Final 352

The nurse educator is providing education to a group of nursing students about treatments for trigeminal neuralgia. Which student statement indicates a need for additional teaching? "Cold weather is known to cause increased pain." "Acupuncture may be prescribed to help reduce pain." "Eating easily chewed foods helps avoid weight loss." "Tegretol may be prescribed to decrease seizure activity."

"Tegretol may be prescribed to decrease seizure activity."

The nurse is preparing a patient for surgery prior to her hysterectomy with out oophorectomy. The nurse is witnessing the patients signature on a consent form. Which comment by the patient would best indicate informed consent? " I know I'll be fine because the physician said he has done this procedure a hundred times. "Because the physician isn't taking my ovaries, i"ll still be able to have children." "The physician us going to remove my uterus and told me about the risk bleeding" " I know I'll have pain after surgery but they'll do their best to keep it to a minimum".

"The physician us going to remove my uterus and told me about the risk bleeding"

The nurse is completing a Mini Mental Status Examination with a patient. What should the nurse ask to evaluate remote memory? "Where did you work in the 1970s?" "Where did you park your car today?" "What television show was on during breakfast?" "Remember the colors red, green, blue, and yellow."

"Where did you work in the 1970s?"

You are performing a cardiac stress test for a 50 year old male client who is six feet tall and weighs 230 pounds. How many beats per minute is the "maximum heart rate" for this client to achieve during testing?

170 bpm

A patient with Guillain-Barre who weighs 198 lbs. is prescribed intravenous immunoglobulin 2 g/kg IV to be infused over three days. How many grams of the medication should the nurse have sent from the pharmacy to infuse over the next 24 hours?

60 grams

Which of the following age groups has the highest percentage of people with Alzheimer's disease in the US? 85+ years of age 75-84 years of age 65-74 years of age < 65 years of age

75-84 years of age

You are starting your bedside nursing shift. Which of the following patients would you assess first? A client with a new seizure disorder on 2L O2 NC who recovered consciousness 30 minutes ago A client with lower extremity weakness from Guillain-Barre whose pulse oximeter is alarming A client with a viral meningitis headache who has called the nurses station twice for pain medication A client with post-polio syndrome who called requesting assistance with walking to the bathroom

A client with lower extremity weakness from Guillain-Barre whose pulse oximeter is alarming

Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency A holosystolic murmur heard at best at the cardiac apex A loud S1S2 split, and mitral opening snap A high pitched sound heard at the third left intercostal space A mid systole ejection click or murmur at the base

A holosystolic murmur heard at best at the cardiac apex

The nurse is teaching therapeutic lifestyle changes to reduce cardiovascular risk. Which of the following goals should be included? (Mark all that apply.) Achieve long-term smoking cessation Maintain a BMI of less than 35 Perform 30 min of daily aerobic exercise Drink ≤ three alcoholic beverages per day Keep sodium intake below 3000mg/day

Achieve long-term smoking cessation Perform 30 min of daily aerobic exercise

You admit a patient to the PACU who undergone a surgical procedure under general anesthesia. General anesthesia puts this patient at risk for: Peripheral edema Anemia Dehydration Atelectasis

Atelectasis

A patient is scheduled for an electroencephalogram. What pre-procedure information should the nurse emphasize with this patient? Avoid washing hair for two days prior to the test Avoid caffeine for 8 to 12 hours before the test Restrict the intake of fluids for six hours after the test Apply minimal products to the hair the morning of the test

Avoid caffeine for 8 to 12 hours before the test

A nurse is caring for a patient directly following percutaneous coronary angioplasty (PTCA). Which of the following assessment findings would the nurse report immediately to the physician? Reports 3/10 pain at the groin puncture site BP of 88/50 and a pulse of 102 bpm Slight bleeding from groin puncture site Capillary refill of 4 secs in affected extremity

BP of 88/50 and a pulse of 102 bpm

Which laboratory data confirm the diagnosis of congestive heart failure? Chest x-ray (CXR). Liver function tests. Blood urea nitrogen (BUN). Beta-type natriuretic peptide (BNP).

Beta-type natriuretic peptide (BNP).

Your client who has a continuous epidural infusion for post-operative pain control has a loss of sensation at the L4 level. Based on this, which of the following g would you assess? lung sounds Bowel sounds Temperature Bladder scan

Bladder scan

The nurse is reviewing orders written for a patient with trigeminal neuralgia. Which medication should the nurse expect to be prescribed for this patient? Prochlorperazine (Compazine) Benztropine (Cogentin) Carbamazepine (Tegretol) Carvedilol (Coreg)

Carbamazepine (Tegretol)

Which of the following characteristics is associated with the post-ictal state following a seizure? Epileptic cry Urinary incontinence Body rigidity Confusion

Confusion

What is the most important focus of the nurse assisting with a lumbar puncture procedure? Assisting with specimen collection Explaining the procedure to the client Ensuring the client remains in position Encouraging the client to relax

Ensuring the client remains in position

The client is being evaluated for valvular heart disease. Which information would be most significant? History of coronary artery disease History of smoking for 10 years Family history of hyperlipidemia History of rheumatic heart disease

History of rheumatic heart disease

The preoperative nurse has completed the pre-surgical assessment of an 82 year old female patient who is schedule for a left total knee replacement. When planning the patient care, the nurse should address the consequences of the patients aging cardiovascular system. These include as increased risk of which of the following? Hyperphosphatemia Hypervolemia Hyponatremia Hyperkalemia

Hypervolemia

A patient is unable to feel light touch down the anterior left leg and top of the left foot. How should the nurse document this finding? Hyperesthesia Anesthesia Hypoesthesia Paresthesia

Hypoesthesia

The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse Pericardial friction rub Muffled heart sounds Bounding peripheral pulses Nondistended neck veins

Muffled heart sounds

Which of the following ECG components represents atrial depolarization? QRS complex T wave P wave QT Interval

P wave

A client with heart failure becomes orthopneic. What action should the nurse implement to address this problem. Place head of bed in High Fowler's position Administer nitroglycerin per order Encourage ambulation with assistance Encourage increased fluids

Place head of bed in High Fowler's position

A patient with myasthenia gravis has lost 6 kg over the past two months. What should the nurse suggest to improve this patient's nutritional status? Increase fats and carbohydrates in meals Plan pyridostigmine doses to occur before meals Restrict oral fluids before and during meals Eat three to five large meals per day

Plan pyridostigmine doses to occur before meals

During the admitting assessment of a patient with newly diagnosed AIDS the nurse carefully assesses for symptoms related to infection in patients with AIDS. What is the most common infection? Clostridium Difficile (C-diff) Kaposi's sacroma Pneumocystis pneumonia (PCP) Viral meningitis

Pneumocystis pneumonia (PCP)

A patient has been experiencing a tonic-clonic seizure for five minutes. What should the nurse do first? Provide rescue breathing Assess carotid pulse Prepare to insert an airway Insert an intravenous access line

Prepare to insert an airway

The circulating nurse will be participating in a 78 year-old patient's total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR? Pressure points should be assessed and will padded. The patient must be firmly restrained at all times. The preoperative shave should be done by the4 circulating nurse. The patient should be placed in Trendelenburg position.

