Term 2 Cumulative Exam

A patient is to collect a specimen for a stool guaiac test. Which direction should the patient be given? A. "Be sure to use a sterile container to collect the specimen." B. "Be sure to take a laxative 2 days prior to collecting the stool." C. "Do not eat red meat for at least 3 days before collecting the specimen." D. "Do not drink carbonated beverages for 8 hours before collecting the specimen."

Answer: "Do not eat red meat for at least 3 days before collecting the specimen." The stool guaiac test assesses for the presence of blood in the specimen. The patient must have a red meat-free diet for at least 3 days before a stool guaiac test can be considered accurate. Laxative use is not needed prior to collection of the specimen. The container used will be clean but not sterile. Intake of carbonated beverages will not impact the specimen.

Patients with ileostomies should be given which instruction? A. "Do not take enteric-coated tablets." B. "Increase your intake of dried fruits." C. "Add more high-fiber foods to your diet." D. "If you notice a blockage, take a laxative."

Answer: "Do not take enteric-coated tablets." Ileostomy patients should not take time-release capsules and enteric-coated tablets, as there is not enough time for adequate absorption before the medication is expelled through the stoma. Dried fruits and high-fiber foods should be avoided. If a blockage is noted, the patient should seek medical attention and never take a laxative.

A patient is suspected of having colon cancer. Which question is most important to ask to see if the patient is at risk? A. "Do you eat a lot of wild mushrooms?" B. "Do you eat a lot of barbecued foods?" C. "Has anyone in your family had rectal polyps?" D. "Has anyone in your family had bowel cancer?"

Answer: "Has anyone in your family had bowel cancer?" Colon cancer has a familial link, making this inquiry the most appropriate. Charred meats can increase one's risk for colon cancer. Familial history of rectal polyps and dietary intake of wild mushrooms are less important.

The nurse is caring for a patient who has had his eye removed after suffering an injury. The patient is a candidate for the placement of an artificial eye. Which statement by the patient indicates understanding of when an artificial eye will be placed? A. "I should have my artificial eye placed in about 6 weeks." B. "I am excited that my new eye will be placed in about 2 weeks." C. "Unfortunately, I will not have my artificial eye until about 6 months." D. "It will likely take about a year before I can be fitted for my artificial eye."

Answer: "I am excited that my new eye will be placed in about 2 weeks." A low-sodium diet and niacin (a water-soluble B vitamin) have been shown to be effective in reducing the symptoms of Meniere disease. Canned soups have elevated sodium levels and should be avoided. There is no reason to restrict lean meats, potassium-rich foods, or complex carbohydrates.

Which statement made by a patient might indicate a precipitating factor of acute gastritis? A. "I really like tequila." B. "I never touch alcohol." C. "I just started a new diet." D. "I try to get in a 2-mile walk every day."

Answer: "I really like tequila." Drinking excessive amounts of alcohol, infection from eating contaminated food, Helicobacter pylori bacteria, and ingestions of aspirin, ibuprofen, corticosteroids, or nonsteroidal anti-inflammatory drugs (NSAIDS) are gastrointestinal (GI) irritants. Exercise and a healthy diet help prevent gastritis.

A patient on bed rest has been instructed on performing quadriceps setting exercises. What statement by the patient indicates the need for further instruction? A. "I should hold the muscle in contraction for at least a minute." B. "I should release the muscle and count to five before contracting again." C. "The exercises will benefit me most if I perform them three to four times a day." D. "These exercises are good to recondition my muscles in preparation for getting out of bed."

Answer: "I should hold the muscle in contraction for at least a minute." Quadriceps setting exercises are a helpful tool to recondition the muscles after injury or surgery. The muscle contraction should be "held" for a count of five, not a full minute. The patient would be correct in stating that he should release the muscle and count to five before contracting again, that the most benefit will be obtained from performing them three to four times a day, and that they are good for reconditioning muscles in preparation for getting out of bed.

The nurse is caring for a patient who has been recently diagnosed with hepatitis caused by the hepatitis B virus and who is taking lamivudine (Epivir). Which statement, if made by the patient, indicates the need for further teaching about this medication? A. "I will still need to use condoms." B. " I will call my provider if I develop a fever or sore throat." C. "I should anticipate difficulties sleeping for the next months." D. "I will be cured of the virus when I have finished the course."

Answer: "I will be cured of the virus when I have finished the course." Epivir is not a cure for hepatitis B, but it does control the symptoms. The patient should alert the provider should a fever or signs of an infection develop. Insomnia and gastrointestinal (GI) disturbances usually resolve after a month. The patient will still need to use Standard Precautions regarding body fluids and blood.

The nurse is caring for a patient who has been recently diagnosed with hepatitis caused by the hepatitis B virus and who is taking lamivudine (Epivir). Which statement, if made by the patient, indicates the need for further teaching about this medication? A. "I will still need to use condoms." B. "I will call my provider if I develop a fever or sore throat." C. "I should anticipate difficulties sleeping for the next month." D. "I will be cured of the virus when I have finished the course."

Answer: "I will be cured of the virus when I have finished the course." Epivir is not a cure for hepatitis B, but it does control the symptoms. The patient should alert the provider should a fever or signs of an infection develop. Insomnia and gastrointestinal (GI) disturbances usually resolve after a month. The patient will still need to use Standard Precautions regarding body fluids and blood.

The nurse is caring for a patient who is preparing for discharge after having had an upper GI series. Which patient statement demonstrates a need for further discharge instruction? A. "I'll take a laxative." B. "I'll drink lots of water." C. "I can expect my stool to be white for up to 3 days." D. "I will not be able to drink fluids that contain any caffeine."

Answer: "I will not be able to drink fluids that contain any caffeine." After an upper GI series, the patient does not have any dietary intake restrictions. Caffeine use is not contraindicated. Increased fluids, laxatives, and white stools are included in the education of the patient after an upper GI series.

A patient with cystitis is given a urinary antiseptic, phenazopyridine. Which statement, if made by the patient, indicates that the patient understood the instructions regarding the drug? A. "I should stay out of the sunlight." B. "It's likely that my urine will turn orange." C. "I need to take this medication with milk." D. "It's likely that I will experience a little dizziness."

Answer: "It's likely that my urine will turn orange." The use of phenazopyridine will turn urine orange. It is not necessary to avoid sunlight or take the medication with milk, and the patient is not expected to experience dizziness.

Which statement by the patient indicates that the patient understands his health maintenance organization (HMO) insurance plan? A. "All health care costs in my HMO are fully covered." B. "I must received preapproval for any physician's office visit." C. "My health plan contracts with medical groups to provide services." D. "My plan reduces costs by establishing a network of preferred provider."

Answer: "My health plan contracts with medical groups to provide services." The HMO contracts with medical groups to provide services. Patients may be allowed to arrange for certain services independently (e.g., annual gynecology examinations) with preapproval. A network of preferred providers describes a preferred provider organization. Few health care plans provide full coverage for all costs.

The patient presents to the clinic after falling from her bike and is diagnosed with a Grade II ankle sprain. The nurse should make which statements to the patient regarding the treatment of her sprained ankle? A. "Rest your ankle as much as possible." B. "Prop your ankle on pillows while resting." C. "You should wrap your ankle with an elastic bandage." D. "Take stimulant laxatives with your narcotic pain medication." E. "Place an ice pack on your ankle for 30 minutes every 4 hours." F. "Begin walking on your injured ankle after 24 hours, and increase your ambulation as tolerated."

Answer: "Rest your ankle as much as possible.", "Prop your ankle on pillows while resting.", "You should wrap your ankle with an elastic bandage."

The nurse observes a patient's wife sitting alone after visiting hours, crying. When the nurse approaches her, she states, "I'm so worried about him." Which is the best response by the nurse? A. "Tell me what is worrying you." B."Would you like to talk with the doctor?" C. "Would you like to talk with the social worker?" D. "Are you worried about him being in the hospital."

Answer: "Tell me what is worrying you." The most therapeutic response is an open-ended one that allows the wife the opportunity to discuss her concerns. The questions asking the wife if she would like to talk to the doctor, would like to talk to the social worker, or if she is worried about her husband being in the hospital are direct, closed-ended questions suggesting only a "yes" or "no" answer and do not encourage the wife to express her concerns.

The patient presents to the clinic with symptoms indicative of osteoporosis. The nurse anticipates which study will be performed in order to confirm the diagnosis? A. Chest x-ray B. Nuclear scan C. Bone density D. Computed tomography (CT) scan

Answer: Bone density Bone density evaluation is the most relevant diagnostic for osteoporosis. A CT scan and chest x-ray can provide information about damage associated with osteoporosis. A nuclear scan would not be helpful for the patient with osteoporosis.

The new nurse demonstrates an understanding of the job description of the unlicensed assistive personnel (UAP) by making which statement(s)? (select all that apply) A. "The UAP may assist the nurse with direct patient care" B. " The UAP may perform care without direct supervision" C. "The UAP is able to do whatever the nurse delegates to them" D. " The UAP is trained and certified to perform certain nursing task"

Answer: "The UAP may assist the nurse with direct patient care" and " The UAP is trained and certified to perform certain nursing task" The UAP may assist the nurse or perform certain nursing tasks independently that the UAP has been trained and certified to perform, with supervision by the licensed nurse. Unlicensed personnel may be delegated only tasks that they can legally be expected to do and that the nurse can be reasonably sure they are able to perform. The nurse remains responsible for the care provided by the UAP.

The health care provider has prescribed an isotonic IV solution administration for a patient. The nursing student correctly identifies which solutions as being isotonic? A. Sterile distilled water, 5% detrose in water B. 0.9% normal saline, lactated Ringer's solution C. 5% detrose in 0.45% normal saline, Ringer's solution D. 10% detrose in water, 5% detrose in 0.9% normal saline

Answer: 0.9% normal saline, lactated Ringer's solution. An isotonic solution is equal in concentration to that of body fluids. D5W is considered isotonic, but sterile distilled water is hypotonic and is never used as an IV solution. Ringer's solution is isotonic, but D5 in ½ normal saline is a hypertonic solution. 10% dextrose is hypertonic.

