Exam 2 - Med surg
A male patient with gonorrhea asks the nurse how he can reduce his risk of contracting another sexually transmitted infection. The patient is not in a monogamous relationship. The nurse should instruct the patient to do which of the following? a. Ask all potential sexual partners if they have a sexually transmitted disease. b. Wear a condom every time he has intercourse. c. Consider intercourse to be risk-free if his partner has no visible discharge, lesions, or rashes. d. Aim to limit the number of sexual partners to fewer than five over his lifetime.
b
A medical patient rings her call bell and expresses alarm to the nurse, stating, Ive just coughed up this blood. That cant be good, can it? How can the nurse best determine whether the source of the blood was the patients lungs? a. Obtain a sample and test the pH of the blood, if possible. b. Try to see if the blood is frothy or mixed with mucus. c. Perform oral suctioning to see if blood is obtained. d. Swab the back of the patients throat to see if blood is present.
b
A NP is examining a pt who presented at the free clinic w/vulvar pruritus. For which assessment finding would the practitioner look that may indicate the pt has an infxn caused by Candida albicans? a. cottage cheese-like discharge b. yellow-green discharge c. gray-white discharge d. watery discharge w/a fishy odor
a
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didnt know it would be this hard to live like this. What response by the nurse is best? a. Assess the clients coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.
a
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this? a. Maintaining a patent airway b. Preventing the need for suctioning c. Maintaining the sterility of the patients airway d. Increasing the patients lung compliance
a
A female pt tells the nurse that she thinks she has a vaginal infxn bc she has noted inflammation of her vulva and the presence of a frothy, yellow-green discharge. The nurse recognizes that the clinical manifestations described are typical of what vaginal infxn? a. Trichomonas vaginalis b. Candidiasis c. Gardnerella d. Gonorrhea
a
A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurses practice? a. Frequent handwashing reduces transmission of pathogens from one patient to another. b. Wearing gloves is known to be an adequate substitute for handwashing. c. Bar soap is preferable to liquid soap. d. Waterless products should be avoided in situations where running water is unavailable.
a
A nurse is caring for a pregnant patient w/active herpes. The teaching plan for this patient should include which of the following? a. babies delivered vaginally may become infected w/ the virus b. recommended treatment is excision of the herpes lesions c. pain generally does not occur w/ a herpes outbreak during pregnancy d. pregnancy may exacerbate the mothers symptoms, but poses no risk to the infant
a
A nurse is caring for a pt who has been diagnosed w/psoriasis. The nurse is creating an education plan for the pt. What info should be included in this plan? a. use caution when taking nonprescription meds b. avoid public places until symptoms subside c. wash skin frequently to prevent infxn d. liberally apply corticosteroids as needed
a
A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate? a. does anyone in your family have eczema or psoriasis? b. have any of your family members been diagnosed w/malignant melanoma? c. do you have a family hx of vitiligo or port-wine stains? d. does any member of your family have a hx of keloid scarring?
a
A nurse is providing self-care education to a pt who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the pt? a. wash your face w/water and gentle soap each morning and evening b. before bedtime, clean your face w/rubbing alcohol on a cotton pad c. gently burst new pimples before they form a vesicle head d. set aside time each day to squeeze blackheads and remove the plug
a
A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis? a. Patients who are habitual users of alcohol and tobacco b. Patients who are habitual users of caffeine and other stimulants c. Patients who eat a diet high in spicy foods d. Patients who have gastrointestinal reflux disease (GERD)
a
A nurse who provides care in a busy ED is in contact with hundreds of patients each year. The nurse has a responsibility to receive what vaccine? a. Hepatitis B vaccine b. Human papillomavirus (HPV) vaccine c. Clostridium difficile vaccine d. Staphylococcus aureus vaccine
a
A nursing home patient has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents? a. Contact b. Droplet c. Airborne d. Positive pressure isolation
a
A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication? a. Sinus infections b. Esophageal strictures c. Pharyngitis d. Laryngitis
a
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? a. to remove air from the pleural space b. to drain copious sputum secretions c. monitor bleeding around the lungs d. to assist w/mechanical ventilation
a
A patient on Airborne Precautions asks the nurse to leave his door open. What is the nurses best reply? a. I have to keep your door shut at all times. Ill open the curtains so that you dont feel so closed in. b. Ill keep the door open for you, but please try to avoid moving around the room too much. c. I can open your door if you wear this mask. d. I can open your door, but Ill have to come back and close it in a few minutes.
a
A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions? a. Wearing a mask and gown when starting an IV line b. Washing hands immediately after removing gloves c. Recapping all needles promptly after use to prevent needlestick injuries d. Double-gloving when working with a patient who has a blood-borne illness
b
An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value? a. Highest airflow during a forced inspiration b. Highest airflow during a forced expiration c. Airflow during a normal inspiration d. Airflow during a normal expiration
b
An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? a. Encouraging patients to carry a corticosteroid rescue inhaler at all times b. Educating patients about recognizing and avoiding asthma triggers c. Teaching patients to utilize alternative therapies in asthma management d. Ensuring that patients keep their immunizations up to date
b
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment? a. On a scale from 1 to 10, how bad would rate your shortness of breath? b. When was the last time you ate or drank anything? c. Are you feeling any nausea along with your shortness of breath? d. Do you think that some medication might help you catch your breath?
a
A pediatric nurse practitioner is caring for a child who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. What potential causative agent should the nurse describe? a. Pets b. Lack of sleep c. Psychosocial stress d. Bacteria
a
A pt has just been diagnosed w/psoriasis and frequently has lesions around his right eye. What should the nurse teach the pt about topical corticosteroid use on these lesions? a. cataract development is possible b. the ointment is likely to cause weeping c. corticosteroid use is contraindicated on these lesions d. the pt may develop glaucoma
a
A pt has recently been diagnosed w/ advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this pt, what major nursing diagnosis should the nurse include? a. deficient knowledge about early signs of melanoma b. chronic pain r/t surgical excision and grafting c. depression r/t reconstructive surgery d. anxiety r/t lack of social support
a
An 80-yold pt is brought to the clinic by her son. The son asks why his mother has gotten so many spots on her skin. What would be na appropriate response by the nurse? a. as people age, they normally develop uneven pigmentation in their skin b. these spots are called liver spots or age spots c. older skin is more apt to break down and tear, causing sores d. these are usually the result of nutritional deficits earlier in life
a
The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication? a. It inhibits the release of histamine and other chemicals. b. It inhibits the action of proton pumps. c. It inhibits the action of the sodium-potassium pump in the nasal epithelium. d. It causes bronchodilation and relaxes smooth muscle in the bronchi.