Pressure points should be assessed and will padded

Which of the following ECG components represents ventricular depolarization? QT Interval T wave QRS complex P wave

QRS complex

Before preparing a client for surgery, the nurse develops a teaching plan. What is the primary purpose of preoperative teaching? Obtain informed consent for surgery Determine client's psychological readiness for surgery Explain the risks associated with surgery Reduce the risk for postoperative complications

Reduce the risk for postoperative complications

The nurse provides care to a patient who is diagnosed with Parkinson's disease (PD). Which patient data supports the implementation of fall precautions in the plan of care? (Mark all that apply) Rigidity Tremors Orthostatic hypotension Mask-like face Difficulty swallowing

Rigidity Tremors Orthostatic hypotension

The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is Priority? Risk for injury, imbalance Anticipatory grieving, anxiety Decreased cardiac output , diminished brain function Altered nutrition, less than body requirements

Risk for injury, imbalance

A patient is diagnosed with a health problem that causes demyelization of the peripheral nerves. Which cell structure is being affected? Microglia Oligodendrocytes Astrocytes Schwann cells

Schwann cells

Which type of isolation technique is designed to decrease the risk of transmittion of recognized or unrecognized sources of infection? Airborne Precautions Standard Precautions Contact Precautions Droplet Precautions

Standard Precautions

The nurse identifies the nursing diagnosis of chronic pain as being appropriate for a patient with fibromyalgia. Which manifestation did the patient most likely report that caused the nurse to select this diagnosis. Acute chest pain Tender points in the knees Pain from eyestrain Pain from a severe skin rash

Tender points in the knees

What is the most important focus of the circulating nurse when positioning the client on the operating table prior to the actual operation? To allow the surgeon maximum visualization of the operative site. To minimize the client's risk for anesthesia complications To provide space at the operating table for the entire surgical team To avoid skin pressure and prevent neuromuscular damage.

To avoid skin pressure and prevent neuromuscular damage.

The nurse recognizes that gastro-intestinal distress associated with right-sided heart failure is caused by: Poor GI perfusion due to mesenteric arterial constriction Venous states related engorgement of abdominal organs. Electrolyte imbalance related to cramping of GI smooth muscle Stress induced acidity causing ulceration within the bowel

Venous states related engorgement of abdominal organs.

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply. Nurses notes Social work assessment Verification form Laboratory reports

Verification form Laboratory reports

The nurse is performing a pre-admission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware? Informs the patient of need for postoperative transportation Determines the patient's suitability as a surgical candidate Discusses and reviews patient's health insurance coverage Verifies completion of preoperative diagnostic testing

Verifies completion of preoperative diagnostic testing

Following a patient's lumbar puncture, the nurse examines the lab analysis of a patient's cerebral spinal fluid. Which of the following results would prompt the nurse to recommend that the physician enter an order for IV antibiotics for this patient? WBC's = 485 mm3 Glucose = 60 mg/dL Protein = 40 mg/dL Clear appearance

WBC's = 485 mm3

At what time during the procedure does the scrub nurse count sponges and instruments? Prior to the opening and closing of the sterile field While setting the sterile field and before closing the incision While handing the surgeon the instruments and sponges During the time out period before surgery and at the end of surgery

While setting the sterile field and before closing the incision

What medication is commonly given in the pre-operative area to alleviate anxiety? metoprolol ( Toprol XL) oxycodone (Lortab) midazolam (Versed) cefazolin ( Ancef)

midazolam (Versed)

An adult patient is diagnosed with fibromyalgia . The patients asks the nurse whether a recent infection with the Coxsackie B virus could have caused fibromyalgia? Which response by the nurse is most appropriate? "Coxsackie B virus may have triggered the fibromyalgia. " "Coxsackie B virus definitely caused the fibromyalgia." "Coxsackie B virus has nothing to do with fibromyalgia. " " Fibromyalgia is a psychiatric disorder."

"Coxsackie B virus may have triggered the fibromyalgia. "

A nurse is educating Mr Smith who is a client being discharged from the hospital with stable angina. When having the patient verbalize understanding of the education, which statement indicates a need for further education? "I can take more than three doses of nitroglycerine if I space them five minutes apart." "I am to summon emergency personnel if my chest pain does not improve after taking nitroglycerine." "I should strive to 30 minutes or more of light to moderate exercise in my daily routine." "I will decrease my consumption of alcohol to no more than one to two drinks per day."

"I can take more than three doses of nitroglycerine if I space them five minutes apart."

A patient with systemic lupus erythematous (SLE) is being treated with immunosuppressant drugs and corticosteroids. Which patient statement indicates the need for further teaching? "I can to events with large crowds " "I will report any symptoms of infection immediately." "I should avoid getting the flu shot." "I will use contraception to avoid pregnancy"

"I can to events with large crowds "

The nurse is collecting a health history for a patient in an outpatient clinic who reports joint pain for the last two months. The patient is diagnosed with rheumatoid arthritis (RA). When planning care for this patient, which statement supports the nursing diagnosis of Activity Intolerance? "I take ibuprofen for the pain as needed "I seem to get tired early in the day but recover by dinner time" "I find it difficult to move when I first get up in the morning" "My joints are stiffest at night before I go to sleep. "

"I find it difficult to move when I first get up in the morning"

A patient with rheumatoid arthritis "RA" is being seen in the outpatient clinic for a progress check-up. The nurse is reviewing the patient's sign-off care and determines that the patient has met a goal of treatment when the patient makes which statement? "I sleep for 10 hours at night " "I have increased pain in my joints all the time now." "I do not perform household chores at all anymore "I have delegated many household chores to my children and spouse"

"I have delegated many household chores to my children and spouse"

Which of the following reports by a husband of an 80 yo female client would cause the RN to suspect this client is developing Alzheimer's disease? "She simply can not figure out how to log into our computer to read our email." "I have to shop with her now because she wanders for hours and can't find our usual stuff." "If she's not in front of her calendar, she usually can't tell you the date and day of the week." "It sometimes takes her a while to remember the name of a familiar person."

"I have to shop with her now because she wanders for hours and can't find our usual stuff."

The RN is teaching a client regarding the safety precautions when taking warfarin. Which statements made by the client indicates the need for further teaching? (Mark all that apply.) "I need to use a soft toothbrush." "I will join a novice hockey league for exercise." "I am to use an electric razor when shaving." "I should eat plenty of green leafy vegetables." "I will consult my care provider before taking aspirin."

"I will join a novice hockey league for exercise." "I should eat plenty of green leafy vegetables."

