Unit One Review..

A 30-year-old patient with a history of rheumatic heart disease comes to the emergency room. He complains of sudden loss of strength in the left arm while working on the computer. He is unable to lift his arm and complains that his arm "just fell." There is no pain. What might be the possible diagnosis?

Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. Rheumatic heart disease is one cause of embolic stroke in young to middle-aged adults.

A nurse finds that a patient who recently lost a job has started engaging in long exercise sessions. The nurse concludes that the patient is using an emotion-focused coping. How does emotion-focused coping help in reducing stress?

Emotion-focused coping helps to manage the feelings associated with the stressful event. It decreases the negative emotions by promoting a feeling of well-being.

A 68-year-old patient has undergone a total hip replacement and has glaucoma. The nurse forms a nursing diagnosis of disturbed sensory perception related to increased intraocular pressure. The plan of care should focus on which main element?

Encouraging medication compliance to reduce the risk of vision loss Drug therapy is necessary to prevent the eventual vision loss that accompanies glaucoma. For this reason, the nurse should encourage the patient to remain compliant with drug therapy.

Cirrosis diet

Even though a low-protein diet has been questioned in the treatment of patients with cirrhosis, it remains in use.

While caring for a patient who had a pituitary tumor removed, which finding should be reported immediately to the primary health care provider?

Excessive thirst A patient who has had surgery on the pituitary gland is at risk for diabetes insipidus. Excessive thirst is an indicator of inadequate antidiuretic hormone (ADH) synthesis or release. The nurse should monitor the urine output closely and notify the primary health care provider of excessive thirst.

The nurse is teaching a patient who has been newly diagnosed with Raynaud's phenomenon to avoid potential triggers, which include which of these?

Exposure to cold (not heat), emotional upsets, tobacco use, and caffeine often bring on symptoms of Raynaud's phenomenon.

What is the difference between extrenal and internal factors ?

Extrenal factors are those that are outside the body. Such as Religious or spiritual influences and the Internal factors are inside the body. Ex. is age, health status and personality characteristics.

The nurse is caring for a patient admitted to the health care facility with acute alcohol toxicity. Which would the nurse identify as a sign of Wernicke's encephalopathy?

Eye abnormalities such as nystagmus, or paralysis of the lateral rectus muscles, indicate Wernicke's encephalopathy. Most patients with Wernicke's encephalopathy have decreased serum magnesium levels and other signs of malnutrition.

During administration of chemotherapy to a patient with breast cancer, the patient develops urticaria and shortness of breath. What should the nurse do after stopping the therapy? Uticaria is an allergic reaction that causes rash red skin patches.

First you should ensure airway patency, assess the RR and pulse ox. The patient is going through an allergic reaction and could lead to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or sever bronchospasm.

A nurse performing an assessment of a patient with acute decompensated heart failure auscultates fine crackles bilaterally. The nurse knows that crackles are an indicator of

Fluid in the alveoli Fluid in the alveoli is the correct answer as crackles are made by the sound of air moving through fluid filled alveoli.

The nurse providing dietary instruction to a patient with hypertension would advise the patient to cut down on the intake of which foods?

Foods high in fat and sodium—including canned vegetables, red meat, and processed cheeses—should be avoided by the patient with hypertension

A patient with chronic obstructive pulmonary disease (COPD) needs to be taught about effective huff coughing in a stepwise manner. In which order should the nurse put the steps for teaching the patient?

For effective huff coughing, the patient should assume a sitting position with his head slightly flexed, shoulders relaxed, knees flexed, forearms supported by a pillow, and, if possible, feet on the floor. Then the patient should inhale slowly through the mouth while breathing deeply from the diaphragm; the patient should hold his breath for 2 to 3 seconds. The patient should forcefully exhale quickly, as if fogging up a mirror with his breath to create a "huff," which moves the secretions to larger airways.

A patient presents with burning pain in the epigastrium accompanied by nausea. On interviewing the patient, the nurse finds that the patient has been taking nonsteroidal antiinflammatory drugs (NSAIDs) on a regular basis to relieve headaches. Which condition should the nurse suspect?

Gastritis occurs as the result of a breakdown in the normal gastric mucosal barrier. NSAIDs inhibit the synthesis of prostaglandins that are protective to the gastric mucosa and thus cause gastritis. Symptoms of gastritis include anorexia, nausea and vomiting, epigastric tenderness, and a feeling of fullness.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment.

The nurse is caring for a 70-year-old patient. What are the symptoms of dementia that the nurse should be observant for?

In dementia, there is progressive neurodegeneration, and vascular changes lead to cognitive impairment. The cognitive impairment manifests as abrupt changes in behavior, memory loss, and cognitive dysfunction, which are all symptoms of dementia. Other symptoms include dysfunction or loss of orientation, attention, language, judgment, and reasoning

The nurse assesses a patient with polycythemia vera and reviews the patient's lab results. The nurse recognizes that the condition is associated with:

In polycythemia vera, hemoglobin and hematocrit are increased because of a hyperproliferation of red blood cells.

On a home visit to a patient who underwent cataract surgery, the nurse finds that the patient has intense pain in the operated eye. What should be the immediate nursing action?

In the postoperative period after a cataract surgery, the pain is usually mild. However, if the patient complains of intense pain, it should be immediately communicated to the surgeon, as it may indicate hemorrhage, infection, or increased intraocular pressure and thus may need prompt intervention

A nurse reviews the lab report of a patient that shows the white blood cell count is 15 × 109/L. Which condition is the patient likely experiencing?

Infection A patient's medical report shows the white blood cell count to be 15 × 109 /L. The normal range of white blood cell count is 4-11 × 109 /L. Elevations in white blood cell count are associated with infection, as white blood cells (WBCs) are immune cells.

The nurse anticipates that treatment of the patient with severe hyperphosphatemia includes:

Insulin infusion For severe hyperphosphatemia, hemodialysis or an insulin and glucose infusion can decrease levels rapidly

A patient has an initial positive PPD (purified protein derivative) skin test result. A repeat PPD's result is also positive. No other signs or symptoms of tuberculosis or allergies are evident. Which medication(s) does the nurse anticipate will be prescribed?

Isoniazid (INH

A patient has been diagnosed with community-acquired pneumonia (CAP). The nurse knows that:

It can occur in patients who reside in a long-term care facility within 14 days of symptoms

What is problem-focused coping ?

It focuses on attempting to resolve the problem causing the stress. Ex. a young adult who failed a test and gets a tutor.

In case of severe hyperkalemia manifested by irritation, irregular pulse, and changes in ECG findings, the nurse should act immediately to prevent cardiac arrest. The nurse should administer intravenous calcium gluconate to reverse the membrane potential effects of extracellular fluid (ECF) potassium

It is a blood test that shows if there is excess fluid in the heart. BNP is a hormone that is produced when the atrial pressure increases. This blood test is used to diagnose the severity and treatment outcomes of congestive heart failure (CHF)

What is emotion focused coping ?

It is an individual managing emotions or feelings during a stressful event. In includes discussing feelings with a friends or taking a hot bath.Ex. Going for a jog after failing a test

What is acute alcohol toxicity?

It may occur with binge drinking or the use of alcohol with other CNS depressants. It is considered an emergancy because there is a narrow range between the intoxication, the anestetic, and the lethal doses of alcohol. Alcohol induced CNS depression leads to respiratory and circulatory failure.

The nurse is monitoring a patient who is experiencing a hyperacute rejection following transplantation of an organ. Which of these statements is true about this type of rejection

It occurs minutes to hours after transplantation. There is no treatment for hyperacute rejection, and the transplanted organ is removed. It is a rare event because a final cross-match is performed just before the transplant.

A nurse is performing a physical assessment of a patient and finds that the lymph nodes are hard and fixed. How should the nurse interpret the finding?

It suggests malignancy A hard and fixed lymph node is an abnormal finding and warrants further investigation. Hard or fixed nodes suggest malignancy. Palpated nodes which are mobile, firm, and nontender are considered normal. Tender nodes usually indicate inflammation.

A patient is admitted to the hospital after being involved in a motor vehicle accident. The patient has asymmetrical chest excursion and an absence of breath sounds on the left side. The nurse suspects:

Left pneumothorax When the left part of the chest is crushed, breathing is compromised and asymmetrical excursion is seen. This information, along with the absence of breath sounds, is an indication of a left pneumothorax. The injury is located on the left side of the chest.

Hyperkalemia on an ECG

Loss of P wave, tall peaked T wave, and ST segment depression

A patient with glaucoma is taking timolol (Timoptic drops). The nurse, who is reinforcing principles of medication administration with the patient, should include that the patient:

May experience blurred vision after administration of the drops lasting several minutes

A 68-year-old patient was admitted with abdominal pain, nausea, and severe diarrhea. Based on this information, the nurse assesses this patient for which primary acid-base imbalance?

