kid milli;

50. What the common complaints with Addison's disease? A. Weght gain, anorexia, constipation B. Weight loss, weakness, fatigue C. Constipation, weight loss,  salt craving D. Increased appetite, weight loss, insomnia

ANS: B

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

ANSWER: 2 Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for melanoma.

47. Which menu choice indicates that the patient understands the nurse teaching about recommended dietary choices for iron-deficiency anemia? A. Omelet and whole wheat toast B. Cantaloupe and cottage cheese C. Strawberry and banana fruit plate D. Cornmeal muffin and orange juice

ANS: A Rationale: Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

43 Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? A. A patient with chronic heart failure B. A patient who has viral pneumonia C. A patient who has right leg cellulitis D. A patient with multiple abdominal drains

ANS: A Rationale: Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process

44. After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess? A. A 23-yr-old who is complaining of severe fatigue B. A 33-yr-old with a fever of 100.8 C. A 56-yr-old with frequent explosive diarrhea D. A 66-yr-old who has white pharyngeal lesions

ANS: B Rationale: Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems

68. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? A. Patient reports no stool for 5 days. B. Serum calcium level is 15 mg/dL. C. Urine sample has Bence-Jones protein. D. Patient is complaining of severe back pain.

ANSWER: 2 Rationale: Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening.

73. Your patient's TSH (thyroid-stimulating hormone) level is 0.001. What condition does this value indicate? a. Hyperactive anterior pituitary function b. Hyperthyroidism c. Hypoactive anterior pituitary function d. Hypothyroidism

ANS: b. (HYPERthyroidism) A low TSH result may indicate: An overactive thyroid gland (hyperthyroidism) Excessive amounts of thyroid hormone medication in those who are being treated for an underactive (or removed) thyroid gland. ... Damage to the pituitary gland that prevents it from producing adequate amounts of TSH.

26. What is the origin of microvascular disease associated with diabetes mellitus? 1. Vasoconstriction from hyperglycemia 2. Repeated hypoglycemic events 3. Changes in the capillary basement membrane causing hypoxia on a cellular level 4. Increased athersclerotic plaques on the intima

Answer 3

87. A nurse prepares to administer prescribed regular and NPH insulin. Place the nurse's actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab.

ANS: 3, 1, 2, 8, 7, 4, 6, 5

45. A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which information will be useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Glomerular filtration rate (GFR) c. Blood urea nitrogen (BUN) level d. Creatinine level

ANS:2 Rationale: GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

82. A nurse assesses a patient with ulcerative colitis. Which complications are paired correctly with their physiologic processes? Select all that apply. 1. Toxic megacolon & transmural inflammation resulting in pyuria and fecaluria. 2. Lower gastrointestinal bleeding & erosion of the bowel wall. 3. Abscess formation & localized pockets of infection develop in the ulcerated bowel lining. 4. Fistula & dilation and colonic ileus caused by paralysis of the colon. 5. Nonmechanical bowel obstruction & paralysis of colon resulting from colorectal cancer.

Ans: 2, 3, 5 Rationale: Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

79. A nurse teaches a patient with diabetes mellitus about foot care. Which statements would the nurse include in this patient's teaching? (Select all that apply.) a. Treat any blisters or sores with Epsom salts. b. Wash your feet every other day. c. Do not walk around barefoot. d. Soak your feet in a tub each evening. e. Trim toenails straight across with a nail clipper.

Answer: C,E Rationale: Patients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The patient would be instructed to not walk around barefoot or wear sandals with open toes. These actions place the patient at higher risk for skin breakdown of the feet. The patient would be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The patient should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds

13. Your patient has been preliminarily diagnosed with Cushing 's syndrome. What diagnostic test do you anticipate the physician ordering for this patient? 1. Computerized tomography of the brain, chest, and abdomen; 24-hour urine cortisol levels; ACTH serum concentrations 2. Urine ACTH concentrations, thyroid panel, C-reactive protein level 3. Serum and urine cortisol levels, thyroid panels, beta-natriuretic peptide levels 4. Computerized tomography of the brain, chest, and abdomen; thyroid levels; basic metabolic panel