The nurse is educating the patient with osteoporosis on the best diet choices to improve bone density. The patient would demonstrate an understanding of the teaching by selecting which food choice that has the highest calcium content? A. 1 cup spinach B. 1 cup chopped kale C. 1 cup low-fat yogurt D. 1 ounce sliced carrots

Answer: 1 cup low fat yogurt Low-fat yogurt is the best source for well-absorbed calcium. Spinach, kale, and some other green leafy vegetables do contain calcium, but it is not as readily absorbed. Carrots are not a source of calcium.

The nurse is caring for a patient who has experienced a stroke. The nurse has implemented range-of-motion exercises. The nurse recognizes that contractures may begin within what time period? A. 1 week B. 1 month C. 2 weeks D. 24 hours

Answer: 1 week When skeletal muscles are not regularly stretched and contracted to their normal limits, they attempt to adapt themselves to this limited use by becoming shorter and less elastic. An "adaptive shortening," or contracture, begins to form within 3 to 7 days after immobilization of a body part, and the process usually is complete in 6 to 8 weeks.

The patient in the outpatient surgery center has just returned from surgery to decompress the medial nerve as treatment for carpal tunnel syndrome. Which assessment finding immediately after surgery would alert the nurse to a possible complication? A. Nail beds that are pink B. Numbness of the fingertips C. 5-second nail bed capillary refill D. Fingertips that are warm to the touch

Answer: 5-second nail bed capillary refill The nurse should assess the perfusion of the hand. A capillary refill time of more than 3 seconds may indicate a problem and should be reported to the surgeon immediately. Right after surgery, the patient is not expected to have sensation in the fingers. Pink, warm skin is a normal finding.

The nurse is reviewing the chart of a patient who recently underwent a total gastrectomy and notes the patient is receiving total parenteral nutrition (TPN). The nurse understands which information about TPN? A. A form of intravenous (IV) feeding B. A type of intestinal decompression C. A new method of tube-feeding a patient with dysphagia D. A method of feeding a patient through a tube inserted through an incision in the stomach

Answer: A form of intravenous (IV) feeding TPN is indicated when the patient cannot ingest or digest food normally or has a problem with malabsorption. If a patient has continued weight loss and a negative nitrogen balance, TPN is indicated. TPN is essentially a form of IV feeding. However, because the amounts and kinds of nutrients needed for long-term nutritional maintenance usually cannot be handled as well by peripheral veins, the nutrient mix is given into a larger central vein such as the superior vena cava. A Replogle or Salem sump tube is used for GI decompression. Gastrostomy tubes are inserted through an incision in the stomach; enteral feeding is instilled through this tube.

Which is the best example for a nurse being a patient advocate? A. A nurse upholding the policies of the facility B. A nurse calling a physician for pain medication C. A nurse communicating effectively and thus establishing trust with patient D. A nurse asking qualified unlicensed assistive personnel to perform selected nursing task

Answer: A nurse calling a physician for pain medication Nurses advocate for patients by standing up for patients' rights and ensuring that patients' needs are met. The nurse stands up for the patient's right to pain control when calling the physician. Upholding the facility policies, communicating effectively, and delegating appropriately are all important tasks of the nurse, but they do not best exemplify the nurse being a patient advocate.

The licensed practical nurse/licensed vocational nurse (LPN/LVN) may be limited from assuming primary care responsibility for which patient? A. A patient who has bipolar disorder B. A patient who is 3 hours postpartum C. A patient who has a central line venous access device D. A patient who is 2 days postoperative for an appendectomy

Answer: A patient who has a central line venous access device The LPN/LVN may be part of an intravenous team if postgraduate training/certification has occurred but cannot assume primary care of a patient with a central line venous access device. An LPN/LVN can be assigned responsibility for care of a patient who is postpartum, a stable postoperative patient, and a patient with bipolar disorder.

A patient is to have a culture and sensitivity test. Which education should the nurse provide to the patient regarding a culture and sensitivity test? A. The skin is inspected using a special light B. A sample of tissue is removed from the skin. C. A sample of exudate is taken from the lesion. D. Pressure will be applied to the lesion to determine the patient's sensitivity level.

Answer: A sample of exudate is taken from the lesion. When a bacterial, viral, or fungal infection of the skin is suspected, the dermatologist may wish to know the causative organism and the drug most appropriate for treating the specific infection. A sampling of exudate (drainage) is taken from the lesion and sent to the laboratory for culturing. Once the organism has been cultured, colonies can be tested for sensitivity to certain anti-infective agents. These tests take the guesswork out of treating infectious skin disease and very quickly determine which drug will be most effective in treating it. A biopsy requires removal of a sample of tissue.

Good nursing care includes protection of the skin and prevention of skin tears. Which are the categories of skin tears based on the Payne-Martin classification system? A. A skin tear without tissue loss B. A skin tear with complete tissue loss C. A skin tear with deep tissue exposure D. A skin tear with deep tissue and muscle exposure E. A skin tear with complete tissue loss in which the epidermal flap is missing

Answer: A skin tear without tissue loss, A skin tear with complete tissue loss, and A skin tear with complete tissue loss in which the epidermal flap is missing Skin tears based on the Payne-Martin classification system include a skin tear without tissue loss, a skin tear with complete tissue loss, and a skin tear with complete tissue loss in which the epidermal flap is missing. A tear with deep tissue and/or muscle exposure is not considered a skin tear and is not among the skin tears based on Payne-Martin classification system.

A 56-year-old patient is admitted to the hospital with pneumonia and shingles. The nurse is aware that shingles is caused by which occurrence? A. Reactivation of herpes simplex B. Compromised immune function C. Exposure to individuals with genital herpes D. Activation of varicella-zoster in individuals who have had varicella

Answer: Activation of varicella-zoster in individuals who have had varicella Shingles is an activation of the chickenpox virus in an adult. Although related to it, the herpes simplex virus does not cause chickenpox or shingles. Herpes simplex II does not cause chickenpox or shingles. A compromised immune system (such as might occur when a patient has pneumonia or another infection the immune system is fighting) does predispose an individual to opportunistic viruses, such as herpes zoster and herpes simplex, however.

A nurse collecting data from a client who has multiple fracture in his left leg notes increasing edema. Because this is often the first sign of a serious complication of fracture, the nurse should suspect which of the following? A. Fat embolism syndrome B. Acute compartment syndrome C. Pulmonary embolism D. Osteomyelitis

Answer: Acute compartment syndrome ​Edema is an early sign of acute compartment syndrome, a complication that involves increased pressure within the fascia leading to reduced circulation to the area. Rationale -Fat embolism syndrome (Confusion, not edema, is an early sign of fat embolism syndrome.) -Pulmonary embolism (​Dyspnea, not edema, is an early sign of pulmonary embolism.) -Osteomyelitis (Fever and chills, not edema, are early signs of osteomyelitis.)

A nurse in a provider's office is talking with a client about risk factors for osteoarthritis. Which of the following factors should the nurse includes? (Select all that apply.) A. Bacteria B. Diuretics C. Aging D. Obesity E. Smoking

Answer: Aging, obesity, and smoking Bacteria is incorrect. Bacterial infections can lead to infectious arthritis, which does not cause irreversible damage to joints. Infection is not a risk factor for osteoarthritis. ​Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for osteoarthritis. ​Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the body's weight over time. ​Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the body's weight over time. ​​Smoking is correct. Smoking is a risk factor for osteoarthritis, as smoking predisposes people to the loss of cartilage in the knees.

A patient has been admitted to the unit with a urinary tract obstruction and has been scheduled for an intravenous pyelogram (IVP). Nursing responsibilities for this patient will include which action? A. Keeping the patient in the fasting state B. Asking about allergies to contrast media C. Preparing the patient for nausea and vomiting to occur after the test D. Holding all aspirin and nonsteroidal anti-inflammatory drug (NASID) medication

Answer: Asking about allergies to contrast media The IVP is used to visualize the kidneys, ureters, and bladder. It is used to detect obstructions related to stones or tumors. Because the contrast medium generally used contains iodine, allergies to shellfish or iodine-containing substances are significant. The patient having an IVP does not have to be NPO (nothing by mouth). The use of aspirin and NSAID medications will not significantly alter the ability of the diagnostic test to be performed. Nausea and vomiting are not routine occurrences after the test.

Which nursing action is most appropriate for monitoring a patient with a casted lower extremity for infection? A. Assess vital signs every hour while the patient is awake. B. Remove the cast weekly to check the wound for signs of infection. C. Remove the cast bi-weekly to check the wound for signs of infection. D. Assess temperature trends and sniff around the cast for signs of foul odor.

Answer: Assess temperature trends and sniff around the cast for signs of foul odor. The most appropriate nursing action for monitoring a patient with a casted lower extremity for signs of infection is to assess for signs of infection every shift: assess wound for redness, swelling, and tenderness; administer prophylactic antibiotics as ordered; assess temperature trends and trend of white blood count values for signs of infection; assess patient for subjective signs of malaise; and sniff around the cast for signs of foul odor indicating infection. The cast should never be removed bi-weekly or weekly unless the physician orders it to be removed. Assessing vital signs is important but is not required on an hourly basis.

The patient has been prescribed a non-potassium-sparing diuretic. Which food(s) should the nurse suggest the patient include in his diet? (select all that apply) A. Eggs B. Bananas C. Tomatoes D. Aged cheese E. Baked potato with skin

Answer: Bananas, tomatoes, and baked potato with skin. Foods high in potassium should be included in the patient's diet if he is taking a diuretic that does not conserve potassium. Bananas, tomatoes, and baked potatoes with the skin are just three foods that are high in potassium. Eggs and aged cheese are not potassium-rich foods.

