for this patient, what would you be sure to include? (select all that apply.) a. Fingerstick blood glucose checks before meals and at bedtime b. Sliding-scale insulin dosing as ordered c. bed rest unit the COPD exacerbation resolved d. Teaching about the Atkins diet for weight loss e. Demonstration of the components of foot care

abe

what lab values would the nurse interpret for a pt experiencing problems wit urinary elimination as a result of acute pyelonephritis? select all that apply. a. observe complete blood count for election of differentials. b. observe for elevation of BUN and serum creatinine levels c. observe for electrolyte imbalances, such as hypokalemia d. observe arterial blood gases for alkalosis and respiratory compensation e. observe UA for bacteria, leukocyte esterase, nitrate, or red blood cells

abe

52. The nurse is teaching the pt and family about factors that predispose the pt to episodes of exacerbation of MG. Which factors does the nurse mention? (select all) a. infection b. stress c. change in diet d. any physical exercise e. enemas f. strong cathartics

abef

To clarify pertinent data, what questions are appropriate to ask Mr. D? Select all that apply. a. when did your symptoms start? b. how many times have you vomited c. what was your last blood sugar reading d. wit didn't you go to see your physician e. where does your abdomen hurt f. did you take any insulin today g. do you have any allergies?

abefg

4. Ryan is scheduled to have an open CT scan w/ contrast procedure. What questions should be asked prior to administering the IV contrast through ryan's saline lock? (select all) a. what happens when he eats shellfish (crustaceans)? b. has he ever been allergic to peanuts? c. does he have an allergy to iodine? d. does he have any metal piercing on his body or metal implants?

ac

The nurse is interviewing a pt with suspected PKD. What questions does the nurse ask the pt? Select all that apply. a. is there any family history of PKD or kidney disease? b. Do you have a hx of sexually transmitted disease? c. have you had any constipation or abdominal discomfort? d. hace you noticed a change in urine color or frequency? e. hace you had any problems with headaches? f. is there a family history of sudden death from a myocardial infarction?

acde

41. The nurse is teaching a pt with MS and her family about her exercise program. Which points must the nurse include? (select all) a. ROM exercises are an important component b. rigorous activity should follow stretching exercises c. increased body temp can lead to increased fatigue d. progressive increased walking distances can lead to jogging e. stretching and strengthening exercises will be part of your program

ace

46. A pt with MG is experiencing impaired communication related to weakness of the facial muscles. Which interventions are best in assisting the pt to communicate with the staff and family? (Select all) a. instruct the pt to speak slowly b. use short, simple sentences c. ask yes or no questions d. use hand signals e. have the pt use a picture, letter, or word board

ace

kidney tissue change in chronic glomerulonephritis are caused by which factors? select all that apply. a. ischemia b. fluid overload c. hypertension d. obstruction e. infection

ace

20. Which statements about MG are accurate? (select all) a. it is an acquired autoimmune disease b. it usually occurs in young adults c. it occurs slightly more in men than women d. it is often accompanied by weight gain and distal weakness e. it is associated with hyperplasia of the thymus gland f. it is characterized by remissions and exacerbations

acef

6. Which assessment data warrants immediate intervention by the ED nurse? (select all) a. ryan complains of loss of sensation and reflexes below his elbows. His skin is flushed and his extremities are warm to touch. b. ryan is not able to demonstrate deep breaths when asked to breathe in deep and cough c. ryan's respirations are 20 breaths/min and he is talking without difficulty d. ryan's BP is 80/45 mmHg and his pulse is 48 BPM e. ryan appears to have bladder distention

ade

Which tasks can you delegate to an experienced UAP to facilitate for Mr.D's transfer to the ICU? Select all that apply. a. Giving Mr.D's roommate directions to the ICU b. Independently transporting Mr.D to the ICU c. Collecting and organizing the chart and laboratory reports d. Obtaining a portable oxygen tank and cardiac monitor e. Connecting Mr.D's ECG leads to the portable cardiac monitor f. Obtaining the last set of vital sign values

adef

In caring for Mr. D, you are vigilant for signs and symptoms for hypokalemia. What are you watching for? Select all that apply. a. fatigue b. seizure activity c. hallucinations d. muscle weakness e. hypotension f. weak pulse g. shallow respirations h. cold. clammy skin

adefg

30. The nurse is caring for a pt who has been in a long-term care facility for several months following an SCI. The pt has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. Which are expected outcomes of the training program? (select all) a. demonstrates a predictable pattern of voiding b. is able to independently catheterize himself c. pours warm water over perineum to stimulate voiding d. takes bethanechol chloride (Urecholine) 1 hr before voiding e. is able to empty bladder completely f. does not experience a urinary tract infection

aef

Side effects of local anesthetics

allergic reactions, anaphylaxis, respiratory arrest, dysrhythmias, cardiac arrest, seizures, hypotension

1. During admission assessment, Ms J has all of these findings. For which finding should you notify the health care provider immediately? a. bilateral pitting ankle and calf edema 2+ b. crackles in both lower and middle lobes c. dry and peeling skin on both feet d. faint but palpable pedal and post tibial pulses

b

1. The nurse is taking a history on an older adults pt who reports chronic back pain. The nurse seeks to identify factors that are contributing to the pain. Which question is the most useful in eliciting this information? a. "have you had any recent falls or have you been in an accident?" b. "do you have a history of osteoarthritis?" c. "do you have a history of diabetes mellitus?" d. "are you having pain that radiates down your leg or into the buttocks?"

b

10. The nurse is caring for several pts on a general med-surg unit. The nurse would question the need for oxygen therapy for a pt with which condition? a. pulmonary edema with decreased arterial po2 levels b. valve replacement with increased cardiac output c. anemia with a decreased hemoglobin and hematocrit d. sustained fever with an increased metabolic demand

b

10. The nurse is talking to an older adult male patient who is reasonably healthy for his age, but has benign prostatic hyperplasia (BPH). What condition does the BPH potentially place him at risk for? a. Prerenal acute kidney injury b. Postrenal acute kidney injury c. Polycystic kidney disease d. Acute glomerulonephritis

b

11. A pt is being treated with heparin therapy for a PE. The pt has the potential for bleeding with the administration of heparin. What does the nurse monitor in relation to the heparin therapy? a. lab values for any elevation of PT or PTT value b. PTT values for greater than 2.5 times the control and/or the pt for bleeding c. occurrence of a pulmonary infarction by blood in sputum d. PT values for international normalized ratio for a therapeutic range of 2-3 and/or the pt for bleeding

b

11. Which outcome should the nurse use for evaluation of the efficacy of interventions designed for this nursing diagnosis? a. the client's family inspects the skin for reddened areas daily b. the client exhibits no reddened areas or breaks in the skin c. the nursing staff rotates the client's kinetic bed per unit protocol d. the physical therapist performs passive ROM exercises

b

12. A pt has been newly diagnosed with GBS. the nurse is teaching the pt and family about the condition. Which statement by the family indicates a need for additional teaching? a. "he could recover in 4-6 months" b. "he'll never be able to walk again" c. "he will receive medication for pain" d. "it usually starts with the legs and moves upward"

b

12. Which explanation by the nurse best describes how the TENS unit soothes paint? a) continuous high-pressure stimulation of the pain nerve fibers are blocked b) it sends stimulating pulses through the skin, to block pain signals from reaching the brain c) electrodes are placed at pressure points to measure biofeedback and reduce stress d) needles are inserted to stimulate specific points in the body

b

13. The pt with chronic back pain is receiving ziconotide (Prialt) by intrathecal (spinal) infusion with a surgically implanted pump. The pt develops hallucinations. What is the nurse's best first action? a. request a psychiatric evaluation b. notify the health care provider c. perform an assessment of level of consciousness d. decrease the dose of the medication

b

15. The nurse is reviewing the admission and history notes for a pt admitted for GBS. which medical condition is most likely to be present before the onset of GBS? a. diabetes mellitus b. recent bacterial infection c. peripheral vascular disease d. addison's disease

b

16. A pt involved in a high-speed motor vehicle accident with sustained multiple injuries and active bleeding is transported to the ED by ambulance with immobilization devices in place. There is a high probability of cervical spine fracture; the pt has altered mental status and extremities are flaccid. What is the priority assessment for this pt? a. check the mental status using the glasgow coma scale b. assess the respiratory pattern and ensure a patent airway c. observe for intraabdominal bleeding and hemorrhage d. assess for loss of motor function and sensation

b

16. The nurse is caring for several postoperative patients with high risk for a PE. All of these pts have preexisting chronic respiratory problems. What is a unique assessment finding for a clot in the lung? a. dyspnea b. sudden dry cough c. pursed lip breathing d. audible wheezing

b

17. since Natalie is fairly thin, which site is the best choice for the injection? a) back of the arm b) ventrogluteal c) dorsogluteal d) abdomen, 2 inches from the umbilicus

b

18. A patient is in the diuretic phase of AKI. During this phase, what is the nurse mainly concerned about? a. Assessing for hypertension and fluid overload b. Monitoring for hypovolemia and electrolyte loss c. Adjusting the dosage of diuretic medications d. Balancing diuretic therapy with intake

b

189. a client reports severe pain 2 days after surgery. Which INITIAL action should the nurse take after assessing the character of pain? a) encourage rest b) obtain the vital signs c) administer the prn analgesic d) document the client's pain response

b

19. A patient with prerenal azotemia is administered a fluid challenge. In evaluating response to the therapy, which outcome indicates the goal was met? a. Patient reports feeling better and indicates an eagerness to go home. b. Patient produces urine soon after the initial bolus. c. The therapy is completed without adverse effects. d. The health care provider orders diuretic when the challenge is completed.