Answer_1

31. What are the three major problems associated with macrovascular disease in a patient with diabetes mellitus? a. Diabetic peripheral neuropathy , peripheral vascular disease, cerebral vascular disease b. Peripheral neuropathy, coronary artery disease, cerebral vascular disease c. Retinopathy, coronary artery disease , cerebral vascular disease d. Coronary artery disease, cerebral vascular accident, peripheral vascular disease

answer_ d because diabetes journal

18. How is insulin secretion regulated? 1. Chemical, hormonal, and neuronal controls 2. Chemical, glucagon, and insulin control. 3. Hormonal, exocrine gland secretion and glucose controls 4. Hormonal, insulin, and neuronal controls

answer_1

9. What are physical symptoms do you expect a patient to exhibit if diagnosed with Cushing's syndrome? 1. Moon facies, purple striae on trunk, buffalo hump 2. Moon facies, edema, weight loss 3. Moon facies, easy bruising, weight loss 4. Moon facies, weight loss, ache

answer_1

1. A nurse assesses a patient who has diabetes mellitus and notes that the patient is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the patient's clinical manifestations have not changed. What action would the nurse take next? 1. Administer another half-cup (120 mL) of orange juice. 2. Administer 1 mg of glucagon intramuscularly. 3. Administer 10 units of regular insulin subcutaneously. 4. Administer a half-ampule of dextrose 50% intravenously.

answer_1 Rationale: This patient is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse would administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment would be repeated. The patient does not need intravenous dextrose, insulin, or glucagon.

4. Which of the following should be included in patient education for the patient with Addison's disease? 1. Lifelong condition, follow-up labs, hydrocortisone injection 2. Follow-up labs, Medic-Alert bracelet, no-added salt diet 3. Liberal sodium diet, self -limiting disease 4. Lifelong condition, no-added salt diet, push oral fluids

answer_1 Rationale: Addison pt needs increased salt in the diet so not 2 and 4 Ne

23. Cortisol, glucagon, catecholamines, and growth hormone( GH) as a group are classified as: 1. Serotonin inhibitors 2. Insulin-antagonistic hormones 3. Neuroprotective hormones 4. Gluconeogenic hormones

answer_2

2. Which information will the nurse include when teaching an older patient about skin care? 1. Bathe and wash hair daily with soap and shampoo. 2. Use warm water and a moisturizing soap when bathing. 3. Dry the skin thoroughly before applying lotions. 4. Use antibacterial soaps when bathing to avoid infection.

answer_2 Rationale: Warm water and moisturizing soap will avoid overdrying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in.

17. A nurse cares for a patient with a deficiency of aldosterone. Which assessment finding would the nurse correlate with this deficiency? 1. Serum sodium of 144 mEq/L (144 mmol/L) 2. Increased urine output 3. Blood glucose of 98 mg/dL (5.4 mmol/L) 4. Vasoconstriction

answer_2 Rationale: Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A patient with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the patient would have hyponatremia and hyperkalemia.

8. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? 1. Give the PRN diphenhydramine . 2. Administer PRN acetaminophen (Tylenol). 3. Send a urine specimen to the laboratory. 4. Draw blood for a new type and crossmatch.

answer_2 Rationale: The patient 's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

16. A nurse is assessing a patient who has acute pancreatitis and is at risk for an acid & base imbalance. For which manifestation of this acid & base imbalance would the nurse assess? a. Agitation b. Positive Chvostek's sign c. Seizures d. Kussmaul respirations

answer_4 Rationale: The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek 's sign are manifestations of the electrolyte imbalances that accompany alkalosis.

24. A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL (1.8 mmol/L), and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first? 1. Encourage the patient to drink orange juice. 2. Insert a new intravenous access line. 3. Administer 1 mg of intramuscular glucagon. 4. Administer 25 mL dextrose 50% (D50) IV push.

answer_3 Rationale: The patient 's blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the patient 's blood glucose level. The nurse would insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the patient 's blood glucose level does not rise. Once the patient is awake, orange juice may be administered orally along with a form of protein such as peanut butter.

