COI2 practice questions

The nurse anticipates that part of the self-care education for a patient with multiple sclerosis will include all except:

"If my muscles are feeling tired I will take a hot bath."

A nurse is collecting subjective data from a CHF patient being admitted to the cardiac unit. Which statement by the patient alerts the nurse that this patient may have right-sided heart failure?

"My shoes fit really tight lately" -- Right sided heart failure causes edema in lower extremities.

A client is receiving lasix (Furosemide) twice a day. In planning the client's care the nurse would include monitoring for signs and symptoms of which of the following?

*Hypokalemia, hyponatremia, hypomagnesemia (choose hypokalemia if its in the answer choice)

A nurse is assessing a patient with peripheral artery disease (PAD). Patient complains of recent pain and tingling down his feet/leg as he walks two to three blocks. What important question would the nurse ask next?

...

The nurse educating a patient with seizure disorder on the importance of medication adherence, will also emphasize to the patient to avoid abruptly stopping seizure medications as such poor self-care behavior could put the patient at risk for which of these?

...

The nurse is reviewing the laboratory report for a patient with COPD. Which laboratory finding is most important to report to the health care provider?

...

A patient with type 2 diabetes is at the clinic today for a follow-up visit. Which test will the nurse anticipate the healthcare provider will order to evaluate for glucose control in the past 3 months?

A1C blood test

A 48- year- old diabetis male patient calls the clinic to report he feels shaky and sweaty; and his glucose level was 58 mg/dL, what would the nurse advise him to do?

ANS: 4-6 oz of juice

A nurse obtains a health history from a patient who has a 35 pack- year smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask? --- a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

ANS: A "How much alcohol do you drink in an average week?" -- Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever

A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? --- a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: A Assist with active range of motion (ROM). -- ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

Which information will the nurse include in teaching a female patient who has type 2 diabetes, and diabetic sensory neuropathy of the feet and legs? --- a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.

ANS: A Choose flat-soled leather shoes. -- The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems.

A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? --- a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N)

ANS: A Lispro (Humalog) -- Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

Nursing assessment of a 70-year-old patient is most important make during initiation of thyroid replacement with levothyroxine (synthroid). --- a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness

ANS: B Apical pulse rate -- In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

62. A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? --- a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

ANS: B Check the respiratory rate and effort -- The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

A 63 year old diabetic patient with history of renal insufficiency who takes metformin is scheduled for a computed tomography (CT scan) without contrast. Which of the following would the nurse do?

Keep patient well hydrated? (bc renal insufficiency)

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? --- a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

ANS: B Maintain a consistent daily routine for the patient's care. -- Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first? --- a. Patient with a transient ischemic attack (TIA) returning from carotid duplex studies b. Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram c. Patient with a seizure disorder who has just completed an electroencephalogram (EEG) d. Patient prepared for a lumbar puncture whose health care provider is waiting for assistance

ANS: B Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram -- Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse, blood pressure, and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority.

20. A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching? --- a. The RN checks the blood pressure in both arms. b. The RN palpates the neck to assess thyroid size. c. The RN orders saline eye drops to lubricate the patient's bulging eyes. d. The RN lowers the thermostat to decrease the temperature in the room.

ANS: B The RN palpates the neck to assess thyroid size. -- Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the new RN are appropriate when caring for a patient with an enlarged thyroid.

Which information will the nurse include when teaching a 50 year old who has type 2 diabetes about glyburide (oral) (micronase, DiaBeta, Glynase)? --- a. Glyburide decreases glucagon secretion from the pancreas. b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.

ANS: B-Glyburide stimulates insulin production and release from the pancreas. -- The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

27. Which question will provide the most useful information to a nurse who is interviewing a patient about a possible thyroid disorder? --- a. "What methods do you use to help cope with stress?" b. "Have you experienced any blurring or double vision?" c. "Have you had a recent unplanned weight gain or loss?" d. "Do you have to get up at night to empty your bladder?"

ANS: C "Have you had a recent unplanned weight gain or loss?" -- Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.

6. The nurse is assessing an 18- year-old patient experiencing the onset of symptoms of type 1 diabetes including polyuria and polydipsia. Which question is most appropriate for the nurse to further ask? --- a. "Are you anorexic?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Do you crave sugary drinks?"

