322L Resource Questions

What is the absolute minimum size syringe for CVAD lines and why?

10 ml or more to avoid excess pressure that can blow the tip off the catheter and cause an embolus

The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/mL. Calculate how many milliliters the nurse should use to prepare the patient's dose. _____ mL

2.5 mL

You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. At what time should the nurse anticipate hanging the next bag of D5W? __________

2000

You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. At what time should the nurse anticipate hanging the next bag of D5W? __________

20:00

The nurse is teaching resident at the retirement village about prevention of UTIs. One person asks how much fluid she should drink each day. The nurse determines that she weighs 140 lb. Calculate how many ounces of fluid this person should drink each day. ________________ oz

56

The physician prescribes regular insulin, 6 units per hour by continuous IV infusion. The pharmacy prepares the medication and then delivers an intravenous bag labeled 50 units of regular insulin in 50ml of normal saline. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver the correct dose?

6 mL/hr

. A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? Go to question 5. A. Drainage that was not present previously B. Redness at the abdominal suture line C. Granulation tissue in the wound bed D. The patient reports less pain

A

A 21-yr-old female patient came to the clinic for instruction to prevent recurrence of urinary tract infections. Which patient statement indicates that teaching was effective? "I will urinate before and after having intercourse." "I will use vinegar as a vaginal douche every week." "I should drink three 8-oz glasses of water daily." "I can stop the antibiotics when symptoms disappear."

A

A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? D5W 0.9% saline Packed red blood cells Lactated Ringer's solution

A

A 45-yr-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? Anxiety Cyanosis Bradycardia Hypercapnia

A

A frail 82-yr-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? Bases of the posterior chest area Apices of the posterior lung fields Anterior chest area above the breasts Midaxillary on the left side of the chest

A

A male patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? Arterial pH 7.26 PaCO2 50 mm Hg Patient in tripod position Increased sputum expectoration

A

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? Go to question 4. A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. B. Use a distraction technique to divert the patient's attention during the procedure. C. Position the patient comfortably before the intervention. D. Thoroughly explain the procedure to the patient.

A

A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication? A. To relieve respiratory distress B. To block histamine receptors C. To reduce circulatory overload D. To combat bacterial infection

A

A patient for whom an intravenous antibiotic is prescribed has a multilumen central line in place for central parenteral nutrition (CPN). What should the nurse do? A. Infuse the antibiotic through another lumen of the multilumen central line. B. Interrupt the CPN infusion only long enough to administer the antibiotic. C. Rearrange the antibiotic administration schedule so it does not interfere with the CPN. D. Ask the prescriber if the route of administration for the antibiotic can be changed.

A

A patient has a blood transfusion reaction, and the transfusion is stopped. What should the nurse do with the remaining blood and transfusion administration set? A. Return both to the blood bank. B. Return the blood to the blood bank, and discard the tubing. C. Discard both the blood and tubing. D. Send the blood and the tubing to the laboratory for analysis.

A

A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to a. candidiasis. b. aspergillosis. c. histoplasmosis. d. coccidioidomycosis.

A

A patient is admitted with metabolic acidosis. Which system is not functioning normally? Renal system Buffer system Endocrine system Respiratory system

A

A patient on anticoagulant therapy needs an IV catheter to be removed. What nursing intervention is most appropriate after the nurse removes the catheter? Apply pressure to the IV site for 5 minutes Leave the IV in place and attach a saline lock for 24 hours Elevate the extremity for 10 minutes Use a warm compress at the site for several minutes

A

A patient requires all of the following interventions. Which one would the nurse perform last? Go to question 3. A. Change the dressing on the patient's newly established suprapubic catheter. B. Administer the patient's prescribed medication. C. Offer the patient a bedpan. D. Position the patient for maximum comfort and ease of breathing.

A

A patient underwent a surgical procedure has a urinary catheter. Eight hours after catheter removal and drinking fluids, the patient has not been able to void. What is the nurse's first action to assess for urinary retention? Bladder scan Cystometrogram Residual urine test Kidneys, ureters, bladder (KUB) x-ray

A

A patient was admitted 2 weeks ago after multiple traumatic injuries in a motor vehicle collision. The patient now has a serum creatinine at 3.9 mg/dL and blood urea nitrogen (BUN) of 100 mg/dL. Which medication, if ordered by the health care provider, should the nurse question? Gentamicin Nitrofurantoin Acetaminophen Morphine sulfate

A

A patient who has bronchiectasis asks the nurse, "What conditions would warrant a call to the clinic?" a. Blood clots in the sputum b. Sticky sputum on a hot day c. Increased shortness of breath after eating a large meal d. Production of large amounts of sputum on a daily basis

A

A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? Have the patient perform a Valsalva procedure Clamp the intravenous (IV) tubing to prevent more air from entering the line Have the patient take a deep breath and hold it Notify the health care provider immediately

A

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? Prevent patient infection. Avoid abnormal bleeding. Give pneumococcal vaccine. Provide companionship while isolated.

A

A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? Cover the chest wound with a nonporous dressing taped on three sides. Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.

A

A patient with a history of recurrent urinary tract infections has been scheduled for a cystoscopy. What teaching point should the nurse emphasize before the procedure? "You might have pink-tinged urine and burning after your cystoscopy." "You'll need to refrain from eating or drinking after midnight the day before the test." "The morning of the test, you will drink some water that contains a contrast solution." "You'll require a urinary catheter inserted before the cystoscopy, and it will be in place for a few days."

A

A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient? Antibiotic Corticosteroid Bronchodilator Cough suppressant

A

A patient with a suprapubic catheter is complaining of pain. What will the nurse do first to help this patient? Go to question 4. A. Ensure that the patient is not lying on the drainage tubing. B. Instruct the patient to increase his or her oral fluid intake. C. Observe the rate of drainage in the urine collection bag. D. Notify the health care provider.

A

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately after the procedure? Monitor the patient for laryngeal edema. Assess the patient's level of consciousness. Monitor and manage the patient's level of pain. Assess the patient's heart rate and blood pressure.

A

A patient with suspected renal insufficiency is scheduled for a creatinine clearance diagnostic test. Which instructions would be appropriate for the nurse to provide to the patient? "Empty your bladder and discard the urine; then save all urine for 24 hours." "Your blood creatinine level will be tested after you eat a high-protein meal." "This test should not be performed if you have allergies to iodine or shellfish." "A sterile container must be used to store the urine during the collection period.

A

A patient with type 2 diabetes is reporting a second urinary tract infections(UTI)within the past month. Which medication should the nurse expect to be ordered for the recurrent infection? Ciprofloxacin Fosfomycin Nitrofurantoin Trimethoprim-sulfamethoxazole

A

A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia. b. monitoring chest tube drainage. c. sending pleural fluid for laboratory analysis. d. monitoring the patient's level of consciousness.

A

After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for nursing assistive personnel (NAP) to position the patient for a sterile dressing change? Back to Top A. Interlocking the fingers and keeping the hands above waist level B. Keeping the arms at the sides, with elbows bent and gloved hands pointing up C. Leaving the room momentarily D. Stepping back from the bedside where NAP are working

A

After oropharyngeal suctioning, what does the nurse do with the supplies? Back to Top A. Place the Yankauer catheter in a clean, dry area. B. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. C. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. D. Place dirty gloves in the biohazard receptacle in the patient's room.

A

After oropharyngeal suctioning, what does the nurse do with the supplies? Go to question 3. A. Place the Yankauer catheter in a clean, dry area. B. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. C. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. D. Place dirty gloves in the biohazard receptacle in the patient's room.

A

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? Reposition every 2 hours. Measure the size of the reddened area. Massage the area to increase blood flow. Evaluate the area later to see if it is better.

A

Although a diagnosis of cystic fibrosis (CF) is most often made before age 2 years, an 18-yr-old patient at the student health center with a history of frequent lung and sinus infections has clinical manifestations consistent with undiagnosed CF. Which information would be accurate for the nurse to include when teaching the patient about a scheduled sweat chloride test? "Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." "The test measures the amount of sodium chloride in your postexercise sweat." "If sweating occurs after an oral dose of pilocarpine, the test result for CP is positive." "If the sweat chloride test result is positive on two occasions, genetic testing will be necessary."

A

An 86 year old woman is admitted to the unit with chills and a fever of 104 degrees F. What physiological process explains why she is at risk for dyspnea? Fever increases metabolic demands requiring increased oxygen need. Blood glucose stores are depleted and the cells do not have energy to use oxygen. Carbon dioxide production increases due to hyperventilation. Carbon dioxide production decreases due to hypoventilation.

A

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? Sudden onset of confusion Oral temperature of 102.3oF Coarse crackles in lung bases Clutching chest on inspiration

A

As needed, the suction-control chamber should be refilled with: Sterile water Nonsterile water Sterile saline solution Nonsterile saline solution

A

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to avoid an error during this procedure? Check the identifying information on the unit of blood against the patient's ID bracelet. Select new primary IV tubing primed with lactated Ringer's solution to use for the transfusion. Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction. Add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow

A

Before setting up a sterile field for a sterile procedure in a patient's room, why would the nurse ask any visitors to please leave the patient's bedside? Go to question 3. A. Ensures that no unnecessary movement occurs that could contaminate the sterile field B. Limits distractions while setting up the sterile field C. Ensures a quiet environment during the procedure D. Provides privacy for the patient

A

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion.

A

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)

A

Eight months after the delivery of her first child, a 31-yr-old woman sought care for occasional incontinence when sneezing or laughing. Which measure should the nurse recommend first? Kegel exercises Use of adult incontinence pads Intermittent self-catheterization Dietary changes including fluid restriction

A

How can the nurse best minimize a patient's risk for infection during tracheostomy care? Go to question 2. A. Adhere to sterile technique when appropriate. B. Frequently assess for signs of local or systemic infection. C. Monitor for indications that tracheostomy care is needed. D. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.

A

How can the nurse best minimize a patient's risk for infection during tracheostomy care? Go to question 4. A. Adhere to sterile technique when appropriate. B. Frequently assess for signs of local or systemic infection. C. Monitor for indications that tracheostomy care is needed. D. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.

A

How can the nurse promote infection control while providing perineal care for a female patient who has a catheter? Go to question 5. A. By avoiding the application of tension on the catheter. B. By patting, not rubbing, the skin dry after thoroughly rinsing it. C. By cleansing the patient's labia from the pubic area toward the rectum. D. By using warm water to cleanse the patient's entire perineal area.

A

How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? Instruct the patient to expect a sharp, quick stick. Insert the access device as quickly as possible. Apply a topical anesthetic to the area before inserting the device. Promise that the procedure will not hurt once the device has been inserted.

A

How will the nurse minimize the risk for infection when changing a patient's IV catheter site dressing? A. Use aseptic technique throughout the process. B. Pull the tape toward the insertion site. C. Remove both the gauze dressing and the tape one layer at a time. D. Explain the process to the patient.

A

In evaluating an asthmatic patient's knowledge of self-care, the nurse recognizes that additional instruction is needed when the patient says, a. "I use my corticosteroid inhaler when I feel short of breath." b. "I get a flu shot every year and see my HCP if I have an upper respiratory tract infection." c. "I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies." d. "I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting short of breath."

A

It is determined that a patient who received a blood transfusion received an infection from the blood. Whom should the nurse notify of this infection? A. Blood bank and infection control department B. State health department C. U.S. Centers for Disease Control and Prevention D. Centers for Medicare and Medicaid or the patient's private insurer

A

The best method for determining the risk of aspiration in a patient with a tracheostomy is to a. consult a speech therapist for swallowing assessment. b. have the patient drink plain water and assess for coughing. c. assess for change of sputum color 48 hours after patient drinks small amount of blue dye. d. suction above the cuff after the patient eats or drinks to determine presence of food in trachea.

A

The emergency department nurse is caring for patients exposed to a chlorine leak from a local factory. The nurse would closely monitor these patients for a. pulmonary edema. b. anaphylactic shock. c. respiratory alkalosis. d. acute tubular necrosis.

A

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate do you program into the infusion pump? 125 mL/hr 167 mL/hr 200 mL/hr 1000 mL/hr

A

The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

A

The nurse calculates that the patient is to receive 125 mL of intravenous (IV) normal saline per hour. After programming the infusion pump to deliver at that rate, how would the nurse ensure accurate fluid administration? A. First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour. B. Ask another nurse to assess the programming of the pump. C. Set the pump alarm to sound when half of the fluid has infused. D. Check the IV site for complications.

A

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? Regurgitant murmur at the mitral valve area Point of maximal impulse palpable in fourth intercostal space Heart rate of 94 beats/min and capillary refill time of 2 seconds Respiratory rate of 18 breaths/min and heart rate of 90 beats/min

A

The nurse consistently observes that the positioning of a confused patient's arm has a direct effect on the flow rate of the intravenous (IV) solution. What might the nurse do to ensure infusion of the patient's IV fluid at a consistent rate? A. Restart the IV in another location less affected by the patient's positioning. B. Include this information in the shift report regarding this patient. C. Assess the flow rate every 1 to 2 hours. D. Instruct the patient to avoid positioning the arm in ways that alter the flow rate.

A

The nurse counsels a 64-yr-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the patient avoid? Venison, crab, and liver Spinach, cabbage, and tea Milk, yogurt, and dried fruit Asparagus, lentils, and chocolate

A

The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action? Raise the head of the bed to 60 degrees or higher. Get his oxygen saturation with a pulse oximeter. Take his blood pressure and respiratory rate. Notify the health care provider of his shortness of breath.

A

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)? Go to question 4. A. Measure and empty the urine. B. Palpate the abdomen. C. Ask the patient if she has any pain. D. Document the procedure.

A

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? Work of breathing Fear of suffocation Effects of medications Anxiety and restlessness

A

The nurse is caring for a patient after a right kidney biopsy. Which position would be the most appropriate for this patient immediately after the procedure? Right lateral side-lying position Reverse Trendelenburg position Supine with lower extremities elevated High Fowler's position with arms supported

A

The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in reexpanding the affected lung? Go to question 2. A. Placing the patient in a right side-lying position B. Encouraging the patient to deep breathe and cough every hour C. Regularly assessing the patient's ability to breathe comfortably D. Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale

A

The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? Wheezing becomes louder. Cough remains nonproductive. Vesicular breath sounds decrease. Aerosol bronchodilators stimulate coughing.

A

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? Suction her mouth and throat Turn her on their side Put on oxygen at 2-L nasal cannula Stop feeding her and place on NPO

A

The nurse is concerned that a confused patient's erratic movements may compromise the intravenous (IV) insertion site. Which action can the nurse take to protect the patient and the site from injury? A. Apply an IV site-protection device over the site, such as House UltraDressing. B. Apply restraints to the patient. C. Check the patient frequently. D. Instruct the patient to avoid dislodging the IV catheter.

A

The nurse is getting ready to administer an IV push medication. What is the most important action for the nurse to take before administering the med? Assess the condition of the IV insertion site. Stop the maintenance of IV fluids. Dilute the medication to decrease irritation. Ensure that the correct-size filter needle is applied to the syringe.

A

The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings. What is the correct order of steps to perform this procedure? 1. Place patient in high-Fowler's position. 2. Have patient flex head toward chest. 3. Assess patient's gag reflex. 4. Determine length of the tube to be inserted. 5. Obtain radiological confirmation of tube placement. 6. Check pH of gastric aspirate for verifying placement. 7. Identify patient with two identifiers. 7, 1, 3, 4, 2, 5, 6 1, 3, 4, 7, 2, 6, 5 7, 1, 3, 2, 4, 6, 5 1, 7, 3, 2, 4, 5, 6

A

The nurse is obtaining a focused respiratory assessment of a 44-yr-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? Auscultation of bilateral breath sounds Percussion of anterior and posterior chest wall Palpation of the chest bilaterally for tactile fremitus Inspection for anterior and posterior chest expansion

A

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min

A

The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care? Back to Top A. Supine B. Prone C. Side-lying D. Dorsal recumbent

A

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? Hypersensitivity to eggs Age older than 80 years History of upper respiratory infections Chronic obstructive pulmonary disease (COPD)

A

The nurse is teaching a community group about preventing rheumatic fever. What information should the nurse include? Prompt recognition and treatment of streptococcal pharyngitis Avoidance of respiratory infections in children born with heart defects Completion of 4 to 6 weeks of antibiotic therapy for infective endocarditis Requesting antibiotics before dental surgery for individuals with rheumatoid arthritis

A

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should a. continue to monitor the patient. b. check all connections for a leak in the system. c. lower the drainage collector further from the chest. d. clamp the tubing at progressively distal points away from the patient until the tidaling stops.