The nurse is preparing to discharge a 60 yo female client home with a new diagnosis of cardiovascular disease and stable angina. Which of the following statements by the patient indicates a need for further teaching? "I will get my total cholesterol under 200 (mg/dL)" "I will keep my HDL under 50 (mg/dL)" "I will walk for 30 minutes every day" "I will take my nitroglycerine with me when I walk"

"I will keep my HDL under 50 (mg/dL)"

The nurse is caring for a patient who was diagnosed with rheumatoid arthritis (RA) last year. The patient has recently been placed on prednisone for treatment. Which patient statement indicates that the medication teaching was successful? "I will take the ordered dose at the same time every day." "I will take this medication on a full stomach to enhance absorption " "I will not have to limit my consumption of canned vegetables " "I will not need to monitor by blood sugar more frequently"

"I will take the ordered dose at the same time every day."

The nurse is conducting patient teaching about cholesterol levels in the body. Which of the following patient statements show appropriate understanding? "Increased LDL and decreased HDL raise my risk for coronary artery disease" "Decreased HDL lowers the amount of cholesterol deposited on the artery walls" "Increased LDL lowers the amount of cholesterol deposited on the artery walls" "Increased LDL and decreased HDL lower my risk for coronary artery disease"

"Increased LDL and decreased HDL raise my risk for coronary artery disease"

You are doing diet teaching for a 50 year old male client being discharged on a cardiac prudent diet. What statement by the client indicates effective diet teaching? "I should not put any dressing on my salad because most contain saturated fats" "Not adding salt to my foods will keep me below my daily limit" "Monounsaturated and polyunsaturated fats are the best kinds of fats to eat" "I will count my calories and try not to eat over 2,800 calories per day"

"Monounsaturated and polyunsaturated fats are the best kinds of fats to eat"

Which conditions are considered non-modifiable risk factors for coronary artery disease? (Mark all that apply.) Diabetes mellitus type I Diabetes mellitus type II Obesity Family history of CAD Age above 65 years

Diabetes mellitus type I Family history of CAD Age above 65 years

A patient recently diagnosed with Rheumatoid Arthritis (RA) asks the nurse if the disease is caused by ethnicity? Which response by the nurse is the most appropriate? "RA is most prevalent in men under the age of 2 years" "RA is most prevalent in Caucasian females" "RA affects those of German descent most often" "RA affects all races at the same rate"

"RA affects all races at the same rate"

A nurse is caring for a patient who is newly diagnosed with rheumatoid arthritis (RA). The patient asks the nurse what is the difference between RA and osteoarthritis (OA)? Which response by the nurse is most appropriate? "The onset of OA is gradual while the onset of RA may be rapid and severe." " With OA, multiple joints are symmetrically involved; RA affects one joint at a time." "The pain and stiffness with RA is with activity; OA pain and stiffness is upon arising." "The affected joints in RA feel cool to touch while the joints in OA are warm or hot to touch."

"The onset of OA is gradual while the onset of RA may be rapid and severe."

You are providing care for a 60 yo patient diagnosed with Post-Polio Syndrome. The patient asks "How did I get Polio again?". Which of the following is the nurse's best response? "Polio virus lays dormant in the nervous system and can reoccur in those over 50 years old." "Your neurons are damaged from the original Polio infection and are now dying." "You may have contracted another strain of Polio. Have you traveled to another country?" "The surviving neurons from your original Polio infection are fatigued from overuse."

"The surviving neurons from your original Polio infection are fatigued from overuse."

A patient with a seizure disorder asks the purpose of staying awake all night prior to having an electroencephalogram in the morning. What should the nurse explain to this patient? "This will help to see whether or not your seizure medication is adequate during times of stress." "Sleep deprivation should cause a seizure which will prove that you have a seizure disorder." "You will be expected to sleep during the test and staying awake tonight will help you to be sleepy tomorrow." "We want to see your brain waves during a seizure and sleep deprivation can help cause a seizure."

"We want to see your brain waves during a seizure and sleep deprivation can help cause a seizure."

Which commands does the nurse use when conducting a neurological assessment for a patient? (Mark all that apply) "Wiggle the toes on your right foot." "Squeeze my fingers." "Touch your nose." "Raise your hands in the air."

"Wiggle the toes on your right foot."

A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. How should the nurse respond? "An infection enters the spinal cord and erodes the nerves at the roots." "Your body's white blood cells are now actively destroying your nerves." "Your immune system invades and damages the nerves' protective covering." "The pathophysiology is not well understood but this usually follows a vaccination."

"Your immune system invades and damages the nerves' protective covering."

The nurse is assessing a patient with memory issues for other cognitive deficits consistent with dementia. Which of the following will the nurse assess? Ability to transfer from a seated to standing position Ability to express ones self and understand language Ability to maintain a pleasant affect during assessment Ability to make eye contact when spoken to

Ability to express ones self and understand language

The school nurse is preparing to teach a health class to ninth grade regarding sexuality transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? Adolescents with a normal immune system are not at risk for developing AIDS Protected sex is no longer an issue because there is a vaccine for the HIV virus Females taking birth control pills are protected from becoming infected with HIV Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV

Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV

You are called STAT to a patient's room. The client appears to be having a grand mal seizure. The wife is anxiously holding the client down in bed. You immediately call for help. What is the next best nursing intervention for this patient? Position the client in the recovery position (right side lying) Wait for help and assist the wife in holding the client in bed Pull the patient to the floor and put a pillow under the head Adjust the bed position to flat and low and pad the side-rails Tilt the head back and hold it there to maintain an airway

Adjust the bed position to flat and low and pad the side-rails

The nurse is preparing to administer warfarin (Coumadin).an oral anticoagulant, to a client with a mechanical valve replacement . The clients's INR is 2.7 Which action should the nurse take? Assess for abnormal bleeding Prepare to give vitamin K Hold the medication and notify the HCP Administer the medication

Administer the medication

Which nursing intervention performed by the nurse when caring for a client with coronary artery disease helps decrease myocardial oxygen needs? Administering nitroglycerine as ordered Administering statin drugs as ordered Administering aspirin as ordered Administering calcium channel blockers as ordered

Administering calcium channel blockers as ordered

Which of the following interventions is appropriate for a client with bacterial meningitis? Administration of an antiviral Administration of a muscle relaxant Administration of a vasodilator Administration of a glucocorticoid

Administration of a glucocorticoid

The nurse is caring for a client with a leg ulcer caused by arterial insufficiency. Which of the following is a recommended treatment for arterial insufficiency of the leg? Administration of nitroglycerin paste. Application of compression stockings. Elevation of the lower extremities Application of wet-to dry dressings

Administration of nitroglycerin paste.