a
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what? a. impaired gas exchange b. collapsed bronchial structures c. necrosis of the alveoli d. closed bronchial tree
a
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? a. Their location over a specific area of the lung b. The volume of the sounds c. Whether they are heard on inspiration or expiration d. Whether or not they are continuous breath sounds
a
The nurse is planning the care of a pt who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the pts care plan? a. risk for disturbed body image r/t to skin lesions b. risk for disuse syndrome r/t to dermatitis c. risk for ineffective role performance r/t to dermatitis d. risk for self-care deficit r/t to skin lesions
a
The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up? a. Periorbital edema b. Headache unrelieved by OTC medications c. Clear drainage from nose d. Blood-tinged mucus when blowing the nose
a
A NP is seeing a 16-yold male pt who has come to the dermatology clinic for treatment of acne? The NP would know that the treatment may consist of which of the following meds? a. Acyclovir (Zovirax) b. Benzoyl peroxide and erythromycin (benzamycin) c. Diphenhydramine (Benadryl) d. Triamcinolone (Kenalog)
b
A NP working in a dermatology clinic finds an open lesion on a pt who is being assessed. What should the nurse do next? a. obtain a swab for culture b. assess the characteristics of the lesions c. Obtain a swab for pH testing d. apply a test dose of broad=spectrum topical antibiotic
b
A dermatologist has asked the nurse to assist w/examination of a pts skin using a Woods light. This test will allow the physician to assess for which of the following? a. the presence of minute regions of keloid scarring b. unusual patterns of pigmentation on the pts skin c. vascular lesions that are not visible to the naked eye d. the presence of parasites on the epidermis
b
A gerontologic nurse is analyzing the data from a patients focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change? a. increased diffusion of gases b. decreased diffusion capacity for oxygen c. decreased shunting of blood d. increased centilation
b
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? a. by avoiding the use of moisturizing lotions on older adults skin b. by protecting older adults against shearing injuries c. by avoiding use of ice packs to treat muscle pain d. by protecting older adults against excessive sweat accumulation
b
An older adult patient tells the nurse that she had chicken pox as a child and is eager to be vaccinated against shingles. What should the nurse teach the patient about this vaccine? a. Vaccination against shingles is contraindicated in patients over the age of 80. b. Vaccination can reduce her risk of shingles by approximately 50%. c. Vaccination against shingles involves a series of three injections over the course of 6 months. d. Vaccination against shingles is only effective if preceded by a childhood varicella vaccination.
b
Assessment of a pts leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion? a. keloid b. ulcer c. fissure d. erosion
b
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? a. Fluid intake for the last 24 hours b. Baseline arterial blood gas (ABG) levels c. Prior outcomes of weaning d. Electrocardiogram (ECG) results
b
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patients room. The nurse asks the patient when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take? a. Immediately take the sputum specimen to the laboratory. b. Discard the specimen and assist the patient in obtaining another specimen. c. Refrigerate the sputum specimen and submit it once it is chilled. d. Add a small amount of normal saline to moisten the specimen.
b
The nurse has assessed a patients family history for three generations. The presence of which respiratory disease would justify this type of assessment? a. bradycardia and frontal HA b. dyspnea and substernal pain c. peripheral cyanosis and restlessness d. HoTN and tachycardia
b
The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? a. Teach him postural drainage. b. Teach him how to perform huffing. c. Teach him to use a mini-nebulizer. d. Teach him how to use a metered dose inhaler.
b
The nurse is assessing a pt who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding? a. obtain a sputum sample b. perform a swallowing assessment c. inspect the pts tongue and mouth d. assess the pts nutritional status
b
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? a. Between 10 and 15 mm Hg b. Between 15 and 20 mm Hg c. Between 20 and 25 mm Hg d. Between 25 and 30 mm Hg
b
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? a. sputum production b. shortness of breath c. throat discomfort d. epistaxis
b
The nurse is caring for a patient who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the patient asks, Will this chronic infection hurt my new kidney? What should the nurse know about chronic rhinosinusitis in patients who have had a transplant? a. The patient will have exaggerated symptoms of rhinosinusitis due to immunosuppression. b. Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. c. Chronic rhinosinusitis can damage the transplanted organ. d. Immunosuppressive drugs can cause organ rejection.
b
The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patients needs? a. Non-rebreathing mask b. Nasal cannula c. Simple mask d. Partial-rebreathing mask
b
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? a. how to milk the chest tubing b. how to splint the incision when coughing c. how to take prophylactic antibiotics correctly d. how to manage the need for fluid restriction
b
The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurses postprocedure care? a. Assisting with pulmonary function testing (PFT) b. Maintaining the patients chest tube c. Administering oral suction as needed d. Performing chest physiotherapy
b
The nurse is doing discharge teaching in the ED with a patient who had a nosebleed. What should the nurse include in the discharge teaching of this patient? a. Avoid blowing the nose for the next 45 minutes. b. In case of recurrence, apply direct pressure for 15 minutes. c. Do not take aspirin for the next 2 weeks. d. Seek immediate medical attention if the nosebleed recurs.
b
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? a. An appropriate perfusion diffusion ratio b. An adequate ventilation perfusion ratio c. Adequate diffusion of gas in shunted blood d. Appropriate blood nitrogen concentration
b
The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis? a. Afrin b. Beconase c. Sinustop Pro d. Singulair
b
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response? a. CPAP allows a higher percentage of oxygen to be safely used. b. CPAP allows a lower percentage of oxygen to be used with a similar effect. c. CPAP allows for greater humidification of the oxygen that is administered. d.. CPAP allows for the elimination of bacterial growth in oxygen delivery systems.