A

The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? Provide a light blanket. Encourage a hot shower. Monitor temperature every hour. Turn up the thermostat in the patient's room.

A

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? Test the drainage for the presence of glucose. Suction the nose to maintain airway clearance. Document the findings and continue monitoring. Apply a drip pad and reassure the patient this is normal.

A

The nurse observes erythema at the insertion site of a patient's IV infusion device. When asked, the patient denies pain at the site. Using the phlebitis scale, what score does the nurse give the injury? A. 1 B. 2 C. 3 D. 4

A

The nurse receives a physician's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product? Infuse the fresh frozen plasma as rapidly as the patient will tolerate. Hang the fresh frozen plasma as a piggyback to the primary IV solution. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. Hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.

A

The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.

A

The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? Albuterol Ipratropium bromide Salmeterol (Serevent) Beclomethasone (Qvar)

A

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 Thrombocytopenia Megaloblastic anemia Myelodysplastic syndrome

A

The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? Artifact Anemia Dark skin color Thick acrylic nails

A

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? Elevated D-dimers Elevated fibrinogen Reduced prothrombin time (PT) Reduced fibrin degradation products (FDPs)

A

The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? Restlessness, tachypnea, tachycardia, and diaphoresis Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis Combativeness, retractions with breathing, cyanosis, and decreased output Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

A

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? "Close lips tightly around the mouthpiece and breathe in deeply and quickly." "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

A

The provider has ordered that a patient be 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion? A. Calculate the hourly volume of normal saline the patient should receive. B. Determine the drop factor of the tubing that will be used for the infusion. C. Calculate the drops per minute at which the tubing will be regulated. D. Determine the drops per mL that the tubing will deliver.

A

The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute? A. 25 drops/minute B. 30 drops/minute C. 35 drops/minute D. 40 drops/minute

A

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

A

Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? Record the amount and continue to monitor drainage. Notify the physician. Strip the chest tube starting at the chest Increase the suction by 10 mm Hg

A

What assessment do you make before hanging an intravenous (IV) fluid that contains potassium? Urine output Arterial blood gases Fullness of neck veins Level of consciousness

A

What best describes measurement of post-void residual (PVR)? Bladder scan the patient immediately after voiding. Catheterize the patient 30 minutes after voiding. Bladder scan the patient when they report a strong urge to void. Catheterize the patient with a 16 Fr/10 mL catheter

A

What is the correct order for discontinuing intravenous (IV) access? 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure. 6, 4, 2, 1, 5, 3, 7 4, 6, 2, 1, 5, 3, 7 6, 4, 2, 5, 3, 1, 7 6, 2, 4, 1, 3, 7, 5

A

What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound

A

What is the initial infusion rate for a 20% fat emulsion? A. 1 mL/min B. 2 mL/min C. 5 mL/min D. 10 mL/min

A

What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? A. Injecting the medication at the prescribed rate B. Observing the insertion site after giving the medication C. Instructing the patient about side effects to report to the nurse D. Using an alcohol swab to wipe the insertion port on the primary tubing

A

What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials.

A

What is the nurse's priority when changing the appliance for a patient with an ileal conduit? Keep the skin free of urine. Inspect the peristomal area. Cleanse and dry the area gently. Affix the appliance to the faceplate.

A

What is the removal of devitalized tissue from a wound called? Debridement Pressure reduction Negative pressure wound therapy Sanitization

A

What might the nurse do to improve a patient's cooperation during the removal of an IV access device? A. Describe the entire procedure to the patient. B. Assure the patient that you will remove the IV catheter quickly. C. Assure the patient that the procedure will take only about 5 minutes. D. Tell the patient that the procedure will cause only a slight burning sensation.

A

What might the nurse do to minimize the risk for injury in a patient receiving IV therapy? A. Regulate the flow rate of the infusion. B. Assess the patient frequently for pain at the IV site. C. Monitor the IV site frequently for signs of infiltration and phlebitis. D. Educate the patient regarding symptoms of infiltration and phlebitis.

A

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? Fingernails Chest excursion Spinal curvatures Respiratory pattern

A

What would the nurse do if a sterile solution splashed onto a sterile field and contaminated the field during a dressing change? Go to question 4. A. Collect new supplies, and prepare another sterile field. B. Complete the dressing change in a timely manner. C. Move the lip of the bottle closer to the receptacle when pouring the remaining liquid. D. Reposition the receptacle closer to the edge of the sterile field.

A

When adding a sterile liquid to a sterile field, which action will contaminate the field? Go to question 2. A. Extending your arm over the sterile field to pour the liquid into the receptacle B. Holding the bottle with the label facing the palm C. Adding a liquid with a usable period that expires in 2 days D. Placing the receptacle 1 inch (about 2.5 cm) from the edge of the sterile field.

A

When are sterile nonlatex gloves recommended for a sterile procedure? Go to question 4. A. When there is a possible sensitivity issue B. When the staff member prefers them C. When latex gloves are not conveniently available D. When the patient prefers them

A

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? Administer oxygen Notify the health care provider Rapidly administer more IV fluid Reposition the patient on the right side

A

When caring for a patient with acute bronchitis, the nurse will prioritize a. auscultating lung sounds. b. encouraging fluid restriction. c. administering antibiotic therapy. d. teaching the patient to avoid cough suppressants.

A

When initially teaching a patient the supraglottic swallow after a radical neck dissection, with which food or fluid should the nurse begin? Cola Applesauce French fries White grape juice

A

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? Increasing dyspnea Temperature below 98.6°F Decreased sputum production Unable to drink 3 L of low-sodium fluids 33.

A

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient? Go to question 3. A. Reposition the patient at least every 2 hours. B. Assess the patient's bony prominences every shift. C. Educate the family about the importance of healthy skin. D. Assist the patient in the selection of high-protein foods.

A

Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? Go to question 5. A. Comparing presuctioning and postsuctioning respiratory assessment data B. Confirming that the patient's pulse oximetry value is >90% C. Asking the patient to report any symptoms of dyspnea D. Assessing the patient's skin for signs of cyanosis

A

Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? Back to Top A. Attach the tubing to the patient's gown with a safety pin. B. Tape the tubing to the patient's bed. C. Attach the tubing to the nearest side rail. D. Loop the tubing through the bed frame.

A

Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? A. Keep the hub parallel to the skin. B. Cleanse the site with an antibacterial swab. C. Cut the dressing to facilitate its removal. D. Turn the IV tubing roller clamp to the "off" position.

A

Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? Go to question 4. A. The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. B. A registered nurse, not NAP, must remove the catheter. C. Catheter removal must be executed within 10 minutes of beginning the procedure. D. Catheter removal must take place within 5 days of catheter insertion.

A

Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? Anchor the vein by placing a thumb 1 to 2 inches below the site. Insert the device tip at a 45-degree angle distal to the proposed site. Place the patient's left arm in a dependent position for 5 minutes before assessment. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.

A

Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? Go to question 5. A. Increase the irrigation drip rate. B. Notify the patient's health care provider of the blood and clots in the urine. C. Encourage the patient to increase fluid intake. D. Apply ice to the patient's lower abdominal area

A

Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours.

A

Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? Go to question 3. A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter C. Performing proper hand hygiene and applying gloves before inserting the catheter D. Terminating the insertion if the patient reports pain at any time during the procedure

A

Which measure may be taken to minimize the staff's risk for infection from a urine specimen? Go to question 5. A. Firmly securing the lid of the urine specimen container B. Using a sterile urine specimen container C. Using a sterile syringe to access the sampling port D. Placing the urine specimen container in the refrigerator until the laboratory comes to get it

A

Which nursing diagnosis is priority when caring for a patient with renal calculi? Acute pain Risk for constipation Deficient fluid volume Risk for powerlessness

A

Which patient is most at risk for the development of a pressure ulcer? An older patient who is septic, bedridden, and incontinent An obese woman with leukemia who is receiving chemotherapy A middle-aged thin man in a halo cast after a motor vehicle accident An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis

A

Which patient safety issue is specific to administration of medication by IV bolus? A. Determining that the medication is compatible with the IV solution B. Checking for patient allergies before giving the medication C. Identifying the patient using two identifiers D. Checking the medication against the medication administration record (MAR) three times

A

Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? 3.1 mEq/L 3.9 mEq/L 4.6 mEq/L 5.3 mEq/L

A

Which statement about the parietal and visceral pleurae is correct? A potential space exists between the two. A small space separates the two. The visceral pleura covers the chest wall and diaphragm. The parietal pleura covers the inside of both lungs. The parietal pleura covers the inside of both lungs.

A

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? Go to question 2. A. "Please direct the light to better illuminate the patient's perineal area." B. "You need to be comfortable inserting a catheter in a patient of her size." C. "See if a size 14-French catheter is big enough." D. "Find out if the patient has any allergies to latex or iodine."

A

While admitting a patient with pericarditis, the nurse will assess for what manifestations of this disorder? Pulsus paradoxus Prolonged PR intervals Widened pulse pressure Clubbing of the fingers

A

While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do? Go to question 2. A. Nothing B. Create a new sterile field C. Use sterile forceps to move the gauze pad toward the center of the sterile field D. Dispose of the gauze before continuing the procedure

A

While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do? Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. Use the flow meter each morning after taking medications to evaluate their effectiveness. Increase the doses of the long-term control medication if the peak flow numbers decrease. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

A

While the nurse is giving an IV infusion of a piggyback medication, the patient's IV site becomes cool, pale, and swollen. The nurse should take which action? Stop the current infusion and change to another site. Slow down the rate of the infusion. Flush the IV line with normal saline. Retape the IV catheter to decrease the pressure.

A

Why might the nurse offer the patient a bedpan before establishing a sterile field? Go to question 5. A. Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement. B. A patient's becoming incontinent constitutes a breach in sterile technique. C. Refocusing the patient's attention on a task decreases anxiety. D. Assessing the patient's ability to follow instructions will help the nurse maintain the sterile field.

A

You assess four patients. Which patient has greatest risk for hypomagnesemia? A 72-year-old with chronic alcoholism A 79-year-old with bone cancer A 41-year-old with hypernatremia A 46-year-old with respiratory acidosis

A

An older woman was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem are (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. decreased central venous pressure.

A, B , E

A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) The organism is usually transmitted through the fecal-oral route. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. Everyone coming into the room must be wearing a gown and gloves. While the patient is in contact precautions, he cannot leave the room. C. difficile dies quickly once outside the body

A, B, C

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) Teaching correct handwashing to assigned patients Using correct procedures in starting and caring for an intravenous infusion Providing perineal care to a patient with an indwelling urinary catheter Isolating a patient who has just been diagnosed as having tuberculosis Decreasing a patient's environmental stimuli to decrease nausea

A, B, C

When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations (select all that apply.)? Osler's nodes Janeway's lesions Splinter hemorrhages Subcutaneous nodules Erythema marginatum lesions

A, B, C

Which patients are most at risk for developing infective endocarditis (select all that apply.)? Older woman with disseminated coccidioidomycosis Homeless man with history of intravenous drug abuse Patient with end-stage renal disease on peritoneal dialysis Man with complaints of chest pain and shortness of breath Adolescent with exertional palpitations and clubbing of fingers Female with peripheral intravenous site for medication administration

A, B, C

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) Infiltration at vascular access device (VAD) site Patient lying on tubing Roller clamp wide open Tubing kinked in bedrails Circulatory overload

A, B, D

In addition to urine function, the nurse recognizes that the kidneys perform numerous other functions important to the maintenance of homeostasis. Which physiologic processes are performed by the kidneys (select all that apply.)? Production of renin Activation of vitamin D Carbohydrate metabolism Erythropoietin production Hemolysis of old red blood cells (RBCs)

A, B, D

The nurse is caring for a patient who exhibits labored breathing, using accessory muscles, and is coughing up pink frothy sputum. The patient has bilateral lung bases and diminished breath sounds. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.) SpO2 levels Amount, color and consistency of sputum production Fluid status Change in respiratory rate and pattern Pain in lower leg

A, B, D

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? A temperature of 101.4°F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days

A, B, D

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) Proper cleaning requires mechanical removal of all soil from an object or area. General environmental cleaning is an example of medical asepsis. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. Cleaning in a direction from the least to the most contaminated area helps reduce infections. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

A, B, D

When planning health care teaching to prevent or detect early head and neck cancer, which people would be the priority to target (select all that apply)? a. 65-year-old man who has used chewing tobacco most of his life b. 45-year-old rancher who uses snuff to stay awake while driving his herds of cattle c. 21-year-old college student who drinks beer on weekends with his fraternity brothers d. 78-year-old woman who has been drinking hard liquor since her husband died 15 years ago e. 22-year-old woman who has been diagnosed with human papilloma virus (HPV) of the cervix

A, B, D, E

Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chicken pox/herpes zoster? (Select all that apply.) Disposable gown N 95 respirator mask Face shield or goggles Surgical mask Gloves

A, B, E

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply.)? Asbestos exposure Exposure to uranium Chronic interstitial fibrosis History of cigarette smoking Geographic area in which he was born

A, B,D

For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply)? a. Patient with seizures b. Patient with head injury c. Patient who had thoracic surgery d. Patient who had a myocardial infarction e. Patient who is receiving nasogastric tube feeding

A, B,E

. A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.) It allows migration of organisms into the bladder. The insertion procedure is not done under sterile conditions. It obstructs the normal flushing action of urine flow. It keeps an incontinent patient's skin dry. The outer surface of the catheter is not considered sterile.

A, C

The patient had myocarditis and is now experiencing fatigue, weakness, palpitations, and dyspnea at rest. The nurse assesses pulmonary crackles, edema, and weak peripheral pulses. Sinoatrial tachycardia is evident on the cardiac monitor. The Doppler echocardiography shows dilated cardiomyopathy. What collaborative and nursing care of this patient should be done to improve cardiac output and the quality of life (select all that apply.)? Decrease preload and afterload. Relieve left ventricular outflow obstruction. Control heart failure by enhancing myocardial contractility. Improve diastolic filling and the underlying disease process. Improve ventricular filling by reducing ventricular contractility.

A, C

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) To relieve edema To reduce shivering To improve blood flow to an injured part To protect bony prominences from pressure ulcers To immobilize area

A, C

A dehydrated patient is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions (select all that apply.)? Lung sounds Bowel sounds Blood pressure Serum sodium level Serum potassium level

A, C, D

The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? (Select all that apply.) The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. The fat emulsion will help control hyperglycemia during periods of stress. The parenteral nutrition will help your wounds heal. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours.

A, C, D

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) Avoid grapefruit and grapefruit juice, which impair drug absorption. Increase the amount of carbohydrates for energy. Take a multivitamin that includes vitamin D for bone health. Cheese and eggs are good sources of protein. Limit fluids to decrease the risk of edema.

A, C, D

What should the nurse teach a young woman with a history of urinary tract infections about UTI prevention? (Select all that apply.) Keep the bowels regular. Limit water intake to 1-2 glasses a day Wear cotton underwear Cleanse the perineum from front to back. Practice pelvic muscle exercise (Kegel) daily.