A client diagnosed with elevated blood pressure 4 months ago was given necessary instructions on a low sodium diet and 30 min per day of exercise. She reports for her follow-up visit today with the following vital signs: BP = 138/90; HR = 80; RR = 18; T = 97.9. The RN's highest priority action would be: Provide education for reducing dietary cholesterol Provide education for reducing caloric intake Advocate for obtaining a baseline stress test Advocate for starting anti-hypertensive medication

Advocate for starting anti-hypertensive medication

The nurse is performing a pre-operative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately 2 bottles of wine a day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient? Alcohol withdrawal syndrome 1 week after his last drink Alcohol withdrawal syndrome upon administration of anesthesia Alcohol withdrawal syndrome 2 to 4 days after his last drink Alcohol withdrawal syndrome immediately following surgery

Alcohol withdrawal syndrome 2 to 4 days after his last drink

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? An elevated B-type natriuretic peptide (BNP). An elevated creatine kinase (CK-MB). A positive D-dimer. A positive ventilation/perfusion (V/Q) scan.

An elevated B-type natriuretic peptide (BNP).

The OR nurse will be caring for a patient who will receive a trans-sacral bloc. For what patient would the use of a trans-sacral block be appropriate? A child who requires a closed reduction of a right humerus fracture. Middle-aged man schedule for a a thoracotomy. A 50 year-old woman who will be having a reduction mammoplasty An older adult man who will undergo an inguinal hernia repair

An older adult man who will undergo an inguinal hernia repair

The patient's surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical would. This requires the nurse to prioritize assessments related to what complication? Hypothermia Infection Anaphylaxis Malignant hyperthermia

Anaphylaxis

The nurse is reviewing medical orders for a patient with encephalitis. Which medication should the nurse expect to be prescribed as a priority for this patient? Antibiotic Antiseizure Antiemetic Antiviral

Antiviral

Which nursing diagnosis is most appropriate for a client during the pre-operative phase of surgery? Anxiety related to fear of post-operative pain Knowledge deficit related to pain management Impaired mobility related to post-operative pain. Risk for acute pain related to the surgical incision

Anxiety related to fear of post-operative pain

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure. Which sign and symptoms would the nurse expect to find when assessing this client? Radial pulse of 90 and Cap refill less than 3 seconds Apical pulse rate of 110 and 4+ pitting edema of the feet Thick white sputum and crackles that clear with cough The client is sleeping with no pillows and is eupenic

Apical pulse rate of 110 and 4+ pitting edema of the feet

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. An expected nursing intervention for this patient would be what? Apply protective eye shield to affected eye Puree foods to liquid consistency Place client on contact isolation Avoid touching face on affected side

Apply protective eye shield to affected eye

A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)? Hyperreflexia Areflexia Hyperanalgesia Hyporeflexia

Areflexia

While assessing a patient, the nurse notes that the patient's ankle-brachial index( ABI) of the right leg is 0.40. The nurse is aware that this may indicate what? Arterial narrowing Adequate peripheral circulation Inadequate coronary output Venous narrowing

Arterial narrowing

The client is 12 hours post-laminectomy. Which nursing interventions should be implemented ? Administer IV anticoagulants and place on eight (8) L/min. Assess ability to void and log roll the client every 2(two) hours Medicate with IV steroids and keep the be in Trendelenburg position Place stand bags on each side of th head and give cathartic .

Assess ability to void and log roll the client every 2(two) hours

A patient with myasthenia gravis undergo a thymotomy tomorrow morning. What pre-operative preparation should the nurse recommend for this patient? Assess pyridostigmine PO dose and obtain the equivalent dose of neostigmine IV Hold all medications until after surgery to prevent interactions with anesthesia Start patient on parenteral nutrition to prevent complications from malnutrition Check blood glucoses and start insulin via sliding scale if patient becomes hypoglycemic

Assess pyridostigmine PO dose and obtain the equivalent dose of neostigmine IV

The client diagnosed with pericarditis is complaining of pain. Which intervention should the nurse implement first. Evaluate the clients urine output Encourage the client to use the incentive spirometry Assess the client for cardiac complications Administer oxygen therapy via nasal canula

Assess the client for cardiac complications

The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? Check the HCP's orders and determine what laboratory tests will be done Place in contact isolation and don a mask and gown before entering the room. Assess the client's body weight and ask what the client has been able to eat. Teach the client about total parenteral nutrition and monitor the subclavian IV site.

Assess the client's body weight and ask what the client has been able to eat.

The client diagnosed with AIDS is experiencing voluminous diarrhea . Which interventions should the nurse implement? Assess the client's skin turgor every day Weigh the client daily in the same clothes and at the same time. Encourage the client to drink carbonated beverages Assist the client with a warm sitz bath PRN. Monitor diarrhea, charting amount, character, and consistency

Assess the client's skin turgor every day Weigh the client daily in the same clothes and at the same time. Assist the client with a warm sitz bath PRN. Monitor diarrhea, charting amount, character, and consistency

The nurse is providing care to a patient who is receiving non steroidal anti-inflammatory drugs (NSAIDS) in the treatment of rheumatoid arthritis. When providing care to this patient, which actions by the nurse are appropriate? Select all that apply Assessing for an allergic reaction Monitoring for signs of renal problems Advising against abrupt discontinuation of drugs Assuring the patient there is no relationship between NSAIDS and heart disease Encouraging the patient to take with water, milk, or small snack to help avoid stomach distress .

Assessing for an allergic reaction Monitoring for signs of renal problems Advising against abrupt discontinuation of drugs Encouraging the patient to take with water, milk, or small snack to help avoid stomach distress .

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis, Which intervention would the nurse implement first? Sponge the client's forehead. Obtain a pulse oximetry reading. Take the client's vital signs. Assist the client to a sitting position.

Assist the client to a sitting position

Which cranial nerves (CN) does the nurse assess when providing care to a patient who is diagnosed with myasthenia gravis? (Mark all that apply) CN VIII CN IX CN X CN XI CN XII

CN IX CN X CN XI CN XII

The nurse is providing patient teaching related to dietary changes for lowering blood pressure. Which of the following meals would you choose as the best example of this diet? Tuna salad Sandwich with: 3/4 cup canned tuna 2 Tbsp low fat mayo 1/2 chopped pickle 1 tsp dill 2 slices whole wheat bread Salad with: 1/2 cup fresh cucumber slices 1/2 cup tomato wedges 1 Tbsp sunflower seeds 2 Tbsp low calorie Italian dressing Chicken breast sandwich with: 3 oz skinless chicken breast 2 slices whole wheat bread 3/4 oz slice low fat cheddar cheese 1 large leaf lettuce 2 slices tomato 1 Tbsp low fat mayo 1 cup fresh cantaloupe chunks 1/3 cup unsalted almonds 1 cup apple juice 3 oz skinless chicken with: 3 tbsp low fat chicken gravy 1 cup fresh green beans sautéed with: 1 tsp canola oil & 1 Tbsp soy sauce 1 small baked potato with: 2 Tbsp sour cream 2 Tbsp grated cheddar cheese 1 Tbsp chopped scallions 1 small whole wheat roll with: 1 tsp margarine 1 small apple 1 cup low-fat milk 2 cups cooked spaghetti with: 3/4 cup low sodium marinara 3 Tbsp Parmesan cheese Spinach salad with: 1 cup fresh spinach leaves 1/4 cup seasoned croutons 1/4 cup fresh grated carrots 1/4 cup fresh sliced mushrooms 2 Tbsp blue cheese dressing 1/2 cup canned corn

