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EXAM 1 MED SURGE 2020

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1. The nurse educator facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse educator to intervene? The student wears a mask at the sink area. The student wears street clothes in the unrestricted area. The student wears surgical scrubs in the semirestricted area. The student covers head and facial hair in the semirestricted area.

1. When teaching seniors at a community recreation center, which information will the nurse include about ways to prevent fractures? Tack down scatter rugs in the home. Most falls happen outside the home. Buy shoes that provide good support and are comfortable to wear. Range-of-motion exercises should be taught by a physical therapist.

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 needsimmediate intervention? The patients most recent blood pressure (BP) reading is 158/91 mm Hg. The patients pulse has dropped from 68 to 57 beats/minute. The patient has developed wheezes throughout the lung fields. The patient complains that the fingers and toes feel quite cold.

10. Which statement by the patient indicates a good understanding of the nurses teaching about a new short- arm plaster cast? I can get the cast wet as long as I dry it right away with a hair dryer. I should avoid moving my fingers and elbow until the cast is removed. I will apply an ice pack to the cast over the fracture site off and on for 24 hours. I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.

12. Anakinra (Kineret) is prescribed for a 49-year-old patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about avoiding concurrently taking aspirin. symptoms of gastrointestinal (GI) bleeding. self-administration of subcutaneous injections. taking the medication with at least 8 oz of fluid.

12. Heparin is ordered for a patient with a nonST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? Heparin enhances platelet aggregation. Heparin decreases coronary artery plaque size. Heparin prevents the development of new clots in the coronary arteries. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

13. A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? Laryngospasm Complaint of nausea Weak chest wall movement Patient unable to recall the correct date

14. A patient is being prepared for a spinal fusion. While in the holding area, which action by a member of the surgical team requires rapid intervention by the charge nurse? Wearing street clothes into the nursing station Wearing a surgical mask into the holding room Walking into the hallway outside an operating room without the hair covered Putting on a surgical mask, cap, and scrubs before entering the operating room

14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? Do you have any allergies? Do you take aspirin on a daily basis? What time did your chest pain begin? Can you rate your chest pain using a 0 to 10 scale?

15. A 19-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient had several knee injuries as a teenager. recently returned from South America. is sexually active with multiple partners. has a parent who has rheumatoid arthritis.

15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patients response to the activity, which assessment data would indicate that the exercise level should be decreased? Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. Oxygen saturation drops from 99% to 95%. Heart rate increases from 66 to 92 beats/minute. Respiratory rate goes from 14 to 20 breaths/minute.

15. The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? Reinforce the dressing. Apply an abdominal binder. Take the patients vital signs. Recheck the dressing in 1 hour for increased drainage.

16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences bleeding from the gums. increase in blood pressure. a decrease in level of consciousness. a nonsustained episode of ventricular tachycardia.

16. The nurse notices a circular lesion with a red border and clear center on the arm of an 18-year-old summer camp counselor who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse takenext? Palpate the abdomen. Auscultate the heart sounds. Ask the patient about recent outdoor activities. Question the patient about immunization history.

17. A 29-year-old patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with anakinra (Kineret). etanercept (Enbrel). doxycycline (Vibramycin). methotrexate (Rheumatrex).

18. After the health care provider has recommended amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse isbest? You are upset, but you may lose the foot anyway. Many people are able to function with a foot prosthesis. Tell me what you know about your options for treatment. If you do not want an amputation, you do not have to have it.

2. Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

23. A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for a left hand arthroplasty. Which patient statement to the nurse indicates a realistic expectation for the surgery? This procedure will correct the deformities in my fingers. I will not have to do as many hand exercises after the surgery. I will be able to use my fingers with more flexibility to grasp things. My fingers will appear more normal in size and shape after this surgery.

23. A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? Rheumatoid factor (RF) Antinuclear antibody (ANA) Anti-Smith antibody (Anti-Sm) Lupus erythematosus (LE) cell prep

24. The nurse is planning care for a patient with hypertension and gout who has a red and painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

24. When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include? Keep the left shoulder elevated on a pillow or cushion. Keep the hand immobile to prevent soft tissue swelling. Call the health care provider for increased swelling or numbness of the hand. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.

25. A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided long-arm cast and a sling. Which nursing intervention will be included in the plan of care? Use surgical net dressing to hang the arm from an IV pole. Immobilize the fingers of the left hand with gauze dressings. Assess the left axilla and change absorbent dressings as needed. Assist the patient in passive range of motion (ROM) for the right arm.

28. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? There is bruising at the shoulder area. The patient reports arm and shoulder pain. The right arm appears shorter than the left. There is decreased shoulder range of motion.

28. When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, My arthritis isnt that bad yet. The side effects of methotrexate are worse than the arthritis. The most appropriate response by the nurse is You have the right to refuse to take the methotrexate. Methotrexate is less expensive than some of the newer drugs. It is important to start methotrexate early to decrease the extent of joint damage. Methotrexate is effective and has fewer side effects than some of the other drugs.

3. An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? The new nurse assists a nauseated patient to a supine position. The new nurse positions an unconscious patient supine with the head elevated. The new nurse turns an unconscious patient to the side upon arrival in the PACU. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.

30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? Inverted P wave Sinus tachycardia ST-segment elevation First-degree atrioventricular block

31. A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a knee immobilizer. gentle knee flexion. monitored anesthesia care. physical activity restrictions.

31. A patient with an acute attack of gout in the right great toe has a new prescription for probenecid (Benemid). Which information about the patients home routine indicates a need for teaching regarding gout management? The patient sleeps about 8 to 10 hours every night. The patient usually eats beef once or twice a week. The patient takes one aspirin a day to prevent angina. The patient usually drinks about 3 quarts water daily.

31. The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? Weak pedal pulses Absent bowel sounds Blood pressure 137/88 mm Hg 25 mL urine output over last hour

32. Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse take first? Elevate the leg on 2 pillows. Apply a compression bandage. Check leg pulses and sensation. Place ice packs on the lower leg.

33. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to: elevate the right leg. splint the lower leg. check the pedal pulses. verify tetanus immunizations.

35. The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? Take the blood pressure. Assess patient orientation. Check the oxygen saturation. Observe for facial asymmetry.

35. Which laboratory data is important to communicate to the health care provider for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis? The blood glucose is 90 mg/dL. The rheumatoid factor is positive. The white blood cell (WBC) count is 1500/L. The erythrocyte sedimentation rate is elevated.

36. A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? Ecchymosis of the left thigh Complaints of severe thigh pain Slow capillary refill of the left foot Outward pointing toes on the left foot

39. Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? A 38-year-old man who plays on a summer softball teamb. A 56-year-old man who is a member of a construction crewc. A 56-year-old woman who works on an automotive assembly lined. A 49-year-old woman who is newly diagnosed with diabetes mellitus

41. A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to lower heart rate. control blood glucose levels. prevent changes in heart muscle. reduce the frequency of chest pain.

