Exam 1 Lewis - 2nd Sem.

29. Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately? A) Presence of the Chvosteks sign B) Abnormal serum potassium level C) Decreased thyroid hormone level D) Bleeding on the patients

A) Presence of the Chvosteks sign

18. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray? A) Grape juice B) Milk carton C) Mixed green salad D) Fried chicken

B) Milk carton

39. Which IV solution would the nurse anticipate administering to a patient with an extracellular fluid (ECF) deficit who requires isotonic fluid replacement? (Select all that apply.) A) Saline 0.9% B) Saline 0.45% C) Dextrose 10% D) Lactated Ringer's E) Dextrose 5% in saline 0.25%

A) Saline 0.9% D) Lactated Ringer's E) Dextrose 5% in saline 0.25%

25. The nurse measures a patient's blood pressure as 172/82 mm Hg. What is the patient's mean arterial pressure (MAP)?

112 mm Hg

24. The nurse obtains a blood pressure of 176/83 mm Hg for a patient. What is the patients mean arterial pressure (MAP)? (Numerical Value only)

114 mm Hg

25. There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening? A) 38-year old with a 7-mm nevus on the face that has recently become darker B) 62-year-old with multiple small, soft, pedunculated papules in both axillary areas C) 42-year-old with complaints of itching after using topical fluorouracil on the nose D) 50-year-old with concerns about skin redness after having a chemical peel 3 days

A) 38-year old with a 7-mm nevus on the face that has recently become darker

14. The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? A) 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain B) 52-year-old with a BP of 212/90 who has intermittent claudication C) 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL D) 48-year-old with a BP of 172/98 whose urine shows microalbuminuria

A) 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain

9. The nurse has just finished teaching a hypertensive patient about the newly prescribed ramipril (Altace). Which patient statement indicates that more teaching is needed? A) A little swelling around my lips and face is okay. B) The medication may not work as well if I take any aspirin. C) The doctor may order a blood potassium level occasionally. D) I will call the doctor if I notice that I have a frequent cough.

A) A little swelling around my lips and face is okay.

4. A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? A) Prepare the patient for a biopsy. B) Teach about the use of corticosteroid creams. C) Explain how to apply tretinoin (Retin-A) to the face. D) Discuss the need for topical application of antibiotics.

A) Prepare the patient for a biopsy.

38. Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) A) Administer patch testing to a patient with allergic dermatitis. B) Interview a new patient about chronic health problems and allergies. C) Apply a sterile dressing after the health care provider excises a mole. D) Explain potassium hydroxide testing to a patient with a skin infection. E) Teach a patient about site care after a punch biopsy of an upper arm lesion.

A) Administer patch testing to a patient with allergic dermatitis C) Apply a sterile dressing after the health care provider excises a mole

7. A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? A) Assign the patient to a room near the nurses station. B) Place the patient in a room nearest to the water fountain. C) Place the patient on telemetry to monitor for peaked T waves. D) Assign the patient to a semi-private room and place an order for a low-salt diet.

A) Assign the patient to a room near the nurses station.

1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? A) Blood pressure is 90/40 mm Hg. B) Urine output is 30 mL over the last hour. C) Oral fluid intake is 100 mL for the last 8 hours. D) There is prolonged skin tenting over the sternum.

A) Blood pressure is 90/40 mm Hg.

6. The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan? A) Clean the infected areas with soap and water. B) Apply alcohol-based cleansers on the lesions. C) Avoid use of antibiotic ointments on the lesions. D) Use petroleum jelly (Vaseline) to soften crusty areas.

A) Clean the infected areas with soap and water.

22. Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? A) Collect a detailed diet history. B) Provide a list of low-sodium foods. C) Help the patient make an appointment with a dietitian. D) Teach the patient about foods that are high in potassium.

A) Collect a detailed diet history.

26. A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? A) Cool, wet cloths or dressings can be used to reduce itching. B) Take cool or tepid baths several times daily to decrease itching. C) Add oil to your bath water to aid in moisturizing the affected skin. D) Rub yourself dry with a towel after bathing to prevent skin maceration. E) Use of an over-the-counter (OTC) antihistamine can reduce scratching.

A) Cool, wet cloths or dressings can be used to reduce itching. B) Take cool or tepid baths several times daily to decrease itching. E) Use of an over-the-counter (OTC) antihistamine can reduce scratching.

19. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? A) Daily alcohol intake B) Intake of dietary protein C) Multivitamin/mineral used D) Use of over-the-counter (OTC) laxatives

A) Daily alcohol intake

38. The nurse observes that the patient's central venous catheter insertion site is red and tender to touch. the patient's temperature is 101.8F. What should the nurse plan to do? A) Discontinue the catheter and culture the tip. B) Use the catheter only for fluid administration. C) Change the flush system and monitor the site. D) Check the site more frequently for any swelling.

A) Discontinue the catheter and culture the tip.

4. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? A) Increase fluids if your mouth feels dry. B) More fluids are needed if you feel thirsty. C) Drink more fluids in the late evening hours. D) If you feel lethargic or confused, you need more to drink.

A) Increase fluids if your mouth feels dry.

9. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? A) Infuse 5% dextrose in water at 125 mL/hr. B) Administer IV morphine sulfate 4 mg every 2 hours PRN. C) Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. D) Administer 3% saline if serum sodium decreases to less than 128

A) Infuse 5% dextrose in water at 125 mL/hr.

13. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? A) Lung sounds B) Urinary output C) Peripheral pulses D) Peripheral edema

A) Lung sounds

15. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

A) Metabolic acidosis

33. The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? A) Monitor ionized calcium level B) Give oral calcium citrate tablets. C) Check parathyroid hormone level. D) Administer vitamin D supplements.

A) Monitor ionized calcium level

25. A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? A) Notify the patients health care provider. B) Obtain an order to draw a potassium level. C) Review the magnesium level on the patients chart. D) Teach the patient about the risk of magnesium-containing

A) Notify the patients health care provider.

16. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? A) Oral digoxin (Lanoxin) 0.25 mg daily B) Ibuprofen (Motrin) 400 mg every 6 hours C) Metoprolol (Lopressor) 12.5 mg orally daily D) Lantus insulin 24 U subcutaneously every

A) Oral digoxin (Lanoxin) 0.25 mg daily

15. The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? A) Serum creatinine of 2.8 mg/dL B) Serum potassium of 4.5 mEq/L C) Serum hemoglobin of 14.7 g/dL D) Blood glucose level of 96

A) Serum creatinine of 2.8 mg/dL

28. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? A) The patient is experiencing laryngeal stridor. B) The patient complains of generalized fatigue. C) The patients bowels have not moved for 4 days. D) The patient has numbness and tingling of the lips.

A) The patient is experiencing laryngeal stridor.

24. The nurse working in the dermatology clinic assesses a young adult female patient who is taking isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of a need for further questioning of the patient? A) The patient recently had an intrauterine device removed. B) The patient already has some acne scarring on her forehead. C) The patient has also used topical antibiotics to treat the acne. D) The patient has a strong family history of rheumatoid arthritis.

A) The patient recently had an intrauterine device removed.

10. A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? A) Thinning of the affected skin B) Alopecia of the affected areas C) Reddish-brown discoloration of the skin D) Dryness and scaling in the areas of treatment

A) Thinning of the affected skin

2. Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? A) Use a sunscreen with a high SPF when exposed to the sun. B) Sun exposure may decrease the effectiveness of the medication. C) Photosensitivity may result in an artificial-looking tan appearance. D) Wear sunglasses to avoid eye damage while taking this medication.

A) Use a sunscreen with a high SPF when exposed to the sun.

6. Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication when the patient reveals a history of. . . A) asthma B) daily alcohol use C) peptic ulcer disease D) myocardial infarction (MI)

A) asthma

20. The charge nurse observes a new registered nurse doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to. . . A) increase the dietary intake of high-potassium foods. B) make an appointment with the dietitian for teaching. C) check the blood pressure (BP) with a home BP monitor at least once a day. D) move slowly when moving from lying to sitting to standing.

A) increase the dietary intake of high-potassium foods.

2. The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? A) Low dietary fiber intake B) No regular aerobic exercise C) Weight 5 pounds above ideal weight D) Drinks a beer with dinner on most

B) No regular aerobic exercise

12. Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus? A) 102/60 mm Hg B) 128/76 mm Hg C) 139/90 mm Hg D) 136/82 mm

B) 128/76 mm Hg

21. Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? A) Blood glucose level of 175 mg/dL B) Blood potassium level of 3.0 mEq/L C) Most recent blood pressure (BP) reading of 168/94 mm Hg D) Orthostatic systolic BP decrease of 12 mm

B) Blood potassium level of 3.0 mEq/L

34. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? A) Obtain the baseline weight. B) Check the patients blood pressure C) Draw blood for serum electrolyte levels. D) Ask about any extremity numbness or tingling.