20. A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? 1. Administer lorazepam (Ativan) 0.5 mg PO. 2. Schedule an intravenous pyelogram (IVP). 3. Insert a urinary retention catheter. 4. Draw blood for a serum creatinine level.

answer_3 Rationale: The patient 's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient 's agitation may resolve after the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP may be used as a diagnostic test but does not need to be done urgently.

19. A nurse admits a patient from the emergency department. Patient data are listed below: History Laboratory Values History of diabetes Physical Assessment On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL, Afebrile, Oriented to person only Values WBC: 5,200/mm PaO2 on room air 85 mm Hg What action by the nurse is the priority? 1. Start an IV of normal saline at 50 mL/hr. 2. Collect a sputum sample for culture. 3. Administer oxygen at 4 L per nasal cannula. 4. Begin broad-spectrum antibiotics.

answer_3 All actions are appropriate for this patient who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.

6. A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/L. Which action will the nurse include in the plan of care? 1. Prepare for platelet transfusion. 2. Use low-molecular-weight heparin (LMWH). 3. Discontinue the heparin and flush intermittent IV lines using normal saline. 4. Administer prescribed warfarin (Coumadin).

answer_3 Rationale: All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/L. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis. [Chapter 31; question 10]

5. An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of the hypertension? 1. Instruct the patient about the need to decrease stress levels. 2. Schedule the patient for regular blood pressure (BP) checks in the clinic. 3. Teach the patient how to self-monitor and record BPs at home. 4. Inform the patient and caregiver that major dietary changes will be needed.

answer_3 Rationale: In the phenomenon of white coat; hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.

12. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the 1. gastric analysis. 2. stool occult blood. 3. bilirubin level. 4. Schilling test.

answer_3 Rationale: Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

3. A nurse assesses a patient who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? 1. Blood osmolarity has decreased. 2. Urine remains negative for ketone bodies. 3. Serum potassium level has increased. 4. Glasgow Coma Scale score is unchanged.

answer_4 A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the patient's state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.

14. At 4:45 PM, a nurse assesses a patient with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the patient is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) Dietary Intake At 06:30; 95 At 11:30; 70 At 16:30; 47 Breakfast: 10% eaten patient states that she is not hungry Lunch: 5% eaten;patient is nauseous; vomits =once After reviewing the patient's assessment data, which action is appropriate at this time? 1. Reorient the patient and apply a cool washcloth to the patient's forehead. 2. Assess the patient's oxygen saturation level and administer oxygen. 3. Provide a glass of orange juice and encourage the patient to eat dinner. 4. Administer dextrose 50% intravenously and reassess the patient.

answer_4 Rationale: The patient's symptoms are related to hypoglycemia. Since the patient has not been tolerating food, the nurse would administer dextrose intravenously. The patient's oxygen level could be checked, but based on the information provided, this is not the priority. The patient will not be reoriented until the glucose level rises.

76. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000L during chemotherapy is to a. check all stools for occult blood. b. check the temperature every 4 hours. c. encourage fluids to 3000 mL/day. d. provide oral hygiene every 2 hours.

answer_A Rationale: Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

75. A nurse is caring for several older patients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Report any new onset of cough. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Encourage between-meal snacks.

answer_C Rationale: Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in patients are important to detect the onset of possible pneumonia but do not prevent it.

74. A nurse teaches a patient who has viral gastroenteritis. Which dietary instruction would the nurse include in this patient's teaching? a. You should only drink 1 L of fluids daily b. Increase your protein intake by drinking more milk c. Drink plenty of fluids to prevent dehydration d. Sips of cola or tea may help to relieve your nausea

answer_C Rationale: The patient should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

7. What are the five treatments for the management of a patient with Addison's disease in an adrenal crisis? 1. Steroids, salt, sugar, support, search for cause 2. Steroids, sugar, stress test, serologic tests, salt 3. Steroids, search for cause, stress test, serial labs, salt 4. Steroids, saline, sulfa antibiotics, supplemental oxygen, struma (goiter)

ANS: 1

46. A patient is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Monitoring the patient for nausea b. Providing warm packs for comfort c. Assessing the IV site every hour d. Educating the patient on side effects

ANS: 3 Rationale: Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all patients receiving chemotherapy. Warm packs may be helpful for comfort, but if the patient reports that an IV site is painful, the nurse needs to assess further.