A, C, D

Your patient has severe hypercalcemia. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

A, C, D

A patient is concerned that he may have asthma. Of the symptoms that he relates to the nurse, which ones suggest asthma or risk factors for asthma (select all that apply)? a. Allergic rhinitis b. Prolonged inhalation c. History of skin allergies d. Cough, especially at night e. Gastric reflux or heartburn

A, C, D, E

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? Obesity Pneumonia Malignancy Cigarette smoking Prolonged air travel

A, C, D, E

Which treatments in CF would the nurse expect to implement in the management plan of patients with CF (select all that apply)? a. Sperm banking b. IV corticosteroids on a chronic basis c. Airway clearance techniques (e.g., Acapella) d. GoLYTELY given PRN for severe constipation e. Inhaled tobramycin to combat Pseudomonas infection

A, C, D, E

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? Maintain adequate fluid intake. Maintain a 30-degree elevation. Splint the chest when coughing. Maintain a semi-Fowler's position. Instruct patient to cough at end of exhalation.

A, C, E

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient (select all that apply.)? Do you awaken abruptly during the night? Do you sleep more than 8 hours per night? Do you need to sleep with the head elevated? Do you often need to urinate during the night? Do you toss and turn when trying to fall asleep?

A, C, E

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) Use a transfer device, e.g. transfer board Have head of bed elevated when transferring patient Have head of bed flat when re positioning patients Raise head of bed 60 degrees when patient positioned supine Raise head of bed 30 degrees when patient positioned supine

A, C, E

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented prior to the test? (Select all that apply.) Ask the patient about any allergies and reactions. Instruct the patient that a full bladder is required for the test. Instruct the patient to save all urine in a special container. Ensure that informed consent has been obtained. Explain that the test includes instrumentation of the urinary tract.

A, D

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) Notify the surgeon Allow the area to be exposed to air until all drainage has stopped Place several cold packs over the area, protecting the skin around the wound Cover the area with sterile, saline-soaked towels and immediately. Cover the area with sterile gauze and apply an abdominal binder

A, D

Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

A, D

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). Sharp pleuritic pain that worsens on inspiration Crackles over lung bases of affected lung Tracheal deviation toward the affected lung Worsening dyspnea Absent lung sounds to auscultation on affected side

A, D, E

It is important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)? a. Confusion b. Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chvostek's sign

A, D, E

You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply.)? The potassium level may be increased if the patient has nephropathy. The patient has been eating excessive amounts of foods that increase potassium levels. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A, D, E

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about (select all that apply.)? Strict hand washing Daily nasal swabs for culture Monitor temperature every hour. Daily skin care and oral hygiene Encourage eating all foods to increase nutrients. Private room with a high-efficiency particulate air (HEPA) filter

A, D, F

Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) Frequent position changes. Keeping the buttocks exposed to air at all times Using a large absorbent diaper, changing when saturated Using an incontinence cleaner Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel Applying a moisture barrier ointment

A, D, F

A plan of care for the patient with COPD could include (select all that apply) a. exercise such as walking. b. high flow rate of O2 administration. c. low-dose chronic oral corticosteroid therapy. d. use of peak flow meter to monitor the progression of COPD. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

A, E

The urinalysis of a patient reveals a high microorganism count. What data should the nurse use to determine which part of the urinary tract is infected (select all that apply.)? Pain location Fever and chills Mental confusion Urinary hesitancy Urethral discharge Postvoid dribbling

A, E

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)? Weakness Paresthesia Facial spasms Muscle tremors Depressed reflexes

A, E

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply.)? Exercise Allergies Emotional stress Decreased humidity Upper respiratory infections

A,,B,C, E

. A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply.)? Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic. Drink noncaffeinated fluids daily. Obtain antibiotic therapy promptly.

A,B, C

Your patient has severe hypercalcemia. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

A,C, D

A 22-yr-old patient's blood pressure during a pre-employment physical examination was 110/68 mm Hg. During a health fair 2 months later, the blood pressure is 154/96 mm Hg. What renal problem could contribute to this rise in blood pressure? Renal trauma Renal artery stenosis Renal vein thrombosis Benign nephrosclerosis

B

A nurse is admitting a patient with advanced renal carcinoma. Which clinical manifestations represent the "classic triad" observed in patients with renal cancer? Fever, chills, and flank pain Hematuria, flank pain, and palpable mass Hematuria, proteinuria, and palpable mass Flank pain, palpable abdominal mass, and proteinuria

B

A nurse notes blanching, coolness, and edema at a client's peripheral intravenous site. Which nursing action is most appropriate? Check for a blood return. Discontinue the intravenous line. Apply a warm compress. Measure the area of infiltration.

B

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? Serous Purulent Fibrinous Catarrhal

B

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? Level of consciousness Quality of breath sounds Presence of the gag reflex Tracheostomy cuff pressure

B

A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient? Plan for 30 minutes of rest before and after every meal. Encourage foods high in protein, iron, vitamin C, and folate. Instruct the patient to select soft, bland, and nonacidic foods. Give the patient a list of medications that inhibit iron absorption.

B

A patient has been diagnosed with acute myelogenous leukemia (AML). What should the nurse educate the patient that care will focus on? Leukapheresis Attaining remission One chemotherapy agent Waiting with active supportive care

B

A patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? Brentuximab vedotin (Adcetris) Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone

B

A patient has sought care because of recent difficulties in establishing and maintaining a urine stream as well as pain that occasionally accompanies urination. How should the nurse document this abnormal assessment finding? Anuria Dysuria Oliguria Enuresis

B

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though her color is ruddy not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon Monoxide does which of the following: Stimulates hyperventilation causing respiratory alkalosis Forms a strong bond with hemoglobin thus preventing oxygen binding in the lungs Stimulates hypoventilation causing respiratory acidosis Causes alveoli to overinflate leading to atelectasis

B

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? Pain level Intake and output Oxygen saturation Level of consciousness

B

A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? Institute isolation precautions Clean the central line port through which the TPN is infusing with alcohol Change the TPN tubing every 24 hours Monitor glucose levels to watch and assess for glucose intolerance

B

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? Warm, moist heat and massage Rest, ice, compression, and elevation Antipyretic and antibiotic drug therapy Active movement and exercise to prevent stiffness

B

A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of a blood transfusion? A. 1 mL/min B. 2 mL/min C. 10 mL/min D. 25 mL/min

B

A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first? Go to question 5. A. Supply a urine hat. B. Explain to the patient why I&O has been ordered. C. Assess the patient's ability to self-monitor and record I&O. D. Provide the patient's family with instructions.

B

A patient receiving a unit of blood begins to show signs of a transfusion reaction. How frequently should the nurse monitor the patient's vital signs after stopping the transfusion? A. Every 5 minutes B. Every 15 minutes C. Every 30 minutes D. Every hour

B

A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? 0.9% sodium chloride 25% albumin solution Lactated Ringer's solution 5% dextrose in 0.45% saline

B

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? Start IV fluids. Maintain oxygenation. Maintain distal warmth. Check peripheral pulses.

B

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? Suction the tracheostomy opening. Maintain the airway with a sterile hemostat. Use an Ambu bag and mask to ventilate the patient. Insert the tracheostomy tube obturator into the stoma.

B

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in the left knee joint. What should be the emergency nurse's immediate action? Immediate transfusion of platelets Resting the patient's knee to prevent hemarthroses Assistance with intracapsular injection of corticosteroids Range-of-motion exercises to prevent thrombus formation

B

A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? Oxygen tent Venturi mask Nasal cannula Oxygen-conserving cannula

B

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? Confirm the IV solution is 0.9% saline. Obtain the vital signs before the transfusion is initiated. Monitor the patient for shortness of breath and back pain. Double check the patient identity and verify the blood product.

B

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? Administer aspirin on a scheduled basis around the clock. Provide acetaminophen every 4 hours to maintain consistent blood levels. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. Provide drug interventions if complementary and alternative therapies have failed.

B

A patient's IV site has developed phlebitis scored as a 4 on the phlebitis scale. What would the nurse do to help treat the site? A. Apply a cool compress. B. Apply a warm compress. C. Apply a pressure dressing. D. Apply an elastic compression wrap.

B

A post-operative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? Increase the rate of the CBI Assess the intake and output Decrease the rate of the CBI Assess vital signs

B

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? Apple Custard Popsicle Potato chips

B

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM

B

After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? Bronchospasm Pneumothorax Pulmonary edema Respiratory acidosis

B

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? Recommend she be evaluated for an OAB medication. Start a scheduled toileting program. Recommend she be evaluated for an indwelling catheter. Start a bladder retraining program

B

An left-handed patient who had a right mastectomy several years ago has good veins in her right hand. Where should the nurse place the IV catheter? Right hand Left lower arm The patient's preferred location Right antecubital site

B

As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? Back to Top A. Complete the catheter insertion in 5 seconds or less. B. Remove the catheter. C. Encourage the patient to take several deep breaths to minimize the nausea. D. Stop advancing the catheter, and allow the patient to rest for several minutes.

B

As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? Go to question 4. A. Complete the catheter insertion in 5 seconds or less. B. Remove the catheter. C. Encourage the patient to take several deep breaths to minimize the nausea. D. Stop advancing the catheter, and allow the patient to rest for several minutes.

B

As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority? Go to question 3. A. Provide all the necessary supplies and linen for this task. B. Assess the patient's ability to perform proper perineal care. C. Ensure that the patient has privacy while performing perineal care. D. Document any complaints of irritation or pain in the perineal area.

B

Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? 5 15 30 60

B

Crepitus on palpation of the skin surrounding the chest tube may indicate: Deep-tissue emphysema Subcutaneous emphysema. Excessive drainage. Inadequate drainage.

B

During normal breathing, exhalation: Decreases intrapleural pressure. Increases intrapleural pressure. Causes intrapulmonary pressure to decrease compared to atmospheric pressure. Causes the parietal pleura to recoil outward along with the chest wall.

B

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? Binder Ice bag Elastic bandage Absorptive dressing

B

How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles.

B

How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? Back to Top A. Asking the patient about symptoms of respiratory difficulty. B. Comparing respiratory assessment data from before and after the suctioning procedure. C. Confirming that the patient's pulse oximetry value is >90%. D. Auscultating the patient's chest after suctioning.

B

How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? Go to question 5. A. Asking the patient about symptoms of respiratory difficulty. B. Comparing respiratory assessment data from before and after the suctioning procedure. C. Confirming that the patient's pulse oximetry value is >90%. D. Auscultating the patient's chest after suctioning.

B

The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? Implement the "as needed" order to irrigate the catheter. Assess the catheter and drainage tubing for obvious occlusion. Notify the health care provider immediately. Assess the vital signs and intake and output record.

B

The blood bank notifies the nurse that the two units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? Immediately pick up both units of blood from the blood bank. Infuse the blood slowly for the first 15 minutes of the transfusion. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

B

The effects of cigarette smoking on the respiratory system include a. hypertrophy of capillaries causing hemoptysis. b. hyperplasia of goblet cells and increased production of mucus. c. increased proliferation of cilia and decreased clearance of mucus. d. proliferation of alveolar macrophages to decrease the risk for infection.

B

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs? Hypertension and pulmonary edema Oropharyngeal candidiasis and hoarseness Elevation of blood glucose and calcium levels Adrenocortical dysfunction and hyperglycemia

B

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? "I will pay less for medication because it will last longer." "More of the medication will get down into my lungs to help my breathing." "Now I will not need to breathe in as deeply when taking the inhaler medications." "This device will make it so much easier and faster to take my inhaled medications."

B

The nurse expects the long-term treatment of a patient with hyperphosphatemia secondary to renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.

B

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? "Are you allergic to chicken?" "Could you be pregnant now?" "Did you ever have influenza?" "Have you ever had hepatitis B?"

B

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."

B

The nurse is caring for a 62-yr-old woman taking tolterodine (Detrol) to treat urinary urgency and incontinence. Which instruction should be included in the discharge plan? "Stop smoking for 2 to 3 weeks before starting to take this medication." "Suck on sugarless candy or chew sugarless gum if you develop a dry mouth." "Have your vision checked every 6 months because this drug can cause cataracts." "Ask your physician to prescribe an extended-release form if you have loose stools."

B

The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is malted milk. orange juice. tomato juice. hot chocolate.

B

The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of pain. atelectasis. pneumonia. pleural effusion.

B

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? Antibiotics Frequent change of position Oxygen humidification Chest physiotherapy

B

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? Administration of packed red blood cells Administration of oral or IV corticosteroids Administration of clotting factors VIII and IX Maintenance of reverse isolation and application of standard precautions

B

The nurse is caring for a patient with a nephrostomy tube. The tube has stopped draining. After receiving orders, what should the nurse do? Keep the patient on bed rest. Use 5 mL of sterile saline to irrigate. Use 30 mL of water to gently irrigate. Have the patient turn from side to side.

B

The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate? Encourage deep breathing and coughing. Assist with or perform phlebotomy at the bedside. Teach the patient how to maintain a low-activity lifestyle. Perform thorough and regularly scheduled neurologic assessments.

B

The nurse is concerned that a patient's central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication? A. Check for blood return. B. Palpate the skin for coiling. C. Listen for gurgling sounds. D. Assess for pain at the site.

B

The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care? Go to question 4. A. Wear sterile gloves. B. Wear clean gloves. C. Wear an isolation gown. D. Use hot water.

B

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? Cough reflex Mucociliary clearance Reflex bronchoconstriction Ability to filter particles from the air

B

The nurse is performing an assessment for a patient and preparing to palpate the kidneys. How should the nurse position the patient for this assessment? Prone Supine Seated at the edge of the bed Standing, facing away from the nurse

B

The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? A. 0.45% normal saline B. 0.9% normal saline C. Dextrose 5% and 0.45% normal saline D. Dextrose 5% and 0.9% normal saline

B

The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure? Go to question 2. A. Administer a prophylactic antibiotic before the procedure, as prescribed. B. Follow sterile technique during the procedure. C. Ensure proper hand hygiene before the procedure. D. Educate the patient in order to minimize movement and talking during the procedure

B

The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? "Avoid shaking the inhaler before use." "Breathe out slowly before positioning the inhaler." "Using a spacer should be avoided for this type of medication." "After taking a puff, hold the breath for 30 seconds before exhaling." 29.

B

The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? 11:45 AM 12:00 noon 12:30 PM 3:30 PM

B

The nurse provides discharge instructions for a 40-yr-old woman newly diagnosed with cardiomyopathy. Which statement indicates that further teaching is necessary? "I will avoid lifting heavy objects." "I can drink alcohol in moderation." "My family will need to take a CPR course." "I will reduce stress by learning guided imagery.

B

The nurse provides nutritional counseling for a 45-yr-old man with nephrotic syndrome. The nurse determines teaching has been successful if the patient selects which breakfast menu? Scrambled eggs, milk, yogurt, and sliced ham Oatmeal, nondairy creamer, banana, and orange juice Cottage cheese, peanut butter, white bread, and coffee Waffle, bacon strips, tomato juice, and canned peaches

B

The nurse receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will a. call the health care provider to question the order. b. administer both vaccines at the same time in different arms. c. administer the flu shot and tell the patient to come back 1 week later to receive the pneumococcal vaccine. d. administer the pneumococcal vaccine and suggest FluMist (nasal vaccine) instead of the influenza injection.

B

The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? Fastening tube to the gown with new tape Placing patient supine while giving a bath Hanging a new container of enteral feeding Ambulating patient with enteral feedings still infusing

B

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? Apical pulse Daily weight Bowel sounds Deep tendon reflexes

B

The patient had a history of rheumatic fever and has been diagnosed with mitral valve stenosis. The patient is planning to have a biologic valve replacement. What protective mechanisms should the nurse teach the patient about using after the valve replacement? Long-term anticoagulation therapy Antibiotic prophylaxis for dental care Exercise plan to increase cardiac tolerance Take β-adrenergic blockers to control palpitations

B

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? Local response Systemic response Infectious response Acute inflammatory response

B

There is no urine when a catheter is inserted into a female's urethra. What should the nurse do next? Remove the catheter and start all over with a new kit and catheter. Leave the catheter there and start over with a new catheter. Pull the catheter back and re-insert at a different angle. Ask the patient to bear down and insert the catheter further.