b
What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis? a. To decreased nurses susceptibility to health care-associated infections b. To decrease risk of transmission to vulnerable patients c. To eventually eradicate the influenza virus in the United States d. To prevent the emergence of drug-resistant strains of the influenza virus
b
What would the critical care nurse recognize as a condition that may indicate a pts need to have a tracheostomy? a. a pt has a respiratory rate of 10 breaths/min b. a pt requires permanent ventilation c. a pt exhibits symptoms of dyspnea d. a pt has respiratory acidosis
b
Which assessment action will help the nurse determine if an obese patient has metabolic syndrome? a. Take the patients apical pulse. b. Check the patients blood pressure. c. Ask the patient about dietary intake. d. Dipstick the patients urine for protein.
b
While assessing a newly admitted pt you note the following: impaired coordination, decreased muscle strength, limited ROM, and reluctance to move. What nursing diagnosis do these s/s most clearly suggest? a. ineffective health maintenance b. impaired physical mobility c. disturbed sensory perception: kinesthetic d. ineffective role performance
b
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? a. Every 2 hours when the patient is awake b. When adventitious breath sounds are auscultated c. When there is a need to prevent the patient from coughing d. When the nurse needs to stimulate the cough reflex
b
You are the nurse caring for a female pt who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided pt teaching about pressure ulcers and healing promotion. You assess that the pt has understood the teaching by observing what? a. patient performs ROM exercises b. pt avoids placing her body wt on healing site c. pt elevates her body parts that are susceptible to edema d. pt demonstrates the technique for massaging the wound site
b
The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply. a. Progressive weakening of human immune systems b. Use of extended-spectrum antibiotics c.Population movements d. Increased global travel e. Globalization of food supplies
b, c, d, e
A 30 yold pt has come to the clinic for her yearly examination. The pt asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer? a. use of oral contraceptives increases the risk of ovarian cancer b. most cases of ovarian cancer are attributed to tobacco use c. most cases of ovarian cancer are considered to be random, w/no obvious causation d. the majority of women who get ovarian cancer have a family hx of the disease
c
A 35-yold kidney transplant pt comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring or this pt recognizes that this is what type of Kaposis sarcoma? a. classic b. AIDS-related c. immunosuppresion-related d. endemic
c
A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem? a. Adenoiditis b. Chronic tonsillitis c. Obstructive sleep apnea d. Laryngeal cancer
c
A 61-year-old man is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Demonstrate use of the incentive spirometer. b. Plan methods for bathing and turning the patient. c. Assist with IV insertion by holding adipose tissue out of the way. d. Develop strategies to provide privacy and decrease embarrassment.
c
A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the clients pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.
c
A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members. The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what? a. Shigella b. Escherichia coli c. Clostridium difficile d. Norovirus
c
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of what? a. Pneumothorax b. Lung tumors c. Infection d. Pulmonary edema
c
A mother brings her 12 month-old son into the clinic for his measles-mumps-rubella (MMR) vaccination. What would the clinic nurse advise the mother about the MMR vaccine? a. Photophobia and hives might occur. b. There are no documented reactions to an MMR. c. Fever and hypersensitivity reaction might occur. d. Hypothermia might occur.
c
A new pt has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would likely be ordered to identify the causative allergen? a. skin scrapings b. skin biopsy c. patch testing d. Tzanck smear
c
A new pt presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the pts fingernail surfaces are pitted. The nurse should suspect the presence of what health problem? a. eczema b. systemic lupus erythematosus (SLE) c. psoriasis d. COPD
c
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? a. Determine whether the patient can now perform forced expiratory technique (FET). b. Percuss the patients lungs and thorax. c. Measure the patients oxygen saturation. d. Have the patient perform incentive spirometry.
c
A nurse in a dermatology clinic is reading the electronic health record of a new pt. The nurse notes that the pt has a hx of a primary skin lesion. What is an example of a primary skin lesion? a. crust b. keloid c. pustule d. ulcer
c
A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? a. Shallow respirations b. Increased anterior-posterior (A-P) diameter c. Bilateral wheezes d. Bradypnea
c
A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risk of basal cell carcinoma (BCC)? a. teaching participants to improve their overall health through nutrition b. encouraging participants to ID their family hx of cancer c. teaching participants to limit their sun exposure d. teaching participants to control exposure to environmental and occupational radiation
c
A nurse is providing care for a pt who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment? a. assessment of the pts stool for evidence of intestinal sloughing b. assessment of the pts apical HR for dysrhythmias c. assessment of the pts joints for pain and decreased ROM d. assessment for cognitive changes resulting from neurologic lesions
c
A nurse is reviewing gerontologic considerations r/t care of pts w/dermatologic problems. What vulnerability results from the age-related loss of subq tissue? a. decreased resistance to UV radiation b. increased vulnerability to infxn c. diminished protection of tissues and organs d. increased risk of skin malignancies
c
A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? a. Dyspnea and increased respiratory secretions b. Nausea and vomiting c. Cough and oral thrush d. Fatigue and decreased level of consciousness
c
A nurse is working w/a family whose 5-yold daughter has been diagnosed w/impetigo. What educational intervention should the nurse include in this family's care? a. ensuring that the family knows that impetigo is not contagious b. teaching about the safe and effective use of topical corticosteroids c. teaching about the importance of maintaining high standards of hygiene d. ensuring that the family knows how to safely burst the child's vesicles
c
A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis? a. Teaching focuses on safe and effective use of antibiotics. b. The patient should be preliminarily screened for surgery. c. Symptom management is the main focus of medical and nursing care. d. The focus of care is resting the voice to prevent chronic hoarseness
c
A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patients resonating chamber in speech? a. trachea b. pharynx c. paranasal sinuses d. larynx
c
A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response? a. The physician may feel that mechanical ventilation will have to be used long-term. b. Long-term use of an endotracheal tube diminishes the normal breathing reflex. c. When an endotracheal tube is left in too long it can damage the lining of the windpipe. d. It is much harder to breathe through an endotracheal tube than a tracheostomy.