b

19. An older adult pt on anticoagulation therapy for a PE is somewhat confused and requires assistance with activities of daily living. Which instruction specific to this therapy does the nurse give to the UAP? a. count and report episodes of urinary incontinence b. use a lift sheet when moving or turning the pt in bed c. assist with ambulation because the pt is likely to have dizziness d. give the pt an extra blanket, because the pt is likely to feel cold

b

19. Assessment of a pt with a lower spinal cord injury confirms that the pt has paralysis of the bilateral lower extremities. How does the nurse document this finding? a. paraparesis b. paraplegia c. quadriparesis d. quadriplegia

b

192. a client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is still experiencing pain. What should the nurse do FIRST? a) monitor the client's pain level for another hour b) determine the integrity of the intravenous delivery system c) reprogram the pump to deliver a bolus dose every 8 minutes d) arrange for the client to be evaluated by the health care provider

b

2. The nurse is preparing to physically assess a pt's subjective report of paresthesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the nurse use? a. use a doppler to locate the pedal pulse, dorsalis pedis pulse, or popliteal pulse b. ask the pt to identify sharp and dull sensation by using a paperclip and cotton ball c. use a reflex hammer to test for deep tendon patellar or Achilles reflex d. ask the patient to walk across the room and observe his gait and equilibrium

b

2. What is the most common site of origin for a clot to occur, causing a PE? a. right side of the heart b. deep veins of the legs and pelvis c. antecubital vein in upper extremities d. subclavian veins

b

2. to assess the quality of Natalie's pain, the nurse asks which question? a) "on a scale of 0-10, how would you rate your pain?" b) "what word best describes the pain you are experiencing?" c) "What actions do you take to relieve the pain?" d) "what do you fear most about your pain?"

b

21. The nurse is assessing a pt with a spinal cord injury and recognizes that the pt is experiencing autonomic dysreflexia. What is the nurse's first priority action? a. check for bladder distention b. raise the head of the bed c. administer an antihypertensive medication d. notify the primary health care provider

b

21. The nurse is caring for a patient with AKI that developed after a severe anaphylactic reaction. What is the primary treatment goal of the initial phase that will help to prevent permanent kidney damage for this patient? a. Correct fluid volume by administering IV normal saline b. Maintain a mean arterial pressure (MAP) of 65 mm Hg c. Prevent kidney infections by administering antibiotics d. Give antihistamines to prevent allergic response

b

21. What is the most important common electrodiagnostic test performed to detect MG? a. EMG b. repetitive nerve stimulation (RNS) c. tensilon challenge test d. EPS

b

21. you are the charge nurse. Which pt will you assign to a nurse floated to your unit from the surgical ICU? a. pt with kidney stones scheduled for lithotripsy this morning b. pt who has just undergone surgery for renal stent placement c. newly admitted pt with an acute UTI d. pt with chronic kidney failure who needs teaching on peritoneal dialysis

b

22. what is the cause of a cholinergic crisis? a. not enough anticholinesterase drugs b. too many anticholinesterase drugs c. some type of infection d. allergic reaction to anticholinersterase drugs

b

23. A pt in whom acute kidney failure has been dx has had a urine output of 1560ml for the past 8hrs. The lpn/lvn who is caring for this pt, under your supervision, asks you how a pt with kidney failure can have such a large urine output. What is your best response? a. the pts kidney failure was due to hypovolemia and we have given him IV fluids to correct the problem b. acute kidney failure pts go through a diuretic phase when their kidneys begin to recover and may put out as much as 10L of urine per day c. with that much urine output, there must have been a mistake in the pts dx d. an increase in urine output like this is an indicator that the pt is entering the recovery phase of acute kidney failure

b

23. The nurse is preparing a quadriplegic pt for discharge and has taught the pt's spouse to assist the pt with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught? a. the spouse assists the pt to the side of bed to encourage deep breaths b. the spouse places her hands below the pt's diaphragm and pushes upward as the pt exhales c. the spouse places her hands above the pt's diaphragm and pushes upward as the patient inhales d. the spouse places the pt in an upright sitting position to encourage deep breaths

b

233. A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end stage renal disease (ESRD) a. fluid b. protein c. sodium d. potassium

b

234. What should the nurse do when caring for a client who is receiving peritoneal dialysis? a. maintain the client in the supine position during the procedure b. position the client from side to side if fluid isn't draining adequately c. remove the cannula at the end of the procedure and apply a dry, sterile dressing d. notify the health care provider if there is a deficit of 200mL in the drainage return

b

24. the nurse is reviewing lab results for a pt with a new onset PE. What is the INR therapeutic range? a. 1-1.5 b. 2-3 c. 3-4.5 d. 5

b

25. the nurse assesses Natalie's pain and determines that the evaluation of her use of the PCA pump is correct. Natalie's pain has lessened, and she no longer needs any demand doses of morphine. The nurse consults with the surgeon, and the morphine is discontinued. Natalie's new prescription is for hydrocodone/acetaminophen. What is the rationale for combing these two ingredients? a) the antagonistic effect of the two medications reduces the risk for adverse effects b) the synergistic effect of the two medications improves pain control c) the combination effect decreases the risk for significant allergic reactions d) the equianalgesic effect allows each medication to work more efficiently

b

27. A pt with MG and the nurse are having a long discussion about plans for the future. After an extended conversation, what does the nurse anticipate will occur in this pt? a. speech will be slurred and difficult to understand b. voice may become weaker or exhibit a nasal twang c. voice quality will become harsh and strident d. voice will become toneless and affect will be flat

b

27. The nurse and the nursing student are working together to bathe and reposition a pt who is in a halo fixator device. Which action by the nursing student causes the supervising nurse to intervene? a. uses the log-roll technique to clean the patient's back and buttocks b. turns the pt by pulling on the top of the halo device c. positions the pt with the head and neck in alignment d. supports the head and neck area during the repositioning

b

27. Which class of antidiabetic medication must be held after using contrast media until adequate kidney function is established? a. alpha-glucosanide inhibitors, which include miglitol (Glyset) b. biguanides, which include metformin (glucophage) c. meglitinides, which include natelinide d. second-generation sulfonylureas, which include glipizide (glucotrol)

b

28. The nurse is caring for several pts with SCIs. Which task is best to delegate to the UAP? a. encourage use of incentive spirometry; evaluate the pt's ability to use it correctly b. log-roll the pt; maintain proper body alignment and place a bedpan for toileting c. check for skin breakdown under the immobilization devices during bathing d. insert a foley catheter and report the amount and color of the urine

b

30. The nurse requests a dietary consult to address the patient's high rate of catabolism. Which nutritional element is directly related to this metabolic process? a. Carbohydrates b. Proteins c. Liquids d. Fats

b

32. What is considered a positive diagnostic finding of a tensilon test? a. after the cholinesterase inhibitor is administered, there are no observable changes in muscle strength or tone b. within 30-60 seconds after receiving the cholinesterase inhibitor, there is increased muscle tone that lasts 4-5 min c. within 30 min of receiving the cholinesterase inhibitor, there is improved muscle strength that lasts for several weeks d. after the cholinesterase inhibitor is first administered, the pt will experience muscle weakness and then return to baseline

b

33. Which statement about insulin is true? a. exogenous insulin is necessary for management of all cases of type 2 b. insulin's effectiveness depends on the individual pt's absorption of the drug c. insulin doses should be regulated according to self-monitoring urine glucose levels d. insulin administered in multiple doses per day decreases the flexibilitiy of a pt's lifestyle

b

34. The nurse is caring for a pt newly diagnosed with MG. The nurse is vigilant for complications related to both myasthenic crisis and cholinergic crisis. what is the priority nursing assessment for this pt? a. monitor cardiac rhythm and rate b. assess respiratory status and function c. monitor fatigue and activity levels d. perform neurologic checks every 2-4 hours

b

35. A diabetic pt is on a mixed-dose insulin protocol of 8 units regular insulin and 12 units NPH insulin at 7am. At 10:30am, the pt reports feeling uneasy, shaky, and has a headache. Which is a probable explanation for this? a. the NPH insulin's action is peaking and there is an insufficient blood glucose level b. the regular insulin's action is peaking and there is an insufficient blood glucose level c. the pt consumed too many calories at breakfast and now has an elevated blood glucose level d. the symptoms are unrelated to the insulin administered in the early morning or food taken in at lunchtime

b

36. A pt with MG develops difficulty coughing. Auscultation of the lungs reveals coarse crackles throughout the lung fields. The nurse identifies the pt is unable to cough effectively enough to clear the airway of secretions. Which intervention is best for this pt? a. administer O2 2L per nasal cannula b. ask respiratory therapist to perform chest physiotherapy c. perform endotracheal suction d. perpare intubation equipment

b

37. A pt with MG is experiencing cholinergic crisis. Interventions include IV atropin 1 mg. what is the nurse's major respiratory concern when caring for this pt? a. increase heart rate b. difficulty with airway clearance c. copious secretions d. oxygen administration

b

39. A pt with MS is prescribed oral fingolimod (Gilenya). Which key point must the nurse teach the pt about the drug? a. "you must be carefully monitored for allergic or anaphylactic reaction because the drug tends to build up in the body" b. "we need to teach you how to monitor your pulse rate because this drug can cause a slow heart rate" c. "this drug will decrease the frequency of clinical relapses that you will have with MS" d. "it will improve your ability to walk but also puts you at increased risk for seizure activity"

b

39. The nurse is reviewing a patient's laboratory results. In the early phase of CKD, the patient is at risk for which electrolyte abnormality? a. Hyperkalemia b. Hyponatremia c. Hypercalcemia d. Hypokalemia

b

4. to determine the etiology of Natalie's anxiety, what is the priority nursing intervention? a) refer the client to the clinic social worker b) continue the interview with the client c) review the healthcare provider's notes d) recognize that pain causes anxiety

b

42. A pt with MG has been referred to a surgeon for a procedure that may improve the pt's symptoms. Which procedure does the nurse anticipate will be recommended for this pt? a. percutaneous stereotactic rhizotomy b. thymectomy c. resecting severed nerve ends d. partial or complete severance of a nerve

b

42. The pt with MS has dysarthria (slurred speech). For which complication must the nurse monitor in this pt? a. dysmetria b. dysphagia c. ataxia d. vertigo

b

44. Which diabetic complication is associated with neuropathy? a. end-stage kidney disease b. muscle weakness c. permanent blindness d. eye hemorrhage

b

45. The 50-yr-old pt recently diagnosed with ALS is prescribed riluzole (Rilutek). When should the nurse teach the pt to take this drug? a. with a meal or snack b. on an empty stomach c. at bedtime d. one hour after taking an antacid

b

45. The nurse is performing teaching for the family of a pt with MG about fatigue and ADLs. Which statement by a family member indicates a need for additional teaching? a. "rest is critical because increased fatigue can precipitate a crisis" b. "we should do hygienic care for her to avoid undue frustration and fatigue" c. "activities should be done after we give her the medication" d. "the physical therapist will be able to recommend some energy-saving devices"

b

46. The night shift nurse sees a patient with kidney failure sitting up in the bed. The patient states, "I feel a little short of breath at night or when I get up to walk to the bathroom." What assessment does the nurse do? a. Check for orthostatic hypotension because of potential volume depletion b. Auscultate the lungs for crackles, which indicate fluid overload. c. Check the pulse and blood pressure for possible decreased cardiac output d. Assess for normal sleep pattern and need for PRN sedative

b

52. A patient receives dialysis therapy and the health care provider has ordered sodium restriction to 3g daily. What does the nurse teach this patient? a. Add smaller amounts of salt at the table or during cooking. b. Identify foods that are high in sodium (e.g., bacon, potato chips, fast foods). c. Avoid foods that have a metallic, salty, or bitter taste d. Eat larger amounts of bland foods with very minimal amounts of spicing.