85. A procainamide drip is ordered ( 2 gms in 250 ml D5W) to infuse 4 mg/min. The patient weighs 165 pounds. Calculate the drip rate in ml/hr for which the infusion pump will be set at. Round to the whole number.

ANS: 30 ml/hr

53. Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide? A. Glyburide stimulates insulin production and release from the pancreas. B. Glyburide decreases glucagon secretion from the pancreas C. Glyburide should be taken even if the morning blood glucose level is low D. Glyburide should not be used for 48 hours after receiving IV contrast media.

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

54.A patient is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate A. Community social worker for Meals on Wheels B. Visiting nurses for directly observed therapy C. Physical therapy for homebound therapy services D. Occupational therapy for job retraining

ANS: B Rationale: Directly observed therapy is often utilized for managing patients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.

Scenario 49. A nurse reviews the chart and new prescriptions for a patient with diabetic ketoacidosis Vital Signs and Assessment Laboratory Results Medications Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Serum potassium: 2.6 mEq/L (2.6 mmol/L Potassium chloride 40 mEq/L (40 mmol/L) IV bolus STAT Increase IV fluid to 100 mL/hr What action would the nurse take? A. Increase the intravenous flow rate before administering the potassium. B. Increase the intravenous rate and then consult with the provider about the potassium prescription. C. Administer the potassium and then consult with the provider about the fluid prescription. D. Administer the potassium first before increasing the infusion flow rate.

ANS: B Rationale: The patient is acutely ill and is severely dehydrated and hypokalemic. The patient requires more IV fluids and potassium. However, potassium would not be infused unless the urine output is at least 30 mL/hr. The nurse would first increase the IV rate and then consult with the provider about the potassium.

48. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse action should be to... A. obtain a urine specimen to send to the laboratory. B. administer oxygen therapy at a high flow rate. C. disconnect the transfusion and infuse normal saline. D. notify the health care provider about the symptoms.

ANS: C rationale: The patient symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

41. Which of the following conditions can cause a thyroid storm in a patient with hyperthyroidism? A. Increased iodine intake B. An overdose of PTU (propylyhyrouricil) C. Decreased iodine intake D. Trauma or infection

ANS: D

42. A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level is 114 mEq/L (114 mmol/L). What action would the nurse take first? a. Consult with the dietitian about increased dietary sodium. b. Handle the patient gently by using turn sheets for repositioning. c. Instruct unlicensed assistive personnel to measure intake and output. d. Restrict the patient's fluid intake to 600 mL/day.

ANS: D Rationale: With SIADH, patients often have dilutional hyponatremia. The patient needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. Adding sodium to the patients diet will not help if he or she is retaining fluid and diluting the sodium. The patient is not at increased risk for fracture, so gentle handling is not an issue. The patient would be on intake and output; however, this will monitor only the patient intake, so it is not the best answer. Reducing intake will help increase the patient sodium

51. A nurse cares for a patient with hepatic portal-systemic encephalopathy (PSE). The patient is thin and cachectic in appearance, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? A. Low dietary protein is needed to prevent fluid from leaking into the abdomen. B. Increasing dietary protein will help the patient gain weight and muscle mass. C. A low-protein diet will help the liver rest and will restore liver function. D. Less protein in the diet will help prevent confusion associated with liver failure

ANS: D Rationale: A low-protein diet is prescribed when serum ammonia levels increase and/or the patient shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the patient dietary protein will cause complications of liver failure and would not be suggested. Increased intravascular protein will help prevent ascites, but patients with liver failure are not able to effectively synthesize dietary protein.

52. The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety? A. Suggest the use of over-the-counter sedative medications. B. Discuss a high-protein, high-calorie diet with the patient. C. Titrate O2 to keep saturation at least 90%. D. Teach the patient how to use pursed-lip breathing.