ANS: C "Have you lost weight lately?" -- Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very Dilute.

The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? --- A. "I can have an occasional alcoholic drink if I include it in my meal plan." B. "I will need a bedtime snack because I take an evening dose of NPH insulin." C. "I can choose any foods, as long as I use enough insulin to cover the calories." D. "I will eat something at meal times to prevent hypoglycemia, even if I am not hungry."

ANS: C "I can choose any foods, as long as I use enough insulin to cover the calories." -- Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.

A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? --- a. Thigh. b. Buttock. c. abdomen. d. upper arm.

ANS: C Abdomen -- Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.

Which hospitalized patient will the nurse assign to the room closest to the station? --- a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination

ANS: C Patient with new-onset confusion, restlessness, and irritability after surgery -- This patient's history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses' station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues.

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? --- a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

ANS: C Place needed objects on the patient's left side. -- During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

A 37 year old patient is being admitted with a diagnosis of cushing syndrome. Which findings will the nurse expect during the assessment? --- a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

ANS: C Purplish streaks on the abdomen -- Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.

When taking care of patient with myasthenia gravis, which assessment is most important for the nurse to do? --- a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

ANS: C Respiratory effort -- Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescripted dose of aspirin? --- a. The patient has dysphagia. b.The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

ANS: C The patient reports that symptoms began with a severe headache. -- A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

17. After change- of- shift report on the Alzheimer's disease/ dementia unit, which patient will the nurse assess first? --- a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast

ANS: D Patient who developed a new cough after eating breakfast -- A new cough after a meal in a patient with dementia suggests possible aspiration, and the patient should be assessed immediately. The other patients also require assessment and intervention but not as urgently as a patient with possible aspiration or pneumonia.

A patient being treated with carbidopa/levodopa (sinemet) for Parkinson's disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed? --- a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

ANS: D Uncontrolled head movement -- Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. What should the nurses anticipate will be tested next? --- a. Calcitonin b. catecholamine c. thyroid hormone d. parathyroid hormone

ANS: D parathyroid hormone -- Parathyroid hormone is the major controller of blood calcium levels. Although calcitonin secretion is a countermechanism to parathyroid hormone, it does not play a major role in calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium level.

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to: --- a. save the lunch tray for the patient's later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat.

ANS: D request that if testing is further delayed, the patient be returned to the unit to eat. -- Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

While collecting subjective data from a patient with suspected cushing's syndrome, which of these will be one of the important questions for the nurse to ask this patient?

ANS: Past use of steroids

When a brain-injured patient responds to painful stimuli with extension and external rotation of arms and wrists, the nurse reports the response as.

ANS: decerebrate posturing

A 23- years- old college student presents to the ER lethargic with complaint of fever nausea, vomiting, headache and fatigue that started abruptly last night, upon physical examination, the nurse notices that when patient's necks is flexed, flexion of the knees and hip follow, the nurse immediately notifies the doctor, initiates respiratory isolation as this patient is showing signs and symptoms of which of the following:

ANS: meningitis -- Brudzinski's sign of meningitis is the sign in which hip and knee flexion follow neck flexion. The symptoms listed are also symptoms of meningitis.

A patient with injury in the parietal lobe of the brain is likely to have difficulty with:

ANS: right-left confusion, agraphia, acalculia, aphasia, agnosia, coordination

Janet, a 35-year-old patient with history of seizure disorder just lost consciousness and started having a tonic-clonic seizure while eating breakfast in a shared hospital room, nurse mary would do all the following except:

ANS: you would do these: bring them slowly to the floor, pillow or cushion the head, lay on their side, clear the area (maybe have someone else get help?)

A 50 year old female has been diagnosed with hypothyroidism and the doctor prescribes levothyroxine (synthroid) for her , the patient asks the nurse to teach her how to take this new medication; the nurse would include which the following in this patient's medication teaching?

ANS?: take on an empty stomach

A patient experiences prolonged chest pain that is not immediately reversible. The patient's health care provider explains that the cause of the pain is that a once- stable athrosclerotic plaque has ruptured, causing platelet aggregation and thrombus formation. Which condition is consistent with this explanation?

Acute coronary syndrome -- When ischemia is prolonged and not immediately reversible, ACS develops. ACS is associated with deterioration of a once stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as STEMI.