B

What direction would the nurse provide to nursing assistive personnel (NAP) assisting with a sterile procedure in which sterile solutions are being used? Go to question 3. A. "Hand me that cup of water so I can pour it over my sterile field." B. "Would you please get me another bottle of sterile water?" C. "Pour the sterile water into the container at the edge of the field." D. "Open the sterile water bottle, and hold the label so that I can see it."

B

What does the Braden Scale evaluate? Skin integrity at bony prominences, including any wounds Risk factors that place the patient at risk for skin breakdown The amount of repositioning that the patient can tolerate The factors that place the patient at risk for poor healing

B

What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? Back to Top A. Complete the suctioning process in 20 seconds or less. B. Keep the oxygen mask near the patient's face during the suctioning procedure. C. Encourage the patient to take several deep breaths before suctioning begins. D. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

B

What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? Go to question 4. A. Complete the suctioning process in 20 seconds or less. B. Keep the oxygen mask near the patient's face during the suctioning procedure. C. Encourage the patient to take several deep breaths before suctioning begins. D. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

B

What is the best reason for a nurse to select a prepackaged sterile kit for a sterile procedure? Go to question 4. A. Sterile prepackaged kits do not have expiration dates. B. The wrapper of the sterile kit can be used as a sterile field. C. Adding supplies to the sterile field takes less time than using a prepackaged kit. D. The prepackaged sterile kit will take up less space on the bedside table.

B

What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? A. Remove the tubing from the primary line Y-site port, and cap the end. B. Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. C. Place an unopened secondary setup at the bedside, and discard the used one. D. Change both the primary and secondary tubing upon terminating the piggyback infusion

B

What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback? A. Use a site into which a primary solution is already infusing. B. Assess the IV site before initiating the IV piggyback medication. C. Select a relatively small vein to infuse the IV medication. D. Instruct NAP to notify you immediately if the insertion site appears swollen.

B

What is the most important nursing intervention to ensure the patient's safety when initiating infusion of an analgesic by mini-infusion pump? A. Checking the flow rate of the primary infusion B. Staying with the patient during the first few minutes of the infusion C. Explaining the purpose of the medication to the patient D. Documenting the patient's expected response to the analgesic

B

What nursing intervention decreases the risk for catheter associated urinary tract infection (CAUTI)? Cleanse the urinary meatus 3-4 times daily with antiseptic solution. Hang the urinary drainage bag below the level with the bladder. Empty the urinary drainage bag daily. Irrigate the urinary catheter with sterile water.

B

What would the nurse do first to ease breathing for a patient with mild dyspnea? Go to question 4. A. Administer oxygen at 2 L/min by nasal cannula. B. Help the patient into an upright sitting position. C. Monitor the patient's pulse oximetry level. D. Determine if the patient has a history of respiratory pathology.

B

What would the nurse do first to ease breathing for a patient with mild dyspnea? Go to question 5. A. Administer oxygen at 2 L/min by nasal cannula. B. Help the patient into an upright sitting position. C. Monitor the patient's pulse oximetry level. D. Determine if the patient has a history of respiratory pathology.

B

What would the nurse do first when preparing to begin oxygen therapy for a patient? Go to question 2. A. Educate the NAP about the oxygen orders. B. Review the medical prescription for delivery method and flow rate. C. Place a "No Smoking" sign outside of the hospital room. D. Ensure that suction equipment is present in the room.

B

What would the nurse do first when preparing to begin oxygen therapy for a patient? Go to question 4. A. Educate the NAP about the oxygen orders. B. Review the medical prescription for delivery method and flow rate. C. Place a "No Smoking" sign outside of the hospital room. D. Ensure that suction equipment is present in the room.

B

What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP? Back to Top A. Assess the patient's level of consciousness every 4 hours. B. Monitor the patient's pulse oximetry readings. C. Verify the pressure settings for both inspiratory and expiratory pressure. D. Evaluate daily arterial blood gases (ABGs)

B

What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP? Go to question 5. A. Assess the patient's level of consciousness every 4 hours. B. Monitor the patient's pulse oximetry readings. C. Verify the pressure settings for both inspiratory and expiratory pressure. D. Evaluate daily arterial blood gases (ABGs)

B

What would the nurse do to assess a patient's risk for embolus when removing a venous access device? A. Inspect the site for redness. B. Visualize the tip of the IV device. C. Palpate the site for possible edema. D. Ask the patient to rate any pain at the site.

B

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly? A. Use an infusion pump to regulate the flow rate of the piggyback medication. B. Hang the piggyback medication higher than the primary fluid. C. Attach the piggyback medication to the most proximal insertion port on the primary tubing. D. Use a secondary infusion set for the piggyback tubing.

B

When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site? A. Occlusion alarm sounds on infusion pump B. Patient's oral temperature gradually increases C. Patient's neck veins become distended D. The nurse cannot achieve blood return

B

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? Patient comfort Airway patency Incisional drainage Blood pressure and heart rate

B

When caring for a patient with a lung abscess, what is the nurse's priority intervention? a. Postural drainage b. Antibiotic administration c. Obtaining a sputum specimen d. Patient teaching regarding home care

B

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? Order fruits and fruit juices to be offered between meals. Order a high-calorie, high-protein diet with six small meals a day. Teach the patient to use frozen meals at home that can be microwaved. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

B

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing? Thirst Fatigue Headache Abdominal pain

B

When evaluating a post-thoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to: A. Strip the chest tube every hour to maintain drainage. B. Place the device below the patient's chest. C. Double clamp the tube except during assessment. D. Remove the tubing from the drainage device to check for proper suctioning.

B

When irrigating a wound, how would the nurse know the right amount of pressure to apply? Go to question 3. A. Calculate the wound size. B. Follow the general rule of keeping the pressure between 4 and 15 psi. C. Keep the pressure strong enough to cause moderate pain. D. Gentle enough that is does not create a splash off of the wound.

B

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest. b. using sequential compression devices. c. encouraging the patient to cough and deep breathe. d. teaching the patient how to use the incentive spirometer.

B

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? An overproduction of the antiprotease a1-antitrypsin Hyperinflation of alveoli and destruction of alveolar walls Hypertrophy and hyperplasia of goblet cells in the bronchi Collapse and hypoventilation of the terminal respiratory unit

B

When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? Go to question 2. A. Urinary incontinence B. Urinary tract infection (UTI) C. Adequate oral hydration D. Kidney stones

B

When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of sterile water through the catheter? Go to question 2. A. To moisten the exterior of the plastic catheter B. To ensure that the catheter's suction is functioning properly C. To minimize friction as the catheter moves within the oral cavity D. To avoid startling the patient with the sound created by the suction

B

Which action by the nurse would reduce his or her exposure to bloodborne pathogens while administering fluids to a patient by mini-infusion pump? A. Cleaning the injection port with an antiseptic swab B. Applying clean gloves C. Recapping the end of the mini-infusion tubing after use D. Performing hand hygiene prior to administration

B

Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? Go to question 2. A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment (PPE). C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, timely way.

B

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? Go to question 4. A. Placing the specimen in a biohazard bag B. Having someone take the specimen to the lab immediately C. Cleaning the outside surface of the container D. Ensuring that a stock of sterile urine collection kits is available

B

Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? Go to question 5. A. Pinning the tubing to the patient's hospital gown B. Compressing the bulb while replacing the port cap C. Emptying the drainage container only when it is 90% full D. Placing the drainage container below the wound site

B

Which action would the nurse perform when preparing to suction a patient's oropharynx? Go to question 2. A. Apply sterile gloves. B. Place the patient in a semi-Fowler's or sitting position. C. Remove the nasal cannula. D. Flush the suction catheter with 200 mL of warm tap water.

B

Which action would the nurse perform when preparing to suction a patient's oropharynx? Go to question 4. A. Apply sterile gloves. B. Place the patient in a semi-Fowler's or sitting position. C. Remove the nasal cannula. D. Flush the suction catheter with 200 mL of warm tap water.

B

Which action would the nurse take if an intravenous (IV) insertion site appeared red, warm, and swollen? A. Assess for blood return. B. Discontinue the infusion. C. Change the existing dressing. D. Secure the tubing with more tape.

B

Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? Go to question 3. A. Change the tubing every 8 hours. B. Use slow, even pressure when injecting the irrigating fluid. C. Adhere to aseptic technique during the irrigation process. D. Monitor the patient's temperature every 4 hours.

B

Which device is used for wound irrigation? Go to question 2. A. 19-gauge needle attached to a 10-mL syringe B. 19-gauge needle attached to a 35-mL syringe C. Sterile container held 30.5 cm (12 inches) above the wound D. Foley irrigating syringe

B

Which direction to nursing assistive personnel (NAP) would help to maintain a sterile field while conducting a sterile procedure? Go to question 5. A. "Please see to it that nothing contaminates this sterile field while I get some additional supplies." B. "I'd like you to make sure that the patient doesn't reach toward the sterile field while I'm changing the dressing." C. "Hand me the item closest to the edge of the sterile field." D. "Place a sterile drape over these supplies for a moment while I answer my other patient's call light."

B

Which instruction might the nurse give to nursing assistive personnel (NAP) caring for a patient receiving a fat emulsion? A. "Check the patient's IV site for any signs of phlebitis." B. "I will need to know the patient's vital signs every 4 hours." C. "Slow down the IV rate if the patient complains of pain at the insertion site." D. "Be sure the patient understands the reason that the infusion has been ordered."

B

Which instruction reflects the nurse's correct understanding of the role of nursing assistive personnel (NAP) in caring for a patient receiving an intravenous (IV) antibiotic medication by piggyback? A. "Assess the IV site frequently for signs of infiltration." B. "Let me know immediately if the patient complains of pain at the IV site." C. "Notify the physician that the patient is allergic to the medication prescribed." D. "Remember to hang the piggyback medication higher than the primary solution."

B

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound? Back to Top A. Assessing the site for signs of redness or swelling B. Reporting the presence of wound odor C. Removing a soiled outer dressing D. Opening sterile dressings during the dressing change

B

Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? Go to question 3. A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B. Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning

B

Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? Go to question 5. A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B. Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning

B

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? Keep the pressure ulcer clean and dry. Maintain protein intake of at least 1.25 g/kg/day. Use a 10-mL syringe to irrigate the pressure ulcer. Irrigate the pressure ulcer with hydrogen peroxide.

B

Which is not an expected outcome on a first voiding after catheter removal? Go to question 5. A. Mild burning B. Fever and back pain C. Producing only a small amount of urine D. Discomfort

B

Which measurements would the nurse use to calculate the surface area of a patient's pressure injury? Go to question 2. A. Height and weight B. Length and width C. Length and depth D. Width and depth

B

Which nursing action is most important to ensure patient safety when infusing a fat emulsion? A. Perform hand hygiene before initiating any contact with the lipid solution. B. Assess the patient every 10 minutes for 30 minutes after starting the infusion. C. Change the infusion tubing with each administration. D. Perform frequent inspection of the patient's access site.

B

Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? Go to question 2. A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing

B

Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? Go to question 5. A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing`

B

Which nursing action will best ensure the safety of a patient who is about to receive an infusion of parenteral nutrition? A. Assess the patient's blood glucose level by fingerstick. B. Verify the physician's order for central parenteral nutrition (CPN) and the flow rate. C. Confirm that the CPN infusion pump's alarm system is functioning properly. D. Instruct the patient concerning the purpose for administering the CPN solution.

B

Which nursing intervention is most appropriate in providing care for an adult patient with newly diagnosed adult onset polycystic kidney disease (PKD)? Help the patient cope with the rapid progression of the disease. Suggest genetic counseling resources for the children of the patient. Expect the patient to have polyuria and poor concentration ability of the kidneys. Implement appropriate measures for the patient's deafness and blindness in addition to the renal problems.

B

Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? Go to question 4. A. The collection bag has been placed on the side rail of the bed. B. The excess catheter tubing has been coiled beside the patient's inner thigh. C. The collection bag has been placed on the bed. D. The collection bag is held above the level of the bladder while ambulating the patient.

B

Which of the following is the correct order for insertion of an indwelling catheter in a female patient? 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus. 5. Drape the patient with the sterile square and fenestrated drapes. 6. When urine appears advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing. 7, 5, 2, 1, 4, 6, 3, 8, 9 5, 7, 2, 4, 1, 6, 3, 8, 9 5, 7, 1, 2, 4, 6, 3, 9, 8 5, 7, 2, 1, 4, 3, 6, 8, 9

B

Which patient do you plan to teach regarding water restriction? A 23-year-old with extracellular fluid volume (ECV) deficit A 34-year-old with hyponatremia A 47-year-old with hypercalcemia A 69-year-old with metabolic acidosis

B

Which patient is most likely to experience anemia related to an increased destruction of red blood cells? A 59-yr-old man whose alcoholism has precipitated folic acid deficiency A 23-yr-old African American man who has a diagnosis of sickle cell disease A 30-yr-old woman with a history of "heavy periods" accompanied by anemia A 3-yr-old child whose impaired growth and development is attributable to thalassemia

B

Which practice protects the nurse from infection when changing the dressing on an infected pressure injury? Back to Top A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment. C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, efficient manner.

B

Which statement might a nurse make to nursing assistive personnel (NAP) when caring for a patient prescribed an intravenous (IV) bolus of analgesic medication? A. "Assess the IV site frequently for signs of inflammation." B. "Let me know immediately if the patient complains of pain at the insertion site." C. "Make sure the patient knows what results to expect from the medication." D. "Observe the IV site for sudden swelling when the IV bolus is administered."

B

Which statement might the nurse make to nursing assistive personnel (NAP) assigned to care for a patient with an established suprapubic catheter? Go to question 3. A. "Tell me if the catheter site looks inflamed." B. "I need to know the patient's temperature each time it's taken." C. "Wear sterile treatment gloves when you remove the dressing." D. "Let me know if the patient's catheter is infected."

B

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? Back to Top A. "Teach the patient the signs of a urinary tract infection." B. "Tell me when and how much the patient first voids." C. "Explain that voiding might be uncomfortable for 4 to 5 days." D. "Assess the patient for a distended bladder before the end of the shift."

B

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? Assessing the need for suctioning Suctioning the patient's oropharynx Assessing the patient's swallowing ability Maintaining appropriate cuff inflation pressure

B

Which task might the nurse delegate to nursing assistive personnel (NAP) caring for a patient receiving IV medication via mini-infusion pump? A. Assessing the IV site frequently for signs of infiltration B. Notifying the nurse if the pump alarm sounds C. Informing the physician that the patient is allergic to the prescribed medication D. Ensuring that the medications being delivered intravenously are compatible

B

Which technique would the nurse use to change a patient's tracheostomy ties? Back to Top A. Use a slipknot. B. Ensure that two fingers fit snugly under the tie. C. Knot the ends of the tie in the eyelets on the faceplate. D. Ask the patient to hold his or her breath while the ties are changed.

B

Which test result identifies that a patient with asthma is responding to treatment? An increase in CO2 levels A decreased exhaled nitric oxide A decrease in white blood cell count An increase in serum bicarbonate levels

B

Which wound would be allowed to heal by secondary intention? Go to question 4. A. Cleft lip repair B. Infected hysterectomy incision C. Exploratory laparoscopy incision D. Facial laceration caused by a pocket knife

B

While opening a prepackaged sterile kit, a package of sterile 4 × 4-in gauze pads falls to the floor. What will the nurse ask ancillary staff to do to ensure the integrity of the sterile field Back to Top A. "I will have to set up another sterile field; please take these items away." B. "Please go to the clean utility room and get me a package of sterile 4 × 4-in gauze pads." C. "Please watch that nothing contaminates this sterile field while I go and get a replacement item." D. "Please explain to the patient the importance of remaining still during this procedure so no other items will be contaminated."