b

55. Along with exercise, what is the recommended calorie reduction for a pt with diabetes who must lose weight? a. 100-200 cal/day b. 250-500 cal/day c. 501-600 cal/day d. 601-750 cal/day

b

55. The nurse is caring for a patient with ESKD and dialysis has been initiated. Which drug order does the nurse question? a. Erythropoietin b. Diuretic c. Ace inhibitor d. Calcium channel blocker

b

55. based on the client's reported pain level, the nurse administers 8mg of the prescribed morphine. The medication is available in a 10mg syringe. Wasting of the remaining 2mg of morphine should be done by the nurse and a witness. Who should be the witness? a) nursing supervisor b) LPN c) client's health care provider d) designated nursing assisstant

b

58. The nurse is reviewing the medication list and appropriate dose adjustments made for a patient with CKD. The nurse would question the use and/or dosage adjustment of which type of medication? a. Antibiotics b. Magnesium antacids c. Oral antidiabetics d. Opioids

b

6. The nurse is assessing a pt who presented to the ED reporting acute onset of numbness and tingling in the right leg. How does the nurse document this subjective finding? a. paraparesis b. paresthesia c. ataxia d. quadriparesis

b

6. as team leader, you observe the UAP perform all of these actions for ms j. Which action must you intervene? a. assisting her to replace the oxygen nasal cannula b. measuring vs after the pt drinks fluids c. ambulating with the pt to the bathroom and back d. washing her back, legs and feet with warm water

b

62. A patient with CKD is restless, anxious, and short of breath. The nurse hears crackles that begin at the base of the lungs. The pulse rate is increased and the patient has frothy, blood-tinged sputum. What does the nurses do first? a. Facilitate transfer to the ICU for aggressive treatment. b. Place the patient in a high-Fowler's position c. Continue to monitor vital signs and assess breath sounds. d. Administer a loop diuretic such as furosemide (Lasix).

b

64. As a patient with ESKD experiences isosthenuria. What must the nurse be alert for? a. The diuretic stage b. Fluid volume overload c. Dehydration d. Alkalosis

b

65. A pt with type 2 DM often has which laboratory value? a. elevated thyroid studies b. elevated triglycerides c. ketones in the urine d. low hemoglobin

b

67. As a result of kidney failure, excessive hydrogen ions cannot be excreted. With acid retention, the nurse is most likely to observe what type of respiratory compensation? a. Cheyne-Stokes respiratory pattern b. Increased depth of breathing c. Decreased respiratory rate and depth d. Increased arterial carbon dioxide levels

b

687. A client with acute kidney failure states why am i twitching and my fingers and toes tingling? The nurse should respond "this is caused by" a. acidosis b. calcium depletion c. potassium retention d. sodium chloride depletion

b

7. The nurse reads in the patient's chart that he has acute-on-chronic kidney disease. How does the nurse interpret this information? a. Kidney disease has progressed to the need for dialysis transplant. b. Patient has chronic kidney disease and has sustained an acute kidney injury. c. Acute kidney injury requires aggressive management to prevent chronic disease. d. The condition could be acute or chronic; further diagnostic testing is needed.

b

72. A patient and family are trying to plan a schedule that coordinates with the patient's dialysis regimen. The patient asks, " How often will I have to go and how long does it take? What is the nurse's best response? a. " If you are compliant with the diet and fluid restrictions. you spend less time in dialysis: about 12 hours a week." b. "Most patients requires about 12 hours per week: this is usually divided into three 4-hour treatments." c. " It varies from patient to patient. You will have to call your health care provider for the specific instructions." d. " If you gain a large amount of fluid weight, a longer treatment time may be needed to prevent severe side effects."

b

73. A pt with DM has signs and symptoms of hypoglycemia. The pt is alert and oriented with a blood glucose of 56 mg/dL. What does the nurse do next? a. give a glass of orange juice with two packets of sugar and continue to monitor the pt b. give 8 oz of skim milk and then a carbohydrate and protein snack c. give a complex carbohydrate and continue to monitor the pt d. administer D50 IV push and give the pt something to eat

b

732. in the PACU it is reported that the client recieved intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as pert of the client's INITIAL 24-hour postoperative care? a) assessing the client for tachycardia b) monitoring of respiratory rate hourly c) administering naloxone every 3 to 4 hours d) observing the client for signs of CNS excitement

b

75. The nurse is assessing a patient's extremity with an arteriovenous graft. The nurse notes a thrill and a bruit, and the patient reports numbness and a cool feeling in the fingers. How does the nurse interpret this information in regard to the graft? a. The graft is functional and these symptoms are expected b. The patient has "steal syndrome" and may need surgical intervention c. The graft is patent. but the blood is flowing in the wrong direction. d. The patient needs to increase active use of hands and fingers.

b

8. A pt has a long history of chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending a surgical procedure for spine stabilization. Which procedure does the nurse anticipate this pt will need? a. laparoscopic diskectomy b. spinal fusion c. laminectomy d. traditional diskectomy

b

8. The nurse suspects a pt has a PE and notifies the provider who orders an ABG. The provider is en route to the facility. The nurse anticipates and prepares the pt for which additional diagnostic test? a. ultrasound b. pulmonary angiography c. 12-lead ECG d. ventilation and perfusion scan

b

8. The pt is receiving oxygen at 5L/min by nasal cannula. What priority intervention must the nurse use at this time? a. switch to a mask delivery system b. humidify the oxygen with sterile water c. monitor for manifestations of oxygen toxicity d. add extension tubing for pt mobility

b

8. after discussing renal replacement therapies with the health care provider and nurse, ms j is considering hemodialysis (HD). which statement indicates that ms j needs additional teaching about HD? a. i will need surgery to create an access route for HD b. i will be able to eat and drink what i want once i start dialysis c. i will have a temporary dialysis catheter for a few months d. i will be having dialysis 3 times every week

b

81. The critical care nurse is caring for an older pt admitted with HHS. What is the first priority in caring for this pt? a. slowly decreasing blood volume b. fluid replacement to increase blood volume c. potassium replacement to prevent hypokalemia d. diuretic therapy to maintain kidney function

b

86. The nurse is teaching a patient about performing PD at home. In order to identify the earliest manifestation of peritonitis what does the nurse instruct the patient to do? a. Monitor temperature before starting PD. b. Check the effluent for cloudiness. c. Be aware of feeling of malaise. d. Monitor for abdominal pain

b

9. The home health nurse has been caring for a pt with a chronic respiratory disorder. Today the pt seems confused when she is normally alert and oriented x3. What is the priority nursing action? a. notify the provider about the mental status change b. check the pulse oximeter reading c. ask the pts family when this behavior started d. perform a mental status exam

b

9. The provider orders heparin therapy for a pt with a relatively small PE. The pt states "I didn't tell the doctor my complete medical history" Which condition may affect the providers decision to immediately start heparin therapy? a. Type 2 DM b. recent cerebral hemorrhage c. newly diagnosed osteoarthritis d. asthma since childhood

b

95. The nurse is caring for the kidney transplant patient who is 3 days postsurgery. The nurse notes a sudden and abrupt decrease in urine. The nurse alerts the health care provider because this is a sign of which anomaly? a. Rejection b. Thrombosis c. Stenosis d. Infection

b

A 75 year old patient is having an exploratory laparotomy tomorrow. The wife tells the nurse that at night the patient gets up and walks around his room. What priority action does the nurse take after hearing this information? a. Notifies the provider b. Develops a plan to keep the patient safe c. Obtains an order for sleep medication d. Tells the patient not to get out of bed at night

b

A client received "as needed" (PRN) morphine, lorazepam (Ativan), and cyclobenzaprine (Flexeril). The UAP reports that the client has a respiratory rate of 10/min. What is the priority action? a) Call the physician to obtain an order for naloxone (Narcan). b) Assess the client's responsiveness and respiratory status. c) Obtain a bag-valve mask and deliver breaths at 20/min. d) Double-check the drug order to see what the client should have received.