The nurse is assessing the stooling patterns of an assigned patient. The patient reports stools as being clay colored. The nurse knows this may indicate which condition? A. Bile is not reaching the intestines. B. The stool contains undigested fat. C. The stool has an excessive amount of bilirubin. D. The patient is experiencing upper gastrointestinal (GI) bleeding.

Answer: Bile is not reaching the intestines. The clay-colored stool indicates the bile is not reaching the patient's intestines due to an obstruction in the bile ducts. Intestinal bleeding will present as black or red stools. Stools containing undigested fat will float in the toilet.

The nurse reads in the chart that a patient has been diagnosed with uveitis. The nurse knows that which structure(s) are involved in this diagnosis? A. Retina B. Choroid C. Optic nerve D. Ciliary Body E. Vitreous humor

Answer: Choroid Otosclerosis refers to the excess formation of bone in the ears. This impairs hearing. A potential treatment is a stapedectomy. Stapedectomy is not used for mastoiditis, labyrinthitis, or Meniere disease.

A patient who has chronic pain is thinking about having acupuncture. Before discussing this treatment option with the patient, the LPN/LVN is aware that acupuncture is considered __ therapy. A. Biomedical B. Unapproved C. Questionable D. Complementary and alternative medicine (CAM)

Answer: Complementary and alternative medicine (CAM) CAM focuses on assisting the body's own healing powers and restoring body balance. Acupuncture is not considered to be biomedical, unapproved, or questionable therapy.

When a patient experiences a severe exacerbation of Crohn disease, the priority pharmacologic treatment would be administration of which class of medication? A. Analgesics B. Antibiotics C. Antidiarrheals D. Corticosteroids

Answer: Corticosteroids Reducing inflammation during severe exacerbation of Crohn disease is the priority. This is accomplished by the administration of corticosteroids. Analgesics, antibiotics, and antidiarrheals may be necessary to treat symptoms, but corticosteroids are the cornerstone of therapy for Crohn disease.

Fever and chills, not edema, are early signs of osteomyelitis. A. Cranial enlargement B. Skeletal pain C. Wadding gait D. Cold extremities E. Vision deficits

Answer: Cranial enlargement, skeletal pain, and waddling gait Cranial enlargement is correct. When the skull is involved, Paget's disease causes thickening and enlargement of the skull bones and enlargement of the cranium. ​Skeletal pain is correct. Paget's disease causes pain and tenderness over the affected bones. ​Waddling gait is correct. When the legs are involved, Paget's disease causes bowing of the legs and a waddling gait. ​Cold extremities is incorrect. Paget's disease causes warmth over the affected bones. ​Vision deficits is incorrect. When the skull is involved, Paget's disease causes hearing loss, not vision loss.

The nurse is caring for a patient with pitting edema to the lower extremities. Which intervention(s) for pitting edema are the nurse likely to include in the nursing care plan of this patient? (select all that apply) A. Daily weight B. High-calorie diet C. Intake and output record D. Skin care and mouth care E. Edema assessment using an edema scale every shift

Answer: Daily weight, Intake and output record, Edema assessment using an edema scale every shift Measuring the patient's weight daily, monitoring the intake and output, and assessing the edema using the proper scale every shift are methods that will assist the nurse in properly assessing and monitoring any changes in the patient's edema.

What are the three most common symptoms of cancer of the pancreas? A. Dark urine, jaundice, and weight loss B. Jaundice, abdominal distention, and edema C. Dark stools, food intolerance, and weight loss D. Pruritus, right upper quadrant pain, and weight gain

Answer: Dark urine, jaundice, and weight loss Symptoms of pancreatic cancer include dark urine, jaundice, weight loss, epigastric pain, anorexia, vomiting, a dislike for red meat, glucose intolerance, clot formation, and clay-colored stools.

The nurse is providing education to a middle-aged female about her changing health needs. The nurse should be sure to include information on which age-related changes? A. Loss in bone mass B. Decrease in height C. Increase circulation D. Decrease muscle mass E. Increased mineral exchange

Answer: Decreased muscle mass, decrease in height, and loss of bone mass Osteoporosis is especially prevalent in women and is partially responsible for the decrease in height of both genders. Loss of muscle mass and strength is also a function of aging. Mineral exchange and circulation decrease with age.

A patient's blood urea nitrogen (BUN) is found to be elevated. This finding is most suggestive of the fact that the patient has which condition? A. An infection B. Dehydration C. Liver damage D. Protein deficiency

Answer: Dehydration BUN is the most common test used to evaluate kidney function and hydration status. High BUN levels can indicate poor kidney function, dehydration, or increased breakdown of body protein as caused by severe burns or excessive exercise.

The older adult patient presents to the emergency department complaining of severe vomiting for 3 days. The nurse knows which is the major complication of continuous vomiting? A. Weight loss B. Cardiac dysrhythmias C. Aspiration of vomitus D. Dehydration

Answer: Dehydration Older adult patients experiencing continuous vomiting are at particular risk for dehydration. Significant weight loss would not occur immediately; it is a sign of prolonged nutritional deficiency. If the vomiting were to continue, the resulting hypokalemia could result in dysrhythmias.

When obtaining a history on a patient with suspected kidney disease, the most significant information would be a personal or family history of which condition(s)? A. Diabetes B. Gastric ulcers C. Hypertension D. Lactose intolerance E. Cardiovascular disease

Answer: Diabetes, hypertension, and cardiovascular disease Diabetes, hypertension, and cardiovascular disease are all known causes of kidney disease. Gastric ulcers and lactose intolerance do not impact functioning of the urinary system.

A patient has been scheduled for LASIK surgery to correct his myopia. Which statement best describes this procedure? A. Diagonal incisions are made in the cornea; the central cornea is not incised. B. The cornea is reshaped using pulsation of ultraviolet (UV) light on the central superficial tissue. C. Superficial layers of the cornea are lifted while a laser reshapes the deeper layers of tissue. D. Vertical incisions are made in the central cornea followed by reshaping of the lens with pulsation of UV light.

Answer: Diagonal incisions are made in the cornea; the central cornea is not incised, Superficial layers of the cornea are lifted while a laser reshapes the deeper layers of tissue, and Vertical incisions are made in the central cornea followed by reshaping of the lens with pulsation of UV light. Labyrinthitis refers to an inflammation of the vestibular portion of the labyrinth of the inner ear. Manifestations include sensorineural hearing loss, nystagmus, and nausea. There is no increase in production of cerumen or ear pain.

A patient is admitted with anorexia, nausea and vomiting, and weight loss. When developing the plan of care, which information is a priority to be obtained? A. Ability to cook own food B. Cultural preferences for food C. Dietary history D. Pattern of anorexia

Answer: Dietary history, Pattern of anorexia, Factors that cause vomiting Dietary history, pattern of anorexia, and factors that cause vomiting are needed to initiate a plan of care. Determining the ability to cook and the cultural preferences for food are not immediately necessary to formulate a nursing care plan for the patient; they may be obtained at a later time.

The nurse is participating in a patient care conference to plan the care for a patient with osteoporosis. Which issues should be discussed for inclusion in this patient's care plan? A. Pain B. Difficult breathing C. Potential for excessive fluid D. Difficulty providing own hygiene E. Difficulty moving about the house and/or work setting

Answer: Difficulty providing own hygiene, Difficulty moving about the house and/or work setting, and pain Pain, difficulty providing own hygiene, and moving about the house are common issues that should be discussed when planning the patient's care. There is no indication the patient has difficulty breathing or managing fluid intake.

Which finding, if present after a patient has right eye surgery, should be reported to the provider immediately as it may indicate hemorrhage? A. Experiencing some confusion B. Tearing of the unaffected eye C. A sudden pain in the affected eye D. Difficulty reading with the unaffected eye

Answer: Difficulty reading with the unaffected eye The priority goal when caring for the patient experiencing vertigo and dizziness is patient safety. The patient should be encouraged to rest during the episode. Limiting salt is helpful if the patient has been diagnosed with Meniere disease but is not helpful during an acute episode. Vitamin B12 has not been shown to be helpful with Meniere disease.

A patient with glaucoma is being treated with miotic eyedrops. Following administration of the medication, the nurse should note which reaction? A. Pupil dilation B. Pupil constriction C. Decreases edema of the cornea D. Diminished redness of the sclera

Answer: Diminished redness of the sclera Immediately after cataract removal it is important to avoid coughing, sneezing, and rubbing the eyes or moving the head suddenly. The patient is not required to remain on bed rest. The patient should be positioned on the nonoperative side. Cold compresses are not used in the postoperative period.

A 57-year-old man is admitted with a diagnosis of cirrhosis. The nurse is aware that he will most likely require which intervention(s)? A. Diuretics B. Increased fluids C. Bleeding precautions D. Vegetable-based proteins E. Lactulose administration

Answer: Diuretics, Lactulose administration, Vegetable-based proteins, Bleeding precautions Because the liver produces clotting factors and is now dysfunctional, risk for bleeding exists. The liver cannot metabolize proteins, especially albumin, properly. This leads to edema and ascites and requires diuretics, preferably potassium wasting. Ammonia buildup is likely; lactulose binds with this toxic metabolic by-product and allows for its excretion through the GI tract. Patients with liver disorders are at high risk for fluid volume excess.

A 57-year-old man is admitted with a diagnosis of cirrhosis. The nurse is aware that he will most likely require which intervention(s)? A. Diuretics B. Increase fluids C. Bleeding precautions D. Vegetable-based proteins E. Lactulose administration

Answer: Diuretics, Bleeding precautions, Vegetable-based proteins, and Lactulose administration Because the liver produces clotting factors and is now dysfunctional, risk for bleeding exists. The liver cannot metabolize proteins, especially albumin, properly. This leads to edema and ascites and requires diuretics, preferably potassium wasting. Ammonia buildup is likely; lactulose binds with this toxic metabolic by-product and allows for its excretion through the GI tract. Patients with liver disorders are at high risk for fluid volume excess.