A patient reports severe chest pain radiating to the neck and arms. Assessment findings include a scratching, grating, and high- pitched sound at the lower sternal border of the chest. Which condition would the nurse suspect?

Acute pericarditis -- Severe chest pain radiating to the neck, arms, and shoulders indicates acute pericarditis. Pericardial friction rub is scratching, grating, and high-pitched sound heard at the lower sternal border of the chest; this condition is associated with patients who have acute endocarditis. Subacute nodules are small, firm, painless, and hard swellings over the knees, elbows, and wrists associated with rheumatic fever. Rheumatic endocarditis and chronic rheumatic carditis are complications associated with rheumatic fever.

The nurse could hear a patient with known history of asthma wheezing severely while she is on the patient, which inhaler would the nurse advise the patient to use immediately?

Albuterol (beta 2 antagonist)

A 68-year-old patient is in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor at rest: the nurse knowing the type of neurological disease with these symptoms, will plan on likely giving the patient education on which of these medication that the healthcare provider might prescribe?

Ans: Antiparkinson meds Sinemit, requip, mirapex

The nurse taking care of a new patient admitted with tumor in the frontal lobe anticipates that the patient would likely have a problem with:

Ans: Speech articulation, behavior, moral decision making and emotional outburst

A patient receives regular insulin (novolin R) at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00AM b. 12:00AM c. 2:00PM d. 4:00PM

Ans: A 10:00 AM The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? --- a. Oxygen, nitroglycerin, aspirin, and morphine b. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine c. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen d. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

Ans: A Oxygen, nitroglycerin, aspirin, and morphine

The nurse is caring for a hospitalized older patient who has nasal packing in place aftera nosebleed. Which assessment finding will require the most immediate action by the nurse? --- a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient reports level 8 (0 to 10 scale) pain. d. The patient's temperature is 100.1° F (37.8° C).

Ans: A The oxygen saturation is 89% -- Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate aneed for nursing action but not as immediately as the low O2saturation.

The nurse is providing education to a patient with dilated cardiomyopathy (CMP). Which patient statement indicates the need for further teaching? --- a. "I may need to start taking a diuretic." b. "I may be given a prescription for nitroglycerin." c. "Most patients with this diagnosis respond well to treatment." d. "I should alternate periods of rest with required activities of daily living."

Ans: C. "Most patients with this diagnosis respond well to treatment." -- Dilated CMP does not respond well to therapy, and patients experience multiple episodes of heart failure (HF). Nitrates and diuretics decrease preload and may be prescribed. Alternating periods of rest with activity is needed to reduce the workload of the heart.

After receiving change-of-shift report on the following four patients, which should the nurse see first? --- a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due

Ans: A) a 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed -- tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls on the floor. The nurse will first: --- a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

Ans: A) assess the patient for a possible head injury. -- *The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication.

Following assessment of a patient with pneumonia, the nurse identifiers a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 bpm d. Resting pulse oximetry (SpO2) of 85%

Ans: A. Weak, nonproductive cough effort (The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.)

The nurse admits a patient to the hospital with addisonian crisis. Which patient statement supports the need to plan additional teaching? --- a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

Ans: B "I had the flu earlier this week, so I couldn't take the hydrocortisone." -- The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.

The nurse is educating a patient with asthma about inhaler use, Which patient action when using albuterol and beclomethasone inhalers indicates a need for further teaching? --- a. Take the albuterol at the same time each day. b. Administer the beclomethasone inhaler prior to using the albuterol inhaler. c. Use beclomethasone if experiencing an acute episode. d. Avoid shaking the beclomethasone before use.

Ans: B Administer the beclomethasone inhaler prior to using the albuterol inhaler. -- (When a client is prescribed an inhaled beta 2-agonist (such as albuterol) and an inhaled glucocorticoid (such as betamethasone) the client should take the beta 2-agonist first, it promotes bronchodilation and enhances absorption of the glucocorticoid.)