B

While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? Back to Top A. Remove the catheter, and rinse it thoroughly in sterile water for reuse. B. Keep the catheter in place, and begin again with a new sterile catheter. C. Remove the catheter, relubricate it, and insert it into the urinary meatus. D. Stop advancing the catheter, and notify the health care provider.

B

While performing catheter care, the nurse moves her hand, allowing the patient's labia to close around the catheter. Why would the nurse repeat this part of the care? Go to question 4. A. The catheter may have traumatized the labia. B. The labia have contaminated the area. C. The patient's perineal area must be reassessed for infection. D. The nurse must ensure that the catheter is not pulling on the bladder.

B

While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient's gown. Which action is most appropriate in this situation? Back to Top A. Place the sterile supplies only on the portion of the drape that did not touch the gown. B. Collect the supplies necessary and establish a new sterile field. C. Determine if the contact occurred within the outer 1-inch perimeter of the drape. D. Establish the sterile field on the opposite side of the drape.

B

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

B

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? Fully compensated respiratory alkalosis Partially compensated respiratory acidosis Normal acid-base balance with hypoxemia Normal acid-base balance with hypercapnia

B

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider? Antibiotics Loop diuretics Bronchodilators Antihypertensives

B

he nurse is caring for a 55-yr-old man who has a catheter in the right radial artery for invasive arterial blood pressure monitoring after abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? Arterial pressure bag is inflated to 250 mm Hg. Calculated mean arterial pressure is 74 mm Hg. Patient's head of bed elevation is at 30 degrees. Capillary refill time in the right hand is 5 seconds.

B

he nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? 2 minutes 5 minutes 10 minutes 15 minutes

B

he nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? Place it in water to see if it floats. Keep track of the number of inhalations used. Shake the canister while holding it next to the ear. Check the indicator line on the side of the canister.

B

he nurse teaches a 53-yr-old male patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement by the patient to the nurse indicates correct understanding of the instructions? "I should not use a spacer device with this inhaler." "I will rinse my mouth each time after I use this inhaler." "I will feel my breathing improve over the next 2 to 3 days." "I should use this inhaler immediately if I have trouble breathing."

B

hen preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of sterile water through the catheter? Go to question 3. A. To moisten the exterior of the plastic catheter B. To ensure that the catheter's suction is functioning properly C. To minimize friction as the catheter moves within the oral cavity D. To avoid startling the patient with the sound created by the suction

B

The nurse would delegate which of the following to nursing assistive personnel (NAP)? (Select all that apply.) Repositioning and retaping a patient's nasogastric tube Performing glucose monitoring every 6 hours on a patient Documenting PO intake on a patient who is on a calorie count for 72 hours Administering enteral feeding bolus after tube placement has been verified Hanging a new bag of enteral feeding

B, C

Which nursing interventions should the nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) Attach a 3 mL syringe to the inflation port Allow the balloon to drain into the syringe by gravity. Initiate a voiding record/bladder diary Pull catheter quickly Clamp the catheter prior to removal.

B, C

Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.) Set up sterile field before patient and other staff come to the operating suite. Keep the sterile field in view at all times. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. Only health care personnel within the sterile field must wear personal protective equipment. The sterile gown must be put on before the surgical scrub is performed.

B, C

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: (Select all that apply.) Heart disease. Sepsis. Pleural effusion. Cardiac arrhythmias. Diarrhea.

B, C, D

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)? Have patient restrict fluid intake to less than 2000 mL/day. Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake to 3000 to 4000 mL. Any heartburn can be managed with an as needed calcium-containing antacid.

B, C, D

Which statement(s) describe(s) the management of a patient following lung transplantation (select all that apply)? a. High doses of O2 are administered around the clock. b. The use of a home spirometer will help to monitor lung function. c. Immunosuppressant therapy usually involves a three-drug regimen. d. Most patients experience an acute rejection episode in the first 2 days. e. The lung is biopsied using a transtracheal method if rejection is suspected.

B, C, E

In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply.)? Cyanosis Tripod position Kussmaul respirations Accessory muscle use Increased AP diameter

B, D

What does it mean when a patient is diagnosed with a multidrug-resistant organism in his or her surgical wound? (Select all that apply.) There is more than one organism in the wound that is causing the infection. The antibiotics the patient has received are not strong enough to kill the organism. The patient will need more than one type of antibiotic to kill the organism. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. There are no longer any antibiotic options available to treat the patient's infection.

B, D

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) Collection of wound drainage Provides support to abdominal tissues when coughing or walking Reduction of abdominal swelling Reduction of stress on the abdominal incision Stimulation of peristalsis (return of bowel function) from direct pressure

B, D

Which of the following skills can be delegated to nursing assistive personnel (NAP)? (Select all that apply.) Nasotracheal suctioning Oropharyngeal suctioning of a stable patient Suctioning a new artificial airway Permanent tracheostomy tube suctioning Care of an endotracheal tube (ETT)

B, D

Which patients are at high risk for nutritional deficits? (Select all that apply.) The divorced computer programmer who eats precooked food from the local restaurant The middle-age female with celiac disease who does not follow her gluten-free diet The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal

B, D

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply.)? Tilt patient's head backwards. Apply ice compresses to the nose. Tilt head forward while lying down. Pinch the entire soft lower portion of the nose. Partially insert a small gauze pad into the bleeding nostril.

B, D, E

When should a nurse wear a mask? (Select all that apply). The patient's dental hygiene is poor. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. The patient is in droplet precautions. The nurse is assisting a health care provider in the insertion of a central line catheter.

B, D, E

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include (select all that apply) a. encouraging regular exercise such as swimming. b. washing around the stoma daily with a moist washcloth. c. encouraging participation in postlaryngectomy support group. d. providing pictures and "hands-on" instruction for tracheostomy care. e. teaching how to hold breath and trying to gag to promote swallowing reflex.

B, c, D

. The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with "good lung" down Performing postural drainage every 4 hours

C

A 25-yr-old patient with a group A streptococcal pharyngitis does not want to take the antibiotics prescribed. What should the nurse tell the patient to encourage the patient to take the medications and avoid complications of the infection? "The complications of this infection will affect the skin, hair, and balance." "You will not feel well if you do not take the medicine and get over this infection." "Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." "You may not want to take the antibiotics for this infection, but you will be sorry if you do not."

C

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? Limit foods high in potassium Calcium gluconate IV piggyback Spironolactone (Aldactone) daily Administer intravenous insulin and glucose

C

A 67-yr-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? "Bibasilar wheezes present on inspiration." "Diminished breath sounds in the bases of both lungs." "Fine crackles posterior right and left lower lung fields." "Expiratory wheezing scattered throughout the lung fields."

C

A 68-yr-old patient with bronchiectasis has copious thick respiratory secretions. Which intervention should the nurse add to the plan of care for this patient? Use the incentive spirometer for at least 10 breaths every 2 hours. Administer prescribed antibiotics and antitussives on a scheduled basis. Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. Provide nutritional supplements that are high in protein and carbohydrates.

C

A 72-yr-old man with a history of aortic stenosis is admitted to the emergency department. He reports severe left-sided chest pressure radiating to the jaw. Which medication, if ordered by the health care provider, should the nurse question? Aspirin Oxygen Nitroglycerin Morphine sulfate

C

A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? Go to question 4. A. Reassure the patient that the procedure will take only a few minutes. B. Promise to reposition the patient as soon as the catheter has been inserted. C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. D. Explain to the patient that the position will allow the catheter insertion to be more efficient.

C

A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first? Back to Top A. Notify the health care provider. B. Apply pressure over the site. C. Cover the site with a sterile dressing. D. Help the patient into a side-lying position.

C

A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) admitted for pneumonia. What laboratory finding would be consistent with decreased kidney function in this patient? Serum uric acid of 5.2 mg/dL Urine specific gravity of 1.040 Serum creatinine 2.3 of mg/dL Blood urea nitrogen (BUN) of 10 mg/dL

C

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? Increased platelet count Increased blood urea nitrogen Increased number of band neutrophils Increased number of segmented myelocytes

C

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? Frequent examination of the character and quantity of exudate Monitoring for signs and symptoms of local or systemic infections Assessment of the patient's circulation distal to the location of the dressing Assessment of the range of motion of the ankle and the patient's activity tolerance

C

A patient has scleroderma and hypertension. The nurse knows this could be related to which renal diagnoses? Obstructive uropathy Goodpasture syndrome Chronic glomerulonephritis Calcium oxalate urinary calculi

C

A patient informs the nurse that they are having burning on urination, dysuria, and frequency. What is the best response by the nurse? "Drink less fluid so you don't have to void so often." "Take some acetaminophen to decrease the discomfort." "Come in so we can check a clean-catch urine specimen." "Avoid caffeine and spicy food to decrease inflammation."

C

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3-, 24. You interpret these laboratory values to indicate: Metabolic acidosis. Metabolic alkalosis. Respiratory acidosis. Respiratory alkalosis.

C

A patient is admitted to your unit for dehydration. Which of the following assessments would the nurse identify as a possible sign of fluid imbalance? Go to question 2. A. Heart rate at 80 beats per minute B. Capillary refill of less than 2 seconds C. Reduced turgor of the skin D. B/P of 118/78 mmHg

C

A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? Lobectomy surgery is usually needed to drain the abscess. IV antibiotic therapy will be used for a 6-month period of time. Oral antibiotics will be used until there is evidence of improvement. Culture and sensitivity tests are needed for 1 year after resolving the abscess

C

A patient is prescribed 1000 mL of intravenous (IV) normal saline to run over 8 hours. The initial fluid is hung at 0800. How many milliliters of fluid will have infused by 1200? A. 125 mL B. 250 mL C. 500 mL D. 625 mL

C

A patient is to receive 3 units of packed red blood cells over 8 hours. What will the nurse do to maintain the patency of the patient's IV access line after each of the first two units of blood has transfused? A. Infuse 0.9% normal saline at 100 mL/hour. B. Infuse dextrose 5% and 0.9% normal saline at the KVO (keep-vein-open) rate. C. Infuse 0.9% normal saline at the KVO rate. D. Cap the intravenous line.

C

A patient received two 300-mL units of packed red blood cells, and the line was flushed with 25 mL of solution between the units. What is the total amount of fluid the nurse will document having provided to the patient? A. 675 mL B. 650 mL C. 625 mL D. 600 mL

C

A patient receiving a unit of blood complains of feeling cold and begins to have shaking chills. What is the nurse's first action? A. Measure the patient's temperature. B. Measure the patient's blood pressure. C. Stop the transfusion. D. Place a warmed blanket over the patient.

C

After drawing blood from a central venous access device (CVAD), which action would minimize the patient's risk for infection when reconnecting prescribed intravenous fluids? A. Wearing clean gloves B. Changing the IV tubing C. Cleansing the IV needleless connector and the end of the IV tubing with a 2% chlorhexidine swab D. Aspirating for blood return before flushing the catheter

C

An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? Dress it with an absorbent dressing for exudate. Handle the wound gently and let it dry out to heal. Debride the nonviable, eschar tissue to allow healing. Use negative-pressure wound (vacuum) therapy to facilitate healing.

C

An older male patient visits his primary care provider because of burning on urination and production of foul-smelling urine. What contributing factor should the health care provider consider? High-purine diet Sedentary lifestyle Benign prostatic hyperplasia (BPH) Recent use of broad-spectrum antibiotics

C

During an assessment of a 45-yr-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? Laryngospasm Pulmonary edema Narrowing of the airway Overdistention of the alveoli

C

During assessment of the IV site the nurse observes redness and tenderness on palpation. The nurse discontinues the IV and documents that the IV was discontinued and restarted because of which complication? Clotting of the IV catheter Infiltration Phlebitis Puncturing of the opposite side of the vein

C

During the assessment in the emergency department, the nurse is palpating the patient's chest. Which finding is a medical emergency? Increased tactile fremitus Diminished chest movement Tracheal deviation to the left Decreased anteroposterior (AP) diameter

C

Following a pneumonectomy, an appropriate nursing intervention is a. monitoring chest tube drainage and functioning. b. positioning the patient on the unaffected side or back. c. doing range-of-motion exercises on the affected upper limb. d. auscultating frequently for lung sounds on the affected side.

C

How can the nurse best minimize the patient's risk for infection when administering an IV bolus of an analgesic? A. Use the injection port closest to the patient. B. Assess the IV insertion site for signs of infiltration. C. Follow aseptic technique during the entire process. D. Instruct the patient to report any adverse medication reactions.

C

How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm? A. Encircle the arm with tape. B. Secure the tubing and catheter hub with tape. C. Secure the tubing in two different locations on the arm. D. Label the dressing with the date and time of application.

C

How would the nurse assess a patient's central venous access device (CVAD) for damage or breakage? A. Assess the patient's neck veins for distention. B. Palpate the patient's arm. C. Check the catheter for pinholes and tears. D. Palpate the area around the insertion site.

C

How would the nurse safely apply an enzyme debridement ointment? Go to question 4. A. Daub ointment on dead tissue at the wound edges. B. Put ointment on a tongue blade, and gently spread it on the center of the wound. C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. D. Apply a gauze dressing to ensure contact with the ointment.

C

Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? Acute respiratory failure Secondary respiratory infection Fluid volume excess resulting from cor pulmonale Pulmonary edema caused by left-sided heart failure

C

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? Category/Stage II Category/Stage IV Unstageable Suspected deep tissue damage

C

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? Water-seal chamber has 5 cm of water. No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site

C

The major advantage of a Venturi mask is that it can a. deliver up to 80% O2. b. provide continuous 100% humidity. c. deliver a precise concentration of O2. d. be used while a patient eats and sleeps.

C

The major advantage of a Venturi mask is that it can a. deliver up to 80% O2. b. provide continuous 100% humidity. c. deliver a precise concentration of O2. d. be used while a patient eats and sleeps. 583

C

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? Temperature of 98.4°F Oxygen saturation 96% Pulse rate of 72 beats/min Respiratory rate of 18/ breaths/min

C

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding? Absence of dyspnea Improved mental status Effective and productive coughing PaO2 within normal range for the patient

C

The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? Go to question 5. A. Begin to establish a sterile field. B. Open and assemble the urine drainage bag. C. Remove soiled gloves, and perform hand hygiene. D. Center the drape over the patient's labia.

C

The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately? Go to question 3. A. Rectal temperature of 99.6° F B. Pulse rate of 88 beats per minute C. Redness noted on the external urethral meatus D. 200 mL of pale yellow urine in the drainage bag

C

The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determined by x-ray. b. a tracheal deviation to the unaffected side is present. c. paradoxical chest movement occurs during respiration. d. there is decreased movement of the involved chest wall.

C

The nurse instructs an African American man who has sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement? "When I take a vacation, I should not go to the mountains." "I should avoid contact with anyone who has a respiratory infection." "When my vision is blurred, I will close my eyes and rest for an hour." "I may experience severe pain during a crisis and need narcotic analgesics."

C

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a â-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? IV fluids Biofeedback therapy Systemic corticosteroids Pulmonary function testing

C

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? Allow time to calm the patient. Observe for signs of diaphoresis. Evaluate the use of intercostal muscles. Monitor the patient for bilateral chest expansion.

C

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse check on first? A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer A 40-yr-old patient with a temperature of 100.8oF (38.2oC) and a neutrophil count of 256/µL A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

C

The nurse is caring for a 48-yr-old male patient admitted for exacerbation of chronic obstructive pulmonary disease. The patient develops severe dyspnea at rest, with a change in respiratory rate from 26 breaths/min to 44 breaths/min. Which action by the nurse would be the most appropriate? Have the patient perform huff coughing. Perform chest physiotherapy for 5 minutes. Teach the patient to use pursed-lip breathing. Instruct the patient in diaphragmatic breathing.