ANS: D Rationale: Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

60. Gout/musculoskeletal system/patient education/nutrition The nurse is teaching a patient with gout dietary strategies to prevent exacerbations of other problems. Which statement by the nurse is most appropriate? A. Liver is a good source of iron. B. Never eat hard cheeses or sardines. C. Have 10 to 12 ounces (300 to 360 mL) of juice a day. D. Drink 1 to 2 L of water each day.

ANSWER 4: Rationale: Kidney stones are common in patients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Patients with gout should not eat organ meats or fish with bones, such as sardines.

61. Diabetes mellitus/preoperative nursing A preoperative nurse assesses a patient who has type 1 diabetes mellitus prior to a surgical procedure and is NPO. The patient 's blood glucose level is 160 mg/dL (8.9 mmol/L). What action would the nurse take? A. Document the finding in the patient 's chart. B. Call the surgeon to cancel the procedure. C. Administer a 2 units of regular insulin subQ. D. Draw blood gases to assess the metabolic state.

ANSWER: 1 Rationale: Patients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL (7.8 and 10 mmol/L) throughout the perioperative period. The nurse would document the finding and proceed with other operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not required.

77. A nurse prepares to admit a patient who has herpes zoster. Which actions would the nurse take? (Select all that apply) a. Check the admission prescriptions for analgesia. b. Choose a roommate who also is immune suppressed. c. Ensure that gloves are available in the room. d. Prepare a room for reverse isolation. e. Assess staff for a history of or vaccination for chickenpox.

Answer: A,C,E Rationale: Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in patients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this patient in a private room. Herpes zoster is a disease of immune suppression, so no one who is immunosuppressed would be in the same room

22. A nurse works in the rheumatology clinic and sees patients with rheumatoid arthritis (RA). Which patient would the nurse see first? 1. Patient with a worse joint deformity since the last visit 2. Patient who has a puffy-looking area behind the knee 3. Patient with a red, hot, swollen right wrist 4. Patient who reports jaw pain when eating

Answer_3 Rationale: All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this patient first.

39. A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan? a. Screening for metastasis will be important. b. Low dose systemic chemotherapy is used to treat BCC. c. Treatment plans include watchful waiting. d. Minimizing sun exposure will reduce risk for future BCC.

answer_d BCC is frequently associated with sun exposure and preventive measures should be taken for future sun exposure. BCC spreads locally, and does not metastasize to distant tissues. Since BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC.

86. A lidocaine drip is infusing on your 90 kg patient at 22 ml/hr. The lidocaine concentration is 2 grams in 250 mL of D5W. How many mg/min is your patient receiving? Round to the whole number.

ANS: 3 mg/min

58. A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? A. More protein is allowed because urea and creatinine are removed by dialysis. B. Increased calories are needed because glucose is lost during hemodialysis. C. Unlimited fluids are allowed because retained fluid is removed during dialysis. D. Dietary potassium is not restricted because the level is normalized by dialysis.

ANSWER: 1 Rationale: When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

64. Electrolyte imbalance A nurse is caring for a patient who has the following laboratory results: potassium 3.4 mEq/L (3.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? A. Grip strength B. Depth of respirations C. Bowel sounds D. Electrocardiography

ANSWER: 2 Rationale: A patient with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the patient 's respiratory status first to ensure that respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the patient 's respiratory status.

67. Falls/safety/older adult An older adult patient is in the hospital. The patient is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this patient? A. Order a bedside commode for the patient. B. Keep the light on in the bathroom at night. C. Use side rails to keep the patient in bed. D. Put the patient on a toileting schedule.

ANSWER: 2 Rationale: Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The patient does not need a commode or a toileting schedule. Side rails used to keep the patient in bed are considered restraints and should not be used in that fashion.

59.Which action will the nurse include in the plan of care for a patient who has thalassemia major? A. Teach the patient to use iron supplements. B. Administer iron chelation therapy as needed. C. Notify health care provider of hemoglobin 11 g/dL. D. Avoid the use of intramuscular injections.

ANSWER: 2 Rationale: The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

65. A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102F (38.9C), and severe back pain. Which prescribed action will the nurse implement first? A. Administer morphine sulfate 4 mg IV. B. Infuse normal saline 500 mL over 30 minutes. C. Give acetaminophen (Tylenol) 650 mg. D. Schedule complete blood count and coagulation studies.