Chicken breast sandwich with: 3 oz skinless chicken breast 2 slices whole wheat bread 3/4 oz slice low fat cheddar cheese 1 large leaf lettuce 2 slices tomato 1 Tbsp low fat mayo 1 cup fresh cantaloupe chunks 1/3 cup unsalted almonds 1 cup apple juice

For which of the following populations is a meningitis booster vaccine recommended? Home healthcare workers Patients with heart failure College students living in dorms Hospital food service workers

College students living in dorms

The nurse is discussing goals to relieve pain and fatigue with patient newly diagnosed with fibromyalgia. Which goal statement would be realistic for this patient to achieve within 30 days. Join an exercise group Walk her son to school daily Cook dinner 5 nights a week Get a job outside the house

Cook dinner 5 nights a week

VITAL SIGNS: 0830: pulse 82, respirations 14, blood pressure 92/60, temperature 98.9, pulse ox 96% 1030: pulse 92, respirations 20, blood pressure 110/82, temperature 96.3pulse ox 93% While assessing a client in the Post Anesthesia Care Unit (PACU) the nurse compares the preoperative vital signs at 0830 to the current vital signs at 1030 . Based on this what should the nurse do first? Administer oxygenate 4L via nasal canula Call the physician for a pain medication Increase the IV fluid rate Cover with a warming blanket

Cover with a warming blanket

A nurse is planning the care for a patient with an exacerbation of Parkinson's Disease. The nurse is aware that treatment will focus on what pathophysiology for this disease? Premature degradation of acetylcholine Insufficient synthesis of epinephrine Delayed re-uptake of serotonin Decreased availability of dopamine

Decreased availability of dopamine

The nurse is caring for a client on bed rest following successful stenting of a 90% occluded left main coronary artery. The urine output has been 100ccs in 4 hours, the BP = 89/55, the HR = 100, T = 98.8, RR = 16, O2Sats = 90% on 2L O2 via nasal cannula. Given the client's diagnosis, these assessment findings are most consistent with: Fluid volume deficit Urinary retention Decreased cardiac output Impaired gas exchange

Decreased cardiac output

What is the priority problem in the client diagnosed with congestive heart failure? Fluid volume overload. Decreased cardiac output. Activity intolerance. Knowledge deficit.

Decreased cardiac output.

The nurse is planning care for an adolescent patient who has systemic lupus erythematosus (SLE). Which action by the patient indicates the implemented plan is appropriate? Discussing skin changes with a friend Refusing to attend school Refraining to attend social functions Discussing skin changes with a HCP.

Discussing skin changes with a friend

Which of the following assessment findings best indicates right sided heart failure ? Bradycardia Pulmonary edema Dyspnea and cough Distended neck veins

Distended neck veins

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking Levodopa for seven years. What is a common side effect of Levadopa for which the nurse would assess this patient? Dyskinesia Weight gain Dry cough Hypotension

Dyskinesia

A patient with Guillain-Barré syndrome (GBS) loses respiratory function three weeks into the acute phase. When should the nurse expect respiratory function to return in this patient? At the end of the plateau stage Early in the recovery stage At the end of the recovery stage During the plateau phase

Early in the recovery stage

A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)? Elevated glucose level Elevated protein level Increased number of red blood cells Reduction in white blood cell count

Elevated protein level

The nurse is caring for a client with a diagnosis of unstable angina. Which of this client's assessment findings best indicates myocardial cell death? Elevation of Serum troponin- T and I Elevation of ST segment on an EKG Elevation of heart rate and respiratory rate Elevation of chest pain with activity

Elevation of Serum troponin- T and I

A patient recovering from a lumbar puncture rates a headache as being 8 on a pain scale of 0 to 10. What should the nurse do while waiting for the health-care provider to prescribe pain medication? Encourage increasing oral fluid intake Raise the head of the bed Gently massage the lower spine Assist to sit out of bed in a chair

Encourage increasing oral fluid intake

The nurse is reviewing orders written for a patient with myasthenia gravis. Which medication order should the nurse question before administering? (Mark all that apply) Warfarin Erythromycin Furosemide Verapamil Nicotine patch

Erythromycin Verapamil Nicotine patch

Which of the following does a brain natural peptide assess? Lack of myocardial perfusion Myocardial electrolyte imbalance Excessive myocardial stretching Myocardial membrane rupture

Excessive myocardial stretching

The nurse assesses a patient who is admitted after a traumatic brain injury (TBI) to the frontal lobe. Which manifestation does the nurse anticipate upon assessment? Sensation difficulty Color perception impairment Long-term memory impairment Expressive speech difficulty

Expressive speech difficulty

Which of the following is true related to women's signs and symptoms before or during a myocardial infarction? Women do not experience chest pain in the early stages of an MI Chest pain is the best indicator of MI in both men and women Fatigue and weakness are common signs and symptoms in women Chest pain in women indicates a high-grade MI with high mortality

Fatigue and weakness are common signs and symptoms in women

The nurse assesses a patient who is sleepy with slowed responses to stimuli. Which term does the nurse use when documenting this patient's level of consciousness (LOC)? Lethargic Stupor Conscious Coma

Lethargic

You are teaching a new RN graduate about the current understanding of what causes Alzheimer's type dementia. Which of the following would you list as contributing to the development of Alzheimer's dementia? Under use of mental exercises (i.e. reading and doing word puzzles) Formation of plaques and neuro-fibrillary tangles in the brain Multiple small brain infarctions that occur over several years All of these responses contribute to the development of this disease

Formation of plaques and neuro-fibrillary tangles in the brain

You are developing a plan of care for a patient with Guillain-Barre´ syndrome. What nursing intervention would receive priority for this patient? Place client on seizure precautions Support in coping with terminal illness Frequent assessment for full bladder Place client on contact isolation

Frequent assessment for full bladder

The nurse is planning care for a patient recovering from surgery to debulk a brain tumor. Why should self-monitoring of capillary blood glucose level be a part of this plan? Manipulation of cerebral tissue Glucocorticoid medication administration Interruption of brain glucose regulation Nausea and anorexia from chemotherapy

Glucocorticoid medication administration

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? Assist the client to go down to the smoking area for a cigarette. Transport the client to the intensive care unit (ICU) via a stretcher. Provide the client going home discharge-teaching instructions. Help position the client who is having a portable x-ray done.

Help position the client who is having a portable x-ray done.