c
A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patients nutrition during treatment? a. A 1.5 L/day fluid restriction b. A high-potassium, low-sodium diet c. A liquid or soft diet d. A high-protein diet
c
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis? a. increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall b. decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall c. lung fields dull to percussion, absent breath sounds, and a pleural friction rub d. normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall
c
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? a.Non-rebreather air mask b. Tracheostomy collar c.Venturi mask d. Face tent
c
A patients diagnostic testing revealed that he is colonized with vancomycin-resistantenterococcus (VRE). What change in the patients health status could precipitate an infection? a. Use of a narrow-spectrum antibiotic b. Treatment of a concurrent infection using vancomycin c. Development of a skin break d. Persistent contact of the bacteria with skin surfaces
c
A patients severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patients statements suggests a need for further education? a. I know that these drugs can sometimes make my heart beat faster. b. Ive heard that this drug is particularly good at preventing asthma attacks during exercise. c. Ill make sure to use this each time I feel an asthma attack coming on. d. Ive heard that this drug sometimes gets less effective over time.
c
A pt has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this pts care, the nurse should include which of the following nursing diagnoses? a. risk for deficient fluid volume r/t excess sebum synthesis b. ineffective thermoregulation r/t occlusion of sebaceous glands c. disturbed body image r/t excess sebum production d. ineffective tissue perfusion r/t occlusion of sebaceous glands
c
A pt has just been told that he has malignant melanoma. The nurse caring for this pt should anticipate that the pt will undergo what treatment? a. chemotherapy b. immunotherapy c. wide excision d. radiation therapy
c
A pt has presented w/ s/s that are consistent w/contact dermatitis. What aspect of care should use nurse prioritize when working w/this pt? a. promoting adequate perfusion in affected regions b. promoting safe use of topical antihistamines c. identifying the offending agent, if possible d. teaching the pt to safely use an EpiPen
c
A pt presents at the dermatology clinic w/suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition? a. skin biopsy b. patch test c. tzanck smear d. examination w/a Woods light
c
A pt w/squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? a. chemotherapy b. radiation therapy c. surgical excision d. biopsy of sample office
c
A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes r/t skin cancer in the community. What action has the greatest potential to achieve this goal? a. educating participants about the relationship btwn general health and risk of skin cancer b. educating participants about treatment options for skin cancer c. educating participants about the early s/s of skin cancer d. educating participants about the health risks associated w/smoking and assisting with smoking cessation
c
A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups? a. Preschool-aged children b. Adults with diabetes and/or renal failure c. Older adults with compromised health status d. Infants under the age of 12 months
c
A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this clients airflow obstruction? a. Administer corticosteroids by metered dose inhaler b. Administer inhaled anticholinergics c. Administer an inhaled beta-adrenergic agonist d. Utilize a peak flow monitoring device
c
A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing? a. Gradually increase levels of physical exertion. b. Change filters on heaters and air conditioners frequently. c. Take prescribed medications as scheduled. d. Avoid goose-down pillows.
c
An immunosuppressed patient is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family? a. Family members should avoid receiving vaccinations until the patient has recovered from his or her illness. b. Wipe down hard surfaces with a dilute bleach solution once per day. c. Maintain cleanliness in the home, but recognize that the home does not need to be sterile. d. Avoid physical contact with the patient unless absolutely necessary.
c
An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? a. avoid the application of skin emollients b. apply antibiotic ointment as ordered following baths c. avoid using hot water during the pts baths d. administer acetaminophen 4 times daily as ordered
c
It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis? a. Pharyngitis is more common in children whose immunizations are not up to date. b. There are no effective, evidence-based treatments for pharyngitis. c. Use of warm saline gargles or throat irrigations can relieve symptoms. d. Heat may increase the spasms in pharyngeal muscles.
c
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? a. pleurisy b. emphysema c. asthma d. pneumonia
c
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? a. Deflate the cuff overnight to prevent tracheal tissue trauma. b. Inflate the cuff to the highest possible pressure in order to prevent aspiration. c. Monitor the pressure in the cuff at least every 8 hours d. Keep the tracheostomy tube plugged at all times.
c
The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment? a. The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min. b. The patient requires a high-flow system for use with a tracheostomy collar. c. The patient desires a portable oxygen delivery system that can deliver 2 L/min. d. The patients respiratory status requires a system that provides an FiO2 of 65%.
c
The infectious control nurse is presenting a program on West Nile virus for a local community group. To reduce the incidence of this disease, the nurse should recommend what action? a. Covering open wounds at all times b. Vigilant handwashing in home and work settings c. Consistent use of mosquito repellants d. Annual vaccination
c
The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? a. absence of breath sounds b. wheezing w/discontinuous breath sounds c. faint breath sounds w/prolonged expiration d. faint breath sounds w/fine crackles
c
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood? a. A capillary blood sample b. Pulse oximetry c. an arteiral blood gas (ABG) study d. a complete blood count (CBC)
c
The nurse is caring for a patient in the ED for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis? a. Keep nasal passages clear. b. Use decongestants regularly. c. Humidify the indoor environment. d. Use a tissue when blowing the nose.
c
The nurse is caring for a patient who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting? a. Using antibacterial soap when bathing patients with MRSA b. Conducting culture surveys on a regularly scheduled basis c. Performing hand hygiene before and after contact with every patient d. Using aseptic housekeeping practices for environmental cleaning
c
The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess? a. Decreased urine output and hypertension b. Headache and vision changes c. Confusion and lethargy d. Jaundice and elevated liver enzymes
c
The nurse is completing a patients health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? a. have you ever been employed in a factory, smelter, or mill? b. does anyone in your gamily have any form of lung disease? c. do you currently smoke, or have you ever smoked? d. have you ever lived in an area that has high levels of air pollution?
c
The nurse is creating a plan of care for a patient diagnosed w/acute laryngitis. What intervention should be included in the pts plan of care? a. Place warm clothes on the patients throat, as needed. b. Have the patient inhale warm steam three times daily. c. Encourage the patient to limit speech whenever possible. d. Limit the patients fluid intake to 1.5 L/day.