Metabolic acidosis Because gastric secretions are rich in hydrochloric acid, the patient with severe diarrhea will lose significant amounts of bicarbonate and is at increased risk for metabolic acidosis and a fall in pH.

A diabetic patient fasting before surgery reports feeling dizzy and deep rapid breathing. A nurse observes that the patient has developed Kussmaul respirations. What condition is the patient most likely experiencing?

Metabolic acidosis The patient is likely to be experiencing diabetic ketoacidosis which is a type of metabolic acidosis. Kusmmaul respirations are deep rapid breaths that develop due to metabolic acidosis

What substance is it most appropriate for the nurse to use to remove an insect from a patient's ear?

Mineral oil causes the least amount of trauma and irritation to the ear canal. Water and hydrogen peroxide should not be used because the insect could swell, which would make it more difficult to remove. Alcohol may cause both irritation of the ear canal and swelling of the insect.

Which statement by a patient diagnosed with stable angina indicates understanding of the disease process?

Mismatch between oxygen demand of cardiac muscles and supply of oxygen leads to myocardial ischemia that is represented by pain.

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient?

Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems.

What are some manifestations for stress that a patient can have ?

Musculoskeletal pain what exists because there is an increased muscle tension from SNS stimulation from stress response. The other manifestaion would be weight loss , loss of appetite and hyperventilation, hypertension and increased heart rate, sweating and GI upset.

Myocardial infarction

Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave.

A patient with angina pectoris asks the nurse about the cause of the pain. The nurse explains that the pain is primarily produced by:

Myocardial ischemia he pain of angina pectoris is caused by an inadequate oxygen supply to the myocardium, resulting in ischemia.

The nurse provides teaching to a patient with asthma who has been advised to use nebulization. What should the nurse include in the instructions about nebulization?

Nebulization involves administering drug solution as mists produced by small machines called nebulizers. An upright position allows for efficient breathing that ensures adequate penetration and deposition of the aerosolized medication. The patient should hold the inspiration for 2 to 3 seconds to ensure penetration of the medication.

The nurse cares for a patient with a diagnosis of tuberculosis. Which assessment finding best indicates that the patient has been following the prescribed treatment plan?

Negative sputum cultures A patient's sputum is expected to convert to negative within 3 months of the beginning of treatment.

A nurse is teaching a patient about prevention of peptic ulcers. What instructions should the nurse give the patient?

Nicotine, a component of cigarettes, causes gastric irritation, and therefore smoking should be avoided by those with peptic ulcers. Washing hands thoroughly with soap after using the restroom and before eating would help prevent the Helicobacter pylori infection that causes peptic ulcers. Any symptom of gastric irritation such as nausea and epigastric pain must be reported to the health care provider to prevent lethal consequences of peptic ulcer disease.

A 75-year-old patient reports leg pain that awakens the patient at night. The patient reports that the same pain develops in the legs when they are elevated and disappears when the legs are dangled. The nurse assesses a lesion on the inner aspect of the ankle. The patient is most likely experiencing:

Nighttime leg pain is common in older adults. However, it may also indicate the ischemic resting pain of peripheral vascular disease. Alterations in arterial circulation cause pain that worsens with leg elevation and is relieved when the extremity is dangled because gravity assists in arterial circulation. Lymphatic obstruction would present as edema of an extremity. Venous insufficiency presents as leathery brown skin of the lower legs, edema, and the development of stasis ulcers. Musculoskeletal abnormalities are not related to this disease process.

A nurse at the health care facility is caring for a patient on anticoagulant therapy for venous thromboembolism. Which interventions should the nurse perform for this patient?

Nursing interventions for the patient taking anticoagulant therapy include evaluation of platelet count for signs of heparin-induced thrombocytopenia. The nurse should preferably use a small-gauge needle for venipuncture. The patient should be monitored for decreased blood pressure or increased heart rate, which are indicative of internal bleeding.

The nurse is examining the lymph nodes in a patient's neck. Which of these is an abnormal finding?

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

A patient experiences left ventricular failure. Which manifestation of this condition does the nurse recognize?

Orthopnea Orthopnea, difficulty breathing except when sitting or standing, is a symptom of advanced heart failure, especially left-sided failure. When the heart fails as a pump, blood backs up into the lungs, causing fluid to leak from the alveolar membrane. As this process continues, pulmonary edema may develop.

A nurse is preparing discharge teaching for a patient with orthostatic hypotension. Which instructions should be a part of the discharge plan?

Orthostatic hypotension is a condition where there is a decrease in blood pressure upon rising to a standing position from a lying down or sitting position. The patient should be instructed to rise slowly from the sitting and lying down position and move only when no dizziness occurs. The patient should sit or lie down if there is dizziness. This prevents the risk of falling. Standing still for prolonged periods may cause venous stasis and worsen hypotension. Doing leg exercises helps to increase venous return to the heart and lowers blood pressure.

Sinus Tachycardia

P wave is present ; followed by QRS. The rhythm is also regular HR is 100-160bpm

Sinus Bradycardia

P waves are present and are followed by QRS. The rhythm is regular but HR less than 60 BPM Seen in athletes and with beta blockers and with they sleep

Second degree AV block

P waves usually occuring regularly rates consistent with SA node initiation

First degree AV block

P-R interval prolonged In first degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 seconds.

The nurse is giving a patient instructions regarding the management of gastroesophageal reflux disease (GERD). Which statement indicates that further teaching is required?

Patients with GERD should be instructed to avoid milk, especially at bedtime, because it increases gastric acid secretion. There is not a specific diet for GERD, but rather the recommendation to avoid particular foods. Small frequent meals are recommended to prevent gastric distention.

The nurse is assessing a patient with lower extremity peripheral artery disease (PAD). Which symptom would the nurse find in a patient with lower extremity PAD?

Patients with lower extremity PAD experience loss of hair on the legs, feet, and toes. Peripheral pulses are absent and lower leg edema is absent unless the leg is constantly in a dependent position. Patients with lower extremity PAD generally experience intermittent claudication or rest pain in the foot. Patients with venous disease experience lower leg edema and heaviness in the calf or thigh.

The nurse is assessing a patient who has been found to have a diffuse infiltrate on a chest x-ray. The patient states, "I am afraid that I have cancer." The nurse will assess the patient for which most common symptom of lung cancer?

Persistent cough One of the most common symptoms of lung cancer, and often the one reported first, is a persistent cough. Other manifestations may occur but they are not the most common symptoms. The patient may complain of dyspnea or wheezing, and blood-tinged sputum may be produced by bleeding. Chest pain, if present, may be localized or unilateral, ranging from mild to severe. Later manifestations include nonspecific systemic symptoms such as anorexia, fatigue, weight loss, and nausea and vomiting. Hoarseness may be present as a result of laryngeal nerve involvement. Hypercalcemia may occur because of paraneoplastic syndrome.

The nurse is caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would be identified as an adverse effect related to this therapy?

Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal 2.4--4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

What are physiological stressors

Physical conditions or diseases that cause stress by affecting the normal functioning of the body system. Ex. Pain, excessive noise, and starvation.

Which strategy is most important for a nurse to include when planning care for a patient who has leukopenia?

Placing the patient in a private room Leukopenia is the reduction in the number of leukocytes in the blood. This leaves a patient prone to infection. The risk of infection can be reduced by placing a patient in a private room

The electrocardiogram of a patient indicates hidden P waves in preceding T waves and a normal QRS complex. The nurse recognizes that the patient is most likely experiencing what condition?

Premature atrial contraction A premature atrial contraction occurs at the atrium and occurs before the next sinus beat occurs. A premature atrial contraction occurs in either the left atrium or right atrium and travels along the atria. The electrocardiogram of a premature atrial contraction usually shows hidden P waves in preceding T waves with prolonged PR interval.

In presbyopia the lens of the eye loses flexibility and is unable to accommodate close vision. The nurse recognizes that this condition generally occurs in:

Presbyopia is an age-related change in vision that generally occurs in men and women older than 40 years

In reinforcing health teaching to a patient diagnosed with primary open-angle glaucoma, the nurse would include which information about the disorder?

Pressure damage to the optic nerve may occur because of clogged drainage channels..With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain properly from the eye. This leads to damage to the optic nerve over time.

The nurse is teaching the patient who was diagnosed recently with primary hypertension. Which instruction has the highest priority?

Primary hypertension doesn't have an identified cause, but contributing factors include high sodium intake. Therefore, decreasing intake or complete elimination of food high in sodium will help to reduce blood pressure in the patient diagnosed with primary hypertension.

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women?

Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in blood pressure (BP). Along with exercise for 30 minutes on most days, the dietary approaches to stop hypertension (DASH) eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP.

A patient who had a mastectomy one month ago would experience what type of stress?