b

A patient is requesting moderate sedation for repair of a torn meniscus and has no medical contraindications. How does the nurse respond to this patients request? a. Your surgeon will decide if you will receive moderate sedation or general anesthesia b. You can discuss your request for moderate sedation with your surgeon and anesthesiologist c. Most patients prefer general anesthesia. Can you tell me why you want moderate sedation? d. It can be frightening to see surgery done on yourself. You need to think about that

b

A patient who can barely ambulate with a walker at home is having a left total knee replacement. What is the most appropriate category for this surgery? a. Urgent b. Restorative c. Simple d. Palliative

b

A patient with an abdominal aortic aneurysm is having surgical repair. What is the correct classification for this surgery? a. Restorative b. Emergent c. Urgent d. Minor

b

A pt with PKD reports sharp flank pain followed by blood in the urine. how does the nurse interpret these S/S? a. infection b. ruptured cysts c. increased kidney size d. ruptures renal artery aneurysm

b

APTT 70, control APTT 35. IV pump is infusing at 50ml/hour and mrs b has observable hematuria. what action should the nurse initiate first? A. obtain a stat APTT b. stop the heparin infusion c. assess VS d. Observe the surgical site for bleeding

b

After a nephrectomy, one adrenal gland remains. based on this knowledge, which type of medication replacement therapy does the nurse expect if the remaining adrenal gland function is insufficient? a. potassium b. steroid c. calcium d. estrogen

b

An ambulance arrives in a few minutes. two paramedics and an ED RN on a ride-along take control of situation. the nurse assists the paramedics as they prepare ryan for transport to the trauma center. 2. if respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising ryan's spine further? a. logroll to side while maintaining neutral alignment b. perform the jaw-thrust technique c. flex the neck with a wedge pillow d. use the chin-life/head-tilt technique

b

An insulin infusion is ordered for Mr. D to begin at 0.1 units/kg/hr. Mr.D weighs 155 lb. The pharmacy delivers a premixed bag of 100 units of regular insulin in 100 mL of normal saline. Another nurse has calculated the infusion pump setting as 10 mL/hr. What will you do next? a. Tell the nurse to obtain a pump and start the infusion as calculated b. advise the nurse to recalculate the infusion rate. c. Call the physician and ask for exact pump setting to be clarified d. allow the nurse to independently administer the infusion using her own best judgement

b

An older adult male pt reports an acute problem with urine retention. the nurse advises the pt to seek medical attention because permanent kidney damage can occur in what time frame? a. in less than 6 hours b. in less than 48 hours c. within several weeks d. within several years

b

For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? a) Closely assess for nonverbal signs such as grimacing or rocking. b) Obtain baseline behavioral indicators from family members. c) Look at the MAR and chart to note the time of the last dose of analgesic and the client's response. d) Give the maximum PRN dose within the minimum time frame for relief.

b

For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function with your continued support and supervision? a) Therapeutic touch b) Application of heat and cold c) Meditation d) Transcutaneous electrical nerve stimulation (TENS)

b

If pharmacologic therapy is initiated which lab value would indicate to the nurse that the heparinization has been reached? a. hemoglobin 9.0 b. APTT 65 secs, control 35 secs c. INR 1 d. platelets-250,000

b

Immediately following the sigmoidoscopy, its important for the nurse to assess for which manifestation? a. headache b. abdominal guarding c. concentrated urine d. inelastic skin turgor

b

In emergency department during initial assessment of a newly-admitted patient with diabetes, the nurse discovers all of these findings. Which findings should be reported to the health care provider immediately. a. hammer toe of the left second metatarsophalangeal joint b. rapid respiratory rate with deep inspirations c.numbness and tingling bilaterally in the feet and hands d. decreased sensitivity and swelling of the abdomen

b

Jess develops a fever and tachycardia. She complains of abdominal cramps and the nurse palpates an abdominal mass over the area of the transverse colon. Jess is restless and confused. The nurse recognizes this complication of ulcerative colitis as a. tenesmus b. toxic megacolon c. carcinoma d. rectal fistula

b

Jess receives prescriptions for diphenoxylate PRN, prednisone, sulfasalazine, and azathioprine. Jess's prescription for sulfa reads, "take 1g 3x a day". Jess takes the med at 0800, 1200, 1800 which are her mealtimes. After 2 weeks of this regimen she reports that her diarrhea has worsened and that she vomits frequently. What instruction should the nurse provide jess? a. Stop the med immediately. You are experiencing an allergic reaction b. you need to increase the length of time between each dose of the med c. you should take the med on an empty stomach to avoid these problems d.. your symptoms are worsening so you will probably need a higher dose

b

Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, "None of these doctors has done anything to help." Which client statement concerns you the most? a) "I twisted my back last night, and now the pain is a lot worse." b) "I'm so sick of this pain. I think I'm going to find a way to end it." c) "Occasionally I buy pain killers from a guy in my neighborhood." d) "I'm going to sue you and the doctor; you aren't doing anything for me."

b

Ryan is experiencing S&S of spinal shock and neurogenic shock. clients are at greater risk of developing both simultaneously with SCI involving cervical and upper thoracic areas. 7. Which intervention should the nurse implement first? a. assess ryan for symptoms of paralytic ileus b. notify ED HCP immediately c. assist ED HCP in inserting an endotracheal tube d. prepare to administer the vasoconstrictor dopamine

b

The acute, life threatening complication of MH results from the use of which agents? a. Hypnotics and neuromuscular blocking agents b. Succinylcholine and inhalation agents c. Nitrous oxide and pancuronium for muscle relaxation d. Fentanyl and regional anesthesia for spinal block

b

The nurse identifies the dietary teaching provided for a client with diabetes is understood when the client states, my diet: a. should be rigidly controlled to avoid emergencies b. can be planned around a wide variety of commonly used foods c. is based on nutritional requirements that are the same for all people d. Must not include eating any combination dishes and processed foods.

b

The nurse is reviewing the lab results for a pt being evaluated for trouble with passing urine. the UA shows tubular epithelial cells on microscopic examination. how does the nurse interpret this finding? a. the obstruction is resolving b. the obstruction is prolonged c. glomerular filtration rate is reduced d. glomerular filtration rate is adequate

b

The nurse is reviewing the pt's hx, assessment findings, and lab results for a pt with suspected kidney problems. which manifestations is the main feature of nephrotic syndrome? a. flank asymmetry b. proteinuria greater than 3.5 g of protein in 24 hours c. serum sodium 148 mmol/L d. serum cholesterol (total) 190 mg/dL

b

The nurse is to administer a heparin antagonist. Which med will be administered? a. vitamin K b. protamine sulfate c. enoxaparin d. ticlopidine (ticlid)

b

The preoperative patient tells the nurse that she is afraid that she may experience a reaction if she must receive blood during or after her surgery. What is the nurse's best response to the patient's concern? a. The likelihood that you will need a blood transfusion for your surgery is minimal, so don't worry about this b. You could donate some of your own blood a few weeks before your surgery. (autologous donation) c. With todays technology and procedures, it is very unlikely that you would have a reaction to donated blood. d. The nursing staff follows strict procedures to prevent such an event from ever happening

b

The student nurse is assisting in the postoperative care of a pt who had a recent nephrectomy. the student demonstrate a reluctance to move the pt to change the linens because "the pt seems so tired." the nurse reminds the student that a priority assessment for this pt is to assess for which factor? a. skin breakdown on the pt's back b. blood on the linens beneath the pt c. urinary incontinence and moisture d. the pt's ability to move self in bed

b

To which nursing dx should the nurse give the highest priority when planning care for mrs. b? a. pain related to decreased venous flow b. risk for injury related to anticoagulant therapy c. impaired physical mobility related to prescribed bedrest d. knowledge deficit related to lack of discharge teaching

b

When should jess empty her pouch? a. anytime she has any drainage b. when the pouch is 1/3 to 1/2 full c. when the pouch is almost 75% full d. only when the pouch is completely full

b

Which factor/manifestation is primary associated with acute pyelnophritis? a. obstruction caused by hydroureter b. active bacterial infection c. decreased urine specific gravity d. alcohol abuse

b

Which nursing interventions are appropriate during stage 2 of anesthesia? a. Prepare for and assist in treatment of cardiovascular and/or pulmonary arrest. Document in record b. Shield patient from extra noise and physical stimuli. Protect the patient's extremities. Assist anesthesia personnel as needed. Stay with patient c. Close operating room doors and control traffic in and out of room. Position patient securely with safety belts. Maintain minimal discussion in operating room d. Assist anesthesia personnel with intubation of patient. Place the patient in position for surgery. Prep the patient's skin in area of operative site

b

Which nursing interventions will prevent the potential intraoperative complication of radial joint stiffness, pain and inflammation? a. Support the wrist with padding; don't overtighten wrist straps b. Place pillow or foam padding under body prominences; maintain good body alignment; slightly flex joints and support with pillows, trochanter rolls and pads c. Pad the elbow, avoid excessive abduction, secure the arm firmly on an arm board positioned at shoulder level d. Place a safety strap above or below the area. Place a pillow or padding under the knees

b

You are caring for a young client with diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose level is 650 mg/dL, but she refuses insulin; however, she wants the pain medication. What is the best action? a) Notify the charge nurse and obtain an order for a transfer to intensive care. b) Explain that insulin is a priority and inform the health care provider. c) Withhold the pain medication until she agrees to accept the insulin. d) Give her the pain medication and document the refusal of the insulin.

b

You are preparing to transfer Mr.D to the ICU, and you observe the cardiac monitor pattern. Which finding is of greatest concern? a. P wave precedes every QRS complex b. Ventricular dysrhythmias are occurring c. QRS complexes are occurring more frequently d. The isoelectric line shows an artifact

b

You are reviewing the intensive care unit admission orders. there is an order for an IV potassium infusion. related specifically to the order for potassium, which information would the UCI nurse be most interested in knowing? a. Mental status has improved with therapy b. urinary output is 60 mL/hr and urine is a clear yellow color c. Blood pressure was 100/60 mmHg on admission and is now 125/76 mmHg d. One IV site showed infiltration, but the current IV line flushes easily

b

You are reviewing the potassium values that were obtained when Mr.D first arrived in the ED. Which serum potassium level would you the most? a. 3.5 mEq/L b. 2.0 mEq/L c. 5.8 mEq/L d. 6.0 mEq/L

b

You are trying to call a report to the ICU but you are told, "We were not notified about the admission." You call the admitting clerk, but she says, "I was never notified." You ask the unit secretary and he tells you, "I forgot to do it." What should you do first? a. Report the unit secretary to the manager b. Ask the secretary to call the admission office now c. Take the secretary aside and allow him to explain his actions d. Ask the ICU to take the report regardless of the clerical omission

b

a pt had chronic glomerulonephritis. in order assess for uremic symptoms, what does the nurse do? a. evaluate the blood urea nitrogen (BUN) b. ask the pt to extend the arms and hyperextend the wrists c. gently palate the flank for asymmetry and tenderness d. auscultate for the presence of an S3 heart sound

b

a pt has late-stage chronic glomerulonephritis. which educational bronchus would be the most appropriate to prepare for the pt? a. how to take your antiinfective medication b. important points to know about dialysis c. what are the side effects of radiation therapy? d. precautions to take during immunosuppressive therapy

b

a pt is diagnosed with chronic glomerulonephritis. the pt's spouse reports that the pt is irritable, forgetful and has trouble concentrating. which assessment finding does the nurse expect on further examination? a. increased respiratory rate b. elevated blood urea nitrogen c. high white count with a left shift d. low blood pressure and bradycardia

b

a pt os diagnosed with kidney cancer and the HCP recommends the best therapy. which treatment does the nurse anticipate teaching the pt about? a. chemotherapy b. surgical removal c. hormonal therapy d. radiation therapy

b

a pt with diabetic nephropathy reports having frequent hypoglycemic episodes "so my doctor reduced my insulin, which means my diabetes is improving." what is the nurse's best response? a. congratulations! you must be following the diet and lifestyle instruction very carefully b. when kidney function is reduced, the insulin is available for a longer time and thus less of it is needed c. you should probably talk to your doctor again. you have been diagnosed with nephropathy and that changes the situation d. let me get you a brochure about the relationship of diabetes and kidney disease. it is a complex and hard to understand.