The nurse is caring for a patient 24 hours after the surgical insertion of a T-tube for a common bile duct obstruction. After assisting the patient to the restroom, the nurse notes that the patient's stool is soft, formed, and brown. What should the nurse do first? A. Document the assessment B. Stat-page the health care provider C. Request to administer a Fleet enema D. Encourage the patient to ambulate frequently

Answer: Document the assessment Stool that returns to normal (soft, formed, brown) indicates that bile is now entering the small intestines; this should be documented. The provider should be notified, but it is not an emergency warranting a stat-page. Although it is recommended that the patient ambulate frequently, encouraging this is not the first action to be undertaken by the nurse. A Fleet enema is not necessary at this point.

The nurse is caring for a patient 24 hours after the surgical insertion of a T-tube for a common bile duct obstruction. After assisting the patient to the restroom, the nurse notes that the patient's stool is soft, formed, and brown. What should the nurse do first? A. Document the assessment. B. Stat-page the health care provider. C. Request to administer a Fleet enema. D. Encourage the patient to ambulate frequently

Answer: Document the assessment. Stool that returns to normal (soft, formed, brown) indicates that bile is now entering the small intestines; this should be documented. The provider should be notified, but it is not an emergency warranting a stat-page. Although it is recommended that the patient ambulate frequently, encouraging this is not the first action to be undertaken by the nurse. A Fleet enema is not necessary at this point.

The patient presents to the clinic for a routine exam. Which signs or symptoms, if demonstrated or reported by the patient, indicate a possible eye disorder? A. Double vision B. Blurred vision C. Flashing lights D. Tear production E. Irises of differing colors

Answer: Double vision, Blurred vision, and Flashing lights Eye disorders may manifest with flashing lights, blurred vision, and double vision. Different color irises are unusual but do not impair vision. Tear production is normal; excessive tearing is not.

A patient reports discomfort from flatus after surgery. What action(s) can be suggested by the nurse to help to relieve the flatus buildup? A. Drink hot coffee B. Encourage ambulation C. Trendelenburg position D. Drink chilled carbonated beverages E. Encourage bed rest until the pain subsides

Answer: Encourage ambulation and Trendelenburg position During the postoperative period, patients are at an increased risk for flatus buildup. This is due to analgesics, bowel manipulation, and anesthetic agents. Activities that will aid in the passage of flatus include ambulation and the use of a slight Trendelenburg position. Inactivity and hot and chilled beverages are associated with increased flatus buildup.

A patient who is recovering from a severe burn is permitted oral feedings. Which diet is most appropriate for this patient? A. Low in protein and low in calories B. Low in protein and high in calories C. High in protein and low in calories D. High in protein and high in calories

Answer: High in protein and high in calories A diet high in protein and calories is necessary for healing. The patient has increased metabolic needs directly proportional to the size of the burn area. Nutritional needs may be increased 50% to 150% above normal, and caloric requirements may be as high as 5000 calories per day. Caloric needs are calculated to include the patient's weight, age, and percentage of burn over total body surface.

The patient presents to the clinic complaining of constipation, abdominal pain, and mucous in her stool. The patient states, "I have the same stomach problems my mom had when she was my age. It's always worse after I eat ice cream, so I try to avoid that. I only drink water because I'm on my feet all day. I'm a teacher, so my job can be very stressful at times. I've tried stool softeners and laxatives that help sometimes, but my stomach only feels better after I stool." The nurse suspects irritable bowel syndrome (IBS) due to the patient having which triggers? A. Family history B. Female gender C. Dairy sensitivity D. Stressful lifestyle E. Frequent laxative use F. Lack of caffeine in the diet

Answer: Family history, Female gender, Dairy sensitivity, and Stressful lifestyle IBS may be triggered by a familial history. It affects females more than males, and it is related to food sensitivities, stress, and caffeine ingestion. The patient's use of laxatives does not appear to be a trigger for this disease because she is constipated.

A patient with a sigmoid colostomy is taught to irrigate her colostomy daily to accomplish which goal? A. Prevent infection B. Keep the bowel sterile C. Increase the diameter of the bowel D. Gain control over the time elimination occurs

Answer: Gain control over the time elimination occurs A sigmoid colostomy will usually drain formed stool on a relatively regular schedule. Irrigation of the colostomy gives the patient some control over when elimination takes place. The procedure is done daily or every other day at about the same time and takes close to an hour. The bowel is not sterile. Irrigation does not help prevent infection or increase the diameter of the bowel.

The patient in the clinic has recently been diagnosed with viral hepatitis. The nurse anticipates that which test will be used to predict the virus's response to therapy? A. Genotype assay B. Molecular assay C. Western blot test D. Enzyme immunoassay

Answer: Genotype assay The genotype assay can predict the patient's prognosis. The molecular assay detects viral nucleic acid. The enzyme immunoassay detects antibodies to various types of hepatitis. The Western blot test is used to screen for human immunodeficiency virus.

The patient in the clinic has recently been diagnosed with viral hepatitis. The nurse anticipates that which test will be used to predict the virus's response to therapy? A. Genotype assay B. Molecular assay C. Western blot test D. Enzyme immunoassay

Answer: Genotype assay The genotype assay can predict the patient's prognosis. The molecular assay detects viral nucleic acid. The enzyme immunoassay detects antibodies to various types of hepatitis. The Western blot test is used to screen for human immunodeficiency virus.

A patient questions the use of herbal remedies to manage motion sickness on an upcoming trip. Which has been used with success to manage this health complaint? A. Ginger B. Ginkgo C. Ginseng D. Goldenrod

Answer: Ginger Ginger has been used for centuries in Asia to combat nausea and vomiting, motion sickness, and dyspepsia. It is available candied, in capsules, fluid extract, and tablets, and tincture or as fresh ginger root that can be grated and used to make tea. Gingko biloba, ginseng, and goldenrod are not used for motion sickness.

The nurses recognize the importance of testing intraocular pressure in the diagnosis of which disorder? A. Myopia B. Glaucoma C. Hyperopia D. Strabismus

Answer: Glaucoma Glaucoma is a condition caused by elevations in intraocular pressure. Myopia, hyperopia, and strabismus are visual disorders but are not associated with elevated ocular pressures.

The nurse is educating a patient who has been recently diagnosed with inflammatory bowel disease about a therapeutic diet. Which meal selection, if made by the patient, indicates an understanding of the teaching? A. Broiled fish with rice and roasted broccoli B. Fried shrimp with french fries and coleslaw C. Whole-grain pasta with marinara sauce and meatballs D. Grilled chicken, mashed potatoes, and strawberry gelatin

Answer: Grilled chicken, mashed potatoes, and strawberry gelatin The patient with inflammatory bowel disease should consume a diet that is high in protein and calories but low in fat and fiber. This includes grilled meat, mashed potatoes, and strawberry gelatin. Roasted broccoli, coleslaw, and whole-grain pasta are high in fiber. Fried shrimp and french fries are high in fat.

A 56-year-old man is admitted with a diagnosis of gastroesophageal reflux disease (GERD). The nurse anticipates the patient to report gastroesophageal discomfort after which meal? A. Hamburger, peas, and cola B. Turkey, salad, and a glass of red wine C. Chicken in lemon sauce, rice, and fruit juice D. Poached salmon, mashed potatoes, and milk

Answer: Hamburger, peas, and cola Foods with significant fat content (hamburger) and xanthine-containing beverages (tea, cola, coffee) decrease the tone and contractility of the esophageal sphincter, allowing gastric contents to flow back up into the esophagus. Turkey, salad, red wine, chicken, rice, fruit juice, poached salmon, potatoes, and milk are less likely to cause discomfort.

The nurse is caring for a patient with an electrical burn. What should be monitored on this patient? A. The lungs B. The heart C. The kidneys D. The gastric mucosa

Answer: Heart Electrical burns damage tissue deep within the body. The extent of damage is not always visible and the entrance site and exit site may appear small. Cardiac monitoring should be initiated even if the patient does not complain of chest pain. The lungs, kidneys, and gastric mucosa should be monitored with other types of burns.

The nurse practices Universal Precautions to protect himself from which blood-borne types of hepatitis viruses? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E

Answer: Hepatitis B, Hepatitis C, and Hepatitis D Hepatitis B, C, and D are all transmitted by blood products and objects contaminated by blood products. Hepatitis A is transmitted by fecal-oral route; poor sanitation and contaminated water and shellfish; and often from infected food. Hepatitis E is transmitted by fecal-oral route and contaminated water or food.

The nurse practices Universal Precautions to protect himself from which blood-borne types of hepatitis viruses? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E

Answer: Hepatitis B, Hepatitis C, and Hepatitis D Hepatitis B, C, and D are all transmitted by blood products and objects contaminated by blood products. Hepatitis A is transmitted by fecal-oral route; poor sanitation and contaminated water and shellfish; and often from infected food. Hepatitis E is transmitted by fecal-oral route and contaminated water or food.

The nurse notes the patient's urine is dark orange in color. What question is most appropriate for the nurse to ask the patient? A. "Are you currently menstruating?" B. "Are you currently on antibiotics?" C. "How much fluid intake have you had recently?" D. "How much protein have you eaten ion the past 2 days?"

Answer: How much fluid intake have you had recently?" Dark amber or orange urine is associated with dehydration or increased metabolic state (e.g., fever), urobilinogen (a by-product of bilirubin normally excreted through stool and urine), or bilirubin (a component of bile normally metabolized and excreted via stool and urine). Foods that may result in this color of urine include carrots. Menstrual blood in the urine may result in pink- or red-tinged urine. Antibiotics and protein do not change the color of the urine.