Psychologic stressor R/T the loss of a breast through surgical removal affects the self image of the patient .

The nurse notices that a patient with pulmonary edema experiences shortness of breath while lying down. What is the most likely reason for the development of orthopnea in this patient?

Pulmonary congestion In pulmonary edema, there is congestion in the lungs, which causes inadequate oxygenation. In a recumbent position, the congestion is further increased, causing further hypoxemia, which causes orthopnea or shortness of breath while lying down

The nurse notices that a patient with pulmonary edema experiences shortness of breath while lying down. What is the most likely reason for the development of orthopnea in this patient?

Pulmonary congestion In pulmonary edema, there is congestion in the lungs, which causes inadequate oxygenation. In a recumbent position, the congestion is further increased, causing further hypoxemia, which causes orthopnea or shortness of breath while lying down.

A patient is diagnosed with pulmonary embolism. What nursing actions are appropriate for this patient?

Pulmonary embolism requires prompt therapy for a good prognosis. Oxygen therapy should be administered as prescribed. An IV line should be maintained for medications and fluid therapy. Anticoagulants and fibrinolytics may have adverse effects, and the nurse should monitor the patient for side effects. The patient should be placed in a semi-Fowler's position to assist in breathing. The patient should be encouraged to cough and perform deep breathing exercises for better pulmonary function.

Lab Values RBC Hgb Hct

RBC-3.8--5.1 × 106/μL Hgb 11.7--16.0 g/dL Hct 35%--47% platelet count 150,000--400,000/μL.

Atrial Fibrillation

Rapid , indiscernible P waves ( >350 bpm) Ventricular rhythm irregularly irregular

What statement is incorrect regarding Clostridium difficile infection?

Recurrent C. difficile infection occurs in about 20% of patients, and the probability of a recurrence rises with each subsequent infection.

The nurse provides preprocedure teaching for a patient who is scheduled for bedside thoracentesis. What does the nurse explain is the primary purpose of thoracentesis?

Relieving an abnormal accumulation of fluid in the pleural space Thoracentesis involves the insertion of a large-bore needle into the pleural space to relieve an abnormal accumulation of fluid in the pleural space. The procedure can significantly relieve symptoms related to this fluid accumulation, such as shortness of breath and discomfort

Assessment of a patient's peripheral intravenous (IV) site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first?

Remove the patient's IV catheter The priority intervention for superficial phlebitis is removal of the offending IV catheter.

What is a side effect of diazepam (Valium)

Respiratory depression. This is why when you give this drug, you should measure the RR. The focused assessment should be on airway, breathing and circulation. If the RR is decreased, the o2 sat may or may not be decreased.

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and now is experiencing bleeding in the left knee joint. What should be the emergency nurse's immediate response to this?

Resting the patient's knee to prevent hemarthroses In patients with hemophilia , joint bleeding requires resting of the joint to prevent deformities from hemarthrosis.

The nurse is monitoring a patient who is having a thoracentesis for recurrent pleural effusion. Which of these assessment findings would be of most concern?

Restlessness and sudden complaint of dyspnea During and after a thoracentesis, monitor the patient's vital signs and pulse oximetry and observe the patient for any manifestations of respiratory distress, which may indicate a possible complication, such as pneumothorax or pulmonary edema.

A patient has what is suspected to be a gastric ulcer perforation. Which symptom does the nurse expect will be present?

Rigid abdomen Perforation results in spillage of gastric or duodenal contents into the upper peritoneal cavity. The patient experiences sudden upper abdominal pain because the spillage causes irritation of pain receptors in the visceral and parietal layers of the peritoneum. The body then attempts to protect the area by contracting the abdominal muscles, resulting in a rigid, boardlike abdomen.

Identify risk factors associated with development of cataracts.

Risk factors for developing cataracts include advanced age, exposure to ultraviolet light, and conditions in which blood glucose levels are elevated, such as diabetes mellitus, or patients receiving long-term corticosteroid medications. Aging and these conditions alter metabolic processes that lead to the lens becoming cloudy and then opaque.

In caring for a patient admitted with poorly controlled hypertension, the nurse should understand that which laboratory test result would indicate the presence of target organ damage?

Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6--1.3 mg/dL. This elevated level indicates target organ damage to the kidneys.

A 55-year-old man weighs 115 kg and has a history of tobacco use, high blood pressure, and a sedentary lifestyle. When developing a plan of care for this patient, the nurse recalls that the most important risk factor for peripheral artery disease (PAD) includes which of these?

Significant risk factors for PAD include tobacco use, diabetes, hyperlipidemia, elevated C-reactive protein, and uncontrolled hypertension , with the most important being tobacco use.

The nurse is teaching a patient how to use a hand-held nebulizer. Which guideline is correct?

Sit in an upright position during the treatment he patient is placed in an upright position that allows for most efficient breathing to ensure adequate penetration and deposition of the aerosolized medication. The patient must breathe slowly and deeply through the mouth and hold inspirations for two or three seconds. Deep diaphragmatic breathing helps ensure deposition of the medication. Instruct the patient to breathe normally in between these large forced breaths to prevent alveolar hypoventilation and dizziness. After the treatment instruct the patient to cough effectively.

Which lung cancer diagnosis is associated with the most rapid growth rate?

Small cell carcinoma is the most malignant form of lung cancer, with a very rapid growth rate. Squamous cell carcinoma has a slow growth rate, owing to its tendency to not metastasize. Large cell carcinoma is highly metastatic via the lymphatics and blood, but its growth rate is not as rapid as small cell. Adenocarcinoma is the most common type of lung cancer, a non-small cell lung cancer.

The nurse receives a health care provider's prescription to change a patient's intravenous (IV) from D5½ normal saline (NS) with 40 mEq KCl/L to D5 NS with 20 mEq KCl/L. Which serum laboratory value on this same patient best supports the rationale for this IV prescription change

Sodium 136 mEq/L, potassium 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV prescription decreases the amount of potassium and increases the amount of sodium. For this prescription to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

In which programs should the nurse instruct a patient with Crohn's disease to participate during an exacerbation of the disease?

Stress management Exacerbation of Crohn's disease may be partly related to stress and involves symptoms that are psychologically stressful. For this reason, stress management may be helpful. Aerobic exercise, smoking cessation, and weight reduction are all part a healthy lifestyle that may support reduction of stress;

A nurse assesses a patient with suspected peptic ulcer disease. Which symptom will the patient most likely report?

Symptoms of peptic ulcer disease (PUD) are variable and often absent. However, discomfort, if present, may occur before meals or 2 to 3 hours after meals and at bedtime. The discomfort may be relieved by eating because the food will dilute and buffer gastric acid.

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient?

Synchronized cardioversion Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response).

When assessing the patient for orthostatic hypotension, after taking the blood pressure (BP) and pulse (P) in the supine position, what should the nurse do next?

Take BP and P with patient sitting When assessing for orthostatic changes in BP after measuring BP in the supine position, the patient then is placed in a sitting position and BP is measured within one to two minutes, and then repositioned to the standing position with BP measured again, within one to two minutes. The results then are recorded with a decrease of 20 mm Hg or more in systolic blood pressure (SBP), a decrease of 10 mm Hg or more in diastolic blood pressure (DBP), or an increase in pulse of greater than or equal to 20 beats/minute from supine to standing, indicating orthostatic hypotension.

An older patient relates that he or she has increased fatigue and a headache. The nurse identifies pale skin and glossitis on assessment. In response to these findings, which teaching will be helpful to the patient if he or she has microcytic, hypochromic anemia?

Take the iron with orange juice one hour before meals.

The primary health care provider prescribes warfarin (Coumadin) for a patient with venous thromboembolism. Which information should the nurse include in the patient's discharge teaching plan?

Teaching for a patient prescribed warfarin includes avoiding any trauma or injury that might cause bleeding, such as contact sports. Routine laboratory monitoring is needed to assess the therapeutic effect of the medication and whether a change in drug dose is needed.

A patient comes to the emergency room presenting with dyspnea, tachycardia, violent agitation, tracheal deviation, neck vein distension, and hyperresonance to percussion. Which condition should the nurse suspect?

Tension pneumothorax is the result of increased air in the pleural space and causes shifting of bodily organs and an increase in intrathoracic pressure. The patient usually presents with cyanosis, air hunger, violent agitation, tracheal deviation, neck vein distension, and hyperresonance to percussion. Hemothorax is an accumulation of blood in the pleural space, and the patient usually presents with dyspnea, diminished breath sounds, dullness to percussion, and shock, depending on blood loss. Flail chest is a fracture of two or more ribs, and the patient presents with paradoxical movement of the chest wall and respiratory distress. Cardiac tamponade occurs when blood collects in the pericardial sac, and the patient presents with muffled, distant heart sounds, hypotension, neck vein distension, and increased central venous pressure.