C

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

C

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? Unit secretary A physician's assistant Another registered nurse An unlicensed assistive personnel

C

The nurse is caring for a patient with a diagnosis of disseminated intravascular coagulation (DIC). What is the first priority of care? Administer heparin. Administer whole blood. Treat the causative problem. Administer fresh frozen plasma.

C

The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? Electrolyte levels and daily weights Assessment of speech and swallowing Respiratory rate and oxygen saturation Pain assessment and assessment of mobility

C

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide that would be beneficial to the patient? Take enteric-coated iron with each meal. Take cobalamin with green leafy vegetables. Take the iron with orange juice one hour before meals. Decrease the intake of the antiseizure medications to improve.

C

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry.

C

The nurse is caring for an older adult patient taking bumetanide. What age-related changes does the nurse inform the patient that may be experienced? Benign enlargement of prostatic tissues Decreased sensation of bladder capacity Decreased function of the loop of Henle Less absorption in the Bowman's capsule

C

The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? Loosen or remove the tourniquet. Advance the catheter 1 inch into the vein. Lower the catheter until it is flush with the skin. Thread the catheter into the vein up to the hub.

C

The nurse is interpreting a tuberculin skin test (TST) for a 58-yr-old female patient with end-stage renal disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? Acid-fast bacilli cultured at the injection site 15-mm area of redness at the TST injection site 11-mm area of induration at the TST injection site Wheal formed immediately after intradermal injection

C

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? The wound will be stapled together until it heals. The healing will contract the area to close the wound. The wound will be left open and heal from the edges inward. The wound will be sutured after the current infection is controlled

C

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required? "I will be given amphotericin B to treat the fungus." "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers."

C

The nurse knows that hemolytic anemia can be caused by which extrinsic factors? Trauma or splenic sequestration crisis Abnormal hemoglobin or enzyme deficiency Macroangiopathic or microangiopathic factors Chronic diseases or medications and chemicals

C

The nurse prepares a patient for discharge after a cystoscopy. It is most important for the nurse to provide additional information in response to which patient statement? "I should drink plenty of fluids to prevent complications." "If my urine is cloudy, I should contact my health care provider." "Bright red bleeding is normal for a few days after the procedure." "Sitz baths and acetaminophen will help to reduce my discomfort."

C

The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order? A. Infusing D5W 1000 mL for 8 hours and then discontinuing the infusion B. Infusing D5W at a rate of 125 mL/hr for 24 hours and then discontinuing the infusion C. Infusing D5W at a rate of 125 mL/hr until the health care provider changes the order D. Calling the health care provider to clarify the order

C

The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms

C

The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? Loosening secretions so that they may be coughed up more easily Promoting maximal inhalation for better oxygenation of the lungs Preventing bronchial collapse and air trapping in the lungs during exhalation Increasing the respiratory rate and giving the patient control of respiratory patterns

C

The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? Stridor Vesicular Coarse crackles Bronchovesicular

C

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect to teach the patient about? Nasal packing Epistaxis balloon Gastrostomy tube Peripheral skin care 11.

C

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? Frequency, family history, hematemesis Weight loss, activity tolerance, orthopnea Cough sound, sputum production, pattern Smoking status, medications, residence location

C

The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? Thoracentesis Bronchoscopy Arterial blood gases Pulmonary function tests

C

The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? Recheck by performing another blood glucose test. Call the primary health care provider. Check the medical record to see if there is a medication order for abnormal glucose levels. Monitor and recheck in 2 hours.

C

The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's. d. 5% dextrose in 0.45% saline.

C

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? Notify the health care provider. Document the fistula formation. Assess the patient and vaginal drainage. Have the UAP apply a dressing to the vagina.

C

The wound bed of a patient's pressure injury is red. What does this finding indicate to the nurse? Go to question 5. A. Necrotic tissue B. Presence of slough C. Granulation tissue D. Development of an infection

C

What instructions should the nurse give the NAP concerning a patient who has had an indwelling urinary catheter removed that day? Limit oral fluid intake to avoid possible urinary incontinence. Expect patient complaints of suprapubic fullness and discomfort. Report the time and amount of first voiding. Instruct patient to stay in bed and use a urinal or bedpan.

C

What is a critical step when inserting an indwelling catheter into a male patient? Slowly inflate the catheter balloon with sterile saline. Secure the catheter drainage tubing to the bed sheets Advance the catheter to the bifurcation of the drainage and balloon ports. Advance the catheter until urine flows, then insert ¼ inch more.

C

What is the correct sequence for suctioning a patient? 1. Open kit and basin. 2. Apply gloves. 3. Lubricate catheter. 4. Verify functioning of suction device and pressure. 5. Connect suctioning tubing to suction catheter. 6. Increase supplemental oxygen. 7. Reapply oxygen. 8. Suction airway. 6, 4, 3, 1, 2, 5, 8, 7 4, 6, 1, 2, 3, 8, 5, 7 4, 6, 1, 3, 2, 5, 8, 7 6, 4, 1, 3, 2, 5, 7, 8

C

What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands? Go to question 5. A. Using powdered sterile gloves B. Keeping the fingernails trimmed and smoothly filed C. Selecting the proper glove size D. Drying the hands thoroughly before applying the gloves

C

What is the primary reason the nurse applies sterile gloves rather than clean ones when caring for a patient with a newly inserted suprapubic catheter? Go to question 2. A. To protect the nurse and other patients from pathogens B. To collect a sterile urine sample C. To reduce the patient's risk for infection D. To reduce the patient's risk for injury

C

What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks? Go to question 5. A. Kinks in the tubing cause the patient unnecessary discomfort. B. Kinks allow the drainage bag to become overly full. C. Kinks are associated with the development of urinary tract infection (UTI). D. Kinks result in scant, dark amber-colored urine.

C

What is the purpose of splinting the abdomen with a small pillow during controlled coughing? Go to question 3. A. To minimize chest discomfort caused by the coughing B. To expand lung capacity during the inspiratory phase of the cough C. To maximize transdiaphragmatic pressure during the expiratory phase of the cough D. To focus the patient's attention on the abdominal muscles used during the cough

C

What output will the nurse direct nursing assistive personnel (NAP) to measure for a hospitalized patient for whom I&O measurement is prescribed? Go to question 3. A. Nasogastric tube drainage B. Chest tube drainage C. Urine collection drainage D. Ileostomy bag drainage

C

What would the nurse do to ensure the correct administration of gravity drip intravenous (IV) fluid after changing the tubing on a patient's primary infusion? A. Change the tubing with each new infusion bag. B. Wear clean treatment gloves when changing the tubing. C. Recheck the drip rate by counting the drops for 1 full minute. D. Assess the condition of the patient's insertion site for possible infiltration.

C

When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? Back to Top A. Increase the oxygen level as needed for the patient's comfort. B. Store extra oxygen cylinders horizontally. C. Place a "No Smoking" sign at the entrance to the house. D. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.

C

When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? Go to question 3. A. Increase the oxygen level as needed for the patient's comfort. B. Store extra oxygen cylinders horizontally. C. Place a "No Smoking" sign at the entrance to the house. D. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.

C

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? Polyuria Bradycardia Restlessness Difficulty breathing

C

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? White blood cell (WBC) count of 8000/ìL; temperature of 101?5? F White blood cell (WBC) count of 4000/ìL; temperature of 100?5? F White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F White blood cell (WBC) count of 16,500/ìL; temperature of 98.8?5? F

C

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? Pale yellow urine Slightly cloudy urine Light pink urine Dark amber urine

C

When caring for a patient with nephrotic syndrome, which food selection indicates the patient understands dietary teaching? Peanut butter and crackers One small grilled pork chop Salad made of fresh vegetables Spaghetti with canned spaghetti sauce

C

When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? Back to Top A. After performing hand hygiene at the start of the procedure B. Before removing the inner dressing C. After removing the original dressing materials and performing hand hygiene a second time D. Just before cleansing the wound with sterile water

C

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? Go to question 2. A. Checking the patency of the indwelling catheter tubing B. Placing the urinary collection bag below the level of the bladder C. Clamping the catheter tubing for 15 minutes before collection D. Asking the patient to drink a glass of water 30 minutes before the collection

C

When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips? The total volume Two-thirds of the volume One-half of the volume One-quarter of the volume

C

When drawing blood from a patient's central venous access device (CVAD), what can the nurse do to minimize pressure on the device during flushing? A. Clamp the device. B. Use a 3-mL syringe for the flush. C. Use a 10-mL syringe for the flush. D. Cleanse the catheter hub with an alcohol swab.

C

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is 500 to 1500 mL. 1200 to 2200 mL. 2000 to 3000 mL. 3000 to 4000 mL.

C

When pouring a sterile liquid into a container on a sterile field, why does the nurse hold the bottle with the label facing the palm of the hand? Go to question 5. A. The label is not sterile and will contaminate the field if it is splashed. B. The pour spout faces down when the bottle is held with the label facing the palm. C. The label may become illegible if it is splashed. D. The handgrips on the bottle are molded to fit correctly when the label is facing the palm.

C

When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? Go to question 4. A. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room. B. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. D. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.

C

When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? Go to question 5. A. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room. B. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. D. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.

C

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? Lactated Ringer's 5% dextrose in water 0.9% sodium chloride 0.45% sodium chloride

C

When preparing to infuse a bag of parenteral nutrition through a patient's central line, the nurse notices that the solution has coalesced. What is his or her best response? A. Warm the infusion in the microwave. B. Vigorously shake the bag. C. Contact the pharmacy for a new infusion bag. D. Increase the infusion rate on the pump.

C

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? Back to Top A. Remove the cotton balls from the kit for later use. B. Advance the catheter 10 to 12 inches or until urine flows. C. Lubricate the first 5 to 7 inches of the catheter. D. Hold the penis at a 45-degree angle during insertion

C

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? Smoking causes a hoarse voice. Cough will become nonproductive. Decreased alveolar macrophage function Sense of smell is decreased with smoking.

C

When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? Fat soluble vitamins and dietary salt should be avoided. Insulin may be needed with a diabetic diet if diabetes mellitus develops. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.

C

Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? A. Using microdrip tubing for the infusion B. Using macrodrip tubing for the infusion C. Using a volume-control device for the infusion D. Not infusing more than 25 mL/hour of IV fluids

C

Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? Change the injection cap after the administration of IV medications. Use a 5-mL syringe to flush the catheter between medications and after use. During removal of the catheter, have the patient perform the Valsalva maneuver. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

C

Which action is the most important step the nurse can take to keep the field sterile when using an overbed table as the work surface for a sterile field? Go to question 5. A. Position the table out of the patient's reach. B. Assess the table for stability. C. Position the height of the table to be above waist level. D. Assemble ahead of time any supplies and equipment not included in the kit.

C

Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? Go to question 3. A. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago B. Removing the outer cannula and placing the obturator C. Holding the tracheostomy tube while the nurse changes the neck ties D. Monitoring oxygen saturation levels and placing oxygen if needed

C

Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? Go to question 4. A. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago B. Removing the outer cannula and placing the obturator C. Holding the tracheostomy tube while the nurse changes the neck ties D. Monitoring oxygen saturation levels and placing oxygen if needed

C

Which action will best minimize a patient's risk for infection while receiving central parenteral nutrition (CPN)? A. Infuse the CPN only with a filter in the line. B. Assess the patient frequently for signs and symptoms of infection. C. Change the CPN infusion tubing at least once every 24 hours. D. Frequently inspect the patient's central venous access site.

C

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? Go to question 2. A. Frequently pull on the drainage system tubing. B. Use the largest-size catheter possible. C. Clean the urinary meatus daily. D. Apply antiseptics to the urinary meatus.

C

Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field? Back to Top A. Wear clean treatment gloves. B. Collect supplies with sterile gloves to avoid contamination. C. Do not allow the wrapper to touch the sterile field. D. Place the supplies in the 1-inch perimeter of the sterile field.

C

Which action would the nurse perform first when preparing to apply sterile gloves? Go to question 3. A. Perform hand hygiene. B. Place the package on a stable, flat surface. C. Assess the glove packaging for wetness or tears. D. Open the outer packaging.

C

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? Back to Top A. Wear clean gloves when inserting the catheter. B. Inflate the balloon on the catheter before using it. C. Use the smallest-size catheter possible. D. Empty the urine by disconnecting the catheter from the collection bag.

C

Which assessment do you use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? Dryness of mucous membranes Presence or absence of edema Fullness of neck veins when supine Fullness of neck veins when upright

C

Which factor indicates that tracheostomy placement would be preferable to endotracheal intubation? The patient is unable to clear secretions. The patient is at high risk for aspiration. A long-term airway is probably necessary. An upper airway obstruction is impairing the patient's ventilation

C

Which information is not necessary for the nurse to include when documenting the use of an EID for an intravenous infusion? A. Location of the insertion site B. Time at which the infusion began C. Patient's pulse and heart rate D. Hourly volume flow rate of the infusion

C

Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? Go to question 2. A. "Tell me how he tolerates the irrigation." B. "Be sure to check for signs of a urinary tract infection." C. "Measure and report the patient's temperature to me every 4 hours." D. "Ask the patient about pain level."

C

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a CVAD? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site is painful or swollen."

C

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a venous access device? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know if you notice that the dressing has become damp." D. "Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red."

C

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? "Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." "Let me know when you notice that the IV bag contains less than 100 milliliters." "Explain the symptoms of infection to the patient."

C

Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed? A. "Remember to wear gloves to minimize the risk for infection." B. "Be sure to keep pressure on the site for at least 2 to 3 minutes." C. "Let me know if you notice any bleeding on the site dressing." D. "Make sure the patient knows to notify me if the IV site becomes painful."

C

Which instruction should the nurse provide when teaching a patient to exercise the pelvic floor? Tighten both buttocks together. Squeeze thighs together tightly. Contract muscles around rectum. Lie on back and lift the legs together.

C

Which instruction to nursing assistive personnel (NAP) reflects the nurse's correct understanding of the NAP's role in caring for a patient receiving intravenous (IV) fluids by gravity drip? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know when you notice that the IV bag contains less than 100 mL." D. "Tell the patient to notify me if the IV site is painful, swollen, or red."

C

Which instruction would the nurse give to nursing assistive personnel (NAP) when caring for a patient who is receiving IV fluids? A. "If the IV tubing gets disconnected, quickly reconnect it for me and let me know." B. "It's okay for you to turn off the pump alarm when it beeps." C. "Let me know when the IV bag is almost empty." D. "Please check the IV site for me, and let me know if it's tender."

C

Which nursing action reduces the risk for injury in a patient with a suprapubic catheter? Go to question 5. A. Applying sterile gloves before cleansing the catheter insertion site B. Cleansing the skin surrounding the insertion site C. Securing the catheter to the abdomen D. Keeping the drainage bag above the level of the patient's bladder

C

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? a. Auscultating lung sounds after suctioning is complete b. Providing a means of communication for the patient during the procedure c. Assessing the patient's oxygenation saturation before, during, and after suctioning d. Administering pain and/or antianxiety medication 30 minutes before suctioning

C

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? Do you leak urine when you cough or sneeze? Do you need help getting to the toilet? Do you dribble urine constantly? Does it burn when you pass your urine?

C

Which nursing intervention is most appropriate when caring for a patient with dehydration? Monitor skin turgor every shift. Auscultate lung sounds every 2 hours. Monitor daily weight and intake and output. Encourage the patient to reduce sodium intake.

C

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? Leave a gap of 3-5 inches between the tip of the penis and drainage tube Shave the pubic area so that hair does not adhere Wash with soap and water prior to applying the condom type catheter. Apply tape to the condom sheath to keep it securely in place.