b

after the nurse instructs a pt with PKD on home care, the pt knows to contact health care provider immediately when what s/s occurs? a. urine is a clear, pale, yellow color b. weight has increased by 3 pounds in 2 days c. two day shave passed since the last bowel movement d. morning systolic blood pressure has decreased by 5 mmHg

b

in PKD, the effect on the renin-angiotensin system in the kidney has which result? a. adrenal insufficient b. increased blood pressure c. increased urine output d. oliguria

b

the nurse is assessing a pt who reports chills, high fever, and flank pain with urinary urgency and frequency. on physical examination, the pt has costovertebral angle (CVA) tenderness, pulse is 110 beats/min, and respirations are 28/min. how does the nurse interpret this findings a. complicated cystitis b. acute pyelonephritis c. chronic pyelonephritis d. acute glomerulonephritis

b

the nurse is assessing a pt with possible acute glomerulonephritis. during the inspection of the hands, face, and eyelids, what is the nurse primarily observing for? a. redness b. edema c. rashes d. dryness

b

the nurse is caring for a postoperative nephrectomy pt. the nurse notes during the first several hours of the shift a marked and steady downward trend in blood pressure. how does the nurse interpret this finding? a. hypertension had been corrected. b. internal hemorrhage is possible c. the other kidney is failing d. this is an expected response to medication

b

which pt hx factor is considered causative for acute glomerulonephritis? a. urinary incontinence 6 months ago b. strep throat 3 weeks ago c. kidney stones 2 years ago d. mild hypertension diagnosed 1 year ago

b

The nurse is assessing a patient for severe pain in the right wrist after falling off a step stool. How does the nurse assess this patient's motor function? a) Performing passive range of motion in the wrist. b) Asking the patient to move the fingers. c) Having the patient flex and extend the elbow. d) Instructing the patient to rotate the wrist.

b) Asking the patient to move the fingers.

A patient comes to the ED with crush syndrome from a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him at a construction site. The patient has signs and symptoms of hypovolemia, hyperkalemia, and compartment syndrome. Management of care for this patient will focus on preventing which complications? (Select all) a) Sepsis b) Cardiac dysrithmias c) Respiratory failure d) Acute kidney failure e) Fluid overload

b) Cardiac dysrithmias d) Acute kidney failure

An older adult patient has a fractured humerus. The physicain is considering the use of electrical bone stimulation and asks the nurse to take a medical history on the patient. Which specific condition, which is a contraindication for this therapy, does the nurse ask the patient about? a) Seizures b) Cardiac pacemaker c) Stroke d) Peripheral nerve damage

b) Cardiac pacemaker

The nurse is helping to evaluate several patients to determine candidacy for the Ilizaroz external fixation device. Which patient is the best candidate? a) Older woman who lives alone with a fracture of nonunion b) Child with congenital bone deformity whose mother is a licensed practical nurse c) Teenager with an open fracture and bone loss of the left lower leg d) Middle aged man with a new comminuted fracture of the dominant forearm

b) Child with congenital bone deformity whose mother is a licensed practical nurse

A patient in a body cast reports nausea, vomiting, and epigastric pain. the nurse notifies the physician for orders. Which intervention is the most conservative, and therefore the first thing to try, to address this patient's symptoms? a) Insert a nasogastric tube and attach to low wall suction. b) Cut a window over the abdominal area of the cast. c) Obtain an order for an x-ray to diagnose a paralytic ileus. d) Administer prn antiemetic and prn pain medication.

b) Cut a window over the abdominal area of the cast.

A 30-year old patient who is hospitalized for repair of a fractured tibia and fibula sorts shortness of breath. Which complication related to the injury might the patient be experiencing? a) Hypovolemic shock b) Fat embolism c) Acute compartment syndrome d) Pneumonia

b) Fat embolism

The nurse is caring for several orthopedic patients who are in different types of traction. What should the nurse do in assessing the traction equipment? (Select all) a) Inspect all ropes, knots and pulleys once every 24 hours. b) Inspect ropes and knots for fraying or loosening every 8 to 12 hours. c) Check the amount of weight being used against the prescribed weight. d) Observe the traction equipment for proper functioning. e) Check if the ropes have been changed or cleaned within the past 48 hours.

b) Inspect ropes and knots for fraying or loosening every 8 to 12 hours. c) Check the amount of weight being used against the prescribed weight. d) Observe the traction equipment for proper functioning.

A patient comes to the ED after falling off his four-wheeler. His lower leg is obviously broken; it is bleeding and bone fragments are protruding from the skin. What type of fracture does this patient likely have? a) Impacted b) Open (compound) c) Comminuted (fragmented) d) Displaced

b) Open (compound)

The nurse is reviewing the orders for a patient who was admitted for 24-hour observation of a leg fracture. A cast is in place. Which order does the nurse question? a) Elevate the lower leg above the level of the heart. b) Perform neurovascular assessments ("circ checks") every 8 hours. c) Apply ice packs for 24 hours. d) Provide regular diet as tolerated.

b) Perform neurovascular assessments ("circ checks") every 8 hours.

What members of the health care team will be consulted to teach a patient about proper use of the cane? (Select all) a) Occupational therapist b) Physical therapist c) Registered nurse d) Unlicensed assistive personnel e) Medical social worker

b) Physical therapist c) Registered nurse

In the emergency care of a patient with a fracture, which action does the nurse implement first? a) Check the neurovascular status of the area distal to the extremity: temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs. b) Remove the patient's clothing (cut if necessary) to inspect the affected area while supporting the injured area above and below the injury. Do not remove shoes because this can cause increased trauma. c) Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture. d) Immobilize the extremity by splinting: include joints above and below the fracture site. recheck circulation after splinting.

b) Remove the patient's clothing (cut if necessary) to inspect the affected area while supporting the injured area above and below the injury. Do not remove shoes because this can cause increased trauma.

A patient is informed by the physician that he must have a fiberglass cast applied to the lower extremity. What does the nurse teach the patient about the procedure before the cast is applied? a) The cast will be applied after a stockinette is fitted to your skin. b) The cast material will dry and become rigged in a few minutes. c) The cast will increase your risk for skin breakdown. d) The plaster is not a waterproof material.

b) The cast material will dry and become rigged in a few minutes.

A patient is receiving scheduled prn narcotics for severe pain related to a musculoskeletal injury. The nurse finds that the patient's abdomen is distended and bowel sounds are hypoactive. Because the nurse suspects that the patient is having a medication side effect, which question does the nurse ask the patient? a) Are you having nausea and vomiting? b) When was your last bowel movement? c) Does your abdomen hurt? d) Ar you having diarrhea or loose stool?

b) When was your last bowel movement?

A patient with breast cancer is scheduled for a left mastectomy. The patient has informed the surgeon and nurse that she is a Jehovah's Witness and doesn't want any blood transfusions. In preparation for intraoperative care of this patient, what measures does the nurse take? (select all that apply) a. Obtain 2 units of packed RBCs, typed and crossmatched b. Make provider aware of patient's request for no blood transfusions c. ensure autotransfusion device is in place intraoperatively d. Ensure patient has a medical necessity order for emergency blood transfusion e. Inform the patient of potential risks if blood transfusion isn't given

b, c

In which situations is regional anesthesia used instead of general anesthesia? (select all that apply) a. For an endoscopy or cardiac catheterization b. In patients who have had an adverse reaction to general anesthesia c. In some cases when pain management after surgery is enhanced by regional anesthesia d. In patients with serious medical problems e. When the patient has a preference and a choice is possible

b, c, d, e

The nurse screens a preoperative patient for conditions that may increase the risk for complications during the perioperative period. Which conditions are possible risk factors? (select all that apply) a. Emotionally stable b. 67 years old c. Obesity d. Marathon runner e. Pulmonary disease

b, c, e

Which factors may lead to an anesthetic overdose in a patient? (select all that apply) a. Amount of anesthesia retained by fat cells b. Patient who is older c. Slowed metabolism and drug elimination d. An uncooperative patient e. Liver or kidney disease

b, c, e

The nurse is preparing the patient for surgery. Which common laboratory tests does the nurse anticipate to be ordered? (select all that apply) a. Total cholesterol b. Urinalysis c. Electrolyte levels d. Uric acid e. Clotting studies f. Serum creatinine

b, c, e, f

Which statements best describe the preoperative period? (select all that apply) a. It begins when the patient makes the appointment with the surgeon to discuss the need for surgery. b. It ends at the time of transfer to the surgical suite. c. It is a time during which the patient's need for surgery is established d. It begins when the patient is scheduled for surgery. e. It is a time during which the patient receives testing and education related to impending surgery

b, d, e

Which nursing interventions will reduce pain related to decreased venous flow? select all that apply a. apply cold packs b. elevate the affected leg c. gently massage the affected leg d. administer NSAIDs prn for pain e. apply a warm compress

b, e

91. Which patients are likely to be excluded from receiving a transplant? (select all that apply) a. Patient who has breast cancer 6 years ago b. Patient with advanced and uncorrectable heart disease c. Patient with a chemical dependency d. Patient who is 70 years of age and has a living related donor e. Patient with diabetes mellitus

b,c

34. What are the characteristics of continuous venovenous hemofiltration (CVVH)? (select all that apply) a. Requires placement of arterial and venous access b. Uses a pump to drive blood from the patient catheter into the dialyzer c. Risk of air embolus d. More commonly used for patients who are critically ill e. Most convenient method for home care patients

b,c,d

87. During PD, the nurse notes slowed dialysate outflow. What does the nurse do to troubleshoot the system? (select all that apply) a. Ensure that the drainage bag is elevated b. Inspect the tubing for kinking or twisting c. Ensure that clamps are open d. Turn the patient to the other side e. Make sure the patient is in good body alignment f. Instruct the patient to stand or cough

b,c,d,e

92. A daughter is considering donating a kidney to her mother for organ transplant. What information does the nurse give to the daughter about the criteria for donation? (select all that apply) a. Age limit is at least 21 years old b. Systemic disease and infection must be absent c. There must be no history of cancer d. Hypertension or kidney disease must be absent e. There must be adequate kidney function as determined by diagnostic studies f. The donor must understand the surgery and be willing to give up the organ.