c
The nurse is performing a comprehensive assessment of a pts skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way? a. by examining the pt under a Woods light b. by inspecting the pts skin in direct sunlight c. by palpating the pts skin d. by performing percussion of major skin surfaces
c
The nurse is performing an initial assessment of a pt who has a raised, pruritic rash. The pt denies any prescription medication and denies any allergies. What would be an appropriate question to ask this pt at this time? a. is anyone in your family allergic to anything? b. how long have you had this abrasion? c. do you take any OTC drugs or herbal preparations? d. what do you do for a living?
c
The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? a. Continue suctioning the patient until no more secretions are obtained. b. Perform chest physiotherapy rather than nasotracheal suctioning. c. Wait several minutes and then repeat suctioning. d. Perform postural drainage and then repeat suctioning.
c
The nurse is planning health education for a pt who has experienced a vaginal infxn. What guidelines should the nurse include in this program regarding prevention? a. wear tight-fitting synthetic underwear b. use bubble bath to eradicate perineal bacteria c. avoid feminine hygiene products, such as sprays d. restrict daily bathing
c
The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? a. Anxiety related to diagnosis of cancer b. Altered nutrition related to swallowing difficulties c. Ineffective airway clearance related to airway alterations d. Impaired verbal communication related to removal of the larynx
c
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient? a. Safe technique for self-suctioning of secretions b. Technique for performing postural drainage c. Correct and safe use of oxygen therapy equipment d. How to provide safe and effective tracheostomy care
c
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process? a. Explain the suctioning procedure to the patient and reposition the patient. b. Turn on suction source at a pressure not exceeding 120 mm Hg. c. Assess the patients lung sounds and SAO2 via pulse oximeter. d. Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.
c
The nurse is providing care for a 90-yold pt whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area? a. pt elbows b. soles of pts feet c. pt heels d. pt knees
c
The nurse is teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions? a. Prescription medications can be safely supplemented with OTC medications. b. Use only one pharmacy so the pharmacist can check drug interactions c. read drug labels carefully before taking OTC meds d. Consult the internet before selecting an OTC med
c
The triage nurse in the ED is assessing a pt who has presented w/ c/o pain and swelling in her right lower leg. The pts pain became much worse last night and appeared along w/fever, chills, and sweating. The pt states, I hit my leg on the car door 4 or 5 days ago and it has been sore ever since. The pt has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this pt? a. platelet transfusion to treat thrombocytopenia b. warfarin to treat arterial insufficiency c. antibiotics to treat cellulitis d. heparin IV to treat VTE
c
When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the portal of entry for tuberculosis? a. Integumentary system b. Urinary system c. Respiratory system d. Gastrointestinal system
c
When assessing a 25-yold female, the nurse notes that the pt has hair on her lower abdomen. Earlier in the health interview, the pt stated that her menses are irregular. The nurse should suspect what type of health problem? a. metabolic disorder b. malignancy c. hormonal imbalance d. infectious process
c
When assessing for substances that are known to harm workers lungs, the occupational health nurse should assess their potential exposure to which of the following? a. Organic acids b. Propane c. Asbestos d. Gypsum
c
Which statement by the nurse is most likely to help a morbidly obese 22-year-old man in losing weight on a 1000-calorie diet? a. It will be necessary to change lifestyle habits permanently to maintain weight loss. b. You will decrease your risk for future health problems such as diabetes by losing weight now. c. You are likely to notice changes in how you feel with just a few weeks of diet and exercise. d. Most of the weight that you lose during the first weeks of dieting is water weight rather than fat.
c
While taking a health hx on a 20 yold female pt, the nurse ascertains that this pt is taking miconazole (Monistat). This nurse is justified in presuming that this pt has what medical condition? a. bacterial vaginosis b. Human papillomavirus (HPV) c. Candidiasis d. Toxic shock syndrome (TSS)
c
You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers? a. turn and reposition the pt a minimum of every 8 hrs b. vigorously massage lotion into bony prominences c. post a turning schedule at the pts bedside and ensure staff audience d. slide, rather than lift, the pt when turning
c
You are the nursing caring for a pt who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this pt. What rationale would you cite for this nursing action? a. you know that this pt will have a decreased LOC b. you know that this pt may not be motivated to prevent pressure ulcers c. you know that the risk for pressure ulcers is directly relation to duration of immobility d. you know that the risk for pressure ulcers is related to what caused the immobility
c
You have been referred to the care of an extended care resident who has been diagnosed w/a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this pt? a. whole wheat macaroni w/cheese b. skin milk, oatmeal, and whole wheat toast c. steak, baked potato, spinach and strawberry salad d. eggs, hash browns, coffee, and an apple
c
The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis? a. Asthma b. Pneumonia c. Lung cancer d. COPD
d
The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? a. Resumption of the patients ADLs b. The familys willingness to care for the patient c. Nutritional status and fluid balance d. Signs and symptoms of respiratory complications
d
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? a. keep pt in a low Fowlers position b. perform tracheostomy care at least once per day c. maintain continuous bedrest d. monitor cuff pressure every 8 hours
d
The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action? a. Smoking decreases the amount of mucus production. b. Smoke particles compete for binding sites on hemoglobin. c. Smoking causes atrophy of the alveoli. d. Smoking damages the ciliary cleansing mechanism.
d
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? a. cognition is decreased b. daily arterial blood gases (ABGs) are necessary c. slight tracheal bleeding is anticipated d. cough reflex is depressed
d
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding? a. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. b. Inform the physician promptly that there is in imminent leak in the drainage system. c. Encourage the patient to do deep breathing and coughing exercises. d. Document that the chest drainage system is operating as it is intended.
d
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure? a. Administer a bolus of IV fluids. b. Arrange for the insertion of a peripherally inserted central catheter. c. Administer nebulized bronchodilators every 2 hours until the test. d. Withhold food and fluids for several hours before the test.
d
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? a. nitrogen narcosis b. infection c. impaired diffusion d. shunting
d
The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? a. Walk 1 mile 3 to 4 times a week. b. Use weights daily to increase arm strength. c. walk on a treadmill 30 mins daily d. perform shoulder exercises five times daily
d
The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching? a. Finish the bottle of nasal spray to clear the infection effectively. b. Nasal spray can only be shared between immediate family members. c. Nasal spray should be administered in a prone position. d. Overuse of nasal spray may cause rebound congestion.