A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be the most useful for monitoring this patient? --- a. I b. II c. V2 d. V6

Ans: B II -- (Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area)

The nurse advises a patient with myasthenia gravis (MG) to except: --- a. perform physically demanding activities early in the day. b. exercise 1 hour, 4-5 days a week c. do frequent weight-bearing exercise to prevent muscle atrophy. d. Balance exercise and rest

Ans: B exercise 1 hour, 4-5 days a week

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? --- a. A patient who reported dizziness after receiving the first dose of captopril. b. A patient who is cool and clammy, with new-onset confusion and restlessness c. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

Ans: B. A patient who is cool and clammy, with new-onset confusion and restlessness -- (The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management)

The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient indicates teaching was effective? --- a. "I will use my inhaler right before the test" b. "I won't eat or drink anything 8 hours before the test." c. "I should inhale deeply and blow out as hard as I can during the test." d. "My blood pressure and pulse will be checked every 15 minutes after the test"

Ans: C "I should inhale deeply and blow out as hard as I can during the test." -- (For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.)

The echocardiography report of a patient with infective endocarditis (IE) indicates the presence of a vegetative mass in the right ventricle. The nurse recalls that what complication could result from this condition? --- a. Renal embolization b. Liver embolization c. Pulmonary embolization d. Cerebral embolization

Ans: C Pulmonary embolization -- Vegetations are the primary lesions of infective endocarditis (IE) that stick to the endocardium of the heart. Vegetations occurring in the right side of the heart could dislodge and then occlude the pulmonary artery, causing pulmonary embolism. Vegetations occurring in the left side of the heart can dislodge and cause embolism in the brain, liver, kidneys, and spleen. This can lead to renal, liver, or cerebral embolization.

A patient hospitalized with a new diagnosis of Guillain- Barre syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate? --- a. intubation and mechanical ventilation. b. administration of corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. infusion of immunoglobulin (Sandoglobulin).

Ans: C insertion of a nasogastric (NG) feeding tube.

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

Ans: D "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." -- (The follow-up chest x-ray examination will be done in 6-8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may also be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions)

A nurse is educating a patient with COPD on the use of an ipratropium inhaler. Which patient statement indicates a need for further teaching? --- a. "I can rinse my mouth following the two puffs to get rid of the bad taste." b. "I should wait at least 1-2 min between each puff of the inhaler." c. "Because this medication is not fast acting, I cannot use it in an emergency if my breathing gets worse." d. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

Ans: D "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily." -- Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient's respiratory status.

The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? --- A. "If I overeat at a meal, I will still take the usual dose of medication." B. "Other medications besides the Glucotrol may affect my blood sugar." C. "When I am ill, I may have to take insulin to control my blood sugar." D. "My diabetes won't cause complications because I don't need insulin."

Ans: D "My diabetes won't cause complications because I don't need insulin." -- The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

An adult patient with no medical history is being seen in a clinic for a routine physical exam. The patient's blood pressure reading is 159/94. The patient asks the nurse: "Does this mean that I have hypertension?". Which response would the nurse provide? --- a. "Do not worry. Everything is fine." b. "It is a normal blood pressure reading for an adult." c. "Yes, you do have hypertension, because your blood pressure is over 140/90." d. "You need a follow-up appointment to recheck your blood pressure to make this determination."

Ans: D. "You need a follow-up appointment to recheck your blood pressure to make this determination" -- Hypertension is defined as a persistent systolic BP of 140 mm Hg or more, diastolic BP of 90 mm Hg or more, or current use of antihypertensive medication. A diagnosis of hypertension will not be made based on one elevated blood pressure reading. Considering the fact that the patient does not have any medical problems and that this reading is the first elevated blood pressure reading, a follow-up office visit is required. Providing false reassurance to the patient is leading to misinformation. For any person of age 18 and older, a BP higher than 140/90 is considered elevated.

The nurse checks for swallowing ability by checking gag reflex before feeding patients with the following disease(s) because she understands that patients with this or these disease(s often have swallowing difficulty and thus at risk for aspiration:

Ans: Dysphagia

A 27- year- old patient with history of seizure disorder has been admitted to your unit due to changing seizure characteristics, type and increased frequency within the past 2-3 months, a nurse familiar with diagnostic testing for this disorder anticipates that among other tests, the doctor is most likely to order which of these monitor this patient's seizure activity?

Ans: Electroencephalography (EEG) -- Used for dx of seizures. If pt. If scheduled for one, you may need to withhold any sedatives based on the doctor's order.

A patient with which one of these diseases is likely to have profound depression, uncontrollable fits of anger, hallucination and delusion?