A patient is admitted to the medical unit with heart failure and is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position this patient? High Fowler's position Trendelenberg position Left side-lying position Flat, supine position

High Fowler's position

A patient is suspected of having early signs of Alzheimer's disease. What diagnostic testing should the nurse expect to provide a diagnosis of this disorder? History and physical examination Cerebral spinal fluid glucose Cerebral angiography Serum inflammation markers

History and physical examination

The nurse is taking a history from a patient newly diagnosed with trigeminal neuralgia. Which of the following does the nurse identify as a risk factor for development of this disorder? Has a BMI of 34 Works as a computer operator History of hypertension Takes birth control pills

History of hypertension

You are providing care for a client who is one hour post-cardiac catheterization with one vessel PTCA and stent placement. Which nursing interventions you would anticipate in providing post-procedure care for this client. (Mark all that apply.) Maintain foley catheter and document hourly urine output until patient is able to ambulate. Hold firm pressure for 15-30 min following sheath removal from puncture site. Maintain continuous pulse oximetry and apply supplemental oxygen PRN to keep Sats ≥ 90%. Assist client in performing hourly range of motion exercises of the affected extremity. Apply ace wrap pressure dressing to puncture site and maintain pressure for two hours. Assess and document vital signs, puncture site and pulses every 15 minutes for the first hour.

Hold firm pressure for 15-30 min following sheath removal from puncture site. Maintain continuous pulse oximetry and apply supplemental oxygen PRN to keep Sats ≥ 90%. Assess and document vital signs, puncture site and pulses every 15 minutes for the first hour.

The nurse is planning the care of a patient who has type I diabetes and who will be undergoing knee replacement surgery. This patient's care plan should reflect an increased risk of what post-surgical complications? Select all that apply. Hypoglycemia Delirium Acidosis Glucosuria Fluid Overload

Hypoglycemia Acidosis Glucosuria

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthesia . For which adverse effect should the nurse most closely monitor the patient? Cerebral ischemia Arthritis Pulmonary edema Hypothermia

Hypothermia

The nurse is concerned that a patient's Alzheimer's disease is progressing. What finding did the nurse use to confirm this suspicion? Misplacement of health insurance cards Leaving the practitioner's office without taking prescriptions Inability to recall the word for "car" Unable to find sweater in the waiting room

Inability to recall the word for "car"

The clients is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? Pulsus Paradoxus Complaints of fatique and arthralgia Pink frothy sputum Increased chest pain with inspiration

Increased chest pain with inspiration

Which of the following nursing diagnoses is most appropriate for clients with acute Encephalitis? Failure to thrive Ineffective tissue perfusion Impaired memory Risk for infection

Ineffective tissue perfusion

The nurse is creating a plan of care for a 70 year old obese patient with a history of Type II diabetes. Which of the following post-operative complications does the nurse realize is a higher risk for this client? Bleeding Infection Incontinence Pain crisis

Infection

A nurse teaches the client undergoing HIV testing that if antibodies to the AIDS virus are present in the blood, this indicates HIV is suppressed by medication Immunity to HIV HIV is inactive in the body Infection to HIV

Infection to HIV

An Asian male accompanies his spouse to the clinic and states" I want you to fix may wife and tell her that there is nothing wrong with her" The patient reports pain, sleep disorders, and stiffness. Which would be the most appropriate for the the nurse to include in the plan of care for this client ? Medications used to treat fibromyalgia An exercise program to increase energy Information and literature on fibromyalgia Suggested dietary changes to help with the pain

Information and literature on fibromyalgia

The nurse is admitting a 65 yo client with a small bowel obstruction who is evidently confused and has a memory deficit. What is the best initial nursing response to this finding? Initiate falls risk protocols to maintain client safety while attempting to determine the client's pre-hospitalization cognitive status Call and report this finding to the client's doctor and request an order for a sedative to maintain client safety Continue monitoring mental status every 15 min while continuing your admission assessments and administering treatments as ordered Use frequent verbal reorientation until resolved knowing this is a common response to illness in the elderly population that is likely to resolve itself

Initiate falls risk protocols to maintain client safety while attempting to determine the client's pre-hospitalization cognitive status

In caring for a client with Parkinson's disease you discover that she is having difficulty rising from sitting to the standing position. In relation to this, which of the following would you recommend to the family? Installation of grab bars and raised toilet seat in the bathroom Installation of a home alert system with a call button device Purchase of a wheelchair and removal of area rugs Purchase of high bar stools placed in favorite sitting areas

Installation of grab bars and raised toilet seat in the bathroom

The client with pericarditis is prescribed a non-steroidal anti inflammatory (NSAID). Which teaching instruction should the nurse discuss with the client? Tell the client to take the medication when the pain level is 8 Discuss that the medication may make the client drowsy Instruct the client to take the medication with food Explain the importance of tapering off the medication

Instruct the client to take the medication with food

You are providing preoperative teaching to a client schedule for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage and frequency. Which of the following interventions provides the patient with the most accurate information? Instruct the patient to stop taking St. John's Wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. Instruct the patient to continue any herbal supplements unless otherwise instructed. These will have minimal effect. Instruct the patient to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias Instruct the patient to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure

Instruct the patient to stop taking St. John's Wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.

The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record? Peripheral vascular disease Dependent rubor Deep vein thrombosis Intermittent claudication

Intermittent claudication

A patient with myasthenia gravis is being prepared for a edrophonium (Tensilon) test. What should the nurse ensure is available prior to the beginning of this test? Oxygen with mask Intravenous atropine Albuterol inhaler Nasogastric suction

Intravenous atropine

The nurse is caring for a patient who is in status epilepticus. Which of the following does the nurse expect to give for the purpose of stopping this seizure? Intravenous methylprednisolone (Solu-Medrol) Oral lorazepam (Ativan) Oral phenytoin (Dilantin) Intravenous diazepam (Valium)

Intravenous diazepam (Valium)

Which is true regarding Prinzmetal's angina? It is caused by fixed plaque formations. It normally occurs between midnight and 8 a.m. It is a variation of stable angina. It is associated with physical activity.

It normally occurs between midnight and 8 a.m.