d
The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patients discharge teaching? a. How to count her respirations accurately b. How to collect serial sputum samples c. How to independently wean herself from treatment d. How to perform diaphragmatic breathing
d
The nurse is providing patient teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season? a. Take preventative antibiotics, as ordered. b. Gargle with warm salt water regularly. c. Dress herself and her infant warmly. d. Wash her hands frequently.
d
The nurse receives a phone call from a clinic patient who experienced fever and slight dyspnea several hours after receiving the pneumococcus vaccine. What is the nurses most appropriate action? a. Instruct the patient to call 911. b. Inform the patient that this is an expected response to vaccination. c. Encourage the patient to take NSAIDs until symptoms are relieved. d. Ensure that the adverse reaction is reported.
d
While assessing a dark-skinned pt at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis? a. cyanosis b. addisons disease c. polycythemia d. vitiligo
d
While performing an initial assessment of a pt admitted w/appendicitis, the nurse observes an elevated blue-black lesion of the pts ear. The nurse knows that this lesion is consistent w/what type of skin cancer? a. basal cell carcinoma b. squamous cell carcinoma c. Dermatofibroma d. malignant melanoma
d
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? a. immediately after a meal b. first thing in the morning c. at bedtime d. after a period of exercise
b
A middle-aged female pt has been offered testing for HIV/AIDS upon admission to the hospital for an unrelated health problem. The nurse observes that the pt is visibly surprised and embarrassed by this offer. How should the nurse best respond? a. most women w/HIV don't know they have the disease. if you have it, its important we catch it early b. this testing is offered to every adolescent and adult regardless of their lifestyle, appearance or hx c. the rationale for this testing is so that you can begin treatment as soon as testing comes back, if its positive d. you're being offered this testing bc you are actually in the prime demographic for HIV infxn
B
An adult patient in the ICU has a central venous catheter in place. Over the past 24 hours, the patient has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the patients care may have increased susceptibility to CLABSI? a. The patients central line was placed in the femoral vein. b. The patient had blood cultures drawn from the central line. c. The patient was treated for vancomycin-resistant enterococcus (VRE) during a previous admission. d. The patient has received antibiotics and IV fluids through the same line.
a
An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization? a. Centers for Disease Control and Prevention (CDC) b. American Medical Association (AMA) c. Environmental Protection Agency (EPA) d. American Nurses Association (ANA)
a
An unresponsive Caucasian pt has been brought to the ER by EMS. While assessing this pt, the nurse notes the pts face is a cherry-red color. What should the nurse suspect? a. carbon monoxide poisoning b. anemia c. jaundice d. uremia
a
During a health education session, a participant asks the nurse how a vaccine can protect from future exposures to diseases against which she is vaccinated. What would be the nurses best response? a. The vaccine causes an antibody response in the body. b. The vaccine responds to an infection in the body after it occurs. c. The vaccine is similar to an antibiotic that is used to treat an infection. d. The vaccine actively attacks the microorganism.
a
Family members are caring for a patient with HIV in the patients home. What should the nurse encourage family members to do to reduce the risk of infection transmission? a. Use caution when shaving the patient. b. Use separate dishes for the patient and family members. c. Use separate bed linens for the patient. d. Disinfect the patients bedclothes regularly
a
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment? a. Chest auscultation b. Pulmonary function testing c. Chest percussion d. Thoracic palpation
a
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears wheezing throughout the lung fields. What might this indicate? a. pt has a narrowed airway b. pt has pneumonia c. pt needs physiotherapy d. pt has a hemothorax
a
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? a. 20 cm H2O b. 15 cm H2O c. 10 cm H2O d. 5cmH2O
a
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses best response? a. A PFT measures how much air moves in and out of your lungs when you breathe. b. A PFT measures how much energy you get from the oxygen you breathe. c. A PFT measures how elastic your lungs are. d. A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.
a
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? a. Stable vital signs and ABGs b. Pulse oximetry above 80% and stable vital signs c. Stable nutritional status and ABGs d. Normal orientation and level of consciousness
a
The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home? a. A humidification system b. An air conditioning system c. A water purification system d. A radiant heating system
a
The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance? a. Emphysema b. Pulmonary fibrosis c. Pleural effusion d. Acute respiratory distress syndrome (ARDS)
a
The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? a. Pulmonary function studies b. Exercise tolerance tests c. Arterial blood gas values d. Chest x-ray
a
The nurse has assessed a patients family history for three generations. The presence of which respiratory disease would justify this type of assessment? a. asthma b. obstructive sleep apnea c. community-acquired pneumonia d. pulmonary edema
a
The nurse is an ambulatory care center is admitting an older adult pt who has bright red moles on the skin. Benign changes in elderly skin that appears bright red moles are termed what? a. cherry angiomas b. solar lentigo c. seborrheickeratoses d. xanthelasma
a
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? a. presence of a cough and gag reflex b. absence of nausea c. ability to demonstrate deep inspirtion d. oxygen saturation of 92%
a
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? a. Removal from the ventilator, tube, and then oxygen b. Removal from oxygen, ventilator, and then tube c. Removal of the tube, oxygen, and then ventilator d. Removal from oxygen, tube, and then ventilator
a
The nurse places a patient in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection? a. Mode of transmission b. Agent c. Susceptible host d. Portal of entry
a
When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include? a. Blood glucose test b. Cardiac enzyme tests c. Postural blood pressures d. Resting electrocardiogram
a
When writing a plan of care for a pt w/psoriasis, the nurse know that an appropriate nursing dx for this pt would be what? a. impaired skin integrity r/t scaly lesions b. acute pain r/t blistering and erosions of the oral cavity c. impaired tissue integrity r/t epidermal shedding d. anxiety r/t risk for melanoma
a
While waiting to see the physician, a pt shows the nurse skin areas that are flat, non-palpable, and have had a change of color. The nurse recognizes that the pt is demonstrating what? a. macules b. papules c. vesicles d. pustules
a
You are caring for a pt who has been diagnosed w/genital herpes. When preparing a teaching plan for this pt, what general guidelines should be taught? a. thorough handwashing is essential b. sun bathing assists in eradicating the virus c. lesions should be massaged w/ointment d. self-infxn cannot occur from touching lesions during a breakout
a
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. a. Post thoracotomy b. Spontaneous pneumothorax c. Need for postural drainage d. Chest trauma resulting in pneumothorax e. Pleurisy
a, b, d
The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? Select all that apply. a. Time frame of exposure b. Type of respiratory protection used c. Immunization status d. Breath sounds e. Intensity of exposure
a, b, d, e
A nurse educator is teaching a group of medical nurses about Kaposis sarcoma? What would the educator ID as characteristics of endemic Kaposis sarcoma? Select all that apply. a. affects people predominantly in the eastern half of Africa b. affects men more than women c. does not affect children d. cannot infiltrate e. can progress to lymphadenopathic forms
a, b, e
A nurse is participating in a vaccination clinic at the local public health clinic. The nurse is describing the public health benefits of vaccinations to participants. Vaccine programs addressing which of the following diseases have been deemed successful? Select all that apply. a. Polio b. Diphtheria c. Hepatitis d. Tuberculosis e. Pertussis
a, b, e
A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply. a. Chest tightness b. Crackles c. Bradypnea d. Wheezing e. Cough
a, d, e
A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother? a. I will relay your request promptly to the doctor, but I suspect that she wont get back to you if its a cold. b. Ill certainly inform the doctor, but if it is a cold, antibiotics wont be used because they do not affect the virus. c. Ill phone in the prescription for you since it can be prescribed by the pharmacist. d. Amoxicillin is not likely the best antibiotic, but Ill call in the right prescription for you.