What changes are evident on a cardiac monitor for a patient who had a myocardial infarction (MI)?

The ECG changes are prominent after a myocardial injury. The ST segment is usually elevated and is considered significant if it is placed 1 mm or more above the isoelectric line. However, this should be at least present in two continuous leads. The Q wave is wide and deep and is known as the pathologic Q wave. It is also greater than 0.03 second in duration.

A nurse assessing a patient with pancreatitis suspects the presence of Grey Turner sign when the patient exhibits:

The Grey Turner sign includes a bluish discoloration, or ecchymosis, on the left or right flank area, the result of internal bleeding caused by pancreatitis.

When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication?

Have the patient put pressure on the inner canthus of the eye after administration. Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. Applying pressure to each eyeball, having the patient close the eyes and move them back and forth, and having the patient try to blink out excess medication will not minimize systemic effects of the medication.

The nurse is reviewing the types of hearing loss. The patient who has a sensorineural hearing loss should display which of the following?

Hears sound but does not understand speech. The patient with sensorineural hearing loss has the ability to hear sound but not to understand speech.

A nurse provides education to a group of nursing students related to specific parts of the body that are involved in the process of hemolysis. Which body parts should be included in the teaching?

Hemolysis means the destruction of RBCs. The most common sites of hemolysis in the body are the liver, spleen, and bone marrow.

A nurse is providing care for a patient with hemophilia who has developed bleeding in one of the knee joints. Which self-care strategies will help the patient in rehabilitation?

Hemophilia increases the risk of bleeding in joints. Packing the joint with ice provides comfort and reduces inflammation. Providing rest to the affected joint is important to promote healing and prevent further bleeding. Weight bearing should be avoided until the swelling subsides and muscle strength improves. Aspirin-based medications should be avoided as they increase the risk of bleeding

What is an autosomal recessive, multisystem disease characterized by altered function of the exocrine glands?

CF is an autosomal recessive, multisystem disease characterized by altered function of the exocrine glands. This defect primarily affects the lungs, pancreas and biliary tract, and sweat glands. Sweat glands excrete increased amounts of sodium and chloride.

A patient is given cardiopulmonary resuscitation (CPR) until the defibrillator is ready. Arrange these interventions in the order in which the nurse should perform them.

CPR should be in progress until the defibrillator is available. The defibrillator is turned on and the energy level is set. The synchronizer switch is turned off. Defibrillator gel pads are applied to the chest, one to the right of the sternum just below the clavicle and the other to the left of the apex. The defibrillator is charged, and the paddles are positioned on the chest. The nurse should call and look to see that everyone is "all clear" to ensure that personnel are not touching the patient or the bed at the time of discharge. The charge is delivered by depressing buttons on both paddles simultaneously.

A nurse is caring for a patient with malignant lung cancer who experiences weakness, lethargy, depressed reflexes, and bone pain. The nurse suspects the patient may have hypercalcemia. Which changes in the electrocardiogram indicate hypercalcemia

Hypercalcemia may result from malignancies. Bone destruction due to tumor invasion may cause a release of calcium, leading to high levels of calcium in the blood. This causes altered transmembrane potentials affecting conduction time, and is manifested as a shortened ST segment and QT interval.

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism?

Hypertension promotes atherosclerosis and damage to the walls of the arteries Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

A nurse has been caring for a patient with a high fever and diarrhea for the past five days. Which clinical manifestations suggest extracellular fluid volume deficit?

Hypovolemia or extracellular fluid deficit occurs when there is excess loss of body fluid, as can often occur after prolonged diarrhea. Its clinical manifestations include restlessness, concentrated urine, and dry mucous membranes. Dehydration may make the patient restless. Urine may be concentrated due to low urine output. The mucous membranes get dry because of fluid deficit.

A nurse is caring for a patient who is a chronic smoker who experiences hypoxemia. How does cigarette smoke cause hypoxemia?

Hypoxemia is a decrease in the oxygen content of the blood. Carbon monoxide has a high affinity to hemoglobin. Carbon monoxide does not allow hemoglobin to combine with oxygen, so when it binds to hemoglobin, it reduces the oxygen carrying capacity of the blood and sometimes leads to hypoxemia. The toxic gases in cigarette smoke dilate the distal airways and constrict the bronchus, resulting in air trapping Nicotine increases the myocardial consumption of oxygen, causing myocardial ischemia.

When administering intravenous (IV) potassium chloride (KCl) to a patient to correct hypokalemia, which interventions are important?

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

Chronic stress causes what in patients?

Immunosuppression and the risk for upper respiratory infections ( colds and flu) which is increased in individuals with chronic stress. Stress affects immune function by 1. decreasing the number and function of the natural killer cells. 2. decreasing lymphocyte growth 3. altering production of cytokines 4. decreasing the phagocytosis by neutrophils and monocytes. This is also why patient who are under stress should avoid people with active infections.

A nurse is caring for a patient diagnosed with heart failure who experiences fatigue. What could be the reason for fatigue?

Impaired perfusion to vital organs

A nurse is reviewing a patient's laboratory reports, which show a large number of immature blast white blood cells in the blood. Which condition is likely to be found in the patient?

In acute leukemia, a complete blood count shows a large number of immature blast white blood cells present in the blood.

The nurse is reviewing various food choices for a patient who has been newly diagnosed with celiac disease. Which food choices are appropriate selections for this patient?

Celiac disease is treated with lifelong avoidance of dietary gluten. Salsa and corn chips, yogurt with fresh fruit, and scrambled eggs and sausage would be appropriate choices for the patient with celiac disease. Wheat, barley, oats, and rye products must be avoided.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash on the palms of the hand and soles of the feet, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations?

Cells in the transplanted bone marrow are attacking the host tissue.

Which of the conditions is not a common cause of an upper gastrointestinal (GI) bleed?

Cholecystitis affects the gastrointestinal system but is not associated with an upper GI bleed

A nurse is caring for a patient with a history of chronic stable angina who complains of chest pain. Which factor is true of ischemia related to angina?

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

A patient is diagnosed with a vitamin B12 deficiency. Which symptoms would the nurse find in the patient?

Cobalamin deficiency can affect the production of red blood cells (RBCs). A deficiency of RBCs in the blood circulation can manifest as numbness sensation, impaired muscle movement, and extreme sensitivity in nerves. Lacking physical strength or energy is the sign of low Hgb level (anemia).

A patient has been admitted to a medical unit with signs and symptoms of an intestinal blockage. The nurse should expect a prescription to prepare the patient for which diagnostic procedure?

Colonoscopy is an endoscopic diagnostic procedure that provides visualization of the colon.

While assessing the skin of a patient with anemia, the nurse would look for which manifestations?

Color pale or with a cyanotic tinge In patients with red blood cell (RBC) disorders the skin may be pale or pasty, or it may have a cyanotic tinge in severe anemia. Yellowing of the skin, or jaundice, is caused by an accumulation of bile pigment caused by rapid or excessive hemolysis or liver damage. Flushed skin in the face and neck areas may indicate an increase in hemoglobin (polycythemia) or congestion of the capillaries. Erythrocytosis often produces small vessel occlusions, causing a purple, mottled appearance of the face, nose, fingers, or toes.

The nurse recalls that paroxysmal nocturnal dyspnea is a condition indicative of what more serious problem?

Congestive heart failure A classic symptom of congestive heart failure is paroxysmal nocturnal dyspnea, which awakens the patient after several hours of sleep.

A patient is diagnosed with acute pancreatitis. When providing dietary teaching, what are the points that a nurse should tell the patient?

Consuming a low-fat, high-carbohydrate diet is essential in pancreatitis. Fats should be avoided because they stimulate the secretion of cholecystokinin, which then stimulates the pancreas. Alcohol is an irritant and must be avoided. Carbohydrates are less stimulating to the pancreas and are encouraged. Fluid intake should be increased to prevent dehydration.

During rounds, the nurse notes that a patient who had a total gastrectomy the day before has a very small amount of fluid draining from the nasogastric (NG) tube. What is the nurse's priority action?

Continue to monitor the patient and NG tube drainage After total gastrectomy, the NG tube does not drain a large quantity of secretions because removal of the stomach has eliminated the reservoir capacity. The nurse will only need to continue to monitor the patient and the NG tube drainage

A patient is prescribed lisinopril (Prinivil) for the treatment of hypertension. The patient asks about side effects of this medication. Which side effects should the nurse include?

Cough, dizziness, and hypotension are side effects of angiotensin-converting enzyme (ACE) inhibitors.

What factors affecting a patinets response should the nurse be aware of when planning care for a patient experiencing physiologic or emotional/psychological stressors

Cultural and ethnic influences gave an extrenal effect on how various stressors affect the indivual .

A patient presents to the outpatient clinic with concerns over persistent signs and symptoms of heartburn (pyrosis). What is the most appropriate response for the nurse?