ANSWER: 2 Rationale: The patient 's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

63. Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? A. Take a daily multivitamin with iron. B. Limit fluids to 2 to 3 quarts per day. C. Avoid exposure to crowds when possible. D. Drink only two caffeinated beverages daily.

ANSWER: 3 Rationale: Exposure to crowds increases the patient 's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

. 57. Thyroid gland disorder/medications A nurse cares for a patient who has hypothyroidism as a result of Hashimoto 's thyroiditis. The patient asks, "How long will I need to take this thyroid medication? How does the nurse respond? A. When blood tests indicate normal thyroid function, you can stop the medication. B. You will need to take the thyroid medication until the goiter is completely gone. C. You'll need thyroid pills for life because your thyroid won 't start working again. D. Thyroiditis is cured with antibiotics. Then you won 't need thyroid medication.

ANSWER: 3 Rationale: Hashimoto 's thyroiditis results in a permanent loss of thyroid function. The patient will need lifelong thyroid replacement therapy. The patient will not be able to stop taking the medication.

66. Acid-base imbalance/laboratory values A nurse evaluates the following arterial blood gas values in a patient: pH 7.48, PaO2, 98 mm Hg, PaCO2, 28 mm Hg, and HCO3, 22 mEq/L (22 mmol/L). Which patient condition does the nurse correlate with these results? A. Diabetic ketoacidosis and emphysema B. Diarrhea and vomiting for 36 hours C. Anxiety-induced hyperventilation D. Chronic obstructive pulmonary disease (COPD)

ANSWER: 3 Rationale: The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the patient with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

56. Acid-base imbalance/laboratory values/elimination A nurse is caring for a patient who is experiencing excessive diarrhea. The patient 's arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16 mmol/L). Which provider order does the nurse expect to receive? A. Indwelling urinary catheter B. Furosemide (Lasix) 40 mg intravenous push C. Sodium bicarbonate 100 mEq diluted in 1 L of D5W D. Mechanical ventilation

ANSWER: 3 Rationale: This patient 's arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this patient 's acid-base balance as the pH is below 7.2 and the bicarbonate level is abnormal. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the patient 's pH, the patient has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for patients who cannot keep their oxygen saturation at 90%, or who have respirator muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for this patient

55. Crohn's disease/bowel care A nurse plans care for a patient with Crohn 's disease who has a heavily draining fistula. Which intervention would the nurse indicate as the priority action in this patient 's plan of care? A. Antibiotic administration B. Intravenous glucocorticoids C. Low-fiber diet D. Skin protection

ANSWER: 4 Rationale: Protecting the patient 's skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a patient who has Crohn 's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

83. A nurse cares for patients with hormone disorders. Which are common key features of hormones? (Select all that apply.) 1. Most hormones cause target tissues to change activities by changing gene activity. 2. Continued hormone activity requires continued production and secretion. 3. Control of hormone activity is caused by negative feedback mechanisms. 4. Most hormones are stored in the target tissues for use later. 5. Hormones may travel long distances to get to their target tissues.

Ans: 2, 3, 5 Rationale: Hormones are secreted by endocrine glands and travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the body's needs, and continued hormone activity requires continued production and secretion. Control is maintained via negative feedback. Hormones are not stored for later use, and they do not alter genetic activity.

84. A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? Select all that apply. a. Hyperkalemia & Salt substitutes b. Hypophosphatemia & Calcium deficit c. Hypomagnesemia & Kidney failure d. Hypernatremia & Hyperaldosteronism e. Hypocalcemia & Diarrhea

Ans: a, d, e Rationale: Salt substitutes contain potassium and are a cause of hyperkalemia. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Decreased kidney function is a cause of magnesium excess, not deficit. Hyperphosphatemia creates a relative calcium deficit.

78. The nurse is teaching an elderly patient on the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply) a. Older adults may not have a fever with severe infection. b. Skin tests for tuberculosis may be falsely negative. c. Older adults show expected changes in white blood cell counts. d. Older patients are at more risk for respiratory tract and genitourinary infections. e. Older adults should receive influenza, pneumococcal, and shingles vaccinations.