b
A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patients exposure risk to toxic substances? a. Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air. b. Wear protective attire and devices when working with a toxic substance. c. Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins. d. Always wear a disposable paper face mask when you are working with inhalable toxins.
b
A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? a. Rescue inhalers b. Anti-inflammatory drugs c. Antibiotics d. Antitussives
b
A patient has a concentration of S. aureus located on his skin. The patient is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? a. Infection b. Colonization c. Disease d. Bacteremia
b
A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function? a. acid base balance b. perfusion c. diffusion d. ventilation
b
A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, Does this kind of cancer tend to spread to other parts of the body? What is the nurses best response? a. In many cases, this type of cancer spreads to other parts of the body. b. This cancer usually does not spread to distant sites in the body. c. You will have to speak to your oncologist about that. d. Squamous cell carcinoma is nothing to be concerned about, so try to focus on your health.
b
A patient is admitted from the ED diagnosed with Neisseria meningitides. What type of isolation precautions should the nurse institute? a. Contact precautions b. Droplet precautions c. Airborne precautions d. Observation precautions
b
A patient is alarmed that she has tested positive for MRSA following culture testing during her admission to the hospital. What should the nurse teach the patient about this diagnostic finding? a. There are promising treatments for MRSA, so this is no cause for serious concern. b. This doesnt mean that you have an infection; it shows that the bacteria live on one of your skin surfaces. c. The vast majority of patients in the hospital test positive for MRSA, but the infection doesnt normally cause serious symptoms. d. This finding is only preliminary, and your doctor will likely order further testing.
b
A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? a. Correct use of a ventilator b. Correct use of incentive spirometry c. Correct use of a mini-nebulizer d. Correct technique for rhythmic breathing
b
A patient states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor? a. Cold viruses are increasingly resistant to common antibiotics. b. The virus is shed for 2 days prior to the emergence of symptoms. c. A genetic predisposition to viral rhinitis has recently been identified. d. Overuse of OTC cold remedies creates a rebound susceptibility to future colds.
b
A pt has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the pts subsequent care? a. teaching the pt to safely and effectively administer immunosuppressants b. helping the pt ID and avoid the offending agent c. teaching the pt how to maintain meticulous sin hygiene d. helping the pt perform wound care in the home environment
b
A pt is diagnosed w/ Afib and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this pt? a. ulcer b. ecchymosis c. scar d. erosion
b
A pt w/a decreased LOC is in a recumbent position.How should the nurse best assess the lung fields for a pt in this position? a. inform that physician that the pt is in a recumbent position and anticipate an order for a portable chest x-ray b. turn the pt to enable assessment of all the pts lung fields c. avoid turning the pt, and assess the accessible breath sounds from the anterior chest wall. d. obtain a pulse oximetry reading, and, if the reading is low, reposition the pt and auscultate breath sounds.
b
A pt w/a genital herpes exacerbation has a nursing dx of acute pain related to the genital lesions. What nursing intervention best addresses this diagnosis? a. cover the lesions w/a topical antibiotic b. keep the lesions clean and dry c. apply a topical NSAID to the lesions d. remain on bed rest until the lesions resolve
b
A pt w/a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to r/o a skin malignancy? a. tzanck smear b. skin biopsy c. patch testing d. skin scrapings
b
A public health nurse is teaching a mother about vaccinations prior to obtaining informed consent for her childs vaccination. What should the nurse cite as the most common adverse effect of vaccinations? a. Temporary sensitivity to the sun b. Allergic reactions to the antigen or carrier solution c. Nausea and vomiting d. Joint pain near the injection site
b
A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents? a. the child's scalp should be monitored for 48 to 72 hours before starting treatment b. nits may have to be manually removed from the child's hair shaft c. the disease is self-limiting and symptoms will abate w/in 1 week d. efforts should be made to improve the child's level of hygiene
b
A nurse is preparing to perform the physical assessment of a newly admitted pt. During which of the following components of the assessment should the nurse gloves? Select all the apply. a. palpation of the pts scalp b. palpation of the pts upper extremities c. palpation of a rash on the pts trunk d.palpation of a lesion on the pts upper back e. palpation of the pts fingers
c, d
A 65-yold man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are r/t the fact that he is Jewish. What health problem should the nurse suspect? a. stasis ulcers b. bullous pemphigoid c. psoriasis d. classic kaposis sarcoma
d
A nurse is assessing a teenage pt w/acne vulgaris. The pts mother states, I keep telling him that this is what happens when you eat as much chocolate as he does. What aspect of the pathophysiology of acne should inform the nurse response? a. a sudden change in pts diet may exacerbate. rather than alleviate, the pts symptoms b. chocolate is not among the foods that are known to cause acne c. elimination of chocolate from the pts diet will likely lead to resolution w/in several months d. diet is thought to play a minimal role in the development of acne
d
A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? a. To ensure long-term prevention of asthma exacerbations b. To cure any systemic infection underlying asthma attacks c. To prevent recurrent pulmonary infections d. To gain prompt control of inadequately controlled, persistent asthma
d
A nurse is planning the care of a pt w/herpes zoster. What medication, if administered w/in the first 24 hours of the initial eruption, can arrest herpes zoster? a. prednisone (Deltasone) b. Azanthioprine (Imuran) c. Triamcinolone (kenalog) d. Acyclovir (Zovirax)
d
A nurse is providing care for a pt who has developed Kaposis sarcoma secondary to HIV infxn. The nurse should be aware that this form of malignancy originates in what part of the body? a. connective tissue cells in diffuse locations b. smooth muscle cells of the GI and respiratory tract c. neural tissue of the brain and spinal cord d. endothelial cells lining small blood vessels
d
A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient? a. Hold the spirometer at your lips and breathe in and out like you normally would. b. When youre ready, blow hard into the spirometer for as long as you can. c. Take a deep breath and then blow short, forceful breaths into the spirometer. d. Breathe in deeply through the spirometer, hold your breath briefly, and then exhale.