Ans: Huntington's disease

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to chew and swallow?

Ans: Imbalanced nutrition: less than body requirements

The nurse taking care of a stroke patient with expressive aphasia expects that the patient will likely have:

Ans: Inability to talk (express oneself)

A 35-year-old female patient with history of headaches presents to the clinic this morning with reports of one-sided throbbing headache, photophobia, nausea and vomiting that started early this morning. Nurse John educates the patient to stay in a quiet, dimly lit environment or room because he suspects this patient may be having what type of headache?

Ans: Migraine

A patient with new diagnosis of diabetes asks the nurse about the different types of diabetes and what causes them, the nurse educated this patient by telling her what which type of diabetes is more caused by autoimmune, genetics, starts at a young age and can only be controlled with insulin?

Ans: Type 1 diabetes

After change-of-shift report, which patient should the nurse assess first? --- a. 40-year-old male with celiac disease who has frequent frothy diarrhea b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer

Ans: b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting Pain and vomiting -- with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? --- a. Cerebral aneurysm clipping. b. Heparin intravenous infusion. c. Oral low-dose aspirin therapy. d. Tissue plasminogen activator (tPA).

Ans: c. Oral low-dose aspirin therapy. -- Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

The nurse is caring for a patient with a diagnosis of acute tuberculosis (TB) and anticipates which item will be included in the patient's treatment plan?

Avoid alcohol because it increases the hepatotoxicity associated with isoniazid (INH) -- Directly observed therapy must be continued through both phases in patients who are risk for noncompliance with drug therapy. Drug therapy includes a two-phase process, with an initial and continuation phase. Baseline LFTs are done before treatment is begun and then monitored monthly

A patient who had a thyroidectomy earlier today develops laryngeal stridor and severe muscular cramp and spasm in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? --- a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

B Administer IV calcium gluconate. -- The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.

The nurse plans to teach a patient diagnosed with pneumonia to do all of the following except?

Bradycardia

The nurse is caring for a patient with epistaxis. When patient action may prevent appropriate healing after the nurse has completed an anterior nasal packing?

Care for epistaxis pt: Patient should be in a sitting position, leaning slightly forward with head tilted forward. Apply direct pressure by squeezing the entire soft lower part of the nose together 5-15 minutes. Reassure and calm the pt; if bleeding does not stop within 15 minutes, seek medical assistance.

Nurse mary understands that her patient with brain injury who has been experiencing severe problems with balance and coordination likely has damage in which part(s) of the brain?

Cerebellum

The nurse is evaluating a 3 day diet history with a patient who has an elevated lipid panel and coronary artery disease (CAD). What meal selection indicates that the patient is following the right diet?

Correct diet for CAD: Decreased saturated fats and cholesterol Decreased Red meat, Egg yolks, whole milk. Increased Carbohydrates and fiber. Increased omega-3 fatty acids (fishy bois).

A nurse has received an order to discharge a patient who was admitted due to stroke, knowing the risk factors for stroke, what in this patient's admission data would prompt the nurse to reiterate lifestyle changes he needs to make in order to help prevent another stroke?

Current cigarette smoking and alcohol use.

Which finding would the nurse expect to observe in a patient who has complications of pericarditis?

Decreased blood pressure with tachycardia,

A 70- year- old male has been on admission for 1 week due pneumonia and has remained stable; but suddenly today he became confused, disoriented, agitated and delusional, the nurse plans to provide for safety, administer prescribed medication, re- orient patient and encourage family to bring familiar objects from home as she suspects patient may have which of the following neurological problem?

Delirium

A 23 year old male with a history of diabetes caused by genetic and environmental factors, which he manages with insulin only, presents to ER with nausea and vomiting, abdominal pain, confusion, excessive thirst and urination, severely elevated glucose level, and fruity-smelling breath. The nurse examines these symptoms as:

Diabetic Ketoacidosis (DKA)

The nurse will include which teaching to a student nurse about cystic fibrosis?

Diet and medication, chloride sweat test

A patient with Cushing's syndrome will likely have which of these lab results?

Elevated serum cortisol, Elevated blood glucose, Hypernatremia, Hypokalemia

A 44 yr old hypertensive male called the outpatient clinic to inform the doctor that he wanted to stop taking his blood pressure medications due to erectile dysfunction. What is the most appropriate instruction the nurse should give to this patient?