42. Which information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-management? Avoid use of over-the-counter antihistamines or decongestants. A low-residue, low-fiber diet will reduce any abdominal distention. A gradual increase in your daily exercise may help decrease fatigue. Chronic fatigue syndrome usually progresses as patients become older.

43. When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? Assess for nasal bleeding and pain. Apply ice to the face to reduce swelling. Use a cervical collar to stabilize the spine. Check the patients alertness and orientation.

46. Based on the information shown in the accompanying figure and obtained for a patient in the emergency room, which action will the nurse take first? Administer the prescribed morphine 4 mg IV. Contact the operating room to schedule surgery. Check the patients oxygen saturation using pulse oximetry. Ask the patient about the date of the last tetanus immunization.

5. A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? Draw blood for rheumatoid factor analysis. Teach the patient about injections for the nodules. Assess the nodules for skin breakdown or infection. Discuss the need for surgical removal of the nodules.

8. A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? Patient drinks 2 to 3 L of fluid in 24 hours. Patient uses the spirometer 10 times every hour. Patients breath sounds are clear to auscultation. Patients temperature is less than 100.4 F orally.

9. Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? Blood glucose test Liver function tests C-reactive protein level Serum electrolyte levels

1. The nurse obtains a blood pressure of 176/83 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?

114 mm Hg

1. Which finding will the nurse expect when assessing a 58-year-old patient who has osteoarthritis (OA) of the knee? Discomfort with joint movement Heberdens and Bouchards nodes Redness and swelling of the knee joint Stiffness that increases with movement

17. Which statement by a patient scheduled for surgery is most important to report to the health care provider? I had a heart valve replacement last year. I had bacterial pneumonia 3 months ago. I have knee pain whenever I walk or jog. I have a strong family history of breast cancer.

5. A patient who is scheduled for a therapeutic abortion tells the nurse, Having an abortion is not right. Which functional health pattern should the nurse further assess? V alue-belief Cognitive-perceptual Sexuality-reproductive Coping-stress tolerance

18. An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? Notify an elder protective services agency about the possible abuse. Make a referral for a home assessment visit by the home health nurse. Have the family member stay in the waiting area while the patient is assessed. Ask the patient how the injury occurred and observe the family members reaction.

ANS: C

11. Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? Assist the patient to the bathroom and stay with the patient to prevent falls. Offer a urinal or bedpan and position the patient in bed to promote voiding. Allow the patient up to the bathroom because medication onset is 10 minutes. Ask the patient to wait because catheterization is performed just before the surgery

12. While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority? Place a medical alert sticker on the front of the patients chart. Alert the anesthesia care provider of the family members reaction to surgery. Reassure the patient that there will be close monitoring during and after surgery. Administer 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure.

13. A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? Withhold the usual scheduled insulin dose because the patient is NPO. Obtain a blood glucose measurement before any insulin administration. Give the patient the usual insulin dose because stress will increase the blood glucose. Administer a lower dose of insulin because there will be no oral intake before surgery.

13. A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? Administer the ordered opioid. Check the oxygen (O2) saturation. Take the blood pressure and pulse. Apply wrist restraints to secure IV lines.

13. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? The patient states that the pelvis feels unstable. Abdomen is distended and bowel sounds are absent. There are ecchymoses across the abdomen and hips. The patient complains of pelvic pain with palpation.

19. A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor blood glucose. blood pressure. erythrocyte count. lymphocyte count.

21. The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? Potassium 3.5 mEq/L Albumin level 2.2 g/dL Hemoglobin 11.2 g/dL White blood cells 11,900/L

3. Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? Performs the same responsibilities as the anesthesiologist. Releases or discharges patients from the postanesthesia care area. Administers intraoperative anesthetics ordered by the anesthesiologist. Manages a patients airway under the direct supervision of the anesthesiologist.

32. Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? Decreased C-reactive protein (CRP) Elevated blood urea nitrogen (BUN) Positive antinuclear antibodies (ANA) Positive lupus erythematosus cell prep

39. When assessing for Tinels sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. tingling in the right thumb and fingers .c. burning in the right elbow and forearm. d. tremor when gripping with the right hand.

4. A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? Notify the dietitian about the food allergies. Alert the surgery center about a possible latex allergy. Reassure the patient that all allergies are noted on the medical record. Ask whether the patient uses antihistamines to reduce allergic reactions.

4. An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, I do not know if I can take care of myself with this patch over my eye. Which action by the nurse ismost appropriate? Refer the patient for home health care services. Discuss the specific concerns regarding self-care. Give the patient written instructions regarding care. Assess the patients support system for care at home.

41. After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? I am going to join a soccer team to get more exercise. I will need to stop drinking so much coffee and soda. I will call the doctor every time my symptoms get worse. I should avoid using over-the-counter medications for pain.

45. Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? Monitor for difficulty in breathing. Document the patients oral intake. Check finger strength and movement. Apply capsaicin (Zostrix) cream to hands.

6. Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery? Stated allergy to cats and dogs History of spinal and hip arthritis V erbalization of anxiety by the patient Having a sip of water 3 hours previously

7. A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? Teach the patient to fully exhale into the incentive spirometer. Administer ordered analgesic medications before these activities. Ask the patient to state two possible complications of immobility. Encourage the patient to state the purpose of splinting the incision.

9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will reduce heart palpitations. decrease spasm of the coronary arteries. increase the force of the heart contractions. help prevent plaque from forming in the coronary arteries.

10. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? Care for the surgical incision Medications used during surgery Deep breathing and coughing techniques Oral antibiotic therapy after discharge home

11. A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? Assess the patients pain. Orient the patient to the unit. Take the patients vital signs. Read the postoperative orders.

12. The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? Use printed materials for instruction so that the patient will have more time to review the material. Direct the teaching toward the wife because she is the obvious support and caregiver for the Provide additional time for the patient to understand preoperative instructions and carry out procedures. Ask the patients wife to wait in the hall in order to focus preoperative teaching with the patient himself.

4. The nurse will anticipate the need to teach a 57-year-old patient who has osteoarthritis (OA) about which medication? Adalimumab (Humira) Prednisone (Deltasone) Capsaicin cream (Zostrix) Sulfasalazine (Azulfidine)

4. When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? A. Effect of atherosclerosis on blood vessels B. Mechanism of action of anticoagulant drug therapy C. Symptoms indicating that the patient should contact the health care provider D. Impact of the patients family history on likelihood of developing a serious stroke

4. Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? Keep the ankle loosely wrapped with gauze. Apply a heating pad to reduce muscle spasms. Use pillows to elevate the ankle above the heart. Gently move the ankle through the range of motion.