b,c,d,e,f

21. What does the nurse monitor for in a pt with a PE? (select all that apply) a. N/V b. cyanosis c. rapid heart rate d. dyspnea e. paradoxical chest movement f. crackles in lung fields

b,c,d,f

3. To improve a pts oxygenation to a normal level, the amount of oxygen administered is based on which factors? select all that apply a. symptom management only b. pulse oximetry reading c. respiratory assessment d. the pts subjective complaints e. ABG results

b,c,e

68. The older adult with DM asks the nurse for advice about beginning an exercise program. What is the nurse's best response? (select all) a. begin with high-density activities b. start low-intensity activities in short sessions c. be sure to include a warm-up and cool-down periods d. start with periods of 20 min or less e. changes in activity should be gradual

b,c,e

7. A pt requires home oxygen therapy. When the home health nurse enters the pts home for the initial visit, he observes several issues that are saftey hazards related to the pts oxygen therapy. What hazards do these include? select all that apply a. bottle of wine in the kitchen b. pack of cigarettes on the coffee table c. several decorative candles on the mantelpiece d. grounded outlet with a green dot on the plate e. electric fan with a frayed cord in the bathroom f. computer with a 3 pronged plug

b,c,e

78. The nurse is caring for a patient with an arteriovenous fistula. What is included on the nursing care for this patient? (select all that apply) a. Keep small clamps handy by the bedside. b. Encourage routine range-of-motion exercises. c. Avoid venipuncture or IV administration on the arm with the access device d. Instruct the patient to carry heavy objects to build muscular strength e. Assess for manifestations of infection of the fistula f. Instruct the patient to sleep on the side with the affected arm in the dependent position.

b,c,e

5. Post-renal kidney injury can result from which conditions? (select all that apply) a. Septic shock b. Cervical cancer c. Nephrolithiasis or ureterolithiasis d. Heart failure e. Neurogenic bladder f. Prostate cancer

b,c,e,f

59. what are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (select all that apply) a) diuresis b) pain relief c) antipyresis d) bronchodilation e) anticoagulation f) reduced inflammation

b,c,f

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? (Select all that apply.) a) Client who needs preoperative teaching for the use of a PCA pump b) Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone c) Client who underwent a toe amputation and has diabetic neuropathic pain d) Client with terminal cancer and severe pain who is refusing medication e) Client who reports abdominal pain after being kicked, punched, and beaten f) Client with arthritis who needs scheduled pain medications and heat applications

b,c,f

1. Which descriptors are typical of type 2 diabetes mellitus? (select all that apply) a. autoimmune response causes beta cell destruction b. cells have decreased ability to respond to insulin c. diagnosis is based on results of 100-g glucose tolerance test d. most pts diagnosed are obese adults e. usually has abrupt onset of thirst and weight loss

b,d

Mrs b should also be instructed to avoid which OTC products? select all that apply a. antihistamines b. aspirin, salicylates, ibuprofen and naproxen c. calcium carbonate d. acetaminophen e. antidiarrheal agents

b,d

Which actions should be implemented during the administration of low molecular weight heparin? select all that apply a. massage the site after injection to promote absorption b. use subQ sites in abdomen c. apply pressure over the site after injection to prevent bleeding d. rotate injection sites e. aspirate for blood before injecting the med

b,d

2. Which conditions will increase the bodys need for more oxygen? select all that apply a. hypothyroid b. infection in the blood c. Diabetes mellitus d. body temp of 101F e. hemoglobin level of 8.7

b,d,e

3. What are common causes of pre renal kidney injury? (select all that apply) a. Uretral cancer b. Hypovolemic shock c. Enlarged prostate gland d. Sepsis e. Severe burns

b,d,e

13. after the nurse explains how the TENS unit soothes pain, Natalie wants to know the best way to apply and use the unit. Which instructions should the nurse include? (select all that apply) a) after applying the electrodes, set the unit to provide continuous stimulation b) be sure to use conducting gel or conductor pads when applying the electrodes to the skin c) remove the electrodes and change sites each time the skin is stimulated d) turn on the unit only when your pain medication does not provide relief e) clean the skin where electrodes will be placed and dry thoroughly

b,e

25. Which are considered the early signs of diabetic nephropathy? (select all) a. positive urine RBCs b. microalbuminuria c. positive urine glucose d. positive urine WBCs e. elevated serum uric acid

b,e

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) a) Anxious client with chronic pain who frequently uses the call button b) Client on the second postoperative day who needs pain medication before dressing changes c) Client with human immunodeficiency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain d) Client with chronic pain who is to be discharged with a new surgically-implanted catheter e) Client who is reporting pain at the site of a peripheral IV line f) Client with a kidney stone who needs frequent PRN pain medication

b,e,f

The patient with gastroenteritis due to infection with the Norovirus asked the nurse how this illness occurred. Which statement by the patient indicates correct understanding of the nurses teaching? a. "I got this infection from being around my grandchildren when they had respiratory illnesses." b. "It is likely that I got this illness from either contaminated water or food." c. "I may have gotten sick when I was traveling last month." d. "It's really important that everything I eat is cooked until it is well done."

b. "It is likely that I got this illness from either contaminated water or food"

The nurse is teaching a patient with IBS about complementary and alternative therapies for the disease. Which patient statements indicate that teaching has been effective? Select all that apply a. Hydrotherapy may help decrease symptom b. probiotics can help decrease bacteria and decrease my IBS symptoms c. peppermint oil has been used to expel gas and relax spastic intestinal muscles d. fish oil can be used to ease constipation e. Ginkgo can be used for abdominal discomfort and to expel gas

b. "Probiotics can help decrease bacteria and decrease my IBS symptoms" c. "Peppermint oil has been used to expel gas and relax spastic intestinal muscles"

The nurse is providing teaching for a patient with an anal fissure as a complication of Crohn's disease. Which statement by the patient indicates the need for further teaching? a. "I will use warm sits baths." b. "A diet that is low in bulk-producing agents is best for me." c. "Hydrocortisone cream may be helpful to decrease discomfort." d. " Topical antiinflammatory agents will help if I am uncomfortable."

b. "a diet that is low in bulk producing agents is best for me"

Which statement by a patient indicates an understanding of surgical management of hemorrhoids? a. "It will take 10 to 14 days for the rubber band used on the hemorrhoid to fall off." b. "My first bowel movement after the surgery may be very painful." c. "After surgery, I will need to eat a low-fiber, low -fiber diet." d. "Stool softeners and laxatives are avoided after hemorrhoid surgery."

b. "my first bowel movement after the surgery may be very painful"

18. The nurse is evaluating electrolyte values for a pt with acute pancreatitis and notes that the serum calcium is 6.8 mEq/L. How does the nurse interpret this finding? a. Within normal limits considering the dx of acute pancreatitis b. A result of the body not being able to used bound calcium c. A protective measure that will reduce the risk of complications d. Full compensation of the parathyroid gland

b. A result of the body not being able to used bound calcium

31. What are manifestations of pancreatic cancer? SELECT ALL a. light-colored urine and dark-colored stools b. Anorexia and weight loss c. Splenomegaly d. Ascites e. Leg or calf pain f. Weakness and fatigue

b. Anorexia and weight loss c. Splenomegaly d. Ascites e. Leg or calf pain f. Weakness and fatigue

32. The nurse is teaching a pt and family how to prevent exacerbations of chronic pancreatitis. Which teaching point does the nurse include? a. Moderation in the use of caffeinated beverages b. Avoidance of alcohol and nicotine c. Consume a bland, high-fat, low-protein diet d. Regular exercise, stressing aerobic activities

b. Avoidance of alcohol and nicotine

Which are common manifestation in a 28-year-old patient with dehydration secondary to gastroenteritis? Select all that apply a. Peripheral edema b. Elevated temperature c. Dry mucous membranes d. Hypertension e. Oliguria

b. Elevated temperature c. Dry mucous membranes e. Oliguria

What is the priority nursing concern for a patient with gastroenteritis? a. Nutrition therapy b. Fluid replacement c. Skin care d. Drug therapy

b. Fluid replacement

33. The pt is to continue pancreatic enzyme replacement therapy (PERT) after discharge. Which statement indicates that the pt understands teaching about this therapy? a. I will take the enzymes before meals with a full glass of water b. I will take the enzymes after I take my ranitidine (Zantac) c. I will mix the enzymes with chopped meat d. I will chew the capsules before swallowing the enzymes

b. I will take the enzymes after I take my ranitidine (Zantac)