B) Check the patients blood pressure

3. A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? A) Skin turgor B) Daily weight C) Presence of edema D) Hourly urine

B) Daily weight

12. An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? A) Pallor B) Edema C) Confusion D) Restlessness

B) Edema

26. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? A) Discontinue the nasogastric suction. B) Give the patient the PRN IV morphine sulfate 4 mg. C) Notify the health care provider about the ABG results. D) Teach the patient how to take slow, deep breaths when anxious.

B) Give the patient the PRN IV morphine sulfate 4 mg.

1. Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? A) Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. B) Have the patient sit in a chair with the feet flat on the floor. C) Assist the patient to the supine position for BP measurements. D) Obtain two BP readings in the dominant arm and average the results.

B) Have the patient sit in a chair with the feet flat on the floor.

16. A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask first? A) Did you take any acetaminophen (Tylenol) today? B) Have you been consistently taking your medications? C) Have there been any recent stressful events in your life? D) Have you recently taken any antihistamine medications?

B) Have you been consistently taking your medications?

27. Which assessment data from an older patient admitted with bacterial pneumonia would be of concern to the nurse? A) Brown macules on hands B) History of allergic rashes C) Skin wrinkled with tenting on both hands D) Longitudinal nail ridges and sparse scalp hair

B) History of allergic rashes

8. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? A) Administer the KCl as a rapid IV bolus. B) Infuse the KCl at a rate of 10 mEq/hour. C) Only give the KCl through a central venous line. D) Discontinue cardiac monitoring during the infusion.

B) Infuse the KCl at a rate of 10 mEq/hour.

39. A 35-yr-old female patient has a new prescription for isotretinoin. Which additional assessment information will be most important for the nurse to obtain? A) History of sun exposure by the patient B) Method of contraception used by the patient C) Length of time the patient has had acne lesions D) Appearance of the treated areas on the patient's face

B) Method of contraception used by the patient

27. Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A) Administer IV antibiotics through the implantable port. B) Monitor the IV sites for redness, swelling, or tenderness. C) Remove the patients non-tunneled subclavian central venous catheter. D) Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

B) Monitor the IV sites for redness, swelling, or tenderness.

8. A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? A) Ringlike rashes with red, scaly borders over the entire scalp B) Papular, wheal-like lesions with white deposits on the hair shaft C) Patchy areas of alopecia with small vesicles and excoriated areas D) Red, hivelike papules and plaques with sharply circumscribed

B) Papular, wheal-like lesions with white deposits on the hair shaft

28. The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. Which action would the nurse take to determine if the lesion is related to intradermal bleeding? A) Elevate the patient's leg. B) Press firmly on the lesion C) Check the temperature of the skin around the lesion. D) Palpate the dorsalis pedis and posterior tibial pulses.

B) Press firmly on the lesion

18. A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? A) Inform the patient about the reasons for a possible change in drug dosage. B) Question the patient about whether the medication is actually being taken. C) Inform the patient that multiple drugs are often needed to treat hypertension. D) Question the patient regarding any lifestyle changes made to help control

B) Question the patient about whether the medication is actually being taken.

30. A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? A) Arterial blood pH is 7.32 B) Serum calcium is 18 mg/dL C) Serum potassium is 5.1 mEq/L. D) Arterial oxygen saturation is 91%.

B) Serum calcium is 18 mg/dL

34. During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term would the nurse use to document the distribution of these lesions? A) Confluent B) Symmetric C) Zosteriform D) Generalized

B) Symmetric

31. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? A) The bibasilar breath sounds are decreased. B) The patellar and triceps reflexes are absent. C) The patient has been sleeping most of the day. D) The patient reports feeling sick to my stomach.

B) The patellar and triceps reflexes are absent.

40. The nurse is interviewing a patient with contact dermatitis who reports severe itching. Which finding indicates a need for patient teaching? A) The patient applies corticosteroid cream to pruritic areas. B) The patient applies warm compresses to the area twice daily. C) The patient adds oilated oatmeal to the bath water every day. D) The patient takes diphenhydramine at night for persistent itching.

B) The patient applies warm compresses to the area twice daily.

17. The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? A) Urine output over 8 hours is 250 mL less than the fluid intake. B) The patient cannot move the left arm and leg when asked to do so. C) Tremors are noted in the fingers when the patient extends the arms. D) The patient complains of a headache with pain at level 8/10 (0 to 10 scale).