Answer: A,B,D,E Rationale: Immunity changes during an adult's life and older adults have decreased immune function. The number and function of neutrophils and macrophages are reduced leading to reduced response to infection and injury, such as temperature elevation. The usual response of an increased white blood cell count is delayed or absent. Older adults are less able to make new antibodies in response to the presence of new antigens requiring repeat vaccinations and immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased risk for bacterial and fungal infections due to the decreased number of circulating T-lymphocytes

10. A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? 1. Obtain the forced expiratory volume (FEV) flow rate. 2. Listen to the patient 's breath sounds. 3. Ask about inhaled corticosteroid use. 4. Determine when the dyspnea started.

Answer_2 Rationale: Assessment of the patient 's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient 's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

11. A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next? 1. Increase the dose of the leukotriene inhibitor. 2. Administer a bronchodilator and recheck the peak flow. 3. Instruct the patient to keep the scheduled follow-up appointment. 4. Teach the patient about the use of oral corticosteroids.

Answer_2 Rationale: The patient 's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symptoms now and use the bronchodilator.

21. A nurse is working with an older patient admitted with mild dehydration. What teaching does the nurse provide to best address this issue? 1. Take your diuretic in the morning 2. Dehydration can cause incontinence. 3. Have something to drink every 1 to 2 hours. 4. Cut some sodium out of your diet.

Answer_3 Rationale: Older adults often lose their sense of thirst. Plus older adults have less body water than younger people. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting “some” sodium from the diet will not address this issue. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the patient to take a diuretic in the morning rather than in the evening also will not directly address this issue.

15. The nurse is taking a health history from a 29-yr-old pregnant patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take? 1. Teach the patient about administering regular insulin 2. Teach about an increased risk for fetal problems with gestational diabetes. 3. Schedule the patient for a fasting blood glucose level. 4. Schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy.

Answer_3 Rationale: Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. Teaching plans would depend on the outcome of a fasting blood glucose test and other tests.

25. A patient has a platelet count of 9800/mm3. What action by the nurse is most appropriate? 1. Place the patient on protective isolation precautions. 2. Obtain cultures as per the facility 's standing policy. 3. Assess the patient for calf pain, warmth, and redness. 4. Instruct the patient to call for help to get out of bed.

Answer_4 A patient with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the patient would be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

80. A nurse is assessing a patient who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Skeletal muscle weakness b. Paralytic ileus c. Electrocardiogram changes d. Slow, shallow respirations e. Orthostatic hypotension

answer: A,B,C Rationale: Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in patients with hyperkalemia. The other choices are potential complications of hypokalemia.

81. A nurse assesses a patient who potentially has hyperaldosteronism. Which serum laboratory values would the nurse associate with this disorder? (Select all that apply.) a. Potassium: 5.0 mEq/L (5.0 mmol/L) b. Sodium: 150 mEq/L (150 mmol/L) c. pH 7.50 d. Potassium: 2.5 mEq/L (2.5 mmol/L) e. Sodium: 130 mEq/L (130 mmol/L) f. pH 7.28

answer: b,c,d Rationale: Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. Hyponatremia, hyperkalemia, and acidosis are manifestations of adrenal insufficiency.

35. A nurse cares for a patient who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 07:00. At which time would the nurse assess the patient for potential problems related to the NPH insulin? a. 23:00 b. 20:00 c. 16:00 d. 08:00

answer_c Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the patient at 08:00 would be too soon. Checking the patient at 20:00 and 23:00 would be too late. The nurse would check the patient at 16:00.

32. An older adult is brought to the emergency department because of sudden onset of confusion. After the patient is stabilized and comfortable, what assessment by the nurse is most important? a. Determine if there are new medications. b. Evaluate the patient for gait abnormalities. c. Assess for orthostatic hypotension. d. Perform a delirium screening test.

answer_a Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse should determine if the patient is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the patient's condition.