Which interventions does the nurse expect to implement when caring for a patient with diverticulitis? Select all that apply a. Laxatives and enemas are ordered b. IV fluids to prevent dehydration c. Broad spectrum antibiotics d. Teach the patients to refrain from lifting or straining e. Keep the patient NPO if symptoms are severe

b. IV fluids to prevent dehydration c. Broad spectrum antibiotics d. Teach the patients to refrain from lifting or straining e. Keep the patient NPO if symptoms are severe

17. The pt with acute cholecystitis had a pacemaker. Which diagnostic test is contraindicated? a. ERCP b. Magnetic resonance cholangiopancreatography (MRCP) c. Ultrasonography of the RUQ d. Hepatobiliary (HIDA) scan

b. Magnetic resonance cholangiopancreatography (MRCP)

11. The nurse is caring for an older adult pt with acute biliary pain. Which drug order the the nurse question? a. Ketorolac (Toradol) b. Meperidine (Demerol) c. Morphine d. Hydromorphone (Dilaudid)

b. Meperidine (Demerol)

28. The nurse detects an epigastric mass while assessing a pt with acute pancreatitis. The pt describes epigastric pain that radiates to his back. What does the nurse suspect? a. Liver cirrhosis b. Pancreatic pseudocyst c. Gallstones d. Chronic pancreatitis

b. Pancreatic pseudocyst

Which diagnostic test measures urinary excretion of vitamin B12 for diagnosis of pernicious anemia and other malabsorption syndromes? a. Bile acid breath test b. Schilling test c. Hydrogen breath test d. D-xylose absorption test

b. Schilling test

Which serum lab value requires follow up by the nurse? a. Sodium of 135 mEq/L b. WBC of 14,000/mm3 c. Creatinine of 0.8 mg/dl d. Hemoglobin of 14g/dL

b. The normal WBC count is 5,000-10,000/mm3. Normal sodium- 135-145mEq/l. Normal creatinine- 0.6-1.3 mg/dL. Normal hemoglobin-11.7-15.5 g/dL

8. A pt is scheduled for tests to verify the medical dx of cholecystitis. For which diagnostic test does the nurse provide pt teaching? a. extracorporeal shock wave lithotripsy (ESWL) b. Ultrasonography of the RUQ c. Endoscopic retrograde cholangiopancreatography (ERCP) d. Serum level of aspartate aminotransferase (AST)

b. Ultrasonography of the RUQ

The nurse on the surgical unit is expecting to admit the patient who has had an appendectomy with abscess. What does the nurse anticipates care for this patient will include? Select all that apply a. Clear liquids b. Wound drains c. IV antibiotics d. Nonsteroidal anti-inflammatory drugs (NSAIDS) for pain control e. Nasogastric (NG) tube care

b. Wound drains c. IV antibiotics e. Nasogastric tube care

Which are examples of mechanical bowel obstructions? Select all that apply a. Paralytic ileus b. Adhesions c. Tumors d. Absent peristalsis e. Fecal impaction

b. adhesions c. Tumors e. Fecal impaction

After colostomy surgery, which intervention does the nurse employ? a. cover the stoma with a dry, sterile dressing b. applying a pouch system as soon as possible c. make a hole in the pouch for gas to escape d. watch for the colostomy to start functioning on day 1

b. apply a pouch system as soon as possible

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of RA? a. inflammation of the synovial membrane rarely occurs b. bony ankylosis of a joint is irreversible and causes immobility c. complete immobility is desired during the acute phase of inflammation d. redness and swelling of a joint signify irreversible damage has occurred.

b. bony ankylosis of a joint is irreversible and causes immobility

A client is admitted with acute gouty arthritis. Which medication does the nurse anticipate the health care provider may prescribe to prevent and treat an acute attack of gout? a. ibuprofen (motrin) b. colchicine (colsalide) c. probenecid (benemid) d. hydrocortisone (cortef)

b. colchicine (colsalide)

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? a. surgery b. comfort c. education d. motivation

b. comfort

Then nurse is performing an assessment of a patient with RA. Which findings does the nurse expect? a. head and neck pain b. early morning joint pain c. increased range of motion (ROM) in the hands d. absence of joint swelling

b. early morning joint pain

What do post operative measures for a male patient who has had an inguinal herniorrhaphy include? a. applying a warm pack to the scrotum b. elevating the scrotum on a pillow c. encouraging use of a bedpan to void d. decreasing fluid intake to decrease bladder emptying

b. elevating the scrotum on a pillow

Which characteristics pertain to Crohn's disease? Select all that apply a. Begins in the rectum and proceeds in a continuous manner toward the cecum b. Fistulas commonly develop c. Five to six soft, loose stools per day that are nonbloody d. Increased risk of colon cancer e. Some patients experience extra intestinal manifestations such as migratory polyarthritis. ankylosing spondylitis, and erythema nodosum f. Cobblestone appearance of the internal intestine

b. fistulas commonly develop c. 5-6 soft, loose stools per day that are nonbloody f. Cobblestone appearance of the internal intestine

An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone (Deltasone) 20 mg daily for 4 days. Which medical order should you question? a. discontinue prednisone after today's does b. give a "catch-up" dose of varicella vaccine c. check the patient's C-reactive protein level d. administer ibuprofen (Advil) 800mg PO.

b. give a "catch-up" dose of varicella vaccine

What statement is true about the medical treatment of ulcerative colitis? a. Infliximab (Remicade) is approved as a first-line therapy b. Immunomodulators are not thought to be effective; however, in combination with steroids, they may offer a synergistic effect. c. When a therapeutic level of glucocorticoids is reached, the dosage of the drug stays the same to maintain the therapeutic effect d. The method of action for the aminosalicylates is interruption of the pain pathway

b. immunomodulators are not thought to be effective; however, in combination with steroids, they may offer a synergistic effect.

Arthrocentesis done one the patient with RA may reveal which elements in the synovial fluid of the joint? (select all that apply) a glucose and glycogen b. inflammatory cells and immune complexes c protein, such as albumin d. platelet aggregation e. increased WBCs

b. inflammatory cells and immune complexes e. increased WBCs

Which nursing intervention is part of nonsurgical management for a patient with peritonitis? a. Monitor weekly weight and intake and output b. Insert a nasogastric tube to decompress the stomach c. Order a breakfast tray when the patient is hungry d. Administer NSAIDS for pain

b. insert a nasogastric tube to decompress the stomach

What nursing care does a patient with a nasogastric tube require? select all that apply a. Assessment of proper placement at least every 12 hours b. Keep patient in a semi-Fowler's position c. Confirmation of NG tube placement by x-ray if it is repositioned d. Monitor contents of the NG tube e. Irrigation of the tube with 30 mL of normal saline as ordered f. Questioning the patient about the passage of flatus

b. keep the patient in a semi Fowler's position c. Confirmation of NG tube placement by x-ray if it is repositioned d. Monitor contents of the NG tube e. Irrigation of the tube with 30 mL of normal saline as ordered

22. Which diagnostic test is the most accurate in verifying a dx of acute pancreatitis? a. trypsin b. lipase c. alkaline phosphatase d. Alanine aminotransferase

b. lipase

Which foods should the nurse teach a client with gout to avoid to limit painful attacks. (select all that apply) a. eggs b. liver c. cheese d. salon e. shellfish

b. liver e. shellfish

The trauma patient has ecchymosis in the shape and distribution of a seatbelt. What is the nurses best first action? a. Start a third large-bore IV b. Notify the health care provider c. Insert a urinary catheter d. Get a 12-lead electrocardiogram

b. notify the healthcare provider

The nurses providing care for a patient with a bowel obstruction notes that the patient has started passing flatulence and had a small bowel movement. What has occurred with this patient? a. Blockage is complete b. Peristalsis has returned c. Peritonitis has occurred d. The patient is rehydrated

b. peristalsis has returned

The patient has been diagnosed with acute appendicitis. Based on this diagnosis, which intervention does the nurse perform? a. Start a bowel cleansing program b. Prepare the patient for surgery c. Apply a heating pad to the lower abdomen d. Assess the patient's knowledge about dietary modifications.

b. prepare the patient for surgery

Which nursing care actions should the nurse delegate to the unlicensed assistant personnel for an older patient with a bowel obstruction? Select all that apply a. Administer analgesics as needed b. Provide mouth care every 2 hours c. Assess abdomen for distention d. Teach the patient about surgical procedures e. Provide the patient with a few ice chips

b. provide mouth care every 2 hours e. provide the patient with a few ice chips

A client with RA asks the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question? a. lubricate the joint b. reduce inflammation c. provide physiotherapy d. prevent ankylosis of the joint

b. reduce inflammation

What are characteristics of primary gout? (select all that apply) a. results from medications such as diuretics b. sodium urate deposited in the synovium c. affects large joints most commonly d. affects middle-aged and older men e. peak time of onset after age 50

b. sodium urate deposited in the snovium d. affects middle-aged and older men

What can be expected for a patient with recently diagnosed systemic lupus erythematosus (SLE)? a. an acute inflammatory disorder b. spontaneous remission and exacerbations c. symptoms limited to arthritis d. symptoms limited to skin lesions

b. spontaneous remission and exacerbations

You assess a 24-year-old patient with RA who is considering using methotrexate (Rheumatrex) for treatment. Which patient information is most important to communicate to the health care provider? a. the patient has many concerns about the safety of the drug b. the patient has been trying to get pregnant c. the patient takes a daily multivitamin tablet d. the patient says that she has taken methotrexate in the past.

b. the patient has been trying to get pregnant

Emergency care of a patient with abdominal trauma includes which interventions? Select all that apply a. Insertion of at least two large-bore IV catheters in the lower extremities b. Type and cross-matching of 4 to 8 units of blood c. Measurement of arterial blood gases d. Continuous hemodynamic monitoring e. Insertion of a foley catheter

b. type and cross matching of 4-8 units of blood c. Measurement of arterial blood gases d. Continuous hemodynamic monitoring e. insertion of a foley catheter

Because of the inflammatory process in RA, a pannus forms in the joint. What is a pannus? a. scar tissue restricting the joint b. vascular granulation tissue in the joint c. necrotic tissue sloughing into the joint d. fluid encapsulated in the joint

b. vascular granulation tissue in the joint.