IT MUST BE FRUSTRATING TO DEAL WITH (something around this answer

a 85 year old female with a history of uncontrolled hypertension is in the emergency room with symptoms and signs of stroke. In prioritizing her care, which of the following would the nurse do first?

Notify the physician

Which finding would the nurse expect to observe in patient who has a complication of pericarditis?

Pericardial friction rub

A patient arrives to the emergency department by ambulance with a sudden change in mental status and a feeling of impending doom. The nurse reviews the patient's medical history and notes recent international air travel. The nurse suspects that the patient is experiencing which condition?

Pulmonary embolism? Flying on an airplane can increase risk of blood clots.

Upon entering a patient's room, the nurse notices that 67 year old male initially admitted for pneumonia appears confused, slurred speech, with one-sided weakness, the nurse calls for help and initiates intervention as she suspects her patient's symptoms suggest which of the following

Stroke

The nurse is taking care of a patient with pneumonia. Which findings are the best indicator that the patient is developing acute respiratory distress syndrome (ARDS)?

The patient's PaO2 remains at 45 mmHg.

The nurse is teaching a patient with COPD about the use of theophylline. Which of the following patient statements would indicate teaching was effective?

Therapeutic level 5-15 mcg/ml

The nurse educates his asthmatic patient to rinse his mouth after administering inhaled corticosteroid in order to reduce the risk for which of the following

Thrush (fungal infection)

A nurse is caring for a patient with COPD who is experiencing dyspnea and has a forced expiratory volume of 70% of predicted value. The nurse can anticipate that which medication may be included in the plan of care for the patient?

Use of short-acting bronchodilator

A patient's history includes an ejection fraction of 30%, diabetes, reports of stabbing chest pain that is relieved upon rest, and prescription for Captopril. If the patient is intolerant of Captopril. Which medication would the nurse expect will be prescribed?

Valsartan

A home health nurse is at the home of an asthmatic patient for a visit when the patient started having dry cough, wheezing, and records a peak flow meter reading of 60%. Which action shows the nurse understands the patient's symptoms and peak flow meter results?

Yellow Zone: Usually 50- 80% of personal best, indicates caution, sometimes is triggering asthma. (i guess)

Which statement by the patient indicates a need for additional instruction in administering insulin? --- a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I can buy the 0.5-mL syringes because the line markings will be easier to see." c. "I do not need to aspirate the plunger to check for blood before injecting insulin." d. "I should draw up the regular insulin first, after injecting air into the NPH bottle."

a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I can buy the 0.5-mL syringes because the line markings will be easier to see." c. "I do not need to aspirate the plunger to check for blood before injecting insulin." d. "I should draw up the regular insulin first, after injecting air into the NPH bottle."

The nurse recognizes which medication is the most appropriate for a patient with chronic kidney disease (CKD) who has a glycosylated hemoglobin of 5% blood pressure of 140/95 mm Hg, and whose urinalysis reveals the presence of protein?

angiotensin receptor blocker

Which respiratory defense mechanism may have failed in a patient who smokes one pack of cigarettes per day and has developed a diagnosis of pneumonia? --- a. Cough reflex b. Filtration of air c. Alveolar macrophages d. Mucociliary clearance system

ans: C Alveolar macrophages -- Alveolar macrophages rapidly phagocytize inhaled foreign particles, such as bacteria, and often fail because of cigarette smoking.

A female patient with chronic hypertension is admitted to the emergency department with a sudden rise in blood pressure. Which question is the priority for the nurse to ask the patient? --- a. Are you pregnant? b. Do you need to urinate? c. Do you have a headache or confusion? d. Are you taking antiseizure medications as prescribed?

ans: C Do you have a headache or confusion? -- The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensve encephalopathy, from increased cerebral capillary permeability leading to cerebral edema. Pregnancy can lead to secondary hypertension. Needing to urinate and taking anti-seizure medication do not indicate a hypertensive emergency.

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? --- a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes.

A patient with brain injury who is having a problem with maintaining normal heart rate, respiration and blood pressure, likely sustained injury in which of the following parts of the brain? Ans: Brain stem (medulla oblongata)

medulla oblongata (brain stem)