34. What are the major differences between the Somoygi effect and the Dawn Phenomenon. a. The Somygi effect is nocturnal hypoglycemia with rebound hyperglycemia and the Dawn Phenomenon is increased morning glucose without nocturnal hypoglycemia. b. They are the same process. c. The Dawn Phenomenon is nocturnal hypoglycemia, and the Somygi effect is greatly increased blood sugars in the morning. d. The Dawn Phenomenon is morning hypoglycemia, and the Somygi effect is nocturnal hypoglycemia.

answer_a because this is true by definition

27. Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Absence of wheezes or crackles b. Pulse oximetry reading of 92% c. Even, unlabored respirations d. Respiratory rate of 18 breaths/min

answer_b For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.

38. A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

answer_b The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count 500/L), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

71.The nurse is working with a patient who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the patient. What finding by the nurse indicates goals for this patient problem are being met? a. Has a positive outlook on life b. Attends meetings of a book club c. Uses assistive devices to protect joints d. Takes medication as directed

answer_b Rationale: All of the activities are appropriate for a patient with RA. Patients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this patient problem are being met.

69. A patient is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result would the nurse report to the surgeon immediately? a. Hemoglobin: 8.1 g/dL (81 mmol/L) b. International normalized ratio (INR): 4.2 c. Albumin: 2.1 g/dL (21 g/L) d. Hematocrit: 28% (0.28)

answer_b Rationale: An INR as high as 4.2 poses a serious risk of bleeding during the operation and would be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.

30. A nurse cares for a patient who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The patient states, "When I wake up I am in pain." What action would the nurse take? a. Ask a family member to initiate the PCA pump for the patient. b. Administer intravenous morphine while the patient sleeps. c. Encourage the patient to use the PCA pump upon awakening. d. Contact the provider and request a different analgesic.

answer_c The nurse would encourage the patient to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the patient sleeps places the patient at risk for respiratory depression. The nurse would also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the patient should push the pain button on a PCA pump.

72. A patient has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. Weigh yourself every day on the same scale b. Eat plenty of high-protein, high-iron foods c. Notify your provider at once if you get a fever d. Be sure you get enough sleep at night

answer_c Rationale: Fever is the classic sign of a lupus flare and would be reported immediately. Rest and nutrition are important but do not take priority over teaching the patient what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

36. A patient admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the patient questions this action, saying, "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. This is really just to administer your antibiotics. b. Everyone with pneumonia is dehydrated. c. Breathing so quickly can be dehydrating. d. Why do you think you are so dehydrated?

answer_c Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the patient useful information that addresses this specific concern.

33. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Monitor the patient for shortness of breath or chest pain during the transfusion. c. Obtain the temperature, blood pressure, and pulse before the transfusion. d. Double-check the product numbers on the PRBCs with the patient ID band.

answer_c UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

40. The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History Physical Assessment Laboratory Results Fatigue, which has increased over last month Frequent constipation Conjunctiva pale pink, moist Multiple bruises Clear lung sounds Hct 33% WBC 1500/µL Platelets 70,000/µL a. Increasing fatigue b. Thrombocytopenia c. Constipation d. Neutropenia

answer_d The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.

29. Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. Routine continuous dosage narcotics are prescribed to prevent a crisis. b. There are no effective medications that can help prevent sickling. c. Home oxygen therapy is frequently used to decrease sickling. d. Risk for a crisis is decreased by having an annual influenza vaccination.

answer_d Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

37. A patient has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the healthcare provider immediately? a. Red blood cell (RBC) count: 5.2 million/L b. White blood cell (WBC) count: 12,500/mm c. Albumin: 5.1 g/dL (7.4 mcmol/L) d. Alanine aminotransferase (ALT): 180 U/L

answer_d INH can cause liver damage, especially if the patient drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a patient with an infection.

28. The nurse on an inpatient rheumatology unit receives a hand-off report on a patient with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the patient further? a. Red blood cell count: 5.2/mm b. White blood cell count: 4400/mm c. Platelet count: 210,000/mm d. Creatinine: 3.9 mg/dL (345 mcmol/L)

answer_d Lupus nephritis is the leading cause of death in patients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

70. Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Platelet count 450,000/L c. K= 3.8 d. Calf swelling and pain

answer_d Rationale: The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.