The nurse is providing education to a patient with a body mass index (BMI) of 42. The nurse should educate the patient about which conditions for which he is at risk? A. Insomnia B. Hypertension C. Hyperlipidemia D. Hyperthyroidism E. Obstructive sleep apnea F. Type 1 diabetes mellitus

Answer: Hypertension, Hyperlipidemia, Obstructive sleep apnea

An 82-year-old patient is admitted to the unit with a temperature of 100.2° F, urine specific gravity (SG) of 1.032, and dry tongue. The nurse should recognize which to be the most critical aspect of the plan of care? A. A diuretic B. An antibiotic C. An antipyretic D. IV solution

Answer: IV solution The patient is hypovolemic; she requires IV fluid replacement. The slight elevation in temperature may be related to her dehydration. This is further supported by her urine SG of 1.032; normal urine SG is approximately 1.010 to 1.025. There are no data to support a need for an antibiotic. The patient's body temperature is elevated, but this is not the priority of care. The patient is most likely dehydrated and cannot afford to lose additional fluid volume, so a diuretic would be inappropriate.

A 70-year-old patient who was treated for a respiratory problem is to be discharged from the hospital. The patient says the physician told her that she must leave "because of DRGs." To discuss this statement with the patient, the LPN/LVN must understand that diagnostic-related groups (DRGs) are a way of reimbursing the hospital in which manner? A. For each day of service provided B. Based on whether a patient is cured C. In advance for care provided for a particular diagnosis D. In a flat rate for the care of a patient with a particular diagnosis

Answer: In a flat rate for the care of a patient with a particular diagnosis Under the DRG system, the fee the government will pay for hospitalization depends on the DRG category (illness). Hospitals receive a flat fee for each patient's DRG category, regardless of length of stay in the hospital; thus hospitals have an incentive to treat patients and discharge them as quickly as possible. The hospital is not reimbursed based on whether the patient was cured or in advance for care provided for a particular diagnosis.

The nurse is caring for an older adult patient who reports continued problems with constipation. What intervention can be implemented to promote timely bowel movements? A. Increase fiber intake. B. Limit fluid intake to 1500 mL daily. C. Administration of an oil retention enema weekly. D. Take a mild over-the-counter laxative each evening.

Answer: Increase fiber intake. Fiber intake will promote defecation. Fluid intake should be at least 2500 mL daily unless contraindicated by medical conditions. Laxative and enema use should be avoided if possible. Too frequent use of these aids may result in reliance on them to have a bowel movement.

The nursing assessment of a patient with a suspected disorder of the urinary system should include which data? A. Initiation of voiding B. Urine specific gravity C. Abdominal distention D. Volume of urine voided E. Frequency of headaches

Answer: Initiation of voiding, Urine specific gravity, Abdominal distention, and Volume of urine voided Initiation and volume of voiding, urine specific gravity, and abdominal distention are related to bladder and kidney function. Frequency of headaches is not related to kidney and bladder function.

The nurse is caring for a patient who underwent a cholecystectomy 8 hours ago. The patient calls the nurse to the room to report severe pain in the abdomen. What should the nurse do first? A. Prepare the patient to return to surgery B. Instruct the patient to ambulate in the halls C. Palpate the patient's abdomen for tenderness D. Inspect the patient's abdomen for distention or rigidity

Answer: Inspect the patient's abdomen for distention or rigidity The nurse should first inspect the patient's abdomen for distention or rigidity. If the patient's abdomen is rigid, the nurse should not touch it. The nurse should alert the provider and prepare the patient to return to surgery, because this is sign of peritonitis, which could have resulted from bowel perforation. If the patient's abdomen is distended but not rigid, the nurse should instruct the patient to ambulate in the halls to help dissipate the free air in the abdomen from the surgery.

The nurse is caring for a patient who underwent a cholecystectomy 8 hours ago. The patient calls the nurse to the room to report severe pain in the abdomen. What should the nurse do first? A. Prepare the patient to return to surgery. B. Instruct the patient to ambulate in the halls. C. Palpate the patient's abdomen for tenderness. D. Inspect the patient's abdomen for distention or rigidity.

Answer: Inspect the patient's abdomen for distention or rigidity. The nurse should first inspect the patient's abdomen for distention or rigidity. If the patient's abdomen is rigid, the nurse should not touch it. The nurse should alert the provider and prepare the patient to return to surgery, because this is sign of peritonitis, which could have resulted from bowel perforation. If the patient's abdomen is distended but not rigid, the nurse should instruct the patient to ambulate in the halls to help dissipate the free air in the abdomen from the surgery.

The nurse is providing discharge education to a patient after a roux-en-Y gastric bypass procedure. Which nutritional supplements must this patient take for the rest of his life? A. Iron B. Calcium C. Folic acid D.

Answer: Iron, calcium, Folic acid, vitamin B12 After a roux-en-Y gastric bypass procedure, the patient is at risk for iron, calcium, folic acid, and vitamin B12 deficiencies and must take these supplements for life. The patient is not at risk for a vitamin C or D deficiency.

A patient has been diagnosed with gastric cancer. What is associated with increased incidence of this disease? A. Refined sugars B. Dairy products C. Carbonated beverages D. Luncheon meats ("cold cuts")

Answer: Luncheon meats ("cold cuts") Nitrites, found in processed foods such as luncheon meats, have been strongly linked to gastric cancer. Refined sugars, dairy products, and carbonated beverages have not been associated with development of gastric cancer.

In the immediate care provided to a burn victim with second- and third-degree burns of the arms and legs, the LPN/LVN should expect the primary health care provider to order which intervention? A. Antibiotics to ward off infection B. Sedative injection to calm the patient C. Ample occlusive dressings to protect the patient's damaged skin D. Isotonic balanced intravenous solution (sodium chloride, sodium lactate, potassium chloride, and calcium chloride or 5% dextrose in water [D5W]) to maintain fluid balance

Answer: Isotonic balanced intravenous solution (sodium chloride, sodium lactate, potassium chloride, and calcium chloride or 5% dextrose in water [D5W]) to maintain fluid balance A priority concern in the patient who has experienced severe burns is the prevention of shock. Fluid resuscitation will be implemented using an isotonic solution (sodium chloride, sodium lactate, potassium chloride, and calcium chloride or D5W). Antibiotic use may be included in the plan of care but is not of greater priority than the prevention of shock. The patient may be medicated for pain and anxiety, but it is not the priority action. Occlusive dressings are not the appropriate option for this patient.

The nurse is preparing to care for a patient who requires skeletal traction. The nurse knows which statement is true regarding skeletal traction? A. It has a high risk of infection. B. It is used for only fractures of the lower extremity bones. C. It uses a series of removable pins, ropes, and weights to realign bones. D. It requires nurses to frequently assess and modify the amount of weight applied.

Answer: It has a high risk of infection. Because of the pins or wires inserted into the affected bone, risk of infection is high and pin care must be meticulously performed. Skeletal traction does not allow the nurse to modify the amount of weight applied. Skeletal traction is used for the management of musculoskeletal conditions not limited to fractures.

During the immediate postoperative period following cataract removal, what is the priority action by the LPN/LVN? A. Position the patient on the operative side. B. Keep the patient on bed rest for the first 24 hours. C. Provide cold compresses to be placed on the operative side. D. Be sure the patient avoids coughing, sneezing, rubbing the eyelids, or sudden movements of the head.

Answer: Keep the patient on bed rest for the first 24 hours and Be sure the patient avoids coughing, sneezing, rubbing the eyelids, or sudden movements of the head. Uveitis affects the uveal tract, which includes the iris, the ciliary body, and the choroid. The retina, the optic nerve, and the vitreous humor are not part of the uveal tract.

A patient is scheduled for a stapedectomy. The LPN/LVN should understand that this procedure is done when a patient has which problem? A. Mastoiditis B. Otosclerosis C. Labyrinthitis D. Meniere disease

Answer: Labyrinthitis A complication of eye surgery is hemorrhage. Sudden onset of pain in the affected eye may signal bleeding and should be reported to the surgeon. Some confusion may be normal following general anesthesia. Tearing of the unaffected eye and difficulty reading with the unaffected eye are not signs of hemorrhage.

The nurse is caring for a patient with late-stage cirrhosis. The nurse considers which factor when participating in a patient care conference? A. Late-stage cirrhosis is irreversible B. Late-stage cirrhosis can be managed with lifestyle changes C. Late-stages cirrhosis can be cured with lactulose and spironolactone D. Late-stage cirrhosis is characterized by period of remission alternating with flare-ups

Answer: Late-stage cirrhosis is irreversible After cirrhosis reaches the late stage, it is irreversible. Lactulose is used to manage ammonia levels and hepatic encephalopathy, but it is not curative. Cirrhosis does not have remission periods

The nurse is caring for a patient with late-stage cirrhosis. The nurse considers which factor when participating in a patient care conference? A. Late-stage cirrhosis is irreversible. B. Late-stage cirrhosis can be managed with lifestyle changes. C. Late-stage cirrhosis can be cured with lactulose and spironolactone. D. Late-stage cirrhosis is characterized by periods of remission alternating with flare-ups.

Answer: Late-stage cirrhosis is irreversible. After cirrhosis reaches the late stage, it is irreversible. Lactulose is used to manage ammonia levels and hepatic encephalopathy, but it is not curative. Cirrhosis does not have remission periods.

A patient with a history of Meniere disease is discussing dietary options with the nurse. The patient demonstrates an understanding of the necessary dietary changes by agreeing to restrict which food item? A. Lean meats B. Canned soups C. Potassium-rich foods D. Complex carbohydrates

Answer: Lean meats The traditional time between eye removal and the placement of a permanent prosthesis is approximately 6 weeks. Two weeks, about 6 months, or 1 year are not the appropriate time for an artificial eye placement.

A patient wearing corrective lenses has a visual acuity of 20/200. The nurse knows this patient has which characteristic? A. Legally blind B. Age-related presbyopia C. Low night vision due to loss of rods D. Proper correction for astigmatism

Answer: Legally blind Vision correctable to 20/200 is by definition legally blind. This patient is able to see at 20 feet what the healthy eye can see at 200 feet. Night vision is not related to visual acuity. The patient's age is unknown, as is the patient's astigmatism correction.