"I know it is uncomfortable for you. Have you been taking your medication as prescribed and making the necessary dietary adjustments?"It is important to ascertain the patient's adherence to prescribed medication and dietary parameters first. Instructing the patient to allow time for the medication to take affect is not addressing the dietary aspect of care.

The nurse has provided teaching to a patient who has diverticular disease but is not experiencing an acute episode at this time. Which statement by the patient reflects an adequate understanding of the teaching?

"I will decrease my intake of fat and red meat." A high-fiber diet, mainly from fruits and vegetables, and decreased intake of fat and red meat are recommended for preventing diverticular disease. High levels of physical activity also seem to decrease the risk. A high-fiber diet also is recommended once diverticular disease is present.

The nurse is providing patient teaching for the patient with venous leg ulcers. Which statement by the patient indicates a need for further education?

"I will put on my stockings after I get out of bed each day." The patient should apply stockings in bed before rising in the morning (not after rising).

The nurse provides discharge instructions to a patient with glaucoma. Which statement by the patient indicates understanding of the teaching?

"I'll check the labels on my nonprescription drugs." Nonprescription drugs, even caffeine, may increase intraocular pressure, resulting in enough pressure to cause damage. Therefore it is important for the patient to check the contents of all drug labels

The postoperative patient states that he or she has never taken pantoprozole (Protonix) in the past. The patient asks why he or she is getting this medication if the patient has never had heartburn. What is the best response by the nurse?

"This will reduce the amount of acid in your stomach until you can eat a regular diet again." Pantoprazole is a proton-pump inhibitor which decreases acid production in the stomach. It minimizes damage to the gastric mucosa while the patient is on bed rest and hospitalized after surgery.

A 65-year-old patient without any past medical problems has his or her blood pressure checked at a primary health care provider's office during an annual physical examination. The blood pressure (BP) reading is 158/92. The patient is asking the nurse who was checking the blood pressure: "Does this mean that I have hypertension?" What is the most appropriate answer from the nurse?

"You need to have a follow-up appointment to recheck your BP. The diagnosis of hypertension is made based on two or more elevated blood pressure readings. Considering the fact that the patient does not have any medical problems and that this reading is the first elevated blood pressure reading, a follow-up office visit is required.

Normal Eosinophil count is

2% to 4% This also indicates allergies

Normal WBC count is

4000--11,000/μL 4-11 × 109 /L Leukopenia is a condition in which the white blood cells count less than 4000/μL.

A patient with AIDS has been put on antiretroviral therapy and has been taking the medications for 4 weeks. During the one-month follow-up visit, what findings will help the nurse identify whether the patient is responding to the treatment

90% drop in viral load - means that the treatment is working.. Remember Viral load drops and CD4 cell count goes up. A CD4 cell count above 14% also indicates good treatment. 3 unit drop in the viral load on a log scale is equivalent to a 99% reduction in viral load which means patient is going good with treatment.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend?

A high fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

Dietary education for the patient with heart failure should include information on:

A low sodium diet is advised for heart failure patients.

Decreased cardiac output The patient's ECG tracing is a paroxysmal supraventricular tachycardia (PSVT). Depending on the rate and duration of PSVT, the patient often experiences symptoms related to decreased cardiac output. The cardiac output drops because of decreased ventricular filling time.

A patient complains of suddenly feeling dizzy. The ECG tracing is the following. A nurse understands the dizziness is most likely a result of:

A patient with a history of peptic ulcer disease has presented to the emergency department reporting severe abdominal pain and has a rigid, board-like abdomen that prompts the health care team to suspect a perforated ulcer. What intervention should the nurse anticipate?

A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube.

While monitoring a patient with premature ventricular contraction (PVC), what types of ECG findings is a nurse is likely to observe?

A premature ventricular contraction (PVC) is a contraction that results from an ectopic focus in the ventricles. In other words, the QRS complex occurs prematurely. The P wave is rarely visible and is usually lost in the QRS complex of the PVC. The PR interval is not measurable, and the rhythm is irregular because of premature beats.

After providing education to a patient with otosclerosis, the nurse determines that the teaching was effective when the patient states that the hearing loss is due to:

A problem with the bones in the middle ear

A patient presents with a sty in the left eye. Which nursing actions are appropriate to manage the patient's condition?

A sty, also called a hordeolum, is caused by a Staphylococcus aureus infection of the sebaceous glands in the lid margin. The infection is manifested as a red, swollen, circumscribed, and acutely tender area. The patient should be instructed to apply warm, moist compresses at least 4 times a day to decrease the swelling and tenderness. Lid scrubs should be performed daily. Infection should be treated with appropriate antibiotic ointments or drops, as prescribed.

A patient's ECG tracing has a short QT interval and a high peaked T wave. Which prescription should the nurse question?

D5W with 20 meq KCL to run at 125 mL/hr A short QT interval and a high peaked T wave are indicative of hyperkalemia. The prudent nurse should question any prescription that could increase the potassium level in the patient. IV insulin with D50W and calcium gluconate are given to force the potassium back into the cells, temporarily correcting the hyperkalemia. Polystyrene sulfonate binds with potassium in the gastrointestinal (GI) tract and excretes it via feces.

A patient with chronic heart failure is administered angiotensin-converting enzyme (ACE) inhibitors. The nurse notes that the patient has developed edema of the face and eyelids. What are appropriate actions that should be included in the immediate plan for treatment?

ACE inhibitors are more likely to cause angioedema, which is an allergic condition leading to edema of face and airways. It is a life-threatening condition. The nurse should immediately discontinue the ACE inhibitors to prevent any further complications. The healthcare provider should be informed to determine the further course of action. The patient may need to be intubated if there is respiratory distress.

A 92-year-old patient has been admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. Which assessment findings are consistent with the patient's clinical picture?

Abdominal distention and high-pitched bowel sounds above the obstruction

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report?

Absence of pain or pressure Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma manifestations include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.

A patient presents with acute upper quadrant pain radiating to the back that the patient rates as a 10 on a 1-to-10 pain scale. The patient says, "I'm nauseated, and I've vomited several times." The diagnosis is cholecystitis with cholelithiasis. Which collaborative nursing diagnosis does the nurse recognize as the highest priority?

Acute Pain related to inflammation and blockage of the biliary tract

For which problem is percutaneous coronary intervention (PCI) most clearly indicated?

Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction

A patient who had a kidney transplant 30 days ago has recorded a low white blood cell (WBC) count. What explanation should the nurse give to the patient for the decreased WBC count

Acute viral infection Antirejection medications Rejection of the transplanted kidney does not cause leukopenia. The possible signs of rejection include decreased urine output, increased serum creatinine, hypertension, and edema. Immunosuppressants such as azathioprine (Imuran) and cyclosporine (Sandimmune) are given to prevent rejection; these drugs may also cause a reduction in WBC count. These drugs reduce immunity and make the patient susceptible for infection. Acute viral infections like cold or influenza can cause leukopenia.

A nurse is caring for a neutropenic patient admitted to the health care facility with a febrile episode. Which priority intervention would the nurse perform first?

Administer a broad spectrum IV antibiotic

The nurse finds that the patient with renal disease is irritable and has an irregular pulse. ECG changes suggest severe hyperkalemia. What should be the first nursing intervention?

Administer intravenous calcium gluconate In case of severe hyperkalemia manifested by irritation, irregular pulse, and changes in ECG findings, the nurse should act immediately to prevent cardiac arrest. The nurse should administer intravenous calcium gluconate to reverse the membrane potential effects of extracellular fluid (ECF) potassium

A nurse finds that a patient has severe diarrhea and may be at risk of fluid volume deficit. After the appropriate prescription by the health care provider, what is the most appropriate nursing intervention to treat fluid deficit in the patient?

Administer lactated Ringer's solution To correct fluid deficit in the patient the nurse would administer lactated Ringer's solution to replace both water and any needed electrolytes. Isotonic normal saline is used when rapid volume replacement is needed.

The nurse is providing care for a patient who has been admitted with alcohol withdrawal delirium. Which intervention should be the first priority for the nurse?

Administering benzodiazepines Benzodiazepines frequently are used to treat the signs and symptoms of alcohol withdrawal delirium and should be administered as soon as possible. You don't need to ask the patient about when the last time they took alcohol because the pateint is already going through the withdraw symptoms.

The patient has a prescription for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack?

Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?

Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priority.

After having a myocardial infarction (MI), the nurse notes the patient has jugular venous distention, weight gain, peripheral edema, and heart rate of 108/minute. What should the nurse suspect is happening?

An MI is a primary cause of heart failure . The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure,

What is nystagmus?

An involuntary jerking of the eyes. Nystagmus is a sign of wernickes encephalopathy that is from chronic alcoholism

he nurse is administering a dose of digoxin (Lanoxin). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom?

Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity.

The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. The nurse should know that which drugs probably will be used for this patient?

Antibiotic(s), proton pump inhibitor, and bismuth

A patient who is a sex worker is complaining of rapid weight loss, oral thrush, nonproductive cough, progressive shortness of breath, fever, night sweats, and fatigue. Her chest x-ray shows interstitial infiltrates, and a blood test reveals that her CD4+ count is 140 cells/μL. She is taking medication for acquired immunodeficiency syndrome (AIDS). What measures can improve the health of this patient?

Antifungal medication Adequate oxygenation Adherence to current medications The most important measure for the patient is to comply with the current drug regimen to prevent further damage by HIV infection. This patient needs adequate oxygenation to prevent further damage by HIV infection. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection of the lungs presented as pneumonia, nonproductive cough, hypoxemia, progressive shortness of breath, fever, night sweats, and fatigue. It is an opportunistic infection. It needs antifungal medication, and, therefore, antibiotics are not required in this case.

When assessing a patient's nutritional-metabolic pattern related to hematologic health, what should the nurse do?

Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes.

On examining a patient suspected of having appendicitis, what characteristics of the ailment is the nurse likely to find?

Appendicitis is usually manifested by muscle guarding, localized tenderness, and rebound tenderness. The patient may have pain over the McBurney's point, which is the area halfway between the umbilicus and the right iliac crest. The patient may prefer to lie still, with the right leg flexed.

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What nursing care is the priority for this patient after this procedure?

Apply a pressure dressing The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure

The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact?

Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.

A patient with a history of epilepsy is admitted to the hospital for treatment of fever and shortness of breath. The patient is diagnosed with pneumonia. On taking history, the nurse finds that the patient had an episode of seizures four days ago with profuse vomiting. What type of pneumonia does the patient have?

Aspiration pneumonia A patient who has seizures is at risk of developing aspiration pneumonia

The nurse is caring for a patient who is 24 hours post-pacemaker insertion. Which nursing intervention is most appropriate at this time?

Assessing the incision for any redness, swelling, or discharge

A patient presents with traumatic hemothorax. What action should the nurse perform immediately?

Assist the health care provider in inserting a chest tube. Hemothorax is an accumulation of blood in the pleural space resulting from injury to the chest wall, lung, blood vessels, diaphragm, or mediastinum. In the case of traumatic hemothorax, the nurse should assist in the immediate insertion of a chest tube, which is required for evacuation of blood. This blood can be recovered and reinfused for a short time after the injury. Further assessment can be done later. Hemothorax needs immediate intervention, and observing for 24 hours is not advisable.

What will caring for a patient with a diagnosis of polycythemia vera likely require the nurse to do?

Assist with or perform phlebotomy at the bedside

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg orally (PO), the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history?

Atenolol is a cardioselective β1 -adrenergic blocker that reduces blood pressure and could affect the β2 -receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.

Atrial Flutter

Atrial rate of 240-400 bpm QRS complexes normal Saw tooth shaped flutter waves

A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient?

Avoid straining during defecation to keep venous pressure low. Straining during a bowel movement increases venous pressure and could cause rupture of the varices.

A patient undergoes gastrectomy. What should the nurse recommend to decrease the symptoms of dumping syndrome?

Avoiding fluids with meals prevents dilution and liquefaction of food and thus slows the movement of food into the jejunum. Postgastrectomy patients are often instructed to eat "dry" meals. Remaining in a high Fowler's position after meals may increase the risk for dumping syndrome. Also To prevent dumping syndrome after gastrectomy, the patient should avoid large meals, instead dividing meals into six small meals to avoid overloading the intestines at mealtimes.

A patient is scheduled for a Schilling test. The nurse explains that the purpose of the test is to measure:

B12 absorption The Schilling test measures B12 absorption. It is usually prescribed as the definitive test for pernicious anemia when other signs of the disease are present.

A patient is diagnosed with bacterial conjunctivitis. The nurse expects what patient symptoms?

Bacterial conjunctivitis manifests as discomfort, pruritus, redness, and a mucopurulent drainage in the eye. It occurs due to unhygienic conditions. The infection is caused by S. aureus. It can be treated with antibiotic drops. Itching, burning, irritation, and photophobia are signs of blepharitis. Tearing, redness, photophobia, and foreign body sensation are symptoms of epidemic keratoconjunctivitis. Red, swollen, circumscribed, and acutely tender areas in the lid margin are the symptoms of hordeolum.

The patient with osteoporosis and hypertension understands dietary teaching when the patient selects which meal for dinner?

Baked salmon with one cup of spinach and steamed carrots

What is the most common sign during an initial assessment that alerts the nurse that the patient has chronic obstructive pulmonary disease?

Barrel chest The patient with chronic obstructive pulmonary disease (COPD) develops a barrel chest over time because trapped air enlarges the lungs and thoracic cavity, thereby reducing chest flexibility.

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every six hours. What should the nurse explain as the best way to prevent oral infection while taking this medication?

Because beclamethosone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection. The mouth should be rinsed after the second puff, not before each puff.

The nurse is admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. The patient is assessed for which anticipated primary acid-base imbalance if the obstruction is high in the intestine?

Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis

The nurse, assessing a patient with hepatitis A, expects which common clinical manifestations?

Because of inflammation, the liver is unable to clear free bilirubin from the blood, resulting in jaundice. However, jaundice may appear at any time during the course of the disease, even as a late sign. Because of insufficient metabolism of toxins by the liver, fatigue and anorexia may be experienced. Diarrhea with clay-colored stools and fever are also associated manifestations of hepatitis. Extremes in blood pressure, constipation, and excessive thirst are not common clinical manifestations of hepatitis.

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient?

Because the patient with COPD needs to use greater energy to breathe, there often is decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day, taking in a high-calorie, high-protein diet, with non-protein calories divided evenly between fat and carbohydrate.

The nurse is caring for a patient who had a laparotomy one day ago and has a nasogastric tube in place. During suctioning of the nasogastric tube, the nurse finds that the nasogastric aspirate has become bright red in color. What action should the nurse take first?

Bright red color in the aspirate indicates ongoing hemorrhage. The surgeon should be notified immediately.

A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs, but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis?

Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized vascular vessels of the upper and lower extremities, leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program.

The nurse is providing care for older adults on a subacute, geriatric medicine unit. What effect is aging likely to have on hematologic function of older adults?

Decreased hemoglobin Older adults frequently experience decreased hemoglobin levels as a result of changes in erythropoiesis. As a result of the aging process, hematological values may change but are considered normal for the older adult. The serum iron level may be decreased.

Presbyopia

Defined as: impaired near vision

A patient is scheduled for surgery to have a permanent ostomy created. What does the nurse remember is the preferred site for the ostomy?

Descending colon The descending colon is the preferred site for a permanent ostomy. Because the colon absorbs water in large quantities, the preferred site is as close to the end of the colon as possible, where stools will be of a more normal consistency

A nurse reviews a patient's medical history and identifies which findings as the most important risk factors for coronary artery disease?

Diabetes, high cholesterol, hypertension, obesity, and smoking

For which clinical manifestation that occurs in both ulcerative colitis and Crohn's disease should the nurse monitor the patient?

Diarrhea

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by the primary health care provider. What should this patient be taught to avoid?

Drugs to treat erectile dysfunction The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death.

A nurse helps a patient move from a lying down position to a standing position. The patient suddenly becomes dizzy. What is the probable reason for the dizziness?

During any change in position, the vasomotor center is activated and stimulates the sympathetic nervous system (SNS) response. The SNS response ensures that cerebral blood flow is maintained by causing peripheral vasoconstriction and by increasing venous return. If the patient feels dizzy when changing positions, it means that the vasomotor center is not being stimulated. If the peripheral arteries constrict and the venous return to the heart is increased, the blood flow to the heart is maintained and may prevent dizziness in the patient.

A nurse examines a patient with cardiovascular problems and assesses for the presence of pitting edema. What is the best location to assess for edema?

Edema is a common and early symptom of cardiovascular conditions. This edema is commonly seen in dependent areas, such as on the feet and the ankle, due to gravity. Edema on the face, wrist, or chest may be due to other, noncardiac conditions.

The nurse is caring for a patient with right-sided heart failure. Which assessment findings should the nurse expect?

Edema, ascites, and anasarca are manifestations of right-sided heart failure caused by fluid retention.

A nurse works in a critical care unit. When attending to a patient, the nurse finds that the patient has developed atrial fibrillation. What should be the treatment for this patient?

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

A nurse has received an alcoholic patient in the emergency room following a motor vehicle accident. How should the nurse determine the patient's concentration of alcohol?