A patient with a colostomy may safely include which food item into the diet? a. Burritos b. Yogurt c. Cabbage d. Carbonated beverages

b. yogurt

The nurse is caring for a pt with nephrotic syndrome. what interventions are included in the plan of care for this pt? select all that apply. a. fluids should be restricted b. administer mild diuretics c. assess for edema d. administer antihypertensive medication e. frequently assess the pt's mental status

bcd

a pt with PKD would exhibit which s/s? Select all that apply. a. frequent urination b. increased abdominal girth c. hypertension d. kidney stones e. diarrhea

bcd

a pt had been informed by the HCP that treatment will be needed for renal artery stenosis. the nurse prepares to teach about a variety of treatment options. what treatments will the nurse include in the teaching plan? a. kidney transplant b. hypertension control c. ballon angioplasty d. renal artery bypass surgery e. synthetic blood vessel graft f. percutaneous ultrasonic pyelolithotomy

bcde

what are the key features associated with chronic pyelonephritis? Select all that apply. a. abscess formation b. hypertension. c. inability to conserve sodium d. decreased urine-concentration ability, resulting in nocturia e. tendency to develop hyperkalemia and acidosis

bcde

what might the nurse notice if the pt is experiencing problems with urinary elimination as result of acute pyelonephritis? Select all that apply. a. pt urinates large amounts of dilute urine b. pt reports pain and burning on urination c. pt reports back or flank pain d. urine is cloudy and foul-smelling e. urine may be darker or smoky or have obvious blood in it.

bcde

13. Which strategies should be incorporated in the plan of care to provide emotional support for a pt with GBS who has ascending paralysis? (select all) a. limit information provided to the pt and family b. encourage the pt to verbalize feelings c. teach the pt and famly about the condition d. explain all procedures and tests e. allow regularly scheduled rest periods f. assess previous coping skills

bcdef

the nurse is caring for a pt with kidney cell carcinoma who manifests paraneoplastic syndromes. what findings does the nurse expect to see in this pt? select all that apply. a. urinary tract infection b. erythrocytosis c. hypercalcemia d. liver dysfunction e. decreased sedimentation rate f. hypertension

bcdf

24. The nurse is caring for a pt with a recent SCI. Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? (select all) a. frequently perform passive ROM exercises b. loosen or remove any tight clothing c. monitor stool output and maintain a bowel program d. keep the pt immobilized with neck or back braces e. monitor urinary output and check for bladder distention

bce

51. Following a thymectomy for a pt with MG, the nurse notes that the pt is restless and experiencing chest pain and shortness of breath. What are the nurse's best actions at this time? (select all) a. instruct the pt to use incentive spirometry b. administer oxygen c. raise the HOB 45 degrees d. place the pt supine to encourage rest and sleep e. notify the rapid response team f. assist the pt to sit at the end of the bed

bce

5. After the CT is done, ryan is transported to the MRI scan. what questions are appropriate to ask ryan prior to beginning the procedure? (select all) a. has he ever been told he is allergic to iodine? b. is he claustrophobic or afraid of closed-in, small spaces? c. when was the last time he ate or drank anything? d. does he have any metal piercings on his body or metal implants? e. does he have any allergies to eggs?

bd

689. A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? select all a. polyuria b. lethargy c. hypotension d. muscle twitching e. respiratory acidosis

bd

20. Which symptoms indicate that a pt with a spinal cord injury is experiencing autonomic dysreflexia? (select all) a. flaccid paralysis b. hypertension c. hypotension d. severe headache e. blurred vision f. loss of reflexes below the injury

bde

34. The nurse is giving home care instructions to a pt who will be discharged with a halo device. What does the nurse instruct the pt to avoid? (select all) a. going out in the cold b. swimming or contact sports c. sexual activity d. bathing in the bathtub e. driving

be

Ryan's friends are standing around him, unsure of what to do. They are afraid he is badly hurt; ryan states he will be fine in a few minutes. someone calls 911. 1. what should ryan's friends do while waiting for emergency personnel to show up? (select all) a. help ryan move his legs and assist him to sit up b. place a blanket over ryan and make sure no one moves him c. attempt to stabilize his neck with any type of soft material d. carefully put ryan in the back of a truck with one man holding his neck e. ensure that the scene around ryan is safe and that he is not in any immediate danger

be

Which instructions are important for the nurse to provide jess regarding food and fluid intake during the stool specimen collection? select all a. avoid caffeine b. avoid red meat c. increase fluid intake d. remian NPO after midnight e. don't take supplemental ascorbic acid (vitamin C)

be

1. The nurse is assessing a pt with a diagnosis of Guillain-Barre syndrome (GBS). Which S&S are consistent with GBS? (select all) a. bilateral sluggis pupil response b. sudden onset of weakness in the legs c. muscle atrophy of the legs d. change in LOC e. decrease deep tendon reflexes f. ataxia

bef

10. A pt with GBS is receiving IV immunoglobulin. The nurse monitors for which major potential complication of this drug therapy? a. headache b. itching c. anaphylaxis d. fever

c

10. assessment of ms j after dialysis reveals all of these findings. which assessment finding necessitates immediate action? a. weight decrease of 4.5lbs b. systolic bp decrease of 14mmHg c. decreased LOC d. small blood spot near the center of the dressing

c

11. Which combination of drugs is the most nephrotoxic. a. Angiotensin-converting enzyme (ACE) inhibitors and aspirin. b. Angiotensin II receptor blockers and antacids c. Aminoglycoside antibiotics and non steroidal anti-inflammatory drugs (NSAIDS) d. Calcium channel blockers and antihistamines

c

11. when a pt is requiring oxygen therapy, what is important for the nurse to know? a. pts require 1-10L/min by nasal cannula in order for oxygen to be effective b. oxygen induced hypoventilation is the priority when the paco2 levels are unknown c. why the pt is receiving oxygen, expected outcomes, and complications d. the goal is the highest Fio2 possible for the particular device being used

c

13. For a patient with AKI, the nurse would consider questioning the order for which diagnostic test? a. Kidney biopsy b. Ultrasonography c. Computed tomography with contrast dye d. Kidney, ureter, bladder (KUB) x-ray

c

13. The nurse is administering oxygen to a pt who is hypoxic and has chronic high levels of carbon dioxide. Which oxygen therapy prevents a respiratory complication for this pt? a. Fio2 higher than usual 2-4L/min per nasal cannula b. venturi mask of 40% for the delivery of oxygen c. lower concentration of oxygen per nasal cannula d. variable Fio2 via partial rebreather mask

c

14. A pt is receiving a high concentration of oxygen as a temporary emergency measure. Which nursing action is the most appropriate to prevent complications associated with high flow oxygen? a. auscultate the lungs every 4 hours for oxygen toxicity b. increase the oxygen if the Pao2 level is less than 93 c. monitor the prescribed oxygen level and length of therapy d. decrease the oxygen if the pts condition doesn't respond

c

14. what characteristic of scheduled drugs results in the need for these specific protocols? a) large doses can be fatal b) respiratory depression can occur c) there is a high potential for abuse d) tolerance develops with repeated use

c

15. The nurse is caring for a pt with a spinal cord injury who is experiencing neurogenic shock. The pt's systolic BP is 88 mmHg despite starting a dopamine drip 2 hours earlier. There is a new order to infuse 500 mL of Dextran-40 over 4 hours. At what rate does the nurse set the infusion pump? a. 75 mL/hr b. 100 mL/hr c. 125 mL/hr d. 150 mL/hr

c

16. A pt is receiving warmed and humidified oxygen. The respiratory therapist informs the nurse that several other pts on other units have developed hospital acquired infections and pseudomonas aeruginosa has been identified as the organism. What does the nurse do? a. place the pt in respiratory isolation b. obtain an order for a sputum culture c. change the humidifier every 24 hours d. obtain an order to discontinue the humidifier

c

17. The nurse is caring for several pts at risk for DVT and PE. Which conditions causes the pt to be a candidate for placement of a vena cava filter? a. massive PE causing the pt to experience shock symptoms b. multiple emboli with deteriorating cardiopulmonary status c. recurrent bleeding while receiving anticoagulants d. no response to oxygen therapy and conservative management

c

18. The pt with GBS is immobile and shows evidence of malnutrition. What is the nurse's priority concern for this pt? a. respiratory failure b. inability to perform ADLs c. risk for pressure ulcers d. cardiac dysrhythmias

c

18. the nurse will first place the palm of the hand on what anatomical spot to locate the injection site? a) the upper outer quadrant of the buttock b) the anterosuperior iliac spine c) the greater trochanter d) the iliac crest

c

193. a client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? a) maintain the settings programmed by the health care provider b) turn the machine on several times a day for ten to twenty minutes c) adjust the dial on the unit until the client states the pain is releived d) apply the color-coded electrodes on the client where they are most comfortable

c

2. During shift report, the nurse hears that a pt with GBS has a decrease in vital capacity that is less than 2/3 of normal, and there is a progressive inability to clear and cough up secretions. The physician has been notified and is coming to evaluate the pt. What intervention is the nurse prepared to implement for this pt? a. frequent oral suctioning b. rigorous chest physiotherapy c. elective intubation d. elective tracheostomy

c

2. which task associated with 24hr urine collection is appropriate to delegate to the UAP? a. instructing ms. j to collect all urine with each voiding b. teaching ms j the purpose of collecting urine for 24hrs c. ensuring that all urine obtained for the test is kept on ice d. assessing ms j's urine for color, odor and sediment

c

20. to ensure that the(guided imagery) exercise is most effective, what action should the nurse implement? a) help the client cross her legs in a semi-yoga position b) encourage the client to lie down rather than sit in a chair c) include as many sensory images as possible in the experience d) suggest that an image involving water may be more restful

c

22. A pt is receiving oxygen therapy through a nonrebreather mask. What is the correct nursing intervention? a. maintain liter flow so that the reservoir bag is up to 1/2 full b. maintain 60-70% Fio2 at 6-11l/min c. ensure that valves and rubber flaps are patent, functional, and not stuck d. assess for effectiveness and switch to partial rebreather mask for more precise Fio2

c