The nurse caring for a patient with metabolic acidosis would expect the patient to exhibit which symptom? A. Flushing B. Lethargy C. Hyperactivity D. Shallow, slow respiration

Answer: Lethargy The symptoms of metabolic acidosis include weakness, lethargy, headache, and confusion. If the acidosis is not relieved, these symptoms progress to stupor, unconsciousness, coma, and death. Flushing, hyperactivity, and shallow, slow respiration are not symptoms of metabolic acidosis.

The nurse is reviewing the health history of an assigned patient. Which data in a patient's history might indicate a predisposition to diverticular disease? A. Frequent laxative use B. Low dietary fiber intake C. High dietary fiber intake D. History of passing scant, small stools E. History of chronic diarrhea; vomiting

Answer: Low dietary fiber intake and History of passing scant, small stools Low-fiber diets and chronic constipation are high-risk factors for development of diverticular disease. Frequent laxative use, high dietary fiber intake, and a history of chronic diarrhea and vomiting may result in other GI disorders, but do not contribute to the development of diverticular disease.

The patient has been diagnosed with acne rosacea. The nurse should educate the patient to avoid which substances? A. Tea B. Milk C. Beer D. Juice E. Wine F. Coffee

Answer: Tea, Beer, Wine, and coffee Caffeine-containing drinks (e.g., tea and coffee) and foods, alcoholic drinks (including beer and wine), and spicy foods cause flare-ups of rosacea. Milk and juice do not cause rosacea flare-up.

A patient's burns have become infected with Pseudomonas. The nurse should anticipate using which topical dressing? A. Silver nitrate B. Povidone-iodine C. Mafenide acetate D. Silver sulfadiazine

Answer: Mafenide acetate Mafenide acetate is effective against a Pseudomonas infection. The patient should also receive pain medication before dressing changes; this medication produces a burning sensation when applied to wounds. Silver nitrate, silver sulfadiazine, and povidone-iodine are not the best options for a Pseudomonas infection.

When a urine culture is ordered, nursing responsibilities include which action? A. Keeping the specimen warm B. Collecting at least 200mL of urine C. Obtaining the first voided urine in the morning D. Maintaining sterility of the specimen collection container

Answer: Maintaining sterility of the specimen collection container A urine culture is used to determine pathogens in voided urine. The specimen container should be sterile to avoid contamination. It is not necessary to collect the first voided urine. The specimen should not be kept warm. There is no need to collect 200 mL of urine to perform the test.

A patient has been diagnosed with sensorineural hearing loss. The patient questions potential causes of this type of hearing loss. Which are associated with a sensorineural hearing loss? A. Meningitis B. Use of Ibuprofen (Motrin) C. Use of furosemide (Lasix) D. Wax buildup in the ear E. Exposure to loud noises

Answer: Meningitis, Use of Ibuprofen (Motrin), Use of furosemide (Lasix), and Exposure to loud noises There are two types of hearing loss related to problems in the ear: (1) sensorineural and (2) conductive. The majority of hearing loss is due to a disorder of the hearing nerve (sensorineural loss). Conductive hearing loss is caused by a problem transmitting sound impulse through the auditory canal, the tympanic membrane, or the bones of the middle ear. Damage to the eardrum, use of ibuprofen or furosemide, and repeated exposure to loud noises may be associated with sensorineural hearing loss. Conductive hearing loss may be attributed to wax buildup in the ear.

The nurse is assessing a patient who was admitted for dehydration. Which assessment finding is an indication that the dehydration is resolving? A. Loose skin B. Sunken eyes C. 1200 mL urine output D. Moist mucous membrane

Answer: Moist mucous membrane Moist mucous membranes are one sign that the patient's hydration status is resolving. Sunken eyes and loose skin are signs of dehydration. 1200 mL of urine output alone does not indicate hydration status; this would have to be compared to other factors, such as intake.

A patient has ingested a large amount of a cathartic containing magnesium. The nurse should observe for which symptom of hypermagnesemia? A. Muscle weakness B. Hyperactive reflexes C. Respiration of 30 breaths/mins D. Insomnia, twitching, and tremors

Answer: Muscle weakness A patient with excessive magnesium level would have muscle weakness, not hyperactive reflexes. Excessive magnesium level would depress the respiratory rate to fewer than 12 breaths/min, not 30. A low magnesium level, rather than a high magnesium level, would cause insomnia, twitching, and tremors.

A patient has a caloric test to check for alterations in vestibular function. The patient asks the nurse what the normal test findings will be. The LPN/LVN should explain to the patient that if the test is normal, the patient is likely to experience which symptom? A. No response B. Flushing of the skin C. Nausea and vomiting D. Tingling of the earlobes

Answer: Nausea and vomiting The caloric test will be used to assess vestibular functioning. A normal result may cause the patient to experience nystagmus, vertigo, nausea, and vomiting. No response indicates an abnormal result. The patient is not expected to experience flushing of the skin or tingling of the earlobes.

Which defines the roles and scopes of practice of LPN/LVNs? A. Medicare B. Healthy People 2020 C. Nurse practice act (NPA) D. National Council of State Board of Nursing

Answer: Nurse practice act (NPA) Each state's NPA defines the roles and scopes of practice of LPN/LVNs. Medicare is a federal public insurance program that helps to partially fund health care for people 65 years old and older and their spouses. The NCSBN is the group that develops the nursing licensing examination. Healthy People 2020 is a health promotion and disease prevention agenda created by the U.S. Department of Health and Human Services to improve the health of all people in the United States.

The nurse is caring for a patient experiencing stomatitis. Which factor is most likely to have contributed to development of stomatitis? A. Morbid obesity B. Vegetarian diet C. Good oral hygiene D. Nutritional deficiencies

Answer: Nutritional deficiencies Factors likely to have contributed to the development of stomatitis is nutritional deficiencies, trauma from ill-fitting dentures, malocclusions of the teeth, poor oral hygiene, excessive smoking, excessive drinking of alcohol, pathogenic microorganisms, radiation therapy, and drugs used in chemotherapy for malignancies and anticonvulsants. Morbid obesity and intake of a vegetarian diet do not contribute to the development of stomatitis.

The nurse is performing an assessment on a patient with labyrinthitis. Which symptom(s) would likely to be noted? A. Nausea B. Ear pain C. Nystagmus D. Loss of hearing E. Extra production of cerumen

Answer: Nystagmus LASIK uses a laser to correct myopia. The middle layer of the cornea is reshaped with a laser after a very thin outer layer of the cornea is peeled back. The outer layer is replaced. Incisions and UV light are not used in the LASIK procedure.

The patient presents to the clinic with severe dermatitis that is refractory to avoidance of irritants, maintenance of skin moisture, and skin lubrication. The nurse anticipates which treatments will be prescribed? A. Oatmeal baths B. Prescription tretinoin C. Topical hydrocortisone D. Use of salicylic skin cleanser E. Frequent exfoliation of the skin

Answer: Oatmeal baths and Topical hydrocortisone The patient with severe dermatitis that has not been helped by nonpharmacologic therapies may require topical or systemic hydrocortisone for inflammation control. Oatmeal baths may be soothing to the patient's skin. Tretinoin, salicylic acid, and frequent exfoliation are drying and irritating to the skin and would worsen the patient's symptoms.

A patient has a corneal abrasion. Which factor in the patient's history is most closely related to this problem? A. The patient smoke B. The patient is 75 years old C. The patient wears contact lenses D. The patient has a history of renal disease

Answer: The patient wears contact lenses A corneal abrasion may result from exposure to contact lenses. This is especially true when the lenses are worn extensively. Smoking, age, and renal disease are not associated with corneal abrasions.

The specific cause of dysphagia can be determined more easily when the LPN/LVN obtains which information about the patient? A. Patient's vital signs, especially rate and depth B. Level of physical activity tolerated by the patient C. Patient's bowel habits and whether laxatives are taken habitually D. Observing conditions under which the patient experiences difficulty swallowing

Answer: Observing conditions under which the patient experiences difficulty swallowing When assessing the patient with dysphagia the nurse should observe carefully the kinds of food the patient can tolerate and the conditions under which difficulties are experienced. Knowing the consistency and temperature of the foods most easily ingested by the patient is helpful. The patient's vital signs, level of tolerated physical activity, and bowel habits are important assessment data but are not related to the patient's dysphagia.

A patient has been admitted to the hospital with GI bleeding. Which is a priority nursing action for this patient? A. Obtain complete vital signs. B. Administer prescribed medication for pain. C. Administer prescribed antacids every 2 hours. D. Administer prescribed medication for nausea and vomiting.

Answer: Obtain complete vital signs. The patient experiencing GI bleeding is at risk for hypovolemic shock. Assessment of vital signs will provide indicators of the patient's condition. The nurse should also plan to administer pain medication, antacids, and antiemetic medications.

When planning care for the patient with acute pancreatitis, the LPN/LVN knows that which intervention is a priority of care? A. Pain control B. Nutritional supplementation C. Observation for mental changes D. Observation for intestinal obstruction

Answer: Pain control The patient with acute pancreatitis presents with pain. The intervention having the highest priority involves management of the pain. Nutritional supplementation and observation for mental changes and intestinal obstruction are appropriate interventions, but not the ones of highest importance.

When planning care for the patient with acute pancreatitis, the LPN/LVN knows that which intervention is a priority of care? A. Pain control B. Nutritional supplementation C. Observation for mental changes D. Observation for intestinal obstruction

Answer: Pain control The patient with acute pancreatitis presents with pain. The intervention having the highest priority involves management of the pain. Nutritional supplementation and observation for mental changes and intestinal obstruction are appropriate interventions, but not the ones of highest importance.

The nurse is preparing to care for a patient with psoriasis. The nurse should anticipate which skin assessment? A. Fluid-filled blisters B. Patches covered with silvery scales C. Zigzag lesions that are slightly raised D. An area of local swelling and redness

Answer: Patches covered with silvery scales Psoriasis is a noncontagious, chronic, and recurring skin disorder that typically appears as inflamed, edematous skin lesions covered with adherent silvery-white scales. These scales are the result of an abnormally rapid rate of proliferation of skin cells. Zigzag lesions, fluid-filled blisters, or an area of local swelling and redness are not anticipated assessment data in a patient with psoriasis.