The blood alcohol concentration test is the most reliable way to find out the concentration of alcohol in the body. Blood sugar levels are increased in alcoholics, but sugar level tests do not accurately reveal the concentration of alcohol in the body. Alcohol levels cannot be tested in urine.

The nurse is assessing a patient who has peripheral artery disease (PAD). Which of these assessment findings is considered a classic symptom of lower extremity PAD?

The classic symptom of lower extremity PAD is intermittent claudication, which is ischemic muscle pain that is caused by exercise, resolves within 10 minutes or less with rest, and is reproducible

The patient reports tenderness when the patient touches the leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent what?

The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins and venous thromboembolism may occur.

A nurse is teaching a patient about strategies to prevent angina caused by coronary artery disease. The nurse tells the patient to avoid heavy meals as they can further compromise the blood supply to the heart. What is the most likely reason for the nurse to give such advice?

The digestive system requires more blood supply for a longer period of time to digest heavy meals. Therefore blood is diverted to the gastrointestinal system, which causes reduced blood supply to the myocardium.

The nurse receives a health care provider's prescription to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which procedure is most appropriate for infusing this blood product?

The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in Factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set.

A student is experiencing stress because the student does not feel prepared for an oral examination in the morning. Which hormone is likely having the most significant effect on the student's current physiologic state?

The mediating and controlling effects of cortisol on stress are pronounced.

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report?

The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted

The nurse is aware that the primary symptoms of a sliding hiatus hernia are associated with reflux and should assess the patient for:

The most common symptom of a hiatal hernia is heartburn, also known as pyrosis. It results from reflux of gastric secretions into the esophagus. Regurgitation of gastric contents and dysphagia are other common symptoms.

The health care provider has prescribed intravenous (IV) vancomycin for a patient with pneumonia. Which action should the nurse perform first?

The nurse should ensure that the sputum for culture and sensitivity has been sent to the laboratory before administering the antibiotic. It is important that the organisms be correctly identified (in the culture) before their numbers are affected by the antibiotic; the test also will determine whether the proper antibiotic has been prescribed (sensitivity testing).

A patient has been classified as having stage 2 hypertension on the basis of the blood pressure recorded. The primary goal of therapy for the patient is to normalize the blood pressure. What should be the target blood pressure for this patient?

The nurse's goal is to normalize the blood pressure (BP) of this patient. Therefore, the target blood pressure would be 120/80mmHg, which is the normal BP. Blood pressure of 150/90 is indicative of stage 2 hypertension.

The nurse is interviewing a patient with a duodenal ulcer. Which characteristic of pain is the nurse likely to find?

The pain related to a duodenal ulcer is cramplike and appears 5 to 6 hours after a meal. The pain is located in the midepigastric region beneath the xiphoid process. The pain is relieved by food intake.

A blood type and crossmatch has been prescribed for a male patient who is experiencing an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains what this means?

The patient has A antigens on his red blood cells (RBCs) An individual with type A blood has A antigens, not A antibodies, on his RBCs.

A patient sustains multiple injuries in a motor vehicle accident and is hypovolemic due to hemorrhage. Blood transfusions are given to replace the lost blood. The nurse finds that the patient has now developed laryngeal stridor, dysphagia, and numbness and tingling around the mouth. What could be the reason for these new manifestations?

The patient has developed hypocalcemiaLaryngeal stridor, dysphagia, and numbness and tingling around the mouth after multiple blood transfusions can be attributed to hypocalcaemia. Blood and blood products have citrate in them, which can bind with calcium in the body and make it unavailable. Multiple blood transfusions have thus caused hypocalcemia. This usually manifests as laryngeal stridor, dysphagia, and numbness and tingling around the mouth.

A patient is brought to an emergency department in an unconscious condition. The hemoglobin level of the patient is 20 g/dl. How should the nurse interpret the lab result?

The patient is dehydrated. The hemoglobin level in a normal healthy adult is 11 to 17 g/dl. The hemoglobin level may increase as a result of hemoconcentration as found in dehydration.

The nurse is attending to a patient with second degree atrioventricular (AV) block. The patient is scheduled for pacemaker implantation. What instructions should a nurse give to the patient?

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

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate?

The patient should decrease intake of sodium . This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower blood pressure.

A patient with cirrhosis of the liver has ascites and is being prepared for a paracentesis. What instructions should the nurse give the patient?

The patient should void urine immediately before the paracentesis

Which factor places a conscious patient at risk for pneumonia?

The patient who has difficulty swallowing needs assistance in eating, drinking, and taking medication to prevent aspiration. Difficulty swallowing increases risk of aspiration. Treating postoperative pain effectively provides comfort, permitting the patient to cough and deep breathe and achieve optimum mobility.

Before discharge, the nurse discusses nutrition with the patient with emphysema and pneumonia. The nurse instructs the patient to:

The patient with emphysema should conserve energy to eat and should rest for at least 30 minutes before eating to increase energy needed to eat. The patient should consume five to six small meals per day, avoid hot foods, and exercise after eating to conserve energy.

An elderly patient with a history of bilateral cataracts is admitted to the hospital with pneumonia. What intervention will facilitate the patient's ability to see?

The patient with intact cataracts will see better with the use of increased lighting and magnifiers, including enlarged print.

A patient's complete blood count is RBC 1.8 × 106/μL, WBC 2 × 109/L, platelets 90 × 109/L. How should the nurse interpret the test results?

The patient's complete blood count is suppressed. There is a marked decrease in the number of RBCs, WBCs, and platelets. This condition is called pancytopenia.

A nurse is attending to a patient admitted with sinus bradycardia. What could be the probable causes of bradycardia in the patient?

The possible causes of sinus bradycardia include increased intracranial pressure, hypothermia, and treatment with calcium channel blockers. Increased intracranial pressure may suppress the cardiac centers in the brain, thus reducing the heart rate. Hypothermia may cause reduced venous return, thereby causing bradycardia. Calcium channel blockers cause bradycardia by decreasing automaticity of the SA node, and delaying the AV node conduction.

The nurse is performing a health history and physical examination on a newly admitted patient. Significant information obtained from the physical examination that relates to the hematologic system includes

The presence of petechiae Note any petechiae or ecchymotic areas on the skin and, if present, document the frequency, size, and cause. The location of petechiae can indicate an accumulation of blood in the skin or mucous membranes. Small vessels leak under pressure, and the platelet numbers are insufficient to stop the bleeding. Petechiae are more likely to occur where clothing constricts the circulation.

The nurse is caring for a patient with manifestations of left-sided heart failure. What is the priority nursing intervention?

The priority nursing intervention is auscultation of lung sounds. Excess fluid volume often leads to pulmonary congestion.

The purpose of this exercise is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping.

The purpose of PLB is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn, and it gives the patient more control over breathing, especially during exercise and periods of dyspnea.

The nurse is discussing postoperative care with a patient who had inguinal hernia repair the previous day. Which statement by the patient reflects a need for additional education?

The statement about returning to work at the moving company does not reflect an adequate understanding of instructions. The patient may be restricted from heavy lifting for six to eight weeks. After a hernia repair, encourage deep breathing, but not coughing. Teach patients to splint the incision and keep their mouths open when coughing or sneezing is unavoidable. Scrotal edema is a painful complication and scrotal support with application of an ice bag may help relieve pain and edema.

Symptoms of right-sided heart failure are caused by:

The symptoms of right-sided heart failure are caused by the backup of blood into the venous system.Aka Systemic Venous congestion Pre load is increased in right sided HF and the cardia output is decreased

A patient has had persistent nausea and vomiting for the last 5 days. Which immediate nursing interventions available are appropriate for this patient

The vital signs should be monitored continuously to determine the physiological state of the patient. Patients with persistent vomiting should immediately be put on NPO status (no food or liquid by mouth) and should be given intravenous fluids to prevent dehydration. A nasogastric tube should be placed for aspiration of stomach contents.

A nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD). The lab reports of the patient reveal a hemoglobin level of 20 g/dL. What could be the reason for the increased hemoglobin?

There production of RBC increases in response to hypoxia. In COPD there is constant hypoxia so because of this the body is trying to compensate by making more RBC to increase oxygen levels which leads to polycythemia or increased HgB levels.

What is wernicke's encephalopathy?

This is a neurological disorder caused by thiamine deficiency, typically from chronic alcoholism or persistent vomiting, and marked by mental confusion, abnormal eye movements and unsteady gait. It is preventable and reversible with the administration of IV thiamine and glucose since pts who are alcholics tend to be hypoglycemic.

The nurse is reviewing the genetic testing results of a patient, and sees that the patient has a human leukocyte antigen (HLA) allele that is positive for ankylosing spondylitis. Which of these statements is true about the HLA antigens and disease conditions?

This patient has a higher risk than the general population for developing ankylosing spondylitis..