40. Which action will the urgent care nurse take when caring for a patient who has a possible knee meniscus injury? Encourage bed rest for 24 to 48 hours. Avoid palpation or movement of the knee. Apply a knee immobilizer to the affected leg. Administer intravenous narcotics for pain relief.

5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? I can expect some nausea as a side effect of nitroglycerin. I should only take the nitroglycerin if I start to have chest pain. I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart. Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.

5. Which action most effectively demonstrates that a new staff member understands the role of scrub nurse? Documents all patient care accurately Labels all specimens to send to the lab Keeps both hands above the operating table level Takes the patient to the postanesthesia recovery area

6. A patient undergoing an emergency appendectomy has been using St. Johns wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit? Increased pain Hypertensive episodes Longer time to recover from anesthesia Increased risk for postoperative bleeding

6. A patients T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is themost appropriate? Notify the patients surgeon. Place the patient on bed rest. Document the color and amount of drainage. Irrigate the T-tube with sterile normal saline.

6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to best meet this patients needs? a. Suggest that the patient move to an urban area. b. Assess the patient for chronic diseases that are unique to rural areas. c. Ensure transportation to appointments with the health care provider. d. Obtain adequate medications for the patient to last for 4 to 6 months

7. The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find dilated superficial veins. swollen, dry, scaly ankles. prolonged capillary refill in all the toes. a serosanguineous drainage from the ulcer.

10. The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they a. stand rather than sit when performing household and yard chores. b. strengthen small hand muscles by wringing sponges or washcloths. c. protect the knee joints by sleeping with a small pillow under the knees. d. avoid activities that require repetitive use of the same muscles and joints.

14. The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 103/L; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 103/L. Which action should the nurse take? Call the surgeon and anesthesiologist immediately. Ask the patient about any symptoms of a recent infection. Discuss the possibility of blood transfusion with the patient. Send the patient to the holding area when the operating room calls.

15. As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, I have never taken it off since the day I was married. Which response by the nurse is best? Have the patient sign a release and leave the ring on. Tape the wedding ring securely to the patients finger. Tell the patient that the hospital is not liable for loss of the ring. Suggest that the patient give the ring to a family member to keep.

15. Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? Need to increase carbohydrate intake Methods of keeping the wound area dry Purpose of prophylactic antibiotic therapy Application of elastic compression stockings

16. A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best? Check for skin tenting. Notify the health care provider. Ask the patient about any dizziness. Tell the patient dry mouth is an expected side effect.

17. The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? Elevate the patients head. Suction the patients mouth. Increase the oxygen flow rate. Perform the jaw-thrust maneuver.

17. When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patients arms. Which action should the nurse take immediately? Apply lotion to the affected areas. Cover the arms with sterile drapes. Recheck the patients arms in 30 minutes. Notify the anesthesia care practitioner (ACP) immediately.

18. The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? The patient drinks 3 or 4 cups of coffee every morning before going to work. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. The patients father died after receiving general anesthesia for abdominal surgery.

20. A 71-year-old patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of sertraline (Zoloft). famotidine (Pepcid). oxycodone (Roxicodone). hydrochlorothiazide (HydroDIURIL).

20. A patient who takes a diuretic and a b-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? Hematocrit 36% Blood pressure 144/82 Pulse rate 58 beats/minute Serum potassium 3.2 mEq/L

20. While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? When I stand too long, my feet start to swell. I get short of breath when I climb a lot of stairs. My fingers hurt when I go outside in cold weather. My legs cramp whenever I walk more than a block.

21. The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? I should not cross my legs while sitting. I will use a toilet elevator on the toilet seat. I will have someone else put on my shoes and socks. I can sleep in any position that is comfortable for me.

22. A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, I never leave my house because I hate the way I look. An appropriate nursing diagnosis for the patient is activity intolerance related to fatigue and inactivity. impaired social interaction related to lack of social skills. impaired skin integrity related to itching and skin sloughing. social isolation related to embarrassment about the effects of SLE.

22. The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? Tympanic temperature 99.2 F (37.3 C) Fine crackles audible at both lung bases Redness and swelling along the suture line 200 mL sanguineous fluid in the wound drain

22. Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty? Avoid extension of the right knee beyond 120 degrees. Use a compression bandage to keep the right knee flexed. Teach about the need to avoid weight bearing for 4 weeks. Start progressive knee exercises to obtain 90-degree flexion.

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? Patient takes a daily multivitamin tablet. Patient checks BP daily just after getting up. Patient drinks wine three to four times a week. Patient uses ibuprofen (Motrin) daily to treat osteoarthritis.

24. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication? Have the patient take this medication with an aspirin. Administer the medication at the patients usual bedtime. Have the patient take the colesevelam with a sip of water. Give the patients other medications 2 hours after the colesevelam.

3. Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) hemoglobin count. additional antibiotic. decrease in IV infusion rate. blood urea nitrogen (BUN) level.

3. The nurse performs a comprehensive geriatric assessment of a patient who is being assessed for admission to an assisted living facility. Which question is the most important for the nurse to ask? A. Have you had any recent infections? B. How frequently do you see a doctor? C. Do you have a history of heart disease? D. Are you able to prepare your own meals?

30. The home health nurse is doing a follow-up visit to a 41-year-old patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? The patient takes a 2-hour nap each day. The patient has been taking 16 aspirins daily. The patient sits on a stool while preparing meals. The patient sleeps with two pillows under the head.

30. Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

34. The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is activity intolerance related to deconditioning. risk for constipation related to prolonged bed rest. risk for impaired skin integrity related to immobility. risk for infection related to disruption of skin integrity.

38. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

41. Which finding in a patient with a Colles fracture of the left wrist is most important to communicate to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

43. After the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the health care provider? Knee crepitation is noted with normal knee range of motion. Patient reports embarrassment about having Heberdens nodes. Patients knee pain while golfing has increased over the last year. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

44. After change-of-shift report, which patient should the nurse assess first? Patient with a Colles fracture who has right wrist swelling and deformity Patient with a intracapsular left hip fracture whose leg is externally rotated Patient with a repaired mandibular fracture who is complaining of facial pain Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic

7. A 48-year-old patient with a comminuted fracture of the left femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should loosen the traction and help the patient turn onto the unaffected side. place a pillow between the patients legs and turn gently to each side. turn the patient partially to each side with the assistance of another nurse. have the patient lift the buttocks by bending and pushing with the right leg.

7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? A. Teach the patient to have all prescriptions filled at the same pharmacy. B. Instruct the patient to avoid taking over-the-counter (OTC) medications. C. Make a schedule for the patient as a reminder of when to take each medication. D. Have the patient bring all medications, supplements, and herbs to each appointment.