The nurse is caring for a patient who has a urinary catheter. Which nursing intervention should be done to help prevent infection? A. Keep the drainage bag above the level of the catheter or insertion site B. Keep the drainage bag above the level of the catheter hanging on the side rail of the patient's bed. C. Perform perineal care once with bathing, cleaning the urinary meatus and catheter with soap and water. D. Perform perineal care at least twice daily, cleaning the urinary meatus and catheter with soap and water

Answer: Perform perineal care at least twice daily, cleaning the urinary meatus and catheter with soap and water When a patient has a urinary catheter, the nursing intervention to help prevent infection is to perform perineal care at least twice daily, cleaning the urinary meatus and catheter with soap and water. Cleaning the perineal area once with bathing is not enough to help prevent infection. The drainage bag should always be kept below the level of the catheter or insertion site, not above and never on the patient's side rail.

The nurse is caring for a patient with a skin tear. Which dressing is most appropriate to apply to the area? A. Paste B. Hydrocolloid C. Moist sterile gauze D. Petroleum-based ointment

Answer: Petroleum-based ointment A petroleum-based ointment provides protection for a skin tear and keeps the wound bed moist to promote healing. A moist sterile gauze is used for a deeper or infected wound. Hydrocolloid is used for deeper pressure ulcers. Paste is used to fill in a deep wound.

A patient has been diagnosed with gastritis. Which medication can the nurse anticipate will be prescribed? A. Aspirin B. Carafate C. Ampicillin D. Ranitidine

Answer: Ranitidine Ranitidine functions as a gastric-acid inhibitor. Carafate may be used in conjunction with cimetidine, but its action is to create a barrier protecting the gastric mucosa from exposure to excess stomach acid. Aspirin and NSAIDs are known gastric irritants, and can result in GI bleeding without an already existing gastritis. Ampicillin is an antibiotic; it is not relevant to the treatment of gastritis.

The nurse understands and is practicing cost containment when doing what action? A. Eating snacks set aside for patient use only B. Accidentally taking ink pens and notepads home C. Recycling pulse oximetry probes according to policy D. Staying clocked in when going to the hospital gift shop after work

Answer: Recycling pulse oximetry probes according to policy Cost-containment practices involve holding costs within fixed limits while remaining competitive in the health care marketplace. Recycling appropriately is an excellent way to contain costs. Eating food not designated for staff, removing supplies from the hospital for personal use, and doing personal things on company time are not appropriate uses of the facility's funds.

The nurse knows that the "Five Rights" of delegating consist of what? (select all that apply) A. Right assignment B. Right supervision C. Right staff person D. Right circumstances E. Right communication F. Right collaborative standard

Answer: Right assignment, Right supervision, Right staff person, Right circumstances, Right communication The NCSBN identifies "Five Rights" to include when delegating: (1) right task, (2) right circumstance, (3) right person, (4) right direction or communication, and (5) right supervision. Right collaborative standard is not among the "Five Rights."

The nurse is caring for the patient following abdominal surgery. Which symptom, if demonstrated by the patient, indicates the development of peritonitis? A. Fever B. Projectile vomiting C. Severe abdominal pain D. Anorexia with weight loss

Answer: Severe abdominal pain Peritonitis is an inflammation of the peritoneum. It usually occurs when one of the organs it encloses ruptures or is perforated so that the organ's contents (including bacteria) are spilled into the abdominal cavity. Primary symptoms of peritonitis include nausea and vomiting, and severe abdominal pain and distention. Fever may result later. Projectile vomiting and anorexia are symptoms of many abdominal disorders.

When a patient has herpes zoster (shingles), the LPN/LVN should expect the patient to report which symptom? A. Severe pain B. A rash on the arms C. Pustules on the legs D. Respiratory involvement

Answer: Severe pain Shingles begins with vague symptoms of chills and low-grade fever and possibly some gastrointestinal disturbance. There may be only aching or discomfort along the nerve pathway with or without erythema. About 3 to 5 days after onset, small groups of vesicles appear on the skin. They are usually found on the trunk and spread halfway around the body, following the nerve pathways leading from the spinal nerve to the skin. Rash on the extremities and respiratory involvement are not expected.

The student nurse reviews the records of a patient with pneumonia and finds that the patient has a blood pH of 7.46. The student is correct in determining that this pH is considered __. A. Slightly acidic B. Grossly acidic C. Slightly alkaline D. Grossly Alkaline

Answer: Slightly Alkaline. Normal blood pH is 7.35 to 7.45, so 7.46 would be considered slightly alkaline; 7.36 and lower would be considered acidic.

During the change of shift report, the nurse notes the patient has several papular lesions. The oncoming nurse will most likely observe which lesion? A. Small, solid elevation of the skin B. Small sac containing serous fluid C. Firm, raised, deep lesion of the skin D. Small elevation of the skin filled with purulent matter

Answer: Small, solid elevation of the skin A papule is an elevated, solid lesion that is less than 1 cm in diameter. Examples of papules include warts (verruca) and elevated moles.

The nurse is assessing injuries on a patient admitted to the unit who had fallen at home several hours ago. When looking at the patient's history, the nurse notices that he has smoked at least four packs of cigarettes per day for the past 60 years. What impact does smoking have on the musculoskeletal health of a patient? A. Smoking increases the risk of more falls in the elderly. B. Smoking increases the risk of developing osteoporosis. C. Smoking decreases the risk of developing osteoporosis. D. Smoking decreases the risk of a hip fracture as you age.

Answer: Smoking increases the risk of developing osteoporosis. Smoking has a significant impact on the musculoskeletal health of a patient because it increases the risk of developing osteoporosis, increases the risk of a hip fracture with aging, increases the risk of developing exercise-related injuries, has a detrimental effect on fracture and wound healing, has a detrimental effect on athletic performance, and is associated with low back pain and rheumatoid arthritis.

When collecting a 24-hour urine specimen, nursing responsibilities include which action? A. Starting the timing of the collection after the first voided urine B. Beginning urine sample collection with the first voided specimen C. Collecting a urine sample from the patient every hour for 24 hours D. Encouraging sufficient patient fluid intake to ensure 2L of urine production

Answer: Starting the timing of the collection after the first voided urine Unless otherwise ordered, the first void should be discarded; the collection should then be timed and begun for all urine voided for the next 24 hours. Collecting a urine sample every hour is not correct procedure for maintaining a 24-hour urine specimen. It is not necessary to encourage fluid intake in order to ensure 2 L of urine production.

An elderly patient reports a loss of interest in eating. The patient's history indicates the patient's spouse died a few months ago. When providing information to the patient, which action by the nurse is likely to be most helpful in increasing the patient's intake? A. Having the patient keep a food diary. B. Giving the patient a list of high-calorie foods. C. Reminding the patient of the importance of eating. D. Suggesting to the patient's family members that someone join the patient for meals.

Answer: Suggesting to the patient's family members that someone join the patient for meals. Psychosocial factors have a significant impact on one's desire for food. Appetite depends on complex mental processes having to do with memory and mental associations that can be pleasant or extremely unpleasant. Appetite is stimulated by the sight, smell, and thought of food. The physical and social environment in which a person is eating stimulates appetite. It would not be helpful for the nurse to have the patient keep a food diary, to give the patient a list of high-calorie foods, or to remind the patient of the importance of eating.

The nurse is reviewing the assessment documentation on an older adult patient made the previous shift. The nurse notes what changes occur in the eye with aging? A. Equal in size, not completely round, and not reactive to light. B. Complete round, pupils bulging, and pupil size enlarges C. Reactive to light, wider visual field, and ability to see dim light D. Sunken look, cornea flattens, and cataracts may form

Answer: Sunken look, cornea flattens, and cataracts may form Changes that occur in the eye with aging include the eyes appear to be sunken because subcutaneous fat and tissue elasticity decreases; the cornea flattens and develops an irregular curvature after age 65. The lens of the eye changes age 40, gradually losing water and becoming hard and cataracts may form. Pupils are still reactive to light, pupils flatten rather than bulging, and a narrower visual field occurs and pupil size becomes smaller, rather than larger, causing an inability to see dim light.

When assigned to care for a patient who has gout, the LPN/LVN should assess for which condition? A. Evidence of unilateral joint deformity B. Decreased range-of-motion of most joints C. Swelling and pain in the big toe or other joint D. Signs of compression of the spine from collapsed vertebrae

Answer: Swelling and pain in the big toe or other joint Gouty arthritis most commonly impacts the big toe but may be noted in other joints. There are no signs of spinal nerve compression associated with the condition. Joint deformity and reduction in the range-of-motion of most of the body's joints are not associated with the condition.

Which measure is usually included in the care of a patient with stress incontinence? A. Encouraging the patient to drink caffeinated fluids B. Teaching the patient pelvic floor strengthening exercises C. Suggesting that the patient have a glass of water before bedtime D. Discouraging the patient from voiding more frequently than every 4 hours

Answer: Teaching the patient pelvic floor strengthening exercises The use of strengthening exercises (such as Kegel exercises) is helpful in the management of stress incontinence. Caffeinated fluids, water before bedtime, and voiding less frequently than every 4 hours increase the patient's risk for incontinence.

When a patient experiences dizziness and vertigo, which action should be included in the patient's care? A. Reminding the patient to limit intake of salt B. Telling the patient to increase intake of vitamin B12 C. Encouraging the patient to remain as active as possible D. Instructing the patient to lie down and remain as still as possible

Answer: Telling the patient to increase intake of vitamin B12 Miotics, such as pilocarpine, are administered for treatment of glaucoma to cause pupillary constriction and lower intraocular pressure. Miotics do not result in pupil dilation, changes in sclera coloring, or changes to the cornea.