B) The patient cannot move the left arm and leg when asked to do so.

15. The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? A) The patient applies corticosteroid cream to pruritic areas B) The patient uses Neosporin ointment on minor cuts or abrasions. C) The patient adds oilated oatmeal (Aveeno) to the bath water every day. D) The patient takes diphenhydramine (Benadryl) at night if itching occurs.

B) The patient uses Neosporin ointment on minor cuts or abrasions.

35. A patient who reports chronic itching of the ankles continuously scratches the area. Which assessment finding would the nurse expect? A) Hypertrophied scars on both ankles B) Thickening of the skin around the ankles C) Yellowish-brown skin around both ankles D) Complete absence of melanin in both ankles

B) Thickening of the skin around the ankles

21. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? A) Avoid using friction when cleaning around the CVAD insertion site. B) Use the push-pause method to flush the CVAD after giving medications. C) Obtain an order from the health care provider to change CVAD dressing. D) Position the patients face toward the CVAD during injection cap changes.

B) Use the push-pause method to flush the CVAD after giving medications.

11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? A) Give the prescribed PRN lorazepam (Ativan). B) Start the prescribed PRN oxygen at 2 to 4 L/min. C) Administer the prescribed normal saline bolus and insulin. D) Encourage the patient to take deep, slow breaths with guided imagery.

C) Administer the prescribed normal saline bolus and insulin.

7. The nurse notes the presence of white lesions that resemble milk curds in the back of a patients throat. Which question by the nurse is appropriate at this time? A) Do you have a productive cough? B) How often do you brush your teeth? C) Are you taking any medications at present? D) Have you ever had an oral herpes infection?

C) Are you taking any medications at present?

3. Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension? A) Encourage the use of hard candy to prevent dry mouth. B) Instruct the patient to ask for help if heart palpitations occur. C) Ask the patient to request assistance when getting out of bed. D) Teach the patient that headaches may occur with this medication.

C) Ask the patient to request assistance when getting out of bed.

35. Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? A) Notify the health care provider. B) Offer reassurance to the patient. C) Auscultate the patients breath sounds. D) Give the prescribed PRN morphine sulfate

C) Auscultate the patients breath sounds.

17. When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurses best action? A) Instruct the patient about the importance of nutrition in skin health. B) Make a referral to a podiatrist so that the nails can be safely trimmed. C) Consult with the health care provider about the need for further diagnostic testing. D) Teach the patient about using moisturizing creams and lotions to decrease dry skin.

C) Consult with the health care provider about the need for further diagnostic testing.

31. The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items would the nurse gather for this procedure? A) Sterile gloves B) Patch test instruments C) Cotton-tipped applicators D) Syringe and intradermal needle

C) Cotton-tipped applicators

14. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved? A) Hematocrit 28% B) Absence of skin tenting C) Decreased peripheral edema D) Blood pressure 110/72 mm

C) Decreased peripheral edema

23. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? A) Oral temperature of 100.1 F B) Serum sodium level of 138 mEq/L (138 mmol/L) C) Gradually decreasing level of consciousness (LOC) D) Weight gain of 2 pounds (1 kg) above the admission

C) Gradually decreasing level of consciousness (LOC)

11. A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? A) Cleanse the skin carefully with an antiseptic soap. B) Shield any unaffected areas with lead-lined drapes. C) Have the patient use protective eyewear while receiving PUVA. D) Apply petroleum jelly to the areas surrounding the psoriatic lesions.

C) Have the patient use protective eyewear while receiving PUVA.

33. A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. For which type of biopsy would the nurse prepare? A) Shave biopsy B) Punch biopsy C) Incisional biopsy D) Excisional biopsy

C) Incisional biopsy

30. A patient with dark skin has been admitted to the hospital with acute decompensated heart failure. How would the nurse assess this patient for cyanosis? A) Inspect the skin color of the earlobes. B) Apply pressure to the palms of the hands. C) Look at the lips and oral mucous membranes. D) Measure capillary refill time of the nail beds.

C) Look at the lips and oral mucous membranes.

24. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? A) Skin turgor B) Heart sounds C) Mental status D) Capillary refill

C) Mental status

22. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? A) K+ 3.4 mEq/L (3.4 mmol/L) B) Ca+2 7.8 mg/dL (1.95 mmol/L) C) Na+ 154 mEq/L (154 mmol/L) D) PO -3 4.8 mg/dL (1.55 mmol/L)

C) Na+ 154 mEq/L (154 mmol/L)

36. After receiving change-of-shift report, which patient should the nurse assess first? A) Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping B) Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water C) Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes D) Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium- phosphate precipitates

C) Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

36. Which observation about the skin of an older patient is the priority for the nurse to discuss with the health care provider? A) Dry, scaly patches on the face B) Numerous varicosities on both legs C) Petechiae on the chest and abdomen D) Small dilated blood vessels on the face

C) Petechiae on the chest and abdomen

19. The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A) Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. B) Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). C) Set up the automatic blood pressure machine to take BP every 15 minutes. D) Assess the patients environment for adverse stimuli that might increase

C) Set up the automatic blood pressure machine to take BP every 15 minutes.

29. The home health nurse notices irregular patterns of bruising at different stages of healing on an older patient's body. Which action would the nurse take first? A) Ensure the patient wears shoes with nonslip soles. B) Discourage using throw rugs throughout the house. C) Talk with the patient alone and ask about the bruising. D) Suggest that the health care provider prescribe radiographs.

C) Talk with the patient alone and ask about the bruising.

11. An older patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? A) Schedule the patient for regular blood pressure (BP) checks in the clinic. B) Instruct the patient about the need to decrease stress levels. C) Tell the patient how to self-monitor and record BPs at home. D) Inform the patient that ambulatory blood pressure monitoring will be needed.

C) Tell the patient how to self-monitor and record BPs at home.

20. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? A) There is a decreased risk for infection when 25% dextrose is infused through a central line. B) The prescribed infusion can be given much more rapidly when the patient has a central line. C) The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line. D) The required blood glucose monitoring is more accurate when samples are obtained from a central line.

C) The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.

20. The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? A) The patient takes a tepid bath before applying the cream. B) The patient spreads the cream using a downward motion. C) The patient applies a thick layer of the cream to the affected skin. D) The patient covers the area with a dressing after applying the cream.

C) The patient applies a thick layer of the cream to the affected skin.

10. During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? A) The patients most recent blood pressure (BP) reading is 158/91 mm Hg. B) The patients pulse has dropped from 68 to 57 beats/minute. C) The patient has developed wheezes throughout the lung fields. D) The patient complains that the fingers and toes feel quite cold.

C) The patient has developed wheezes throughout the lung fields.

13. Which information will the nurse include when teaching an older patient about skin care? A) Dry the skin thoroughly before applying lotions. B) Bathe and wash hair daily with soap and shampoo. C) Use warm water and a moisturizing soap when bathing. D) Use antibacterial soaps when bathing to avoid infection.

C) Use warm water and a moisturizing soap when bathing.

5. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? A) Assess for facial muscle spasms. B) Ask the patient about loose stools. C) Suggest that the patient avoid orange juice with meals. D) Ask the health care provider to order a basic metabolic panel.

D) Ask the health care provider to order a basic metabolic panel.

16. The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurses best action? A) Teach the patient about the treatment of fungal infection. B) Discuss the use of drying agents to minimize infection risk. C) Instruct the patient about the use of mild soap to clean skinfolds. D) Ask the patient about type 2 diabetes or if there is a family history of it.

D) Ask the patient about type 2 diabetes or if there is a family history of it.

23. A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? A) Discuss the possibility of enrolling in a worker-retraining program. B) Encourage the patient to volunteer to work on community projects. C) Suggest that the patient use cosmetics to cover the psoriatic lesions. D) Ask the patient to describe the impact of psoriasis on quality of life.

D) Ask the patient to describe the impact of psoriasis on quality of life.

5. A patient has just been diagnosed with hypertension and has been started on captopril (Capoten). Which information is important to include when teaching the patient about this medication? A) Check blood pressure (BP) in both arms before taking the medication. B) Increase fluid intake if dryness of the mouth is a problem. C) Include high-potassium foods such as bananas in the diet. D) Change position slowly to help prevent dizziness and falls

D) Change position slowly to help prevent dizziness and falls

21. The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)? A) Applying antibiotic cream to the groin. B) Obtaining cultures from ruptured lesions. C) Evaluating the patients personal hygiene. D) Cleaning the skin with antimicrobial soap.

D) Cleaning the skin with antimicrobial soap.

17. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? A) Maintain the patient on bed rest. B) Auscultate lung sounds every 4 hours. C) Monitor for Trousseaus and Chvosteks signs. D) Encourage fluid intake up to 4000 mL every day.

D) Encourage fluid intake up to 4000 mL every day.

37. The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. the nurse will plan to teach the patient how to self-assess for which skin changes? (Select all that apply.) A) Vitiligo B) Alopecia C) Intertrigo D) Erythema E) Actinic keratosis

D) Erythema E) Actinic keratosis

13. Which information should the nurse include when teaching a patient with newly diagnosed hypertension? A) Increasing physical activity will control blood pressure (BP) for most patients. B) Most patients are able to control BP through dietary changes. C) Annual BP checks are needed to monitor treatment effectiveness. D) Hypertension is usually asymptomatic until target organ damage occurs.

D) Hypertension is usually asymptomatic until target organ damage occurs.

6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? A) I will try to drink at least 8 glasses of water every day. B) I will use a salt substitute to decrease my sodium intake. C) I will increase my intake of potassium-containing foods. D) I will drink apple juice instead of orange juice for breakfast.

D) I will drink apple juice instead of orange juice for breakfast.

19. A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? A) After I apply the medication, I can go ahead and get dressed as usual. B) I will need to minimize my time in the sun while I am using the Elidel. C) I will rub the medication gently onto the skin every morning and night. D) If the medication burns when I apply it, I will wipe it off and call the doctor.

D) If the medication burns when I apply it, I will wipe it off and call the doctor.

23. The nurse is caring for a 70-year-old who uses hydrochlorothiazide (HydroDIURIL) and enalapril (Norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? A) Patient takes a daily multivitamin tablet B) Patient checks BP daily just after getting up. C) Patient drinks wine three to four times a week. D) Patient uses ibuprofen (Motrin) daily to treat osteoarthritis.

D) Patient uses ibuprofen (Motrin) daily to treat osteoarthritis.

10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

D) Respiratory alkalosis

12. A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? A) Curettage B) Cryosurgery C) Punch biopsy D) Surgical excision

D) Surgical excision

4. After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? A) The patient avoids eating nuts or nut butters. B) The patient restricts intake of chicken and fish. C) The patient has two cups of coffee in the morning. D) The patient has a glass of low-fat milk with each meal.

D) The patient has a glass of low-fat milk with each meal.

5. A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? A) The patient has multiple dysplastic nevi. B) The patient is fair-skinned and has blue eyes. C) The patients mother died of a malignant melanoma. D) The patient uses a tanning booth throughout the winter.

D) The patient uses a tanning booth throughout the winter.

22. The nurse assesses a patient who has just arrived in the post-anesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? A) The patient complains of incisional pain. B) The patients heart rate is 110 beats/minute. C) The patient is unable to detect when the eyelids are touched D) The skin around the incision is pale and cold when palpated

D) The skin around the incision is pale and cold when palpated

32. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? A) The patients radial pulse is 105 beats/minute. B) There is sediment and blood in the patients urine. C) The blood pressure increases from 120/80 to 142/94 D) There are crackles audible throughout both lung fields

D) There are crackles audible throughout both lung fields

1. Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? A) Use a sunscreen with an SPF of at least 8 to 10 for adequate protection. B) Water resistant sunscreens will provide good protection when swimming. C) Increase sun exposure by no more than 10 minutes a day to avoid skin damage. D) Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).

D) Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).

8. Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? A) Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. B) Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. C) Assist the patient up in the chair for meals to avoid complications associated with immobility. D) Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

D) Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

14. What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? A) Change the dressing using sterile gloves. B) Soak the dressing in sterile normal saline. C) Apply antibiotic ointment over the wound. D) Wash hands and properly dispose of soiled dressings.

D) Wash hands and properly dispose of soiled dressings.

9. The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patients instructions? A) 5-FU will shrink the lesion so that less scarring occurs once the lesion is excised. B) You may develop nausea and anorexia, but good nutrition is important during treatment. C) You will need to avoid crowds because of the risk for infection caused by chemotherapy. D) Your cheek area will be painful and develop eroded areas that will take weeks to heal.

D) Your cheek area will be painful and develop eroded areas that will take weeks to heal.

7. A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that. . . A) BP recheck should be scheduled in a few weeks. B) dietary sodium and fat content should be decreased. C) there is an immediate danger of a stroke and hospitalization will be required. D) diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

D) diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

37. The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? A) pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% B) pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% C) pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% D) pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

D) pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%