8. A patient received inhalation anesthesia during surgery. Postoperatively the nurse should monitor the patient for which complication? Tachypnea Myoclonus Hypertension Laryngospasm

8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care? Remind the patient that making changes is usually stressful. Discuss the reason for the move to the facility with the patient. Restrict family visits until the patient is accustomed to the facility. Have staff members write notes welcoming the patient to the facility.

8. The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate? Ascertain that there will be no interactions with anesthetic agents. Teach the patient that these products may be continued preoperatively. Advise the patient to stop the use of all herbs and supplements at this time. Discuss the herb and supplement use with the patients health care provider.

1. When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 147/82 and an ankle pressure of 112/74. The nurse calculates the patients ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).

0.76

1. A patient scheduled for an elective hysterectomy tells the nurse, I am afraid that I will die in surgery like my mother did! Which response by the nurse is most appropriate? Tell me more about what happened to your mother. You will receive medications to reduce your anxiety. You should talk to the doctor again about the surgery. Surgical techniques have improved a lot in recent years.

1. The nurse plans to complete a thorough assessment of an older patient. Which method should the nurse use to gather the most complete information? A.Use a geriatric assessment instrument to evaluate the patient. B.Ask the patient to write down medical problems and medications. C. Interview both the patient and the primary caregiver for the patient. D. Review the patients medical record for a history of medical problems.

11. The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a warm bath followed by a short rest. a short routine of isometric exercises. active range-of-motion (ROM) exercises. stretching exercises to relieve joint stiffness.

12. A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? Notify the health care provider. Assess the incision for redness. Reposition the left leg on pillows. Check the patients blood pressure.

13. A 37-year-old patient with 2 school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that home life is very stressful. Which response by the nurse is most appropriate? Tell me more about situations that are causing you stress. You need to see a family therapist for some help with stress. Your family should understand the impact of your rheumatoid arthritis. Perhaps it would be helpful for your family to be involved in a support group.

14. A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? Perform a bladder scan. Encourage increased oral fluid intake. Assist the patient to ambulate to the bathroom. Insert a straight catheter as indicated on the PRN order.

15. A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? You will need to check and clean the pin insertion sites daily. The external fixator can be removed for your bath or shower. You will need to remain on bed rest until bone healing is complete. Prophylactic antibiotics are used until the external fixator is removed.

16. A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis? I cant get my shoes on at the end of the day. I cant seem to ever get my feet warm enough. I have burning leg pains after I walk two blocks. I wake up during the night because my legs hurt.

16. When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F. Which action should the nurse take first? Have the patient use the incentive spirometer. Assess the surgical incision for redness and swelling. Administer the ordered PRN acetaminophen (Tylenol). Ask the health care provider to prescribe a different antibiotic.

16. Which action included in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist? Pass sterile instruments and supplies to the surgeon. Teach the patient about what to expect in the operating room (OR). Continuously monitor and interpret the patients echocardiogram (ECG) during surgery. Give the postoperative report to the postanesthesia care unit (PACU) nurse.

18. The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? The right calf is swollen, warm, and painful. The patients temperature is 100.3 F (37.9 C). The 24-hour oral intake is 600 mL greater than the total output. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

18. The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding relief of joint pain. increased urine output. elevated serum uric acid. increased white blood cells (WBC).

19. A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? Administer the prescribed PRN IV morphine sulfate Notify the health care provider about the ongoing knee pain. Reassure the patient that postoperative pain is expected after knee surgery Teach the patient that the effects of ketorolac typically last about 6 to 8 hours

2. A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse? The patient is planning to drive home after surgery. The patient had a sip of water 4 hours before arriving. The patients insurance does not cover outpatient surgery. The patient has not had surgery using general anesthesia before.

2. An older patient who takes multiple medications for chronic cardiac and pulmonary diseases is alert and lives with a daughter who works during the day. During a clinic visit, the patient verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. Which nursing diagnosis should the nurse assign as the priority for this patient? A. Risk for injury related to drug interactions B. Social isolation related to weakness and fatigue C. Compromised family coping related to the patients many care needs D. Caregiver role strain related to need to adjust family employment schedule

2. Which statement, if made by a new circulating nurse, is appropriate? I will assist in preparing the operating room for the patient. I will remain gloved while performing activities in the sterile field. I will assist with suturing of incisions and maintaining hemostasis as needed. I must don full surgical attire and sterile gloves while obtaining items from the unsterile field

20. The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5 F (35.8 C). Which action should the nurse take? Cover the patient with a warm blanket and put on socks. Notify the anesthesia care provider about the temperature. Avoid the use of opioid analgesics until the patient is warmer. Administer acetaminophen (Tylenol) 650 mg suppository rectally.

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? Collect a detailed diet history. Provide a list of low-sodium foods. Help the patient make an appointment with a dietitian. Teach the patient about foods that are high in potassium.

23. After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery Patient who has bibasilar crackles and a temperature of 100F (37.8C) on the first postoperative day after chest surgery Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

3. The occupational health nurse will teach the patient whose job involves many hours of typing about the need to obtain a keyboard pad to support the wrist. do stretching exercises before starting work. wrap the wrists with compression bandages every morning. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

30. Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)? Reposition the patient every 1 to 2 hours. Assess for skin irritation on the patients back. Teach the patient quadriceps-setting exercises. Determine the patients pain level and tolerance.

33. Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? Blurred vision Joint tenderness Abdominal cramping Elevated blood pressure

36. A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? The blood pressure is 86/50 mm Hg. The white blood cell count is 11,500/L. The patient is taking ibuprofen (Motrin). The patient says the knee pain is severe.

37. A 63-year-old patient hospitalized with polymyositis has joint pain, an erythematosus facial rash, eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is risk for aspiration related to dysphagia. disturbed visual perception related to swelling. acute pain related to generalized inflammation. risk for impaired skin integrity related to scratching.

40. Which action will the nurse include in the plan of care for a 40-year-old with newly diagnosed ankylosing spondylitis? Advise the patient to sleep on the back with a flat pillow. Emphasize that application of heat may worsen symptoms. Schedule annual laboratory assessment for the HLA-B27 antigen. Assist patient to choose physical activities that allow the spine to flex.

44. A 28-year-old with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? Crackles are heard in both lung bases. Red, scaly patches are noted on the arms. Hemoglobin level is 11.1g/dL and hematocrit is 35%. Patient reports continued back pain after a week of etanercept therapy.

7. A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, Will the doctor put me to sleep with a mask over my face? Which response by the nurse is most appropriate? A drug may be given to you through your IV line first. I will check with the anesthesia care provider. Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon? General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face. Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep.

7. The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? Auscultate for adventitious breath sounds. Obtain the patients blood pressure and temperature. Remind the patient about harmful effects of smoking. Ask the health care provider about prescribing a nicotine patch.

9. Which action should the perioperative nurse take to best protect the patient from burn injury during surgery? Ensure correct placement of the grounding pad. Check all emergency sprinklers in the operating room. Verify that a fire extinguisher is available during surgery. Confirm that all electrosurgical equipment has been properly serviced.