The patient presents to the clinic with a compound fracture of the right leg. The nurse anticipates the administration of which classes of medications? A. Aspirin B. Tetanus booster C. Hepatitis B vaccine D. Intravenous (IV) morphine E. IV antibiotics

Answer: Tetanus booster, Intravenous (IV) morphine, and IV antibiotics The nurse should anticipate administering a tetanus immunization or booster, IV narcotic pain medications, and IV prophylactic antibiotics to prevent infection and control pain in the patient who has suffered an open fracture. The patient has an open wound, so aspirin is not appropriate due to the risk of bleeding. The hepatitis B vaccine is not necessary for this patient.

When a patient receives a hypotonic solution intravenously (IV), what happens to the patient's cells? A. There is a net loss of water across the cell membrane B. There is no change in the cells because there is no fluid shift C. The cell begins to swell as water enters the intracellular compartment D. The cells begin to shrink as water is pulled from the intracellular compartment

Answer: The cells begin to swell as water enters the intracellular compartment. A hypotonic solution has a lower osmotic pressure than that of body fluids. During IV administration with a hypotonic solution, cells will swell as water passes from the less concentrated solution across the cell membrane and into the cell. Hypertonic fluid causes cells to shrink. There is a net gain, not loss, of water across the cell membrane. The fluid shift causes the change in the cells.

When a patient with burns has a full-thickness wound, which of these tissues are involved? A. The subcutaneous fat only B. The entire dermis and muscles C. The deeper layers of the dermis only D. The entire dermis and subcutaneous tissue

Answer: The entire dermis and subcutaneous tissue A method to evaluate the depth of burns is based on the layers of skin that have been damaged. Full-thickness wounds involve all layers of skin and the destruction of the epidermal appendages. Wounds of this type will require grafting for the wound to heal and for optimal function to be restored. Partial-thickness wounds are those in which the epidermal appendages (sweat and oil glands and hair follicles) are not destroyed; these wounds will heal by themselves if no further injury occurs from either infection or inappropriate treatment for the phases of wound healing. Grafting may or may not be necessary.

For the patient who needs the support of a crutch while walking, the type of crutch selected will depend on which assessment? A. The gait the patient will use B. What is most comfortable for the patient C. The availability of insurance reimbursement D. The extent of the patient's disability or paralysis

Answer: The extent of the patient's disability or paralysis The type of crutch to be used will depend on the extent of disability or paralysis and the patient's ability to bear weight and maintain balance. If the crutches are too short or too long, the patient will have problems with moving and shifting his or her weight. Reimbursement, the type of gait, and what is most comfortable for the patient are important considerations, but less so than the extent of the patient's disability.

The nurse is reviewing a patient's chart and notes the patient's vision in his left eye is 20/70. The nurse uses this information to make which interpretation of the patient's vision? A. The patient can read the line on the chart labeled 20 at 70 feet. B. The patient can read the line on the chart labeled 70 at 20 feet. C. The patient can see 20/70ths of what a patient of that age can see D. The patient can see 20/70ths of what a normally sighted person can see

Answer: The patient can read the line on the chart labeled 70 at 20 feet. The Snellen eye chart is used to assess visual acuity. The chart is placed 20 feet from the patient, and first one eye is occluded and then the other eye is occluded. The person begins reading lines of letters that decrease in size. Visual acuity is expressed as a fraction for each eye. The numerator (first) figure indicates the distance between the patient and the chart. The denominator (second) figure expresses the distance at which a person with 20/20 vision could read that line. Visual acuity of 20/20 in each eye is normal. A visual acuity of 20/70 means the smallest line this patient could read at 20 feet can be read at 70 feet by a person with 20/20 (or normal) vision. Visual acuity of 20/200 indicates the person is legally blind.

The nurse is assisting the patient to use the 4-point gait with crutches. Which behavior by the patient demonstrates understanding? A. The patient initially advances the left foot. B. The patient initially advances the right foot. C. The patient initially advances the left crutch. D. The patient initially advances the right crutch.

Answer: The patient initially advances the left crutch. When performing the 4-point crutch gait, the patient should begin by advancing the left crutch followed by advancing the right foot.

A patient complains of tinnitus. Which factor, if present in the patient's history, may be most closely related to the patient's complaint? A. The patient takes zinc supplement B. The patient is a high school student C. The patient takes large doses of Aspirin D. The patient is slightly dehydrated from gastroenteritis

Answer: The patient takes large doses of Aspirin Ototoxicity is often initially manifested with tinnitus. Excessive doses of aspirin are linked to ototoxicity. Zinc supplements, being a high school student, and dehydration are not directly associated with tinnitus.

A magnetic resonance imaging (MRI) test is scheduled. What should be included in the information provided to the patient? A. The test will take approximately 60 minutes. B. The patient will have an intravenous (IV) line started prior to the test. C. Solid foods are restricted for 6 to 8 hours prior to the test. D. There is only a limited amount of radiation exposure associated with the test.

Answer: The test will take approximately 60 minutes. The MRI will take approximately 30 to 90 minutes. There are no dietary restrictions. An IV will not be needed. There is no radiation exposure associated with the test.

One week postoperatively, the LPN/LVN notes that the stoma of a patient who had a colostomy has a purple hue. The nurse's actions are based on which understanding about this finding? A. This is a normal finding. B. There may be too much blood flow. C. There may be an obstruction in blood flow. D. The stoma is healing more quickly than expected.

Answer: There may be an obstruction in blood flow. The stoma is inspected for a normal pink or red color, which indicates adequate blood supply. It should look like healthy mucous membrane such as that inside the mouth. Later, the stoma will shrink in size and may be less highly colored. A deepening of color to a purplish hue may indicate obstruction of blood flow to the stoma.

For which reason are patients with esophageal varices prone to hemorrhage? A. They have portal hypotension B. There is poor circulation within the veins C. They are no longer able to produce vitamin K D. There is an accumulation of ammonia in the blood

Answer: They are no longer able to produce vitamin K Esophageal varices are engorged veins (similar to varicose veins) that line the esophagus. They are the result of portal congestion and hypertension. The congestion can lead to massive bleeding when the vein walls rupture from increased pressure or esophageal irritation. Another factor in hemorrhage is that the liver is no longer able to make vitamin K. Ammonia buildup does not increase the patient's risk for hemorrhage.

For which reason are patients with esophageal varices prone to hemorrhage? A. They have portal hypotension. B. There is poor circulation within the veins. C. They are no longer able to produce vitamin K. D. There is an accumulation of ammonia in the blood

Answer: They are no longer able to produce vitamin K. Esophageal varices are engorged veins (similar to varicose veins) that line the esophagus. They are the result of portal congestion and hypertension. The congestion can lead to massive bleeding when the vein walls rupture from increased pressure or esophageal irritation. Another factor in hemorrhage is that the liver is no longer able to make vitamin K. Ammonia buildup does not increase the patient's risk for hemorrhage.

The patient presents to the emergency department after a soccer game. The patient reports that she made a sharp turn and heard and felt a large pop from her knee. The patient reports, "Now, when I'm walking, it feels like my knee just gives out, and I almost fall. Plus, it's twice the size of my other knee, and I can't straighten it all the way." The nurse recognizes that these symptoms correspond with which injury? A. Torn meniscus B. Dislocated patella C. Torn quadriceps muscle D. Torn anterior cruciate ligament injury

Answer: Torn anterior cruciate ligament injury The turning motion followed by a loud pop with the patient's complaint of severe swelling, joint instability, and decreased extension indicates a torn anterior cruciate ligament. A meniscal tear has less swelling and joint instability, although some exists. If the patient had dislocated her patella, the patella would be in a different spot than normal, and this would be part of the patient's chief complaint. The patient's complaint centers on the knee, not the quadriceps.

A nurse at an urgent care center cares for four clients with leg of foot injuries. which of the following client reports should suggest to the nurse that the client has an ankle sprain? A. Dropping a 10 lb weight on his lower leg at the health club B. Having ankle pain after running a 10 mile race C. Twisting his foot while running bases during a baseball game D. Getting hit by another soccer player on the field

Answer: Twisting his foot while running bases during a baseball game ​A sprain is a stretching injury to ligaments around a joint. Wrenching or twisting motions generally cause this type of injury.

The nurse is caring for a patient with a hearing disorder who has begun to complain of dizziness and a disorder of the vestibular system is suspected. Which diagnostic test would be most appropriate? A. Rinne test B. Vestibular testing C. Audimetric testing D. Evoked-response audiometry

Answer: Vestibular testing An electronystagmography test assesses for diseases of the vestibular system. Evoked-response audiometry assesses the abnormality of nerve pathways between the brainstem and the eighth cranial nerve. Audiometry is used to assess the presence and degree of hearing loss. Impedance audiometry evaluates middle-ear function.

The nurse is caring for a patient with ulcerative colitis who recently underwent a colectomy and the creation of an ileal reservoir. How will this patient eliminate stool from his body? A. Continuously into a collection pouch B. With a catheter inserted into the reservoir C. Via his anus, over which he retains control D. Intermittently via the ostomy into a collection pouch

Answer: With a catheter inserted into the reservoir Patients with ileal reservoirs or Kock pouches are able to empty the reservoir via catheter and not wear a collection pouch. A collection pouch is necessary for traditional ileostomies, with which stool is evacuated continuously rather than intermittently. The patient with an ileoanal anastomosis retains control over the anal sphincter and defecates normally.

To understand what type of fluid a patient needs, the LPN/LVN should understand that the term semipermeable membrane indicates that: A. The membrane is only a temporary structure B. Only electrically charged particles may pass through the membrane C. The membrane does not allow for the passage of anything but water D. The membrane allows some particles to pass through and prohibits the passage of others

Answers: The membrane allows some particles to pass through and prohibits the passage of others A semipermeable membrane allows fluid to move between the interstitial and intracellular compartments and between the interstitial and intravascular compartments by osmosis. Semipermeable membranes are permanent structures. Passage through this type of membrane does not require electrically charged particles. More than just water can pass through semipermeable membranes.