C

Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection

C

Which patient is exhibiting an early clinical manifestation of hypoxemia? A 48-yr-old patient who is intoxicated and acutely disoriented to time and place A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair A 72-yr-old patient who has four new premature ventricular contractions per minute A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output

C

Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? Supine Lithotomy High Fowler's Reverse Trendelenburg

C

Which protocol does not vary among institutions? Go to question 2. A. Acceptability of wearing artificial nails in patient care areas B. Use of impervious transparent dressings to cover open lesions on nurse's hands during sterile procedures C. Use of sterile gloves for sterile procedures D. Sterile gloves are only available in "one size fits all"

C

Which response might the nurse give to nursing assistive personnel (NAP) who reports that the alarm is sounding on a patient's electronic infusion device (EID)? A. "Assess the IV site for signs of inflammation." B. "Be sure to change the dressing on the IV site." C. "I'll check the IV site and pump." D. "Turn off the alarm."

C

Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? Go to question 2. A. Patient complains of discomfort during the procedure. B. Patient has a severe bout of nonproductive coughing and complains of sore throat. C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. D. Patient's pulse rate increases by 10 bpm.

C

Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? Go to question 3. A. Patient complains of discomfort during the procedure. B. Patient has a severe bout of nonproductive coughing and complains of sore throat. C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. D. Patient's pulse rate increases by 10 bpm.

C

Which statement by the patient would indicate that he or she understands the safe use of oxygen? Go to question 5. A. "The nurse told me that my oxygen saturation must be maintained at 85% or above." B. "I know that oxygen is a medication I can adjust whenever I need to." C. "I'll alert the nurse immediately if I have any increased difficulty breathing." D. "I often experience difficulty breathing for no apparent reason, but that is expected."

C

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen."

C

Which statement reflects the nurse's understanding of the importance of accurate urinary output measurement for a patient with acute renal failure? Back to Top A. "If the output begins to decrease, I will notify the physician immediately." B. "Increasing his fluid intake both orally and intravenously should boost his urine output." C. "I will use a collection system with an hourly measurement device added." D. "I will explain to the patient and family why I&O is being measured and recorded."

C

Which step to protect the patient from infection is of special concern when preparing a mini-infusion pump to deliver an analgesic? A. Ensure that the syringe is secure within the mini-infusion pump. B. Identify any history of allergic reaction to the prescribed analgesic. C. Use an antiseptic swab to wipe the proximal injection port on the primary tubing. D. Carefully depress the syringe plunger to fill the tubing with medication.

C

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? Continue with ambulation. Obtain a physician's order for arterial blood gas. Obtain a physician's order for supplemental oxygen. Move the oximetry probe from the finger to the earlobe.

C

While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? Go to question 3. A. Rinse off the supplies that were contaminated with urine. B. Cleanse the patient's urinary meatus. C. Replace all contaminated supplies, and begin the process again. D. Change the patient's bed linens.

C

While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? Go to question 2. A. Encourage the patient to take several deep breaths. B. Interrupt suction to the catheter for at least 10 seconds. C. Discontinue suctioning by removing the suction catheter. D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.

C

While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? Go to question 3. A. Encourage the patient to take several deep breaths. B. Interrupt suction to the catheter for at least 10 seconds. C. Discontinue suctioning by removing the suction catheter. D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.

C

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon. Notify the health care provider and complete an incident report. Listen to the patient's lung sounds and assess respiratory status. Asses the patient's cardiovascular status by checking pulse and blood pressure.

C

You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? Sodium, 136 mEq/L; potassium, 3.6 mEq/L Sodium, 145 mEq/L; potassium, 4.8 mEq/L Sodium, 135 mEq/L; potassium, 4.5 mEq/L Sodium, 144 mEq/L; potassium, 3.7 mEq/L

C

Your older-adult patient is receiving intravenous (IV) 0.9% NaCl. You detect new onset of crackles in the lung bases. What is your priority action? Notify a health care provider Record in medical record Decrease the IV flow rate Discontinue the IV site

C

he nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium after noting which assessment finding? Decreased respiratory rate Increased respiratory rate Increased peak flow readings Decreased sputum production

C

he nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation

C

patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? Coughing up thick sputum only occasionally Coughing up thin, watery sputum after nebulization Decreased ability to clear airway through couching Lung sounds clear only after coughing

C

patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? Bilateral erythema of especially large tonsils Temperature 102.2°F, diaphoresis, and chills Contraction of neck muscles during inspiration β-hemolytic streptococcus in the throat culture

C

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? Take the antibiotic until the wound feels better. Take the analgesic every day to promote adequate rest for healing. Be sure to wash hands after changing the dressing to avoid infection. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. Notify the health care provider of redness, swelling, and increased drainage.

C, D

Which interventions should the nurse perform before using an open-suctioning technique for a patient with an endotracheal (ET) tube (select all that apply.)? Put on clean gloves. Administer a bronchodilator. Perform a cardiopulmonary assessment. Hyperoxygenate the patient for 30 seconds. Perform hand hygiene before performing the procedure. Insert a few drops of normal saline into the ET to break up secretions.

C, D

. A patient with TB has been admitted to the hospital and is placed in an airborne infection isolation room. What should the patient be taught (select all that apply)? a. Expect routine TST to evaluate infection. b. Visitors will not be allowed while in airborne isolation. c. Take all medications for full length of time to prevent multidrug-resistant TB. d. Wear a standard isolation mask if leaving the airborne infection isolation room. e. Maintain precautions in airborne infection isolation room by coughing into a paper tissue.

C, D, E

A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include (select all that apply) a. antiviral agents to treat influenza. b. treatment with antibiotics starting ASAP. c. a throat culture or rapid strep antigen test. d. supportive care, including cool, bland liquids. e. comprehensive history to determine possible etiology.

C, D, E

2. Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? Go to question 3. A. Using a 5-mL syringe to deflate the balloon B. Using sterile scissors to cut the valve to deflate the balloon C. Tugging gently on the catheter to pull the balloon through the urethra D. Checking the documentation for the volume of fluid used to inflate the balloon

D

5. Which action is the most effective in minimizing the risk of contamination when using sterile liquids during a sterile procedure? Back to Top A. Touch only the outer 1½ -inch margin of the sterile field unless you are wearing sterile gloves. B. Assess the patient for any known allergies to the sterile solution. C. Compare the label of the solution with the specific solution necessary for the procedure. D. Avoid splashing when pouring sterile liquids onto the sterile field.

D

A 55-yr-old female patient develops acute pericarditis after a myocardial infarction. Which assessment finding indicates a possible complication? Presence of a pericardial friction rub Distant and muffled apical heart sounds Increased chest pain with deep breathing Decreased blood pressure with tachycardia

D

A 68-yr-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which nursing action is most important? Use the open-suctioning technique. Administer morphine for discomfort. Limit noise and cluster care activities. Elevate the head of the bed 30 degrees.

D

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? Apply an external splint to the nose. Insert plastic nasal implant surgically. Humidify the air for mouth breathing. Maintain surgical packing in the nose.

D

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation? Increased breathlessness but increased activity tolerance Decreased breathlessness and decreased activity tolerance Increased activity tolerance and decreased breathlessness Decreased activity tolerance and increased breathlessness

D

A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? "I'll make sure that I rest between activities so I don't get so short of breath." "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." "If I have trouble breathing at night, I'll use two to three pillows to prop up." "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

D

A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? "Long-term home oxygen therapy should be used to prevent respiratory failure." "Oxygen will not be needed until or unless you are in the terminal stages of this disease." "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

D

A patient has consumed three 100-mL cups of ice chips and 4 ounces of ginger ale. What will nursing assistive personnel (NAP) document as this patient's oral intake? Go to question 4. A. 120 mL B. 170 mL C. 220 mL D. 270 mL

D

A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

D

A patient in the intensive care unit is receiving gentamicin for treatment of pneumonia from Pseudomonas aeruginosa. What assessment results should the nurse report to the health care provider? Decreased weight Increased appetite Increased urinary output Elevated creatinine level

D

A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Suction the tracheostomy. Check stoma site for skin breakdown. Complete tracheostomy care using sterile technique. Provide oral care with a toothbrush and tonsil suction tube.

D

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? Sonorous wheezes in the left lower lung Rhonchi mid sternum Crackles only in apex of lungs Inspiratory crackles in lung bases

D

A patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? Skin care that will be needed Method of obtaining the treatment Gastrointestinal tract effects of treatment Treatment type and expected side effects

D

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? Adhesion Contractions Keloid formation Excess granulation tissue

D

A patient is prescribed to receive an infusion of 20% fat emulsion. The nurse informs the patient that this infusion will last how long? A. 2 hours B. At least 4 hours C. No more than 6 hours D. At least 8 hours

D

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? When 25% of the patient's nutritional needs are met by the tube feedings When bowel sounds return When central line has been in for 10 days When 75% of the patient's nutritional needs are met by the tube feedings

D

A patient prescribed to receive two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication? A. In the IV line for the blood product during the transfusion B. In the IV line for the blood product when the line is flushed with normal saline C. In oral form D. Through another IV line

D

A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to a. use aspirin for pain relief. b. remove the packing later that day. c. skip the next dose of antihypertensive medication. d. avoid vigorous nose blowing and strenuous activity.

D

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound? Go to question 2. A. Remove the dressing, inspect the wound, and reapply a new dressing. B. Inspect the wound and reapply the surgical dressing every 2 hours. C. Inspect the wound, and keep the dressing off until the health care provider arrives. D. Wait until the health care provider orders the removal of the surgical dressing.

D

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? Thoracentesis Pulmonary angiogram CT scan of the patient's chest Positron emission tomography (PET)

D

A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes and nose at various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to a. avoid all intranasal sprays and oral antihistamines. b. limit the usage of nasal decongestant spray to 10 days. c. use oral decongestants at bedtime to prevent symptoms during the night. d. keep a diary of when the allergic reaction occurs and what precipitates it.

D

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)

D

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea has a platelet count of 43,000/µL. It is most important for the nurse to take which action? Insert two 18-gauge IV catheters. Administer prescribed enoxaparin. Monitor the patient's temperature every 2 hours. Check stools for presence of frank or occult blood.

D

A patient's central parenteral nutrition (CPN) order has been changed to a different solution, and the present solution is to be discontinued immediately. What should the nurse do until the new solution is delivered by the pharmacy? A. Discontinue the present CPN solution, and clamp the catheter hub. B. Continue the present CPN solution, but readjust the flow to a keep-vein-open (KVO) rate. C. Hang an infusion of 0.9% normal saline at the same infusion rate as the CPN. D. Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN.

D

A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 1200. What is the appropriate nursing action? Assess bowel sounds Raise the head of the bed to at least 45 degrees Position the patient on his or her right side to promote stomach emptying Do not reinstall aspirate and hold the feeding until you talk to the primary care provider

D

After changing the intravenous (IV) tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How would the nurse remove them? A. Begin the process again. B. Add more fluid to the drip chamber. C. Inject a syringe of saline into the tubing to vent the air bubbles. D. Close the clamp, stretch the tubing downward, and flick the tubing.

D

After drawing blood from a patient's central venous access device (CVAD), what would the nurse do to ensure that the device resumes proper functioning? A. Discard the initial 5 mL of aspirated blood. B. Apply an antiseptic to the injection cap. C. Wear clean treatment gloves during the procedure. D. Flush the catheter with preservative-free 0.9% sodium chloride, per agency policy.

D

After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormal finding? Decreased response to hypercapnia Decreased number of functional alveoli Increased calcification of costal cartilage Decreased respiratory defense mechanisms

D

All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one? Go to question 2. A. History of fecal incontinence B. Use of an indwelling urinary catheter C. Drainage tubing is kinked D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene

D

An 80-yr-old patient with uncontrolled type 1 diabetes mellitus is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to do or have what done? Aortic valve replacement Take nitroglycerin for chest pain. Open commissurotomy (valvulotomy) procedure Percutaneous transluminal balloon valvuloplasty (PTBV) procedure 11.

D

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to a. perform postural drainage every hour. b. provide analgesics as ordered to promote patient comfort. c. administer O2 as prescribed to maintain optimal O2 levels. d. teach the patient how to cough effectively to bring secretions to the mouth.

D

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D

Before chest-tube insertion, the patient should be positioned: With the head of the bed elevated 90 degrees and nothing between the shoulder blades. With the head of the bed elevated 45 degrees and nothing between the shoulder blades. Laterally, with a small wedge or bolster between the shoulder blades. Flat, with a small wedge or bolster under the shoulder blades.

D

Before discharge, the nurse discusses activity levels with a 61-yr-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? Slightly increase activity over the current level. Swim for 10 min/day, gradually increasing to 30 min/day. Limit exercise to activities of daily living to conserve energy. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

D

Before performing a wound assessment, which nursing action would reduce the patient's risk for infection? Go to question 5. A. Taking the patient's temperature B. Applying clean gloves C. Assessing the wound for drainage D. Assessing the dressing for drainage

D

During an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? Back to Top A. Notify the health care provider of the patient's complaint. B. Request that the health care provider prescribe oxygen therapy. C. Interview the patient concerning the onset of this problem. D. Instruct the patient to use two bed pillows when lying supine.

D

During an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? Go to question 4. A. Notify the health care provider of the patient's complaint. B. Request that the health care provider prescribe oxygen therapy. C. Interview the patient concerning the onset of this problem. D. Instruct the patient to use two bed pillows when lying supine.

D

During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? Go to question 4. A. Examine the drainage tubing for clots, sediment, and kinks. B. Notify the health care provider. C. Leave the irrigation drip wide open. D. Monitor the patient's vital signs.

D

During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. water accounts for a greater percentage of body weight in the older adult than in younger adults. c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.

D

How would the infusion of the IV fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the EID? A. The infusion would slow to a "keep vein open" rate. B. The patient would receive a bolus of fluid. C. The infusion would continue at the prescribed rate. D. The flow of fluid would stop.

D

If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step? A. Attempt to aspirate the site again. B. Prepare to access another IV site. C. Assess the saline lock site for signs of phlebitis. D. Assess the site for swelling or coolness while flushing the saline lock with normal saline.

D

On admission to the emergency department, a patient with cardiomyopathy has an ejection fraction of 10%. On assessment, the nurse notes bilateral crackles and shortness of breath. Which additional assessment finding would most indicate patient decline? Increased heart rate Increased blood pressure Decreased respiratory rate Decreased level of consciousness

D

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

D

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? Fluid status Potassium Lipids Nitrogen balance

D

The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? Go to question 5. A. "I'll help you set up the sterile field." B. "I'll get a sterile urine cup for you." C. "There are leg straps in the utility room." D. "I'll help keep his legs away from the sterile field."

D

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? Chew a hard candy before the first puff of medication. Rinse the mouth with water before each puff of medication. Ask for a breath mint after the second puff of medication. Rinse the mouth with water after the second puff of medication.

D

The nurse is caring for a 73-yr-old male patient with a history of benign prostatic hyperplasia and symptoms of a urinary tract infection. Which diagnostic finding would support this diagnosis? White blood cell count is 7500 cells/µL. Antistreptolysin-O (ASO) titer is 106 Todd units/mL. Glucose, protein, and ketones are present in the urine. Nitrites and leukocyte esterase are present in the urine.

D

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? Fever and chills Increased blood pressure Increased respiratory rate General malaise and fatigue

D

The nurse is caring for a patient who received a mechanical aortic valve replacement two years ago. Current lab values include an international normalized ratio (INR) of 1.5, platelet count of 150,000/µL, and hemoglobin of 8.6g/dL. Which nursing action is most appropriate? Assess the vital signs. Start intravenous fluids. Monitor for signs of bleeding. Report laboratory values to the health care provide

D

The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? Humidify the oxygen as able. Administer cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.

D

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.

D

The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up? Go to question 2. A. "I'll ask for assistance if I need help positioning her." B. "I'll see if she's up to the care right now." C. "I'll let you know if I notice any signs of redness or discharge." D. "I'll be sure to use hot, soapy water, since she has been incontinent."