A patient is diagnosed with thrombocytopenia and a lymph node biopsy has been scheduled. Which primary nursing interventions should be performed after the procedure

Thrombocytopenia refers to a low platelet count which can predispose to bleeding. Therefore, direct pressure should be applied to the biopsy site to ensure hemostasis. The site should be observed for bleeding because the patient has a high risk of bleeding. The vital signs should be monitored for early detection of complications.

The nurse is monitoring a patient for complications of polycythemia vera. Which disorder is the most common cause of mortality in patients with polycythemia vera?

Thrombosis The major cause of morbidity and mortality from polycythemia vera is related to thrombosis (e.g., stroke).

A patient with pneumonia is being treated at home and has reported fatigue to the nurse. What instructions should the nurse include when teaching the patient about care and recovery at home?

To ensure complete recovery after pneumonia, the patient should be advised to rest, avoid alcohol and smoking, and take every dose of the prescribed antibiotic. The patient should not resume work if feeling fatigued and should be encouraged to drink plenty of fluids during the recovery period.

After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care

Treat the causative problem Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC.

Rejection of the transplanted kidney does not cause leukopenia. The possible signs of rejection include decreased urine output, increased serum creatinine, hypertension, and edema. Immunosuppressants such as azathioprine (Imuran) and cyclosporine (Sandimmune) are given to prevent rejection; these drugs may also cause a reduction in WBC count. These drugs reduce immunity and make the patient susceptible for infection. Acute viral infections like cold or influenza can cause leukopenia.

Two organs can be transplanted together. Ex. Kidney and Pancreas, kidney and liver, and kidney and heart. On imminent death of a donor or patient, organs can be donated with the consent of the legal next of kin, and segments of organs can be transplanted instead of the complete organ

What are the transfusion reaction?

Type 1- hypsersensitivity reaction are IgE mediated reactions to specific allergens. ( pollen, food, drugs, or dust.) Type 2- are transfusion reactions in which agglutinations and cytolysis occur. Type 3- are immune-complex reactions that occur secondary to antigen antibody complexes. Type 4- reactions that are delayed cell mediated immune response reactions

A patient with septic shock is receiving multiple medications. Which intravenous (IV) medication is most likely to cause a hearing loss?

Vancomycin (Vancocin) The IV medication in use that is most likely to cause a hearing loss is vancomycin because it is an ototoxic medication. For that reason, serum drug levels are monitored to maintain therapeutic levels and reduce the risk of ototoxicity

For which dysrhythmia is defibrillation primarily indicated?

Ventricular fibrillation Defibrillation always is indicated in the treatment of ventricular fibrillation.

The nurse recognizes which cardiac dysrhythmia as life-threatening and necessitating immediate intervention?

Ventricular fibrillation Ventricular fibrillation is a life-threatening dysrhythmia that requires immediate intervention. During ventricular fibrillation, the ventricles are quivering and are no longer able to contract to produce effective cardiac output. Because there is no cardiac output, the body is left without oxygenation.

Symptoms of an M.I

Vomiting and extreme fatigue Side note Myocardial ischemia is completely reversible

The nurse is assisting a patient who has been admitted with severe abdominal pain. Suddenly, the patient vomits a large amount of emesis that looks similar to coffee grounds. Which action by the nurse is a priority?

Vomitus with a "coffee ground" appearance is related to gastric bleeding, where blood changes to dark brown as a result of its interaction with HCl acid. The primary health care provider needs to be notified immediately about this change in the patient's condition.

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication?

Warfarin is a vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin.

A patient with hepatitis A infection is being discharged from the hospital. What is the most important instruction that the nurse should include in the discharge teaching?

Wash hands carefully after bowel movements

A patient with cirrhosis of the liver is on furosemide. The nurse should monitor the patient for which findings to prevent complications of diuretic therapy? Select all that apply.

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

A patient has lost an eye after an industrial accident. Which action by the nurse is most appropriate during this time?

When the patient has lost visual function or even the entire eye, he or she will grieve the loss. The nurse should help the patient through the grieving process.

A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these?

While you're still lying in bed in the morning, put on your stockings."

When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate?

With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time.

A patient has had esophageal surgery, and a jejunostomy feeding tube is inserted to administer oral fluids. The nurse has been told to check for signs of intolerance and leakage of feeding into the mediastinum. Which signs should the nurse be observant for?

With tube feedings, the patient should be observed for signs of intolerance of feeding or leakage of the feeding into the mediastinum. Symptoms that indicate leakage are pain, dyspnea, and increased temperature. Feeding is done through the tube in an upright position; therefore, the chance of acid reflux is unlikely.

A patient who is experiencing an asthma exacerbation should be placed in

a high Fowlers position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration

Corticosteriods do not

abort an asthma attack

To diagnose a patient with AIDS the patient should have

an opportunistic infection and CD4 count less than 200

Hypersensitivity to a foreign substance can cause an

anaphylactic reaction. When this happens there is a marked increase in capillary permeability and dilation of arterioles. When there is a decreased peripheral resistance there is hypotension and inadequate circulation to major organs , As a result from the bronchial constriction there is respiratory depression and inadequate circulation to major organs

What are emotional stressors?

are emotions that stimulate a stress response and are perceived to be stressful. Ex. Death of a spouse, and caring for a disabled child.

Trousseaus sign

carpal spasm when blood pressure cuff is inflated for a few minutes) is indicative of hypocalcemia.

The goals of drug therapy in HIV infection are to

decrease viral load, maintain or increase CD4 T cell counts, prevent HIV- related symptoms and ooportunistic infections, delay disease progression and prevent HIV transmission

dyspneic

difficulty breathing

Ventricular Fibrillation-

does not have a measurable heart rate, PR interval, or QRS, and the P wave is not visible and the rhythm is irregular and chaotic. The ECG tracing is ventricular fibrillation, a lethal rhythm requiring a team of health care providers to provide interventions. Therefore, the priority is to call for assistance and then lower the head of the bed and start CPR until the defibrillator arrives. Once the defibrillator is available, CPR should be stopped and the patient defibrillated.

Ventricular Tachycardia

has a rate of 150 to 250 beats/minutes, with a regular or irregular rhythm and P waves occurring independently of the QRS complex.

With a patient who just had a kideny transplant the patient should

have lifelong immunosuppresive drugs daily, will be required . All transplantation will be performed only if the crossmatching is NEGATIVE

An elongated ST segment and a prolonged QT interval are manifestations of

hypocalcemia

A flattened or inverted T wave is a manifestation of

hypokalemia.

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST segment depression and T wave inversion. What should the nurse know that this indicates?

indicate myocardial ischemia from an inadequate supply of blood and oxygen to the heart.

Crackles and wheezes are manifestations of

left-sided heart failure because fluid moves from the pulmonary capillary bed into the pulmonary interstitium and alveoli.

Fluid congestion in the lungs is a symptom of

left-sided heart failure.

In systolic heart failure, the ejection fraction is generally

less than 45%. from an inability of the heart to pump blood effectively, caused by impaired contractile function.

Thrombocytopenia is

low platelets platelet counts falls below 100,000/μL.

Polycythemia Vera is

overproduction of RBC

Synchronized cardioversion is the therapy of choice for the

patient with hemodynamically unstable ventricular or supraventricular tachydysrhythmias.

Sinus Tachycardia is represented on a strip as

rate on this strip is above 101, and it displays normal P wave, PR interval, and QRS complex.

The objective of problem-focused coping is to

reduce the stress by resolving the issue and finding a solution.

The primary diagnostic tests for acute pancreatitis are

serum amylase and lipase.

Albuterol is a

short-acting bronchodilator that should be given first when the patient experiences an asthma attack.

If the patient has a blood pressure within 140 to 159/90 to 99 mm Hg range, then the patient has

stage 1 hypertension. This can be controlled by drugs and lifestyle modifications.

Fibromyalgia presents as

stiffness and pain in a particular part of the body.

The patient will start to experience symptoms of ischemia when

the coronary artery is blocked by 75% or more.

The nurse is reviewing discharge instructions with a patient who is taking warfarin (Coumadin) as treatment for venous thromboembolism (VTE). Which substances will the patient need to avoid while taking warfarin?

the patient on oral anticoagulants needs to be taught to avoid taking aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), fish oil supplements, garlic supplements, ginkgo biloba, and certain antibiotics.

The diagnosis of diastolic heart failure is based on

the presence of heart failure symptoms with a normal ejection fraction, which is between 55% and 60%. high filling pressures because of stiff ventricles

Problem-focused coping helps

to view the problem objectively and attempts to resolve it.

Alcohol withdrawal syndrome occurs

when a person is dependent on alcohol stops drinking alcohol abruptly. It usually just occurs 4-6 hours after the last drink. And the withdrawl symptoms usually last up to 14 days. The symptoms of alcohol withdrawl are sweating, nausea, and insomnia.