1. During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)? A. Sleep disturbances B. Multiple tender points C. Cardiac palpitations and dizziness D. Multijoint pain with inflammation and swelling E. Widespread bilateral, burning musculoskeletal pain

A, B, E

1. In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle accident? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

A,B,C,D,E,F

1. While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patients blood pressure (BP). d. Notify the patients health care provider.

ALL THE ABOVE

2. A patients blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patients dressing. c. Increase the oxygen flow rate. d. Check the patients temperature.

ALL THE ABOVE

11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the most appropriate for the nurse to include in the discharge plan for this patient? Refer the patient to social services for further assessment. Teach the patient how to assess and care for the foot infection. Schedule the patient to return to outpatient services for foot care. Give the patient written information about shelters and meal sites.

ANS: A

12. The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? Use a marked pillbox to set up the patients medications. Discuss the option of moving to an assisted living facility. Remind the patient about the importance of taking medications. Visit the patient daily to administer the prescribed medications.

ANS: A

17. When completing an admission assessment on an older adult, the nurse gives the patient a high fall risk score. Which action should the nurse take first? Use a bed alarm system on the patients bed. Administer the prescribed PRN sedative medication. Ask the health care provider to order a vest restraint. Place the patient in a geri-chair near the nurses station.

ANS: A

9. An older patient complains of having no energy and feeling increasingly weak. The patient has had a 12- pound weight loss over the last year. Which action should the nurse take initially? Ask the patient about daily dietary intake. Schedule regular range-of-motion exercise. Discuss long-term care placement with the patient. Describe normal changes associated with aging to the patient.

ANS: A

1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)? Observe for depression. Review laboratory results. Assess teeth and oral mucosa. Ask about transportation needs. Determine food likes and dislikes.

ANS: A, B, C, D

13. The home health nurse visits an older patient with mild forgetfulness. The nurse is most concerned if which information is obtained? The patient tells the nurse that a close friend recently died. The patient has lost 10 pounds (4.5 kg) during the last month. The patient is cared for by a daughter during the day and stays with a son at night. The patients son uses a marked pillbox to set up the patients medications weekly.

ANS: B

19. The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? Have the family select a LTC facility that is relatively new. Obtain the patients input about the choice of a LTC facility. Ask that the patient be placed in a private room at the facility. Explain the reasons for the need to live in LTC to the patient.

ANS: B

10. The nurse admits an acutely ill, older patient to the hospital. Which action should the nurse take first? Speak slowly and loudly while facing the patient. Obtain a detailed medical history from the patient. Perform the physical assessment before interviewing the patient. Ask a family member to go home and retrieve the patients cane.

ANS: C

14. Which statement, if made by an older adult patient, would be of most concern to the nurse? I prefer to manage my life without much help from other people. I take three different medications for my heart and joint problems. I dont go on daily walks anymore since I had pneumonia 3 months ago. I set up my medications in a marked pillbox so I dont forget to take them.

ANS: C

1. Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? A. Check for placement of IV lines. B. Have the surgeon identify the patient. C. Have the patient state name and date of birth. D. Verify the patient identification band number. E. Ask the patient to state the surgical procedure. F. Confirm the hospital chart identification number.

ANS: C, D, E, F

15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? Palpate over the suprapubic area. Inspect for abdominal distention. Question the patient about hematuria. Invite the patient to use the bathroom.

ANS: D

16. Which patient is most likely to need long-term nursing care management? 72-year-old who had a hip replacement after a fall at home 64-year-old who developed sepsis after a ruptured peptic ulcer 76-year-old who had a cholecystectomy and bile duct drainage 63-year-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

ANS: D

20. The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? Obtain information about food and medication allergies from patients. Take blood pressures daily and document in individual patient records. Choose social activities based on the individual patient needs and desires. Teach family members how to cope with patients who are cognitively impaired.

ANS:B

1. On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse ismost appropriate? Increase the IV fluid rate. Continue to take vital signs every 15 minutes. Administer oxygen therapy at 100% per mask. Notify the anesthesia care provider (ACP) immediately.

10. Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate? Securing an airtight fit for the inhalation mask Starting a 20-gauge IV in the patients unaffected arm Obtaining a nonocclusive dressing to place over the administration site Teaching the patient about epidural patient-controlled anesthesia (PCA) use

10. Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? Clarify the postoperative orders with the surgeon. Help with the transfer of the patient onto a stretcher. Document the appearance of the patients incision in the chart. Provide hand off communication to the surgical unit charge nurse.

11. A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently? The patient moves the right crutch with the right leg and then the left crutch with the left leg. The patient advances the left leg and both crutches together and then advances the right leg. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

12. An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? Potential complication: hypovolemic shock Potential complication: venous thromboembolism Potential complication: fluid and electrolyte imbalance Potential complication: impaired surgical wound healing

14. Which action will the nurse take in order to evaluate the effectiveness of Bucks traction for a 62-year-old patient who has an intracapsular fracture of the right femur? Check peripheral pulses. Ask about hip pain level. Assess for hip contractures. Monitor for hip dislocation.

14. Which information will the nurse include when teaching a 38-year-old male patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition? Exercise by taking long walks. Do daily deep-breathing exercises. Sleep on the side with hips flexed. Take frequent naps during the day.

15. Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient? Adjust the doses of administered anesthetics. Make surgical incision and suture incisions as needed. Coordinate transfer of the patient to the operating table. Provide postoperative teaching about coughing to the patient.

16. A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take? Use a mechanical lift to transfer the patient from the bed to the chair. Check the postoperative orders for the patients weight-bearing status. Avoid administration of pain medications before getting the patient up. Delegate the transfer of the patient to nursing assistive personnel (NAP).

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? Did you take any acetaminophen (Tylenol) today? Have you been consistently taking your medications? Have there been any recent stressful events in your life? Have you recently taken any antihistamine medications?

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? Urine output over 8 hours is 250 mL less than the fluid intake. The patient cannot move the left arm and leg when asked to do so. Tremors are noted in the fingers when the patient extends the arms. The patient complains of a headache with pain at level 8/10 (0 to 10 scale).

17. When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about administration of nasogastric tube feedings. how and when to cut the immobilizing wires. the importance of high-fiber foods in the diet. the use of sterile technique for dressing changes

19. The day after a having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take? Explain the reasons for the phantom limb pain. Administer prescribed analgesics to relieve the pain. Loosen the compression bandage to decrease incisional pressure. Inform the patient that this phantom pain will diminish over time.

19. Which information in the preoperative patients medication history is most important to communicate to the health care provider? The patient uses acetaminophen (Tylenol) occasionally for aches and pains. The patient takes garlic capsules daily but did not take any on the surgical day. The patient has a history of cocaine use but quit using the drug over 10 years ago. The patient took a sedative medication the previous night to assist in falling asleep.