The nurse is reviewing discharge instructions for a patient with myasthenia gravis. What should the nurse emphasize regarding medications? Keep extra doses of medications in a purse or pocket Store extra doses of medications in the refrigerator Take an extra dose of your medication before driving Pack extra doses of medication in checked luggage during air travel

Keep extra doses of medications in a purse or pocket

A patient is diagnosed with a 7 cm abdominal aortic aneurysm. What should the nurse include in this patient's plan of care? Raise the head of the bed 30 degrees Elevate the lower extremities Keep the bed flat Assist to sit out of bed in a chair twice a day

Keep the bed flat

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply. Laboratory reports Verification form Dietician Assessment Social work assessment Nurses notes

Laboratory reports Verification form

A 68 year old male with a long history of heart disease presents to the emergency department complaining of increased shortness of breath. The patient is agitated and coughing up pink frothy sputum. What should the nurse suspect? Right-sided heart failure Unstable angina Myocardial infarction Left-sided heart failure

Left-sided heart failure

The nurse is interviewing a client at a health screening event. Which of the following complaints would the nurse attribute to peripheral arterial disease Leg pain with activity relieved with rest Dizziness with activity relieved with rest Ankle-Brachial index measurement of 1.1 Ankle swelling improved with elevation

Leg pain with activity relieved with rest

What should the nurse establish as the standard LDL goal for a healthy 35yo client? Less than 100 mg/dl Less than 150 mg/dl Less than 50 mg/dl Less than 200 mg/dl

Less than 100 mg/dl

You are developing a teaching plan for a 42 year old female client who is 5 feet 9 inches in height and weighs 135 pounds with newly diagnosed stage 1 hypertension. She reports eating frequently at "fast food" restaurants, drinking a glass or two of wine per week, and "exercise walking" with friends four times per week. Which of the following topics should you address first with this client? Increasing exercise to 30 min of daily Decreasing her caloric intake The adverse effects of alcohol Low-sodium healthy fat food choices

Low-sodium healthy fat food choices

The nurse is admitting a patient experiencing photophobia and nuchal rigidity. For which diagnostic test should the nurse prepare this patient? CT scan with contrast Electroencephalogram Lumbar puncture Evoked potentials

Lumbar puncture

An OR nurse os teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personnel protective equipment should the nurse war at all times in the restricted zone of the OR? Mask covering the nose and mouth Goggles Glovers Reusable shoe covers

Mask covering the nose and mouth

The nurse is caring for a client with an exacerbation of Post-Polio Syndrome following the death of his wife of 40 years. What interventions does the nurse include in this client's plan of care? (Mark all that apply) Maintain cardiac monitoring with telemetry Monitor continuous pulse oximetry providing oxygen PRN Provide assistance with ADLs as needed Plan activities during peak effectiveness of pain medication Give frequent reminders and reorientation as needed

Monitor continuous pulse oximetry providing oxygen PRN Provide assistance with ADLs as needed Plan activities during peak effectiveness of pain medication

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) develops tachycardia during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? Orthostatic hypotension Pulmonary embolism Myocardial ischemia Cerebral hemorrhage

Myocardial ischemia

The mother of three children is diagnosis with fibromyalgia and asks the nurse how to keep up with all of the children's activities. Which suggestion by the nurse is most appropriate? Negotiate with the children to alternate attending their functions Attempt to attend all the functions of the children Avoid attending any after school functions for the children Ask the children to limit their activities.

Negotiate with the children to alternate attending their functions

During a home visit the nurse is concerned that the patient with Alzheimer's disease is deteriorating. What patient observation caused the nurse to have this concern? No recognition of bowel incontinence during the visit Staying away from the stairs leading to the basement Eating cheese and crackers placed on a nearby table Sitting in a chair watching a television program

No recognition of bowel incontinence during the visit

The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? Have the client gargle with an antiseptic based mouthwash several times a day Determine what types of food the client has been eating for the last 24 hours. Notify the HCP for an order for an anti fungal swish-swallow medication Teach the patient to brush the teeth and patchy area with a soft-bristle toothbrush

Notify the HCP for an order for an anti fungal swish-swallow medication

VITAL SIGNS: 0930: pulse 68, respirations 14, blood pressure 120/79, temperature 97.9, pulse ox 96% 1000: pulse 105, respirations 24, blood pressure 100/50, temperature 98.9pulse ox 92% While assessing a client in the Post Anesthesia Care Unit (PACU) the nurse compares the vital signs at 0930 to the current vital signs at 1000. The nurse further assess the client to find the client's skin is cold and moist, and pale. Based on this what should the nurse suspect? Malignant hypothermia Onset of hypovolemic shock Development of atelectasis Normal response to anesthesia

Onset of hypovolemic shock

Which sign/symptoms should the nurse assess in any client who has a long-term valvular heart disease?Select all that apply. Orthopnea Cough Pulsus Paradoxus Paroxysmal nocturnal dyspnea Pericardial friction rub

Orthopnea Cough Paroxysmal nocturnal dyspnea

Which of the following would require urgent intervention by the nurse for a patient in recovery from a cardiac catheterization? Patient requests something for pain in the area of the puncture site Non-bleeding 3cm area of firm swelling at puncture site Patient reports nausea and develops a generalized skin rash Pulse strength decreased in affected extremity

Patient reports nausea and develops a generalized skin rash

Which of the following explains how the Polio Virus is still passed from person to person when all of those showing symptoms are quarantined? Only half of the patients with paralytic polio ever develop paralysis Patients with non-paralytic polio do not have muscular symptoms Abortive polio allows the virus to jump from one patient to another quickly Patients with sub-clinical polio are infected but do not show symptoms

Patients with sub-clinical polio are infected but do not show symptoms

The nurse prepares to assess a patient's cranial nerves. Which tool is needed to assess cranial nerve III? Cotton ball Pen light Lavender Otoscope

Pen light

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? Pia mater Dura mater Arachnoid mater Meninges

Pia mater

A nurse is interviewing a 22 year old college female with known exposure to meningococcal meningitis via her college dorm living situation. Which of the following signs and symptoms of meningitis would the nurse advise the student to report immediately to the campus medical center? (Mark all that apply) Stiff neck Headache Fever Wheezing Runny nose

Stiff neck Headache Fever

A patient, recently diagnosed with rheumatoid arthritis (RA) asks the nurse whether RA will affect her in other ways. When responding to the patient, which systems will the nurse include as possibly being affected by the diagnosis? Select all that apply Reproductive Respiratory Exocrine Cardiovascular Hematologic

Respiratory Exocrine Cardiovascular Hematologic

The client had open heart surgery to replace a mitral valve. Which intervention should the intensive care nurse implement? Restrict the clients liquids as ordered Monitor the total parenteral nutrition Keep the client in the supine position Maintain the oxygen saturation at 90 %

Restrict the clients liquids as ordered

A nurse is caring for a patient with systemic lupus erythematosus (SLE) who is taking hydroxychloroquine (Plaquenil). When providing care for this patient, the nurse monitors for which adverse effect associated with the prescribed medication? Renal toxicity Pulmonary fibrosis Cushingoid effects Retinal toxicity

Retinal toxicity

A patient is diagnosed with a 1 cm abdominal aortic aneurysm. What should the nurse emphasize when discussing this health problem with this patient? Engage in stress management Stop smoking Reduce the intake of saturated fat Increase physical activity

Stop smoking

The nurse is doing a preoperative patient education with a 61 year old male patient who has a 40/pack year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits work schedule in a few months. What would be the best instruction to give to this patient? Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection Reduce smoking by at least 50% to prevent the development of pneumonia Aim to quit smoking in the post-operative period to reduce the chance of surgical complications Stop smoking at least 6 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection

The nurse needs to provide a strong stimulus to illicit a response; however, the patient drifts back to unresponsiveness. What term should the nurse use to document this patient's level of responsiveness? Conscious Stupor Lethargic Coma

Stupor

The nurse is completing a health screening for a school-age child with rheumatoid arthritis "RA". The parents ask the nurse to recommend activities that will promote exercise for their child. Which recommendation by the nurse is the most appropriate? Football Softball Running Swimming

Swimming

The patient enters the outpatient clinic and states to the triage nurse, " I think I have the flu, I'm so tired, I have no appetite, and everything hurts," The triage nurse assesses the patient and finds a butterfly rash over the bridge of the nose and on the cheeks. Based on this data, which diagnosis does the nurse anticipate? Fibromyalgia Gout Systemic lupus erythematosus Lyme disease

Systemic lupus erythematosus

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? Instruct the client to take a cough suppressant if a cough develops. Teach the client how to prevent orthostatic hypotension. Encourage the client to eat bananas to increase potassium level. Explain the importance of taking the medication with food.

Teach the client how to prevent orthostatic hypotension

The nurse is counseling an adult patient with fibromyalgia. What are some elements of counseling that can help this patient develop effective coping skills? Remind the patient that the patient has a progressive chronic disease. Inform the patient that the patient does not need a specialist Suggest to the patient that some symptoms may be psychosomatic Teach the client strategies including distractions, relaxation techniques , or journaling.

Teach the client strategies including distractions, relaxation techniques , or journaling.

The nurse is preparing material for a community health fair. Which type of headache should the nurse identify as being the most common in adults? Tension Mixed Migraine Cluster

Tension

The health care provider is teaching a patient who has tested positive for human immunodeficiency virus (HIV) about the antiretroviral medication maraviroc. Which of following statements best describes how this drug is effective against HIV? The process of viral DNA synthesis is suppressed The cellular membrane of the HIV virus is disrupted New virus particles lose their ability to be infectious The HIV virus is prevented from entering the target cells

The HIV virus is prevented from entering the target cells

Which assessment data would warrant immediate intervention by the nurse? The client diagnosed with a DVT who complains of pain on inspiration The client with an inguinal hernia repair who must void before discharge The immobile client who refused to turn for the last 3 hours The client with an open cholecystectomy who refuses to breath deeply

The client diagnosed with a DVT who complains of pain on inspiration

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? The client diagnosed with myocardial infarction who has an audible S3 heart sound. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. The client with chronic renal failure who has an elevated creatinine level.

The client diagnosed with myocardial infarction who has an audible S3 heart sound.

The nurse is performing a preoperative history and physical exam for a client scheduled for an elective lumbar laminectomy in one hour. Which of the following findings would the nurse report to the surgeon as possible cause to postpone surgery? The client has an acne outbreak on his lower back The client has a history of sleep apnea The client is unable to hear without hearing aids The client is allergic to iodine and penicillin

The client has an acne outbreak on his lower back

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? The client's peripheral pitting edema has gone from a 3+ to 4+. The client is able to take the radial pulse accurately. The client is able to perform ADL's without dyspnea. The client has minimal jugular vein distention.

The client is able to perform ADL's without dyspnea.

The nurse is caring for clients on an orthopedic unit. Which client should be assessed first? The client two (2) days post disk fusion who has T100.4, P 96, R24, and B/P 138/78 The client who has undergone a myelogram and complains of a headache. The client being diagnosed with back pain who is being discharged and whose ride is here. The client diagnosed with back pain who is complaining of a 4+ on a scale of 1-10 scale.

The client two (2) days post disk fusion who has T100.4, P 96, R24, and B/P 138/78

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? The client diagnosed with congestive heart failure who is being discharged in the morning. The client who is having frequent incontinent liquid bowel movements and vomiting. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. The client who is complaining of chest pain on inspiration and a nonproductive cough.

The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.

Which information should the nurse include when teaching a patient information regarding Arthritic Gout Select all that apply The large toe first metatarsophalangeal joint Tophi are present in affected joint Diet should include sardines anchovies and lentils Limit amounts of red wine and alcohol Can be preceded by a diagnosis of Raynaud's phenomenon

The large toe first metatarsophalangeal joint Limit amounts of red wine and alcohol

The clinical faculty has explained the disease process of myasthenia gravis to a student nurse. Which of the following statements by the student nurse show solid understanding? The nerves lose their protective covering and impulses can't reach muscle groups The body doesn't make enough of the neurotransmitter that initiates muscle stimulation The nerve synapses lose response to the neurotransmitter that signals muscle contraction The functional nerve endings wear out, which causes a decrease in muscle coordination

The nerve synapses lose response to the neurotransmitter that signals muscle contraction

In anticipation of a patient's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use post operatively. What action should the nurse teach the patient? The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately post operative period. The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs The patient should rapidly inhale, hold for 30 seconds or as long as possible and exhale slowly.

The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

The client is diagnosed with acute exacerbation of SLE.. She is prescribed high dose steroids. Which statement best explains the scientific rationale for using high dose steroids in treating SLE? The steroids will decrease the chance of the SLE spreading to other organs The steroids will prevent scarring of skin tissues associated with SLE. The steroids will increase the body ability to fight the infection. The steroids will suppress tissue inflammation, which reduces damage to organs.

The steroids will suppress tissue inflammation, which reduces damage to organs.

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states"I dont know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide. To promote optimal lung expansion To prevent pneumothorax To prevent chronic obstructive lung disease (COPD) To enhance peripheral circulation

To promote optimal lung expansion

A patient, recently diagnosed with rheumatoid arthritis (RA) asks the nurse if RA always causes crippling deformities? Which teaching topics will the nurse include as ways to decrease the likelihood of crippling deformities? Use stronger joints for most activity Avoid stress to any current area of deformity Ignore pain as a warning signal Stop an activity if it is beyond your ability to perform. Type instead of hand writing items of possible

Use stronger joints for most activity Avoid stress to any current area of deformity Stop an activity if it is beyond your ability to perform. Type instead of hand writing items of possible

A patient with suspected Parkinson's disease is being initially assessed by the nurse. The nurse would expect the patient to have a tremor. When is the best time to assess for this tremor? While the patient is walking in the hall While the patient is brushing her teeth While the patient is resting in a chair While the patient is doing PT exercises

While the patient is resting in a chair

A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled? Without delay Within the next week Within 24 hours As soon as the scheduled are done

Without delay

Match the following anti-hypertensive medications with their common side-effect. Calcium Channel Blocker Ace Inhibitor Beta Blocker 1. Hypokalemia 2. Peripheral edema 3. Fatigue 4. Bleeding 5. Chronic cough

__2_Calcium Channel Blocker _5__ Ace Inhibitor _3_Beta Blocker