D

The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field? Go to question 4. A. Placing a role of sterile tape on the field B. Holding a prepackaged sterile item in the non-dominant hand while opening it C. Adding supplies that will expire in 2 days D. Placing the needed supplies near the back of the sterile field

D

The nurse is providing care for a patient admitted to the hospital for treatment of nephrotic syndrome. What are the priority nursing assessments? Assessment of pain and level of consciousness Assessment of serum calcium and phosphorus levels Blood pressure and assessment for orthostatic hypotension Daily weights and measurement of the patient's abdominal girth

D

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: Palpable, elevated hardened area around a tuberculosis skin testing site. Sputum for culture and sensitivity identifies mycobacterium tuberculosis Presence of acid fast bacilli in sputum Arterial oxygen tension (PaO2) of 95 mmHg

D

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compresses to the insertion site. b. attempt to force 10 mL of normal saline into the device. c. place the patient on the left side with head-down position. d. instruct the patient to change positions, raise arm, and cough.

D

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? Go to question 3. A. Osteoarthritis B. Glaucoma C. Deafness D. Diabetes mellitus

D

The nurse obtained a urine specimen from a patient. What result should the nurse recognize as an abnormal finding? pH of 6.0 Amber yellow color Specific gravity of 1.025 White blood cells (WBCs) 9/hpf

D

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A patient with a traumatic brain injury A patient with type 1 diabetes mellitus A patient with acute respiratory failure A patient with nasogastric tube suction

D

The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/LVN), and unlicensed assistive personnel (UAP) on a medical unit. The team is caring for many patients with respiratory problems. In what situation should the nurse intervene with teaching for a team member? LPN/LVN obtained a pulse oximetry reading of 94% but did not report it. RN taught the patient about home oxygen safety in preparation for discharge. UAP report to the nurse that the patient is complaining of difficulty breathing. LPN/LVN changed the type of oxygen device based on arterial blood gas results.

D

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? "My liver function will be checked with blood tests every 2 to 3 months." "The medication will decrease the congestion within 3 to 5 minutes after use." "I may develop a serious infection because the medication reduces my immunity." "I will use the medication every day of the season whether I have symptoms or not."

D

The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? "I should avoid using ibuprofen for pain and discomfort." "It is important for me to take my blood pressure medication every day." "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

D

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity

D

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? Electromyography Intraoral electrolarynx Neck type electrolarynx Transesophageal puncture

D

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? Coughing Fever, chills Dust allergy Maxillary pain

D

The patient with pericarditis is complaining of chest pain. After assessment, which intervention should the nurse expect to implement to provide pain relief? Corticosteroids Morphine sulfate Proton pump inhibitor Nonsteroidal antiinflammatory drugs

D

What can the nurse do to help protect the patient from infiltration of IV medication? A. Use the most proximal insertion port on the existing primary tubing. B. Ensure that the syringe has been securely loaded into the mini-infusion pump. C. Set the pump to deliver the medication over the prescribed time period. D. Check the IV site for placement before and after the infusion.

D

What direction would the nurse provide to nursing assistive personnel (NAP) while establishing and maintaining a sterile field? Go to question 3. A. "This work surface is too low. Choose a surface that's above your waist." B. "Begin to establish the sterile field here on the overbed table." C. "Be careful to touch only the outer 1-inch edge of the sterile drape." D. "Remember, reaching over the sterile field constitutes a break in sterile technique."

D

What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? Go to question 5. A. To increase oxygenation B. To reduce blood pressure C. To distract him D. To promote relaxation

D

What is the most effective way to prevent infection when providing catheter care for a patient? Back to Top A. Properly dispose of soiled linen. B. Perform hand hygiene before positioning the patient. C. Secure the catheter to the patient's leg or abdomen. D. Cleanse from the meatus outward.

D

What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? Go to question 5. A. Notify the surgeon of the bleeding. B. Remove the dressing, and assess the wound. C. Assess the patient for signs of shock. D. Further assess the patient and the wound.

D

What is the nursing action to set up suction for a Hemovac drainage system? Go to question 2. A. Set the suction to lowest level possible. B. Hemovacs are always set to medium suction. C. Connect to the wall on intermediate suction. D. Compress the hemovac, creating suction.

D

What is the proper method for cleansing the evacuation port of a wound drainage system? Go to question 3. A. Cleanse it with normal saline. B. Wash it with soap and warm water. C. Rinse it with sterile water. D. Wipe it with an alcohol sponge.

D

What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present.

D

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? A. Instruct the patient to report immediately any sign of bleeding on the site dressing. B. Perform hand hygiene and wear clean gloves while removing the device. C. Encourage the patient to keep a cold compress on the site for 15 minutes. D. Apply firm pressure to the site with sterile gauze for 10 minutes

D

What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? Back to Top A. Evaluate the patient's understanding of the combustible nature of oxygen. B. Arrange for a capable family member to be present during the initial discussion. C. Collect written information to present to the patient as supplemental instructional materials. D. Assess the patient's emotional readiness and physical ability to provide autonomous care

D

What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? Go to question 3. A. Evaluate the patient's understanding of the combustible nature of oxygen. B. Arrange for a capable family member to be present during the initial discussion. C. Collect written information to present to the patient as supplemental instructional materials. D. Assess the patient's emotional readiness and physical ability to provide autonomous care.

D

When a patient reports acute, severe, renal colic pain in the lower abdomen, the nurse suspects that the patient is most likely to have an obstruction at which area? Kidney Urethra Bladder Ureterovesical junction

D

When drawing blood from a central venous access device (CVAD) in which all ports are patent, it is recommended that the nurse select which lumen? A. The shortest B. The longest C. The proximal port D. The distal port

D

When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality? Go to question 4. A. The drainage is odorless. B. The drainage is straw colored. C. The patient doesn't like looking at the drainage tubing. D. The amount of drainage was greater today than yesterday.

D

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? Necrotic tissue Wound drainage Wound circumference Cleansed wound

D

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? Fluid movement from the blood vessels into the cells Fluid movement from the interstitial spaces into the cells Fluid movement from the blood vessels into interstitial spaces Fluid movement from the interstitial space into the blood vessels

D

When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? 60 mL in 90 minutes 1200 mL in 24 hours 300 mL per 8-hour shift 20 mL for 2 consecutive hours

D

When preparing a sterile field using a prepackaged sterile kit, what will influence the nurse's placement of the kit on the overbed table? Go to question 2. A. The tips of the flaps are easily accessible. B. The kit is positioned in the center of the table. C. The sterile contents of the kit are readily available. D. The outermost flap can be opened away from the nurse's body.

D

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A local skin infection requiring antibiotics Sensitive skin that requires special bed linen A stage III pressure ulcer needing the appropriate dressing Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

D

When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? Vomiting Increased urination Decreased heart rate Increased respiratory rate

D

When you assess pain and redness at a vascular access device (VAD) site, which action do you take first? Apply a warm, moist compress Monitor the patient's blood pressure Aspirate the infusing fluid from the VAD Stop the infusion and discontinue the intravenous infusion

D

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's central venous access device (CVAD) site? A. Allow fluid infusions to continue to flow right up to the time of the sample. B. Flush the catheter after aspirating for blood return. C. Ensure that the patient has been resting quietly for at least 15 minutes before taking the sample. D. Discard the first 4 to 5 mL of blood drawn.

D

Which action can the nurse take to minimize the patient's risk for infection when applying new tubing to a primary IV infusion? A. Using aseptic technique throughout the process B. Changing the tubing each shift C. Changing the tubing at the same time a new primary fluid bag is hung when possible D. Using aseptic technique and changing the tubing at the same time a new primary fluid bag is hung are both appropriate to minimize the patient's risk for infection

D

Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? Back to Top A. Attaching the urinary drainage bag to the bed frame B. Inspecting the drainage tubing for kinks C. Disposing of contaminated items after the procedure D. Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter

D

Which action is part of the preparation for nasotracheal suctioning? Go to question 4. A. Place the patient in a supine position. B. Preoxygenate the patient with 100% oxygen. C. Suction 100 mL of warm tap water to flush the suction catheter. D. Place water-soluble lubricant onto the open sterile catheter package.

D

Which action is part of the preparation for nasotracheal suctioning? Go to question 5. A. Place the patient in a supine position. B. Preoxygenate the patient with 100% oxygen. C. Suction 100 mL of warm tap water to flush the suction catheter. D. Place water-soluble lubricant onto the open sterile catheter package.

D

Which action should the nurse avoid before irrigating a patient's foot wound? Go to question 4. A. Assess the patient for a history of allergies to tape and irrigating solution. B. Review the provider's orders for the type of irrigating solution to be used. C. Assess the patient's pain on a scale of 0 to 10. D. Warm the irrigant to body temperature in the microwave.

D

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? Go to question 3. A. Cleansing the wound with sterile water B. Blotting the incision with dry gauze C. Wearing sterile gloves to cleanse the wound D. Using a new gauze pad for each stroke while cleansing the wound

D

Which action would the nurse perform to ensure patient safety during PPN and fat emulsion therapy? A. Change the tubing on the fat emulsion every 48 hours. B. Infuse the fat emulsion through a 0.22-µm IV filter. C. Plan to infuse the fat emulsion over 18 hours. D. Allow a refrigerated fat emulsion to sit at room temperature for 1 hour before infusing it.

D

Which assessment do you interpret as a transfusion reaction? Crackles in dependent parts of lungs High fever, severe hypotension Anxiety, itching, confusion Chills, tachycardia, and flushing

D

Which guideline would be a part of teaching patients how to use a metered-dose inhaler (MDI)? a. After activating the MDI, breathe in as quickly as you can. b. Estimate the amount of remaining medicine in the MDI by floating the canister in water. c. Disassemble the plastic canister from the inhaler and rinse both pieces under running water every week. d. To determine how long the canister will last, divide the total number of puffs in the canister by the puffs needed per day.

D

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? Back to Top A. White blood cell count B. Complete blood count C. X-ray of left foot D. Culture and sensitivity test

D

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous (IV) site dressing? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "If the gauze dressing looks damp, replace it with a dry 4 × 4 gauze." D. "Be sure to notify me if the patient reports that the IV site is painful or swollen."

D

Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock? A. Use the most proximal insertion port on the primary tubing. B. Hang the piggyback solution higher than the primary infusion solution. C. Use a pump to regulate the infusion rate of the piggyback medication. D. Flush the saline lock with sodium chloride solution before initiating the infusion

D

Which of the following describes a hydrocolloid dressing? A seaweed derivative that is highly absorptive Premoistened gauze placed over a granulating wound A debriding enzyme that is used to remove necrotic tissue A dressing that forms a gel that interacts with the wound surface

D

Which of the following diagnosis is a patient who started smoking in adolescence and continues to smoke for 40 years at this risk for? Alcoholism and hypertension Obesity and diabetes Stress-related illnesses Cardiopulmonary disease and lung cancer

D

Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? Inserting the needle with the bevel up Using a vein on the dorsal surface of the arm Holding the skin taut directly below the site All of the above

D

Which statement about chest-tube sizes is correct? The larger the French size, the smaller the tube. Common tube sizes for adults are 10-15 French Smaller tubes are used to drain blood; larger tubes to remove air. Larger tubes are used to drain blood; smaller tubes to remove air.

D

Which statement made by a patient of a 2-month-old infant requires further education? I'll continue to use formula for the baby until he is a least a year old. I'll make sure that I purchase iron-fortified formula. I'll start feeding the baby cereal at 4 months. I'm going to alternate formula with whole milk starting next month.

D

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler? "I can rinse my mouth following the two puffs to get rid of the bad taste." "I should wait at least 1 to 2 minutes between each puff of the inhaler." "Because this medication is not fast acting, I cannot use it in an emergency if my breathing gets worse." "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

D

Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? Back to Top A. "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" B. "See if the catheter is causing the patient any problems and if he is having any pain." C. "Please get two sterile urine collection containers from the utility room." D. "Let me know if the urine contains blood or sediment, or appears cloudy."

D

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time? Go to question 2. A. Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. B. Withdraw the catheter to 1 inch, and ask the patient to cough. C. Encourage the patient to cough as the catheter is advanced. D. Apply pressure to the patient's lower abdomen over the bladder.

D

While changing a patient's hospital gown, the extension set on the IV infusion becomes disconnected and ends up on the bed linens. What would the nurse do? A. Reconnect the extension set. B. Clean the end with an alcohol swab, and reconnect it. C. Pull the IV from the site, and insert a new catheter. D. Change the extension set tubing.

D

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? a. Notify the physician immediately. b. Place the patient in the prone position to facilitate drainage. c. Instill 3 mL of normal saline into the tracheostomy tube to loosen secretions. d. Continue your assessment of the patient, including O2 saturation, respiratory rate, and breath sounds.

D

While palpating the skin around a patient's CVAD insertion site, the nurse elicits a crackling sound. What might this finding indicate? A. Catheter occlusion B. Infection C. Skin erosion D. Subcutaneous emphysema

D

While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained? Go to question 4. A. Cover the field with a sterile drape before leaving the room. B. Collect the necessary supplies after preparing a new sterile field. C. Retrieve the supplies, but instruct the patient not to touch anything on the field. D. Ask the assistant who has been helping with the procedure to bring the necessary supplies.

D

Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? Go to question 3. A. To encourage the bladder to drain fully B. To encourage spontaneous voiding C. To prevent bowel elimination during the procedure D. To reduce the patient's risk of urinary tract infection

D

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? Go to question 3. A. Sterile technique protects the patient from microorganisms in the urine. B. Sterile technique protects the nurse from microorganisms in the urine. C. Sterile technique reduces the amount of pain caused by the procedure. D. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contaminated

D

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as metabolic acidosis. respiratory acidosis. respiratory alkalosis. within normal limits.

D

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Magnesium rising to 2.9 mg/dL Phosphorus falling to 2.1 mg/dL

D

Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

D

A patient admitted to the emergency department after a motor vehicle accident. Which urinalysis findings would the nurse expect if kidney trauma occurred (select all that apply.)? Casts Glucose Bilirubin Myoglobinuria Red blood cells White blood cells

D, E

The nurse is preparing a patient for an intravenous pyelogram (IVP). What is a priority action by the nurse? Administer a cathartic or enema. Assess patient for allergies to penicillin. Keep the patient NPO for 4 hours preprocedure. Advise the patient that a metallic taste may occur during procedure.

a

What is the correct order of steps for removal of protective barriers after leaving an isolation room? 1. Remove gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side. 1, 3, 5, 4, 2 1, 5, 3, 4, 2 1, 3, 4, 5, 2 3, 1, 5, 4, 2

a

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? Reverse isolation Droplet precautions Standard precautions Contact precautions

b

A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order? 1. Notify the health care provider of the patient's status. 2. Reassure the patient and recheck the wound later. 3. Support the patient's fluid and nutritional needs. 4. Use aseptic technique to change the dressing. 4, 1, 2, 3 4, 2, 1, 3 4, 2, 3, 1 2, 4, 1, 3

b

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

b

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? Provide a dark, quiet room to calm the patient. Reduce the level of precautions to keep the patient from becoming angry. Explain the reasons for isolation procedures and provide meaningful stimulation. Limit family and other caregiver visits to reduce the risk of spreading the infection.

c

What is the most effective way to control transmission of infection? Isolation precautions Identifying the infectious agent Hand hygiene practices Vaccinations

c

Which statement by the patient would indicate that he or she understands the safe use of oxygen? Go to question 2. A. "The nurse told me that my oxygen saturation must be maintained at 85% or above." B. "I know that oxygen is a medication I can adjust whenever I need to." C. "I'll alert the nurse immediately if I have any increased difficulty breathing." D. "I often experience difficulty breathing for no apparent reason, but that is expected."

c

A family member is providing care to a loved one who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? Wear gloves before eating or handling food. Place any soiled materials into a bag and double bag it. Have the family member check with the health care provider about need for immunization. Perform hand hygiene after care and/or handling contaminated equipment or material.

d

Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? Reinforce dressing with a clean, dry dressing and call the health care provider. Remove wet dressing and apply new dressing using sterile procedure. Put on gloves before removing the old dressing; then obtain a wound culture. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

d