d
A nurse is working w/a pt who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation? a. alopecia b. yellowish skin tone c. patchy, bronze pigmentation d. hirsutism
d
A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patients midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding? a. Irrigation with a hypertonic solution b. Nasopharyngeal suction c. Normal saline application d. Silver nitrate application
d
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? a. Expiratory wheezes b. Inspiratory wheezes c. Rhonchi d. Crackles
d
A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology? a. maintenance of constant osmotic pressure in the alveoli b. maintenance of muscle tone in the diaphragm c. pH balance in the pulmonary veins/arteries d. adequate flow of blood through the pulmonary circulation
d
A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe? a. It allows for full expansion of the lungs within the thoracic cavity. b. It prevents the lungs from collapsing within the thoracic cavity. c. It limits lung expansion within the thoracic cavity. d. It lubricates the movement of the thorax and lungs.
d
A patient on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? a. Standard precautions only b. Droplet precautions c. Standard and contact precautions d. Standard and airborne precautions
d
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? a. Assure the patient that everything will be all right and that remaining calm is the best strategy. b. Ask a family member to interpret what the patient is trying to communicate. c. Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. d. Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.
d
A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the patient to perform which of the following? a. Apply a cold pack to the affected area. b. Apply a mustard poultice to the forehead. c. Perform postural drainage. d. Increase fluid intake.
d
A pt comes to the clinic complaining of a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent w/herpes zoster? a. grouped vesicles occurring on lips and oral mucous membranes b. grouped vesicles occurring on the genitalia c. rough, fresh, or gray skin protrusions d. grouped vesicles in linear patches along a dermatome
d
A pt has HSV2. The nurse recognizes that which of the following should be included in teaching the pt? a. virus causes cold sores of the lips b. the virus may be cured w/antibiotics c. the virus, when active, may not be contracted during intercourse d. treatment is aimed at relieving symptoms
d
A pt has developed severe contact dermatitis w/burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the pt to do? a. wear powdered latex gloves when in public b. wash her hands w/antibacterial soap every few hours c. maintain room temperature at 75F to 80F whenever possible d. keep her hands well-moisturized at all times
d
A pt has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized? a. maintain the pt on bed rest for the first 24 hrs postoperative b. apply distraction techniques to relieve pain c. provide soft or liquid diet that is high in protein to assist w/healing d. anticipate the need for, and administer, appopriate analgesic meds
d
A pt w/a family hx of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? a. IgA b. IgM c. IgG d. IgE
d
A pt w/genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course the infxn? a. clotrimazole (Gyne-Lotrimin) b. Metronidazole (Flagyl) c. Podophyllin (Podofin) d. Acyclovir (zovirax)
d
A pts health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate w/this health problem? a. chronic pain b. impaired skin integrity c. impaired tissue integrity d. disturbed body image
d
A young student comes to the school nurse and shows a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion? a. vesicle b. macule c. nodule d. wheal
d
An 82-yold pt is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the pts course of treatment? a. increased thickness of the subq skin layer b. increased vascular supply to superficial skin layers c. changes in the character and quantity of bacterial skin flora d. increased time required for wound healing
d
An African American is admitted to the medical unit with liver disease. To correctly assess this pt for jaundice, on what body area should the nurse look for yellow discoloration? a. elbows b. lips c. nail beds d. sclerae
d
An adolescent pts history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this pt consequently faces an increased risk of what health problem? a. bronchitis b. systemic lupus erythematosus (SLE) c. rheumatoid arthritis d. asthma
d
An elderly female pt who is bedridden is admitted to the unit bc of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the pt, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer? a. I b. II c. III d. IV
d
As a clinic nurse, you are caring for a patient who has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. When you do a follow-up call with this patient, you are informed that the patient is feeling better and is stopping the medication after taking it for 4 days. What information should you provide to this patient? a. Keep the remaining tablets for an infection at a later time. b. Discontinue the medications if the fever is gone. c. Dispose of the remaining medication in a biohazard receptacle. d. Finish all the antibiotics to eliminate the organism completely.
d
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patients arterial oxygen saturation (SaO2). What procedure will best accomplish this? a. incentive spirometry b. arterial blood gas (ABG) measurement c. peak flow measurement d. pulse oximetry
d
The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the students nose continues to bleed. Which intervention should the nurse next implement? a. Apply ice to the bridge of her nose b. Lay the patient down on a cot c. Arrange for transfer to the local ED d. Insert a tampon in the affected nare
d
The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan? a. Administration of inhaled corticosteroids b. Assessment of neurologic status c. Turning and coughing d. Signs of pulmonary infection
d