2. In the postanesthesia care unit (PACU), a patients vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? Place the patient in a side-lying position. Encourage the patient to take deep breaths. Prepare to transfer the patient to a clinical unit. Increase the rate of the postoperative IV fluids.

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

2. Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? The patient has gained 3 pounds. The patient has dark-colored stools. The patients pain has become more severe. The patient is using capsaicin cream (Zostrix).

20. Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurses discharge teaching has been effective? I should elevate my residual limb on a pillow 2 or 3 times a day. I should lay flat on my abdomen for 30 minutes 3 or 4 times a day. I should change the limb sock when it becomes soiled or each week. I should use lotion on the stump to prevent skin drying and cracking.

21. Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurses teaching about the condition? I will exercise even if I am tired. I will use sunscreen when I am outside. I should take birth control pills to keep from getting pregnant. I should avoid aspirin or nonsteroidal antiinflammatory drugs.

25. The health care provider has prescribed the following collaborative interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? Draw anti-DNA blood titer. Administer varicella vaccine. Naproxen (Aleve) 200 mg BID. Famotidine (Pepcid) 20 mg daily.

26. A 40-year-old African American patient has scleroderma manifested by CREST (calcinosis, Raynauds phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? Avoid use of capsaicin cream on hands. Keep environment warm and draft free. Obtain capillary blood glucose before meals. Assist to bathroom every 2 hours while awake.

26. A patient is being discharged 4 days after hip replacement surgery using the posterior approach. Which patient action requires immediate intervention by the nurse? The patient uses crutches with a swing-to gait. The patient leans over to pull shoes and socks on. The patient sits straight up on the edge of the bed. The patient bends over the sink while brushing teeth.

26. The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? Begin oral intake. Obtain vital signs. Assess pedal pulses. Start discharge teaching.

27. After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, I feel like I am going to die! Which action should the nurse take first? Stay with the patient and offer reassurance. Administer the prescribed PRN oxygen at 4 L/min. Check the patients legs for swelling or tenderness. Notify the health care provider about the symptoms.

27. The nurse determines that additional instruction is needed when a patient diagnosed with scleroderma says which of the following? Paraffin baths can be used to help my hands. I should lie down for an hour after each meal. Lotions will help if I rub them in for a long time. I should perform range-of-motion exercises daily.

28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? Complaints of incisional chest pain Pallor and weakness of the right hand Fine crackles heard at both lung bases Redness on both sides of the sternal incision

29. A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? Take the patient to have x-rays. Wrap the ankle and apply an ice pack. Administer naproxen (Naprosyn) 500 mg PO. Give acetaminophen with codeine (Tylenol #3).

29. Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)? The patient has joint pain and stiffness. The patients blood glucose is 165 mg/dL. The patient has experienced a recent 5-pound weight loss. The patients erythrocyte sedimentation rate (ESR) has increased.

3. A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? The patients lack of knowledge about postoperative pain control measures The patients statement that her last menstrual period was 8 weeks previously The patients history of a postoperative infection following a prior cholecystectomy The patients concern that she will be unable to care for her children postoperatively

3. After the nurse has finished teaching a 68-year-old patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? I can take glucosamine to help decrease my knee pain. I will take 1 g of acetaminophen (Tylenol) every 4 hours. I will take a shower in the morning to help relieve stiffness. I can use a cane to decrease the pressure and pain in my hip.

3. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? The pain increases with deep breathing. The pain has lasted longer than 30 minutes. The pain is relieved after the patient takes nitroglycerin. The pain is reproducible when the patient raises the arms.

34. A 31-year-old woman is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis. Which information from the patients health history is important for the nurse to report to the health care provider about the methotrexate? The patient had a history of infectious mononucleosis as a teenager. The patient is trying to get pregnant before her disease becomes more severe. The patient has a family history of age-related macular degeneration of the retina. The patient has been using large doses of vitamins and health foods to treat the RA.

37. A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should place the patient in a prone position. check the surgical site for hemorrhage. remove the prosthesis and wrap the site. keep the residual leg elevated on a pillow.

38. A 46-year-old male patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider? The blood glucose is 112 mg/dL. The patient has painful hematuria. Acne is noted on the patients face. The patient has an increased appetite.

38. Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take? Observe the status of the incisional drain device. Administer the ordered oral opioid pain medication. Instruct the patient about the benefits of ambulation. Change the hip dressing and document the wound appearance.

42. Which information obtained by the nurse about a 29-year-old patient with a lumbar vertebral compression fracture is most important to report to the health care provider? Patient refuses to be turned due to back pain. Patient has been incontinent of urine and stool. Patient reports lumbar area tenderness to palpation. Patient frequently uses oral corticosteroids to treat asthma.

45. When caring for a patient who is using Bucks traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? Monitor the skin under the traction boot for redness. Ensure that the weight for the traction is off the floor. Check for intact sensation and movement in the affected leg. Offer reassurance that hip and leg pain are normal after hip fracture.

5. A 22-year-old tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? You will not be able to serve a tennis ball again. You will work with a physical therapist tomorrow. The doctor will use the drop-arm test to determine the success of surgery. Leave the shoulder immobilizer on for the first 4 days to minimize pain.

6. The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place for several months for at least 3 weeks. until swelling of the wrist has resolved until x-rays show complete bony union

6. Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis? Instruct the patient to purchase a soft mattress. Suggest that the patient take a nap in the afternoon. Teach the patient to use lukewarm water when bathing. Suggest exercise with light weights several times daily.

7. A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is most appropriate? Teach the patient about adverse effects of the RA medications. Suggest that the patient use over-the-counter (OTC) artificial tears. Reassure the patient that dry eyes are a common problem with RA. Ask the health care provider about discontinuing methotrexate (Rheumatrex) .

7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? Carvedilol will help my heart muscle work harder. It is important not to suddenly stop taking the carvedilol . I can expect to feel short of breath when taking carvedilol. Carvedilol will increase the blood flow to my heart muscle.

8. When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, I will have to buy some loose clothes that do not bind across my legs or waist. use a heating pad on my feet at night to increase the circulation and warmth in my feet. change my position every hour and avoid long periods of sitting with my legs crossed. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week.

8. Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis? Affected joints should not be exercised when pain is present. Application of cold packs before exercise may decrease joint pain. Exercises should be performed passively by someone other than the patient. Walking may substitute for range-of-motion (ROM) exercises on some days

8. Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? Avoid placing the patient in prone position. Ask the patient about abdominal discomfort. Discuss remaining on bed rest for several weeks. Use the cast support bar to reposition the patient.

9. A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should keep the left arm in dependent position. avoid handling the cast using fingertips. place gauze around the cast edge to pad any roughness. cover the cast with a small blanket to absorb the dampness.

9. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patients oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? Increase the IV fluid rate. Assess for bladder distention. Notify the anesthesia care provider (ACP). Demonstrate the use of the nurse call bell button.

9. The nurse is preparing to witness the patient signing the operative consent form when the patient says, I do not really understand what the doctor said. Which action is best for the nurse to take? Provide an explanation of the planned surgical procedure. Notify the surgeon that the informed consent process is not complete. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

11. Which action will the nurse take immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent? Administer higher doses of analgesic agents Ensure that atropine is available in case of bradycardia Question the order for benzodiazepines to be administered. Provide a quiet environment in the postanesthesia care unit

2. A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about surgical options. elbow injections. wearing a left wrist splint. modifying arm movements.

4. Which action best describes how the scrub nurse maintains aseptic technique during surgery? Uses waterproof shoe covers Wears personal protective equipment Insists that all operating room (OR) staff perform a surgical scrub Changes gloves after touching the upper arm of the surgeons gow

5. An older patient is hospitalized with pneumonia. Which intervention should the nurse implement to provide optimal care for this patient? a. Use a standardized geriatric nursing care plan. b. Minimize activity level during hospitalization. c. Plan for transfer to a long-term care facility upon discharge. d. Consider the preadmission functional abilities when setting patient goals.

17. Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? Record hourly chest tube drainage. Monitor fluid intake and urine output. Check the abdominal incision for any redness. Teach the reason for a prolonged recovery period.

24. The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? Notify the surgeon and anesthesiologist. Wrap both the legs in a warming blanket. Document the findings and recheck in 15 minutes. Compare findings to the preoperative assessment of the pulses.

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? 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain 52-year-old with a BP of 212/90 who has intermittent claudication 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL 48-year-old with a BP of 172/98 whose urine shows microalbuminuria

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? Serum creatinine of 2.8 mg/dL Serum potassium of 4.5 mEq/L Serum hemoglobin of 14.7 g/dL Blood glucose level of 96 mg/dL

19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, I am too nervous to take care of myself. Based on this information, which nursing diagnosis is appropriate? Ineffective coping related to anxiety Activity intolerance related to weakness Denial related to lack of acceptance of the MId. Disturbed personal identity related to understanding of illness

20. The charge nurse observes a new registered nurse (RN) 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 increase the dietary intake of high-potassium foods. make an appointment with the dietitian for teaching. check the blood pressure (BP) with a home BP monitor at least once a day. move slowly when moving from lying to sitting to standing.

21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, I just had a little chest pain. As soon as I get out of here, Im going for my vacation as planned. Which reply would be most appropriate for the nurse to make? What do you think caused your chest pain? Where are you planning to go for your vacation? Sometimes plans need to change after a heart attack. Recovery from a heart attack takes at least a few weeks.

22. An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? Obtain the blood pressure. Obtain blood for laboratory testing. Assess for the presence of an abdominal bruit. Determine any family history of kidney disease.

25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include when cardiac rehabilitation will begin. the typical emotional responses to AMI. information regarding discharge medications. the pathophysiology of coronary artery disease.

26. A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? Generalized muscle aches and pains Dizziness when changing positions quickly Nausea when taking the drugs before eatingd. Flushing and pruritus after taking the medications

27. A patient who is 2 days post-femoral-popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene? The LPN/LVN has the patient sit in a chair for 90 minutes. The LPN/LVN assists the patient to walk 40 feet in the hallway. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. The LPN/LVN places the patient in a Fowlers position for meals.

27. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patients care? Sildenafil (Viagra) Furosemide (Lasix) Captopril (Capoten) Warfarin (Coumadin)

28. A 46-year-old is diagnosed with thromboangiitis obliterans (Buergers disease). When the nurse is developing a discharge teaching plan for the patient, which outcome has the highest priority for this patient? Cessation of all tobacco use Control of serum lipid levels Maintenance of appropriate weight Demonstration of meticulous foot care

29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? Give the scheduled aspirin and lipid-lowering medication. Perform the initial assessment of the catheter insertion site. Teach the patient about the usual postprocedure plan of care. Titrate the heparin infusion according to the agency protocol.

34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? No change in the patients chest pain An increase in troponin levels from baseline A large bruise at the patients IV insertion site A decrease in ST-segment elevation on the electrocardiogram

4. A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management? Statins Antibiotics Thrombolytics Anticoagulants

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 asthma. daily alcohol use. peptic ulcer disease. myocardial infarction (MI).

9. After teaching a patient with newly diagnosed Raynauds phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective? The patient exercises indoors during the winter months. The patient places the hands in hot water when they turn pale. The patient takes pseudoephedrine (Sudafed) for cold symptoms. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

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 little swelling around my lips and face is okay. The medication may not work as well if I take any aspirin. The doctor may order a blood potassium level occasionally. I will call the doctor if I notice that I have a frequent cough.

13. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? I should get a Medic Alert device stating that I take Coumadin. I should reduce the amount of green, leafy vegetables that I eat. I will need routine blood tests to monitor the effects of the Coumadin. I will check with my health care provider before I begin any new medications.

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? Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. Have the patient sit in a chair with the feet flat on the floor. Assist the patient to the supine position for BP measurements. Obtain two BP readings in the dominant arm and average the results.

10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the patient is restless and agitated. blood pressure is 90/54 mm Hg. patient complains about feeling anxious. cardiac monitor shows a heart rate of 61 beats/minute.

11. The health care provider prescribes an infusion of heparin (Hep-Lock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to decrease the infusion when the PTT value is 65 seconds. avoid giving any IM medications to prevent localized bleeding. monitor posterior tibial and dorsalis pedis pulses with the Doppler. have vitamin K available in case reversal of the heparin is needed.

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? 102/60 mm Hg 128/76 mm Hg 139/90 mm Hg 136/82 mm Hg

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? Inform the patient about the reasons for a possible change in drug dosage. Question the patient about whether the medication is actually being taken. Inform the patient that multiple drugs are often needed to treat hypertension. Question the patient regarding any lifestyle changes made to help control BP.

2. A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about low back pain. trouble swallowing. abdominal tenderness. changes in bowel habits.

20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that sudden cardiac death events rarely reoccur. additional diagnostic testing will be required. long-term anticoagulation therapy will be needed .limited physical activity after discharge will be needed to prevent future event

21. When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? Exercise only if you do not experience any pain. It is very important that you stop smoking cigarettes. Try to keep your legs elevated whenever you are sitting. Put elastic compression stockings on early in the morning.

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? Blood glucose level of 175 mg/dL Blood potassium level of 3.0 mEq/L Most recent blood pressure (BP) reading of 168/94 mm Hg Orthostatic systolic BP decrease of 12 mm Hg

22. When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? They will circulate my blood with a machine during the surgery. I will have small incisions in my leg where they will remove the vein. They will use an artery near my heart to go around the area that is blocked. I will need to take an aspirin every day after the surgery to keep the graft open.

23. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? Most patients are able to enjoy intercourse without any complications. Sexual activity uses about as much energy as climbing two flights of stairs. The doctor will provide sexual guidelines when your heart is strong enough . Holding and cuddling are good ways to maintain intimacy after a heart attack.

25. When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? Presence of flatus Loose, bloody stools Hypoactive bowel sounds Abdominal pain with palpation

33. When admitting a patient with a nonST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? Obtain the blood pressure. Attach the cardiac monitor. Assess the peripheral pulses. Auscultate the breath sounds.

33. Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? Monitor for any bleeding after anticoagulation therapy is started. Apply sequential compression device whenever the patient is in bed. Ask the patient about use of herbal medicines or dietary supplements. Instruct the patient to call immediately if any shortness of breath occurs.

34. The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)? Patient who has been complaining of increased edema and skin changes in the legs Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg Patient who has a history of venous thromboembolism and is complaining of some dyspnea Patient who needs teaching about the use of elastic compression stockings for venous insufficiency

39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? Stress that weight loss is a major benefit of increased exercise. Determine what kind of physical activities the patient usually enjoys. Tell the patient that older adults should exercise for no more than 20 minutes at a time. Teach the patient to include a short warm-up period at the beginning of physical activity.

40. Which patient at the cardiovascular clinic requires the most immediate action by the nurse? Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL Patient with stable angina whose chest pain has recently increased in frequency Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

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.

12. A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate? Taking two blood thinners reduces the risk for another clot to form. Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming. Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots. Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner.

14. A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? Sitting at the work counter, rather than standing, is recommended. Exercise, such as walking or jogging, can cause recurrence of varicosities. Elastic compression stockings should be applied before getting out of bed. Taking an aspirin daily will help prevent clots from forming around venous valves

17. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? Assess the feet for pedal edema. Palpate the radial pulses bilaterally. Auscultate for a pericardial friction rub. Check the heart monitor for dysrhythmias.

18. In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? I will check my pulse rate before I take any nitroglycerin tablets. I will put the nitroglycerin patch on as soon as I get any chest pain. I will stop what I am doing and sit down before I put the nitroglycerin under my tongue. I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin.

18. Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed? The nurse avoids rubbing the injection site after giving the drug. The nurse injects the drug into the abdominal subcutaneous tissue. The nurse ejects the air bubble in the syringe before giving the drug. The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.

19. A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynauds phenomenon is suspected. The nurse will anticipate teaching the patient about tests for hyperglycemia. hyperlipidemia. autoimmune disorders. coronary artery disease.

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)? Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). Set up the automatic blood pressure machine to take BP every 15 minutes. Assess the patients environment for adverse stimuli that might increase BP.

23. After receiving report, which patient admitted to the emergency department should the nurse assess first? 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools 50-year-old who is complaining of sudden sharp and worst ever upper back pain 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

29. Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? Erythema of right lower leg Complaint of right calf pain New onset shortness of breath Temperature of 100.4 F (38 C)

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

32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? Acute pain related to myocardial infarction Anxiety related to perceived threat of death Stress overload related to acute change in health Decreased cardiac output related to cardiogenic shock

35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? The troponin level is elevated. The patient denies ever having a heart attack. Bilateral crackles are auscultated in the mid-lower lobes. The patient has occasional premature atrial contractions (PACs).

42. After reviewing information shown in the accompanying figure from the medical records of a 43-year-old, which risk factor modification for coronary artery disease should the nurse include in patient teaching? Importance of daily physical activity Effect of weight loss on blood pressure Dietary changes to improve lipid levels Ongoing cardiac risk associated with history of tobacco use

1. When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the family history of coronary artery disease. increased risk associated with the patients gender. increased risk of cardiovascular disease as people age. elevation of the patients low-density lipoprotein (LDL) level.

1. When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? Male gender Turner syndrome Abdominal trauma history Uncontrolled hypertension

10. The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patients feet is best? The patient is placed in the Trendelenburg position. Two pillows are positioned under the affected leg. The bed is elevated at the knee and pillows are placed under the feet. One pillow is placed under the thighs and two pillows are placed under the lower legs.

11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for decreased blood pressure and heart rate. fewer complaints of having cold hands and feet. improvement in the strength of the distal pulses. the ability to do daily activities without chest pain.

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

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? Heart rate 102 beats/min Pedal pulses 1+ bilaterally Blood pressure 103/54 mm Hg Chest pain level 7 on a 0 to 10 point scale

32. A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform? Ask about leg pain with exercise. Determine the ankle-brachial index. Assess capillary refill in the patients toes. Check for presence of lipodermatosclerosis.

35. The nurse reviews the admission orders shown in the accompanying figure for a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question? Use of treadmill for exercise Referral for dietary instruction Exercising to the point of discomfort Combined clopidogrel and omeprazole therapy

36. A patient had a nonST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? Evaluation of the patients response to walking in the hallway Completion of the referral form for a home health nurse follow-up Education of the patient about the pathophysiology of heart disease Reinforcement of teaching about the purpose of prescribed medications

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? The patient avoids eating nuts or nut butters. The patient restricts intake of chicken and fish. The patient has two cups of coffee in the morning. The patient has a glass of low-fat milk with each meal.

4. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? The patient states that the pain wakes me up at night. The patient rates the pain at a level 3 to 5 (0 to 10 scale). The patient states that the pain has increased in frequency over the last week. The patient states that the pain goes away with one sublingual nitroglycerin tablet.

43. After reviewing a patients history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? Q waves on ECG Elevated troponin levels Fever and hyperglycemia Tachypnea and crackles in lungs

5. A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately apply a compression stocking to the leg. elevate the leg above the level of the heart. assist the patient in gently exercising the leg. keep the patient in bed in the supine position.

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? Check blood pressure (BP) in both arms before taking the medication. Increase fluid intake if dryness of the mouth is a problem. Include high-potassium foods such as bananas in the diet. Change position slowly to help prevent dizziness and falls.

6. A patient at the clinic says, I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though. The nurse should check for the presence of tortuous veins bilaterally on the legs. ask about any skin color changes that occur in response to cold. assess for unilateral swelling, redness, and tenderness of either leg. assess for the presence of the dorsalis pedis and posterior tibial pulses.

6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? I will switch from whole milk to 1% milk. I like salmon and I will plan to eat it more often. I can have a glass of wine with dinner if I want one. I will miss being able to eat peanut butter sandwiches.

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. dietary sodium and fat content should be decreased. there is an immediate danger of a stroke and hospitalization will be required. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? Myoglobin Homocysteine C-reactiveprotein Cardiac-specific troponin

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? Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. Assist the patient up in the chair for meals to avoid complications associated with immobility. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

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